GERD/PUD Flashcards
Acidic gastric contents are normally prevented from back flow into the esophagus by a protective ring of muscle fibers called:
However, patients with GERD have reduced ___ pressure.
lower esophageal sphincter (LES)
reduced LES pressure
^ this causes back flow!
How is GERD diagnosed?
based on patient-reported symptoms (duration, daytime and/or night), frequency (>2 times per week) and risk factors (family history, diet and eating habits, sleep position )
endoscopy might be performed if more serious symptoms arise (esophageal 24 hour pH monitoring)
What is the name of the condition where abnormal cell growth in the esophageal lining which can lead to esophageal cancer?
Barrett’s esophagus
What drugs can worsen GERD symptoms?
Aspirin/ NSAIDs Bisphosphanates Dabigatran Estrogen products Fish oil products Iron supplements NRT Steroids Tetracyclines
How long before a pharmacist should refer a patient to a PCP, with failed OTC attempts to treat GERD?
two weeks; and immediately if alarm sx are present
List the alarm symptoms of GERD
painful swallowing (odynophagia) dysphagia frequent nausea and vomitting hematemesis black bloody stool unintentional weight loss
How is infrequent heartburn (<2 times per week) treated?
PRN OTC antacids or H2RAs
What is the initial treatment of choice for GERD?
an eight-week course of a proton pump inhibitor; and is used to heal any erosive esophagitis
This drug works by neutralizing gastric acid (producing salt and water), which increases gastric pH
Antacids
provides relief within minutes! Short Half life 30-60 mins
What can happen if a person is using OTC antacids that’s mixed with aspirin?
risk of bleeding if used too frequently
Brand: Tums
Generic: calcium carbonate
Brand: Mylanta
Generic: calcium carbonate + magnesium
Brand: Maalox
Generic: calcium carbonate + simethicone
Brand: Milk of Magnesia
Generic: magnesium hydroxide
Brand: Mylanta Classic
Generic: magnesium hydroxide + aluminum + simethicone
Brand: Alkaseltzer
Generic: sodium bicardonate/aspirin/citric acid
*contains >500mg of Na… bad for edema, HF, cirrhosis
What is the dosing for antacids?
varies, but many require administration 4-6x per day
What antacids are preferred in pregnancy?
calcium-containing
Calcium can cause –>
Aluminum can cause –>
Magnesium can cause –>
Calcium can cause –> constipation
Aluminum can cause –> constipation
Magnesium can cause –> loose stools
Initial drug treatment is once daily for 8 weeks, but when can you increase to twice daily?
if partial response or if nighttime symptoms are present
What is the maintenance treatment for GERD?
1st line: PPI at the lowest effective dose
alt: H2RA, if there is no erosive esophagitis
Famotidine
Ranitidine
Cimetidine
what drug class?
H2RAs
Brand: Pepcid, Pepcid AC
Generic: famotidine
Brand: Zantac
Generic: ranitidine
This drug class reversibly inhibit H2 receptors on gastric parietal cells, which decreases gastric acid secretions
H2RAs
used PRN for infrequent or mild heartburn but have a slower onset than antacids
What class has warnings for confusion, especially in elders with renal impairment?
H2RAs
cimetidine - gynecomastia, impotence ; tbh just avoid because drug interactions and side effects lol
For H2RAs, decrease dose when CrCl
<50
This drug class irreversibly binds to the gastric H+/K+ ATPase pump in parietal cells, which shuts down the proton pump and blocks gastric acid secretion
PPIs
*The MOST effective drug for GERD, all the clout
Brand: Nexium
Generic: esomeprazole
INJ!!!!
Brand: Prevacid
Generic: lansoprazole
Brand: Dexilant
Generic: dexlansoprazole
Brand: Protonix
Generic: pantoprazole
INJ!!!!
Which PPIs are taken 60 mins before breakfast?
Nexium
Prevacid
Prilosec
This drug class has warnings for:
C.diff / pneumonia
hypomagnesia
Vitamin B12 deficiency with longterm use (>2 years)
osteoporosis related bone fracture with high doses or longterm use >1 year
PPIs
Don’t use omeprazole and esomeprazole with which drug due to diminishing the effect of the drug?
clop-i-dog-rel
Which PPIs are available IV?
pantoprazole and esomeprazole
Of the H2RAs, which are oral solutions/suspensions?
cimetidine
famotidine
nizatidine
ranitidine
Of the H2RAs, which are inj formulations?
famotidine
ranitidine
Of the PPIs, which are ODT?
lansoprazole
omeprazole
of the PPIs, which are oral solutions/suspension?
lansoprazole packets for suspension ---- esomeprazole omeprazole pantoprazole
Which drugs can be used for peptic ulcer disease?
misoprostol and sucralfate
Which drugs are commonly used when patients have coexisting gastroparesis?
metoclopramide and erythromycin
This drug is a dopamine antagonist and at higher doses blocks serotonin receptors in the chemoreceptor zone of the CNS.
