newhouse Flashcards
(119 cards)
1
Q
GERD
A
symptoms of complications resulting from refluxed stomach contents into the esophagus or beyond, into the oral cavity or lung
2
Q
risk factors of GERD
A
pregnancy, obesity, genetic predisposition, tobacco smoking, delayed gastric emptying, medication and food trigger, comorbid conditions
3
Q
decrease lower esphageal sphincter pressure
A
fatty food
chocolate
coffee, tea, soda
garlic and onions
chili peppers
alcohol
peppermint or spearmint
4
Q
direct irritants
A
spicy foods
orange juice
tomatoes
coffee
5
Q
medication triggers that decrease lower esophageal sphincter pressure
A
anticholinergics
barbituates
caffeine
DHP CCB
dopamine
estrogen and progesterone
nicotine
nitrates
tetracycline
6
Q
direct irritants medication triggers
A
aspirin
bisphosphonates
NSAIDs
iron
quinidine
potassium chloride
7
Q
clinical presentations of GERD syndromes
A
symptom-based (and esophageal tissue injury)
Extraesophageal
8
Q
symptom based clinical presentation
A
reflux chest pain
regurgitation/belching
heartburn
9
Q
extraesophageal clinical presentation
A
chronic cough
laryngitis (hoarse voice)
wheezing
asthma
10
Q
alarm symptoms of GERD
A
bleeding
dysphagia
odynophagia
weight loss
SEEK IMMEDIATE MEDICAL ATTENTION
11
Q
DIAGNOSING GERD
A
clinical history
additional testing
12
Q
clinical history when diagnosing GERD
A
most useful tool in diagnosis
identifying symptoms, triggers, and risk factors
13
Q
additional testing in diagnosing gerd
A
upper endoscopy
ambulatory reflux (pH) monitoring
combined impedence-pH monitoring
manometry
14
Q
upper endoscopy
A
preferred method for assessing mucosal injury and complications
15
Q
indications of upper endoscopy
A
presistent or progressive GERD symptoms despite approprate therapy
dysphagia or pdynophagia present
unexplained weight loss >5%
GI bleed and/or strictures present
Screening for Barrett’s esophagus
pH montiroing placement
16
Q
ambulatory reflux monitoring
A
useful in patients not responding to acid suppression after normal endoscopy.
presenting with extrasophageal symptoms
17
Q
other diagnostic tools
A
manometry/high resolution esophageal pressure topography
Barium radiography
18
Q
manometry/high resolution esophageal pressure topography
A
may be useful in patient who have failed BID PPIs with a normal EGD
19
Q
Barium radiopgraphy
A
lacks sensitivity and specificity. not routinely used for diagnosing GERD
DETECTS HIATAL HERNIA
20
Q
goals of treatment
A
alleviate or eliminiate symptoms
decrease recurrence duration and frequency
promote healing of injurd tissue
prevent complications related to GERD
21
Q
referral appropriate
A
alarming symptoms present
14 day trial of OTC product with no symptom relief
22
Q
OTC tx appropriate
A
no alarm symptoms
mild to moderate symptoms
new onset
indentified triggers minimized
23
Q
PRN medications
A
Antacids and H2RAs
24
Q
Scheduled medications
A
H2RAs and PPIs
25
lifestyle modifications of GERD
weight loss, avoiding meals before bed, avoid tobacco and alcohol, avoid triggers, elevate the head of bed
26
antacids
PRN Med
mechanism: neutralizes gastric acidity
onset: 5 minutes
duration: 30-60 minutesp
27
antacids
calcium, magnesium. aluminum
28
calcium
constipation
milk alkali syndrome
29
magnesium
diarrhea
accumulation
30
aluminum
constipation
confusion/neurotoxicity
31
antacids DRUG INTERACTIONS
fluroquinolones, tetracyclines, antifungals, levothyroxine, iron, steroids, digoxin, HIV meds
32
if you are taking a medication that can interact with antacid,
take it 2 hours before or 6 hours after antacid
33
single element agents
calcium carbonate (tums)
magnesium hydroxide (milk of magnesia)
34
combination products
aluminum and magnesium (Maalox)
Aluminum + mag+ simethicone(mylanta)
calcium + magnesium
calcium +simethacone
35
other PRN medications
alka-seltzer: sodium bicarbonate
pepto-bismol: dismuth subsalicylate
Gas-x: simethacone
36
what is not recommended for children <12 years of age
salicylate containing product (RISK OF REYES SYNDROME)
37
Dosing of TUMS
2-4 tablets PRN up to 4x/day
16 tabs/ day
38
milk of magnesia
5-15 mL PRN up to 4x/day
60 mL/day
39
maalox
10-20 mL PRN or at meals +bedtime up to 4x/day
80 mL/day
40
gaviscon
2-4 tablets or 10-20 mL at meals + bedtime 4x/day
16 tab/ day
41
which of the following antacid components cause constipation?
