M6: GI-Heme

Question 1

Many patients self-medicate with antacids. Which patients should be counseled to not takecalcium carbonate antacids without discussing it with their provider or a pharmacist first?
1.Patients with kidney stones
2.Pregnant patients
3.Patients with heartburn
4.Postmenopausal women

Answer 1

1.Patients with kidney stones

Question 2

Patients taking antacids should be educated regarding these drugs, including letting them know that:
1.They may cause constipation or diarrhea
2.Many are high in sodium
3.They should separate antacids from other medications by 1 hour
4.All of the above

Answer 2

4.All of the above

Question 3

Kelly has diarrhea and is wondering if she can take loperamide (Imodium) for the diarrhea.
Loperamide:
1.Can be given to patients of all ages, including infants and children, for viralgastroenteritis
2.Slows gastric motility and reduces fluid and electrolyte loss from diarrhea
3.Is the treatment of choice for the diarrhea associated with E. coli 0157
4.May be used in pregnancy and by lactating women

Answer 3

2.Slows gastric motility and reduces fluid and electrolyte loss from diarrhea

Question 4

Bismuth subsalicylate (Pepto Bismol) is a common OTC remedy for gastrointestinal complaints.
Bismuth subsalicylate:
1.May lead to toxicity if taken with aspirin
2.Is contraindicated in children with flu-like illness
3.Has antimicrobial effects against bacterial and viral enteropathogens
4.All of the above

Answer 4

4.All of the above

Question 5

Hannah will be traveling to Mexico with her church group over spring break to build houses. She isconcerned she may develop traveler’s diarrhea. Advice includes following normal food and waterprecautions as well as taking:
1.Loperamide four times a day throughout the trip
2.Bismuth subsalicylate with each meal and at bedtime
3.A prescription for diphenoxylate with atropine to use if she gets diarrhea
4.None of the above

Answer 5

2.Bismuth subsalicylate with each meal and at bedtime

Question 6

Josie is a 5-year-old patient who presents to the clinic with a 48-hour history of nausea, vomiting,and some diarrhea. She is unable to keep fluids down and her weight is 4 pounds less than her lastrecorded weight. Besides IV fluids, her exam warrants the use of an antinausea medication. Whichof the following would be the appropriate drug to order for Josie?
1.Prochlorperazine (Compazine)
2.Meclizine (Antivert)
3.Promethazine (Phenergan)
4.Ondansetron (Zofran)

Answer 6

4.Ondansetron (Zofran)

Question 7

Jim presents with complaints of “heartburn” that is minimally relieved with Tums (calcium carbonate) and is diagnosed with gastroesophageal reflux disease (GERD). An appropriate first- step therapy would be:
1. Omeprazole (Prilosec) twice a day
2. Ranitidine (Zantac) twice a day
3. Famotidine (Pepcid) once a day
4. Metoclopramide (Reglan) four times a day

Answer 7

2. Ranitidine (Zantac) twice a day
   H2 antagonist & reassess in 12 weeks

Question 8

Patients who are on chronic long-term proton pump inhibitor therapy require monitoring for:
1. Iron deficiency anemia, vitamin B12 and calcium deficiency
2. Folate and magnesium deficiency
3. Elevated uric acid levels leading to gout
4. Hypokalemia and hypocalcemia

Answer 8

1. Iron deficiency anemia, vitamin B12 and calcium deficiency

Question 9

Sadie is a 72-year-old patient who takes omeprazole for her chronic GERD. Chronic long-term omeprazole use places her at increased risk for:
1. Megaloblastic anemia
2. Osteoporosis
3. Hypertension
4. Strokes

Answer 9

1. Megaloblastic anemia

Question 10

Patrick is a 10-year-old patient who presents with uncomfortable constipation. Along with diet changes, a laxative is ordered to provide more rapid relief of constipation. An appropriate choice of medication for a 10-year-old child would be:
1. PEG 3350 (Miralax)
2. Bisacodyl (Dulcolax) suppository
3. Docusate (Colace) suppository
4. Polyethylene glycol electrolyte solution

Answer 10

2. Bisacodyl (Dulcolax) suppository

Question 11

Methylnaltrexone is used to treat constipation in:
1. Patients with functional constipation
2. Patients with irritable bowel syndrome-associated constipation
3. Children with encopresis
4. Opioid-associated constipation

Answer 11

4. Opioid-associated constipation

Question 12

An elderly person has been prescribed lactulose for treatment of chronic constipation. Monitoring with long-term treatment would include:
1. Electrolytes, including potassium and chloride
2. Bone mineral density for osteoporosis
3. Magnesium level
4. Liver function

Answer 12

1. Electrolytes, including potassium and chloride

Question 13

Gastroesophageal reflux disease may be aggravated by the following medication that affects loweresophageal sphincter (LES) tone:
1.Calcium carbonate
2.Estrogen
3.Furosemide
4.Metoclopramide

Answer 13

2.Estrogen

Question 14

Lifestyle changes are the first step in treatment of gastroesophageal reflux disease (GERD). Foodor drink that may aggravate GERD include:
1.Eggs
2.Caffeine
3.Chocolate
4.Soda pop

Answer 14

2.Caffeine

Question 15

Metoclopramide improves gastroesophageal reflux disease symptoms by:
1.Reducing acid secretion
2.Increasing gastric pH
3.Increasing lower esophageal tone
4.Decreasing lower esophageal tone

Answer 15

3.Increasing lower esophageal tone

Question 16

Antacids treat gastroesophageal reflux disease by:
1.Increasing lower esophageal tone
2.Increasing gastric pH
3.Inhibiting gastric acid secretion
4.Increasing serum calcium level

