64. Gastroesophageal Reflux Disease (GERD) & Peptic Ulcer Disease (PUD)

Question 1

A female patient is using naproxen 250 mg twice daily for Achilles’ tendon pain. She was a long distance runner, but was forced to stop due to the painful heel injury. After using the medication for about a month, she began to experience stomach upset, and her physician prescribed misoprostol 100 mcg QID. The physician stated that he did not wish to begin chronic acid suppression therapy in a young female patient due to recent reports of increased fracture risk. Which of the following statements is correct?

A. The primary side effects of misoprostol are headache and peripheral edema.
B. Misoprostol works by coating the stomach with a protective lining.
C. Misoprostol is safe to use in pregnancy.
D. The primary side effects are diarrhea and abdominal pain.
E. The brand name of misoprostol is Arthrotec.

Answer 1

D. Patient adherence to misoprostol therapy is very poor, due to significant diarrhea and cramping. Misoprostol can induce abortion, and is Pregnancy Category X. It is safest to avoid misoprostol in women of childbearing age.

Question 2

A middle-aged gentleman has reflux symptoms. He has been diagnosed with GERD and told to purchase Prilosec OTC. The patient reports that he will use the medicine whenever he gets symptoms, which occur 3-4 times per week. Choose the correct counseling statement/s: (Select ALL that apply.)

A. It is not appropriate to use this medication as-needed.
B. This medication is best taken daily, before his morning meal.
C. This medication should be started twice daily.
D. This medication should be taken with breakfast.
E. This medication should be taken immediately after eating.

Answer 2

A, B. Counseling points for PPIs: take before meals, consistently (they are not used as-needed). If using a PPI once daily, it should be taken before breakfast. If using twice-daily, it should be taken before breakfast and dinner.

Question 2

A patient has been prescribed cimetidine. Counseling points should include: (Select ALL that apply.)

A. Notify your physician if you experience tender or swollen breasts.
B. This medicine may cause sexual problems, including difficulty having or maintaining an erection.
C. This medicine cannot be used safely with many other medicines; please let the pharmacist know all the other medicines you are taking.
D. Take this medication along with a PPI for optimal effectiveness.
E. This medication may cause CNS-related adverse effects, especially in the elderly.

Answer 2

A, B, C, E. Cimetidine can cause CNS-related adverse effects, especially in the elderly. Tender, swollen breast tissue can occur as well. The breasts do not need to be enlarged to feel sore and tender. Impotence is another side effect unique to this H2RA. Cimetidine is an enzyme inhibitor; watch for drug interactions.

Question 3

A patient has entered the pharmacy and asked the pharmacy technician to help her locate the store-brand version ofPepcid. Which of the following medications should the technician select?

A. Nizatadine
B. Cimetidine
C. Famotidine
D. Ranitidine
E. Omeprazole-Sodium Bicarbonate

Answer 3

C. The generic name of Pepcid is famotidine.

Question 3

A patient is using Nexium once daily. Which of the following is an appropriate generic substitution?

A. Omeprazole
B. Esomeprazole strontium
C. Pantoprazole
D. Esomeprazole
E. Dexlansoprazole

Answer 3

D. The generic name of Nexium is esomeprazole. Esomeprazole strontium is not generic Nexium.

Question 3

A patient is seen at her primary care provider for an annual check-up. The patient reports daily stomach pain that is somewhat relieved by food. The provider conducts a urea breath test, which is positive. Allergies include penicillin and ciprofloxacin. Choose the most appropriate therapeutic regimen.

A. Lansoprazole 30 mg BID + Amoxicillin 1,000 mg BID + Clarithromycin 500 mg BID x 7 days
B. Lansoprazole 30 mg BID + Amoxicillin 1,000 mg BID + Clarithromycin 500 mg BID x 10-14 days
C. Lansoprazole 30 mg BID + Bismuth subsalicylate 525 mg QID + Metronidazole 500 mg QID + Tetracycline 500 mg QID x 7 days
D. Lansoprazole 30 mg BID + Bismuth subsalicylate 525 mg QID + Metronidazole 250 mg QID + Tetracycline 500 mg QID x 14 days
E. Lansoprazole 30 mg BID + Ampicillin 1,000 mg BID + Clarithromycin 500 mg BID x 10 days

Answer 3

D. When treating H. pylori, if alternative therapy is desired due to a penicillin or macrolide allergy, quadruple therapy with bismuth subsalicylate, metronidazole, tetracycline and a PPI can be used for 14 days.

Question 3

A patient is at the pharmacy to receive counseling on Helidac. Which of the following is not an important counseling point for this patient?

A. You will take 4 pills, 4 times per day on the Helidac card
B. You will also require a separate prescription for an acid reducing medication for 28 days
C. Chew the round, pink bismuth tablets and swallow the other pills on the Helidac card
D. You should avoid alcohol while taking Helidac and for 3 days afterward
E. You may experience a red-orange discoloration of your urine

Answer 3

E. Review the counseling for all H. pylori products.

Question 3

A patient has entered the pharmacy and asked the pharmacy technician to help her locate the store-brand version ofZantac. Which of the following medications should the technician select?

A. Nizatadine
B. Cimetidine
C. Famotidine
D. Ranitidine
E. Omeprazole-Sodium Bicarbonate

Answer 3

D. The generic name of Zantac is ranitidine.

Question 3

A patient is using omeprazole 20 mg once daily. Which of the following is the correct brand name for omeprazole?

