Chapter 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 the ____
A
lower esophageal sphincter (LES)
Patients with GERD have reduced LES pressure
2
Q
How many times per week must symptoms of GERD occur in order to be diagnosed
A
≥ 2 times per week
3
Q
Patients who are refractory to GERD treatment may benefit from
A
24-hour esophageal pH monitoring
4
Q
Key drugs that can worsen GERD symptoms
A
ASA/NSAIDs Dabigatran Bisphosphonates Fish Oils Estrogen products Iron supplements Nicotine RTs Steroids Tetracyclines
5
Q
When should a patient with GERD be referred for further evaluation
A
If they do not respond to lifestyle modifications and/or two weeks of self-treatment with OTC products, or if alarm symptoms are present (odynophagia, dysphagia, hematemesis, frequent N/V, unintentional weight loss)
6
Q
How can infrequent heartburn be treated (< 2 times per week)
A
PRN OTC antacids or H2RAs
7
Q
What is the initial treatment of choice for GERD
A
8-week course of a PPI once daily
8
Q
What is used for maintenance treatment if symptoms return after the initial 8 week treatment for GERD
A
PPI at the lowest effective dose
9
Q
Antacid MOA
A
Neutralize gastric acid which increases gastric pH
10
Q
What is the onset and duration of action for antacids
A
Onset: minutes
Duration: 30-60 min
11
Q
Calcium carbonate brand name
A
Tums
12
Q
Calcium carbonate + magnesium brand name
A
Mylanta Supreme
13
Q
Calcium carbonate + simethicone brand name
A
Maalox Advanced Max Strength
14
Q
Magnesium hydroxide brand name
A
Milk of Magnesia
15
Q
Magnesium hydroxide + aluminum + simethicone brand name
A
Mylanta Classic
16
Q
Sodium bicarbonate/ASA/citric acid brand name
A
Alka-Seltzer
17
Q
Antacid warning
A
Aluminum and magnesium can accumulate with severe renal dysfunction
18
Q
Side effect of calcium
A
Constipation
19
Q
Side effect of aluminum
A
Constipation
20
Q
Side effect of magnesium
A
Loose stools
21
Q
Which antacids may be preferred in pregnancy
A
Calcium-containing antacids
22
Q
MOA of H2RAs
A
Reversibly inhibits H2 receptors on gastric parietal cells, which decreases gastric acid secretion
23
Q
Famotidine brand name
A
Pepcid, Zantac 360
24
Q
Which two H2RAs come as an injection
A
famotidine and ranitidine
25
Ranitidine brand name
Zantac, Ranitidine Acid Reducer
26
What warning does H2RA come with
Confusion, usually reversible (risk factors: elderly, severely ill, renal impairment)
27
What are side effects of cimetidine at high doses
Gynecomastia, impotence
28
You must decrease the dose of famotidine, ranitidine, and nizatidine when CrCl < ___
50 mL/min
29
Which H2RA should be avoided due to drug interactions and side effects
Cimetidine
30
MOA of PPIs
Irreversibly bind to the gastric H+/K+-ATPase pump in the parietal cells. This shuts down the proton pump and blocks gastric acid secretion
31
Esomeprazole brand name
Nexium
32
Lansoprazole brand name
Prevacid, Prevacid Solutabs
33
Omeprazole brand name
Prilosec
34
Dexlansoprazole brand name
Dexilant
35
Pantoprazole brand name
Protonix
36
Which PPIs should be taken before breakfast
| How long before?
Esomeprazole, lansoprazole and omeprazole
| at least 60 minutes for eso, others time not specified
37
Esomeprazole should be taken how far in advance before breakfast
at least 60 minutes
38
Which PPI can be taken without regard to meals
Dexlansoprazole, pantoprazole tablet
39
Pantoprazole oral suspension should be taken how far in advance before a meal
30 minutes before
40
Which 2 PPIs come as an injection
Esomeprazole and pantoprazole
41
Esomeprazole + Naproxen brand name
Vimovo
42
PPIs can cause what vitamin deficiency with prolonged use (≥ 2 years)
Vitamin B12
43
What are other warnings of PPIs besides B12 deficiency
C-diff-associated diarrhea, hypomagnesemia, oteoporosis-related bone fractures with high doses or long-term use (≥ 1 year)
44
Which PPIs should not be used with Plavix due to diminishing therapeutic effects
Omeprazole and esomeprazole
45
Which PPI capsules can be opened
Dexlansoprazole, esomeprazole, lansoprazole, omeprazole and rabeprazole (all except pantoprazole)
46
Which H2RAs are OTC
Cimetidine, famotidine, ranitidine
47
Which PPIs are OTC
Esomeprazole, lansoprazole, omeprazole
48
Which PPIs are ODT
Lansoprazole, omeprazole
49
Which H2RAs come as oral solutions/suspensions
All
50
Which PPIs come as packets for suspensions?
