GERDSH1

Question 1

GERD/PUD

Answer 1

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

Question 2

PUD

Answer 2

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 )

Question 3

Antacids

Answer 3

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

Question 4

Antacids Drug interactions

Answer 4

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)

Question 5

H2 Receptor antagonists ( H2RA)

Answer 5

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!

Question 6

H2 receptor blockers
Recommendations
And
SE:

Answer 6

** <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

Question 7

H2 blocker dose comparison

Answer 7

Cimetidine ( Tagamet ) : 400 mg
Famotidine ( Pepcid ) 20 mg
Nizatidine ( Axid ) 150 mg
Ranitidine ( Zantac ) 150 mg

Question 8

PPI

Answer 8

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 )

Question 9

Omeprazole

Answer 9

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

Question 10

DDI: Esomeprazole/ Omeprazole are 2C19 inhibitors and plavix needs cyp2c19 to form active metabolite therefore Esomeprazole/omeprazole will increase or decrease plavix ???

Answer 10

Decrease plavix

Question 11

Omeprazole + bicarbonate

Brand name?

Answer 11

Available OTC

Question 12

Esomeprazole magnesium

Answer 12

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

Question 13

Lansoprazole

Answer 13

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

Question 14

Dexlansoprazole

Answer 14

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

Question 15

Pantoprazole

Answer 15

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

Question 16

Rabeprazole

Answer 16

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

Question 17

PPI adverse effects

Answer 17

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

Question 18

PPI pregnancy

Answer 18

Omeprazole ( C ) , Esomeprazole ( C ) - dont recommend

Lansoprazole ( B ) , pantoprazole ( B ) , Rabeprazole ( B ) - may recommend

Question 19

PPI recommendations

Answer 19

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

Question 20

Which PPI comes ODT?

Answer 20

Lansoprazole

Question 21

Which PPI need to be on an empty stomach ?

Answer 21

Omeprazole
Esomeprazole
Lansoprazole ODT
Pantoprazole suspension
Rabeprazole sprinkle caps

Question 22

Cytoprotective agents

Answer 22

Prostaglandins
- Misoprostal ( cytotec )
• Pregnancy category X

Sucralfate ( carafate )
-Bandaid on ulceration. So when patient eats, it wont effect ulcer. Take before meals

Question 23

Misoprostal ( pregnancy Category X)

Answer 23

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

Question 24

If PUD is NSAID induced then

Answer 24

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

Question 25

Sucralfate ( carafate )

Answer 25

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

Question 26

GERD in children

Answer 26

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

Question 27

GERD in pregnancy

Answer 27

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