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PHAR 255 > GERD > Flashcards

GERD Flashcards

1
Q

Dyspepsia?

A

epigastric pain or discomfort originating from upper GI tract

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2
Q

GERD?

A

reflux of gastric content into esophagus –> very specific cause of dyspepsia

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3
Q

Term if no abnormalities found but have symptoms of dyspepsia?

A

functional dyspepsia

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4
Q

What are pts most commonly GI complaint categorized into?

A

uninvestigated dyspepsia

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5
Q

Potential mechanisms of functional dyspepsia?

A

gastric motility and compliance
visceral hypersensitivity
heliobacter pylori infection
altered gut microbiome
duodenal inflammation
psychosocial dysfunction; anxiety, depression, stress

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6
Q

When does functional dyspepsia treatment change (what cause)?

A

when heliobacter pylori infection

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7
Q

Risk factors for dyspepsia?

A

dietary indiscretion (over eating)
medications
H. pylori
anxiety
IBS
SMoking and alcohol use –> may not cause but worsen dyspepsia

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8
Q

Medications that can cause dyspepsia?

A

Bisphosphonates
Iron
NSAIDs
Potassium
TONS more but those are bolded ones

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9
Q

Main symptoms of dyspepsia?

A

epigastric pain or discomfort
fullness or early satiety
Nausea
upper abdominal bloating
excessive burping or belching
Heartburn and regurgitation –> more likely GERD (which is still dyspepsia but just a defnitive cause)

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10
Q

What is required to be considered dyspepsia?

A

greater than 1 month duration, relapse

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11
Q

Main alarming symptoms in regards to needing diagnositc work-ups?

A

vomitting
bleeding/anemia
abdominal mass or unexplained wt loss
dysphagia or odynophagia ( difficulty swallowing, painful swallowing)
Other important:
chest pain
choking

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12
Q

VBAD ?

A

vomitting
bleeding
abnormal mass
Dysphagia or odynophagia

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13
Q

What to do if any of the VBAD symptoms are present?

A

refer to doc for diagnostic assessments such as endoscopy

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14
Q

Dyspepsia vs GERD?

A

Dyspepsia is general umbrella term
GERD is a subset of dyspepsia main symptoms of heart burn and regurgitation

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15
Q

What is the main step in diagnosing dyspepsia?

A

eliminating other potential causes as the culprit

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16
Q

Steps of dyspepsia diagnosis?

A
  1. eliminate other potential causes as culprit
  2. upper GI location?
  3. New onset of symptoms? other than heartnurm and reflux, >50yrs, red flag symptoms?
  4. NSAID use?
  5. Reflux or regurgitation main symptoms?
  6. H. pylori present?
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17
Q

What % of canadians have some degree of dyspepsia?

A

30%

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18
Q

Age impacted the most for dyspepsia?

A

all ages impacted equally

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19
Q

GERD definition?

A

reflux of stomach acid contents into esophagus, possibly leading to reflux esophagitis or erosive esophagitis.

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20
Q

Causes of GERD?

A

defective lower esophageal sphincter
Increased intra-abdominal
Hiatal hernia
Impaired esophageal peristalsis
delayed gastric emptying
excessive gastric acid production?

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21
Q

reflux esophagitis or erosive esophagitis more common?

A

Reflux 70%
erosive 30%

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22
Q

Risk factors of GERD?

A

Obesity
Pregnancy
Family history
Smoking
Increased ag >65
Hiatal hernia
Stress and Anxiety
Medications
Diet (over eating mainly)

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23
Q

Drugs that induce GERD?

A

Anticholinergics*
Benzos*
Opioids***
alpha blockers
beta blockers
DHP-CCBs
Nicotine
Nitrates
THeophylline
Tetracycline

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24
Q

Dietary contributors to GERD?

A

OVER EATING**
fatty foods
chocolate
coffee
Alcohol
Carbonated Drinks
acidic juices
–> determine what food triggers it avoid it different for each pt

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25
Q

Other potential SEs of GERD (not 2 primary ones)

A

belching
hypersalvation
Non-cardiac chest pain

Chronic cough
throat clearing
SOB
laryngitis
dental erosions

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26
Q

Mild GERD classification?

