final exam lecture 4 Flashcards
causes of GERD
decrease in esophageal resistance
Lower LES pressure (sphincter is more relaxed and open)
delayed gastric emptying
acid pocket formation
Foods that decrease LES pressure
chocolate
Foods that irritate esophageal mucus
spicy/acidic food
medications that decrease LES pressure
Tetracyclines caffeine
Medications that directly irritate esophageal mucosa
Aspirin, NSAID, Bisphosphonates
Name the two categories of clinical presentation of GERD
Symptom based (heart burn, regurgitation, chest pain)
Extraesophageal (cough, laryngitis, wheezing, asthma)
3 key symptoms of symptom based GERD
Heartburn
regurgitation
Reflux chest pain
Extraesophageal symptoms
Wheezing, asthma, laryngitis, cough
What are alarm symptoms for GERD
Dysphagia (difficulty swallowing)
Bleeding
odynophagia (painful swallowing)
weightloss
Length of OTC GERD symptoms?
Length of Px treatment
2 weeks for OTC
8 weeks for Px
Name the treatment options for GERD
Lifestyle mods
PRN meds (antacids, H2RAs)
Scheduled meds (PPIs)
Surgery
PRN meds for GERD
Antacids, H2RAs
scheduled meds for GERD
PPIs, H2RAs
1st line of therapy for GERD symptoms
Lifestyle mods
2nd line of therapy for GERD
OTC TREATMENT
Infrequent symptoms- Antacids PRN
or
Mild/moderate- H2RA or PPI for 14 days
When to refer for GERD symptoms
14 day trial with OTC med
3rd line of treatment for GERD. What to do if failed
PPIx8 weeks. If failed, try different PPI
lifestyle mods for GERD
fatty meals
carbonated beverages
stop smoking
sleep on left side
sleep with head elevated
lose weight
not recommendable for GERD
Alcohol
caffeinated beverages
How do antacids help with GERD
offer immediate symptomatic relief by neutralizing stomach acid.
side effects of antacids
Calcium- causes constipation and mild alkali syndrome
Mg causes Diarrhea and accumulation
Al causes constipation and confusion
All can cause nausea and vomiting
onset and duration for antacids
5 min onset and 30-60 min duration
Common drug interactions for antacids
Antimicrobials (fluoroquinolones, tetracyclines, azole antifungals)
LEVOTHYROXINE
Iron
Steroid
digoxin
HIV meds
When to take medications when taking Antacids
2 hours before or 4-6 hours after antacids
Tums dosing? max number of tabs?
2-4 tabs PRN up to 4X/day
Max- 16 tab/day
most common side effect for CaCO3
Constipation
Most common side effect for MgOH
Diarrhea (MEGA BOWEL MOVEMENTS)
AL- ALL BACKED UP
What elements does maalox contain
Al+Mg+Simethicone
Which medications not to recommend for children under 12 due to reyes syndrome
Alkaseltzer
peptobismol (BSS)
Simethicone (GAS-x)
What side effect to expect from milk of magnesia
Diarrhea (Mg)
Mechanism of H2RAs
reversible inhibition of histamine receptor in parietal cells, decreasing the amount of acid
Most common H2RA
Famotidine (PEPCID)
Dosing of famotidine (PEPCID) (OTC and Rx)
OTC- 10-20 mg up to bid
MAX- 40 mg/day
RX- 10 mg BID PRN
10-60 mins before trigger foods
If symptoms persist after 2-4 weeks increase to 20 Mg BID
Name H2RA drugs
Famotidine (Pepcid)
Cimetidine(tagamet)
Cimetidine (tagamet) dosing
OTC/RX 200 mg daily
30 mins prior to trigger food
Lots of drug-drug interactions
side effects of H2RAs
headache, dizziness, constipation or diarrhea
delirium(in those above 50 yo)
B12 deficiency with longterm use
H2RA clinical pearls
Tachyphylaxis- longer use leads to lower effectiveness
On beers criteria- avoid in pateints with or at risk for delirium