A. Prilosec
B. Nexium
C. AciPhex
D. Prevacid
E. Protonix

Answer 3

A. The brand name of omeprazole is Prilosec.

Question 4

A patient is using Protonix once daily. Which of the following is an appropriate generic substitution?

A. Pantoprazole
B. Omeprazole
C. Esomeprazole
D. Lansoprazole
E. Omeprazole-Sodium Bicarbonate

Answer 4

A. The generic name of Protonix is pantoprazole.

Question 5

A patient is using Zegerid once daily. Which of the following is an appropriate generic substitution?

A. Pantoprazole
B. Omeprazole
C. Esomeprazole
D. Lansoprazole
E. Omeprazole-Sodium Bicarbonate

Answer 5

E. The generic name of Zegerid is omeprazole-sodium bicarbonate.

Question 6

A patient who suffers from heartburn was using an OTC H2RA. He went to his physician complaining of continuing heartburn symptoms. The physician suggested trying OTC omeprazole. He told the patient that omeprazole is stronger than the medicine he has been taking. What is the mechanism of action of omeprazole?

A. Neutralizes pepsin via hydroxylation
B. Neutralizes acid in a buffering reaction (producing salt & water)
C. Reversibly inhibits the histamine-2 receptors on the parietal cells
D. Irreversibly binds to parietal cells which blocks the final step in acid production
E. Irreversibly inhibits the histamine-2 receptors on the parietal cells

Answer 6

D. Proton pump inhibitors (PPIs) block the final step in acid production. They bind to the proton pump, which inactivates the pump, in an irreversible bond. They only bind when the pump is working and thus must be taken prior to or eating. They are the most potent class of acid-suppressing agents.

Question 7

A pharmacist has a patient who frequently purchases OTC antacids for “indigestion pain”, but he suspects that the patient may have a H. pylori infection. Which of the following can be a hint that the patient may, indeed, have a H. pylori infection and should be referred for treatment:

A. If he has ever travelled to Central America
B. If he coughs up blood
C. If eating lessens the pain
D. If eating worsens the pain
E. If he has received antibiotics for any reason during the past six months

Answer 7

C. Usually, with H. pylori infection, the pain will be lessened by eating, especially if the ulcer is in the duodenum. If H. pylori is suspected, the patient should be referred for testing. With gastric ulcers, which are most commonly caused by chronic NSAID therapy, eating worsens the pain.

Question 7

A pregnant female is asking the pharmacist for a recommendation for heartburn symptoms. The symptoms began during the 3rd month of the pregnancy (she is currently 14 weeks pregnant). She states that whenever she eats anything, she has heartburn. She takes a daily prenatal vitamin. She states she gets adequate calcium from the vitamin and a cheese stick she eats with lunch. Choose the most appropriate recommendation.

A. Cimetidine
B. Omeprazole
C. Tums
D. Misoprostol
E. Metoclopramide

Answer 7

C. Calcium antacids are considered first-line in pregnancy.

Question 9

Alarm symptoms in GERD that may warrant additional testing include:

A. Cough, chest pain, bloody stools
B. Chest pain, dysphagia, hematemesis
C. Hypersalivation, cough, sore throat
D. Regurgitation, heartburn, choking
E. Cough, hypersalivation, acid taste

Answer 9

B. Patients with alarm symptoms should be sent immediately for further evaluation.

Question 10

An elderly patient is purchasing several large bottles of Maalox. Her medications include sertraline, furosemide, carvedilol, lisinopril and Epogen. Her conditions include depression, hypertension, heart failure, renal insufficiency and anemia secondary to renal insufficiency. Which of the following recommendations should be made?

A. This medicine should not be used in patients with depression.
B. This medicine contains a salicylate and should be avoided in patients with aspirin allergies.
C. This medication should be separated from the patient’s furosemide.
D. This medicine should not be used continually in patients whose kidneys are not working well
E. This medicine can increase the patient’s blood pressure.

Answer 10

D. Maalox contains aluminum and magnesium hydroxide. A small amount is absorbed, which is excreted renally. This usually poses no health risks and antacids are considered a safe class of medications. However, in patients with poor renal function, both aluminum and magnesium can accumulate when used excessively. This can cause significant toxicities (magnesium can cause arrhythmias and seizures; aluminum is a neurotoxin).

Question 10

An elderly female has hypertension, renal insufficiency (CrCl = 32 mL/min), mild memory loss and early-onset Parkinson disease. She was started on Sinemet two weeks ago. Her movement symptoms are improved, but she is nauseated whenever she takes the medicine. She has gone to her doctor’s office and presents at the pharmacy with a prescription for metoclopramide 10 mg QID. Which of the following statements is/are correct? (Select ALL that apply.)

A. The Parkinson’s disease symptoms will worsen.
B. The dose is correct, but the schedule should be three times daily.
C. She will experience dizziness and sleepiness.
D. Metoclopramide is a COMT-inhibitor.
E. Metoclopramide is a dopamine antagonist.

