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Pharm II > GERD and PUD > Flashcards

GERD and PUD Flashcards

1
Q

Gastric acid secretion is Modulated by what 3 pathways which activate their respective receptors__ __ __

A

paracrine (histamine), neuroendocrine (Ach), and endocrine (gastrin)
(H2, M3, CCK2).

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2
Q

what limits extent of acid secretion?

A

Somatostatin-secreting D cells and prostaglandins

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3
Q

what is the lifestyle characteristics that increase symptoms

A 
High fat meals
Increase in frequency of symptoms
Calorically dense meals
Increase in esophageal acid exposure
Tobacco
Increase in frequency of symptoms
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4
Q

what does not change symptoms of GERD?

A

alcohol intake and caffeine

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5
Q

what are the 4 mechanisms of GERD

A

Decreased Lower Esophageal Sphincter Pressure
Prolonged Esophageal Clearance
Mucosal Resistance
Delayed Gastric Emptying Time

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6
Q

what is the normal fxn of LES

A

Tonic, contracted state, relaxing to permit free passage of food into stomach

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7
Q

what are transient LES relaxations

A

not assoc with swallowing, Mechanism unclear, possible causes: esophageal distention, vomiting, belching, retching

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8
Q

what is responsible for 65% of reflux in GERD

A

transient LES relaxations

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9
Q

what meds can cause decreased LES? lots

A 
Anticholinergics
Barbituates
Benzodiazepines
Caffeine
Dihydropyridine Ca2+ channel blockers
Dopamine
Estrogen
Ethanol
Isoproterenol
Narcotics
Nicotine
Nitrates
Phentolamine
Progesterone
theophylline
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10
Q

foods that decrease LES

A 
Fatty meals
Peppermint/spearmint
Chocolate
Caffinated drinks:
Coffee
Cola
tea
Garlic
Onions
Chili peppers
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11
Q

50% GERD patients have

A

prolonged acid clearance

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12
Q

Esophagus normally cleared by

A

peristalsis

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13
Q

what does increased saliva do?

A

(stimulated by swallowing) provides bicarbonate buffer

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14
Q

decreased saliva is associated with 4

A

Age
Sjogren’s syndrome
Xerostomia
Sleep

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15
Q

mucous secretion in the esophagus does what?

A 
function to protect esophagus
Bicarbonate neutralizes acidic reflux
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16
Q

what foods irritate the mucosa?

A

Spicy food
Citrus juice
Tomato juice
Coffee

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17
Q

without mucous in esoph what might happen?

A

After repeat exposure, H+ ions diffuse into mucosa causing cellular acidification and necrosis

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18
Q

what meds irritate the mucosa?

A 
Alendronate***(drink a full glass of water then stay upright for 30 min)
Aspirin
Iron
NSAIDS
Quinidine
Potassium chloride
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19
Q

what Factors increase gastric volume/decrease gastric emptying

A

smoking and high fat meals

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20
Q

what is the cause of post prandial reflux

A

delayed gastric emptying time

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21
Q

what causes GERD in infants?

A

delayed gastric emptying time

Defects in antral motility
Complications: failure to thrive, pulmonary aspiration

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22
Q

8 life-style factors of GERD

A 
Exercise
Weight-lifting
Cycling
Sit-ups 
Smoking
Obesity
High-fat meals
Supine body position
Tight fitting clothing
Pregnancy
Stress
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23
Q

what are 4 typical symptoms of GERD

A

Heartburn (pyrosis)
Hypersalivation
Belching
Regurgitation

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24
Q

what are 6 atypical symptoms of GERD

A 
Non-allergic asthma
Chronic cough
Hoarseness
Pharyngitis
Chest pain
Dental erosion
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25
Q

what is primary for diagnosing GERD

A

endoscopy and 24 hr amb pH monitoring

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26
Q

what are 4 complications of GERD

A

Esophagitis, stricture, barretts esoph and adenocarcinoma of esoph

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27
Q 
what has symptoms of Continual pain
Dysphagia
Odynophagia
Bleeding
Unexplained weight loss
Choking
A

adenocarc of esoph

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28
Q

how do you suppress gastric acid production? 3

A

Antacids after meals and at bedtime
H2 histamine receptor antagonist
Covalent inhibitors of the H+, K+ -ATPase of the parietal cell (PPIs)

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29
Q

what is part of promotility therapy?