Enhances the response to ACh in the upper GI tract, causing increased motility, accelerated gastric emptying, and inc LES tone
Metoclopramide
Brand: Reglan
Generic: Metoclopramide
When should you take metoclopramide?
30 min before meals, and at bedtime
When CrCl <40, decrease dose 50% to avoid CNS/EPS side effects
This drug has a boxed warning for tardive dyskinesia, and warnings for EPS.. should not be used in PD patients
metoclopramide
can also cause dizziness
Drugs that require an acidic gut (absorption dec by antacids, H2RAs, and PPIs
Separate 2-4h before, 2-6 after
antiretrovirals (rilpivirine - NNRTI, atazanavir - PI)
Antivirals: ledipasvir, velpatasvir/sofosbuvir
azole antifungals
cefpodoxime, cefuroxime
iron
mesalamine
risedronate DR
tyrosine kinase inhibitors: dasatanib, erlotinib, pazopanib
Oral drugs that antacids bind…
INSTIs bisphosphonates isoniazid levothyroxine mycophenolate quinolones sotalol steroids (esp budesonide) tetracyclines
This condition occurs when there is a mucosal erosion within the GI tract - deep into the mucosa
peptic ulcer disease
What are the three most common causes of PUD?
H. pylori (spiral shaped, gram negative)
NSAID induced unclers
stress ulcers
What is the primary symptom of PUD?
dyspepsia, a gastric pain which can feel like gnawing or burning sensation in the middle or upper stomach
If the ulcer is duodenal, pain is typically worse 2-3 hours after eating when the stomach is empty. Eating foot or taking antacids lessens the pain – what is the offender?
H. Pylori
With gastric ulcers, eating generally worsens the pain – what is the offender?
NSAIDs
What is the name of the test that tests for H. pylori?
urea breath test – identifies gas (co2) produced by the bacteria
fecal antigen test detects h pylori in the stool
d/c PPIs, bismuth and antibiotics to avoid false negatives
Due to failure rates with triple therapy (often caused by clarithromycin resistance), it is now recommended for…
QUADRUPLE THERAPY
the use of triple can be used if clarithromycin resistance is <15% and history of no macrolide
The three first-line H. Pylori treatment regimens
1st line - bismuth quadruple therapy
Alt: concomitant therapy
Depends: clarithromycin triple therapy
What is in the bismuth quadruple therapy? How long is the therapy?
bismuth subsalicylate 300mg QID+
metronidazole 250-500mg QID +
tetracycline 500mg QID +
PPI BID (or esomeprazole 40mg daily)
x10-14 days
Brand: Pylera
Generic: bismuth substrate potassium+ metronidazole +tetracycline) …taken QID
you’d want to add PPI BID
Do not use in pregnancy bc of tetracycline!
What is in the concomitant therapy? Take for how long?
amoxicillin 1000mg BID +
clarithromycin 500mg BID +
metronidazole 250-500mg QID +
PPI BID (or esomeprazole 40 mg daily)
x 10-14 days
What is in the clarithromycin triple therapy? used for how long?
Amoxicillin 1,000mg BID +
Clarithromycin 500mg BID +
PPI BID (or esomeprazole 40mg daily)
*if penicillin allergy, switch amoxicillin with metronidazole 500mg TID
Brand: Prevpac
Generic: amoxicillin + clarithromycin + lansoprazole
x 14 days
How do NSAIDs cause drug-induced ulcer?
direct irritation of the gastric epithelium and systemic inhibition of PG synthesis (by inhibiting COX-1)
NSAIDs with selective inhibition of COX-2 (i.e. celecoxib) have deceased ____ risk, but increased _____ risk
dec GI risk
inc CV risk
NSAIDs that approach the selectivity of celecoxib are:
meloxicam
nabumetone
diclofenac
etodolac
Brand: Vimovo
Generic: naproxen/esomeprazole
marketed to reduce the risk of NSAID-induced ulcers
Age >60 History of PUD High dose NSAIDs using >1 NSAID \+ anticoagulants, steroids, SSRIs, SNRIs are risk factors for what?
NSAID induced ulcers
Brand: Yosprala
Generic: aspirin/omeprazole
If an ulcer develops, it should be treated with a ____ x8 weeks, and NSAIDs should be discontinued.
PPIs
if PPI cannot be used, high dose H2RAs or sucralfate are other options
a prostaglandin E1 analog that replaces the gastro-protective prostaglandins removed by NSAIDs
misoprostol
a sucrose-sulfate-aluminum complex that can interact with albumin and fibrinogen to form a physical barrier over an open ulcer
sucralfate
Misoprostol and sucralfate are what types of drugs?
cytoprotective
Brand: cytotec
Generic: misoprostol
This drug has a boxed warning for: abortifacient
misoprostol
Brand: Carafate
generic: sucralfate
* taken BEFORE meals… can cause constipation … has binding interactions
If a patient has phenylketonuria don’t use what drug?
Prevacid SoluTab