Answer 10

A, C, E. Metoclopramide (Reglan) is a dopamine-blocking agent, and will worsen Parkinson symptoms. Further, if over-dosed, the side effects of dizziness and somnolence (and fatigue) will be increased. With a CrCl

Question 10

An elderly gentleman with high cholesterol, hypertension and coronary heart disease (with stent placement) tripped on his front door step and fractured his clavicle. His wife treated the resultant pain with acetaminophen 1,000 mg four times daily, but it did not help. She decided to use over-the-counter ibuprofen, 1-2 tablets, every 4-5 hours. This worked fine for about 2 months until her husband vomited up a coffee-ground looking substance and was transported to the local hospital. He was diagnosed with an NSAID-induced gastric bleed. This incident scared the family and they did not use any pain medicines for some time. After six months, he returned to his gastroenterologist who reported that the ulcer was healed. Now, his wife is asking what she can give him for pain that won’t cause a similar problem. His allergies include Bactrim (rash) and lisinopril (cough). Which of the following is/are appropriate recommendation/s? (Select ALL that apply.)

A. Ibuprofen
B. Fentanyl patch
C. Celecoxib
D. Etodolac + a PPI
E. Indomethacin

Answer 10

D. In patients at high-risk of GI bleeding who must take an NSAID, a PPI should be given concomitantly. Celecoxib should not be used in patients with a history of cardiovascular disease and/or a sulfa allergy.

Question 11

Anandi is going to use Prevpac for a H. pylori infection. Prevpac contains amoxicillin, clarithromycin and lansoprazole. She will take four pills twice daily. Which statement/s concerning Prevpac are correct? (Select ALL that apply.)

A. Amoxicillin can make birth control pills less effective, which may result in pregnancy; use back-up contraception while using this medicine.
B. Swallow the lansoprazole capsules whole; do not crush or chew.
C. Do not use if you are allergic to amoxicillin or other penicillins, or if you are allergic to clarithromycin or similar drugs.
D. This medicine cannot be used with alcohol, or you will have severe nausea and vomiting.
E. This medicine can cause a “metallic” taste in your mouth.

Answer 11

A, B, C, E. Clarithromycin may cause diarrhea, nausea and abnormal metallic taste (each ~3%). Amoxicillin and other antibiotics can make birth control pills less effective. Lansoprazole capsules should not be crushed or chewed.

Question 13

Andrew is a 46 year old male who complains of severe abdominal pain. He takes a multivitamin daily, exercises at least twice a week, and consumes a balanced diet. However, Andrew mentions that he enjoys a shot of whiskey every night before going to bed because he sleeps better, but he doesn’t think that this is contributing to his pain. After receiving a thorough examination from his doctor, it is confirmed that he has a H. pylori infection and he must be treated immediately. Which medication is most appropriate for Andrew?

A. Pylera
B. Helidac
C. Prevpac
D. Vimovo
E. Lortab

Answer 13

C. Prevpac contains lansoprazole, amoxicillin, and clarithromycin. Pylera (bismuth subcitrate potassium + metronidazole + tetracycline) and Helidac (bismuth subsalicylate + metronidazole + tetracycline) both contain metronidazole. Patients should not consume alcohol while taking metronidazole.

Question 14

Chief Complaint: “My chest is burning”
History of Present Illness: LR is a 67 y/o white female with HTN, diet controlled type 2 diabetes, and history of breast cancer. She presents to her PCP with a 4-week history of worsening heartburn unrelieved by OTC medications. She experiences post-meal symptoms almost daily and nighttime symptoms that wake her from sleep 3-4 times per week. Most recently she tried 14 days of Prilosec OTC and her symptoms went away. The symptoms returned 1 week after she stopped the Prilosec and seemed to be worse. She is actively dieting and working to identify her food triggers.
Allergies: NKDA
Past Medical History: As per HPI
Medications:
Norvasc 10 mg PO daily, Soltamox 20 mg PO daily Caltrate 600+D 1 tablet BID
OTC Products Used: Prilosec OTC, Mylanta, and Gaviscon

Physical Exam / Vitals:
Height: 5’5” Weight: 179 pounds
BP: 152/88 mmHg HR: 72 BPM RR: 14 BPM Temp: 97.8°F Pain: 0/10

Labs:
Na (mEq/L) = 140 (135 – 145)
K (mEq/L) = 4.8 (3.5 – 5)
Cl (mEq/L) = 102 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 10 (7 – 20)
SCr (mg/dL) = 0.9 (0.6 – 1.3)
Glucose (mg/dL) = 142 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.5 (1.3 – 2.1)
PO4 (mg/dL) = 3.7 (2.3 – 4.7)
A1C (%) = 8.1

Question:
LR’s physician reviews her insurance formulary and decides to prescribe Dexilant. How should the pharmacist counsel LR to take Dexilant?

A. Take 1 capsule daily without regard to meals.
B. Take 1 capsule daily - 60 minutes before breakfast.
C. Take 1 capsule daily at bedtime.
D. Take 1 capsule daily on an empty stomach.
E. Take 1 capsule daily with a high fat meal.

Answer 14

A. Dexlansoprazole (Dexilant) is unique among the PPIs and can be given without regard to meals. If symptoms are not well-controlled when taken without regard to meals, it can be administered before the meal.

