GERD Flashcards
When LES pressure is low, it is ___ for stomach contents to flow back into the esophagus.
easier
this is bad
Which of the following mechanisms is known to cause or increase the risk of developing GERD?
A) faster gastric emptying
B) higher LES pressure
C) increase in esophageal mucosal resistance
D) acid pocket formation
acid pocket formation
extraesophageal symptoms
* ___ cough
* laryngitis
* wheezing
* ___
- chronic
- asthma
i
immediate medical attention
* dysphagia (difficulty ___ )
* odynophagia
* bleeding
* ___ % unexplained weight loss
automatic referal
- swallowing
- 5%
Rx therapy for GERD should last for ___ weeks
8
OTC therapy for GERD should last ___ weeks
2
diagnostic tests
upper ___ - preferred for assessing mucosal injury and complications
endoscopy
diagnostic tests
___ pH test (+ impedance) - useful for patietns not respodning to acid suppression after normal endoscopy
reflux
diagnostic tests
manometry (+/- impedance) - useful for patients who failed 2 trials of ___ with normal endoscopy findings to identify motor dysfunction
PPIs
looking for functions of the esophagus
diagnostic tests
___ radiography - lacks sensitivity + specificity; not routinely recommended
Barium
Complications of GERD
- ___ esophagitis
- Stricture ( ___)
- ___ esophagus
- ___ (cancer)
- erosive
- narrowing
- Barrett’s
- adenocarcinoma
prn medications for GERD
- antacids
- H2RAs
scheduled medications for GERD
- H2RAs
- PPIs
GERD treatment steps
- lifestyle modifications
- OTC treatments
- Rx treatment (___ weeks )
- If Rx fails, ___
- Surgery
- 8 weeks
- switch
REFER
- ___ symptoms
- OTC trial longer than ___ days with no relief
- alarm
- 14
Antacids
- ___ relief
- make intragastic pH > ___
- decrease activation of pepsinogen to ___
- increased ___ pressure
- immediate
- 4
- pepsin
- LES
T or F: only antacids increase LES pressure
True
antacids
caution in patients with ___ impairment taking ___ or ___ containing products
- renal
- calcium
- aluminum
Side effects of antacids
Calcium
* constipation
* ___ - alkali syndrome
Magnesium
* ___
* accumulation
Aluminium
* consitpation
* ___/neurotoxicity
- milk
- diarrhea
- confusion
Antacid Drug Interactions
affects ___ of :
* fluroquinolones
* tetracyclines
* azole antifungals
* levothyroxine
* Fe
* steroids
* digoxin
* HIV meds
* select oral antineoplastics
absorption
antacid drug interactions
take medications ___ hours before or ___ hours after antacids
- 2 hrs
- 4-6 hrs
single element containing antacids (2)
- Tums (calcium carbonate)
- Milk of Magnesia (magnesium hydroxide)
mixed antacids (4)
- Al + Mg: Maalox and Gaviscon (+ alginate acid)
- Al + Mg + simethicone: Mylanta, Maalox advanced max strength
- Ca + Mg: Rolaids, Mylanta Ultra
- Ca + simethicone: Alka-Seltzer heart burn + gas, Tums gas relief
Brand name
sodium bicarbonate + ASA + citric acid
Alka-Seltzer
Brand name
bismuth subsalicylate
Pepto-Bismol
Brand name
simethicone
Gas-X
T or F: Alka-Selzer is approved for children < 12 years
FALSE; ASA can cause Reye’s syndrome
H2RAs
MOA: ___ inhibition of histamine receptors in ___ cells
- reversible
- parietal
Tums dosing: ___ tablets PRN up to 4x/day
Max: ___ tabs/day
- 2-4
- 16
Milk of Magnesia dosing: ___ mL PRN up to 4x/day
Max: ___mL/day
- 5-15
- 60
Maalox dosing: ___ mL PRN or at meals + bedtime up to 4x/day
Max: ___ mL/day
- 10-20
- 80
Gaviscon dosing: ___ tablets or ___ mL at meals + bedtime 4x/day
Max: ___ tabs/day
- 2-4
- 10-20
- 16
H2RAs
Famotidine (___)
OTC: 10-20 mg up to ___ (Max ___ mg/day)
Rx: ___ BID prn ___ minutes before trigger foods
* if symptoms persist after 2-4 weeks, increase to ___ mg BID for ___ weeks; if symptoms improve, may continue therapy if needed
* onset: ___ hours
* Duration ___ hours
* CrCL < 50 mL/min: give ___% of dose
- Pepcid
OTC: BID, 40 mg/day
Rx: 10 mg, 10-60 min - 20 mg, 2 weeks
- 1-3 hrs
- 10-12 hrs
- 50%
H2RAs
Cimetidine (___)
OTC/Rx: ___ mg daily up to ___ min prior to trigger foods (Max: ___ mg/day)
