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NAPLEX > GERD & PUD > Flashcards

GERD & PUD Flashcards

0
Q

What xterizes GERD?

A

Lower esophageal sphincter (LES) pressure or muscle tone is reduced (or transiently relaxes)

And allows the BACKFLOW of the stomach contents

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1
Q

What’s GERD?

A

GERD is a condition in which the stomach contents leak backwards into the esophagus

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2
Q

List typical sx of GERD?

A

Heartburn

Hypersalivation

Regurgitation

Acid taste in mouth

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3
Q

List alarm conditions in which patients require further testing

A

Chest pain, dysphagia

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4
Q

What’s the reason behind the recent caution to chronic acid suppression from H2RAs and PPIs?

A

Concern about

Risk of GI infections (most commonly caused by C.difficile)
And
Increased risk of nosocomial pneumonia in hospitalized pts

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5
Q

What other factors result in caution to chronic use of PPIs?

A

Increased risk of osteoporosis and fractures with long-term use

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6
Q

While there’s a caution with the use of H2RAs in the elderly per Beers Criteria, which one of them is an absolute C/I in the elderly?

A

Cimetidine (due to drug-drug int, ADRs)

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7
Q

What should pts be aware of, especially the elderly, if H2RAs are overdosed?

A

Risk of worsening:

Dementia

Delirium/confusion

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8
Q

T/F? H2RAs are NOT dosed adjusted for renal impairment?

A

False!

They are dose adjusted in renal impairment

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9
Q

List recommended non-pharmacologic (lifestyle) tx

A

Avoid foods that may reduce LES pressure e.g. Spicy foods, nicotine, caffeine, alcohol, fatty foods, citrus, chocolate

Smaller portions and eat mor frequently

Weight loss - best evidence in improvement

Don’t eat b4 sleeping (last meal should be 2-3 hrs b4 bedtime)

Elevate head of bed 6-8” (with wedges, NOT pillows)

Avoid tight-fitting clothing

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10
Q

List agents used in GERD pharmacologic therapy

A

Antacid

Histamine (H2) Receptor Antagonists (H2RAs)

Proton Pump Inhibitors (PPIs)

Cytoprotective agents

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11
Q

MOA of antacids?

A

Work by neutralizing gastric acid (producing salt and water), thus increasing gastric PH.

They provide relief within mins as antacids don’t req systemic absorption

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12
Q

List drugs under antacids

A

Calcium (Tums)

Magnesium (Phillips Milk of Magnesia (MOM))

Mg + (Al or Ca) (Maalox, Mylanta)

Mag-Al-Simethicone (anti-gas) (Maalox, Max, Mylanta Max Strength)

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13
Q

Brand name of Calcium (antacid)?

A

Tums

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14
Q

Brand name of Magnesium (antacid)?

A

Phillips Milk of Magnesia (MOM)

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15
Q

Brand name of Magnesium + Aluminum/Calcium (antacid)?

A

Maalox

Mylanta

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16
Q

Brand name of Mg-Al-Simethicone (antacid)?

A

Maalox Max

Mylanta Max Strength

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17
Q

What’s the drug of choice during pregnancy?

A

Antacids

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18
Q

Reduced absorption due to chelation is seen in antacid +?

A

Quinolones and Tetracyclines (Doxycycline and Minocyclines are of less clinical concerns)

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19
Q

How do u separate antacids from antibiotics and Itraconazole, Ketoconazole and iron

A

Use antacids 2hrs B4

And

4-8 hrs after

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20
Q

What antibiotics are of less concern wrt to chelation of antacids?

A

Doxycycline and Minocycline

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21
Q

Antacids have a quick onset and quick offset? T/F?

A

True

They usually only last about 1-2 hrs

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22
Q

If a pt has kidney dx, which antacid can they use?

A

Tums (calcium) only

Avoid Mg and Al

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23
Q

If a pt using tums experiences constipation, what’s most likely the active ingredient in it?

A

Al

T4 d/c Al pdts

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24
Q

If a pt using tums experiences loose stools, what’s most likely the active ingredient in it?

A

Mg-containing pdts

Use Tums - contains Ca only

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25
Q

MOA of Histamine H2 Receptor Antagonists (H2RAs)?

A

H2RAs reversible inhibits the H2 receptors in the gastric parietal cells, thus reducing gastric acid secretion

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26
Q

List H2RAs agents

A

Famotidine (Pepcid AC; AC Max strength)

Ranitidine (Zantac)

Pepcid Complete (Ca Carbonate, Magnesium hydroxide, famotidine)

Nizatidine (Axid)

Cimetidine (Tagamet; HB 200)

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27
Q

How are ALL H2RAs agents dosed?