Question 15

Chief Complaint: “My chest is burning”
History of Present Illness: LR is a 67 y/o white female with HTN, diet controlled type 2 diabetes, and history of breast cancer. She presents to her PCP with a 4-week history of worsening heartburn unrelieved by OTC medications. She experiences post-meal symptoms almost daily and nighttime symptoms that wake her from sleep 3-4 times per week. Most recently she tried 14 days of Prilosec OTC and her symptoms went away. The symptoms returned 1 week after she stopped the Prilosec and seemed to be worse. She is actively dieting and working to identify her food triggers.
Allergies: NKDA
Past Medical History: As per HPI
Medications:
Norvasc 10 mg PO daily, Soltamox 20 mg PO daily Caltrate 600+D 1 tablet BID
OTC Products Used: Prilosec OTC, Mylanta, and Gaviscon

Physical Exam / Vitals:
Height: 5’5” Weight: 179 pounds
BP: 152/88 mmHg HR: 72 BPM RR: 14 BPM Temp: 97.8°F Pain: 0/10

Labs:
Na (mEq/L) = 140 (135 – 145)
K (mEq/L) = 4.8 (3.5 – 5)
Cl (mEq/L) = 102 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 10 (7 – 20)
SCr (mg/dL) = 0.9 (0.6 – 1.3)
Glucose (mg/dL) = 142 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.5 (1.3 – 2.1)
PO4 (mg/dL) = 3.7 (2.3 – 4.7)
A1C (%) = 8.1

Question:
Which of the following is consistent with preferred GERD treatment for LR?

A. Intensify LR’s non-drug treatment and educate her on other strategies to reduce GERD.
B. Prevacid for 8 weeks
C. Dexilant for 6 weeks
D. Axid for 4 weeks
E. Reglan for 8 weeks

Answer 15

B. A PPI for 8 weeks is recommended to heal any erosions that may be present.

Question 17

Choose the statement that best describes Helicobacter pylori:

A. An invasive fungi
B. A protozoal organism
C. A gram positive cocci
D. A spiral-shaped gram negative bacterium
E. A spiral-shaped gram positive bacterium

Answer 17

D. Helicobacter pylori (H. pylori), a spiral-shaped gram negative bacterium, is responsible for most peptic ulcers (~70-80%).

Question 18

Christine comes into the pharmacy with a prescription for Helidac, which has been on backorder from the supplier for two weeks. The pharmacist contacts the prescribing physician to inform him that the medication is not in stock. The physician states that the patient must start this medication today and asks if the components that make up Helidac are in stock. Which medications should be selected to fill the Helidac prescription?

A. Lansoprazole, Amoxicillin, Clarithromycin, Cephalexin
B. Lansoprazole, Amoxicillin, Clarithromycin
C. Bismuth subsalicylate, Metronidazole, Minocycline
D. Bismuth subsalicylate, Metronidazole, Tetracycline
E. Bismuth subsalicylate, Metronidazole, Amoxicillin

Answer 18

D. Helidac contains bismuth subsalicylate, metronidazole, and tetracycline. It is given along with an H2RA.

Question 18

Counseling for patients with gastroesophageal reflux disease (GERD) should include the following points: (Select ALL that apply.)

A. Avoid foods that may reduce lower esophageal sphincter pressure or aggravate the condition, including spicy foods, coffee/caffeine, alcohol, chocolate, peppermint/spearmint
B. Elevate the head of the bed (not with pillows, but with a wedge)
C. Eat one large meal late in the evening
D. Lose weight
E. Lie down immediately after eating

Answer 18

A, B, D. Non-drug treatment for GERD includes: weight loss, avoid foods that reduce LES pressure (these are patient specific), elevate the head of the bed 6-8” (not with pillows, but with a wedge), avoid meals with high fat content 2-3 hours before bedtime.

Question 19

Gene is a 70 year old patient who has seen a television commercial for the “little purple pill” and subsequently asked his doctor for a prescription for Nexium. He has had reflux symptoms for years, but was using chewable calcium tablets when he felt enough discomfort. Gene’s insurance plan would not cover Nexium until Gene had failed two trials of the PPIs that are available as generics. Gene is upset. Choose the correct statement:

A. The best PPI, with the highest documented symptom relief, is AciPhex.
B. The best PPI, with the highest documented symptom relief, is Nexium.
C. Due to his age, Gene should be using chlorpromazine instead.
D. There is not much difference in symptom improvement between the various PPIs; he might as well try the less expensive ones first.
E. Due to his age, Gene should be using metoclopramide instead.

Answer 19

D. All PPIs are considered equivalent although one patient may respond better to one agent than another. This is why most insurance plans require the patient to fail trials of generics first.

Question 20

Generally PPIs are taken 30-60 minutes before a meal. What is the rationale behind this direction?

A. The drug must be present in the gut prior to the entry of food.
B. The drug is not well-absorbed on an empty stomach.
C. PPIs inhibit proton pumps that are actively secreting acid.
D. PPIs require gastric acid for absorption.
E. It takes a long time for the beads to dissolve in the stomach.

Answer 20

C. Since PPIs only inhibit proton pumps that are actively secreting acid in response to a meal, they are most effective when taken 30-60 minutes before a meal. This provides sufficient time for the drug to reach the site of action.

Question 21

GH has an appointment with her PCP today. She has had GERD for many years. She tried OTC products with no relief and finally went to her doctor. Her PCP prescribed 8 weeks of Nexium and counseled her on weight loss and avoiding certain foods. Her symptoms completely went away. She has been off Nexium for 3 weeks. Today she reports to her PCP that some of her symptoms have returned but they aren’t as bad or as frequent as before. She has GERD symptoms after eating late at night and immediately going to bed, which she knows she should not do. She has also has symptoms during the day that do not seem to be related to meals. This happens 5-6 days per week. What recommendation is most appropriate for GH at this time?

A. OTC antacids as needed
B. OTC H2RA as needed
C. Her PCP should prescribe an H2RA
D. Her PCP should prescribe a PPI
E. Her PCP should test for H. pylori

Answer 21

C. H2RAs are appropriate for patients who have completed a course of PPI treatment and are still having symptoms that are manageable on an H2RA. GH’s symptoms (5-6 days per week) are too frequent to manage with OTC products. If the H2RA does not control her symptoms, she may require chronic PPI therapy.

