Lecture PUD, GERD

Question 1

GI invaders:

Answer 1

**H. pylori
**NSAIDS
Gastric acid
Pepsin
Smoking (Delays ulcer healing)

GI defenses include:

1. Mucus
2. Bicarbonate
3. Blood flow
4. Prostaglandins

Question 2

gastric ulcers vs duodenal ulcers

Answer 2

Gastric ulcers:
weight loss
HCL - normal or hyposecretion
pain 1/2 to 1 hr after meals
vomiting
eating may increase pain

Duodenal ulcers:
most common
well nourished
pain 2-3 hours after meals
food may decrease pain

Question 3

GERD

Answer 3

Chronic condition characterized by persistent heartburn

Pathophysiology

1. Lower esophageal sphincter weakening or relaxation
   - Often from smoking, hiatal hernia, etc
2. Decreased salivary secretions - Saliva helps wash things down so this is decreased
3. Diminished esophageal motility

Symptoms

1. Heartburn
2. Dysphagia (difficulty swallowing)
3. Dyspepsia (indigestion)
4. Chest pain
5. Nausea
6. Belching

Question 4

H. pylori treatment

Answer 4

2 – 3 antibiotics PLUS Antisecretory agent

antibiotics:
amoxicillin, clarithromycin, tetracycline, metronidazole, tinidazole, bismuth compounds

anti secretory agent:
PPI or histamine2 receptor antagonist (H2RA: Zantac, Tagamet)

Question 5

Ulcer or GERD treatment includes:

Answer 5

1. antacid
2. Histamine receptor antagonists - H2RA
3. PPI

Question 6

antacids

Answer 6

Neutralize or buffer stomach acid

MOM (milk of magnesia),
aluminum hydroxide,
calcium carbonate,
sodium bicarbonate

Note MOM can cause diarrhea, and Aluminum hydroxide can cause constipation. Combine these two to combat both diarrhea and constipation side effects.

Question 7

H2RA (Histamine receptor antagonists)

Answer 7

Suppress gastric acid secretion

cimetidine [Tagamet]
ranitidine	[Zantac]
famotidine [Pepcid]
nizatidine	[Axid]
*All 4 equally effective

30-minute onset of action
PO, IV, IM
avoid taking with antacids (po)
Take before meals (or with)

AEs – significant AEs uncommon
1. Pneumonia
2. CNS effects - Confusion, Restlessness, Hallucinations, Depression
(higher doses, renal disease, older adults)

Question 8

cimitidine

Answer 8

a histamine receptor antagonist (H2RA) with some additional side effects including:

i. antiandronergic effects (gynecomastia, reduced libido, impotence)
ii. hypotension & dysrhythmias (IV)
iii. Inhibits metabolism of warfarin, phenytoin, theophylline (All drugs with low therapeutic range)

Question 9

Proton Pump Inhibitors (PPIs)

Answer 9

most effective for suppressing secretion of gastric acid

omeprazole [Prilosec]
esomeprazole [Nexium]
lansoprazole [Prevacid]
dexlansoprazole [Dexilant]
rabeprazole [Aciphex]
pantoprazole [Protonix]

Well-tolerated – equally effective

NOT “azole”=antifungal

Take 30 min before 1st meal of the day

Used as prophylaxis if on long term use of NSAIDs

AEs

1. HA
2. N/V/D (C. difficile infection risk)
3. Pneumonia
4. Long-term use: fractures, hypomagnesemia, gastric cancer

Interactions:
reduce absorption/effects of some HIV/AIDS drugs, ketoconazole, itraconazole, clopidogrel

Question 10

sucralfate

Answer 10

a PUD, GERD misc drug

“activates” in acidic environment to form a sticky gel that adheres to ulcers

Last up to 6 hours

No serious AEs
constipation

Question 11

bismuth compounds (Kaopectate, Pepto-Bismol)

Answer 11

For dyspepsia, heartburn, and diarrhea
disrupts cell wall of H. pylori
may cause black stools

Question 12

misoprostol (Cytotec)

Answer 12

ONLY approved GI indication: Prevent gastric ulcers in patients on long-term NSAIDs

AE – diarrhea, abd pain
Pregnancy category X

used in L&D for labor induction - stimulates uterine contractions

Question 13

metoclopramide (Reglan)

Answer 13

Short-term therapy in patients who fail to respond to first-line agents
promotes gastric motility