A

Metoclopramide (dopamine antagonist)

Bethanechol (cholinergic agent)

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30
Q

what does elevating the head of the bed do for GERD?

A

increases esophageal clearance

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31
Q

Dietary modifications for GERD - 5

A
  • Avoid foods that lower esophageal sphincter pressure (fats, chocolate, ETOH, peppermint & spearmint)
  • Avoids foods that have instant effect on the esophageal mucosa (spicy foods, OJ, tomato juice, coffee)
  • Include protein-rich foods, augments lower esophageal sphincter pressure
  • Eat small meals and avoid eating prior to sleeping-decrease gastric volume.
  • Loose weight-reduces symptoms.
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32
Q

what is Ulcers extending deep into the muscularis mucosa of the stomach

A

PUD

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33
Q

what are 3 common forms of PUD?

A

Helicobacter pylori associated
NSAID induced
Stress related mucosal damage

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34
Q

what has the following symptoms?Epigastric pain, often worse at night
Pain typically 1-3 hrs after meal and may be relieved by eating
Pain can be episodic

A

Duodenal ulcers

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35
Q

what has the following symptoms?Epigastric pain, often worse with food
Associated symptoms: heartburn, belching, bloating, nausea, anorexia

A

gastric ulcers

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36
Q

h. pylori causes the majority of what type of ulcer

A

Duodenal

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37
Q

NSAID causes the majority of what type of ulcer

A

Gastric

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38
Q

what diet is associated with PUD

A

In high concentrations, alcohol associated with acute gastric mucosal damage, upper GI bleed
Smoking: unclear mechanism, impairs healing, higher death rates

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39
Q

what is a gram-negative rod that colonizes the mucus on the luminal surface of the gastric epithelium
Causes inflammatory gastritis
May be linked to PUD, gastric lymphoma and adenocarcinoma

A

h.pylori

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40
Q

what are 3 transmission of h.pylori?

A

Fecal-oral
Oral-oral
Iatrogenic

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41
Q

what is the MOA of antacids? it does 3 things

A

neutralize acid to raise intragastric pH
Decreased activation of pepsinogen
Increased LES pressure

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42
Q

what are the benefits of antacids?

A

rapid onset

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43
Q

what are the disadvantages of antacids?

A

short duration

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44
Q

what Adds viscous layer which acts as barrier to reflux in antacids>

A

alginic acid (Gaviscon)

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45
Q

what are the Gi ADR of antacids?

A

diarrhea or constipation
Diarrhea: magnesium
Constipation: aluminum
Gas: calcium, sodium bicarbonate

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46
Q

what can sodium bicarb do with in antacids? so what should you avoid?

A

Sodium bicarbonate products can cause fluid overload in pts. with CHF, renal failure, cirrhosis, pregnancy, or any salt-restricted diet; avoid in anyone taking supplemental calcium or with renal dysfunction

47
Q

how does antacids affect drugs?

A

alter gastric pH, increase urinary pH, adsorbing medications, physical barrier to absorption, form insoluble complexes

48
Q

what drugs to antacids affect?

A

Clincally significant:
Abx: quinolone, isoniazid, tetracycline
Ferrous sulfate, quinidine, sulfonylurea

49
Q

Patients using medications >___ days should be evaluated for Risk of Barrett’s esophagus/
Risk of upper GI pathology

A

14

50
Q

Patients excessively using antacids

A

considered more significant disease

51
Q

If potential for drug interactions, separate dosages of antacids and drug by at least __ hours

A

2

52
Q

what is the MOA of H2 receptor antagonists?