Question 22

Heather, a pregnant 33 year old female, comes to your pharmacy with a prescription for Pylera. Her medication profile consists of a Citranal DHA prenatal vitamin. The patient has a noted allergy for codeine and iodine. The patient is symptomatic and the prescriber confirms that treatment will be used. Which of the following components of Pylera could cause tooth discoloration of the baby’s teeth and can interfere with bone development?

A. Bismuth subcitrate potassium
B. Metronidazole
C. Tetracycline
D. All of them can do this
E. None of these agents are likely to do this

Answer 22

C. Tetracycline is not indicated in pregnancy or children less than 8 years of age.

Question 22

Kiki has chronic constipation despite a fiber-rich diet and adequate fluids. It is “idiopathic”. Kiki has had constipation for years and says she has learned to live with it. As she is getting older she experiences occasional heartburn after eating. Choose a good option for Kiki to help with the heartburn:

A. Milk of Magnesia
B. Maalox
C. Tums
D. Famotidine
E. Omeprazole

Answer 22

A. Milk of Magnesia (MOM) will provide benefit for both the heartburn and make the stool somewhat softer in a patient with chronic constipation. Always consider if renal function permits regular use of magnesium or aluminum-containing products.

Question 24

LF approaches the pharmacist for assistance with OTC GERD treatments. LF has been taking Pepcid AC Max Strengthtwice daily for 3 weeks, though she knows the directions say not to take it longer than 2 weeks. The pharmacist asks if LF has seen a physician and LF replies “I haven’t had time and I’m kind of worried about what he will say”. The pharmacist should suggest the following:

A. Switch to a proton pump inhibitor, such as omeprazole, taken daily (30 minutes before breakfast).
B. Switch to an H2RA, such as ranitidine.
C. Reduce the Pepcid dose to once daily.
D. Make an appointment to see a doctor.
E. Use regular enemas to cleanse his bowel.

Answer 24

D. Patients self-treating with OTC products who do not find improvement should be referred for medical evaluation. In any patient with high fever or bloody stools or with any significant clinical symptom it is best to refer for evaluation.

Question 26

Many patients are using chronic acid-suppressing medication for reflux symptoms. The pharmacist should check the profile for medications which require an acidic pH for absorption. Drugs that require an acidic pH for adequate absorption include: (Select ALL that apply.)

A. Ketoconazole
B. Itraconazole
C. Iron
D. Tetracycline
E. Alendronate

Answer 26

A, B, C. Chronic acid-suppressing drugs like H2RAs and PPIs interact with medications that require an acidic environment for absorption. Examples of these medications include: itraconazole, ketoconazole, calcium carbonate, and iron.

Question 27

Melik is a 68 year old male who lives in New York. He has a chronic history of NSAID-induced gastric ulcers although currently he is symptom-free with a healed GI tract, per the gastroenterologist. He is on several medications to manage his hypertension, diabetes, seasonal depression, and cholesterol. His medication profile consists of: Lipitor, Tricor, metformin,Amaryl, Lasix, Celexa, and lisinopril. Melik was in Manhattan at night and got into a fight while resisting a mugger. He hurt his shoulder and the physician is insisting on providing 2-4 weeks of NSAID therapy since he does not wish to give this patient steroids. The last time Melik got steroids he had a bad reaction and became overly-agitated. In addition, he reports that he could not control his blood sugar during the course of steroid therapy. Which agent would be the safest recommendation?

A. Mobic
B. Relafen
C. Toradol
D. Vimovo
E. Feldene

Answer 27

D. Vimovo contains an NSAID plus a PPI to protect the gut lining from NSAID-induced damage. The patient could also purchase a generic NSAID and PPI.

Question 29

MS is an 87 y/o female admitted to the hospital for a hip fracture. She has multiple medical problems including osteoporosis, hypertension, Alzheimer’s disease, atrial fibrillation, and stroke. Despite this, she is in good spirits and her family is at her bedside after her surgery. She has required minimal pain medications and her surgical team is being cautious with opioids due to her age.
Height: 5’3”
Weight: 109 pounds
Vitals: BP: 132/75 HR: 87 RR: 14 T: 99.4 Pain: 4/10
Labs:
Na (mEq/L) = 142 (135 – 145)
K (mEq/L) = 4.9 (3.5 – 5)
Cl (mEq/L) = 102 (95 – 103)
HCO3 (mEq/L) = 28 (24 – 30)
BUN (mg/dL) = 17 (7 – 20)
SCr (mg/dL) = 1.2 (0.6 – 1.3)
Glucose (mg/dL) = 123 (100 – 125)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
Mg (mEq/L) = 2.0 (1.3 – 2.1)
PO4 (mg/dL) = 3.6 (2.3 – 4.7)
AST (IU/L) = 33 (10 – 40)
ALT (IU/L) = 28 (10 – 40)

Plan:
Start cefazolin 1 gm IV Q12H and famotidine 20 mg IV BID. Pain management orders per surgery team.
Question:
48 hours later, MS is confused and her family is very concerned. Though MS has Alzheimer’s disease, this is very different behavior for her. The pharmacy resident reviews MS’s medication profile and learns that H2RAs have a boxed warning for confusion. What risk factors does MS have for H2RA-associated confusion?