| Which one comes as a suspension
Esomeprazole, Omeprazole, Pantoprazole
| Lansoprazole
51
Metoclopramide drug class
Dopamine antagonist
52
Metoclopramide MOA
enhances response to Ach in the upper GIT, causing increased motility, accelerated gastric emptying and increased LES tone
53
Metoclopramide brand name
Reglan
54
When should metoclopramide be taken
before meals and at bedtime
55
Dose of metoclopramide should be decreased by ___% in CrCl < ___ mL/min to avoid CNS/EPS side effects
50%
< 60
56
Metoclopramide boxed warning
Tardive dyskinesia
57
Metoclopramide should be avoided in patients with
Parkinson disease
58
Drugs that should be avoided completely with PPIs & H2RAs
DR formulation of risedronate (Atelvia)
| Rilpivirine & Epclusa should be avoided in combination with PPIs
59
Key drugs that require an acidic gut and absorption will decrease by antacids, H2RAs and PPIs
- Antiretrovirals: Rilpivirine (NNRTI), atazanavir (PI)
- Antivirals: ledipasvir, velpatasvir/sofosbuvir (Epclusa)
- Azole antifungals: itraconazole, ketoconazole, posaconazole oral suspension
- Cephalosporins (oral): cefpodoxime, cefuroxime
- Iron products
- Mesalamine
- Risedronate DR
- TKI: dasatanib, erlotinib, pazopanib
60
Key oral drugs/drug classes that antacids bind
- Antiretrovirals (INSTIs): bictegravir, dolutegravir, elvitegravir
- Bisphosphonates
- Isoniazid
- Levothyroxine
- Mycophenolate
- Quinolones
- Sotalol
- Steroids (esp budesonide)
- Tetracyclines
61
H2RAs should be used with caution with
CNS depressants d/t risk of additive delirium, dementia, and cognitive impairment. Use lower doses in patients with renal impairment
62
All PPIs inhibit which CYP enzyme
2C19
63
Metoclopramide should not be used in combination with which drug class
Antipsychotic drugs
| monitor when in combination with other serotonergic agents
64
What are the 3 most common causes of PUD
H.pylori, NSAID-induced ulcers and stress ulcers which occur in critically ill and mechanically ventilated patients
65
H pylori characteristics
spiral-shaped, pH sensitive, gram negative bacterium
66
Primary symptom of PUD and other symptoms
Primary symptom is dyspepsia, a gastric pain which can feel like a gnawing or burning sensation in the middle or upper stomach
Other sx: heartburn, belching, bloating, cramping, nausea and anorexia
67
If the ulcer is duodenal (usually caused by H.pylori) pain is typically worse when
2-3 hours after eating (when the stomach is empty)
68
What can help the pain from a duodenal peptic ulcer
Eating food or taking antacids lessen the pain
69
If the ulcer is gastric (usually caused by NSAIDs) pain is typically worse when
After eating
70
What is the common, non-invasive diagnostic test used to detect H.pylori
Urea breath test (UBT)
| detects CO2 produced by bacteria
71
Which drugs should be d/c prior to UBT test and fecal antigen test to detect H.pylori and how long before the tests should they be d/c
d/c 2 weeks prior to avoid false negatives
| PPIs, bismuth, and antibiotics
72
Which type of therapy is first-line for H.pylori treatment
Quadruple therapy
73
The use of triple-therapy first line for H.pylori treatments is only recommended if:
clarithromycin resistance rates are low (<15%) and the patient has no previous hx of taking a macrolide antibiotic
74
Which drugs are included in quadruple therapy for H.pylori treatment (resistance rates ≥15%)
Bismuth subsalicylate 300 mg QID
Metronidazole 250-500 mg QID
Tetracycline 500 mg QID
PPI BID (or esomeprazole 40 mg daily)
or use a 3-in-1 combination product + PPI:
Pylera (Bismuth subcitrate potassium 420 mg + metronidazole 375 mg + tetracycline 375 mg) QID + PPI BID
75
Concomitant Therapy for H. pylori (clarithromycin resistance rates < 15% and no previous exposure to macrolide)
amoxicllin 1000 BID
clarithromycin 500 BID
metronidazole 250-500 QID
PPI BID
76
Which drug should not be used in the quadruple therapy for H.pylori treatment if patient has hx of alcohol use
Metronidazole
77
Which drug should not be used in the quadruple therapy for H.pylori treatment if patient is pregnant or if the pt is a child
Tetracycline
78
How long should quadruple therapy be used for H.pylori treatment
10-14 days
79
Which drugs are included in triple therapy for H.pylori treatment
Amoxicillin 1000 mg BID
Clarithromycin 500 mg BID
PPI BID (or esomeprazole 40 mg daily)
OR Prevpac (amoxicillin, clarithromycin, lansoprazole)
| with pcn allergy can replace amox with metronidazole
80
If a patient has a PCN allergy, which drug should be changed and which drug should it be changed to in triple therapy
replace amoxicillin with metronidazole
81
All NSAIDs should be used with caution in:
Any person with CV or renal disease
82
NSAIDs with selective inhibition of COX__ (e.g., celecoxib) have decreased ___ risk but increased ___ risk compared to non-selective NSAIDs
COX2
Decreased GI risk
Increased CV risk
83
NSAIDs that approach the COX 2 selectivity of celecoxib are
meloxicam, nabumetone, diclofenac, and etodolac
84
Which combination product reduces the risk of NSAID-induced ulcers
Naproxen/esomeprazole (Vimovo)
85
Which drug is approved for secondary prevention of CV and cerebrovascular events in patients at risk for aspirin-associated ulcers
Aspirin/omeprazole (Yosprala)
86
If an ulcer develops from NSAID use, what should be used as treatment
PPI for 8 weeks
| + d/c NSAID
87
Drug class for misoprostol
Prostaglandin E1 analog
88
When should sucralfate be taken
Before meals on an empty stomach
89
misoprostol boxed warning
an abortifacient - don't use in women of child-bearing age unless effectvie contraception
90
Side effects of misoprostol
Diarrhea, abdominal pain
91
Side effect of sucralfate
Constipation
92
Risk factors for NSAID-induced ulcers
```
Age > 60 yo
Hx of PUD
High-dose NSAIDs
Using > 1 NSAID (e.g., NSAID + ASA)
Concomitant use of anticoagulants, steroids, SSRIs or SNRIs
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