* onset: ___ hr
* duration: ___ hrs
* only adjust dose with ___ renal impairment
* MANY drug reactions via ___
* not commonly used
- Tagamet
- 200 mg, 30 min, 400 mg/day
- 1 hr
- 4-5 hrs
- severe
- CYPs
H2RAs
Nizatidine (___)
Rx only: ___ mg BID
* adjust dose in renally impaired patients
* Onset: ___ hrs
* Duration: ___ hrs
* not readily available/commonly used. Small revival after ___ was pulled from the market
- Axid
- 150 mg
- 0.5-3 hrs
- 5-10 hrs
- ranitidine
H2RA Side Effects
- Headache
- dizziness/fatigue
- constipation or diarrhea
- Somnolense Confusion/___
- agitation
- ___ deficiency (long term use)
Increased with risk if > 50 years with renal/hepatic impairment
- delirium
- B12
B12 is absorbed and activated in the stomach
H2RAs: Pearls
- ___ occurs with long term use
- ___ Criteria - avoid in patients with/high risk of ___
- used alone or in combination with other classes to treat mild to moderate GERD
- NOT as efficacious as ___
- all H2RAs are considered equally efficacious
- useful in treatment of ___ symptoms
- tachyphylaxis
- Beer’s, delirium
- PPIs
- nocturnal
Which H2RA has the most concern for lots of drug-drug interactions?
A) ranitidine
B) famotidine
C) cimetidine
D) nizatidine
cimetidine
T or F: H2RAs are equally as efficacious as PPIs
False; PPIs are stronger bc they almost completely inhibit acid production
PPIs
MOA: ___ inhibition of proton/potassium ATPase in ____ cells
- irreversible
- parietal
T or F: PPIs do NOT require renal dose adjustments
True
PPIs
Dexlansoprazole (___)
* NO complications: ___ mg daily
* Complications: ___ mg daily for ___ weeks then ___ mg indefinitely
* Onset: ___ hr, then ___ hr
* Duration: ___ hr
* ___ formulation allows 2 different onsets
* can be taken without regard to ___
- Dexilant
- 30 mg
- 60 mg, 8 weeks, 30 mg
- 1-2 hrs, 4-5 hrs
- 16-18 hrs
- dual
- meals
PPIs
Lansoprazole ( ___ )
* Rx: __ mg daily
* OTC: ___ mg daily for ___ days; may repeat in ___ months if needed
* Onset: ___ hrs
* Duration: ___ days
* can open contents of capsule and mix in ___ only
* ___ tablet available
* administer ___ minutes before a meal
- Prevacid
- 15-30mg
- 15 mg, 14 days, 4 months
- 1-3 hrs
- > 1 day
- water
- oral disuntegrating tablet
- 30-60 minutes
PPIs
Omeprazole ( ___ )
* OTC: ___ mg daily for ___ days; may repeat in ___ months if needed
* Rx: ___ mg daily
* when combined with ___, product becomes the only immediate release PPI
* administer ___ min before a meal
* metabolzed by CYP ___
* Onset: ___ hr
* Duration: up to ___ hrs
- Prilosec
- 20 mg, 14 days, 4 months
- 10-40 mg daily
- sodium bicarbonate
- 30-60 min
- CYP2C19
- 1-3 hr
- 72 hrs
PPIs
Pantoprazole ( ___ )
* PO Rx: ___ mg daily
* IV Rx: ___ mg daily
* tablet cannot be ___ or ___
* administer ___ min before a meal
* most common PPI found on hospital formularies
* Onset PO: ___ hrs
* Onset IV: ___ min
* Duration: ___ hrs
Protonix
* 20-40 mg
* 40 mg
* crushed, altered
* 60 min
* 2.5
* 15-30 min
* 24 hrs
PPIs
Rabeprazole ( ___ )
* Rx: ___ mg daily
* can open contents of capsule, but cannot crush tablet
* administer ___ min before a meal
* Onset: ___
* Duration: ___
AcipHex
* 10-20 mg
* 30 min
* 1 hr
* 24 hrs
Rx only
PPI drug interactions
biggest interactions from ___ and ___
* Increase effect (3)
* Decrease effect (4)
omeprazole and esomeprazole
* methoytexate, phenytoin, warfarin
* iron, bisphosphonates, HIV/HCV drugs, clopidogrel
PPIs Short Term Side Effects
- headache
- dizziness
- diarrhea
- flatulence
- nausea
- abdominal pain
- enteric infections ( ___ )
- community-acquired ___
- C. diff
- pneumonia
PPIs Long Term Side Effects
- hypomagnesemia ( due to less ___ )
- bone density decrease/fractures ( less ___ absorption)
- vitamin ___ deficiency
- chronic ___ disease
- absorption
- Ca2+
- B12
- kidney
Which PPI interacts wih clopidogrel and may decrease its effectiveness (meaning it should be avoid if at all possible).
