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NAPLEX 2023 > Chapter 72: GERD & PUD > Flashcards

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

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2
Q

How many times per week must symptoms of GERD occur in order to be diagnosed

A

≥ 2 times per week

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3
Q

Patients who are refractory to GERD treatment may benefit from

A

24-hour esophageal pH monitoring

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4
Q

Key drugs that can worsen GERD symptoms

A 
ASA/NSAIDs
Dabigatran
Bisphosphonates
Fish Oils
Estrogen products
Iron supplements
Nicotine RTs
Steroids
Tetracyclines
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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)

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6
Q

How can infrequent heartburn be treated (< 2 times per week)

A

PRN OTC antacids or H2RAs

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7
Q

What is the initial treatment of choice for GERD

A

8-week course of a PPI once daily

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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

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9
Q

Antacid MOA

A

Neutralize gastric acid which increases gastric pH

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10
Q

What is the onset and duration of action for antacids

A

Onset: minutes
Duration: 30-60 min

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11
Q

Calcium carbonate brand name

A

Tums

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12
Q

Calcium carbonate + magnesium brand name

A

Mylanta Supreme

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13
Q

Calcium carbonate + simethicone brand name

A

Maalox Advanced Max Strength

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14
Q

Magnesium hydroxide brand name

A

Milk of Magnesia

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15
Q

Magnesium hydroxide + aluminum + simethicone brand name

A

Mylanta Classic

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16
Q

Sodium bicarbonate/ASA/citric acid brand name

A

Alka-Seltzer

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17
Q

Antacid warning

A

Aluminum and magnesium can accumulate with severe renal dysfunction

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18
Q

Side effect of calcium

A

Constipation

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19
Q

Side effect of aluminum

A

Constipation

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20
Q

Side effect of magnesium

A

Loose stools

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21
Q

Which antacids may be preferred in pregnancy

A

Calcium-containing antacids

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22
Q

MOA of H2RAs

A

Reversibly inhibits H2 receptors on gastric parietal cells, which decreases gastric acid secretion

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23
Q

Famotidine brand name

A

Pepcid, Zantac 360

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24
Q

Which two H2RAs come as an injection

A

famotidine and ranitidine

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25
Q

Ranitidine brand name

A

Zantac, Ranitidine Acid Reducer

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26
Q

What warning does H2RA come with

A

Confusion, usually reversible (risk factors: elderly, severely ill, renal impairment)

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27
Q

What are side effects of cimetidine at high doses

A

Gynecomastia, impotence

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28
Q

You must decrease the dose of famotidine, ranitidine, and nizatidine when CrCl < ___

A

50 mL/min

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29
Q

Which H2RA should be avoided due to drug interactions and side effects

A

Cimetidine

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30
Q

MOA of PPIs

A

Irreversibly bind to the gastric H+/K+-ATPase pump in the parietal cells. This shuts down the proton pump and blocks gastric acid secretion

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31
Q

Esomeprazole brand name

A

Nexium

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32
Q

Lansoprazole brand name

A

Prevacid, Prevacid Solutabs

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33
Q

Omeprazole brand name

A

Prilosec

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34
Q

Dexlansoprazole brand name

A

Dexilant

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35
Q

Pantoprazole brand name

A

Protonix

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36
Q

Which PPIs should be taken before breakfast

How long before?

A

Esomeprazole, lansoprazole and omeprazole

at least 60 minutes for eso, others time not specified

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37
Q

Esomeprazole should be taken how far in advance before breakfast

A

at least 60 minutes

38
Q

Which PPI can be taken without regard to meals

A

Dexlansoprazole, pantoprazole tablet

39
Q

Pantoprazole oral suspension should be taken how far in advance before a meal

A

30 minutes before

40
Q

Which 2 PPIs come as an injection

A

Esomeprazole and pantoprazole

41
Q

Esomeprazole + Naproxen brand name

42
Q

PPIs can cause what vitamin deficiency with prolonged use (≥ 2 years)

A

Vitamin B12

43
Q

What are other warnings of PPIs besides B12 deficiency

A

C-diff-associated diarrhea, hypomagnesemia, oteoporosis-related bone fractures with high doses or long-term use (≥ 1 year)

44
Q

Which PPIs should not be used with Plavix due to diminishing therapeutic effects

A

Omeprazole and esomeprazole

45
Q

Which PPI capsules can be opened

A

Dexlansoprazole, esomeprazole, lansoprazole, omeprazole and rabeprazole (all except pantoprazole)

46
Q

Which H2RAs are OTC

A

Cimetidine, famotidine, ranitidine

47
Q

Which PPIs are OTC

A

Esomeprazole, lansoprazole, omeprazole

48
Q

Which PPIs are ODT

A

Lansoprazole, omeprazole

49
Q

Which H2RAs come as oral solutions/suspensions

50
Q

Which PPIs come as packets for suspensions?

