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Integrated Drug Structure, Function, and Therapeutics Winter Term > GERD and Peptic Ulcer Disease - Mingura > Flashcards

GERD and Peptic Ulcer Disease - Mingura Flashcards

1
Q

How does normal reflux work?

A
  1. Acid and food reflux into the esophagus
  2. Peristalsis returns stuff to the stomach
  3. Acid remains in the esophagus
  4. Saliva neutralizes acid
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2
Q

How does reflux change in GERD?

A
  • Decreased resting tone of lower esophageal sphincter
  • delayed gastric emptying
  • transient LES relaxation
  • impaired peristalsis
  • decreased salivation
  • impaired tissue resistance
  • no change in acid production
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3
Q

What are the symptoms of GERD?

A 
heartburn
acid brash (lots of salivation)
belching
chest pain
Others:
chronic cough
laryngitis
asthma
dental enamel erosion
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4
Q

What symptoms of GERD would cause alarm?

A 
Bleeding
Anemia
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
weight loss
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5
Q

How is GERD diagnosed?

A

Through clinical history and empiric acid-suppression

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6
Q

What are some key differences between angina and heartburn in regards to chest pain?

A

Heartburn: burning, squeezing, spontaneous or after meals, relieved by antacids or food, worse with lying down
Angina: pressure, heaviness, exertion or stress-induced, relieved by rest or nitroglycerin, radiation to neck or jaw

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7
Q

What lifestyle modifications can you make to assist with GERD symptoms?

A 
weight loss
elevate head
trigger foods - keep diary!
avoid tight-fitting clothes
avoid tobacco/alcohol
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8
Q

What are some side effects associated with sodium bicarbonate?

A

Alkalosis, hypercalcemia in renal impairment if taken with dairy

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9
Q

What are some clinical pearls about antacids?

A
  • chew tablets (breaks tablet down, increases saliva production)
  • check ingredients
  • Ca carbonate is first line for pregnancy after lifestyle modifications
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10
Q

What adverse drug reactions are associated with H2 antagonists?

A

headache, dizziness, confusion, B12 deficiency with long use

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11
Q

What drugs are contraindicated with H2 antagonists?

A

antifungals, monoclonal antibodies

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12
Q

Clinical pearls with H2 antagonists?

A
  • ok with antacids
  • Need to really adjust (50% of famotidine if CrCl is <50mL/min
  • Cimetidine 1A2, 2D6, 3A4
  • tolerance
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13
Q

What drugs are contraindicated with PPI’s?

A
  • azoles, –nib, -antivirals

- omeprazole and esomeprazole are both moderate 2C19 inhibitors

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14
Q

What do you need to watch out for longterm with PPI use?

A
  • Bacterial infection
  • poor absorption of B12, Mg, Ca, Fe
  • gastric cancer
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15
Q

Is there an interaction between methotrexate and PPIs?

A

Yes. Consider switch to H2RA

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16
Q

What PPIs are formulated for IV use?

A

Esomeprazole and Pantoprazole

17
Q

Which two PPIs can be taken without regards to food?

A

Dexlansoprazole and rabeprazole

18
Q

If you are on sucralfate, what other medications do you have to avoid?

A

warfarin, digoxin, and much more.

19
Q

What are some clinical pearls for sucralfate?

A
  • liquid and tablet formulation are brand-only
  • 2nd line for pregnancy
  • 2 hours before, 6 hours after interacting meds. But you have to dose it 4 times daily, so impossible to do correctly
20
Q

What is misoprostol indicated for? What is the black box warning for?

A

NSAID-induced ulcers.

For women of childbearing age (negative pregnancy test, contraception, warnings, begin on 2nd day of normal period.

21
Q

What is bismuth saubsalicylate indicated for? What are some counseling points?

A

dyspepsia, diarrhea, H. pylori treatment (in combo)

- black hairy tongue/stool, Reye’s syndrome

22
Q

What are the guidelines for GERD in pregnancy?

A
  1. Lifestyle modifications
  2. Antacids (calcium carbonate then aluminum hydroxide/mg hydroxide)
  3. Sucralfate
  4. Ranitidine (has more data/famotidine)
    PPIs
23
Q

What are the two kinds of peptic ulcer disease

A

Chronic (NSAID induced or H. pylori)

Acute (stress-related mucosal damage)

24
Q

What are some risk factors for PUD -NSAID induced?

A
  • older than 65
  • NSAID-related dyspepsia
  • High dose NSAIDs, COX1>COX2
  • Chronic conditions
  • H. pylori
  • smoking/alcohol use
  • NSAID + aspirin, prednisone, anticoags, SSRI
25
Q

What percent of peptic ulcers have H. pylori in them?

A

~60% (transmitted by fecal-oral or gastro-oral, contaminated endoscopes)

26
Q

How does a peptic ulcer present?

A
  • burning, fullness, cramping
  • nocturnal causes awakenings
  • relieved by antacids
27
Q

What are warning signs of a peptic ulcer?

A

black, tarry stool
nausea/vomiting, weight loss
changes in pain type

28
Q

What lab tests do you do to diagnose PUD?

A

H/H and fecal occult blood test

29
Q

How do you diagnose H/ pylori?

A

Endoscopy (required), histology (gold standard), culture, biopsy
No endoscopy for antibody test, breath test must be off meds 1-4 weeks

30
Q

How do you treat an H. pylori infection?

A

1st line: bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline)
or non-bismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin)
1st line if clarithromycin resistance ,15% or eradication >85%: PPI triple (PPI + amoxicillin + clarithromycin)
Treatment failure: levofloxacin-containing therapy )PPI + amoxicillin + levofloxacin)
Rifabutin last of all

31
Q

On an antibiogram, what would you choose to fight your bug?

A

The drug that has numbers closest to 100 that is not too broad spectrum for starting out

32
Q

What are antibiogram useful in?

A

They are useful for empiric therapy and resistance trends, and for hospitals to keep track of what bugs are going through.

33
Q

What are some counseling points for H. pylori?

A

Amoxicillin - hypersensitivity reaction
Tetracycline - tooth discoloration in those going through bone growth, photosensitivity
Clarithromycin - nausea/vomiting/diarrhea, headache, 3A4 inhibitor
Metronidazole - disulfiram reaction
Bismuth - discoloration of stool/tongue
Drug interactions with oral contraceptives
Allergies
Compliance

34
Q

What is stress-related mucosal damage? What are some risk factors?

A

When you get stressed, there can be damage done to your mucosal lining. Mechanical ventilation, coagulopathy (INR > 1.5) platelet <50,000 microL, sepsis, hepatic failure, etc.
Leads to PPI overuse in the hospitals

35
Q

There are indications for which prophylaxis with PPIs is recommended. How long do you have to be using technical ventilation for to qualify for prophylaxis with PPIs?

A

48 hours. Need at least two of the following: sepsis, ICU stay >1 week, occult bleeding lasting 6 days or longer, >250mg hydrocortisone

Integrated Drug Structure, Function, and Therapeutics Winter Term (18 decks)

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