Gastrointestinal Conditions: GERD & Peptic Ulcer Disease

Question 1

Typical GERD symptoms

Answer 1

heartburn
hypersalivation
regurgitation of contents into mouth/throat

Question 2

Frequency required to be considered GERD?

Answer 2

> 2 per week

Question 3

Barrett’s esophagus

Answer 3

abnormal cell growth in the esophageal lining which can lead to esophageal cancer

Question 4

GERD treatment algorithm

Answer 4

Lifestyle modifications: weight loss, avoid high fat meals 2-3hrs before bed, avoid food/drink that trigger it

Initial drug txm: PPI X 8 wks, then stop
Maintenance txm: lowest PPI dose or H2RA if no erosive esophagitis n helps symptoms

Question 5

Antacids work by….

Answer 5

neutralizing gastric acid, increasing gastric pH
relief within min, last only 30-60min

can have serious bleeding if combine with aspirin products ie Alka-Seltzer

Question 6

Antacid options

Answer 6

Calcium Carbonate = Tums
Calcium carbonate + magnesium = Mylanta
Magnesium hydroxide = Milk of Magnesia
Calcium carb + magnesium + simethicone = Maalox
Magnesium Hydrocixde + aluminum + simethicone = Mylanta

Question 7

Antacid warnings

Answer 7

aluminum and magnesium can accumulate with severe renal dysfunction, dont recommend CrCl < 3,
risk of bleeding with aspirin containing products

Question 8

Antacid side effects

Answer 8

unpleasant taste

Calcium: constipation, bloating, belching
Aluminum: constipation, hypophosphatemia
Magnesium: loose stools

Question 9

Calcium-containing antacids are preferred in which population?

Answer 9

Pregnancy

Question 10

H2RA medications

Answer 10

Famotidine = Pepcid
Cimetidine = Tagamet

Question 11

H2RA warnings

Answer 11

Confusion, usually reversible
Vit B12 deficiency w/ prolonged use > 2yrs
Famotidine = QT prolongation

Question 12

H2RA side effects

Answer 12

Headache, agitation/vomiting in children < 1yr old
Cimetidine high doses = gyno, impotence

Question 13

H2RA onset and duration

Answer 13

onset w/in 60min
duration: 4-10hrs
can use in pregnancy

Avoid cimetidine (Tagamet) due to drug interactions

Question 14

PPI mechanism of action

Answer 14

Irreversibly bind to gastric H+/K+-ATPase in parietal cells, blocking gastric acid secretion

most effective med for GERD

Question 15

PPI medications

Answer 15

Esomeprazole = Nexium
Lansoprazole = Prevacid
Omeprazole = Prilosec
Dexlansoprazole = Dexilant
Pantoprazole = Protonix

Question 16

Recommended admin of oral PPIs

Answer 16

Esomeprazole = 60min before breakfast
Lansoprazole = before breakfast
Omeprazole = before breakfast
Dexlansoprazole = without regard to meals
Pantoprazole = tablet doesn’t matter, liquid 30min before meal

Question 17

PPI warnings

Answer 17

C.diff
Vit B12 deficiency w/ use > 2 yrs
osteoporosis related bone fractures w/ high dose/long term use > 1yr
can diminish therapeutic effect of clopidogrel

Question 18

Which PPI are available IV?

Answer 18

pantoprazole and esomeprazole

Question 19

Metoclopramide is used to…

Answer 19

inc motility, accelerated gastric emptying and inc LES tone

Question 20

Metoclopramide dosing in inc motility

Answer 20

10-15mg QID 30min before meals and at bed time

Question 21

Metoclopramide boxed warnings

Answer 21

Can cause tardive dyskinesia, inc risk with high doses and > 12wks txm

Question 22

Metoclopramide warnings

Answer 22

EPS
parkinsonian-like symptoms
NMS = rare
avoid using in Parkinson patients

Question 23

Metoclopramide side effects

Answer 23

drowsiness
restlessness
fatigue
htn
pro-arrhythmic
diarrhea

Question 24

Meds to be avoided completely when taking H2RAs and PPIs

Answer 24

dasatinib
pazopanib
DR formulation of risedronte = Atelvia

Erlotinib, rilpivirine, velpatasvir/sofosbuvir (Epclusa) = avoid with PPI

Question 25

General rule for avoiding antacids

Answer 25

2-4hrs before dose
2-6hrs after dose

for select drugs

Question 26

Omeprazole/Esomeprazole should not be used with…

Answer 26

clopidogrel, can dec effectiveness

Question 27

Famotidine should not be used with which kinds of drugs?

Answer 27

high risk QT prolonging drugs

Question 28

3 most common causes of Peptic ulcer disease

Answer 28

H.pyloria positive ulcers
NSAID induced ulcers
stress ulcers

Question 29

Diagnostic tests for H.pyloria infection

Answer 29

Urea breath test (UBT)
fecal antigen tests

Question 30

When is triple therapy recommended instead of quadruple therapy first line in H.pylori

Answer 30

If clarithromycin resistance rates are low ( < 15%) and pt has no previous history of taking a macrolide.

Question 31

Bismuth Quadruple therapy

Answer 31

take for 10-14 days

Bismuth subsalicylate QID, metronidazole QID, tetracycline QID, PPI BID

Pylera = 3 in 1 QID + PPI BID

Question 32

Bismuth Quadruple therapy notes

Answer 32

Dont drink alc with metronidazole
Dont use tetracycline during preg or children < 8yrs old

Tinidaole can be sub for metronidazole

Question 33

Concomitant therapy for H.pylori

Answer 33

take 10-14 days, use if low resistance to clarithromycin and no previous macrolides, preferred over Clarithro triple if previous macrolide exposure

Amox 1g BID
Clarith 500mg BID
Metro 500mg BID
PPI BID

Question 34

Clarithromycin Triple therapy

Answer 34

take for 14 days, if low resistance and no previous macrolide exposure

Amox 1g BID, Clarith 500mg BID, PPI BID

3in1 = Prevpac (amox+clarith+lansoprazole)

if PCN allergy, can replace amox with metro

Question 35

Risk factors for NSAID induced ulcers

Answer 35

Age > 60yrs
Hx of PUD
High dose NSAIDs
Using > 1 NSAID
Concomitant use of anticoagulants, steroids, SSRIs and SNRIs

Question 36

Celecoxib has dec GI risk but inc risk of what

Answer 36

Cardiovascular risk

Question 37

Who can use PPI with NSAIDs?

Answer 37

pts who have high GI risk
can also use cryptoprotective (misoprostol or sucralfate)

Question 38

Misoprostol boxed warnings

Answer 38

used for abortions, careful in women childbearing age

Question 39

Misoprostol side effects

Answer 39

diarrhea
abdominal pain

Question 40

Sucralfate (Carafate) warnings and side effects

Answer 40

warning: caution renal impairment, can accumulate

Side effect: constipation