Discussion Post Module 1

Question 1

What are some GERD triggers?

Answer 1

Some common triggers for GERD include spicy food, highly acidic food i.e., tomatoes or foods containing highly acidic ingredients i.e., pizza, chocolate, fried foods, alcohol, coffee, foods high in fat, carbonated beverages, processed meats, peppermint (Tosetti, et al., 2021).

Question 2

What medications can exacerbate GERD?

Answer 2

These medications include some over the counter medications such as NSIADs, and aspirin, as well as prescription medications like, estrogen replacement therapy and oral contraception, bisphosphonates, nitrates and calcium channel blockers, some TCAs, benzodiazepines, anticholinergics, and some antiasthmatic medications (Mungan & Simsek, 2017).

Question 3

What lifestyle modifications help with GERD?

Answer 3

Some lifestyle modifications include elevating the head of bed, weight loss, eating smaller meals, not eating 3 hours before bed, and smoking cessation (Chisholm-Burns, et al., 2022).

Question 4

How would you differentiate between NSAID-induced ulcers and h.pylori?

Question 5

How would you treat NSAID-induced ulcers?

For how long and why?

Answer 5

Treatment for either would include discontinuing use of NSAIDs, or decreasing the dose if discontinuation is not possible. For NSAID induced PUD if discontinuation of the offending medication does not relieve symptoms starting therapy with a H2RA or PPI would be appropriate intervention, misoprostol can also be used but if often not as well tolerated as the previous mentioned medications, and transition to a COX-2 selective inhibitor is a reasonable option to prevent development of PUD.

Treatment with PPIs or H2Ras is typically at least 4 weeks longer if symptoms persist, ulcer is confirmed, and alarm symptoms are present.

Question 6

What if your patient has bloody diarrhea?

What would that mean?

Answer 6

That likely means that patient has infectious diarrhea.

Question 7

What are the signs and symptoms of bacterial diarrhea versus viral?

How would you treat either?

Answer 7

Treatment goals are the same.

Bacterial diarrhea requires an ABT.

Viral diarrhea is watery diarrhea, while bacterial diarrhea is more likely to have blood and mucus present (Sattar & Singh, 2022).

Question 8

If an elderly patient required a PPI, how would you decrease their risk of bone fracture?

Answer 8

The patient should be pushed to maintain a good diet and exercise routine and get enough calcium and vitamin D supplements to lower this risk.

PPIs lower gastrointestinal pH, absorbing less calcium from food. Supplements containing calcium and vitamin D can enhance bone health and reduce the risk of fractures.

Question 9

Regarding elderly patients requiring a PPI and decreasing their risk of bone fractures, what supplements could they utilize?

Answer 9

PPIs lower gastrointestinal pH, absorbing less calcium from food. Supplements containing calcium and vitamin D can enhance bone health and reduce the risk of fractures.

Supplemental vitamin D can also improve calcium absorption in the body.

Question 10

Regarding elderly patients requiring a PPI and decreasing their risk of bone fractures, what supplements/meds may require a certain pH?

Answer 10

Calcium requires a higher pH to be absorbed. Lower pH (higher acid) lowers absorption of calcium.

For patients using PPIs, calcium citrate, a kind of calcium supplement that can be absorbed in high stomach pH, maybe a better choice.

Question 11

Are any PPIs better than one another?

Answer 11

No. All are equally equipotent.

Question 12

What would you consider doing if your H.pylori patient developed diarrhea during their regimen?

What do you think might be the most likely cause of diarrhea in your h.pylori patient?

Answer 12

A thorough history of the patient’s current medications must be taken first. Investigating whether the diarrhea is brought on by the side effect of drugs, particularly the antibiotics being taken to treat the infection, is crucial. If a drug side effect is responsible for diarrhea, changing to a different antibiotic/reducing the dosage, or administering probiotics may be an option.

