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Therapeutics Y2 Sem 2 > Dyspepsia nd GERD > Flashcards

Dyspepsia nd GERD Flashcards

1
Q

What is the definition of dyspepsia?

A
  • Epigastric pain or discomfort originating from upper GI tract
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2
Q

What is dyspepsia?

A
  • An umbrella term to describe many possible symptoms and causes
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3
Q

What is functional dyspepsia?

A

Where no abnormalities are found

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4
Q

What is GERD?

A
  • Reflux of gastric contents into the esophagus
  • Described as heartburn
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5
Q

What is peptic ulcer disease?

A
  • An ulcer formed in the gastric or duodenal mucosa
  • May have symptoms similar to dyspepsia / GERD
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6
Q

What is the diagnostic flow of dyspepsia?

A
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7
Q

What is generally the functional dyspepsia?

A
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8
Q

What is the causes of dyspepsia (Most common)

A

Normal finding, functional dyspepsia (70%)

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9
Q

What is the next cause of dyspepsia?

A

GERD

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10
Q

What are the risk factors for dysepepsia?

A

Risk factors for dyspepsia
* No strong association with sex, age, socioeconomic status
* Dietary indiscretion
* Medications
* H. pylori infection
* Anxiety
* Irritable bowel syndrome
Alcohol use

Smoking accreddited for making it worse

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11
Q

What is the drug induced dyspepsia drugs we should know?

A

Bisphosphonates
Iron
NSAIDs
Potassium

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12
Q

What are the symptoms of dyspepsia

A
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13
Q

How long does the symptoms of dyspepsia usually last?

A

> 1 month duration of symptoms
Often follows relapsing-remitting course

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14
Q

What are the main alarm symptoms we should be concerned with?

A

VBAD

Vomiting, bleeding, abdominal mass, dysphagia

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15
Q

What is generally the main diagnosis of GERD?

A

Reflux or regurgitation as main symptoms.

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16
Q

What other things do we follow as a systemic approach in patients with dyspepsia?

A

2) Upper GI location?

3) New onset symptoms (other than reflux/heartburn) >50 (++>60) or red flag
symptoms?

4) NSAID use?

5) Reflux or regurgitation as main symptom?

6) H.pylori present?

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17
Q

What is the dietary contributors to GERD?

A

Over-eating

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18
Q

What is the classification of mild GERD?

A
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19
Q

What is the presentation of moderate to severe gerd?

A
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20
Q

What are the further classification of GERD?

A

Non-erosive reflux disease
Erosive esophagitis

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21
Q

What are potential complications of GERD?

A
  • Esophagitis
  • Esophageal stricture
  • Esophageal erosions
  • Barrett’s esophagus
  • Esophageal cancer
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22
Q

What are the Red flags for physician referral?

A
  • VBAD symptoms
  • Choking
  • Constant pain
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23
Q

How is GERD typically diagnosed?

A

made based on symptoms after ruling out other causes

Trial course of pharmacological therapy

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24
Q

Who are the candidates for upper endoscopy?

A

Upper endoscopy not typically required. Candidates:
* New onset symptoms (other than reflux/heartburn) >50 (>60) or red flag
symptoms?
* Any alarm features
* Refractory GERD
* At risk for Barrett’s esophagus

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25
Q

What are the risk factors of barrett’s esophagus?

A

At risk for Barrett’s esophagus
* Male, chronic (>5 years) or frequent (>1/week) GERD AND 2 or more of the following:

  • > 50 years of age
  • Caucasian
  • Central obesity
  • Current or past history of smoking
  • Family history of Barrett’s esophagus
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26
Q

What are some of hte other diagnostic tests of GERD?

A

Barium swallow
Esophageal manometry
Ambulatory esophageal pH monitoring

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27
Q

What are the treatment goals of GERD?

A
  • Relieve symptoms
  • Promote healing of injured mucosa
  • Prevent and treat complications
  • Prevent recurrence
  • Avoid issues with long-term use of pharmacotherapy
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28
Q

What are the three main non-pharmacological treatments we should consider?