famotidine is the best in class
PPI moa
irreversible inhibition of proton pump
Name PPI drugs
Dexlansoprazole (dexilant)
Esomeprazole(nexium)
Lansoprazole (prevacid)
Omeprazole
pantoprazole (protonix)
rabeprazole(aciphex)
All ER except omeprazole
Dexlansoprazole (dexilant) dosing
No complications present- 30 mg daily
Complications present- 60 mg daily x 8 weeks then 30 mg indefinitely
ER
Dual release allows 2 different onsets
Only PPI that is taken without regard to meals
Esomeprazole (nexium) dosing
PO rx 20-40 mg daily
IV RX 20-40 mg daily
OTC- 20 mg daily x 14 days- may repeat course in 4 months if needed (refer if it has not been 4 months0
must be taken 60 mins before meals
Lansoprazole (prevacid) dosing
Rx 15-30 mg daily
OTC 15 mg daily for 14 days, may repeat in 4 months if needed
administer 30-60 mins before meal
Which PPI drug is the only one that is not ER
Omeprazole
omeprazole dosing
OTC- 20 mg daily x 14 days, may repeat in 4 months if needed
Rx- 10-40 mg daily
only IR formulation available
30-60 min before meal
The only two IV PPIs available
Pantoprazole (prilosec)
Esomeprazole
Pantoprazole dosings
Po rx- 20-40 mg
IV rx 40 mg
Tablet can not be crushed
60 min before meal
Rabeprazole (aciphex) dosing
Rx only- 10-20 mg
30 min before meal
Which PPIs do not need renal dose adjustements
No renal dose adjustments for all
side effects of PPIs (short term)
Headache, dizziness, diarrhea, flatulence, nausea
Side effects of PPIs (long term)
Hypomagnesemia
bone density decrease
vit b12 deficiency
CKD
Which drugs are cyp2c19 inhibitors
Omeprazole and esomeprazole
(increase and decrease effects of different meds)
Use of PPI and H2RA combo
reduces nocturnal symptoms
GERD treatment for pregnant women
1st- lifestyle recommendations
if fails then
1st- Antacids or sucralfate
2nd line- H2RAs
Last line- any PPI except omeprazole
GERD treatment for lactating mothers
PPIs and H2RAs are present in breast milk.
Use antacids
symptoms of GERD in pediatric population
Refusing to eat
wheezing
dental erosion
regurgitation
nonpharm options for infants experiencing GERD
Thickening formula/foods
Decreasing volume of intake
Milk free diet
Positioning therapy
Drugs to avoid in children experiencing GERD? What should be used to treat GERD
Aluminum and bismuth subsalicylate. PPIs and H2RAs
3 different causes of PUD
H. Pylori
NSIAD
Stress
Which PUD causes are chronic? Which are acute?
H pylori and NSAID are chronic
Stress is acute
Site of damage in the different causes of PUD
H pylori- Duodenal
NSAID- stomach
Stress- stomach
Which cause of PUD is dependent on intergastric PH
H.pylori
Ulcer depth of the different types of PUD
H. pylori- Superficial
NSAID- Deep
Stress- most superficial
Aggressive vs protective factors for PUD
aggressive- pepsin, NSAID, H. Pylori, Gastric acid
Protective factors- Blood flow to mucosa, bicarbonate, prostaglandins and mucus
How do we know if it is duodenal or stomach PUD
If pain relieves with food, it is duodenum
if worsens it is stomach
Non- pharmacologic treatment for PUD
AVOID NSAIDS
reduce stress
how do we treat PUD caused by H. Pylori
PPI + 2-3 antibiotics
number 1 preferred regimen used for H pylori treatment
QUADRUPLE therapy
PPI BID
BSS
Metronidazole
tetracycline X10-14 days
Which convenience package includes metronidazole, tetracycline and BSS
Helidac (14 days)or pylera(10 days). Must take PPI BID separately