A) Omeprazole
B) Lansoprazole
C) Pantoprazole
D) Dexlansoprazole
Omeprazole
Prokinetic Drugs
- metoclopramide and ___
- used as adjunct therapy is known ___ defect
- problems: these have ___ side effects and are not as effective as ___ suppression therapy
- ___ is NOT recommended
- Sucralfate - NOT useful in GERD management unless ___ reflux GERD present
- bethanechol
- motility
- undesireable, acid
- baclofen
- nonacid
Combination Therapy
antacids + H2RAs
* helpful for heartburn after ___
* Pepcid AC = ___
PPIs + H2RAs
* nighttime administration of a single H2RA dose can help with ___ acid production
* ___ can also help with ___ heartburn
- eating
- famotidine + calcium carbonate and magnesium
- nocturnal
- H2RAs, breakthrough
PPI Clincal Pearls
- ___ formulation is just as effective as PO
- All PPIs are considered equally efficacious
- patients who do not respond to an initial PPI trial should be switched to a different PPI with ___ effective dose
- ___ dosing for patients who faily once daily max tolerated dose PPIs
- when discontinuing after long term theraly, consider ___ due to risk of ___
- Beer’s Criteria
- IV
- lowest
- BID
- tapering, rebound hyperacidicty
Surgery
- anti-reflux surgery focuses on restoring normal ___ pressure
indicated if : - long term therapy is undesireable
- persistent symptoms or damage despite appropriate therapy
- presence of ___ hernia
- LES
- hiatal
Special Populations: Pregnancy
First line: lifestyle recommendations
First line meds: antacids or ___
Second line: ___
Last line: ___ reserved for complications of GERD or treatment failure (exception: ___)
- sucralfate
- H2RAs
- PPIs, omeprazole
Special Populations: Lactation
- ___ and ___ are present in breastmilk
- low risk to infants at standard doses
- stick to ___
- PPIs and H2RAs
- antacids
T of F: GERD symptoms occur in 2/3 of pregnancies
True
Special Populations: Kiddos
Symptoms/Signs
* refusing to eat
* wheezing/coughing
* ___ erosion
* recurrent ___ or belching irritability
Alarm Symptoms
* Weight loss
* fever
* seizure
* persistent vomiting/diarrhea
- dental
- regurgitation
Pediatric GERD Non-Pharm Options
- ___ formula/foods
- ___ volume of intake
- ___ free diet
- ___ therapy
- thickening
- decrease
- milk
- positioning
Pediatric Meds for GERD
PPIs and H2RA’s
* treat for ___ weeks
* only for diagnosed GERD or ____
Simethicone and Probiotics: safe ___
Herbal options: ___ , ___ , or ___
Antacids
* should not use ___
* do not use ___ or ___ in children < 12
- 4-8 weeks
- esophagitis
- OTC
- peppermint, ginger, chamomile
- aluminum or bismuth subsalicylate
T or F: Children’s Pepto is safe to use in kids under 12 years old
True! children’s “pepto” is just calcium carbonate