A. Age > 80 and recent surgery
B. Age > 50 and renal impairment
C. Renal impairment and hepatic impairment
D. Renal impairment and recent surgery
E. Recent surgery and hepatic impairment

Answer 29

B. Confusion from H2RAs is usually reversible when they are discontinued. Risk factors are age > 50 and renal or hepatic impairment. Decrease the dose of famotidine, ranitidine, and nizatidine when CrCl is

Question 31

Owen enters the pharmacy asking for a recommendation for heartburn. He has just come from a party and says he gets bad heartburn when he eats spicy foods or drinks alcohol. This happens 1 to 2 times each week. Owen takesTums occasionally but asks if there is anything stronger he can take on a daily basis so that he doesn’t have to deal with heartburn. What is the best recommendation?

A. Suggest that he avoid bothersome foods and continue to use an antacid or H2RA as needed.
B. Suggest daily use of an H2RA, such as Zantac.
C. Switch from calcium carbonate to Maalox.
D. Suggest daily use of a proton pump inhibitor, such as Prilosec OTC.
E. He should ask his doctor for a prescription for sucralfate.

Answer 31

A. Tums is chewable calcium carbonate. Antacids work quickly and provide relief for 30 - 60 minutes. H2RAs take at least 30 minutes to work, but provide relief for 4 - 10 hours. If the food trigger is known, the patient can try to avoid it or take medications at the appropriate time to treat the symptoms.

Question 32

Proton pump inhibitors can increase the risk of:

A. Pneumonia in hospitalized patients, fractures, and C. difficile
B. Stroke, fractures, and pneumonia in hospitalized patients
C. C. difficile, myocardial infarction, and fractures
D. Pneumonia in hospitalized patients, C. difficile, and stroke
E. Myocardial infarction, stroke, and fractures

Answer 32

A. Chronic use of PPIs can increase the risk of pneumonia in hospitalized patients, C. difficile-associated diarrhea, and fractures. Hypomagnesemia and vitamin B12 deficiency have also been associated with prolonged use.

Question 34

Sandy uses omeprazole daily for heartburn. She is elderly and frail. Which of the following questions should the pharmacist ask Sandy that is important to know when using chronic PPI therapy?

A. Do you get enough vitamin E?
B. Do you monitor your skin to see if it turns yellow?
C. Do you consume dairy products and/or take calcium/vitamin D supplements?
D. Do you have unusual headaches?
E. Do you use zolpidem for sleep?

Answer 34

C. If a patient is taking long-term acid-suppression therapy (especially PPIs), ensure that calcium and vitamin D intake is optimal.

Question 34

Choose the correct statement/s concerning sucralfate: (Select ALL that apply.)

A. It should be taken before meals.
B. The primary side effect is constipation.
C. The brand name is Cytotec.
D. It is a first-line agent for the treatment of GERD
E. It comes in an IV formulation.

Answer 34

A, B. The brand name of sucralfate is Carafate. Due to the aluminum complex, sucralfate is constipating. It has little role in the management of GERD. Sucralfate is taken before meals and at bedtime.

Question 35

Shana is a thirty-three year old female with heartburn symptoms. She feels pain after eating lunch nearly every day and whenever she eats certain foods. She tried eating smaller meals and avoiding spicy foods but found that this provided little benefit. She has been tested for H. pylori and is negative. Which of the following is recommended at this point?

A. The patient should be referred for endoscopy.
B. The patient should be started on alendronate.
C. The patient should be treated empirically with esomeprazole.
D. The patient should be treated empirically with sucralfate.
E. The patient should be treated empirically with misoprostol.

Answer 35

C. An 8-week course of a PPI is recommended for this patient. Lifestyle measures can be helpful, but are not sufficient for many patients. The lifestyle changes she has made should not be abandoned, but rather used in conjunction with drug therapy. Although we are more aware of risks associated with chronic acid-suppressive therapy, chronic therapy may not be necessary. Symptoms should be re-evaluated after 8 weeks.

Question 36

Sucralfate is available in the following formulation/s: (Select ALL that apply.)

A. Oral suspension
B. Oral tablet
C. Injectable
D. Transdermal patch
E. Nasal spray

Answer 36

A, B. Sucralfate is available as a tablet and suspension, but is not available IV, as a transdermal patch, or as a nasal spray.

Question 36

The first-line regimen/s for H. pylori infection, according to the American College of Gastroenterology (ACG) guidelines, consists of the following medications:

A. 14-day “triple” therapy with a PPI, clarithromycin 500 mg BID, and amoxicillin 1,000 mg BID.
B. 7 day “quadruple” therapy with ranitidine, bismuth subsalicylate 525 mg QID, tetracycline 500 mg QID and metronidazole 500 mg QID.
C. 5-day “triple” therapy with a PPI, clarithromycin 500 mg BID, and amoxicillin 1,000 mg BID.
D. 7-day “triple” therapy with a PPI, clarithromycin 500 mg BID, and amoxicillin 1,000 mg BID.
E. 28-day “triple” therapy with a PPI, clarithromycin 500 mg BID and either amoxicillin 1,000 mg BID or metronidazole 500 mg BID.

Answer 36

A. Gastroenterology guidelines prefer 14-day therapy for H. pylori eradication. The PPI is standard dose but taken BID, except esomeprazole (Nexium), which is dosed once daily. Clarithromycin 500 mg BID and amoxicillin 1000 mg BID are the preferred antibiotics in triple therapy. Metronidazole 500 mg BID can be substituted if the patient is allergic to either antibiotic.

