GERDSH1 Flashcards
GERD/PUD
GERD: reflux PUD: ulcer
GERD class sx: heartburn/ regurgitation. Atypical SX: chronic cough chest pain, dental erosion
Alarm sx: GI bleed, black stools, vomiting blood ( HEMATEMESIS )
Causes of GERD: obesitity , Bisphosphonates, zollinger Ellison ( hyper secretion of acid by a tumor )
Complications: long term GERD can cause barret esophagus —-> esophageal cancer
Goal: provide relief, heal esophagitis ( if present )
MEDS: PPI, antacids, H2 blockers, reglan, alginic acid
PUD
Peptic ulcer disease
Causes: Asa, nsaids, alcohol ,
• H. pylori
First line for ulceration: PPI ( lets ulcer heal )
Avoid nsaids or add misoprostol ( preg cat X)
H. Pylori Tx: 2 or 3 ABX
clarithromycin, amoxicillin, tetracycline, metronidazole
&
1 PPI:
Sometimes with a bismuth compound ( bismuth salicylate can cause ringing in the ears )
•sucralfate ( carafate ) - band aid on ulcer. ( take before you eat )
Antacids
NaHCO3- na increase, flatulence
CaCO3- ca can cause constipation, hypercalcemia
Al( OH )3-
Mg( OH )2- Mg causes diarrhea
* you dont give Al and Mg products in CKD patients
Antacids: increase pH, coat mucosa, short term relief
You need address long term prevetnion
Antacids Drug interactions
Chelation of tetracyclines ( minocyclin, doxycycline, tetracycline) do not give antacids 2 hours before or 6 hours after
Quinolones :
2 hours before or 6 hours after antacids ( iron, sucralfate , zinc ) ]
Levothyroxine : separate by at least 4 hours
Absorption of drugs requiring acidic pH
-e.g. ketoconazole, itraconazole , IRON ( we usually give with VitC)
H2 Receptor antagonists ( H2RA)
Cimetidine ( tagament) : tabs/oral soln
- duodenal ulcer : ( 800 mg PO qhs; 400 bid, 300 qid
SE: drowsiness, agitation, diarrhea, at high dosages gynecomastia ( recall sprinolactone, cimetidine, Ketoconazole, and anything that blocks testosterone can causes gynecomastia
-gastric ulcer; GERD
Ranitidine ( Zantac ) IV/IM in hospital and tabs cap syrup
-Duodenal ulcer : 150 mg bid or 300 qhs
Famotidine ( Pepcid ) IV, tabs suspension
Nizatdine : cap, soln
-150 mg bid, 300 mg qhs ( dosing like ranitidine Zantac )
RF: ranitidine and famotidine come IV!
H2 receptor blockers
Recommendations
And
SE:
** <2 episodes per week : naive to tx start with h2 blocker/ ** ≥2 episodes/ week recommend PPI QD
Side effects: CNS ( dizziness /sedation, HA, can worsen dementia or delirium in elderly ) CImetidine : anti androgenic effects: gynecomastia / impotence )
DDI: cimetidine is a Cyp1a2 inhibitor ( like cipro, fluvoxamine) : watch Coumadin ( increase INR ) , watch for Theophylline ( CNS, seizure, coma, death)
*****PREGNANCY DOC : ranitidine ( preg category B) recommend 1/2 the dose
Adjust dose for renal dysfx: CrCl < 50 ml/min : recommend 1/2 the dose
For nocturnal acid breakthrough : add h2ra qhs
H2 blocker dose comparison
Cimetidine ( Tagamet ) : 400 mg
Famotidine ( Pepcid ) 20 mg
Nizatidine ( Axid ) 150 mg
Ranitidine ( Zantac ) 150 mg
PPI
MOA: Irreversible blocking of H+/K+ ATPase of the gastric parietal cells. Take before breakfast.
Omeprazole: Prilosec ( OTC )
Omeprazole, sodium bicarb (Zegrid, zegerid ) OTC
Esomeprazole ( nexium, 24 HR nexium OTC) - ( IV**)
Esomeprazole/ Naproxen ( Vimovo )
Lansoprazole ( Prevacid, Prevacid 24 HR ) ( OTC )
Dexlansoprazole ( Dexilant )
Pantoprazole ( Protonix ) - (IV ***)
Rabeprazole ( Aciphex )
OTC options: prilosec, zegerid, Nexium, Prevacid
IV** ( PE : pantoprazole, Esomeprazole )
Omeprazole
Prilosec
Caps, tabs, suspension, packet,
Caps can be opened ( dont chew contents, swallow )
20-40 mg PO QD on empty stomach 30-60 mins before meals
DDI: clopidogrel ( needs cpy2C19 to become active metabolite ) + Omeprazole ( cyp2C19 inhibitor and Esomeprazole )
• increase warfarin and phenytoin
• decrease Ketoconazole and intraconazole
•can decrease clopidogrel ( plavix)
Zegrid: Omeprazole + sodium bicarbonate
Mix powder with/30 mL of water and consume immediately
DDI: Esomeprazole/ Omeprazole are 2C19 inhibitors and plavix needs cyp2c19 to form active metabolite therefore Esomeprazole/omeprazole will increase or decrease plavix ???
Decrease plavix
Omeprazole + bicarbonate
Brand name?