Answer 16

2.Increasing gastric pH

Question 17

When treating patients using the “Step-Down” approach the patient with gastroesophageal reflux disease is started on_______ first.
1.Antacids
2.Histamine2 receptor antagonists
3.Prokinetics
4.Proton pump inhibitors

Answer 17

4.Proton pump inhibitors

Question 18

If a patient with symptoms of gastroesophageal reflux disease states that he has been self-treatingat home with OTC ranitidine daily, the appropriate treatment would be:
1.Prokinetic (metoclopramide) for 4 to 8 weeks
2.Proton pump inhibitor (omeprazole) for 12 weeks
3.Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks
4.Cytoprotective drug (misoprostol) for 2 weeks

Answer 18

2.Proton pump inhibitor (omeprazole) for 12 weeks

Question 19

If a patient with gastroesophageal reflux disease who is taking a proton pump inhibitor daily is notimproving, the plan of care would be:
1.Prokinetic (metoclopramide) for 8 to 12 weeks
2. Proton pump inhibitor (omeprazole) twice a day for 4 to 8 weeks
3. Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks
4. Cytoprotective drug (misoprostol) for 4 to 8 weeks

Answer 19

2. Proton pump inhibitor (omeprazole) twice a day for 4 to 8 weeks

Question 20

The next step in treatment when a patient has been on proton pump inhibitors twice daily for 12 weeks and not improving is:
1. Add a prokinetic (metoclopramide)
2. Referral for endoscopy
3. Switch to another proton pump inhibitor
4. Add a cytoprotective drug

Answer 20

2. Referral for endoscopy

Question 21

Infants with reflux are initially treated with:
1. Histamine2 receptor antagonist (ranitidine)
2. Proton pump inhibitor (omeprazole)
3. Anti-reflux maneuvers (elevate head of bed)
4. Prokinetic (metoclopramide)

Answer 21

3. Anti-reflux maneuvers (elevate head of bed)

Question 22

Long-term use of proton pump inhibitors may lead to:
1. Hip fractures in at-risk persons
2. Vitamin B6 deficiency
3. Liver cancer
4. All of the above

Answer 22

1. Hip fractures in at-risk persons

Question 23

An acceptable first-line treatment for peptic ulcer disease with positive H. pylori test is:
1. Histamine2 receptor antagonists for 4 to 8 weeks
2. Proton pump inhibitor bid for 12 weeks until healing is complete
3. Proton pump inhibitor bid plus clarithromycin plus amoxicillin for 14 days
4. Proton pump inhibitor bid and levofloxacin for 14 days

Answer 23

3. Proton pump inhibitor bid plus clarithromycin plus amoxicillin for 14 days

Question 24

Treatment failure in patients with peptic ulcer disease associated with H. pylori may be because of:
1. Antimicrobial resistance
2. An ineffective antacid
3. Overuse of proton pump inhibitors
4. All of the above

Answer 24

1. Antimicrobial resistance

Question 25

If a patient with H. pylori-positive peptic ulcer disease fails first-line therapy, the second-line treatment is:
1. Proton pump inhibitor bid plus metronidazole plus tetracycline plus bismuth subsalicylate for 14 days
2. Test H. pylori for resistance to common treatment regimens
3. Proton pump inhibitor plus clarithromycin plus amoxicillin for 14 days
4. Proton pump inhibitor and levofloxacin for 14 days

Answer 25

1. Proton pump inhibitor bid plus metronidazole plus tetracycline plus bismuth subsalicylate for 14 days

Question 26

After H. pylori treatment is completed, the next step in peptic ulcer disease therapy is:
1. Testing for H. pylori eradication with a serum ELISA test
2. Endoscopy by a specialist
3. A proton pump inhibitor for 8 to 12 weeks until healing is complete
4. All of the above

Answer 26

3. A proton pump inhibitor for 8 to 12 weeks until healing is complete

Question 27

Kenneth is taking warfarin and is asking about what he can take for minor aches and pains. The bestrecommendation is:
1.Ibuprofen 400 mg three times a day
2.Acetaminophen, not to exceed 4 grams per day
3.Prescribe acetaminophen with codeine
4.Aspirin 640 mg three times a day

Answer 27

2.Acetaminophen, not to exceed 4 grams per day

Question 28

Juanita had a deep vein thrombosis (DVT) and was on heparin in the hospital and was discharged onwarfarin. She asks her primary care provider NP why she was getting both medications while in thehospital. The best response is to:
1.Contact the hospitalist as this is not the normal guideline for prescribing these twomedications and she may have had a more complicated case.
2.Explain that warfarin is often started while a patient is still on heparin becausewarfarin takes a few days to reach effectiveness.
3.Encourage the patient to contact the Customer Service department at thehospital as this was most likely a medication error during her admission.
4.Draw anticoagulation studies to make sure she does not have dangerouslyhigh bleeding times.

Answer 28

2.Explain that warfarin is often started while a patient is still on heparin becausewarfarin takes a few days to reach effectiveness.

Question 29

The safest drug to use to treat pregnant women who require anticoagulant therapy is:
1.Low-molecular-weight heparin
2.Warfarin
3.Aspirin
4.Heparin

Answer 29

1 low molecular wt heparin
Cat c
Per text book

Question 30

The average starting dose of warfarin is 5 mg daily. Higher doses of 7.5 mg daily should beconsidered in which patients?
1.Pregnant women
2.Elderly men
3.Overweight or obese patients
4.Patients with multiple comorbidities

Answer 30

3.Overweight or obese patients

Question 31

Cecil and his wife are traveling to Southeast Asia on vacation and he has come into the clinic toreview his medications. He is healthy with only mild hypertension that is well controlled. He asks
about getting “a shot” to prevent blood clots like his friend Ralph did before international travel. The correct respond would be:
1.Administer one dose of low-molecular weight heparin 24 hours before travel.
2.Prescribe one dose of warfarin to be taken the day of travel.
3.Consult with a hematologist regarding a treatment plan for Cecil.
4.Explain that Cecil is not at high risk of a blood clot and provide education abouthow to prevent blood clots while traveling.