Question 38

Wallace is going to use Pylera for a H. pylori infection. Pylera contains bismuth subcitrate potassium, metronidazole and tetracycline in one capsule. He will take three capsules four times daily (at meals and at bedtime). Which statement/s concerning Pylera is correct? (Select ALL that apply.)

A. A PPI should be obtained separately and given twice daily during the course of treatment (such as omeprazole 20 mg BID).
B. An exaggerated sunburn reaction has been seen in some individuals taking tetracycline; avoid exposure to sun or tanning beds while taking this medicine.
C. Do not consume alcohol during treatment.
D. If you develop diarrhea during or after this course of treatment, contact your medical provider right away.
E. Do not consume acidic beverages during treatment.

Answer 38

A, B, C, D. If a patient is taking Pylera, it is important to counsel on the following: Alcoholic beverages should not be consumed during therapy and for at least three days afterward. Tetracycline can make patients more sensitive to the sun. A PPI needs to be obtained and taken BID with this regimen. When dispensing broad-spectrum antibacterial coverage include counseling about diarrhea risk as these can cause a C. difficile infection during or after treatment.

Question 39

What is the mechanism of action of famotidine?

A. Neutralizes pepsin via hydroxylation
B. Neutralizes acid in a buffering reaction (producing salt & water)
C. Reversibly inhibits the histamine-2 receptors on the parietal cells
D. Irreversibly binds to parietal cells which blocks the final step in acid production
E. Irreversibly inhibits the histamine-2 receptors on the parietal cells

Answer 39

C. H2RAs (such as famotidine) reversibly bind to histamine receptors on the parietal (acid-producing) cells.

Question 40

What is the mechanism of action of magnesium hydroxide when used for heartburn?

A. Neutralizes pepsin via hydroxylation
B. Neutralizes acid in a buffering reaction (producing salt & water)
C. Inhibits (reversibly) the histamine-2 receptors on the parietal (acid-producing) cells
D. Irreversibly binds to parietal cells; blocks final step in acid production
E. Inhibits (irreversibly) the histamine-2 receptors on the parietal (acid-producing) cells

Answer 40

B. Antacids work by neutralizing acid in a buffering reaction, producing salt and water.

Question 42

What is the mechanism of action of misoprostol?

A. Prokinetic agent
B. Coats the stomach with a protective lining
C. H2RA
D. Prostaglandin analog
E. Proton pump inhibitor

Answer 42

D. Misoprostol (Cytotec) is a prostaglandin analog. It provides gut protection by replacing the GI-protective prostaglandins depleted by chronic non-selective NSAID therapy. Both misoprostol and sucralfate are no longer used commonly, primarily due to the advent of the proton pump inhibitors.

Question 43

What is the mechanism of action of sucralfate?

A. Dopamine blocker
B. Prokinetic agent
C. Binds to surface and provides protective lining for the gut
D. Prostaglandin analog
E. Phosphodiesterase inhibitor

Answer 43

C. Sucralfate binds to the surface of ulcers (attaching to exposed proteins) and coats the ulcer, thus protecting the ulcer surface to some extent from further injury by acid and pepsin. It also directly inhibits pepsin.

Question 44

What is the physical (mechanical) cause of gastroesophageal reflux disease?

A. The parietal cells under-secrete acid.
B. The parietal cells over-secrete acid.
C. The food gets stuck in the esophagus.
D. Lower esophageal sphincter tone is reduced.
E. The gastric muscle contracts suddenly.

Answer 44

D. Gastroesophageal reflux disease (GERD) occurs when the stomach contents leak backward from the stomach, through the lower esophageal sphincter (LES) into the esophagus.

Question 46

When a pharmacist is dispensing Pylera they are careful to counsel the patient that they may notice a temporary and harmless darkening of the tongue and/or black stool. What is causing this effect?

A. The PPI they are taking concurrently
B. Metronidazole
C. Tetracycline
D. Bismuth
E. A breakdown product from the H. pylori

Answer 46

D. Bismuth products cause a temporary and harmless darkening of the tongue and/or black stool. Stool darkening must not be confused with blood in stool. Patients who have H. pylori infection may have bleeding ulcers. Blood in the stool must be reported immediately.

Question 47

Which of the following agents comes in a combination with calcium and magnesium hydroxide in a chewable tablet?

A. Famotidine
B. Ranitidine
C. Pantoprazole
D. Omeprazole
E. Esomeprazole

Answer 47

A. Famotidine comes in combination with the antacids calcium and magnesium in Pepcid Complete. The advantage of using the two classes of agents together is to provide fast relief from the antacid, with longer-lasting relief from the H2RA. By the time the antacid has worn off (in 1-2 hours) the H2RA will have started to work.

Question 48

Which of the following agents comes in a combination with sodium bicarbonate?

A. Famotidine
B. Ranitidine
C. Pantoprazole
D. Omeprazole
E. Esomeprazole

Answer 48

D. Omeprazole comes in combination with sodium bicarbonate (Zegerid). The sodium bicarbonate is added to prevent degradation of the omeprazole by gastric acid in order to permit faster drug absorption but there is no evidence that the relief is provided sooner.

Question 49

Which of the following are possible complications if a H. pylori infection if left untreated? (Select ALL that apply.)

A. Gastritis
B. Stomach ulcers
C. Gastric cancer
D. Cirrhosis
E. Pancreatitis

Answer 49

A, B, C. H. pylori infection can lead to gastritis and is a strong risk factor for certain types of stomach cancer.

