GERD & PUD Flashcards
Symptoms, Screening & Diagnosis of GERD
Sx: heartburn (daytime or nocturnal) & regurgitation
Diagnosis: frequency > 2 Xs per week
Screening: Endoscopy or esophageal pH monitoring
Drugs that can worsen GERD symptoms
Aspirin/NSAIDs Bisphosphonates Dabigatran Estrogen products Fish oil products Iron supplements Nicotine replacement therapy Steroids Tetracyclines
Alarm symptoms that require referred for further evaluation
Odynophagia (painful swallowing) Dysphagia Frequent N/V hematemesis black bloody stools unintentional weight loss
Infrequent heartburn (< 2Xs/wk) can be treated with?
PRN OTC antacids or H2RAs
What is the initial drug treatment of choice for GERD?
8 week course of a PPI
GERD Treatment Algorithm
- Lifestyle modifications
- Weight loss
- Initial drug treatment
- PPI once daily x 8 weeks
- Maintenance treatment
- 1st-line: PPI at lowest effective dose
- Alt: H2RA, if no erosive esophagitis & it relieves sx
- Not recommended: metoclopramide or sucralfate
Antacids
MOA/Drugs (generic/brand)/Side Effects
MOA: antacids works by neutralizing gastric acid (producing salt and water), which increases gastric pH; relief within 30-60 minutes.
______Drugs______
calcium carbonate (TUMS) - safe in pregnancy
+ magnesium (Mylanta)
+ simethicone (Maalox)
magnesium hydroxide (Milk of Magnesia) \+ aluminum + simethicone (Mylanta Classic)
sodium bicarbonate + ASA + citric acid (Alka-Seltzer)
_____Side Effects_____
Calcium: constipation
Aluminum: constipation
Magnesium: loose stools
H2RAs
MOA/Drugs (generic/brand)/Side Effects
MOA; reversibly inhibit H2 receptors, which decreases gastric acid secretion
____Drugs/SE_____
famotidine (Pepcid)
ranitidine (Zantac)
cimetidine (Tagamet) - gynecomastia, impotence (Avoid use lots of DDIs/SE)
_____Notes______
Decrease dose when CrCl < 50 mL/min (famotidine & ranitidine) or CrCl < 30 mL/min (cimetidine)
PPIs
MOA/Drugs (generic/brand)/Notes/Warnings
MOA: irreversibly bind to the gastric H+/K+-ATPase pump, which blocks gastric acid secretion
____Drugs/Notes_____
esomeprazole (Nexium): 60 min b4 brkfst
lansoprazole (Prevacid): min b4 brkfst
omeprazole (Prilosec): b4 brkfst
dexlansoprazole (Dexilant): w/o regards to meals
pantoprazole (Protonix): oral susp 30 min b4 meal
Warnings: C.diff-associated diarrhea, hypomagnesemia, vitamin B12 deficiency with prolonged use (>2yrs), osteoporosis-related bone fractures with high doses & long-term use (>1yr)
Risks Associated with PPI Therapy
Changes in gastric pH
increase risks of GI infections (C. diff & pneumonia)
increase risk of OP & fractures
Beers Criteria: avoid >8wks in elderly
Dopamine antagonist drug
Boxed Warning/Warnings/SE
metoclopramide (Reglan): AC & HS
CrCl < 60 mL/min decrease dose by 50% (avoid SE of CNS/EPS)
Boxed Warning: Tardive dyskinesia (TD)
Warnings: EPS, parkinsonian-like symptoms (Avoid in Parkinson disease)
SE: drowsiness
What drugs should be avoided completely when taking H2RAs and PPIs?
Delayed-release formulation of risedronate (Atelvia)
rilpivirine
velpatasvir/sofosbuvir (Epclusa)
other PPIs
Drugs that require an acidic gut (absorption decrease by antacids, H2RAs and PPIs)
Antiretrovirals: rilpivirine (NNRTI), atazanavir (PI) Antivirals: ledipasvir, velpatasvir/sofosbuvir (Epclusa) Azole antifungals Cephalosporins: cefpodoxime, cefuroxime Iron products Mesalamine Risedronate DR TKIs
Oral drugs/drug classes that antacids bind
Antiretrovirals (INSTIs) Bisphosphonates Isoniazid Levothyroxine Mycophenolate Quinolones Sotalol Steroids (esp. budesonide) Tetracyclines
What CYP enzyme does PPIs inhibit?
CYP2C19
Omeprazole & esomeprazole can decrease the effectiveness of clopidogrel (prodrug) thru CYP2C19 inhibitions (avoid concurrent use)