A
  • Lose and maintain ideal weight
  • Stop smoking
  • Elevate head of bed
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29
Q

What are the 4 main prn and on demand treatments of gerd available (Categories)

A
  • Alginates
  • Antacids
  • Histamine 2 Receptor Antagonists (H2RAs)
  • Proton-pump inhibitors (PPIs)
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30
Q

What are the alinates?

A

Gaviscon formulation

Better than placebo worse than other agents

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31
Q

What are the antacids we should know?

A
  • Aluminum hydroxide
  • Magnesium hydroxide
  • Magnesium trisilicate
  • Calcium carbonate
  • Sodium bicarbonate
  • Combination of above
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32
Q

What are CI with antacids?

A
  • Avoid in severe renal impairment
  • Unless dialysis – calcium carbonate for phosphate binding
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33
Q

What is the MOA of antacids?

A
  • Neutralizes stomach acid
  • Inhibits pepsin generation
  • Binds to bile acids
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34
Q

What is the duration of action of Antacids?

A
  • Rapid acting
  • Short duration of action
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35
Q

What is the general dosing of Antacds?

A
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36
Q

What is the typical dose of elemental per tablet?

A
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37
Q

What are the common side effects of aluminium?

A

Constipation

38
Q

What are the common side effects of magnesium?

A

Laxative effect

39
Q

What are the common side effects of calcium?

A

Well tolerated

40
Q

What are the serious side effects of Aluminum, Mg, Ca

A
  • Aluminum – bone demineralization, neurotoxicity, hypophosphatemia
  • Magnesium – hypermagnesemia
  • Calcium – hypercalcemia, alkalosis
41
Q

What are the DI of antacids?t to chelation

A
42
Q

What are the DI of antacids to impaired absorption?

A
43
Q

What is the efficacy of antacids?

A
  • Limited evidence
  • Slight reduction in symptom severity and frequency
  • Better than placebo, inferior to other agents
  • Possible role of add-on therapy in severe cases
44
Q

What are the 4 H2RAs?

A

Cimetidine
* Famotidine
* Ranitidine
* Nizatidine

45
Q

Which H2RA has the most side effect? Why?

A

Cimetidine, can cross BBB and cause sedation

46
Q

What is the special indication for famotidine?

A

GERD maintenance of remission

47
Q

What are the MOA of H2RAs?

A
48
Q

CI of H2RAs?

A

None

49
Q

What is the onset nad duration of H2RAs?

A
50
Q

When should H2RAs be given?

A

30 – 60 min prior to meal

51
Q

Common side effects of H2RAs?

A
  • Extremely well tolerated
  • Headache, vomiting, diarrhea, drowsiness
52
Q

Common side effect of cimetidine?

A
  • Exception: Cimetidine poorly tolerated
  • Higher rates of above
  • Gynecomastia
53
Q

What are the DI of H2RAs?

A
  • All: decrease absorption of drugs requiring acidity

Cimetidine weakly to moderately inhibits enzymes

54
Q

What is an issue with H2RAs?

A
  • Significant tachyphylaxis demonstrated
55
Q

Are H2RAs better then PPI?

A

No

56
Q

What are the 6 PPIs?

A
  • Rabeprazole
  • Omeprazole
  • Esomeprazole
  • Pantoprazole sodium and magnesium
  • Lansoprazole
  • Dexlansoprazole
57
Q

What is the indication of PPIs?

A
  • Treatment of GERD symptoms
  • Symptomatic relief and healing of erosive esophagitis
  • Symptomatic relief and healing of duodenal and gastric ulcers
  • Prevention of NSAID-induced ulcers
  • Use in H. Pylori eradication regimens
  • Treatment of Zollinger-Ellison syndrome
58
Q

Contraindications of PPIs?

A

No

59
Q

What is Zollinger-Ellison-syndrome?

A

Hyper secretion of acid

60
Q

What is the onset and duration of action of PPIs?

A
60
Q

What is the MOA of PPIs?