Question 50

Which of the following are recommended counseling points for patients who are currently being treated for a H. pyloriinfection? (Select ALL that apply.)

A. It is most likely that you will need to continue the acid reduction medication indefinitely as the lining of your intestine has been damaged.
B. Do not use tetracycline if pregnant or in children or less than 8 years of age.
C. If bismuth subsalicylate is taken with aspirin and ringing in the ears occurs, contact your doctor.
D. Avoid alcoholic beverages during and for at least 3 days after taking metronidazole.
E. If symptoms persist following treatment, follow up with your physician.

Answer 50

B, C, D, E. When patients are treated for H. pylori infection, the acid-suppressive agent is sometimes continued for two weeks after the antibiotics, in order to give the erosion time to heal, but should not be continued indefinitely in most cases. If taking bismuth subsalicylate causes ringing in the ears or if ulcer symptoms persist, patients should contact their physician. Tetracycline should not be used in pregnant women or in children less than 8 years of age. Alcoholic beverages should be avoided during therapy with metronidazole.

Question 51

Which of the following H2RAs are available in an IV formulation? (Select ALL that apply.)

A. Famotidine
B. Ranitidine
C. Nizatidine
D. Cimetidine
E. None of these are available in an IV formulation.

Answer 51

A, B, D. The three H2RAs that come in an IV formulation (for injection) are famotidine, ranitidine and cimetidine.

Question 53

Which of the following is the brand name for lansoprazole?

A. Prilosec
B. Nexium
C. AciPhex
D. Prevacid
E. Protonix

Answer 53

D. The brand name of lansoprazole is Prevacid.

Question 54

Which of the following proton pump inhibitors are available in an injectable formulation? (Select ALL that apply.)

A. Pantoprazole
B. Esomeprazole
C. Lansoprazole
D. Omeprazole
E. Rabeprazole

Answer 54

A, B. Only two PPIs are available in injectable formulations: pantoprazole (Protonix) and esomeprazole (Nexium). Some hospitalized patients may need an injectable. Delivery via NG tube is another option for some patients.

Question 56

Which of the following proton pump inhibitors can be administered down a nasogastric (NG) tube? (Select ALL that apply.)

A. Pantoprazole
B. Lansoprazole
C. Esomeprazole
D. Dexlansoprazole
E. Rabeprazole

Answer 56

A, B, C, D, E. Follow the manufacturer instructions for NG administration - these can adhere to or clog the NG tubing. The capsules can be opened (and mixed with liquid or soft food-do not chew, just swallow the small amount or put down NG tube) but none of them can be crushed or chewed. Lansoprazole (Prevacid) comes as an ODT (orally-disintegrating tablet) that is useful in dysphagia. Pantoprazole comes in a packet that can be given down an NG tube.

Question 57

Which of the following proton pump inhibitors comes in a combination drug with naproxen?

A. Pantoprazole
B. Esomeprazole
C. Omeprazole
D. Dexlansoprazole
E. Rabeprazole

Answer 57

B. Esomeprazole and naproxen come together as the Vimovo formulation. Only PPIs are strong enough acid-suppressing agents to protect the gut from a GI bleed due to chronic NSAID therapy. Or, the patient can use celecoxib. There are long-term health risks with both NSAID use (including GI bleeding and cardiovascular risk-highest with celecoxib) and with long-term PPI therapy (fractures, infections, hypomagnesemia).

Question 58

Which of the following proton-pump inhibitors should be avoided in patients taking clopidogrel? (Select ALL that apply.)

A. Omeprazole
B. Esomeprazole
C. Pantoprazole
D. Rabeprazole
E. Dexlansoprazole

Answer 58

A, B. Omeprazole and esomeprazole should be avoided in patients taking clopidogrel. They inhibit CYP2C19 and can reduce the effectiveness of clopidogrel. The other PPIs have been shown to have a lesser effect on the antiplaletet activity of clopidogrel.

Question 59

Which of the following statements concerning NSAID-induced ulcers are correct? (Select ALL that apply.)

A. Most occur in the fundus region of the stomach.
B. Most occur in the duodenal bulb.
C. Most NSAID-induced ulcers are due to chronic use in the community.
D. Pharmacists should counsel patients to limit the use of OTC NSAIDs as many patients believe the OTC agents are safe to use continuously.
E. Antacid use (taken concurrently with the NSAID) will protect the GI lining.

Answer 59

A, C, D. Most H. pylori-induced ulcerations are in the duodenal bulb (the initial section after the stomach). Most NSAID-induced ulcers are in the fundus region in the stomach; this is the lower part where acid collects, and the NSAID use depletes the GI protective prostaglandins, which in turn causes a depletion of the stomach mucus and bicarb (the protective elements) and increases the destructive elements, such as acid and pepsin.

Question 60

Which type of medication would you add to Helidac or Pylera treatment regimens, respectively (pick drug for Helidac first, then drug for Pylera)?

A. Lodine; Omeprazole
B. Lansoprazole; Pepcid
C. Pepcid; Esomeprazole
D. Esomeprazole; Aciphex
E. Rabeprazole; Sucralfate

Answer 60

C. If the patient is taking Helidac or Pylera, they require acid-suppressant therapy in addition to the combination product. A PPI is required for Pylera and an H2RA is recommended with Helidac for the entire course of therapy, and may continue for two weeks afterwards to help the ulcer heal. The H2RA is recommended for an additional 14 days after the end of theHelidac therapy.