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NAPLEX 2024 > 72. GERD + PUD > Flashcards

72. GERD + PUD Flashcards

1
Q

Acidic gastric contents are normally prevented from backflow into the esophagus by a protective ring of muscle fibers called ___.

A

the lower esophageal sphincter (LES)

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2
Q

Typical GERD symptoms include ___

A

heartburn (daytime or nocturnal), hypersalivation and regurgitation of acidic contents into the mouth or throat

Less common symptoms: epigastric pain, nausea, cough, sore throat, hoarseness, chest pain (may be difficult to distinguish from cardiac pain)

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3
Q

Dx of GERD is based on ___

A

pt-reported symptoms, frequency (≥2x per week), and risk factors (e.g. family hx, diet and eating habits, sleep position)

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4
Q

If pt has alarm symptoms or there is a concern for more serious condition, ___ can be prefered. Pts who are refractory to GERD treatment may benefit from ____

A

endoscopy
24 hr esophageal pH monitoring

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5
Q

Drugs that can worsen GERD symptoms

A

Aspirin/NSAIDs
Bisphosphonates
Dabigatran
Estrogen products
Fish oil products
Iron supplements
Nicotine replacement thearpy
Steroiuds
Tetracyclines

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6
Q

Infrequent heartburn (< ___ times/week) can be treated with PRN OTC ____

A

<2x/week
OTC antacids or H2RAs

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7
Q

Frequent heartburn (≥2x/week) or severe GERD symptoms, ___ course of ___ is the initial treatment of choice and is used to heal any erosive esophagitis

A

8 week course of PPI

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8
Q

After 8 weeks of PPI initial treatment and GERD symptoms return, what is first line maintenance treatment?

A

PPI at lowest effective dose

Alt: H2RA if no erosive esophagitis and it relieves symptoms
Not recommended: metoclopramide or sucralfate

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9
Q

T/F: Since antacids do not require systemic absorption, they provide relief within minutes but duration is short (30-60 mins)

A

True

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10
Q

What is the concern of using antacids containing aspirin (e.g. Alka-Seltzer)

A

Increased risk of bleeding if used too frequently

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11
Q

Examples of antacids used in GERD

A

Calcium carbonate (TUMs)
Calcium carbonate + magnesium (Mylanta supreme)
Calcium carbonate + simethicone (Maalox, Advanced Maximum strength)
Magnesium hydroxide (Milk of Magnesia)
Magneiums hydroxide + aluminum + simethicone (Mylanta Maximum Strength)
Sodium bicarbonate/aspirin/citric acid (Alka-seltzer)

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12
Q

Dosing for antacids vary by product but many require administration ___ times per day

A

4-6 times per day

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13
Q

Concern with aluminum and magnesium in antacids used in GERD

A

Can accumulate with severe renal dysfunction (not recommended if CrCl<30)

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14
Q

Side effects of calcium containing antacids

A

Constipation
Others: bloating, belching

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15
Q

Side effects of aluminum containing antacids

A

constipation
Others: hypophosphatemia

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16
Q

Side effects of magnesium containing antacids

A

Loose stools (use with aluminum may counter-balance

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17
Q

___-containing antacids may be preferred in pregnancy

A

Calcium (Tums)

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18
Q

H2RA MOA

A

reversibly inhibit H2 receptors on gastric parietal cells, which decreases gastric acid secretion

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19
Q

Which H2RA comes as injection formulation?

A

Famotidine

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20
Q

What is the CrCl cut off for renal adj dosing with famotidine ?

A

CrCl <60

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21
Q

Warnings with H2RAs

A

Confusion, usually reversible (risk factors: elderly, severely ill, renal impairment)
Vit B12 deficiency with prolonged use (≥2 years)
Famotidine: QT prolongation with renal dysfunction

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22
Q

Side effects with H2RAs

A

HA, agitation/vomiting in children < 1 yo
Cimetidine (high doses): gynecomastia, impotence

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23
Q

of the H2RAs, why should cimetidine be avoided?

A

D/t drug interactions and side effects

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24
Q

Examples of H2RAs used for GERD

A

Famotidine (Pepcid AC, Zantac 360)
Cimetidine (Tagamet HB)
Nizatidine
Ranitidine (Zantac) – removed from market in April 2020

