Fitzaekerly: Anti- Ulcer Lecture Notes Flashcards
A pregnant woman w/ a duodenal ulcer has been shown to have a positive stool test for h. pylori. If you choose to tx the infection as well as the lesion this pt should be tx w/?
Omeptrazole + amoxicillin + clarithromycin
What drugs would you NOT want to use when treating a pregnant woman?
Tetracycline (teratogen)
Misoprostol (aborficant)
What is the focus of PUD tx in a woman who is pregnant?
Acid suppression
PPIs are LOW RISK
How do you tx a woman who is pregnant and has a PUD if h. pylori is present?
tx is deferred until after delivery unless a woman has severe nausea/vomiting and hyperemesis gravidarum
(clarithro, amox and metronidazole could be used)
What PUD antibiotics are considered possibly unsafe for nursing infants?
bismuth
metronidazole
Which of the following drugs would be the MOST LOGICAL addition to a regimen containing amoxicillin, clarithromycin and tinidazole if the goal is to successfully treat a patient with a duodenal ulcer?
Rabeprazole
**something to REDUCE PAIN is missing…PPI (-prazole)
What drug is bacteriocidal, but may cause a disulfirum-like reaction?
Tinidazole (can make alcoholic sick)
*metronidazole is more frequently taken
Which drug accumulates in parietal cell canaliculi and undergoes conversion before irreversibly inhibiting H+/K+ ATPase?
Lansoprazole
*goes through circulation then accumulates in an acidic compartment
Associate the SE w/ the drug:
- Hypersensitivity
- Muscle pain and weakness
- Milk
- Anorexia, N/V, diarrhea
- Gynecomastic and galactorrhea
- Hypersensitivity= amoxicillin
- Muscle pain and weakness= statins
- Milk= Ca carbonate
- Anorexia, N/V, diarrhea= clarithromyacin
- Gynecomastic and galactorrhea= cimetidine (H2 blocker)
A 72-year-old female reports burning pain under her breastbone. The pain is worse at night, and can sometimes be alleviated by eating. Her stool is dark black, and she also complains of a loss of appetite. She has been taking naproxen for treatment of rheumatoid arthritis for 25 years, and was successfully treated for a duodenal ulcer 15 years ago. She has been taking OTC cimetidine for the past few months, when the pain seems really bad. She has normal renal and hepatic function.
Which of the following changes to her drug regimen would MOST DIRECTLY and EFFECTIVELY treat the cause of her ulcer?
This pt has an NSAID induced ulcer. To most directly tx this cause you want to replace PGE in the gut. This can be done w/ misoprostol. Diclofenac is an NSAID that is less likely to affect the gut.
Switching naproxen for misoprostol + diclofenac
What side effect(s) is (are) unique to cimetidine and are MOST LIKELY to be observed in this patient?
Cimetidine is an H2 receptor antagonist and it’s main adverse affect is inhibition of hepatic drug metabolizing enzymes.
What does misoprostol do?
Big picture: Decreases acid production and stimulates mucous and bicarb secretion.
Misoprostol is a synthetic PGE1 so it won’t interfere w/ cox. the PGE receptor works in opposition to the H2 receptor (they antagonize each other) so it will also decrease acid secretion.
A 45-year-old man with a confirmed duodenal ulcer is taking OTC ranitidine (H2 blocker), which is incompletely managing his pain. What is the best tx option for this pt?
Lansoprazole + Bismuth + Tetracycline + Metronidazole
There is a high probability that this pt’s ulcer is caused by h. pylori so you need to give multiple antibiotics.
A pt is tx w/ quadruple therapy: (lansoprazole + bismuth + tetracycline + metronidazole).
Which of the following mechanisms of action is NOT represented in this therapy?
Disruption of bacterial cell wall
Inhibition of proton pump
Binding to bacterial ribosomal 50S subunit
Binding to bacterial ribosomal 30S subunit
Clarithromycin binds to 50S. (which he is not taking)
Tetracycline binds to 30S.
