GERD/PUD Therapy Lecture PDF Flashcards
Factors that impact gastric acid secretion (4)
- gastrin binding to receptors on parietal cell
- H2 binding to receptors on parietal cell
- Ach binding to parietal cell
- proton pump
Defensive factors that prevent peptic ulcers
- mucus
- bicarb
- blood flow
- prostaglandins
Aggressive factors that cause peptic ulcers
- gastric acid
- pepsin
- pathogen such as helicobacter pylori
- NSAID use
Nondrug therapy to prevent ulceration of GI (2)
- diet plays no role
- alcohol and cigarettes
Histamine 2 receptor antagonist mech of action
-Because parietal cells have receptors for histamine to promote gastric secretions when released from mast cells thruout gastric mucosa, these antagonists prevent secretion
H2 receptor antagonists indications (4)
- gastric or duodenal ulcers (not curative of H pylori infection)
- GERD mild relief
- zolinger ellison syndrome
- heartburn
Cimetidine (tagamet) drug class, ADR’s (2)
- prototype H2 blocker
- antiandrogenic effects causing gynecomastia, reduced libido, impotence, CNS effects
Ranitidine (zantac) differs from cimetidine in 3 ways
- more potent
- fewer ADR’s (no antiandrogen effects)
- fewer interaactions
Sucralfatte (carafate) drug class and mech of action
- aluminum hydroxide complex of sucrose
- Promotes ulcer healing by creating protective barrier against acid and pepsin, forms a viscous and sticky substance that covers ulcer crater for 6 hours
Proton pump inhibitor mech of action
-binds to proton pump of parietal cell causing irreversible inhibition of enzyme that generates gastric acid at the final step, inhibiting up to 90% of 24 hr acid secretion without tolerance in only one a day dosing
Proton pump inhibitor therapeutic uses (4) and ADR’s (6)
- GERD
- peptic ulcer disease
- long term therapy of hypersecretory conditions
- no impact on warfarin
- headache, NVD
- pneumonia
- fractures increased risk of osteoperosis (use lowest dose and maintain Ca2+ and vit D)
- rebound acid hypersecretion when discontinued
- hypomagnesemia
- C diff infection in long term
Omeprazole (prilosec) drug class, administration
PPI, oral in sustained release capsule containing protective enteric coated granules
Omeprazole (prilosec) therapuetic uses (4)
- gastric and duodenal ulcers
- GERD
- erosive esophagitis
- 4-8 week treatment except in hypersecretory states
Omeprazole (prilosec) alternatives (4)
- lansoprazole (prevacid)
- rabeprazole (aciphex)
- pantoprazole (protonix)
- esomeprazole (nexium)
Misoprostol drug class and therapeutic use
Synthetic analogue of prostaglandin E1 used for prevention of gastric ulcers caused by long term NSAID therapy
Misoprostol ADR’s (2)
- NVD
- Pregnancy category X
Antacids mech of action
-Alkaline compounds that neutralize gastric acid reducing descrution of gut wall
Antacids indications (3)
- peptic ulcer disease
- prophylaxis against stress ulcers
- heart burn
Antacids ADR’s (3)
- constipation and diarrhea depending on aluminum or magnesium (many preps balance these out)
- Na+ loading increasing hypertension
- acid rebound
Antacids drug interactions (3)
-can influence dissolution of many drugs (cimetidine and ranitidine) and chelate drugs in stomach preventing absorption (fluorquinolones)
Antacid families (4)
- magnesium hydroxide
- aluminum hydroxide
- calcium carbonate (tums)
- sodium bicarb (unfit for ulcers but treats acidosis)
Milk alkali syndrome
Characterized by hypercalcemia, metabolic acidosis, soft tissue calcification, and impaired renal function
Bismuth subsalicylate (pepto) function
Promote ulcer healing by forming protective coating over ulcer, promotes secretion of bicarb and prostaglandins, suppresses growth of H pylori, as well as assist in diarrhea treatment, and can be prophylaxis against travelers diarrhea
Bisthmus subsalicylate (pepto bismol) ADR’s (2)
- harmless stool color change
- long term risk of neurologic injury
Clarithromycin triple therapy
Less effective due to resistance treatment for H pylori includes standard dose of PPI + 2 antibiotics (clarithromycin + amoxicillin OR metronidazole)
Bisthmuth based quadruple therapy
First line treatment for H pylori including pepto, metronidazole, tetracycline, and standard dose PPI
Clarithromycin based quadruple therapy
First line treatment for h pylori including amoxicilin, clarithromycin, metronidazole, and PPI for 14 days
Helidac, pylera, and prevpac
Combo therapies that implement the triple and quadruple regimens into one pack of pills multiple times a day
Treatment for NSAID related ulcers (2)
8 week course of H2RA or full dose sucralfate OR 4 week course of PPI
At least __% of adults experiencereflux symptoms of heartburn occasionally
50%
Gastric reflux mech of action
Because organs are crowded together we see the increase in abdominal pressure above thoracic causing contents to be pushed upward when the lower esophageal sphincter is weakned or incompetent
Causes of GERD (4)
- Structural/mechanical due to pregnancy or large meal
- hiatal hernia
- posture (lying down after meal)
- delayed gastric emptying due to diabetes, parkinsons, myasthenia gravis, etc
Dietary elements and drugs that decrease lower esophageal pressure (3)
- acidic, fat, or spicy food
- anticholinergics
- Ca2+ channel blockers
Atypical symptoms of GERD (3)
- heartburn which may radiate to shoulders, neck, and back
- hoarseness
- asthma
Alginic acid and example