Which one comes as a suspension

A

Esomeprazole, Omeprazole, Pantoprazole

Lansoprazole

51
Q

Metoclopramide drug class

A

Dopamine antagonist

52
Q

Metoclopramide MOA

A

enhances response to Ach in the upper GIT, causing increased motility, accelerated gastric emptying and increased LES tone

53
Q

Metoclopramide brand name

54
Q

When should metoclopramide be taken

A

before meals and at bedtime

55
Q

Dose of metoclopramide should be decreased by ___% in CrCl < ___ mL/min to avoid CNS/EPS side effects

56
Q

Metoclopramide boxed warning

A

Tardive dyskinesia

57
Q

Metoclopramide should be avoided in patients with

A

Parkinson disease

58
Q

Drugs that should be avoided completely with PPIs & H2RAs

A

DR formulation of risedronate (Atelvia)

Rilpivirine & Epclusa should be avoided in combination with PPIs

59
Q

Key drugs that require an acidic gut and absorption will decrease by antacids, H2RAs and PPIs

A
  • 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
Q

Key oral drugs/drug classes that antacids bind

A
  • Antiretrovirals (INSTIs): bictegravir, dolutegravir, elvitegravir
  • Bisphosphonates
  • Isoniazid
  • Levothyroxine
  • Mycophenolate
  • Quinolones
  • Sotalol
  • Steroids (esp budesonide)
  • Tetracyclines
61
Q

H2RAs should be used with caution with

A

CNS depressants d/t risk of additive delirium, dementia, and cognitive impairment. Use lower doses in patients with renal impairment

62
Q

All PPIs inhibit which CYP enzyme

63
Q

Metoclopramide should not be used in combination with which drug class

A

Antipsychotic drugs

monitor when in combination with other serotonergic agents

64
Q

What are the 3 most common causes of PUD

A

H.pylori, NSAID-induced ulcers and stress ulcers which occur in critically ill and mechanically ventilated patients

65
Q

H pylori characteristics

A

spiral-shaped, pH sensitive, gram negative bacterium

66
Q

Primary symptom of PUD and other symptoms

A

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
Q

If the ulcer is duodenal (usually caused by H.pylori) pain is typically worse when

A

2-3 hours after eating (when the stomach is empty)

68
Q

What can help the pain from a duodenal peptic ulcer

A

Eating food or taking antacids lessen the pain

69
Q

If the ulcer is gastric (usually caused by NSAIDs) pain is typically worse when

A

After eating

70
Q

What is the common, non-invasive diagnostic test used to detect H.pylori

A

Urea breath test (UBT)

detects CO2 produced by bacteria

71
Q

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

A

d/c 2 weeks prior to avoid false negatives

PPIs, bismuth, and antibiotics

72
Q

Which type of therapy is first-line for H.pylori treatment

A

Quadruple therapy

73
Q

The use of triple-therapy first line for H.pylori treatments is only recommended if:

A

clarithromycin resistance rates are low (<15%) and the patient has no previous hx of taking a macrolide antibiotic

74
Q

Which drugs are included in quadruple therapy for H.pylori treatment (resistance rates ≥15%)

A

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
Q

Concomitant Therapy for H. pylori (clarithromycin resistance rates < 15% and no previous exposure to macrolide)

A

amoxicllin 1000 BID
clarithromycin 500 BID
metronidazole 250-500 QID
PPI BID

76
Q

Which drug should not be used in the quadruple therapy for H.pylori treatment if patient has hx of alcohol use

A

Metronidazole

77
Q

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

A

Tetracycline

78
Q

How long should quadruple therapy be used for H.pylori treatment

A

10-14 days

79
Q

Which drugs are included in triple therapy for H.pylori treatment

A

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
Q

If a patient has a PCN allergy, which drug should be changed and which drug should it be changed to in triple therapy

A

replace amoxicillin with metronidazole

81
Q

All NSAIDs should be used with caution in:

A

Any person with CV or renal disease

82
Q

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

A

COX2
Decreased GI risk
Increased CV risk

83
Q

NSAIDs that approach the COX 2 selectivity of celecoxib are

A

meloxicam, nabumetone, diclofenac, and etodolac

84
Q

Which combination product reduces the risk of NSAID-induced ulcers

A

Naproxen/esomeprazole (Vimovo)

85
Q

Which drug is approved for secondary prevention of CV and cerebrovascular events in patients at risk for aspirin-associated ulcers

A

Aspirin/omeprazole (Yosprala)

86
Q

If an ulcer develops from NSAID use, what should be used as treatment

A

PPI for 8 weeks

+ d/c NSAID

87
Q

Drug class for misoprostol

A

Prostaglandin E1 analog

88
Q

When should sucralfate be taken

A

Before meals on an empty stomach

89
Q

misoprostol boxed warning

A

an abortifacient - don’t use in women of child-bearing age unless effectvie contraception

90
Q

Side effects of misoprostol

A

Diarrhea, abdominal pain

91
Q

Side effect of sucralfate

A

Constipation

92
Q

Risk factors for NSAID-induced ulcers

A 
Age > 60 yo
Hx of PUD
High-dose NSAIDs
Using > 1 NSAID (e.g., NSAID + ASA)
Concomitant use of anticoagulants, steroids, SSRIs or SNRIs

NAPLEX 2023 (88 decks)

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