GERD and N/V Flashcards
Parietal cells has receptors for: (on the non gastric lumen side)
Ach, Histamine (H2), gastrin
Treatment for GERD is determined based on ___
severity (symptom based or tissue injury based)
What are symptoms that determine the GERD severity
heart burn, regurgitation, dysphagia
What are tissue injury based determinations of disease severeity for GERD
esophagitis, Barrett’s, strictures, esophageal adenocarcinoma
For GERD treatment, start strong with ____ and step down to ___ when possible
PPI, H2RA
use lowest possible
discontinue 8 weeks of no sx
Always incorporate ___ changes for GERD treatment. These include:
lifestyle
weightless, elevate head of bed, avoid eating 2-3 hrs before bedtime, decrease food triggers
What are the PPIs used (what do they end with)
Prazole (The praise alls)
omeprazole, panto, esome, lanso, dexlanso, rabe
PPIs take __ hours for effect. Because of this they should use ___ or ___ for breakthrough
24-72 hours
H2RA or antacid
PPI side effects
Hypo K
Hypo Mg
Increase risk fractures, B12, CAP
PPIs have a lot of ___ because there is ____
drug drug interactions. decreased/increased absorptions from reduced acid content. (cephalosporins, chemo, HIV meds, Fe supplements) (increased: methylphenidate)
CYP2C19
Which two PPIs should be avoided with clopidogrel
esomeprazole and omeprazole. decreased effectiveness of clopidogrel
Which PPI maybe can be used with clopidogrel
pantoprazole
Which PPI should be used with clopidogrel
Rabeprazole
What to do if in 8 week patient is not responding to PPI
change PPI or BID dosing (ex. 40 twice a day)
What GERD compilation makes someone need to stay on maintenance therapy
Barrett’s
and those who have sx return
Which are the 2 H2RAs used for GERD and which is preferred
Famotidine (Pepcid)-> preferred
Cimetidine (Tagamet)-> not preferred because CYP3A4 interactions
H2RAs take __ for onset and effect lasts for ____ hours. For breakthroughs with this use
1 hour, last 12-24 hours
use antacids for breakthroughs
Side effects of H2RAs
headache, dizziness, diarrhea, constipation
For dosing with H2RAs used for GERD, what to do
high dose, not OTC dosing (write prescription because otherwise taking OTC tog et to that dose is a lot)
could BID or switch drugs
H2RAs have some ____ due to reduced acid content in stomach
What are some reduced/increased absorption?
drug drug interactions
Reduced absorption: cephalosporins, SM chemo, HIV meds, Fe supp, HCV, antifungals
Increased absorption: methylphenidate
Antacids neutralize stomach acid. What 3 components does it have?
CaCO3, Mg(OH)2, Al(OH)3
Antacids have binding ____ at two major med groups
DDIs
levothyroxine, certain cephalosporins (2 hrs before drug or 4 hrs after)
Antacids works _____ and effect can last from ______.
immediately, minutes to hours
great for symptom management
What is the problem with calcium based antacids
Ca2+ is part of the mechanism of releasing acid into the stomach in parietal cells
Ranitidine (Zantac) was removed but it is actually ___ now
famotidine
Promotility agents like _____ can be used with PPI only if etiology is related to ______
metoclopramide
delayed gastric emptying
What are the 6 drugs that treat N/V caused through the chemoreceptor trigger zone (outside blood brain barrier)?
antihistmines, anticholinergics, 5HT3 antagonists, cannabinoids, neurokinin-receptor antagonists, dopamine antagoinists
Simple nausea should be treated with
antacids, H2RA, anti-His, phenothiazine
Motion sickness should be treated with
antihistamine, scopoamine
Post operative N/V should be treated with
Phenothiazine, 5HT-3, RA, steroid, butyrophenone
Chemotherapy NV should be treated with
5TH-3, NK1, lorazepam, dexamethasone, olanzapine, cannabinoids, bdtyrophenone, scopolamine
Pregnancy NV should be treated with
Vitamind B6 and doxylamine
How do antacids work for treating simple nausea? What are brands? what do you need to be careful about
neutralize acid. Brands: tums, rolaids, gaviscon, malanga
DDI from binding!
How do H2RA work to treat simple nausea
reduce acid content
cimetidine has a lot of CYP3A4 interactions (avoid)
Nizatidine/ranitidine-> removed by FDA
Which re the Phenothiazines used? How do they work? What are the major side effects?
Prochlorperazine, promethazine
Block dopamine receptors in CTZ (drug drug interactions)
SE: drowsiness, agitation possible
Meclizine MOA for motion sickness? SEs?
Muscarinic and histamine receptors in VC
SE: drowsiness (from hist)
Scopolamine MOA for motion sickness? How is it delivered? works best when used for_____
block Acetylcholine and histamine receptors in VC
Patch behind the ear
prevention
These are prescription
Types of CINV:
anticipatory, acute, delayed, breakthrough, refractory
Treatment of CINV depends on _________. _____ is key
emetogenic potenial or chemo regime.
prevention
Anticipatory NV from chemo is best treated with______.
lorazepam-> anxiety/anticipation
not first line for ANY other NV
Prevention of acute CINV meds? (there are 4)
5HT3
NK1 receptor antagonists
Dexamethasone
Olanzapine
Too much dopamine could cause
Parkinson-like things
Extrapyramidal side effects (rigid)
What are the 1st and 2nd generation 5HT3 antagonists
1: Ondansetron, granisetron, (Dolasetron not longer avoidable)
2: Palonosetron (more selective for 5HT3
5HT3 has a class effect of ____ especially when paired with
QTc prolongation
antipsychotics, antibiotics, antiarrythmics, antidepressants
What are the 4 Neurokinin receptor antagonists used
Aprepitant (DDIs), Fosaprepitant, Rolapitant, Netupitant/palonosetron (NEPA, this is a combo)
How does dexamethasone work for CINV
?????
we know it prevents acute and delayed CINV and not indicated for simple NV
Breakthrough CINV should be prescribed
phenothiazines, 5HT2 antagonists (PRN)
What are risk factors for post op NV
Patient: age <50, female, non smoker, hx, motion sickness, hydration
Surgery related: general anesthesia, volatile anesthesia, NO, opioids, duration, type of procedure
Prophylaxis for post op NV can be done with (7 things)
5HT3 antagonists, dexamethasone or methylprednisolone, haloperidol (QTc), antihistamines, anticholinergics, NK1 antagonists
To treat post op NV, use ___ (2 things)
phenothiazine, metoclopramide
If B6 and Doxylamine are not working for pregnancy, can use____ which works by
metoclopramide.
blocking dopamine at CTZ
metoclopramide increases rate of _____ which is helpful for ____.
It should not be used with:
gastric emptying, diabetic gastroparesis
haloperidol, olanzapine, any CYP2D6 inhibitors (fluoxetine, paroxetine, bupropion)