A
61
Q

What is the dosage administration of PPIs?

A
62
Q

What is the duration of therapy with respect to GERD?

A

4-8 weeks at standard or double dose

63
Q

What are the indications for double dose ppis?

A
  • If standard dose not effective after adequate trial (~4-8 weeks)
  • Initial presentation of erosive esophagitis
  • Ulcers or GI bleed indications
  • H. Pylori eradication
64
Q

What are the common side effects of PPIs/

A
65
Q

What are the serious side effects of PPIs?

A

Clostridium difficile infection
Microscopic colitis
Hypomagnesemia
Fracture
Fundic gland polyps
B12 Deficiency
Pneumonia
Gastric cancer (Long term usage)
Mortality increase (Concurrent medical conditions)

66
Q

What are the serious side effects not as trusted?

A

Observation studies only indicating

  • All concerns based off low quality evidence with significant confounding
  • Understand there are potential risks
  • Understand PPIs tend to be overused
  • Periodically reassess dose and need for on-going therapy
  • Do not withhold PPIs when benefit demonstrated
67
Q

What is an important DDI with PPIs?

A

Decrease in clopidogrel

68
Q

Which PPIs do not have enzyme effects?

A

Dexlansoprazole, pantoprazole, rabeprazole

69
Q

What is the efficacy of PPIs comparred to H2RAs when comparing intital gerd vs maintenance?

A
70
Q

What are the 2 prokinetic agents?

A

Domperidone and Metoclopramide

71
Q

What is the MOA of prokinetic agents/

A
  • Dopamine antagonists stimulate gastric motility
72
Q

Contraindications of metoclopramide?

A

Contraindications - metoclopramide
* GI obstruction, perforation or hemorrhage
* Seizure disorder
* Extra-pyramidal symptoms
* Parkinsons

73
Q

Contraindications of Domperidone?

A
  • Contraindications – domperidone
  • GI obstruction, perforation or hemorrhage
  • Long QT interval
  • Electrolyte disorders
  • Use with potent 3A4 inhibitors
74
Q

Common side effects of domperidone?

A
  • Dry mouth
  • Mild headache
75
Q

What are the serious side effects of domperidone?

A
  • QT prolongation
  • Gynecomastia
76
Q

What are the two approaches to treatment with GERD?

A
77
Q

What is the summary of efficacy for GERD management?

A
78
Q

What are the monitoring parameters for Safety with respect to antacids?

A

Gauge for overuse, renal function

79
Q

What are the monitoring parameters for Safety with respect to H2RAs?

A

Tachyphylaxis

80
Q

What are the monitoring parameters for Safety with respect to PPIs?

A

Hypomagnesemia
BMD if numerous other risk factors
Increase in C.Diff infections

81
Q

What is considered refractory GERD (3)

A
82
Q

What is the cause of Refractory GERD?

A

medicaiton timing and adherence
Differences in PPI metabolism (2C19, 3A4)
Weakly acidic or alkaline reflux
Reflux hypersensitivity
Alternative diagnoses

83
Q

How might we deprescribe?

A
84
Q

Who should be considered for chronic PPI usage? (4)

A

Barrett’s esophagus
Chronic NSAID users with bleeding risk
Severe esophagitis
Documented history of bleeding GI ulcer

85
Q

When should GERD treatment in infants be considered?

A

Poor weight gain
Blood in sstool or vomitus
Intense irritability temporally related to food intake

86
Q

What are t he warning signs in pediatrics for more serious pathology?

A

Forceful Vomiting
Abdominal tenderness or distension
Fever
Systemic signs

87
Q

What are the safety concerns of acid suppression in pediatrics?

A

Acid rebound
Diarrhea
Pneumonia

88
Q

What should be avoided to use in pregnancy?

A

Sodium bicarbonate and magnesium trisilicate

89
Q

What is the preferred PPI in pregnancy?

A

Pantoprazole

90
Q

What is drug induced esophagitis?

A
91
Q
A

Therapeutics Y2 Sem 2 (17 decks)

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