Pharm - GERD/PUD

Question 1

What are the pharmacologic agents that may cause LES relaxation?

Answer 1

Anticholinergics (diphenhydramines)
Beta adrenergic agonists (albuterol)
Benzodiazepines (diazepam)

Question 2

What can cause increased esophageal pressure?

Answer 2

Obesity
pregnancy

Question 3

What are the typical symptoms of GERD

Answer 3

Heartburn
Dyspepsia

Question 4

What is an atypical symptoms of GERD

Answer 4

Burning throat

Question 5

What are some symptoms that require an immediate referral to GI

Answer 5

Anemia
Chest pain
GI bleeding

Question 6

If given a PPI trial for GERD, what should be done if no improvement after 8 weeks?

Answer 6

refer to GI

Question 7

If given a PPI trial for GERD, what should be done is improvement after 8 weeks?

Answer 7

Taper PPI to lowest effective dose and eventually therapy discontinuation is possible

Question 8

What should be recommended along with PPI trial for initial GERD treatment?

Answer 8

lifestyle changes
-stop smoking
-weight loss
-avoid late/large meals
-elevate head of bed

Question 9

What are the 3 GERD pharm treatment options

Answer 9

Antacids
Histamine 2 receptor antagonists
Proton pump inhibitors

Question 10

What are examples of antacids

Answer 10

Maalox
Mylanta
TUMS

Question 11

Antacids MOA

Answer 11

neutralize acid and raise intragastric pH

Question 12

Antacids clinical pearls

Answer 12

1. quick symptom relief
2. first line for mild, intermittent symptoms
3. breakthrough symptoms for those take H2 or PPI
   -mild intermittent = less than twice weekly symptoms
4. NOT appropriate for chronic symptoms

Question 13

Dosing concern for antacids

Answer 13

take 1-3 hours after meals and other medications to avoid potential drug interactions

Question 14

Common ADE of antacids

Answer 14

constipation
chalky taste
long term use may cause renal dysfunction

Question 15

What are the H2RAs

Answer 15

famotidine (pepcid)
cimetidine
nizatidine
ranitidine is withdrawn from market

Question 16

H2RA MOA

Answer 16

blocked parietal cell acid secretion by reversible H2RA blockade

Question 17

H2RA clinical pearls

Answer 17

1. mild, troublesome GERD symptoms
2. maintenance therapy - patient W/O erosive disease with intermittent symptoms
3. Less effective than PPIs in healing erosive esophagitis

Question 18

H2RA dosing

Answer 18

1. OTC typically 50% dose of prescription formulations
2. Not ideal to use > 2 weeks
3. Renal impairment - requires dose reductions

Question 19

H2RA drug interaction relating to pH

Answer 19

drugs that require low pH for absorption = reduced absorption
-ketoconazole
-itraconazole
-HIV protease inhibitors

Question 20

H2RA cimetidine drug interaction

Answer 20

inhibitor of CYP450
-cyclosporine
-theophylline
-warfarin

Question 21

What are the PPIs

Answer 21

all -prazole ending

Brand:
Nexium
Prilosec
Protonix

Question 22

PPI MOA

Answer 22

irreversibly interacts with the hydrogen potassium adenosine triphosphate (H-K-ATPase) pump - results in long-lasting impairment of acid secretion

Question 23

PPI clinical pearls

Answer 23

1. empiric therapy for patients experiencing frequent, continued symptoms
   -once daily for 8 weeks
2. most potent inhibitors of acid suppression
3. Superior to H2RAs
   -moderate to severe GERD
   -Erosive esophagitis
   -GERD-related complications
4. Symptom relief is delayed compared to H2RAs
5. Not indicated for intermittent episodic symptoms

Question 24

PPI clinical pearl for maintenance therapy

Answer 24

persistent symptoms in patients with complications (erosive esophagitis, Barrett’s esophagus)
Long term therapy - lowest effective dose

Question 25

PPI clinical pearl for partial response/incomplete response

Answer 25

increase dosing to twice daily Switch to a different PPI

Question 26

PPI administration considerations

Answer 26

1. Do not administer with H2RAs -cumulative effects on acid suppression 2. Acceptable to use with H2RAs when time interval between dose is sufficient

