Lecture 4 - Management of GORD

Question 1

When would we refer a patient?

Answer 1

Prolonged symptoms, severe symptoms, unresponsive to therapy, danger symptoms

someone over 50 with the disease

Question 2

Alginates?

Answer 2

Peptac, gaviscon (rafting agents)
form a foam across the top of the stomach (raft), which provides a physical barrier and neutralise stomach acid, making it harder to be pushed back up to the oesophagus

Question 3

Antacids?

Answer 3

Co-magaldrox, magensium trisilicate

neutralise stomach acid, very fast acting

Question 4

Cautions of antacids and alginates?

Answer 4

some interfere with tetracyclines and form chelates

peptac etc have a very high sodium content so shouldn’t use in patients with CV disease or pregnant women with high blood pressure

Question 5

Proton pump inhibitors?

Name and doses

Answer 5

omeprazole (10mg, 20mg, 40mg)

lansoprazole (15mg, 30mg)

esomeprazole (20mg, 40mg)

pantoprazole (20mg, 40mg)

rabeprazole (10mg, 20mg)

Question 6

PPI’s used for?

Answer 6

Peptic ulcer disease, H pylori eradication, hyspepsia, GORD, prevention of NSAID damage and rebleed after surgery

Question 7

PPI in eradication of H pylori

Answer 7

Week long course of antibiotic to treat H pylori with a PPI in high dose to eradicate H pylori

Question 8

PPI effectiveness?

Answer 8

act very effectively with a once/twice daily dosing

Question 9

Esomeprazole?

Answer 9

more expensive than omeprazole/lansoprazole without adding a lot more benefits

Question 10

PPI dosage forms?

Answer 10

GR tablets
GR capsules
GR granules
dispersible tablets
Oro-dispersible tablets 
Oral liquids - from specials manufacturers 
Injections

Question 11

Oral liquid PPI disadvantages?

Answer 11

have very short half-lives (shelf life of ~2 weeks)

omeprazole is most commoly prescribed suspension

Question 12

PPI cautions?

Answer 12

increased risk of bone fracture in prolonged use in susceptible patients

increase risk of C difficile infection (acid counteracts C diff)

mask symptoms of cancer

rebound hyper-secretion of acid on cessation

Question 13

Bone fracture on use of PPI?

Answer 13

Implicated in thinning bones so have to be used with caution in frail elderly people or people with osteoporosis

particularly bad with omeprazole

Question 14

Esomeprazole and omeprazole interactions?

Answer 14

decrease the antiplatelet effect of clopidogrel

Question 15

Pantoprazole drug interactions?

Answer 15

increase the coagulant effect of warfarin (coumarins)

Question 16

Common and very common PPI side effects?

Answer 16

1 in 10 to 1 in 100

abdominal pain, headaches

Question 17

Uncommon PPI side effects?

Answer 17

1 in 100 to 1 in 1000

arthralgia (pain in joints)
parasthesia

Question 18

Rare side effects of PPIs?

Answer 18

1 in 1000 to 1 in 10,000

confusion, gynaecomastia (breast tissue in men)

Question 19

H2 receptor antagonists?

Name and dosage

Answer 19

ranitidine (150mg, 300mg)

cimetidine (200mg, 400mg, 800mg)

famotidine (20mg, 40mg)

nizatidine (150mg, 300mg)

Question 20

H2 receptor antagonist dosage forms?

Answer 20

Tablets
capsules
effervescent tablets
oral liquids
injections

Question 21

Zantac use?

Answer 21

advantages over PPIs because it is available as an oral liquid and has better stability

used in patients fed with naso-gastric tubes

Question 22

H2 receptor antagonist common side effects?

Answer 22

diarrhoea, dizziness

Question 23

H2 receptor antagonist uncommon side effects?

Answer 23

erythema multiform

Question 24

Rare side effects of H2 antagonists?

Answer 24

hepatitis, confusion

can also mask symptoms of cancer

Question 25

Cimetidine interactions?

Answer 25

Involved in CYP450 effect and slows down metabolism of some drugs

increases the blood concentration of erythromycin

Question 26

Famotidine and ranitidine interactions?

Answer 26

reduce plasma concentration of atazanavir

Question 27

Chelates and complexes?

Answer 27

act to reduce the amount of acid being produced

sucralfate (1000mg)
tripotassium dicitratobismuthate (120mg)

Question 28

prostaglandin analogue

Answer 28

misoprostol (200mcg), antisecretory properties

come with a warning because they work in the prostaglandin cycle and cannot be given in pregnancy because it can affect foetal development

Question 29

prokinetic drugs

Answer 29

speed up gastric emptying so acid does not accumulate in the stomach
work well for GORD and peptic ulcers but not duodenal ulcers

domperidone, metoclopramide

Question 30

How are the drugs used?

Answer 30

lowest effective dose for a short period of time

move treatment doses from high to maintenance dose (low) after period of time - dependent upon the indication

used in combination with antibacterial in H pylori infection

Question 31

Long term use of PPIs?

Answer 31

common for PPIs to be prescribed over a long period of time, but adverse reactions are starting to be seen from prolonged use

if people do not need them it is important to take them off

Question 32

Which PPI is associated with fewer issues?

Answer 32

Lansoprazole

Question 33

Alginates and antacids used in combination?

Answer 33

Can be used in combination with any drugs mentioned before because they work quickly and effectively to get rid of immediate symptoms but when used in combination it treats the underlying condition as well