A

Low intesity
No daily interference
< 3 week frequency
< 6 months duration
No nocturnal
No complications

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27
Q

Moderate-Severe GERD classification?

A

High intensity
interferes w/ daily life
> 3 week frequency
>6 month duration
Nocturnal symptoms
Complications present

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28
Q

How many moderate-high criteria does a pt need to be classified there?

A

1-2

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29
Q

2 Qs to ask to determine how severe a pts GERD is?

A

Nocturnal Sx?
Daily interference?

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30
Q

Complications of GERD?

A

esophagitis
esophageal stricture
esophageal erosions
barret’s esophagus
esophageal cancer

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31
Q

Red flags of GERD?

A

VBAD
Choking
Constant pain

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32
Q

Does the presence of GERD complications correlate to GERD symptoms?

A

not very well; can have bad complications and minimal symptoms and vice versa

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33
Q

How to accurately diagnose GERD?

A

hard to do, lots of tests, diagnosis on symptoms and ruling out other causes

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34
Q

Main drug class used to treat GERD?

A

PPI

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35
Q

Refractory GERD?

A

When pt has failed to control GERD on 4-8 week course of a PPI
Sx recur within 3 months of PPI d/c

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36
Q

WHere is GERD more common?

A

western world
asia <5%

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37
Q

Most common age for GERD?

A

> 40

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38
Q

Goals of therapy for treating GERD?

A

relieve symptoms
promote healing of injured mucosa***
prevent and treat complications
prevent reoccurence
avoid issues with long-term use of pharmacologics

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39
Q

Do pts need to be on long term treatment of PPIs?

A

no, 4-8 week course should cure GERD

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40
Q

Non pharm treatments of GERD?

A

lose and maintain ideal wt
stop smoking
elevate head of bed

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41
Q

As needed agents for GERD?

A

alginates
antacids
H2RAs
PPIs

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42
Q

Fastest acting agents for GERD?

A

alginates
antacids

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43
Q

Slowest acting agent for GERD?

A

PPI’s

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44
Q

When to take alginates?

A

1 hour after eating

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45
Q

SEs of alginates?

A

bloating
flatulence
belching

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46
Q

alginate good agent?

A

meh not really

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47
Q

Antacids?

A

Aluminum hydroxide
Magnesium hydroxide
Magnesium trisillicate
Calcium carbonate
Sodium bicarbonate
Can be combos of above

48
Q

CI of antacids?

A

in severe renal impairment

49
Q

What antacid used in dialysis?

A

Ca Carbonate and Aluminum hydroxide used as phosphate binder

50
Q

MOA of antacids?

A

neutralizes stomach acid
inhibits pepsin generation
binds to bile acids

51
Q

Onet and duration of antacids?

A

rapid acting
short duration

52
Q

When to take antacid?

A

20-30 minutes after eating

53
Q

Common SEs of antacids?

A

aluminum: constipation
Magnesium: laxative effect
Ca: well tolerated, potentially constipation

54
Q

Serious SE of antacids?

A

In chronic use not sporadic;
Al: bone demineralization, neurotoxicity, hypophosphatemia
Mg: hypermanesemia
Ca: hypecalcemia, alkalosis

55
Q

DI’s of antacids b/c of chelation?

A

tetracycline
fluroquinolones
iron
bisphosphonates
digoxin
phenytoin
levothyroxine
sotalol

56
Q

How to avoid DI’s with antacids?

A

1hr before meds or 2hrs after to avoid interaction
To be on safe side –> (dig, levo,bisphosphonates) 4hr separation may be better to recommend

57
Q

Does spacing of meds with PPI avoid DI’s?

A

No b/c PPIs are long acting

58
Q

DI’s w/ antacids b/c of impaired absorption or pH sensitive drugs?

A

dabigitran
HIV meds
Fosinopril
ketoconazole
5’-ASA products

59
Q

Antacid efficacy?

A

better than placebo, good add-on b/c not better than other agents (PPIs and H2RA’s)

60
Q

H2RA drugs?

A

cimetidine
famotidine
ranitidine
Nizatidine

61
Q

Main off-label indication for H2RA’s?

