Gastrointestinal Conditions: GERD & Peptic Ulcer Disease Flashcards
Typical GERD symptoms
heartburn
hypersalivation
regurgitation of contents into mouth/throat
Frequency required to be considered GERD?
> 2 per week
Barrett’s esophagus
abnormal cell growth in the esophageal lining which can lead to esophageal cancer
GERD treatment algorithm
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
Antacids work by….
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
Antacid options
Calcium Carbonate = Tums
Calcium carbonate + magnesium = Mylanta
Magnesium hydroxide = Milk of Magnesia
Calcium carb + magnesium + simethicone = Maalox
Magnesium Hydrocixde + aluminum + simethicone = Mylanta
Antacid warnings
aluminum and magnesium can accumulate with severe renal dysfunction, dont recommend CrCl < 3,
risk of bleeding with aspirin containing products
Antacid side effects
unpleasant taste
Calcium: constipation, bloating, belching
Aluminum: constipation, hypophosphatemia
Magnesium: loose stools
Calcium-containing antacids are preferred in which population?
Pregnancy
H2RA medications
Famotidine = Pepcid
Cimetidine = Tagamet
H2RA warnings
Confusion, usually reversible
Vit B12 deficiency w/ prolonged use > 2yrs
Famotidine = QT prolongation
H2RA side effects
Headache, agitation/vomiting in children < 1yr old
Cimetidine high doses = gyno, impotence
H2RA onset and duration
onset w/in 60min
duration: 4-10hrs
can use in pregnancy
Avoid cimetidine (Tagamet) due to drug interactions
PPI mechanism of action
Irreversibly bind to gastric H+/K+-ATPase in parietal cells, blocking gastric acid secretion
most effective med for GERD
PPI medications
Esomeprazole = Nexium
Lansoprazole = Prevacid
Omeprazole = Prilosec
Dexlansoprazole = Dexilant
Pantoprazole = Protonix
Recommended admin of oral PPIs
Esomeprazole = 60min before breakfast
Lansoprazole = before breakfast
Omeprazole = before breakfast
Dexlansoprazole = without regard to meals
Pantoprazole = tablet doesn’t matter, liquid 30min before meal
PPI warnings
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
Which PPI are available IV?
pantoprazole and esomeprazole
Metoclopramide is used to…
inc motility, accelerated gastric emptying and inc LES tone
Metoclopramide dosing in inc motility
10-15mg QID 30min before meals and at bed time
Metoclopramide boxed warnings
Can cause tardive dyskinesia, inc risk with high doses and > 12wks txm
Metoclopramide warnings
EPS
parkinsonian-like symptoms
NMS = rare
avoid using in Parkinson patients
Metoclopramide side effects
drowsiness
restlessness
fatigue
htn
pro-arrhythmic
diarrhea
Meds to be avoided completely when taking H2RAs and PPIs
dasatinib
pazopanib
DR formulation of risedronte = Atelvia
Erlotinib, rilpivirine, velpatasvir/sofosbuvir (Epclusa) = avoid with PPI
General rule for avoiding antacids
2-4hrs before dose
2-6hrs after dose
for select drugs
Omeprazole/Esomeprazole should not be used with…
clopidogrel, can dec effectiveness
Famotidine should not be used with which kinds of drugs?
high risk QT prolonging drugs
3 most common causes of Peptic ulcer disease
H.pyloria positive ulcers
NSAID induced ulcers
stress ulcers
Diagnostic tests for H.pyloria infection
Urea breath test (UBT)
fecal antigen tests
When is triple therapy recommended instead of quadruple therapy first line in H.pylori
If clarithromycin resistance rates are low ( < 15%) and pt has no previous history of taking a macrolide.
Bismuth Quadruple therapy
take for 10-14 days
Bismuth subsalicylate QID, metronidazole QID, tetracycline QID, PPI BID
Pylera = 3 in 1 QID + PPI BID
Bismuth Quadruple therapy notes
Dont drink alc with metronidazole
Dont use tetracycline during preg or children < 8yrs old
Tinidaole can be sub for metronidazole
Concomitant therapy for H.pylori
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
Clarithromycin Triple therapy
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
Risk factors for NSAID induced ulcers
Age > 60yrs
Hx of PUD
High dose NSAIDs
Using > 1 NSAID
Concomitant use of anticoagulants, steroids, SSRIs and SNRIs
Celecoxib has dec GI risk but inc risk of what
Cardiovascular risk
Who can use PPI with NSAIDs?
pts who have high GI risk
can also use cryptoprotective (misoprostol or sucralfate)
Misoprostol boxed warnings
used for abortions, careful in women childbearing age
Misoprostol side effects
diarrhea
abdominal pain
Sucralfate (Carafate) warnings and side effects
warning: caution renal impairment, can accumulate
Side effect: constipation
