GERD, Ulcer, GI Bleed Flashcards
Alarm symptoms of GERD
Dysphasia (difficulty swallowing)
Odynophagia (painful swallowing)
Bleeding
Weight loss
Choking
Chest Pain
Epigastric mass
Require referral for invasive testing (endoscopy)
Nonpharm treatments for GERD
ACG guidelines cite insufficient evidence, so only in these populations:
1) dietary modifications to avoid trigger foods; avoid eating 2-3 hours before bed
2) Weight loss (if overweight/obese)
3) Avoid tobacco, smoking
4) Elevate head of bed if nocturnal symptoms present
First line GERD treatment for esophageal erosion; severe symptoms
“Step down” - start @ max then decrease therapy
Therapeutic PPI
First line GERD treatment for intermittent symptoms (<2x/week)
OTC Antacids
Not appropriate if esophageal erosions present
Can also be used as breakthrough if already on PPI or H2RA
Aluminum and calcium ADR in antacids
constipation
magnesium ADR in Antacids
diarrhea
gaviscon
antacid containing alginic acid which forms viscous layer on top of gastric contents to prevent reflux
Meds that may have reduced absorption from increased pH from all antacids
Azoles (ketoconazole, itraconazole)
Iron
Atazanavir
Rilpivirine
Ledipasvir
Velpatasvir
Nelfinavir
Renal dosing for H2RA
Cimetidine: severe impairment, 300bid
Famotidine:
30-60ml/min: 20-40mg daily or 40mg every other day
<30: 10 or 20mg daily or 20mg every other day
Nizatidine:
20-50: 150mg daily
<20: 150 every other day
H2RA place in therapy
on demand dosing for mild-moderate GERD
less effective than PPI in erosive esophagitis
Long term use may cause tachyphylaxis
PPIs that can be used in NG tube
Omeprazole
Esomeprazole
Lansoprazole
Acute interstitial nephritis and PPIs
Shorten duration of PPI
If long term use: annual renal fxn monitoring, dose reduction, de-prescribing
AIN may recur with PPI rechallenge
Risk of fracture with PPI
Concern for fracture is not a reason to NOT prescribe PPI (unless other risk factor for hip fracture)
If have osteoporosis, may remain on PPI – ensure enough vit D and calcium, exercise, BMD screens
Vitamin deficiencies with PPIs
hypomagnesemia
iron deficiency
B12 deficiency
reevaluate need for PPI; supplement
Cdiff and PPI
Reevaluate need for PPI
If pt on PPI with diarrhea not improving, test for Cdiff
CAP and PPI
Short term use may increase risk
Assess vaccine status
PPI and methotrexate
PPI may inhibit excretion of high dose IV methotrexate, resulting in MTX toxicity
Do not give combo of PPI + high dose MTX. Hold PPI x2 days before AND after MTX administration
Promotility agents and GERD
Recommend against unless evidence of gatroparesis
Metoclopramide (dopamine antagonist)
Bethanecol (cholinergic agonist - off label)
Metoclopramide BBW
Irreversible tardive dyskinesia
Sucralfate place in therapy for GERD
routine use for pregnancy only
Gastric Vs Duodenal ulcer
Eating:
worsens symptoms (gastric)
improves (duodenal)
Both can be caused by H pylori or NSAID use
NSAID Risk factors for ulcer
> 65 y/o
High dose NSAID therapy (ibu >2400mg/day, naproxen 1000mg/day)
History of uncomplicated ulcer
Concurrent use of low-dose aspirin, steroids, anticoagulants
Moderate risk if 1-2 factors
High risk if >2 factors
Serologic H pylori test
QuickVue, H. pylori gII, FlexSure HP
noninvasive test to detect IgG to H pylori
Cannot distinguish between active infection and past exposure
Cannot be used to test for eradication, because antibodies persist after treatment
Urea breath test for H pylori
UBT, BreathTek UBT, PYtest
Noninvasive test to detect exhalation of radiolabeled CO2 after ingestion of 13c which results in CO2
High sensitivity and specificity = use for diagnosis AND eradication
False negatives caused by recent antibiotic or PPI use; wait 4 weeks after completing of therapy to test
Stool antigen test for H pylori
Premier Platinum HpSA; ImmunoCard STAT! HpSA
Antibody test to detect H pylori in stool
Decent sensitivity and specificity (upper 80s) = diagnosis AND eradication
False negatives can be caused by bismuth, abx, ppis – wait 4 weeks after treatment