Acts as a barrier to reflux and coats the esophagus when reflux occurs (gavison – sodium bicarb + alginic acid)
Baclofen (lioresal) drug class and function
GABA receptor agonist that deceases postprandial acid reflux in patients with GERD
Metoclopramide (reglan) mech of action
Inhibition of inhibitory D2 receptors in gut with subsequent release of Ach into myenteric plexus causing peristalsis, increases lower esophageal sphincter tone
Metoclopramide indications (2) and ADR’s (3)
- GERD
- diabetic gastroparesis
-diarrhea, gynecomastia, tardive dyskinesia
Bethanechol (Urecholine) drug class
Muscarinic agonist
Erosive esophagitis treatment (1)
PPI 8-12 weeks followed by tapeing off
PPI dose reduction
After 8-12 weeks should attempt alternate day therapy and eventually try stopping if don’t have relapse of symptoms, if stricture present, chronic maintenance therapy recommended without reduction in dose
Antiemetics offer 3 benefits
- reductjion of anticipatory nausea and vomiting
- prevention of malnutrition and dehydration secondary to vomit
- prevent motion sickness
Standard guidelines for treatment of chemo induced nausea and vomiting
-3 drug regimen consisting of aprepitant, a 5 HT3 receptor antagonist and dexamethasone
Dopamine antagonists used to suppress emesis (3)
Phenothiazines including chlorpromazine, prochloperazine, and triethylperazine
Butyrophenone (1) used to suppress emesis
-haldol
Dexamethasone/methylprednisolone drug class, function, ADR’s (1)
- Corticosteroids
- 2 commonly used to treat emesis associated with cancer chemo
- very few because only used on intermittent basis
Ondansetron (zofran) mech of action
Blocks serotonin (5 HT3) receptors in the upper GI tract
Ondansetron (Zofran) drug class and function, ADR’s (2)
Serotonin receptor antagonist, most effective drug for suppression of nausea and vomiting caused by chemo drugs or anesthesia as well as IBS
-constipation and headache
Granisetron (kytril) function
Similar action to odansetron
copolamine (hyoscine, transderm-scop) drug class, mech of action, ADR’s (3)
- anticholinergic muscarinic antagonist
- most effective drug for prophylaxis and treatment of motion sickness by depressing the neuronal activity in the pathwaybetween vestibular system and vomiting system
- Dry mouth, blurred vision, urinary retention
Antihistamine use for motion sickness and examples (3)
- Less effective than scopolamine for motion sickness but the sedation makes them less desirable
- dimehydrinate (Dramamine), meclizine (Antivert), diphenhydramine (Benadryl)
Diphenoxylate drug class, function, administration
- opioid
- indicated for diarrhea only
- PO only dispensed with combo with atropine (Lomotil) – prevents abuse
Loperamide (immodium) drug class, function
- opioid
- OTC used to treat diarrhea by suppressing bowel motility (including IBS), does not cross BBB leaving CNS effects not noticeable
Paregoric (camphorated tincture of opium) and opium tincture
- dilute solution of powdered opium that has antidiarrheal doses that cause neither euphoria or analgesia
- 25x more potent version indicated for diarrhea but with high abuse potential
Irritable bowel syndrome signs and symptoms
- Cramping, abdominal pain in association with diarrhea, constipation, or both due to an unknown pathophysiologic cause but can have symptoms triggered by stress, depression, or dietary choices
- second only to common cold for missed work days :(
Alosetron (lotronex) drug class and function
- serotonin antagonist
- stringent risk management program due to toxicity but approved for diarrhea predominant IBS in women by slowing transit
2 examples of bulk forming agents for diarrhea
- methylcellulose (citrucel)
- polycarbophil (fibercon)
Antidiarrheals do not help with travelers diarrhea because they…
…prolong the course of the infection
Eluxadone (viberzi) drug class and function and contraindication (1)
Mu opioid receptor agonist and delta receptor antagonist for PO treatment of adults with IBS-D, contraindicated in patients with any biliary duct problems
Polyethylene glycol (Miralax) function
Can increase frequency of bowel movements in patients with IBS-C, well tolerated and safe for long term use
Lubiprostone (amitzia) drug class and function
Selective chloride channel activator, can modestly improve IBS-C
Chronic idiopathic constipaion (CIC) presenting complaint vs IBS-C
Presents with constipation as primary complaint while IBS-C presents with discomfort primarily
Ulcerative colitis mild moderate and severe management
Mild - aminosalicylate
Moderate - budosenide (corticosteroid)
Severe - azathioprine (immunosuppressant)
Crohn’s disease mild moderate and severe management
Mild - budoesonide (corticosteroid)
Moderate to severe - azathioprine or methotrexate
Sulfasalazine (azulfidine) drug class, function, indication (1), ADR (1)
5-ASA (metabolized into this)
suppresses prostoglandin synthesis decreasing inflammatory response
-acute treatment of mild to moderate ulcerative colitis
-Hematologic disorders
Budesonide drug class and function
Synthetic corticosteroid used for induction of remission in mild to moderate ulcerative colitis and crohns disease
Azathioprine (imuran) drug class and function
Thiopurine immunosuppressant, take 3-6 months to reach use effective for long term treatment and not for acute suppression of inflammation associated with ulcerative colitis and crohns