Answer 31

4.Explain that Cecil is not at high risk of a blood clot and provide education abouthow to prevent blood clots while traveling.

Question 32

Robert, age 51 years, has been told by his primary care provider (PCP) to take an aspirin a day. Whywould this be recommended?
1.He has arthritis and this will help with the inflammation and pain.
2. Aspirin has anti-platelet activity and prevents clots that cause heart attacks.
3. Aspirin acidifies the urine and he needs this for prostrate health.
4. He has a history of GI bleed, and one aspirin a day is a safe dosage.

Answer 32

2. Aspirin has anti-platelet activity and prevents clots that cause heart attacks.

Question 33

Sally has been prescribed aspirin 320 mg per day for her atrial fibrillation. She also takes aspirin four or more times a day for arthritis pain. What are the symptoms of aspirin toxicity for which she would need to be evaluated?
1. Tinnitus
2. Diarrhea
3. Hearing loss
4. Photosensitivity

Answer 33

1. Tinnitus

Question 34

Patient education when prescribing clopidogrel includes:
1. Do not take any herbal products without discussing it with the provider.
2. Monitor urine output closely and contact the provider if it decreases.
3. Clopidogrel can be constipating, use a stool softener if needed.
4. The patient will need regular anticoagulant studies while on clopidogrel.

Answer 34

1. Do not take any herbal products without discussing it with the provider.

Question 35

For patients taking warfarin, INRs are best drawn:
1. Monthly throughout therapy
2. Three times a week throughout therapy
3. Two hours after the last dose of warfarin to get an accurate peak level
4. In the morning if the patient takes their warfarin at night

Answer 35

4. In the morning if the patient takes their warfarin at night

Question 36

Patients receiving heparin therapy require monitoring of:
1. Platelets every 2 to 3 days for thrombocytopenia that may occur on day 4 of therapy
2. Electrolytes for elevated potassium levels in the first 24 hours of therapy
3. INR throughout therapy to stay within the range of 2.0
4. Blood pressure for hypertension that may occur in the first 2 days of treatment

Answer 36

1. Platelets every 2 to 3 days for thrombocytopenia that may occur on day 4 of therapy

Question 37

The routine monitoring recommended for low molecular weight heparin is:
1. INR every 2 days until stable, then weekly
2. aPTT every week while on therapy
3. Factor Xa levels if the patient is pregnant
4. White blood cell count every 2 weeks

Answer 37

3. Factor Xa levels if the patient is pregnant

Question 38

When writing a prescription for warfarin it is common to write ______ on the prescription.
1. OK to substitute for generic
2. The brand name of warfarin and Do Not Substitute
3. PRN refills
4. Refills for 1 year

Answer 38

2. The brand name of warfarin and Do Not Substitute

Question 39

Education of patients who are taking warfarin includes discussing their diet. Instructions include:
1. Avoiding all vitamin K-containing foods
2. Avoiding high-vitamin K-containing foods
3. Increasing intake of iron-containing foods
4. Making sure they eat 35 grams of fiber daily

Answer 39

2. Avoiding high-vitamin K-containing foods

Question 40

Patients who are being treated with epoetin alfa need to be monitored for the development of:
1. Thrombocytopenia
2. Neutropenia
3. Hypertension
4. Gout

Answer 40

1. Thrombocytopenia

Question 41

The FDA issued a safety announcement regarding the use of erythropoiesis-stimulating agents (ESAs) in 2010 with the recommendation that:
1. ESAs no longer be prescribed to patients with chronic renal failure
2. The risk of tumor development be explained to cancer patients on ESA therapy
3. Patients should no longer receive ESA therapy to prepare for allogenic transfusions
4. ESAs be prescribed only to patients younger than age 60 years

Answer 41

2. The risk of tumor development be explained to cancer patients on ESA therapy

Question 42

When patients are started on darbepoetin alfa (Aranesp) they need monitoring of their blood counts to determine a dosage adjustment in:
1. 6 weeks if they are a cancer patient
2. 1 week if they have chronic renal failure
3. 2 weeks if they are taking it for allogenic transfusion
4. Each week throughout therapy

Answer 42

1. 6 weeks if they are a cancer patient

Question 43

Jim is having a hip replacement surgery and would like to self-donate blood for the surgery. In addition to being prescribed epogen alpha he should also be prescribed:
1. Folic acid to prevent megaloblastic anemia
2. Iron, to start when the epogen starts
3. An antihypertensive to counter the adverse effects of epogen
4. Vitamin B12 to prevent pernicious anemia

Answer 43

2. Iron, to start when the epogen starts

Question 44

Monitoring for a patient being prescribed iron for iron deficiency anemia includes:
1. Reticulocyte count 1 week after therapy is started
2. Complete blood count every 2 weeks throughout therapy
3. Hemoglobin level at 1 week of therapy
4. INR weekly throughout therapy

Answer 44

1. Reticulocyte count 1 week after therapy is started

Question 45

Patient education regarding taking iron replacements includes:
1. Doubling the dose if they miss a dose to maintain therapeutic levels
2. Taking the iron with milk or crackers if it upsets their stomach
3. Iron is best taken on an empty stomach with juice
4. Antacids such as Tums may help the upset stomach caused by iron therapy

Answer 45

3. Iron is best taken on an empty stomach with juice

Question 46

Patients with pernicious anemia require treatment with:
1. Iron
2. Folic acid
3. Epogen alpha
4. Vitamin B12

Answer 46

4. Vitamin B12

Question 47

The first laboratory value indication that vitamin B12 therapy is adequately treating pernicious anemia is:
1. Hematocrit levels start to rise
2. Hemoglobin levels return to normal
3. Reticulocyte count begins to rise
4. Vitamin B12 levels return to normal