The most likely cause of diarrhea in an elderly H. pylori patient would be a side effect of the antibiotics used to eradicate the infection. This is because antibiotics can disrupt the balance of normal flora in the gut, leading to diarrhea and other gastrointestinal symptoms (Kopacz & Phadtare, 2022).

Side effects of the antibiotic medications used to treat the disease, atrophic gastritis by the H. pylori bacteria, and the development of a new infection, such as Clostridioides difficile due to PPIs, are some of the causes of diarrhea in H. pylori patients (Kakiuchi et al., 2019).

Question 13

What are the common causes of diarrhea?

Would it change how you treat your patient?

What are the goals of treating diarrhea?

Answer 13

Various meds and ABTs.

The goals of treating diarrhea in people with H. pylori include managing symptoms, preventing the spread and dehydration, offering definitive treatment by addressing the underlying causes, providing proper care to prevent skin breakdown, and monitoring for fall risk, especially with elderly patients.

The treatment goals are all the same.

Question 14

When is the best time to take PPIs? Why?

Answer 14

PPIs are best taken in the morning before the patient’s first meal as proton pumps are activated with food intake.

Administering PPIs with food affects the bioavailability of the medication (Ochoa et al., 2020). Therefore, if PPIs were administered with food, this would alter the absorption of the medication as the goal of the medication is to suppress the secretion of acid.

Question 15

What are some medications that interact with PPIs?

Answer 15

It is also important to consider medications that interact with PPIs. For example, omeprazole is metabolized by the CYP450 system and may compete with other medications metabolized by this system. It may also increase the levels of digoxin and methotrexate and decrease the anti platelet effect of clopidogrel. Omeprazole interferes with the hepatic activation of clopidogrel, hindering the anti-platelet effect (Catapano et al., 2021).

Question 16

What are some GERD triggers? What medications can exacerbate GERD, in addition to prolonged steroid use? What lifestyle modifications help with GERD?

Answer 16

Moreover, it is important to consider the risk factors and triggers for gastro-esophageal reflux disease (GERD) symptoms. Lifestyle factors, including obesity, smoking, anxiety/depression, consumption of high-acid foods, large portion sizes, and timing of meals with respect to the individual’s sleep schedule may exacerbate GERD symptoms and increase the frequency of symptoms (Clarett, 2018). Therefore, weight loss, consuming low acid foods, smoking cessation, controlled portions, and regimented meal times may provide symptom relief and help patients’ manage GERD more effectively.

Question 17

Assuming your patient tests positive for H. pylori, describe your therapeutic plan, including possible medication options, patient and drug-related factors used to make your selection, duration of therapy, monitoring, patient education, and any potential follow-up such as labs, testing, or continued use for PPIs.

Answer 17

Classed as a first-line carcinogen, the gram-negative bacterium Helicobacter Pylori (Pylori) can be found in the human stomach and is a clinical challenge due to its link with the development of peptic ulcer disease (PUD), gastritis, Gastric cancer, and mucosa-associated lymphoid tissue lymphoma (MALT) (Mestrovic et al. 2020). At the 2015 Kyoto Consensus, H. pylori was categorized as an infectious disease that requires eradication regardless of symptomatology to prevent future ulcers or malignancies (Mestrovic et al., 2020).

According to Ierardi et al. (2019), the replication cycle and persistence of the bacteria depends on the pH of the intragastric environment, with replication occurring at pH 6-7, and coccoid formation occurring at pH 3-6 which makes it antibiotic resistant. Treatment protocols should therefore take into consideration the increased occurrence of antibiotics resistant H. pylori infection worldwide.

In comparing eradication success of different therapy regimens, Mohd et al. (2019), found that the quadruple therapy, 14-day versus 10-day showed higher rates of eradication. These findings adhere to the guidelines of the American College of Gastroenterology (ACG) and international guidelines (Mohd et al., 2019). Thus, for this patient, we would recommend the 14- days quadruple therapy using tetracycline, metronidazole, a proton pump inhibitor (PPI), and a bismuth salt (Mohd et al. 2019). The patient needs to understand that side effects such as nausea, taste disturbance, headache and diarrhea may occur (Mestrovic et al., 2020).

