Antacids and Acid Supressive Medication Flashcards
Characteristicss of SRMD that is not amenable to endoscopic treatment
Stress Ulcers
Stress ulcers
• Usually diffuse
• Not amenable to endoscopic treatment
• Generally heal with time without intervention as
clinical status improves
Clinical presentation of Stress Ulcers (5)
• Multiple superficial
lesions
• Proximal stomach bulb
• Involves superficial
capillaries
• Acute
• Caused by splanchnic
hypoperfusion
Clinical Presentation: Peptic Ulcer
• Single or few deep
lesions
• Duodenum
• Typically involves
single vessel
- Chronic
- Occurs at anytime
Definition: Endoscopically evident mucosal damage
Superficial lesions identified on endoscopy
MOST frequent
Definition:Occult bleeding
Presence of guaiac-positive stools or nasogastric aspirate
Definition: Overt or clinically evident bleeding
Appearance of coffee grounds in nasogastric aspirate, hematemesis, melena, or hematochezia, guaiac- positive stools
Definition: Clinically significant bleeding
Bleeding with hemodynamic instability and/or blood transfusion
LEAST FREQUENT
- outcome that requires transfusion
Clinically significant bleeding symptoms
- Bleeding + one of the following
- Decrease in systolic blood pressure > 20 mm Hg within 24 h of bleed •
- Orthostatic increase in heart rate of >20 beats/min and decrease in systolic blood pressure >10 mm Hg
- Decrease in Hgb ≥2 g/dL + transfusion of 2 units packed red cells in 24 h OR subsequent transfusion after which Hgb did not increase by at least number of units transfused minus 2 g/dL
Indications for stress-related bleeding
Independent risk factors
1.5% had clinically significant bleeding
Coagulopathy (OR 4.3, p<0.001)
- Respiratory failure requiring mechanical ventilation for ≥48 h (OR 15.6, p<0.001)
- Platelets < 50,000/mm3, INR >1.5, or aPTT >2x normal
What are the other risk factors for stress related bleeding
• Spinal cord/head trauma
• Thermal injury affecting > 35% of total body surface area
• History of GI bleed within the past year
• Postoperative transplantation
• Ulcerogenic medications (nonsteroidal anti-inflammatory
drugs, aspirin, corticosteroids)
What pH will prevent development of stress mucosal disease?
pH of 4 or higher will prevent stress mucosal disease
What is the pH goal for the treatment of UGIB?
pH = 6
MOA: Antacids
Neutralizes gastric acid (dose dependent) increases pH of the gastric contents reduces GI mucosal irritation
MOA: Sucralfate
- Binds to albumin and fibrinogen on damaged GI mucosa –> viscous, adhesive substance that adheres to ulcers when pH <4
MOA: H 2RAs
- Ranitidine
- Cimetidine • Famotidine • Nizatidine
• Competitively blocks histamine subtype 2
receptors on the basolateral membrane of the
parietal cells
• Inhibits gastrin secretion to reduce acid
production
• Do not reliably inhibit vagal induced gastric
secretion
MOA: PPI
Dexlansoprazole • Lansoprazole • Esomeprazole • Pantoprazole • Omeprazole • Rabeprazole
• Binds irreversibly to the H+/K+
AT Pa s e p u m p
• Inhibition of hydrogen ion secretion
into the gastric lumen is inhibited
Adverse Effects of Antacids
- Diarrhea (mostly with magnesium based
- Constipation
- Electrolyte imbalances (hypermagnesemia, hypophosphatemia) hypercalcemia, hypophosphatemia, hyperaluminum)
What happens if you give a lot of Magnesium?
Diarrhea
Adverse Effects of Sucralfate
• Not recommended for routine use
- Adverse effects
- Constipation, aluminum toxicity, hypophosphatemia
- Drug interactions – BIG THING!
- Chelation - binds to lots of drugs causing inhibition of the absorption of that particular drug
- Less efficacious than H2RAs
H2RAs for preventing stress ulcers
- Dose dependent increase in gastric pH
- bigger doses more adverse effects
-
Tachyphylaxis will develop
- Possibly due to up-regulation of alternative pathways (gastrin, acetylcholine)
-
Adverse SE:
- Mental Status Change
- Thrombocytopenia
- Rapid infusion related hypotension
- Risk for nosocomial pneumonia
Uses for PPI - indications OVER H2BLOCKERS
Uses
• Peptic ulcer disease
• Helicobacter pylori
• Chronic NSAID use
• Barrett esophagitis
• Erosive esophagitis
• Zollinger-Ellison syndrome
The DOC for dyspepsia
Antacid
When does PPI start to work?
maximal activity reached 3 days after initiation
- does not work right away
- SUSTAINED RELIEF
NOT USED FOR ACUTE SITUATIONS
Adverse Effects of PPI
* do not discharge patient with PPI if not indicated
Practice Considerations:
Slum dunk you should use a PPI
What causes the highest rates of rebleeding?
- Active bleeding ulcer
- nonbleeding ulcer but vessel present at ulcer
If you have someone with Upper GI bleed what should you do?
- Do an endoscopy
- Start PPI
What should you use for a variceal bleed?
Ocreotide and or vasopressin
Bleeding Ulcers
Endoscopic intervention should be done.