A

nocturnal GERD

62
Q

Which H2RA is indicated for GERD maintanence of remission?

A

famotidine

63
Q

MOA?

A

antagonist of H2 receptor which pump H+ into gastric lumen
Reduction in basal and stimulated gastric acid secretion

64
Q

Onset and duration?

A

1-3hrs onset
3-5 hr duration
For nocturnal suppression lasts 8-13hrs

65
Q

Are H2RA GERD dosing higher or lower than ulcer healing or H. pylori treatment?

A

GERD is lower

66
Q

Common SEs of H2RAs?

A

Headache
vomitting
diarrhea
drowsiness

67
Q

Which H2RA is not well tolerated?

A

cimetidine b/c crosses BBB, gynecomastia also a SE of cimitidine

68
Q

Why is cimetidine garbo in regards to DI’s?

A

inhibits 1A2, 2C19, 2D6, and 3A4
phenytoin, clopidigrel, warfarin, metformin, cyclosporines, etc.

69
Q

How to avoid H2RA itneractions in regards to decreased absorption / pH alteration (other than cimetidine)

A

4hr window to avoid interaction

70
Q

H2RA efficacy?

A

more effective and potent than antacids
very safe
cheap
significant tachyphylaxis (tolerance developed easily can happen on 8 weeks regular use) demonstrated***
great for step-down therapy

71
Q

PPI drugs?

A

Rabeprazole
omeprazole
esomeprazole
pantoprazole sodium/magnesium
lansoprazole
dexlansoprazole

72
Q

Why did pantoprazole switch from Na to Mg?

A

theoretically gives longer duration of action to help with nocturnal GERD, clinically doesn’t seem like it

73
Q

Any PPI better than others?

A

All same efficacy, pt interindividual efficacy/ tolerance

74
Q

Indications of PPI’s?

A

GERD treatment
healing of erosive esophagitis, duodenal and gastric ulcers
prevention of NSAID induced ulcers
H. pylori treatment
zollinger ellison syndrome

75
Q

MOA of PPI’s?

A

inhbit proton pumps to prevent gastric acid secretion

76
Q

Important factor of PPI to work?

A

atleast 30 min before meal, only works on actively proton pumps

77
Q

Onset and duration of PPI’s?

A

itial doses will result in suboptimal gastric acid inhibition
daily use for atleast 3-5 days = maximal inhibiton
Proton pump recovery takes 24-48hrs after d/c PPI

78
Q

What dosing regiment should most pts be initiated on for PPI’s?

A

standard dosing (once daily)

79
Q

when is double-dose regimwent usedfor PPI’s?

A

complciated presentation of GERD (mucosal errosion, ulcers or GI bleed, H. pylori, not effective standard dosing for 4-8 weeks)

80
Q

when is hypersecretory dosing used for PPI’s?

A

Zollinger-ellison syndrome

81
Q

Is there renal dose adjustment with PPI’s?

A

No, can be safely used in dialysis

82
Q

Duration of therapy for PPI’s?

A

4-8 weeks then d/c or step-down

83
Q

Common SE’s of PPI?

A

Very well toelrated
dysgeusia (alterted taste bitter/metalic)

84
Q

Potential Serious SE’s with PPI’s?
(based on fairly weak evidence though)
(very chronic used >5yr use)

A

CDIFF (most well established one)
Microscopic colitis
Hypmagnesemia
Fractures
Fundic gland polyps
B12 defeciency
Pneumonia
Gastric Cancer
Mortality increase; meh not really important

85
Q

Which PPI’s have enzyme interactions?

A

lansoprazole, omeprazole, esomaprazole

86
Q

Can you space PPI’s to avoid DI’s due to absorption/pH?

A

No b/c PPI’s long acting

87
Q

Efficacy of PPI’s?

A

most effecitve agent

88
Q

Prokinetics drugs?

A

domperidone and Metoclopramide

89
Q

Prokinetics use?

A

added for GI motility disorders, vague GI complaints

90
Q

Dosing frequency of prokinetics?

A

TID or QID b/c short duration of action

91
Q

CI of metoclopramide?