calcium and aluminum
C+A
42
Histamine-2 receptor antagonists
MOA: reversible inhibition of histamine receptors in the parietal cells
Onset: 60 minutes
duration: 4-6 hours
43
Famotidine (pepcid)
H2RAs
OTC dosing: 10-20 mg BID (max: 40 mg/day)
Rx: 10 mg BID prn 10-60 minutes before meals.
If symptoms persist even after increasing dose, consider PPI
Renal adjustment: CrCL <50 mL/min: give 50% of dose
44
Cimetidine (tagamet)
Dosing OTC and Rx: 200 mg QD up to 30 minutes before to trigger foods
Renal adjustment: only reduce in severe kidney impairment
Drug interactions: many interactionsvia CYP 1A2, 2C9, 2D6, and 3A4
Not commonly used
45
side effects with H2RAs
headache, constipation or diarrhea, agitation, dizziness or fatigue, somnolence confusion or delirium, B12 deficiency (with long term use)
46
H2RAS pearls
tachyphylaxis occurs with logn term use
Avoid use in patients wth high or at high risk for delirium
NOT as efficacious as PPIs
all H2RAS considered equally efficacious
useful in treatment of nocturnal symptoms
47
Proton Pump Inhibitors
MOA: irreversible inhibition of proton/potassium ATPase
Onset: 2-3 hours
Duration: 24 hours
48
esomeprazole (nexium)
PPI
OTC dosing: 20 mg daily for 14 days; may repeat course in 4 months if needed
PO rx: 20-40 mg once daily
IV rx: 20-30 mg daily
No renal dose adjustments
Must be taken 60 minutes before meals
Metabolized by CYP2C19
49
Lansoprazole
PPI
OTC dosing: 15 mg daily for 14 days; may repeat in 4 months if needed
Rx: 15-30 mg daily
No renal adjustments
ODT available
administer 30-60 minutes before a meal
50
omeprazole (prilosec)
PPI
OTC dosing: 20 mg daily gor 134 days; may repeat in 4 months if needed
rx: 10-40 mg daily
No renal dose adjustments
administer 30-60 minutes before a meal
metabolized by CYP2C19
51
Dexlansoprazole
PPI
Rx only
No complications: 30 mg daily
Complications present: 60 mg daily for 8 weeks, then 30 mg indefinetely
No renal dose adjustments needed
Dual release formulation (onset at 1-2 hours and again at 4-5 hours)
Can be taken without regard to meals
52
Pantoprazole
PPI
rx only
PO rx: 20-40 mg daily
IV rx: 40 mg daily
no renal dose adjustments
tab cannot be crushed or altered
administer 60 minutes before a meal
most common PPI found on hospital formularies
53
Rabeprazole
PPI
Rx only
10-20 mg daily
no renal adjust,ents
administer 30 minutes before a meal
54
PPI DRUG INTERATIONS
PPI inhibits CYP2C19 (omeprazole and esomeprazole are the strongest inhibitors)
Increase effect: methotrexate, phenytoin, warfarin
Decrease effect: iron, bisphosphonates, HIV drugs, clopidigrel
55
short term side effects with PPI
headache/dizziness
diarrhea/flatuence
nausea/ab pain
enteric infections
comminuty acquired penumonia
56
Common side effect of long term PPI
hypomagnesemia
bone density decrease/fractures
Vitamind b12 deficiency
Chronic kidney disease
57
Antacids can be combined with H2RAs
Helpful for heatburn after eating from different onsets
Pepcid AC = famotidine + calcium carbonate and magnesium
58
PPIs + H2RAs
nighttime administrations of a single H2RA dose can help with nocturnal acid production
H2RAs can also help with breakthrough heartburn
59
surgery is last management
anti-refluc surgery
60
anti refluc surgery
reestablishes the anti-reflux barrier by positioning the LES under positive pressure
61
Candidates for surgery
long term meidcation management us undesirable
symptoms
Symptoms or muscosal damage persists despite appropratie pharmacologic therapy
significant EGJ disruption exists
62
Pregnant women with GERD
1.Lifestyle modifications
2. antacids and sucralfate