Answer 47

2. Hemoglobin levels return to normal

Question 48

Patients who are beginning therapy with vitamin B12 need to be monitored for:
1. Hypertensive crisis that may occur in the first 36 hours
2. Hypokalemia that occurs in the first 48 hours
3. Leukopenia that occurs at 1 to 3 weeks of therapy
4. Thrombocytopenia that may occur at any time in therapy

Answer 48

3. Leukopenia that occurs at 1 to 3 weeks of therapy

Question 49

Pernicious anemia is treated with:
1.Folic acid supplements
2.Thiamine supplements
3.Vitamin B12
4.Iron

Answer 49

3.Vitamin B12

Question 50

Premature infants require iron supplementation with:
1.10 mg/day of iron
2.2 mg/kg per day until age 12 months
3.7 mg/day in their diet
4.1 mg/kg per day until they are receiving adequate intake of iron from foods

Answer 50

2
2 mg/kg per day until age 12 months

Question 51

Breastfed infants should receive iron supplementation of:
1.3 mg/kg per day
2.6 mg/kg per day
3.1 mg/kg per day
4.Breastfed babies do not need iron supplementation

Answer 51

3
1 mg/kg per day

Question 52

Valerie presents to the clinic with menorrhagia. Her hemoglobin is 10.2 and her ferritin is 15 ng/mL.Initial treatment for her anemia would be:
1.18 mg/day of iron supplementation
2.6 mg/kg per day of iron supplementation
3.325 mg ferrous sulfate per day
4.325 mg ferrous sulfate tid

Answer 52

4
325 mg ferrous sulfate tid

Question 53

Chee is a 15-month-old male whose screening hemoglobin is 10.4 g/dL. Treatment for his anemiawould be:
1.18 mg/day of iron supplementation
2.6 mg/kg per day of elemental iron
3.325 mg ferrous sulfate per day
4.325 mg ferrous sulfate tid

Answer 53

2.
6 mg/kg per day of elemental iron

Question 54

Monitoring for a patient taking iron to treat iron deficiency anemia is:
1.Hemoglobin, hematocrit, and ferritin 4 weeks after treatment is started
2.Complete blood count every 4 weeks throughout treatment
3.Annual complete blood count
4.Reticulocyte count in 4 weeks

Answer 54

1.Hemoglobin, hematocrit, and ferritin 4 weeks after treatment is started

Question 55

Valerie has been prescribed iron to treat her anemia. Education of patients prescribed iron wouldinclude:
1.Take the iron with milk if it upsets her stomach.
2.Antacids may help with the nausea and GI upset caused by iron.
3.Increase fluids and fiber to treat constipation.
4.Iron is best tolerated if it is taken at the same time as her other medications.

Answer 55

3.Increase fluids and fiber to treat constipation.

Question 56

Allie has just had her pregnancy confirmed and is asking about how to ensure a healthy baby. What is the folic acid requirement during pregnancy?
1. 40 mcg/day
2. 200 mcg/day
3. 800 mcg/day
4. 2 gm/day

Answer 56

3. 800 mcg/day

Question 57

Kyle has Crohn’s disease and has a documented folate deficiency. Drug therapy for folate deficiency
anemia is:
1. Oral folic acid 1 to 2 mg per day
2. Oral folic acid 1 gram per day
3. IM folate weekly for at least 6 months
4. Oral folic acid 400 mcg daily

Answer 57

1. Oral folic acid 1 to 2 mg per day

Question 58

Patients who are being treated for folate deficiency require monitoring of:
1. Complete blood count every 4 weeks
2. Hematocrit and hemoglobin at 1 week and then at 8 weeks
3. Reticulocyte count at 1 week
4. Folate levels every 4 weeks until hemoglobin stabilizes

Answer 58

2. Hematocrit and hemoglobin at 1 week and then at 8 weeks

Question 59

The treatment of vitamin B12 deficiency is:
1. 1,000 mcg daily of oral cobalamin
2. 2 gm per day of oral cobalamin
3. Vitamin B12 100 mcg/day IM
4. 500 mcg/dose nasal cyanocobalamin 2 sprays once a week

Answer 59

1. 1,000 mcg daily of oral cobalamin

Question 60

The dosage of Vitamin B12 to initially treat pernicious anemia is:
1. Nasal cyanocobalamin 1-gram spray in each nostril daily x 1 week then weekly x 1 month
2. Vitamin B12 IM monthly
3. Vitamin B12 1,000 mcg IM daily x 1 week then 1,000 mg IM weekly for a month
4. Oral cobalamin 1,000 mcg daily

Answer 60

3. Vitamin B12 1,000 mcg IM daily x 1 week then 1,000 mg IM weekly for a month

Question 61

Before beginning IM vitamin B12 therapy, which laboratory values should be obtained?
1. Reticulocyte count, hemoglobin, and hematocrit
2. Iron
3. Vitamin B12
4. All of the above

Answer 61

4. All of the above

Question 62

_______ should be monitored when vitamin B12 therapy is started.
1. Serum calcium
2. Serum potassium
3. Ferritin
4. C-reactive protein

Answer 62

2. Serum potassium

Question 63

Anemia due to chronic renal failure is treated with:
1. Epoetin alfa (Epogen)
2. Ferrous sulfate
3. Vitamin B12
4. Hydroxyurea

Answer 63

1. Epoetin alfa (Epogen)

Question 64

Epigastric pain (possibly worse at night), is______ by eating, caused by what type of ulcer?

Answer 64

Relieved, duodenal

Question 65

Epigastric pain is made______ with eating, caused by what type of ulcer?

