GERD and PUD Flashcards
EOR exam 5
What do parietal cells in the stomach secrete?
They secrete hydrochloric acid (HCl) through the H⁺/K⁺-ATPase pump, also known as the proton pump.
What stimulates the secretion of HCl in the stomach?
- Histamine
- Acetylcholine
- The hormone gastrin (Gastrin stimulates stomach muscle contractions to aid in digestion)
What prevents acidic gastric contents from flowing back into the esophagus?
A protective ring of muscle fibers called the lower esophageal sphincter (LES).
What happens in GERD (gastroesophageal reflux disease)?
There is reduced LES pressure, allowing gastric contents to backflow into the esophagus.
What are typical symptoms of GERD?
- Heartburn (daytime or nocturnal)
- Hypersalivation
- Regurgitation of acidic contents into the mouth or throat.
Less common SE: - Epigastric pain, nausea, cough, sore throat, hoarseness, and chest pain.
How is GERD diagnosed?
- Based on patient-reported symptoms
- Duration, daytime/nighttime occurrence
- Frequency (≥ 2 times per week)
- Risk factors like family history, diet, and sleep position.
What is recommended for patients who don’t respond to GERD treatment?
24-hour esophageal pH monitoring.
What are some key drugs that can worsen GERD symptoms?
1.Aspirin/NSAIDs
2. Bisphosphonates
3. Dabigatran
4. Estrogen products
5. Fish oil products
6. Iron supplements
7. Nicotine replacement therapy
8. Steroids
9. Tetracyclines
What are alarm symptoms that require referral?
- Odynophagia (painful swallowing)
- Dysphagia
- Frequent nausea and vomiting
- Hematemesis
- Black or bloody stools
- Unintentional weight loss
How can infrequent heartburn (< 2 times/week) be treated?
With OTC antacids or H2 receptor antagonists (H2RAs) as needed.
What is the initial treatment for frequent (≥ 2 times/week) or severe GERD symptoms?
An 8-week course of a proton pump inhibitor (PPI)
What should be done after the initial 8-week PPI treatment?
- Stop treatment.
- If symptoms return, start maintenance therapy.
What is the first-line maintenance treatment for GERD?
PPI at the lowest effective dose.
What lifestyle modifications are recommended for GERD?
- Weight loss if overweight or recently gained weight
- Elevate the head of the bed
- Avoid eating high-fat meals within 2–3 hours of bedtime
- Avoid foods/beverages that trigger reflux (e.g., caffeine, chocolate, acidic/spicy foods, carbonated beverages)
What is an alternative maintenance treatment if there is no erosive esophagitis?
H2RA (Histamine-2 Receptor Antagonist), if it relieves symptoms.
What treatments are not recommended for GERD ?
Metoclopramide and sucralfate.
How do antacids work?
1.They neutralize gastric acid by producing salt and water, which increases gastric pH
2. Relief occurs within minutes.
3. Short—about 30 to 60 minutes.
Why should caution be used with aspirin-containing antacids like Alka-Seltzer?
1.There is a serious bleeding risk if used too frequently.
What are the common antacid formulations?
- Calcium carbonate (Tums)
a. Calcium carbonate + magnesium (Mylanta Supreme)
b. Calcium carbonate + simethicone (Maalox Advanced Maximum Strength) - Magnesium hydroxide (Milk of Magnesia)
a. Magnesium + aluminum + simethicone (Mylanta Maximum Strength) - Sodium bicarbonate/aspirin/citric acid (Alka-Seltzer)
How often must antacids typically be taken?
Many require dosing 4–6 times per day.
What is a major safety warning with aluminum and magnesium-containing antacids?
They can accumulate in patients with severe renal dysfunction (CrCl < 30 mL/min) and increase bleeding risk with aspirin-containing products
What are common side effects of antacids?
- Unpleasant taste
- Calcium: Constipation, bloating, belching
- Aluminum: Constipation, hypophosphatemia
- Magnesium: Loose stools (often balanced by combining with aluminum)
What antacids are preferred in pregnancy?
- Calcium containing antacids
How do H2RAs work?
They reversibly inhibit H2 receptors on gastric parietal cells, which decreases gastric acid secretion
what drugs belong to the H2RA class ?
- Famotidine (Pepcid AC, Zantac)
- Cimetidine (tagamet)
- Nizatidine
What are the dosing guidelines for famotidine ?
- Rx: injection
- Decrease dose if CrCl < 60 mL/min
What are the key warnings associated with H2RAs?