A

reversibly inhibit histamine-2 receptors on parietal cells

53
Q

what are 2 uses of H2 antagonists?

A

On-demand therapy for intermittent mild to moderate GERD symptoms
Preventive dosing before exercise/meals

54
Q

what is Less effective than PPIs in healing erosive esophagitis

A

H2-receptor antagonists

55
Q

what are 3 H2 antagonists that she wants us to know?

A

Rantitidine, cimetidine, famotidine

56
Q

H2 receptor antagonists are rapidly & well absorbed after what

A

oral admin

57
Q

when is the pk time H2 antagonists work>

A

1-2 hrs

58
Q

A large part of H2 antagonists are ___ in the urine and therefore may need a____ w/renal impairment.

A

excreted unchanged, reduction in dosage

59
Q

what are the ADRs of H2 antagonists

A

Well tolerated
HA, somnolence, fatigue, dizziness, constipation or diarrhea
Thrombocytopenia: rare, reversible

60
Q

what drug interactions does cimetidine have?

A

Inhibition of metabolism of warfarin, phenytoin, nifedipine, propranolol

61
Q

what drugs need an Acidic environment required for absorption, so you would not use with H2 receptor antagonist

A

Ketoconazole, itraconazole, ferrous sulfate

62
Q

what is true about combining antacids and H2receptor antagonist?

A

more effective than antacid tx alone

63
Q

___eliminate symptoms and heal esophagitis more frequently and rapidly than other drugs

A

PPIs

64
Q

what is Shown to normalize impaired quality of life caused by GERD

A

PPIs

65
Q

when should PPIs be taken?

A

Before meals

66
Q

5 prototypes of PPIs

A 
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Esomeprazole (Nexium)
Pantoprazole (Protonix)
Rabeprazole (Aciphex
67
Q

what is the MOA of PPIs?

A

Inhibit the action of the H+,K+ -ATPase

68
Q

what do PPIs need to work?

A

acidic env

69
Q

how long does it take to synthesize new H+,K+ -ATPase molecules

A

18hrs

70
Q

what are ADRs of PPIs?

A

Generally uncommon
N/D/C
HA, dizziness, somnolence

71
Q

if you take PPIs what might you have higher incidence of getting?

A

community-acquired pneumonia
Clinical significance unclear
Pts with asthma, COPD, immunocompromised, young or elderly may be at risk

72
Q

what PPIs are metabolized by P450 enzymes

A

Omeprazole, lansoprazole, esomeprazole and pantoprazole

73
Q

rabeprazole metabolized thru

A

nonenzymatic reduction pathway

74
Q

Omeprazole and esomeprazole reduce metabolism of

A

Diazepam
Phenytoin
warfarin

75
Q

what 3 things do promotility agents do?

A

LES incompetence, decreased esophageal clearance and delayed gastric emptying

76
Q

what are metoclopramide, bethanechol, and cisapride?

A

promotility agents

77
Q

what is contraindicated in Parkinson’s Dz, mechanical obstruction, concomitant use of other dopamine antagonists, anticholinergics, and pheochromocytoma

A

metoclopramide

78
Q

what may increase acid production, not well tolerated due to cholinergic side-effects

A

bethanechol

79
Q

what may cause Fatal cardiac dysrhythmia

A

cisapride

80
Q

what is Not recommended for use except very mild cases of GERD

A

mucosal protectants

81
Q

what is sucralfate

A

non-absorbable aluminum salts - mucosal protectant

82
Q

what is Comparable to H2-receptor antagonist for mild esophagitis but Less effective in refractory esophagitis

A

sucralfate

83
Q

what is the MOA of sucralfate?

A

When the pH is below 4, an extensive polymerization & cross-linking of sucralfate to form a sticky, viscid, yellow-white gel.
The gel adheres to epithelial cells and adheres very strongly to the base of ulcer craters.

84
Q

what are 3 uses of sucralfate?