Answer 65

worse, Gastric

Question 66

a Factor Xa agent, _______ is the antidote approved by the FDA for reversal of Apixaban and Rivaroxaban.

Answer 66

Andexxa

Question 67

Stages of Peristalsis

Answer 67

1. oral
2. Pharyngeal (upper sphincter relaxes
3. Esophageal

Question 68

Mixing and propulsion: chyme to stomach.
Parietal cells H+ secretion occurs via the hydrogen ion (proton pump) in response to stim.
4 phases:

Answer 68

1. Basal (acth/histamines)
2. Cephalic: emotional/sensory stimulation to afferent vagel fibers
3. Gastric:
4. Intestinal Phase

Question 69

Antacids:
Metallic cation vs Basic anion

Answer 69

cation: aluminum, calcium, mag

anion: hydroxide, bicarbonate, carbonate

MOA: neutralizes acids in the GI tract, increasing intragastric pH. ***

affects the absorption of MANY other meds

EDU: no longer than 2 weeks, notify if s/s GIB, constipation w/ alum. based
R/O: PUD and GERD if needed longer
Life changes: stop smoking, elevate head while sleeping, avoid spicy/etoh/chocolate, (foods that affect lower sphincter tone) & CAFFIENE

Question 70

Gerd-1st line treatment?

Answer 70

H2RA receptor antagonists or PPI’s

Question 71

Diarrhea

Answer 71

tx cause: meds, infection, substnaces, lactose

abt use kills normal flora (overgrowth of path org_

Contra: bloody stools, high fever, systemic toxicity

**children: rehydrate; medication not recommended

Question 72

Anti diarrheals-MOA and pearls
Opiod Agonist

Answer 72

Lomotil (diphenoxylate w/ atropine) , Imodium (loperamide), opium

inhibit parasympathetic response
Diminish propulsive peristalsis, delays passage, increased H2O absorb.
AE: norm + paralytic illius w/ toxic megacolon
Lomtil-sched 5 controlled sub. (anticholinergic effects)

**not found to be safe or effective

Question 73

Anti diarrheals-MOA and pearls
Bismouth Compounds

Answer 73

Pepto, Kaopectate
MOA: inhibit parasympathetic (ACh) receptors. stim absorption of fluid and elytes across intestinal wall.

Ind: dyspepsia, acute diarrhea, prevent travellers D.

contra in kids w/ viral illness, and usually not needed

Question 74

GI Cytoprotective Agents:

Answer 74

Sucralfate (carafate): selectively binds to ulcer tissue, acting as barrier; Decr absorb of other drugs

Misoprostol (cytotec): inhibits gastric secretion, w/ protective properties; Preg X;

Ind: ulcers asso w/ NSAIDs; misoprostol QID dosing
Duodenal ulcers: sucralfate for up to 8wks QID, 1hr a meals

Question 75

Antiemetics: MOA

Answer 75

Antihistamines: have strong anticholinergic effects as well as histamine1-blocking effects; MOA: interrupts various visceral afferent pathways that stim n/v

Phenothiazines: block dopamine receptors in the chemoreceptor trigger zone

Butyrophenones: Blocks dopaminergic stimulation of the CTZ

Benzamides: (reglan) blocks dopaminergic receptors in CTZ stimulating cholinergic effects in GI;

Cannabinoids: work in the central nervous system (CNS) to prevent nausea and vomiting associated with cancer chemotherapy; inhibit prostaglandins or block adrengeric activity

HT3 receptor antagonists (-strons): block serotonin on vagal nerve terminals and in the chemoreceptor trigger zone

Anticholinergic (scopolamine)

Substance P/NK1 norepinephrine receptor antagonist; antagonizes neurokinin mediating N/V (CNIV)

Question 76

Antiemetics: ADR

Answer 76

anticholinergic-CNS depression, hypotension
EPS (Rare)-dystonia, tardive dyskinesia
QT prolongation
Phenothiazides and lithium may increase EPS and mask lithium toxicity. NO children

Question 77

Histamine2-Receptor Antagonists (H2RA)

Answer 77

Indications: Heartburn, PUD, GERD, stress ulcer prophylaxis

Agents: Famotidine (Pepcid), ranitidine (Zantac), cimetidine (Tagamet), nizatidine (Axid)

MOA: Inhibition of gastric acid secretion (reduces by 35-50%)*

Adverse Effects: Headache, dizziness, fatigue, somnolence, confusion, CNS-confusion, psychosis, and depression.
*agranulocytosis, thrombocytopenia, and aplastic anemia**

gynecomastia (cimetidine (tagamet)), thrombocytopenia (cimetidine (tagamet); case reports with famotidine, ranitidine)

Comments: Less effective than PPI therapy in healing erosive esophagitis , several interactions, ALL affect absorb of other meds, Monitor liver function with high-dose or long-term use.
Gastroesophageal reflux disease (GERD)- BID
empiric treatment of infants with GERD with H2RAs

PUD not used
Pregnancy category b,

Question 78

antiemetic-prokinetic agents
Reglan

Answer 78

Indications: Adjunct therapy for GERD

Agents: Metoclopramide (Reglan)

MOA: Increases LES pressure/ tone and accelerates gastric emptying

Adverse Effects: Dizziness, fatigue, somnolence, drowsiness, tardive dyskinesia, hyperprolactinemia, cardiac dysrhythmia, neuroleptic malignant syndrome

Comments: Not routinely used or recommended due to inferior efficacy and adverse effect profile

Provides symptomatic improvement for some patients with GERD

Adjust dose in renal impairment

Many drug-drug interactions

**BBW/REMS: Irreversible tardive dyskinesia
Clinical use and dosing

GERD Adults: 10 mg 30 minutes before meals

Diabetic gastroparesis 30 minutes before meals and at bedtime for 2 to 8 weeks

patients with continuous complete remission below 40 mL/minute, their therapy initiated at approximately half the recommended dosage