3. H2RAs
4. PPI: reserved for compications of GERD or tx failure
63
sx and signs of gerd in infants and children
refusing to eat
wheezing/coughing
dental erosion
recurrent regurgitation
irritability
64
sx in infants and children that require additional investigation
weight loss
fever
seizure
persistent vomitting/diarrhea
65
non-pharm options for gerd for infants and children
thickening formula/foods
decreasing
decreasing volume of intake
milk free diet
positioning therapy
66
PPIs and H2RAs for peds
treat for 4-8 weeks
only diagnosed GERD or esophagitis
67
Antacids for peds
should not sure chronically
do not use aluminum or bismuth subsalicylate containing antacids in children <12 years
68
AB is a 42 YOM looking for recoomendatons for his heartturh symtpoms. he trialed lifestyle modifications without relief. What OTC option do you recoomend for AB?
Omeprazole 20 mg QD
69
PPIs
NOT PRN MEDICATIONS
END IN -ZOLE
70
Pantoprazole is an Rx only product and only once a day
True
71
Peptic ulcer diseas
large ulcers that extend into the muscalaris mucosa
72
types of ulcers:
gastric, duodenal
73
most common causes of PUD
h. pylori
nsaids
stress
74
H.pylori PUD
chronic
in the duodenum
more dependent on intragastric pH
epigastric pain SE
superficial ulcer depth
Less severe gi bleeding
75
NSAID PUD
chronic
in the stomach
less dependent on intragastric pH
often asymptomatic
deep
severe GI bleeding
76
stress PUD
acute
in the stomach
less dependent on intragastric pH
asymptomatic
most superficial
more
77
Risk factors for PUD
h.pylori infection
NSAID use
gastric acid hypersecretion
cig smoking
physiologic stress
dietary factors
78
complications of PUD
GI bleed, GI perforation, GI obstruction
CAN BE LIFE THREATENING
79
signs and sx of PUD
Epigastric pain, nausea and vomiting, belching heartburn, bloating, abdominal fullness, weight loss/anorexia, nocturnal pain
80
food can help determine location
if they eat and it relieves pain, its in the duodenum
if they eat and it worsens pain, it is in the stomach
81
non-pharm recs
reduce phsyiologic stress, smoking cessation, avoid NSAIDs, avoid foods that cause dyspepsia, surgery
82
diagnosis of H. pylori induced PUD
endoscopy
Hgb anf HCT low if ulcers are bleeding
lab test specific for h. pylori
-antibody detection
urea breath test
fecal antigen
83
******Bismuth quadruple therpay****
PREFERREDDD REGIMENNNNN
contains:
1. PPI BID
2. bismuth subsalicylate
3. metronidazole
4. tetracycline
USE FOR 10-14 DAYS
84
Helidac
Convenient packaging for h pylori
14 blister cards containing
-metronidazole
-tetracycline
-bismuth subsalicylate
STILL MUST TAKE A PPI BID
85
Pylera
convenient packacking
3 in 1 capsule
STILL MUST TAKE PPI BID
86
vanoprazan dual therapy
vonoprazan 20 mg BID
amox 1G q8h
for 14 days
87
vanoprazon triple therapy
vonoprazon 20 mg BID
amox 1G bid
clarithromycin 500 mg BID
for 14 days
88
vonoprazan
MOA: INHIBITS H+/K+ by comp. bidning at the K+ site which suppresses gastric acid secretion on the surface of gastric parietal cells
Adverse effects: bloating, stomach, pain, nausea, diarrhea, stomach inflammation, UTI
CONTAINS ALL YOU NEED
89
Rifabutin
Triple therapy
TALICIA
4 capsules every 8 h
1. omeprazole 40 mg q 8h
2. amox 1 gm q8h
3. rifabutin 50 q8h
for 14 days
90
ppis in h pylori tx
BID ppis were the backbone of therapy (and still are in some regimens)
H2RAs (famotidine) should not be substituted for a PPI unless the pt cannot tolerate a ppi
ppi not usually necessary beyond 2 weeks of use for eradication (should not be continued indefinitely)
91
PPI in h. pylori
omeprazole 20 mg