Available OTC
Esomeprazole magnesium
Nexium ( caps , suspension , IV 20 or 40 mg )
S-isomer of omeprazole
Can open caps/ can give granules of caps or suspension via NG tube
20-40 mgs QD on empty stomach
Nexium 24 HR - OTC Tabs
FDA approval GERD/PUD is QD. FDA approval for zollinger Ellison is 40 mg BID
Zollinger Ellison: tumor secreting too much acid
Max 20 mg QD if hepatic dysfx
Lansoprazole
Prevacid ( caps, ODT, suspension via compound )
OTC
Prevpac:
Lansoprazole, 30mg + amoxicillin 500 mg ( 2 capsules / each dose ) + Clarithromycin 500 mg
Administer together twice daily for 10 - 14 days
Dexlansoprazole
Isomer of Lansoprazole
R- isomer ( dex)
( DEXILANT ) caps
Can open and sprinkle
Healing dose: 60 mg QD up to 6 weeks,
Maintenance : 30 mg QD for up to 6 months,
Max 30 mg QD with hepatic impairment
Benefit : Granules in caps: granule 1: release within an hour , granule 2: provides second release 4-5 hours after
Pantoprazole
Protonix ( tabs, suspension ( packets) , 40 mg IV**)
With or without food
Oral susp mix in apple sauce ( swallow within 10 mins ) or apple juice ( swallow immediately)
GERD/PUD : 40 mg qd
Zollinger Ellison : 40 mg BID
Rabeprazole
Aciphex ( tabs , sprinkle caps )
20 mgs
Sprinkle caps formulated for kids 30 mins before meals
Tabs with or without food
<1 y/o NOT recommended
1-11 5 mg QD
Bid for zollinger Ellison
PPI adverse effects
SE:
HA dizziness
Chronic use: vit b12 deficiency, C. Diff, increase risk of pneumonia, GI pain, fever
decrease Ca and Mg: fracture risk
- no dose adjustment with decreased CrCl
DDI : omeprazole, Esomeprazole and plavix
Decrease bioavailability with other drugs that need acidic environment ( Ketoconazole, itraconazole, atazanavir, nelfinavir, erlotinib, nilotinib
PPI pregnancy
Omeprazole ( C ) , Esomeprazole ( C ) - dont recommend
Lansoprazole ( B ) , pantoprazole ( B ) , Rabeprazole ( B ) - may recommend
PPI recommendations
Use short term: 10-14 days for h. Pylori
- 4 weeks for duodenal ulcers
-8 weeks for erosive esophagitis
- for mild GERD recommend lifestyle changes ( losing weight ) then an antacid or h2 blocker ( which have less side effects )
- For PUD recommend PPI’s: they heal ulcers more rapidly and to a greater extent than other meds
Which PPI comes ODT?
Lansoprazole
Which PPI need to be on an empty stomach ?
Omeprazole
Esomeprazole
Lansoprazole ODT
Pantoprazole suspension
Rabeprazole sprinkle caps
Cytoprotective agents
Prostaglandins
- Misoprostal ( cytotec )
• Pregnancy category X
Sucralfate ( carafate )
-Bandaid on ulceration. So when patient eats, it wont effect ulcer. Take before meals
Misoprostal ( pregnancy Category X)
CYTOTEC
indication: prevention of NSAID induced GI ulcers - 200 mcg QID w/food
- medical termination of pregnancy < 49 days + mifepristone
MOA:
- synthetic PG E1 analog that replaces the protective prostaglandins that NSAIDS inhibit
- induce uterine contraction
SE:
- Diarrhea : up to 40%, abdominal pain ( 7-20 % )
- Uterine bleeding/ spontaneous abortion
If PUD is NSAID induced then
1) D/C nsaid - recommend apap or celebrex
- start PPI, H2RA or sucralfate to facilitate relief of ulcer sx and healing
- lifestyle ∆’s: quit smoking, avoid food/bev that worsen sx ( acidic, alcohol, caffeine )
-if patient must continue, add Misoprostal ( a prostaglandin analog - at lease 400 mcg/day) , regular dose PPI or double dose h2ra
Sucralfate ( carafate )
Aluminum Sucrose Sulfate, Basic ——-( recall if youre patient has ESRD never give aluminum or Magnesium products)
MOA:
acid —> adheres to defective mucosa → barrier
Pharmacokinetics:
-non- absorbed, however, aluminum salt may accumulate in renal failure
Pregnancy category B
Dosage: 1g/10mL suspension, 1 g tabs
Take on empty stomach 1 g qid
SE: #1 constipation, flatulence , HA, dry mouth
DDI: chelation: give others drugs 2 hours before or 6 hours after sucralfate
GERD in children
For occasional sx: antacids ( TUMs ( worry about constipation ) give Maalox ( worry about diarrhea ) )
For daily sx: h2 blocker or PPI
H2 blockers: Famotidine ( Pepcid ) approved for all ages / Ranitidine ( Zantac ) for >1 month
PPI approved ≥ 1 years old
Lansoprazole ( Prevacid), omeprazole ( Prilosec), Esomeprazole ( nexium ), Rabeprazole ( Aciphex)
If kids cant swallow cap, put granules in apple sauce
OR
Use Prevacid , nexium, Prilosec packets for oral susp or Prevacid solu tabs
GERD in pregnancy
Usually lifestyle: head of bed elevation, dietary trigger avoidance
If persistent sx:
1) antacids ( sodium bicarbonate and magesium triscilicate should be avoided )
2) H2RAs QD after evening meal increase to bid if needed. Ranitidine most widely studied ( preferred over other PPIs)
3) PPIs : Lansoprazole 30 mg before breakfast for refractory or complicated GERD