Question 79

Proton-Pump Inhibitors (PPI)

Answer 79

Indications: PUD, GERD, Zollinger-Ellison syndrome

Agents: Omeprazole, (Prilosec) lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), esomeprazole (Nexium), dexlansoprazole (Dexilant)

MOA: Reduce H+ secretion by inhibition of the H+/K+/adenosine triphosphatase (ATPase) enzyme system at the secretory surface of the parietal cell
Decrease in acid secretion lasts for up to 72 hours after each dose (inhibits gastric secretion)

Adverse Effects: Headache, diarrhea, constipation, abdominal pain, nausea, thrombocytopenia (1-5%), interstitial nephritis leading to CKD
Pregnancy category B or C
Children: omprazole, lansoprazole ok @ 1 year old, protonix not until 5+

Comments: Superior to H2RA for healing PUD/GERD

Slow onset; long duration of action

Administer 30 minutes prior to meal

No adjustment needed for renal dysfunction

Potential increased risk of Clostridium difficile

Several drug-drug interactions

**May increase risk for osteoporosis and hip fractures, kidney disease, increased risk of PNA

Blackbox: interactions with Plavix
Clinical dosing: Duodenal and gastric ulcers

PPIs are combined with antibiotics to treat H. pylori.

GERD Used for 8 weeks, then patient weaned off

May need to double dose for 4 weeks and then decrease dose for another 4 weeks

May mask the symptoms of gastric cancers

Weaning: Decrease from twice/day to once/day, then every other day, with an H2RA used for symptoms, then patient weaned off.
Monitor for neutrapenia, prolonged PT, Thrombocytopenia

Question 80

Mucosal Protectants

Answer 80

Indications: PUD, stress ulcer prophylaxis (?)

Agents: sucralfate (Carafate)

MOA: forms a viscous adhesive that promotes ulcer healing

Adverse Effects: constipation, nausea, dry mouth, metallic taste, aluminum toxicity

Comments: Not for acute symptoms

Requires QID dosing

Relieves symptoms only; does not effectively heal ulcers

Requires acidic environment to produce effect

Accumulates in renal insufficiency; adjust dose for renal

impairment

Inhibits absorption of many drugs

Question 81

Prostaglandins

Answer 81

Indications: Prophylaxis for NSAID induced gastric ulcer

Agents: Misoprostol (Cytotec)

MOA: Moderately inhibits acid secretion and enhances production of mucus & bicarbonate (mucosal defense)

Adverse Effects: Diarrhea, abdominal pain, nausea, flatulence, headache

Comments: Abortifacient (pregnancy X); confirm adequate contraception in women of childbearing age

Effectively prevents gastric ulcers in patients receiving NSAID’s

Requires QID dosing

Frequent incidence of GI related side effects

Question 82

dyspepsia or mild GERD-Which drug first?

Answer 82

H2 receptor antagonist

Question 83

Differences between Duodenal ulcer and Gastric ulcer?

Answer 83

Duodenal ulcer:

Epigastric pain (possibly worse at night), often occurs 1-3 hours following a meal and may be relieved by eating

Heartburn, belching, bloated feeling, nausea, anorexia

Gastric ulcer:

Epigastric pain often made worse with eating

Heartburn, belching, bloated feeling, nausea, anorexia

Question 84

Mod-Severe Gerd

Answer 84

PPI’s for 8 weeks, if improved wean off, if not REFER
If symptoms not relieved- increase PPI to BID for 4-8 weeks, if ok at 4 weeks wean down to daily
if not relieved after 12 weeks-REFER

Question 85

GERD: teaching

Answer 85

So what is the non pharmacological therapy for GERD management? Dietary. Under dietary is a long list of things, but avoiding aggravating foods and beverages certainly is a no brainer, especially caffeine in these patients.

You’re gonna educate them to reduce their fat intake as well as their portion sizes at every meal.

You’re gonna tell them to remain upright following meals and avoid eating meals, or eating of any kind 3 hours prior to bedtime.

You’re also under other categories of lifestyle modifications are gonna talk to them about weight reduction, avoiding tight fitting clothing, reducing or discontinuing nicotine use of any kind.

You’re gonna have them elevate their head of the bed as they sleep 6 to 10 inches

and avoid medications that may affect lower esophageal sphincter tone like that estrogen we already mentioned. And there’s others as well, but that’s the one I really wanna highlight to make sure you know.

A patient with GERD is always, always, always started on an H2 receptor agonist first

Question 86

PUD-

Answer 86

c/b NSAIDS and H. Pylori
Gastric: antral stomach region erosion, raised gastrin
* Duodenal: H. pylori releases toxins, phospholipase enzymes
promoting inflammation and erosion
Tx: Step 1
* Lifestyle modifications and over-the-counter antacids or H2 blockers
Step 2
* H. pylori testing
* Treatment with PPIs
Step 3
* Treatment for H. pylori
Triple therapy: PPI plus
* Clarithromycin: 500 mg twice daily, or
* Metronidazole: 500 mg twice daily
* Amoxicillin: 1 gm twice daily
* Treatment for 10 to 14 days
or
Quadruple therapy: PPI plus
* Metronidazole: 250 mg four times/day
* Tetracycline: 500 mg four times/day
* Bismuth subsalicylate: 525 mg four times/day
* Treatment for 14 days
* Usually used as second-line therapy in patients who fail first-line therapy

Question 87

Constipation: Laxatives

Answer 87

Six classes of laxatives
* Stimulants: cascara, senna, bisacodyl, and castor oil
* Osmotics: magnesium hydroxide, magnesium citrate, sodium phosphate, polyethylene glycol electrolyte solution, and polyethylene glycol (PEG) 3350
* Bulk-producing laxatives: psyllium, methylcellulose, and polycarbophil
* Lubricants: mineral oil
* Surfactants: docusate compounds – docusate sodium,
docusate calcium, and docusate potassium
* Hyperosmolar laxatives: glycerine, lactulose
* Chloride channel activators: lubiprostone
* Opioid-receptor antagonists: methylnaltrexone

Question 88

Stimulant Laxatives: Senna, biscodyl

Answer 88

MOA: Direct stimulation of the enteric nervous system; irritate bowel mucosa
Adverse Effects: Abdominal cramping, nausea, fainting, diarrhea, fluid and electrolyte loss

Comments: Work rapidly
Uses: Acute and chronic constipation
May be required on a long-term basis, especially in patients who are neurologically impaired
Safe for acute and long-term use
Adjunct to chronic opioid therapy ?