A

Effective at promoting healing in PUD
As a maintenance therapy–more efficacious in duodenal than gastric ulcers.
Used to prevent stress ulcers

85
Q

what are More effective when administer prior to meals than after since acid is needed for activation

A

sucralfate and PPIs

86
Q

what are 3 adrs of sucralfate?

A

Constipation—Al3+
Dry mouth
Abdominal discomfort

87
Q

what are Drug int with sucralfate and therefore you should to what

A

Phenytoin Digoxin Tetracycline Ketoconazole
Fluroquinolone antibiotics
Therefore better to administer these meds 2 hours prior to sucralfate.

88
Q

Improvement of symptoms with full dose PPIs usually

A

reverses with discontinuation of therapy

89
Q

what is ineffective in GERD? 2

A

Full dose H2-receptor antagonist once daily not appropriate
Reduced dose PPIs
Alternate day dosing
“Weekend” therapy

90
Q

Dose needed to control symptoms is appropriate dose for

A

maintenance

91
Q

Acid suppression decreases recurrence of

A

esophageal strictures

92
Q

Full dose PPIs lengthen time between

A

symptomatic relapses

93
Q

what are complications of PUD

A

Ulceration and obstruction

94
Q

what increases with NSAIDs use and PUD

A

perforation risk

95
Q

Mortality of what ulcer perforation is higher?

A

gastric

96
Q

what is caused by scarring or edema of duodenal bulb or pyloric channel land lead to gastric retention

A

obstruction

97
Q

what has symptoms of Early satiety, bloating, anorexia, nausea, vomiting, weight loss that occurs over months?

A

obstruction

98
Q

what is PAC?

A

PPI, amox, clarithr

99
Q

what is PMC

A

PPI, metronidazole, and clarithr

100
Q

what is PBMT

A

PPI, PeptoBismol, Metro, Tetra(or amox or clarithr)

101
Q

what does pepto do for PUD? 5

A

-Cytoprotection through enhanced secretion of mucus and HCO3-.
-Inhibit pepsin activity.
-Accumulate bismuth subcitrate in craters of gastric ulcers.
-Antibacterial effects:
Reduce bacterial adherence to mucosal cells
Damage bacterial cell walls.
-Promote healing of both gastric and duodenal ulcers

102
Q

what is the MOA for prostaglandin analogs? and what is an ex

A

Misoprostol is a synthetic analogue of prostaglandin E.
Imitates the action of endogenous prostaglandins (PGE2 and PGI2) in maintaining the integrity of the gastroduodenal mucosal barrier.
Promotes healing.

103
Q

what is indication for prostaglandin analogs?

A

Ulcer healing

Ulcer prophylaxis w/NSAID use

104
Q

what are contraindications for Pg analogs?

A

Hypotension
Breastfeeding
Pregnant

105
Q

what is ADRs of PG analogs?

A

diarrhea and constipation

106
Q

in PUD elim or reduce what things? 3

A 
Psychological stress
Cigarette smoking
The use of NSAIDs including aspirin
Consider APAP
Lowering the dose
Nonacetylated salicylate (salsalate)
Relatively selective COX-2 inhibitors (nabumetone, etodolac) or highly-selective COX-2 inhibitors (celecoxib)
Co-administration w/H2 antagonist or PPI
107
Q

what are diet changes you can make for PUD?

A

Avoid food and beverages that cause dyspepsia or exacerbate ulcer symptoms
Spicy foods
Caffeine
ETOH

108
Q

what is H pylori linked to?

A

PUD, gastric lymphoma, and adenocarcinoma

109
Q

what are complications of H.Pylori?

A

Zollinger ellison syndrome, and Upper GI bleed, perforation, and obstruction

110
Q

What is ZE syndrome?

A

Gastric acid hyper secretion and recurring ulceration from a gastrin secreting tumor

111
Q

how do you treat ZE syndrom?

A

PPI and chemo

112
Q

what presents as insidious occult blood, melana, or hematemesis?

A

upper GI bleed

113
Q

3 ways to treat PUD

A

PAC, PMC, PBMT(adds pepto)

Pharm II (8 decks)

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