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25
PPI MOA
Irreversibly bind to the gastric H+/K+-ATPase pump (proton pump) in parietal cells >> blocks gastric acid secretion
26
Which medication is most effective for GERD?
PPIs
27
Which PO PPIs should be taken before breakfast
Esomeprazoel (Nexium) - at least 60 min before breakfast Lansoprazole (Prevacid, Prevacid SoluTab) - before breakfast (time not specified) Omeprazole (Pilosec) - before breakfast (time not specified) Omeprazole + sodium bicarbonate (Zegerid) - 60 min before breakfast (can control nocturnal symptoms if given at bedtime)
28
Which PO PPIs can be taken without regard to meals?
Dexlansoprazole (Dexilant) - without regard to meals Pantoprazole (Protonix) - tab = without regard to meals, suspension = 30 min before meal Rabeprazole (Aciphex) - tab = without regard to meals, capsul sprinkles = 30 min before meal
29
Examples of PPIs used in GERD
Dexlansoprazole (Dexilant) Esomeprazole (Nexium) - comes in caps/tabs/injection/packet for oral suspension Esomeprazeol + naproxen (Vimovo) Lansoprazole (Prevacid) - comes in cap/ODT Omeprazole (Prilosec) - comes in cap/tab/packet for oral suspension/ODT Pantoprazole (Protonix) - comes in tab/injection/packet for oral suspension Rabeprazole (Aciphex) - comes in tab/capsule sprinkle
30
Warnings with PPIs
C-diff associated diarrhea, hypomagnesemia, vit B12, deficiency with prolonged use ≥2 yrs, osteoporosis-related bone fractures with high doses or long-term (≥1 yr) use PPIs may diminish therapeutic effect of clopidogrel - do not use omeprazole and esomeprazole (rabeprazole or pantoprazole have less risk)_ Others: acute interstitial nephritis (hypersensitivity reaction), cutaneous and systemic lupus erythematosus IV Protonix - thrombophlebitis, SJS/TEN
31
Which H2RAs/PPIs come OTC?
H2RA: Cimetidine, famotidine PPIs: esomeprazole, lansoprazole, omeprazole
32
Which PPIs come in ODT formulation?
Lansoprazole, omeprazole
33
Which H2RAs/PPIs come in oral solution/suspensions?
H2RA: cimetidine, famotidine, nizatidine PPIs: lansoprazole // packets for suspension: esomeprazole, pantoprazole, omeprazole
34
Which H2RAs/PPIs come in injection formulations ?
H2RA: famotidine PPIs: esomeprazole, pantoprazole
35
What is the concern with long-term PPI use?
Chronic changes in gastric pH >> can promote growth of microorganisms and increase risk of GI infections, including C. diff and possibly pneumonia (d/t reflux of gastric contents beyond oral cavity Increase risk of osteoporosis and fractures Beers Criteria recommends PPI not to be used beyond 8 weeks in elderly pts unless clear indication
36
Metoclopramide MOA
Dopamin antagonist At higher doses, blockers serotonin receptors in the chemoreceptor zone of CNS which helps N/V Enhances response to ACh in the upper GI tract >> increased motility, accelerated gastric emptying, and increased LES tone
37
When is metoclopramide (Reglan) taken?
before meals and at bedtime
38
What is CrCl cut off for renal dose adj for metoclopramide (Reglan)
CrCl <60 - decrease dose by 50% to avoid side effects including CNS/EPS side effects
39
Boxed warning for metoclopramide (Reglan)
Can cause tardive dyskinesia - higher risk with high doses, long-term treatment (>12 weeks),and elderly pts
40
Warnings with metoclopramide (Reglan)
EPS (including acute dystonia), Parkinsonian-like symptoms Others: rare neuroleptic malignant syndrome (NMS), depression, suicidal ideation Avoid use in pts with Parkinson disease
41
Side effects with metoclopramide (Reglan)
Drowsiness Others: restlessness, fatigue, HTN, pro-arrhythmic, diarrhea
42
Which meds should be avoided when taking H2RAs or PPIs?
Delayed release formulation of Risedronate (Atelvia) Avoid with PPIs: Erlotinib, rilpivirine, and velpatasvir/sofosbuvir (Epclusa)
43
Drugs that require acidic gut (absorption decreased by antacids, H2RAs, and PPIs)
Antiretrovirals: rilpivirine (NNRTI), atazanavir (PI) Antivirals: ledipasvir, velpatasvir/sofosbuvir Azole antifungals: Sporanox (itraconazole caps), ketoconazole, posconazole oral suspension Cephalosporins (oral): cefpodoxime, cefuroxime Iron products Meselamine Risedronate DR TKI: dasatanib, erlotinib, pazopanib
44
Oral drugs/drug classes that antacids bind
Antiretrovitals (INSTIs): bictegravir, dolutegravir, elvitegravir, raltegravir Bisphosphonates isoniazid Levothyroxine Mycophenolate Quinolones Sotalol Steroids (esp budesonide) Tetracyclines
45
When using H2RAs, use caution with CNS depressants (esp in elderly) d/t risk of additive ____ . Use lower doses in pts with renal impairment
delirium, dementia, and cognitive impairment
46
Cimetidine is an ___ of CYP450 enzymes (e.g. 2C19, 3A4, 1A2)
inhibitor Avoid use with dofetilide, use caution with other drugs including amiodarone, CCBs, clopidogrel, phenytoin, SSRIs, theophylline, and warfarin
47
All PPIs inhibit CYP ____. Most are weak inhibitors but ___ and ___ are moderate inhibitors (can decrease effectiveness of ____ through inhibition) Can increase levels of citalopram, phenytoin, tacrolimus, voriconazole, and warfarin. Do NOT use PPIs with nelfinavir.
