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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
Q

PPI MOA

A

Irreversibly bind to the gastric H+/K+-ATPase pump (proton pump) in parietal cells&raquo_space; blocks gastric acid secretion

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26
Q

Which medication is most effective for GERD?

A

PPIs

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27
Q

Which PO PPIs should be taken before breakfast

A

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)

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28
Q

Which PO PPIs can be taken without regard to meals?

A

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

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29
Q

Examples of PPIs used in GERD

A

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

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30
Q

Warnings with PPIs

A

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
Q

Which H2RAs/PPIs come OTC?

A

H2RA: Cimetidine, famotidine
PPIs: esomeprazole, lansoprazole, omeprazole

32
Q

Which PPIs come in ODT formulation?

A

Lansoprazole, omeprazole

33
Q

Which H2RAs/PPIs come in oral solution/suspensions?

A

H2RA: cimetidine, famotidine, nizatidine
PPIs: lansoprazole // packets for suspension: esomeprazole, pantoprazole, omeprazole

34
Q

Which H2RAs/PPIs come in injection formulations ?

A

H2RA: famotidine
PPIs: esomeprazole, pantoprazole

35
Q

What is the concern with long-term PPI use?

A

Chronic changes in gastric pH&raquo_space; 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
Q

Metoclopramide MOA

A

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&raquo_space; increased motility, accelerated gastric emptying, and increased LES tone

37
Q

When is metoclopramide (Reglan) taken?

A

before meals and at bedtime

38
Q

What is CrCl cut off for renal dose adj for metoclopramide (Reglan)

A

CrCl <60 - decrease dose by 50% to avoid side effects including CNS/EPS side effects

39
Q

Boxed warning for metoclopramide (Reglan)

A

Can cause tardive dyskinesia - higher risk with high doses, long-term treatment (>12 weeks),and elderly pts

40
Q

Warnings with metoclopramide (Reglan)

A

EPS (including acute dystonia), Parkinsonian-like symptoms
Others: rare neuroleptic malignant syndrome (NMS), depression, suicidal ideation
Avoid use in pts with Parkinson disease

41
Q

Side effects with metoclopramide (Reglan)

A

Drowsiness
Others: restlessness, fatigue, HTN, pro-arrhythmic, diarrhea

42
Q

Which meds should be avoided when taking H2RAs or PPIs?

A

Delayed release formulation of Risedronate (Atelvia)

Avoid with PPIs: Erlotinib, rilpivirine, and velpatasvir/sofosbuvir (Epclusa)

43
Q

Drugs that require acidic gut (absorption decreased by antacids, H2RAs, and PPIs)

A

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
Q

Oral drugs/drug classes that antacids bind

A

Antiretrovitals (INSTIs): bictegravir, dolutegravir, elvitegravir, raltegravir
Bisphosphonates
isoniazid
Levothyroxine
Mycophenolate
Quinolones
Sotalol
Steroids (esp budesonide)
Tetracyclines

45
Q

When using H2RAs, use caution with CNS depressants (esp in elderly) d/t risk of additive ____ . Use lower doses in pts with renal impairment

A

delirium, dementia, and cognitive impairment

46
Q

Cimetidine is an ___ of CYP450 enzymes (e.g. 2C19, 3A4, 1A2)

A

inhibitor
Avoid use with dofetilide, use caution with other drugs including amiodarone, CCBs, clopidogrel, phenytoin, SSRIs, theophylline, and warfarin

47
Q

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.

A

2C19
Esomeprazole and omeprazole
Clopidogrel - avoid esomeprazole and omeprazole use with this drug

48
Q

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 ____

A

Parkinsons disease
Serotonin syndrome, EPS, and NMS

49
Q

3 most common causes of PUD are ___

A

H. pylori-positive ulcers (most common)
NSAID induced ulcers
Stress ulcers (occur in critically ill and mechanically-ventilated pts)

50
Q

Describe H. pylori bacterium

A

Spiral-shaped
pH sensitive
gram-negative

51
Q

S/sx of PUD

A

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
Q

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.

A

True

53
Q

T/F: With gastric ulcers, eating generally lessens the pain

A

False - worsens the pain

54
Q

Diagnostic tests for H.pylori include ____.
PPIs, bismuth, and abx should be d/c ____ prior test to avoid false neg test.

A

urea breath test (UBT) which detects CO2 produced by the bacterial
Fecal antigen test which detects H. pylori in stool

2 weeks

55
Q

What is American College of Gastroenterology (ACG) recommended drug treatment for H. pylori infection?

A

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
Q

What is in bismuth quadruple therapy for H. pylori treatment?

A

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
Q

What is in clarithromycin triple therapy for H. pylori treatment?

A

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
Q

What is in concomitant therapy for H.pylori treatment?

A

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
Q

concern with alcohol use and bismuth quadruple therapy

A

Alcohol use - do not use metronidazole

60
Q

Concern with pregnancy/children and bismuth quadruple therapy

A

Do not use tetracycline during pregnancy or in children < 8yo

61
Q

Concern with salicylate allergy and bismuth quadruple thearpy

A

Do not use bismuth subsalicylate

62
Q

NSAIDs with selective inhibition of COX-2 (e.g. ___) have decreased ___ risk but increased ___ risk compared to non-selective NSAIDs

A

celecoxib
decreased GI risk but increased CV risk

63
Q

NSAIDs that approach the selectivity of celecoxib are. _____

A

meloxicam, nabumetone, diclofenac, etodolac

64
Q

Combo products specifically marketed to reduce risk of NSAID-induced ulcers include _____

A

naproxen/esomeprazole (Vimovo)
Ibuprofen/famotidine (Duexis)
Diclofenac/misoprostol (Arthrotec)

65
Q

____ is approved for secondary prevention of CV and cerebrovascular events in pts at risk for aspirin-associated ulcers

A

Yoprala (aspirin/omeprazole)

66
Q

If NSAID-ulcer develops, what do you recommend?

A

treat with PPI for 8 weeks and d/c NSAIDs
If PPIs cannot be used, high-dose H2RA or sucralfate are other options

67
Q

Misoprostol MOA

A

Prostaglandin E1 analog that replaces gastro-protective prostaglandins removed by NSAIDs

68
Q

Sucralfate MOA

A

sucrose-sulfate-aluminum complex and. can interact with albumin and fibrinogen to form physical barrier over an open ulcer&raquo_space; protects ulcer from further insult by HCl acid, pepsin and bile, allowing healing

69
Q

Boxed warning for misoprostol (Cytotec)

A

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
Q

Side effects of misoprostol

A

Diarrhea, abd pain

71
Q

Sucralfate (Carafate) side effects

A

Constipation

72
Q

When is sucralfate (Carafate) taken

A

Before meals (empty stomach) and bed time

73
Q

Why is sucralfate (Carafate) difficult to use?

A

D/t binding interactions (separate antacids by 30 mins and take other drugs 2 hrs before and 4 hrs after)

74
Q

metoclopramide is most commonly used for ____

A

gastroparesis

NAPLEX 2024 (74 decks)

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