- Confusion (especially in elderly, severely ill, or renal impairment; usually reversible)
What are common side effects of H2RAs?
Cimetidine (high doses):
1. gynecomastia
2. impotence
What are special considerations for cimetidine?
Should be avoided due to drug interactions and side effects
How do PPIs work?
They irreversibly bind to the gastric H⁺/K⁺-ATPase pump in parietal cells, shutting down acid production and blocking gastric acid secretion.
How should Esomeprazole (Nexium) be taken?
At least 60 minutes before a meal.
How should Lansoprazole be taken?
Before breakfast
When should Omeprazole (Prilosec) be taken?
Before breakfast
How should Dexlansoprazole be taken?
Without regard to meals
How should Pantoprazole PO suspension be taken?
Oral suspension: 30 minutes before a meal
What are common warnings associated with PPIs?
- Difficile-associated diarrhea (CDAD)
- Hypomagnesemia
- Vitamin B12 deficiency with prolonged use (≥ 2 years)
- Osteoporosis-related bone fractures (especially with high doses or long-term use)
How do PPIs interact with clopidogrel?
Omeprazole and esomeprazole may diminish the therapeutic effect of clopidogrel. Use pantoprazole or rabeprazole instead as they pose less risk.
Which PPIs are available in IV form?
Pantoprazole and esomeprazole.
Which PPI capsules can be opened and mixed with applesauce?
Dexlansoprazole, esomeprazole, lansoprazole, omeprazole, and rabeprazole.
What are the drugs of the PPI class?
- Dexlansoprazole (dexilant)
- Esomeprazole ( Nexium)
+ Naproxen (Vimovo) - Lansoprazole (prevacid)
- Omeprazole (Prilosec)
- Pantoprazole (protonix)
- Rabeprazole
What are the consequences of altered gastric pH from long-term PPI use?
- Promotes microorganism growth
- Increases risk of GI infections (e.g., C. difficile)
- Possibly increases risk of pneumonia (due to reflux beyond oral cavity)
What bone-related risk is associated with long-term PPI use?
Increased risk of osteoporosis and fractures.
What do the Beers Criteria recommend regarding PPI use in elderly patients?
PPIs should not be used beyond 8 weeks unless there’s a clear indication (e.g., high risk for GI bleed from chronic NSAID use or demonstrated need for maintenance).
Q: Which H2RAs are available OTC?
- Cimetidine
- Famotidine
Q: Which PPIs are available OTC?
- Esomeprazole
- Lansoprazole
- Omeprazole
Which PPIs are available as oral suspension (packets)?
Esomeprazole, Omeprazole, Pantoprazole
Are misoprostol and sucralfate recommended for GERD treatment?
No, they are not recommended by guidelines for GERD treatment but may be used for peptic ulcer disease
What is metoclopramide’s role in GERD?
It’s a prokinetic drug, historically used for GERD but not recommended in current guidelines unless the patient has coexisting gastroparesis.
How does metoclopramide work?
- It is a dopamine antagonist.
- At high doses, it also blocks serotonin receptors in the CNS.
- It enhances the response to acetylcholine in the upper GI tract, promoting accelerated gastric emptying and increasing LES tone.
What is the brand name and dosing for metoclopramide ?
- Brand: Reglan
- 10–15 mg QID Taken 30 minutes before meals and at bedtime
- Food must be present in the gut for effectiveness
What is the boxed warning for metoclopramide?
- Risk of tardive dyskinesia (a serious, often irreversible movement disorder), especially with long-term use (>12 weeks), high doses, or in elderly patients.
What are the warnings associated with metoclopramide?
- EPS (including acute dystonia)
- Parkinsonian-like symptoms
- Neuroleptic malignant syndrome (NMS)
- Depression
- Suicidal ideation
- Avoid in patients with Parkinson disease
Which drugs should be completely avoided with H2RAs or PPIs?
- Dasatinib
- Pazopanib
- Risedronate (Atelvia, delayed-release form)
additional meds that should be avoided with PPIs: - Erlotinib
2.Rilpivirine - Velpatasvir/sofosbuvir (Epclusa)
What are common side effects of metoclopramide?
- Drowsiness*
- Restlessness, fatigue, hypertension, pro-arrhythmic effects, and diarrhea
what are the drugs that require an acidic gut (absorption ↓ by antacids, H2RAs, and PPIs)?