2C19 Esomeprazole and omeprazole Clopidogrel - avoid esomeprazole and omeprazole use with this drug
48
Do not use metoclopramide in pts receiving meds for __ disease (antagonistic effect).. Do not use in combo with anypsychotics d/t increased risk of adverse effects When used in combo with SSRIs, SNTIs, and TCAs, monitor for ____
Parkinsons disease Serotonin syndrome, EPS, and NMS
49
3 most common causes of PUD are ___
H. pylori-positive ulcers (most common) NSAID induced ulcers Stress ulcers (occur in critically ill and mechanically-ventilated pts)
50
Describe H. pylori bacterium
Spiral-shaped pH sensitive gram-negative
51
S/sx of PUD
Primary symptom: dyspepsia, gastric pain that can feel like gnawing or burning sensation in the middle or upper stomach Other symptoms: heartburn, belching, bloating, cramping, nausea, anorexia
52
T/F: If ulcer is duodenal (usually caused by H. pylori), pain is typically worse 2-3 hrs after eating; eating food or taking antacids lessens the pain.
True
53
T/F: With gastric ulcers, eating generally lessens the pain
False - worsens the pain
54
Diagnostic tests for H.pylori include ____. PPIs, bismuth, and abx should be d/c ____ prior test to avoid false neg test.
urea breath test (UBT) which detects CO2 produced by the bacterial Fecal antigen test which detects H. pylori in stool 2 weeks
55
What is American College of Gastroenterology (ACG) recommended drug treatment for H. pylori infection?
Bismuth quadruple therapy x10-14 days: Bismuth + metronidazole + tetracycline + PPI BID Concomitant therapy x10-14 days (if clarithromycin resistance rates <15% and no prior exposure to macrolide): amoxicillin + clarithromycin + metronidazole + PPI Clarithromycin triple therapy x14 days (if clarithromycin resistance rates are <15%): amoxicillin (metronidazole if PCN allergy) + clarithromycin + PPI BID
56
What is in bismuth quadruple therapy for H. pylori treatment?
Bismuth quadruple therapy x10-14 days Bismuth 300mg QID metronidazole 250-500 QID tetracycline 500mg QID PPI BID or use 3-in-1 combo + PPI: Pylera (bismuth 420mg + metronidazole 375mg + tetracycline 375mg) QID + PPI BID
57
What is in clarithromycin triple therapy for H. pylori treatment?
Clarithromycin triple therapy x14 days (if clarithromycin resistance rates are <15%): amoxicillin 1000mg BID (metronidazole if PCN allergy) clarithromycin 500mg BID PPI BID (or esomeprazozle 40mg daily) or use 3-in-1 combo: Prevpac (amoxicillin + clarithromycin + lansoprazole)
58
What is in concomitant therapy for H.pylori treatment?
Concomitant therapy x10-14 days (if clarithromycin resistance rates <15% and no prior exposure to macrolide): amoxicillin 1000mg BID clarithromycin 500mg BID metronidazole 500mg BID PPI
59
concern with alcohol use and bismuth quadruple therapy
Alcohol use - do not use metronidazole
60
Concern with pregnancy/children and bismuth quadruple therapy
Do not use tetracycline during pregnancy or in children < 8yo
61
Concern with salicylate allergy and bismuth quadruple thearpy
Do not use bismuth subsalicylate
62
NSAIDs with selective inhibition of COX-2 (e.g. ___) have decreased ___ risk but increased ___ risk compared to non-selective NSAIDs
celecoxib decreased GI risk but increased CV risk
63
NSAIDs that approach the selectivity of celecoxib are. _____
meloxicam, nabumetone, diclofenac, etodolac
64
Combo products specifically marketed to reduce risk of NSAID-induced ulcers include _____
naproxen/esomeprazole (Vimovo) Ibuprofen/famotidine (Duexis) Diclofenac/misoprostol (Arthrotec)
65
____ is approved for secondary prevention of CV and cerebrovascular events in pts at risk for aspirin-associated ulcers
Yoprala (aspirin/omeprazole)
66
If NSAID-ulcer develops, what do you recommend?
treat with PPI for 8 weeks and d/c NSAIDs If PPIs cannot be used, high-dose H2RA or sucralfate are other options
67
Misoprostol MOA
Prostaglandin E1 analog that replaces gastro-protective prostaglandins removed by NSAIDs
68
Sucralfate MOA
sucrose-sulfate-aluminum complex and. can interact with albumin and fibrinogen to form physical barrier over an open ulcer >> protects ulcer from further insult by HCl acid, pepsin and bile, allowing healing
69
Boxed warning for misoprostol (Cytotec)
Abortifacient - do not use to decrease NSAID-induced ulcers in females of childbearing potential unless capable of adhering to effective contraceptive measures Arthrotec (misoprostol/diclofenac): NSAIDs increase risk of serious GI events and CV disease
70
Side effects of misoprostol
Diarrhea, abd pain
71
Sucralfate (Carafate) side effects
Constipation
72
When is sucralfate (Carafate) taken
Before meals (empty stomach) and bed time
73
Why is sucralfate (Carafate) difficult to use?
D/t binding interactions (separate antacids by 30 mins and take other drugs 2 hrs before and 4 hrs after)
74
metoclopramide is most commonly used for ____
gastroparesis

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