A

GI obstruction, perforation, hemorrhage
Seizure disorder
Parkinsons
Extra-pyramidal symptoms (antipsychotic medication use; movement disorders)
–> crosses BBB

92
Q

CI of domperidone?

A

GI obstruction, perforation, or hemorrhage
long QT interval (misleading, only at very high doses)
electrolyte disorder
use with potent 3A4 inhibtors

93
Q

Which prokinetic is used more/ better?

A

domperidone b/c safer and cheaper

94
Q

Metoclopramide SE’s?

A

drowsiness
muscle weakness
headache
dizziness
confusion

95
Q

Serious SEs w/ metoclopramide?

A

gynocomastia
EPS syndrome
pseudoparkinsons
tardive dyskinesia
hyperprolactinemia
(worsen movement disorders more long term use)

96
Q

SEs of domperidone?

A

dry mouth
mild headache

97
Q

Serious SE of dompeidone?

A

QT prolongation
gynecomastia

98
Q

DI’s w/ metoclopramide?

A

2D^ inhibitors
anti-parkinsons agents
antipsychotics
SSRIs and TCAs

99
Q

DI’s w/ domperidone?

A

3A4 substrate
QT prolongation agents

100
Q

Treatment approach of GERD (step-up)

A

lifestyle
prn therapy
shceduled H2RA
schedule PPI

101
Q

Treatment approach of GERD (step-down)

A

shceduled PPI
lowest strength option to control symptoms

102
Q

WHich treatment approach should be used for majority of pts?

A

step-down; PPIs very safe and effective

103
Q

Monitoring for PPIs?

A

reassess sx at 4-8 weeks
if resolved d/c
if recur in >3 months after d/c begin anotehr 4-8 week course; if <3 months retreat but, investigate more
If sx improved but still nt resolved continue for another 4-8 weeks

104
Q

First step in refractory GERD treatment?

A

Failure cause;
timing and adherence of med***
difference in PPI metabolism
weakly acidic or alkaline reflux
reflux hypersensitivity
alternative diagnosis

105
Q

Management of refractory GERD steps?

A
  1. reassess for any VBAD sx
  2. ensure adequate duration
  3. ensure proper adherence and administration
  4. reinforce lifestyle and dietary modifications
  5. optimize or switch PPI
  6. advanced daignostics
  7. adjunct treatment addition (Algiante or antacid, prokinetics, H2RA hs, baclofen)
  8. Surgery
106
Q

Candidates to recommend deprescriping of PPIs?

A

mild-moderate GERD who responded to therapy
peptic ulcer disease treated for proper duration
asymptomatic for 3 consecutive days
H. pylori eradication successful

107
Q

How often should long-term PPI therapy be attempted to deprescribe?

A

once per year

108
Q

Why taper PPI rather than d/c

A

to avoid rebound acid hypersensitivty/ GERD

109
Q

Who does have a valid reason for chronic PPI use?

A

Barrets esophagus
chronic NSAID (includes low dose ASA) w/ bleed risk
severe esophagitis
history of bleeding GI ulcer

110
Q

Management of functional dyspepsia?

A

PPI once daily 4-8 weeks*
H. pylori testing*
switch / add TCA
switch / add prokinetic

111
Q

when is GERD treatment in infants to be considered?

A

poor wt gain
blood in stool or vomitus
intense irratability temporally realted to food intake

112
Q

Treatment of GERD in infants?

A

usually just parent reassurence
lifestyle trigger?
trial of acid supression for 2 weeks (PPIs over H2RA’s, need to be compounded b/c no liquid versions)

113
Q

Saftey concerns for GERD treatment in infants?

A

acid rebound
diarrhea
pneumonia

114
Q

What PPI is preferred in lactation?

A

pantoprazole

115
Q

which antacids should be avoided in pregnancy?

A

Na bicarb
Mg trisillicate

116
Q

Drug induced esophagitis common drugs?

A

doxy/tetracycline
K+ tabs
ASA and NSAIDs
bisphosphonates
clindamycin

117
Q

drug-induced esophagitis Risk increased by?

A

lying down after taking med
swallowing pills w/ only saliva
inadequate water intake
esophageal dysmotility
hiatus hernia
esophageal stricture
large pills
bed ridden

PHAR 255 (14 decks)

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