Since PPIs use can result in a false negative result, its usage should be stopped at least two weeks before testing to see if the H. pylori infection has been eradicated. Therefore, a month after therapy ends, a test for H. pylori antigen in the stool should be carried out by utilizing a monoclonal antibody (ELISA) test to assess eradication success (Mohd et al., 2019). Eradication failure was defined as a positive result of this test.

Question 18

What are some major drug interactions with PPIs that could be a problem in an elderly patient with polypharmacy?

Question 19

Are PPIs recommended in renal or liver disease? Why or why not?

Question 20

Is there a dosing threshold for PPIs?

Answer 20

4-8 weeks.

Unsure on exact dose lol.

Question 21

What lifestyle choices or disease states might make the patient more likely to suffer from GERD? What can they do to improve their disease or lifestyle? If they improved enough to deprescribe, what would you do to lessen the chances of a GERD exacerbation? What steps would you take to deprescribe? What ingestible items, in addition to trigger foods, should they avoid? Table 17-1 lists a few things. Also, what medications might cause or worsen GERD? What non-pharm options exist? What would preclude a patient from self-treating over the counter?

Question 22

How would you diagnose H. pylori?

Answer 22

Helicobacter pylori can be diagnosed via a urea breath test, stool antigen test, blood H. pylori antibodies test, or endoscopy, which is an invasive method and is reserved for atypical or alarming symptoms. A urea breath test is the preferred noninvasive method due to its high sensitivity and specificity (Chisholm-Burns et al., 2019). However, it is important to determine any current acid-suppressive therapy or antibiotic use due to the possibility of false negative results; if this is the case, a stool antigen assay is more appropriate (Chisholm-Burns et al., 2019).

Question 23

How would you differentiate between NSAID-induced ulcers and H. pylori?

Answer 23

Taking detailed histories, such as NSAID use and the presence or lack of symptoms during or after meals, can help a clinician narrow down the possible cause; however, to confirm H. pylori infection, the patient should be tested via a urea breath test. As the narrated notes mentioned, stomach ulcers are usually caused by NSAIDs and duodenal ulcers by H. pylori; however, either one can cause ulcers in either location. Pain from duodenal ulcers is generally relieved by ingestion of food, whereas pain stemming from gastric ulcers is aggravated by food intake. Often, patients gain weight if they experience duodenal ulcers and lose weight with gastric ulcers, although this is not a written rule. The mechanism of ulcer formation is different with H. pylori infection and NSAID use, but the result is the same.

H pylori bacteria produce an enzyme called urease which buffers the acid environment in the stomach by breaking urea into ammonia. In addition to creating a less acidic environment, H. pylori bacteria have adhesive molecules on their surface that allow for attachment and infection of epithelial cells. Flagella aids in the movement and penetration of the mucus. Bacteria also release cytotoxins causing inflammation and apoptosis of epithelial cells. Leakage of acid into gastric mucosa perpetuates more inflammation and damage, resulting in peptic ulcers.

NSAID-induced ulcers result from an imbalance of hydrochloric acid (HCl), mucus, and bicarbonate production. NSAIDs inhibit the COX enzyme that facilitates prostaglandin production. Prostaglandins inhibit HCl secretion; therefore, decreased prostaglandin production directly causes an increase in the secretion of HCl, creating the destruction of mucus and, consequently, the destruction of the stomach epithelium.

Question 24

How would you treat either NSAID-induced or H. pylori ulcers? What if they were allergic to penicillin?

Answer 24

The first step in treating NSAID-induced ulcers (without concurrent H. pylori infection) is to discontinue NSAIDs if possible and replace them with an alternative such as acetaminophen (Chisholm-Burns et al., 2019). The goal is to promote ulcer healing, proton pump inhibitors (PPI), such as Omeprazole, for a duration of four weeks is preferred over H2RAs or sucralfate due to more potent acid suppression and equivalent efficacy for both gastric and duodenal ulcers whereas H2Ras are minimally effective in the treatment of gastric ulcers (Chisholm-Burns et al., 2019). PPI therapy can be continued after four weeks if a patient suffers complications of peptic ulcer disease or if the ulcer is still present and additional time is needed for healing.