A

Mild heartburn - PRN

Documented GERD - Twice daily for up to 12 weeks

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28
Q

What’s the brand name of famotidine? (H2RAs)

A

Pepcid AC; AC Max Strength

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29
Q

What’s the brand name of calcium carbonate, magnesium hydroxide, famotidine? (H2RAs)

A

Pepcid Complete

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30
Q

What’s the brand name of Ranitidine? (H2RAs)

A

Zantac

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31
Q

What’s the dosing and brand name of Famotidine OTC? (H2RAs)

A

Pepcid AC 10, 20mg - Max Strength

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32
Q

What’s the dosing and brand name of Famotidine Rx? (H2RAs)

A

Famotidine Rx

20, 40mg

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33
Q

What’s the dosing of Ranitidine OTC? (H2RAs)

A

75, 150mg

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34
Q

What’s the dosing of Ranitidine Rx? (H2RAs)

A

300mg

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35
Q

Warning associated with H2RAs use?

A

Risk of worsening dementia and confusion

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36
Q

Which H2RAs agent is to be avoided completely in elderly?

A

Cimetidine

Due to drug interactions and ADRs (CNS effects, gynecomastia, impotence)

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37
Q

SEs from H2RAs use?

A

Risk of GI infections

Risk of pneumonia in hospitalized pts

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38
Q

H2RAs and renal impairment?

A

H2RAs must be dose-adjusted in renal impairment (50% of dose)

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39
Q

What can reduce absorption of H2RAs?

A

Itraconazole

Ketoconazole

Calcium carbonate

Iron

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40
Q

Is cimetidine a CYP 3A4 substrate, inducer, inhibitor?

A

CYP 3A4 inhibitor

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41
Q

MOA of Proton Pump Inhibitors (PPIs)?

A

Irreversibly binds to gastric H+/K+ adenosine Triphosphate (ATPase) pump in parietal cells

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42
Q

Where do PPIs work?

A

They block FIINAL step in acid production

43
Q

How are ALL PPIs used?

A

Used daily, 30mins B4 breakfast

OR

BID (2nd dose b4 dinner)

44
Q

Dosing of PPIs for treating duodenal or gastric ulcers caused by H. Pylori?

A

BID

45
Q

List PPIs agents

A

Omeprazole (Prilosec OTC, Prilosec)

Omeprazole/Sodium Bicarbonate (Zegerid, Zegerid OTC)

Pantoprazole (Protonix)

Lansoprazole (Prevacid; SoluTab; 24H-OTC)

Esomeprazole (Nexium)

Rabeprazole (AcipHex)

46
Q

What’s the brand name of Omeprazole? PPIs

A

Prilosec OTC

Prilosec

47
Q

What’s the brand name of Omeprazole/Sodium Bicarbonate? PPIs

A

Zegerid

Zegerid OTC

48
Q

What’s the brand name of Prontoprazole? PPIs

A

Protonix

49
Q

What’s the brand name of Lansoprazole? PPIs

A

Prevacid,

Prevacid SoluTab

Prevacid 24H-OTC

50
Q

What’s the brand name of Esomeprazole? PPIs

A

Nexium

51
Q

What’s the brand name of Rabeprazole? PPIs

A

AcipHex

52
Q

Which PPIs is on record to avoid use with Clopidogrel?

A

Omeprazole and Esomeprazole

53
Q

Which supplements should be used with PPIs if they are used long-term?

A

Calcium (Ca citrate preferred) and Vit. D

54
Q

How soon should u contact the dr if using the PPIs without any relief?

A

14 days and heartburn persists

55
Q

List Cytoprotective Agents used in GERD.

A

Misoprostol (Cytotec)

Sucralfate (Carafate)

56
Q

SE of Misoprostol (Cytoprotective agent used in GERD)?

A

Diarrhea

Abdominal pain

57
Q

Pregnancy category of Misoprostol (Cytoprotective agent used in GERD)?

A

X

58
Q

Howz Sucralfate used?

A

QID B4 meals and QHS

59
Q

SE of Sucralfate (Cytoprotective agent used in GERD)?

A

Comstipation

60
Q

MOA of Metoclopramide?

A

Dopamine antagonist

61
Q

Brand name of Metoclopramide?

A

Reglan

62
Q

What’s the caution with using Metoclopramide (Reglan) in elderly?

A

CNS SE are dose related and more common in elderly

63
Q

When’s Metoclopramide’s use CI?

A

Parkinson’s dx (Metoclopramide is a dopamine antagonist)

64
Q

Metoclopramide (Reglan) dose in renal impairment?

A

2.5-5mg four times a day

65
Q

Which PPIs is available in IV formulation?

A

Nexium (Esomeprazole)

Protonix (Pantoprazole)

66
Q

What can PPIs increase the risk of?

A

Bone fracture

C. difficle infection

Pneumonia in hospitalized pts

67
Q

Start of PUD (peptic ulcer dx)

A

PUD

68
Q

List 3 common causes of PUD

A

H. pylori-positive ulcers

NSAIDs-induced ulcers

Stress ulcers in presence of critical illness & in mechanically-ventilated pts

69
Q

What’s Helicobacter Pylori?

A

Spiral-shaped

Gram-negative

70
Q

What’s the primary sx of PUD?

A

Gastric pain (associated with a burning or gnawing sensation and may awaken a pt at night)

71
Q

What type of PUD is typically caused by H. pylori?

A

Duodenal PUD

72
Q

What type of PUD is typically caused by NSAIDs?