- Antiretrovirals: rilpivirine (NNRTI), atazanavir (PI)
- Antivirals: ledipasvir, velpatasvir/sofosbuvir
- Azole antifungals: itraconazole (Sporanox), ketoconazole, posaconazole oral suspension
- Cephalosporins (oral): cefpodoxime, cefuroxime
- Iron products
- Risedronate delayed-release
- Tyrosine kinase inhibitors: dasatinib, erlotinib, pazopanib
What are the oral drugs that antacids bind?
- Antiretrovirals (INSTIs): bictegravir, dolutegravir, elvitegravir, raltegravir
- Bisphosphonates
- Isoniazid
- Levothyroxine
- Mycophenolate
- Quinolones
- Sotalol
- Steroids (especially budesonide)
- Tetracyclines
How do antacids interfere with drug absorption?
- They can bind or adsorb to some drugs, decreasing their absorption.
How can drug interactions with antacids be managed?
The usual recommendation is to avoid antacids for 2–4 hours before or 2–6 hours after the other medication.
What should be considered when using H2RAs with CNS depressants?
1.Use caution, especially in the elderly, due to the risk of additive delirium, dementia, and cognitive impairment.
How do omeprazole and esomeprazole affect clopidogrel?
- They reduce the effectiveness of clopidogrel (a prodrug) by inhibiting CYP2C19.
Should metoclopramide be used in patients taking medications for Parkinson disease?
No – it has an antagonistic effect and should be avoided.
What drug combinations should be avoided with metoclopramide due to increased risk of adverse effects?
Avoid combining with antipsychotic drugs, droperidol, or promethazine due to increased risk of adverse effects
What should be monitored when metoclopramide is used with SSRIs, SNRIs, or TCAs?
1.Monitor for possible EPS (extrapyramidal symptoms), NMS (neuroleptic malignant syndrome), and serotonin syndrome*
What is peptic ulcer disease (PUD)?
It occurs when there is mucosal erosion within the gastrointestinal tract.
How are ulcers diagnosed or observed?
Through an upper gastrointestinal endoscopy.
What are the three most common causes of PUD?
- Helicobacter pylori (H. pylori)-positive ulcers
- NSAID (non-steroidal anti-inflammatory drug) use
- Stress-induced ulcers (especially in critically ill or mechanically ventilated patients)
What is H. pylori and why is it significant in PUD?
It’s a spiral-shaped, gram-negative bacterium that lives in the acidic stomach and is responsible for 70–95% of peptic ulcers.
What is the primary symptom of PUD?
Dyspepsia, described as a gnawing or burning gastric pain in the middle or upper stomach
How does pain differ between duodenal and gastric ulcers?
- Duodenal ulcer: Pain worsens 2–3 hours after eating (when stomach is empty); food or antacids relieve it. (after stomach)
- Gastric ulcer: Pain generally worsens with eating (often NSAID-related). (in stomach)
What are two common non-invasive diagnostic tests for H. pylori?
- Urea breath test (UBT) – detects carbon dioxide (CO₂) gas produced by the bacteria.
- Fecal antigen test – detects H. pylori in the stool.
Which medications should be discontinued before H. pylori testing and why?
- PPIs, bismuth, and antibiotics should be discontinued at least two weeks prior to testing in order to avoid false negative results.
What does the American College of Gastroenterology (ACG) recommend as first-line therapy for H. pylori?
Quadruple therapy, especially due to rising resistance to clarithromycin.
When is triple therapy considered acceptable for H. pylori treatment?
- Only if clarithromycin resistance is low (≤15%) and the patient has no prior macrolide exposure.
Bismuth Quadruple Therapy (10–14 days)
Q: What drugs are included in bismuth quadruple therapy?
- Bismuth subsalicylate 300 mg QID +
- Metronidazole 250–500 mg QID +
- Tetracycline 500 mg QID +
- PPI BID
Or - use 3-in-1 combo: Pylera
what drugs make up the 3-in-1 combo Pylera?
- Bismuth subcitrate potassium 420 mg +
- Metronidazole 375 mg +
- Tetracycline 375 mg
- all QID + - PPI BID
What alternatives or precautions apply to bismuth quadruple therapy?
- Tinidazole can be substituted for metronidazole, use H2RA if PPI is not tolerated
- Avoid metronidazole with alcohol
- Avoid tetracycline during pregnancy or in children <8 years
what is the duration when taking bismuth quadruple therapy ?
take for 10-14 days
When is concomitant therapy preferred?
When clarithromycin resistance is low (≤15%) and no prior macrolide exposure.
What drugs are included in concomitant therapy?