Question 89

Osmotic Laxatives-MOM, lactulose, mg citrate, PEG/miralax

Answer 89

MOA: Soluble but non-absorbable compounds that draw water into fecal mass, create watery stool
Adverse Effects: Severe flatus, diarrhea, abdominal cramping, electrolyte disturbances
Comments: Uses: Colonic cleansing before GI procedures
Sorbitol, lactulose: Prevent/treat chronic constipation
Produce prompt BM; within 1-3 hours
Maintain adequate hydration with regular use

*MOM should not be used for prolonged periods in patients with renal insufficiency due to the risk of hypermagnesemia

Ok to use in pregnancy or colace

Question 90

Bulk-Forming Laxatives: citrucel, psyllium, polycarbophil (fibercon)

Answer 90

Agents: Methylcellulose (Citrucel), psyllium (Metamucil), polycarbophil (FiberCon)

MOA: Indigestible colloids that absorb water, forming a bulky, emollient gel that distends the colon and promotes peristalsis

Adverse Effects: Increased bloating, flatus, abdominal fullness

Comments: Preferred agents for treatment and prevention

Slow onset of action, not used for rapid relief

Maintain adequate hydration

Esophageal/GI obstruction if taken with insufficient fluid
Preferred agent for tx and prevention of constipation, no children

Safe in pregnancy

Question 91

Stool Surfactant Agents (Softeners)
colace, glycerin, mineral oil

Answer 91

MOA: Cause water and lipids to penetrate/be absorbed into stools; lubricates the stool

Adverse Effects: Abdominal cramping, diarrhea, nausea, nutritional deficiencies (mineral oil) of fat soluable vitamins: A, D, E,K , aspiration pneumonia (mineral oil)

Comments: Prevent constipation and minimize straining

Ineffective for treating constipation

Mineral oil: Long-term use can impair absorption of fat-soluble vitamins (A, D, E, K)

Docusate: Most frequently used laxative to prevent constipation (given when iron and calcium supplementation prescribed)

Question 92

Opioid Receptor Antagonists for constipation
Agents: alvimopan (Entereg), methylnaltrexone (Relistor), naloxegol (Movantik), naldemedine (Symproic)

DO NOT use in ESRD or liver impairment

Answer 92

MOA: opioid receptor antagonists; inhibit peripheral opioid receptors without impacting analgesic effects in CNS

Adverse Effects: diaphoresis, abdominal pain, flatulence, nausea, dizziness, gastrointestinal perforation, arthralgia, HA

Comments: Alvimopan: shorten the period of postoperative ileus in hospitalized patients who have undergone small/large bowel resection

Short-term use only (not to exceed 15 doses)

**Do not use in ESRD or liver impairment

***BBW/REMS program due to cardiovascular toxicity (MI)

Methylnaltrexone: treatment of opioid-induced constipation in patients receiving palliative care for advanced illness who have had inadequate response to other agents; SQ only

Naloxegol: adjust dose for renal impairment; many drug-drug interactions; contraindicated for suspected GI obstruction

Question 93

Laxatives/Constipation Therapy: MOA

Answer 93

Stimulants: direct action on intestinal mucosa by stimulating the myenteric plexus

Osmotics: draw water into the intestinal lumen

Bulk-producing laxatives: natural and semisynthetic polysaccharides and cellulose that mix with water in the intestine

Lubricants: soften stool and lubricates intestine

Surfactants: reduce the surface tension of the oil–water interface on the stool and facilitate admixture of fat and water into the stool

Hyperosmolar laxatives: draws water into intestine

Chloride channel activators: activate CIC-2 chloride channels in the GI tract to produce chloride-rich secretions that soften the stool

Opioid-receptor antagonists: mu receptor antagonist

Question 94

Vitamin K Antagonists: Warfarin

Answer 94

Agents: Warfarin (Coumadin)

Indications: Prophylaxis and treatment of thromboembolic disorders

MOA: Blocks the regeneration of vitamin K epoxide, thus inhibiting synthesis of vitamin K-dependent clotting factors X, IX, VII and II (prothrombin)

Dosage: Individualized and titrated to goal INR (avg 2-3)

Adverse effects: Bruising, bleeding, hemorrhage, tissue necrosis

Comments: Routine use of pharmacogenetic testing for guiding doses is not recommended

Initiate on day 1 or 2 of parenteral heparin therapy

Many drug-drug and drug-food interactions

Contraindicated in pregnancy and when the risk clearly outweigh benefits

INR 4.5-10 with no evidence of bleeding: NO vitamin K for reversal of INR

Antidote: Vitamin K, blood products, prothrombin complex concentrate (PCC), factor VII

mechanical valves including a mechanical mitral valve because there’s a lower flow through that valve itself versus an aortic which is a high flow system. And so the INR goal for mechanical mitral will be 2 and a half to 3 and a half or 2 and a half to 3 depending on what type of valve brand it is.