Endoscopy for H pylori
Invasive test - used less often (cost, time, invasive)
Rapid urease test used on biopsy to detect presence of H pylori
D/c ppi 1 week before endoscope
First line H pylori treatment (clarithromycin triple, bismuth quadruple)
Clarithromycin triple x14 days:
-PPI (standard or double dose) BID
-Amoxicillin 1000mg BID or metronidazole 500mg TID
-Clarithromycin 500mg BID
Bismuth Quadruple x10-14 days:
-PPI standard dose BID
-Bismuth subsalicylate 300mg QID or bismuth subcitrate 120-300mg QID
-Metronidazole 250mg QID or 500mg TID-QID
-Tetracycline 500mg QID
Bismuth quadruple if clarithromycin resistance high, pt has prior macrolide exposure, or pcn allergy
Salvage therapy for H pylori
Bismuth quadruple therapy or
Levofloxacin triple therapy x10-14 days:
-PPI standard BID
-Levofloxacin 500mg daily
-Amoxicillin 1000mg BID
Concomitant H pylori therapy
-PPI standard BID
-Clarithromycin 500mg BID
-Amoxicillin 1000mg BID
-Metronidazole or tinidazole 500mg BID
10 days
Appears as effective as clarithromycin triple therapy but not validated in North America
Vonoprazan
Newly approved treatment for H pylori but not yet included in guidelines
Vonoprazan 20mg BID
Amox 1000mg BID
Clarithromycin 500mg BID
10 days
OR
Vonoprazan 20mg BID
Amoxicillin 1000mg TID
14 days
Indicator of high CV risk before starting NSAIDs
on aspirin for primary prevention
High risk NSAIDS
Piroxicam
Indomethacin
Ketorolac
Moderate risk of ulcer on NSAID
NSAID + PPI or misoprostol
Same if low or high CV risk. Prefer naproxen in high CV risk
Low risk of ulcer on NSAID
low CV risk: NSAID at lowest dose
high CV risk: naproxen _ PPI or misoprostol
High risk of ulcer on NSAID
low CV risk: COX2 inhibitor + PPI or misoprostol
high CV risk: avoid NSAID, avoid COX2 inhibitors
Gatroprotective therapy for NSAID + antiplatelet
PPIs preferred
-Prescribe if GI risk factors requiring NSAIDs + low dose aspirin or low-dose aspirin alone
-Prescribe if receiving any anticoagulant + aspirin
-If warfarin added to aspirin and P2Y12, aim for INR 2.0-2.5
Aspirin plus PPI is superior to clopidogrel for GI bleed risk
Misoprostol limitation for gastroprotection
dosing frequency
diarrhea, abdominal pain ADRs
COX2 inhibitors and CV risk
Associated with thrombotic events
Why? Idea is that COX2 reduces prostacyclin production but COX1 still produces thromboxane A = prothrombotic state
Daily doses of 400-800mg were seen with ~3x risk for fatal/nonfatal MI (dose related risk)
Musculoskeletal pain & CV disease or high risk treatment approach
1) topical NSAID
2) APAP, aspirin, tramadol, short-term narcotic
3) nonacetylated salicylates
4) NonCOX2 selective NSAIDs
4) Celecoxib is last resort
Risk of GI bleed outweighs CV risk
Choose ibuprofen, etodolac, diclofenac, celecoxib
Risk of CV risk outweighs GI bleed risk
avoid COX2 inhibitors
Upper GI bleed Management
1) Fluid resuscitation - give before blood (Hgb <7)
2) Stratify risk for death, recurrence,
3) Endoscopy within 24 hours
4) PPI
PPI for upper GI bleed
Pre-endoscopy:
80mg IVB, then 8mg/hr IV infusion. does NOT reduce mortality, surgery, rebleed.
Post endoscopy:
80mg IVB then 8mg/hr for 72 hours
OR
80mg IVB followed by 40mg PO or IV 2-4x daily x3 days
-Given after endoscopy = decrease in rebleeding, mortality, need for surgery
H2RA or octreotide for upper GI bleed
Not recommended
Independent risk factors for SRMD
Ventilated >48 hours
Coagulopathy (INR >1.5, plt <50)
Thermal injury >35% BSA
Severe head or spinal cord injury
GI bleed within past year
Multiple trauma
Perioperative transplant period
Low intragastric pH
Major surgery (>4 hrs)
Acute lung injury
Risk factor for SMRD (>=2 of following)
Sepsis
ICU >1 week
Occult bleeding
High dose steroids (=250mg hydrocortisone)
Hepatic failure
Acute renal insufficiency
Hypotension
Anticoagulation
SMRD Prevention
PPI similar in efficacy & safety to H2RA
PO or IV similar efficacy
Cimetidine only H2RA with FDA approval for SRMD but all can be used