A

Gastric ulcers

73
Q

What generally lessens the pain associated with duodenal ulcer (primarily caused by H. pylori)?

A

Eating

74
Q

What generally worsens the pain associated with gastric ulcer (primarily caused by NSAIDs)?

A

Eating

75
Q

T/F: Eating LESSENS pain of duodenal ulcers and WORSENS the pain of gastric ulcers?

A

T

76
Q

List other sx of PUD

A

Heartburn

Belching

Bloating

Nausea

Anorexia

77
Q

What’s the concern with untreated H. pylori?

A

Can lead to cancer

78
Q

How soon b4 urea breath test (UTB - test for H. pylori) should H2RAs, PPIs, Bismuth and Antibiotics be d/c?

A

H2RAs, PPIs - 1 to 2 wks B4 UTB

Bismuth, Antibiotics - 4 wks B4 UTB

79
Q

How soon b4 Fecal antigen test (test for H. pylori in stool) should H2RAs, PPIs, Bismuth and Antibiotics be d/c?

A

H2RAs, PPIs, Bismuth and Antibiotics - at least 2 - 4 wks

80
Q

What’s the recommended therapy for PUD?

A

Triple therapy for 14 days

81
Q

What constitutes triple therapy (recommended tx for PUD)?

A

Anti-secretory agent (preferably a PPI)

+

2 antibiotics (Clarithromycin and Amoxicillin)

82
Q

If the pt has a penicillin allergy, what can be used in place of Amoxicillin?

A

Metronidazole

83
Q

What’s the alternative to triple therapy? When would u use this?

A

Quadruple therapy

If pt has used a Macrolide or metronidazole in the past

OR

If local failure rates are known to be high

84
Q

What constitutes quadruple therapy (alternative tx for PUD)?

A

PPI + Bismuth + Metronidazole + Tetracycline for 10-14 days

Can use Helidac or Pylera

85
Q

Whats a second alternative to treating PUD?

A

Sequential therapy:

PPI + Amoxicillin x 5 days, followed by

PPI + Clarithromycin + Tinidazole x 5 days

86
Q

Are drug substitutions in H. pylori permitted in H.pylori education?

A

No

87
Q

List 1st-line H.pylori regimens

A

Triple Drug Therapy

PPI BID (or Esomeprazole 40mg daily) + Amoxicillin 1,000mg BID + Clarithromycin 500mg BID x 14 days

88
Q

Alternative if pt has penicillin or Macrolide allergy?

A

Replace Amoxicillin or Clarithromycin with Metronidazole 500mg BID

89
Q

Dosing in Quadruple therapy in H.pylori?

A

PPI bid (or Esomeprazole daily) + Bismuth subsalicylate 525mg QID + Metronidazole 250mg QID + Tetracycline 500mg QID x 10-14 days

90
Q

If a pt uses alcohol, which med in the quadruple therapy used in H.pylori, what med must be substituted?

A

Metronidazole

91
Q

If a pt is pregnant, which med in the quadruple therapy used in H.pylori, must be substituted?

A

Tetracycline

92
Q

If a pt has Salicylate allergy, which med in the quadruple therapy used in H.pylori must be substituted?

A

Bismuth subsalicylate

93
Q

If a pt is < 8yrs, which med in the quadruple therapy used in H.pylori, must be substituted?

A

Tetracycline

94
Q

If a pt can’t tolerate PPI, which med in the quadruple therapy used in H.pylori must be substituted?

A

Substitue H2RA e.g, Ranitidine 150mg BID, Famotidine 40mg daily, Nizatidine 300 mg/d

95
Q

List combo pdts used in H. pylori

A

Pervpac

Pylera

Helidac

96
Q

What’s the ingredients in Prevpac? Dosing?

A

Lansoprazole/Amoxicillin/Clarithromycin all in 1 blister pack

BID x 14 days

97
Q

What’s the ingredients in Pylera? Dosing?

A

Bismuth subcitrate potassium/Metronidazole/Tetracycline in 1 capsule

Take 3 capsule QID x 10 days

+

PPI BID (Esomeprazole BID) x 10 days

98
Q

What’s the ingredients in Helidac? Dosing?

A

Bismuth subsalicylate/Metronidazole/Tetracycline x 14 days

+

H2RA x 28 days

99
Q

T/F? Clarithromycin is a strong inhibitor?

A

T

100
Q

Effect of metronidazole on warfarin?

A

May increase INR

101
Q

Risk factors for NSAID-induced ulcers?

A

Age > 65 yrs

Previous ulcers

High-dose or chronic NSAID use

Concomitant use of steroids, anticoagulants, SSRIs or SNRIs

102
Q

What may be used in high-risk pts (NSAID-induced ulcer)?

A

COX-2 selective agent e.g. Celecoxib, meloxicam, nabumetone and etodolac

103
Q

In what pt grps are NSAIDs used with caution?

A

Cardiovascular and Renal dx

104
Q

If possible, avoid non-selective NSAIDs and Celecoxib in what pt grps?

A

In pts with both high GI and CV risk

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