64. Gastroesophageal Reflux Disease (GERD) & Peptic Ulcer Disease (PUD) Flashcards
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.
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.
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.
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.
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
A. The brand name of omeprazole is Prilosec.
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
A. The generic name of Protonix is pantoprazole.
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
E. The generic name of Zegerid is omeprazole-sodium bicarbonate.
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
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.
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
C. Calcium antacids are considered first-line in pregnancy.
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
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.
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
B. Patients with alarm symptoms should be sent immediately for further evaluation.
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
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.
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.
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.
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.
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
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
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.
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.
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.
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
B. A PPI for 8 weeks is recommended to heal any erosions that may be present.
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.
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).
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
D. Helicobacter pylori (H. pylori), a spiral-shaped gram negative bacterium, is responsible for most peptic ulcers (~70-80%).
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
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.
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.
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.
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.
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.
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
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.
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
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.
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
C. Tetracycline is not indicated in pregnancy or children less than 8 years of age.
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.
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.