Question 95

Factor Xa inhibitor: xarelto, eliquis, savaysa, Bevyxxa

Answer 95

Agents: Apixaban (Eliquis), betrixaban (Bevyxxa), edoxaban (Savaysa),rivaroxaban (Xarelto)

Indications: Prophylaxis and treatment of VTE, nonvalvular atrial fibrillation

MOA: Selectively inhibits factor Xa

Dosage: Dependent on indication

Adjust dose in hepatic/renal impairment

Adverse effects: Bruising, bleeding, syncope, GI hemorrhage, hematoma, epistaxis, menorrhagia

Comments: Monitoring: None

Contraindications: Severe renal impairment or hepatic impairment

BBW: NO epidural/spinal anesthesia or puncture

Antidote: Factor Xa reversal agent Andexxa (In her lecture she said there was no antidote for factor Xa inhibitors and it was in red but the slide and Epocrates say Andexxa is an antidote with serious BBWs)

Question 96

Heparin unfractionated (UFH)

Answer 96

Indications: Prophylaxis and treatment of thromboembolic disorders, ACS; AC of choice for renal impairment, and LMW for ESRD

MOA: Combines with antithrombin III to inactivate activated Factor X and inhibit prothrombin’s conversion to thrombin

Dosage: Prophylaxis: 5000 units SQ q8h or q12h

Treatment: Individualized, dependent on weight, and adjusted to goal aPTT, ACT, or anti-factor Xa level

Adverse effects: Bruising, bleeding, osteoporosis (long term); Heparin induced

thrombocytopenia (HIT)

Comments: Drug of choice for patients with renal impairment, undergoing procedures, and/or obesity

Rapid-acting; short acting

Administered as a continuous infusion or SQ

Monitoring: APTT, anti-factor Xa level, ACT, TEG, platelets

Antidote: Protamine sulfate

Question 97

Low-molecular weight heparin (LMWH)

Answer 97

Agents: Enoxaparin, dalteparin

Indication: ACS, VTE treatment, and prophylaxis, AC in pregnancy-cat C (monitor anti Xa factor), NO ESRD

MOA: Inhibits the formation and activity of factor Xa and IIa

Dosage: Dependent on indication; adjust dose for renal impairment
Use 4T score to calculate for pt.

Adverse Effects: Bruising, bleeding, thrombocytopenia, HIT, anemia, hematoma, local irritation, injection site pain

Comments: Long acting

Limited data for dosing in obese patients

ESRD: Use heparin

Administered as a SQ injection only

Monitoring: Platelets every 2-3 days w/ thrombo at day 4, factor Xa levels (in pregnancy)

NO epidural/spinal anesthesia or puncture

Antidote: Protamine sulfate (only 60-75% effective)

Question 98

Fondaparinux (Arixtra)

Answer 98

Indications: Prophylaxis and treatment of VTE

MOA: Selectively binds to antithrombin III (ATIII); thus, potentiating the neutralization of Factor Xa

Dosage: Prophylaxis: 2.5 mg SQ daily VTE: 5 to 10 mg SQ daily (based on weight)

Adverse effects: Bleeding, syncope, injection site irritation/pain, fever, anemia, hematoma, thrombocytopenia

Comments: Long acting

Monitoring: None

Contraindicated for eGFR < 30 ml/min or weight less than 50 kg

Discontinue if the platelet count < 100,000

BBW: NO indwelling epidural catheters, epidural/spinal puncture

No antidote available

Question 99

Protamine-antidote to heparin

Answer 99

MOA: Combines with heparin to form a stable complex, neutralizing the anticoagulant effects of heparin

Dosage: 1 mg for every 100 units of heparin remaining in patient; if 30 minutes have elapsed since the injection of heparin, one-half the dose may be sufficient; maximum 50 mg IVPB over 15 minutes

Adverse effects: Flushing, nausea, vomiting, dyspnea, hypotension, bradyarrhythmia, anaphylaxis, pulmonary edema

Comments: Should ONLY be reversed if bleeding is life threatening

Over-reversal can lead to bleeding as protamine intrinsically is an anticoagulant if there is NO heparin to reverse

Administer slowly over 15 minutes; too-rapid administration may cause severe hypotensive or anaphylactic reactions
Give SLOW anaphylaxis or severe hypotension

Question 100

Direct Thrombin Inhibitors

Answer 100

Agents: Argatroban (IV), bivalirudin (IV), dabigatran (PO), desirudin (SQ)

Indications: VTE; alternative to heparin or LMWH; treatment of VTE in patients with HIT; PCI (bivalirudin)

MOA: Inhibits thrombin

Dosage: Individualized, dependent on weight

Adverse effects: Bruising, bleeding, postural hypotension, headache, flushing, tachycardia, nausea

Comments: Reserved for patients with HIT

Adjust dose in renal impairment (bivalirudin, dabigatran, desirudin) and hepatic impairment (argatroban, dabigatran)

Monitoring: APTT (argatroban, bivalirudin, desirudin)

Causes elevations in INR (argatroban)

No antidote available (argatroban, bivalirudin, desirudin)

Dabigatran now has reversal agent: idarucizumab

**Argatroban can cause elevations in INR-but it’s actually a false elevation-ignore it

Question 101

Anti-platelet medications MOA

Answer 101

Aspirin

Inhibits cyclooxygenase

Interferes with platelet aggregation
Preg Cat C (D in 3rd trimester)

Ticlopidine and clopidogrel

Reduces platelet aggregation by inhibiting adenosine diphosphate pathway

Vorapaxar 1/2 life= 8 days
Black box warning not to use in patients with history of stroke or transient ischemic attack (TIA)

Protease-activated receptor-1 antagonist

Inhibits thrombin-induced and thrombin receptor agonist peptide-induced platelet aggregation

Taken with aspirin or clopidrogrel thrombin receptor agonist peptide induced platelet aggregation