Inhibition of the PP –prazole.
Bismuth disrupts bacterial cell wall.
High doses of bismuth subsalicylate can cause…
vomiting, tinnitus, confusion, hyperthermia, respiratory alkalosis and metabolic acidosis.
A 45-year-old man with a gastric ulcer is being treated with esomeprazole and bismuth subsalicylate, as well as tetracycline and metronidazole for 14 days.
Which of the following OTC drugs is MOST LIKELY to increase the probability of treatment failure?
Acetylsalicylic acid Alcohol Magnesium hydroxide Ranitidine Simethicone
Magnesium hydroxide can chelate tetracycline. This increases hte likelihood of treatment failure b/c you don’t get a high enough conc of the drug to get rid of the bug.
Alcohol and NSAIDS- induce ulcers
Ranitidine: is eliminated the same way as metronidazole so you’d have competition for elimination which would INCREASE conc of metronidazole.
Is omeprazole or esomeprazole more effective in people w/ a particular CYP2C19 isozyme (poor metabolizers)? Which one has less of the active ingredient?
esomeprazole
omeprazole
These drugs BOTH require a protective coating against acid in the stomach.
Omeprazole and esomeprazole
These drugs inhibit active proton pumps and depend on timing of drug administration.
PPIs
“all PPIs depend on timing of drug administration—half hour before meal—want to go through stomach and get into SI before stomach starts contracting. Then has to be absorbed by SI, get into blood, and get around to stomach while pumps are active.”
An elderly patient in the intensive care unit develops a stress ulcer, and the decision is made to treat with intravenous pantoprazole. What is an appropriate alternative treatment?
bismuth subsalicylate. calcium carbonate. metronidazole. misoprostol. nizatidine. sucralfate
Sucralfate (protectant)
Bismuth and Ca carbonate are not usually used to treat ulcers in the ICU.
Metronidazole and misoprostol are usually used w/ an h. pylori infection NOT a stress ulcer.
Nizatidine is an H2 blocker….if a PPI like Sucralfate can’t work it’s not likely that Nizatidine will work.
A pt being treat w/ intravenous pantoprozale is at risk for….
C. Dificile infection
Reducing gastric acid raises pH and reduces ability to kill off bugs which can increase the risk of infection.
What are the differences between oral vs. IV pantoprazole? Similarities?
bioavailability
Drug half life of the two is the SAME so you can give it orally once daily.
When do you want to give oral pantoprazole?
when motility is LOW
BEFORE food
What is the BEST anti-ulcer tx for a pt with ZE syndrome?
Lansoprazole
ZE syndrome means that the pt has a tumor that secretes gastrin and INCREASES acid secretion so you want to DECREASE acid secretion.
A PPI is the best way to do this. H2 blockers wouldn’t be good enough.
After consuming most of a large Italian sausage, pepperoni, marinated chicken, ground beef and Canadian bacon pizza, you experience a burning sensation behind your sternum. You choose to treat this by taking some Ca CARBONATE. What tx would reduce these sxs more slowly but for a longer period of time?
Magnesium and aluminum hydroxide (both are antacids that are much slower than ca carbonate)
What is a COMMON SE of Ca carbonate?
Belching
SE of Na bicarbonate?
systemic absorption > severe metabolic alkalosis
SE of Al OH2?
constipation
If you were to consume large amounts of sodium bicarbonate instead of calcium carbonate every time you eat pizza, you might expect to experience:
This would RAISE pH and alkalinize the urine.
Increased absorption of orally-administered drugs that are weak bases.
Decreased renal excretion of drugs that are weak bases.
A 25-year-old woman who is 2 months pregnant comes to your officecomplaining of heartburn and food regurgitation.Her symptoms began shortly after her pregnancy was confirmed.
Which of the following would be theBEST INITIAL treatment for this patient?
Nothing!!
In a pregnant pt one of the first things you should do is try to change life style and NOT include medication.
A doctor would advise a pt taking tetracycline/metronidazole to….
stay out of the sun and avoid drinking alcohol