- Amoxicillin 1000 mg BID+
- Clarithromycin 500 mg BID+
- Metronidazole 500 mg BID+
- PPI BID
(Tinidazole may substitute metronidazole)
What is the duration of treatment when using concomitant therapy
take for 10-14 days
When is clarithromycin triple therapy appropriate?
Only when clarithromycin resistance is low (≤15%) and there’s been no macrolide exposure.
What drugs are in clarithromycin triple therapy?
- Amoxicillin 1000 mg BID
- Clarithromycin 500 mg BID
- PPI BID (or esomeprazole 40 mg daily)
Or use a combination product: - Prevpac
what makes up the 3-in-1 combo Prevpac ?
- amoxicillin +
- clarithromycin +
- lansoprazole)
What to use if patient has a penicillin allergy in clarithromycin triple therapy?
Replace amoxicillin with metronidazole 500 mg TID, or use quadruple therapy.
How do NSAIDs cause gastric mucosal damage?
- Direct irritation of the gastric epithelium
- Inhibition of prostaglandin synthesis by blocking COX-1
How do NSAIDs affect blood pressure and kidney function?
NSAIDs elevate blood pressure and decrease renal blood flow.
In which patients should NSAIDs be used with caution?
Those with cardiovascular or renal disease.
How do COX-2 selective NSAIDs like celecoxib compare to non-selective NSAIDs?
- Lower GI risk
- Higher cardiovascular (CV) risk
Which NSAIDs have COX-2 selectivity similar to celecoxib?
- Meloxicam
- Nabumetone
- Diclofenac
- Etodolac
How can patients with high GI risk reduce the risk of ulcers when taking non-selective NSAIDs?
They can use a PPI to prevent or decrease the risk of ulcers and bleeding.
What are the risk factors for NSAID-induced ulcers?
- Age > 60 years
- History of PUD (including H. pylori-induced)
- High-dose NSAID use
- Use of > 1 NSAID (e.g., ibuprofen + aspirin)
- Concomitant use of anticoagulants, steroids, SSRIs, or SNRIs
What are examples of combination products used to prevent NSAID-induced ulcers?
- Vimovo (naproxen + esomeprazole)
- Duexis (ibuprofen + famotidine)
- Arthrotec (diclofenac + misoprostol)
What is Yosprala, and when is it used?
Yosprala is a combination of aspirin and omeprazole, approved for secondary prevention of cardiovascular and cerebrovascular events in patients at risk for aspirin-associated ulcers
How should a confirmed NSAID-induced ulcer be treated?
1.Use a PPI for 8 weeks
2. Discontinue NSAIDs
What is misoprostol?
A prostaglandin E1 analog that replaces gastro-protective prostaglandins lost due to NSAID use.
What is sucralfate and how does it work?
A sucrose-sulfate-aluminum complex that forms a physical barrier over ulcers to protect them from HCl acid, pepsin, and bile.
what is the brand name of misoprostol ?
Cytotec
what is misoprostol + diclofenac ?
arthrotec
Q: What is the boxed warning for misoprostol?
- It is an abortifacient
- Do not use to reduce NSAID-induced ulcers in females of childbearing potential unless they use effective contraception
What is the boxed warning for Arthrotec (diclofenac/misoprostol)?
Increased risk of serious GI events (e.g., bleeding, ulceration) and CV disease (e.g., MI, stroke)
What are common side effects of misoprostol?
Diarrhea and abdominal pain
what is the brand name of sucralfate ?
Carafate
What is the dosing for sucralfate?
1 gram PO QID — taken before* meals (on an empty stomach) and at bedtime
What is a common side effect of sucralfate?
Constipation
What makes sucralfate difficult to use?
- It has many binding interactions. You must:
- Separate antacids by 30 minutes
- Take other drugs 2 hours before or 4 hours after
What are common side effects of antibiotics used in H. pylori treatment?
- Allergy/anaphylaxis
- Diarrhea
Q: What are side effects associated with bismuth subsalicylate?
- Bleeding or bruising
- Dark tongue and stool
Q: What side effect is common with metronidazole?
Bad taste in the mouth
What should patients avoid when taking metronidazole?
Alcohol during treatment and for at least 3 days after stopping it.
How should Prevpac be taken?
- Each card contains 4 pills (morning and evening doses)
- Take doses before breakfast and dinner
How should Pylera be taken?
- Take three capsules, four times daily
- With a full glass of water
- After breakfast, lunch, dinner, and at bedtime
- Swallow capsules whole
- Pylera be used with a separate acid-reducing medication (e.g., a PPI)
