PUD and GERD

Question 1

Why do NSAIDs increase risk of PUD?

Answer 1

1. Direct or topical irritation

2. inhibition of GI prostaglandin synthesis which is needed to maintain blood flow, stim bicarb and mucous production

Question 2

Which two bisphosphonates can induce ulcerations?

Answer 2

Alendronate (Fosamax)
Risedronate (Actonel)

*take with a full glass of water and sit up

Question 3

Which infection is strongly associated with PUD?

Answer 3

H.pylori

Question 4

H.pylori - how does it damage the gut?

Answer 4

produces a large amount of urease –> catalyzes the breakdown of urea to alkaline ammonia and CO2

Question 5

What is the only cancer you can cure by treating the causative organism?

Answer 5

gastric carcinoma or B-cell lymphoma r/t h.pylori

Question 6

PUD - general approach to treatmen

Answer 6

1. stop smoking
2. take NSAIDs with food
3. stop or decrease NSAID dose
4. Meds: misoprostol, H2RA, PPI or PPI with hs H2RA
5. consider h.pylori

Question 7

How long does treatment of PUD take?

Answer 7

6-8 weeks

Question 8

Oral antacids - drugs

Answer 8

Amphojel, Maalox, Maalox HRF, Mylanta DS

Question 9

What are oral antacids use for?

Answer 9

symptom relief

Question 10

Oral antacids - ADE

Answer 10

diarrhea or constipation

Question 11

Oral antacids - DDI and Why?

Answer 11

binds and prevents absorption or: levothyroxine, tetracyclines, iron, isoniazid, FQs

Why? binds with di valent and tri valent cations like Mg, Ca and Al

Question 12

Which formula of oral antacids may be more effective?

Answer 12

chewable

Question 13

What may be of concern in CHF patients regarding oral antacids?

Answer 13

Na+ content - depends on dose

Question 14

*What medication provides a protective barrier in the esophagus against gastric contents…floats on surface of gastric contents but does not neutralize acid?

Answer 14

Gaviscon (antacid containing alginic acid)

used mostly for GERD

Question 15

*What class are Ranitidine (Zantac), Famotidine (Pepcid) and Cimetidine (Tagamet) in?

Answer 15

Histamine Receptor Antagonist (H2RA)

Question 16

*H2RA - MOA

Answer 16

reversibly inhibit H2 receptors on parietal cells (except famotidine which has some noncompetitive inhibition)

Question 17

Of the H2RAs, which is probably “a little” better and why?

Answer 17

Famotidine (Pepcid) because longer t1/2 (12 hours)

Question 18

Most H2RAs are BID dosing. Why do you give the 2nd dose at bedtime?

Answer 18

because nocturnal acid suppression is important for healing

Question 19

H2RAs - ADE

Answer 19

thrombocytopenia (small risk), increased serum Cr and BMS

Question 20

Which H2RA should be avoided in BMT patients?

Answer 20

Ranitidine (Zantac)

most likely to cause BMS

Question 21

Which H2RA is used for prophylaxis of NSAID induced duodenal ulcers?

Answer 21

Famotidine (Pepcid)

Question 22

How are most H2RAs cleared?

Answer 22

renal (adjust per CrCl)

Question 23

*What class are Esomeprazole (Nexium), Lansoprazole (Prevacid), Panteprazole (Protonix) and Omeprazole (Prilosec)?

Answer 23

“prazoles” = PPI

Question 24

*PPI - MOA

Answer 24

Prodrug that requires activation by acid. Irreversibly bind to H+/K+ ATPase pump on parietal cell and inhibits acid generation.

Question 25

How long does it take to restore proton pumps after DC of PPI?

Answer 25

3-5 days

Question 26

General dosing for PPI

Answer 26

qd

Question 27

*How are most PPIs cleared?

Answer 27

hepatically | watch DDI…esp. CYP450

Question 28

What are the long term safety concerns of PPI?

Answer 28

1. increased risk of fractures (b/c decreased Ca absorption) 2. possible hypomagnesemia 3. gastric carcinoid tumors from hypergastrinemia 4. pneumonia and enteric infections

Question 29

Why is there an increased risk of pneumonia for the elderly on PPI?

Answer 29

Lower acid in the gut allows bacteria to grow and if aspirated, can cause pneumonia.

Question 30

Why is there an increased risk of enteric infections on PPI?

Answer 30

Lower acid in the gut allows bacteria to grow (Salmonella, Shigella, Cholora)

Question 31

*When is misoprostol (cytotec) used?

Answer 31

prophylaxis for PUD if on long term NSAID

Question 32

Misoprostol (cytotec) - ADE

Answer 32

diarrhea and cramping

Question 33

Misoprostol (cytotec) - pregnancy warning

Answer 33

avoid - can cause contractions can be used to stimulate labor

Question 34

*h.pylori triple therapy - PPI

Answer 34

PPI bid + clarithromycin 500 mg bid + AMX 1000 mg bid 80-90% eradication

Question 35

at what pH does the gut heal?

Answer 35

>4

Question 36

ACG guidelines for maintenance of GERD

Answer 36

PPIs

Question 37

Which drug can be given to pregnant women with N/V or HA?

Answer 37

Reglan

Question 38

In what condition is Reglan contraindicated in?

Answer 38

small bowel obstruction

Question 39

How is Reglan eliminated?

Answer 39

renal (adjust per CrCl)

Question 40

"functional GERD" - peak/onset

Answer 40

peaks at 4 months | usually gone by 12 months

Question 41

GERD - non-pharmacological treatment (infants)

Answer 41

``` hypoallergenic formula trial positioning (head up) avoid caffeine, chocolate and spicy foods (breastfeeding) weight control avoid passive smoking ```

Question 42

GERD - non-pharmacological treatments (adult)

Answer 42

``` IBW modify diet avoid ETOH and smoking HOB up avoid tight garments ```

Question 43

Pharmacological options - GERD

Answer 43

1. oral antacids 2. H2RA 3. PPI 4. Prokinetic agents

Question 44

Reglan - ADEs

Answer 44

drowsiness, diarrhea, dystonia, EPS

Question 45

What pro kinetic drug can be used to treat GERD?

Answer 45

Reglan

Question 46

*Risk factors -PUD

Answer 46

NSAIDS h.pylori steroids anti-coagulants

Question 47

Which pathway is DDI most likely with Prilosec (PPI)?

Answer 47

2C19