Treatment of confirmed H. pylori infection and resulting ulcers starts with eradicating the pathogen via a PPI and antibiotic combination regimen. To choose the best combination, again, detailed history including allergies, previous macrolide therapy, alcohol use (metronidazole less prescribed due to disulfiram-like reaction), frequent metronidazole therapy for gynecological infections in women, age due to the possibility of cumulative exposure to fluoroquinolones, the chance of pregnancy, etc. must be considered. The risk of clarithromycin resistance increased with each prior course of macrolides, from 7% among macrolide naïve patients to 50% among patients with three to four prior courses and 80% among patients with at least five prior courses (White et al., 2022). Patients with metronidazole resistance had significantly higher rates of previous metronidazole prescriptions (White et al., 2022).

Bismuth quadruple therapy for 10-14 days is an acceptable first-line treatment, and this is the only available treatment for patients with penicillin allergy (Chisholm-Burns et al., 2019). However, tetracycline is contraindicated in severe hepatic impairment and in pregnancy as it harms the human fetus. Metronidazole can cause an unpleasant metallic taste in addition to QT prolongation, particularly when metronidazole is administered with drugs with the potential for prolonging the QT interval, such as Prozac, Zoloft, Effexor, Haldol, Imitrex, etc. These are just a few examples that must be considered when choosing the most appropriate H. pylori treatment.

Question 25

What would you say to your patient regarding adherence to their H. Pylori regimen? Why is it important?

Answer 25

It is of the utmost importance to adhere to the regimen as prescribed and complete the entire length of the treatment to ensure the complete eradication of bacteria and avoid the development of antibiotic resistance. It is important to discuss expected side effects and be honest with a patient that approximately 20% failure rate of initial treatment is related to compliance and possible antibiotic resistance.

Mayo clinic laboratories tested over 400 specimens and found that around 70% are resistant to clarithromycin, and the resistance rate is even higher for metronidazole (about 80%) (Patel, 2021). There is still a good susceptibility for amoxicillin, ciprofloxacin, and tetracycline; however, these numbers might differ based on geography. The international guidelines for managing H. pylori infection state that when the Clarithromycin resistance rate exceeds 15% of all diagnosed H. pylori infections in a population, eradication treatment with a clarithromycin-containing protocol is not recommended without prior susceptibility testing (Kocsmár et al., 2021).

Question 26

What regimen would you use to salvage if they still tested positive for H. pylori?

Answer 26

The critical part of choosing second-line therapy is that it must differ from the first treatment (Chisholm-Burns et al., 2019). The process of selecting the best second-line treatment is the same as that for the first-line treatment.

Question 27

What lifestyle choices or disease states might make the patient more likely to suffer from GERD? What lifestyle modifications can patients implement to improve their GERD?

Answer 27

Smoking, eating fatty meals, long-term use or high doses of NSAIDs, lying down after meals, and being obese are all associated with developing GERD symptoms. Any modifications such as smoking cessation, weight loss, eating smaller meals, and avoiding laying down for at least 3 hours after a meal can improve GERD symptoms.

Question 28

What medications can exacerbate GERD, in addition to prolonged steroid use?

Answer 28

Pain relievers, potassium, some ABTs, etc.

Question 29

What are the universal goals of therapy for diarrhea?

Answer 29

In all diarrhea cases the main goal is to relieve the symptoms, maintain hydration and nutrition, and treat the underlying cause (Chisholm-Burns, et al. 2022).

Question 30

Are PPIs recommended for renal or liver disease?

Answer 30

No. They may exacerbate these diseases.

Question 31

Is there a dosing threshold for PPIs?

Answer 31

4-8 weeks?