Question 27

What are the IV formulation for PPI

Answer 27

Esomeprazole and Pantoprazole

Question 28

What patient education given with PPI

Answer 28

1. most products take 30-60 minutes before a meal 2. Capsules and tablets are delayed release -do not crush or chew 3. patients with swallowing difficulties -open delayed release capsules and sprinkle on applesauce - liquid formation are available for some products

Question 29

PPI adverse effects

Answer 29

Rebound hypersecretion -reappearance of acid related symptoms when therapy is discontinued for 2 weeks or more -advise tapering off

Question 30

Complications with chronic acid suppression (PPI use)

Answer 30

Fractures Hypomagnesemia Increased incidence of C. diff

Question 31

PPI drug interactions

Answer 31

Ketoconazole/itraconazole/HIV PIs - altered absorption Clopidogrel - avoid combo with: -omeprazole -esomeprazole -lansoprazole

Question 32

What should be used for refractory GERD

Answer 32

Metoclopramide Dopamine antagonist

Question 33

What to note about metoclopramide

Answer 33

>12 weeks is not recommended due to risk of irreversible tardive dyskinesia

Question 34

Where is PUD most common

Answer 34

Stomach and upper duodenum

Question 35

What are the most common causes of PUD

Answer 35

H. pylori NSAIDs

Question 36

What are the symptoms of PUD

Answer 36

Heartburn Epigastric pain Anorexia Weight loss

Question 37

Complications of PUD

Answer 37

GI bleeding Perforation

Question 38

What is the main symptom of gastric ulcer

Answer 38

indigestion of food

Question 39

What are the main symptoms of duodenal ulcers

Answer 39

pain 1-3 hours post ingestion pain relieved by food

Question 40

What is the treatment goal of H. pylori

Answer 40

Eradication relieve symptoms heal and prevent ulcers

Question 41

Primary treatment of H. pylori

Answer 41

Clarithromycin based triple therapy PPI + Clarithromycin + Amoxicillin sub metronidazole for amoxicillin allergy -first line 10-14 days

Question 42

What is the secondary (quadruple) therapy for PUD and when to used it

Answer 42

PPI Bismuth metronidazole tetracycline For failed triple therapy

Question 43

Adverse effect of PUD combo therapy treatment

Answer 43

Diarrhea Metronidazole - disulfuram-like reaction with alcohol intake Bismuth - darkening of tongue and stool

Question 44

What is the most important predictor of treatment failure for PUD (h. pylori)

Answer 44

Lack of adherence and antibiotic resistance

Question 45

What should be done in the case of NSAID induced PUD

Answer 45

discontinue if possible

Question 46

What are the GI risks for NSAID ulcers

Answer 46

1. history of PUD 2. Age >60 3. Concominant meds -anticoags -corticosteroids -other NSAIDs (aspirin)

Question 47

GI risk low vs high

Answer 47

low = 0 risk factors high - 3+ risk factors

Question 48

What are the NSAID ulcer CV risks?

Answer 48

Requirements for low dose aspirin -Prior CV events -diabetes -Hyperlipidemia

Question 49

What to note about CV risk

Answer 49

High arbitrarily defined as a requirement for low dose aspirin

Question 50

Low CV risk + Low GI risk

Answer 50

NSAID alone ok

Question 51

High CV risk + high GI risk

Answer 51

AVOID NSAID or COX-2 inhibitors

Question 52

What is the best option for high CV risk

Answer 52

Naproxen

Question 53

What is the best option for high GI risk

Answer 53

Celecoxib

Question 54

What should be done if high GI and high CV risk

Answer 54

Avoid NSAIDs altogether

Question 55

What is the most COX-2 selective NSAID

Answer 55

celecoxib

Question 56

What are the top 3 most non selective NSAID

Answer 56

Aspirin (#1) ibuprofen naproxen

Question 57

What to remember about GERD/heartburn in pregnancy?

Answer 57

1. Heartburn is the predominant symptom 2. symptoms are worst during last trimester 3. Dietary triggers -fatty foods -spicy foods -caffeine 4. typically resolves after delivery

Question 58

How to treat GERD during pregnancy?

Answer 58

Antacids -magnesium/calcium considered safe H2RA -Famotidine PPI (Cat C) -AVOID omeprazole in first trimester