pantoprazole 40 mg
esomeprazole 20-40 mg
lansoprazole 30 mg
92
antibiotics
metronidazole, amoxicillin, tetracycline, rifabutin, clarithromycin
93
metronidazole SE
avoid alcohol due to disulfiram-like reaction
94
amoxicillin SE
GI upset
95
tetracycline se
photosensivitiy
avoid in children, may permanently stains teeth
96
rifabutin se
discoloration of urine
GI upset
97
clarithromycin se
QTC prolongation
photosensitivity
GI upset
98
probiotics
there is not consensus on the impact of probiotics in H. pylori treatment
some studies have shown increased eradiction rate when compared to placebo, when taken as a supplement with antibiotic therapy
may also reduce adverse effect of therapy
99
treatment considerations of PUD
avoid antimicrobials the pt has already taken
consider allergies and intolerances
patient adherence
100
nsaid induced pud pathophysiology
inhibit COX-1 which stops mucus in stomach and causes ulcers
101
NSAID induced PUD is confirmed with...
endoscopy
Hgb and HCT low if ulcers are bleeding
102
risk factors with NSAID induced ulcers
age >65
previous peptic ulcer
previous ulcer related GI complication
multiple nsaid use
nsaid related dyspepsia
concomitant use of aspirin
103
Prevention stratgiesfor nsaid induced ulcer
Co-therapy woth additional agents
Utilize COX-2 selective NSAIDS
utilize least GI toxic NSAID at lowest effective dose
104
Co-therapy with additional agents
PPIs
Misoprostl
H2RA
105
Utilize COX-2 selective NSAIDS
celecoxib
less likely to cause GI side effects, but increase CV risk
106
utilize least GI toxic NSAID at lowerst effective dose
preferred non selective NSAID: naproxen
decreased CV risk in comparison to celecoxib
107
PPI dosing for NSAID induced ulcers
omeprazole 40 mg daily
pantoprazole 40 mg daily
esomeprazole 40 mg daily
lansoprazole 30 mg daily
108
H2RA dosing for NSAID induced ulcers
famotidine 40 mg HS/ 20 mg BID
Cimetidine 800 mg HS/ 400 mg BID/ 300 mg QID
109
Misoprostol
PREVENTION
moa: prostaglandin E1 analog
increases mucus and bicarbonate secretion
increases surface active phospholipids
increase gastric mucosal blood flow inhibit acid secretion
Dose: 200 mcg QID with food
110
Boxed warning for misoprostol
abortiacient
pregnancy category X, induces labor or abortion
must do pregnancy test prior to initiation in women of child-bearing age
111
Side effects of misoprostol
diarrhea, nasuea, vomiting, abdominal cramping, flatuence, and headache
difficult to tolerate for many patients, limit uses
112
If a pt can stop NSAID:
PPI, H2RA, or sucralfate for 8 weeks
113
if patient is continuing NSAID:
PPI for 12 weeks
use lowest effective of NSAID
may consider continuing PPI
114
sucralfate
MOA: sucrose- sulfate-aluminum complex that interacts with albumin and fibrinogen to form a physical barrier over an open ulcer
Protects ulcer from further insult by gastric acid, pepsin, and bile to allow ulcer heal
Dose: 1 g QID before meals and at bedtime
115
side effects sucralfate
constipation, metallic taste, aluminum toxicity in chronic renal failure
116
counseling tips for sucralfrate
administer on empty stomach 2 hours before or 4 hours after other medications
117
what agent is used in both treatment and prevention of NSAID induced pUD?
omeprazole
118
key takeaway for H pylori induced ulcers
acid suppression + antibiotics
**************ppi typically dosed BID********
treat: 10-14 days
can finish ulcer tx with PPI for at least 14 more days
119
nsaid induced ulcers key takeaways
prevention is key
******ppis are dosed daily **********
treat for 8 weeks if nsaid stopped; 12 weeks if continued
