final exam lecture 4 Flashcards by Matti Daniel

causes of GERD

decrease in esophageal resistance
Lower LES pressure (sphincter is more relaxed and open)
delayed gastric emptying
acid pocket formation

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Foods that decrease LES pressure

chocolate

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Foods that irritate esophageal mucus

spicy/acidic food

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medications that decrease LES pressure

Tetracyclines caffeine

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Medications that directly irritate esophageal mucosa

Aspirin, NSAID, Bisphosphonates

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Name the two categories of clinical presentation of GERD

Symptom based (heart burn, regurgitation, chest pain)
Extraesophageal (cough, laryngitis, wheezing, asthma)

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3 key symptoms of symptom based GERD

Heartburn
regurgitation
Reflux chest pain

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Extraesophageal symptoms

Wheezing, asthma, laryngitis, cough

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What are alarm symptoms for GERD

Dysphagia (difficulty swallowing)
Bleeding
odynophagia (painful swallowing)
weightloss

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Length of OTC GERD symptoms?
Length of Px treatment

2 weeks for OTC
8 weeks for Px

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Name the treatment options for GERD

Lifestyle mods
PRN meds (antacids, H2RAs)
Scheduled meds (PPIs)
Surgery

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PRN meds for GERD

Antacids, H2RAs

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scheduled meds for GERD

PPIs, H2RAs

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1st line of therapy for GERD symptoms

Lifestyle mods

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2nd line of therapy for GERD

OTC TREATMENT
Infrequent symptoms- Antacids PRN
or
Mild/moderate- H2RA or PPI for 14 days

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When to refer for GERD symptoms

14 day trial with OTC med

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3rd line of treatment for GERD. What to do if failed

PPIx8 weeks. If failed, try different PPI

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lifestyle mods for GERD

fatty meals
carbonated beverages
stop smoking
sleep on left side
sleep with head elevated
lose weight

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not recommendable for GERD

Alcohol
caffeinated beverages

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How do antacids help with GERD

offer immediate symptomatic relief by neutralizing stomach acid.

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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

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onset and duration for antacids

5 min onset and 30-60 min duration

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Common drug interactions for antacids

Antimicrobials (fluoroquinolones, tetracyclines, azole antifungals)
LEVOTHYROXINE
Iron
Steroid
digoxin
HIV meds

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When to take medications when taking Antacids

2 hours before or 4-6 hours after antacids

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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