Peptic Ulcer Disease and Dyspepsia Flashcards
What are the 5 gastric protective mechanisms?
- Gastric Mucus: barrier to acid
- Gastric Bicarbonate: neutralizes HCl
- Prostaglandin E and Somatostatin: inhibit gastric acid secretion
- Mucosal Blood Flow: transport oxygen
- Rapid Cell Turnover: renewal of epithelial
What are the 3 Main Causes of PUD?
- Helicobacter Pylori Infection: duodenal ulcer
- Nonsteroidal Anti-Inflammatory Drugs: gastric ulcer
- Stress Related Gastric Mucosal Damage
What are the 3 mediators of the proton pump that stimulates gastric acid secretion?
- Histamine
- ACh
- Gastrin
If the patient has high suspicion or documented PUD/Erosive Esophagitis what is the recommended self-care?
NONE, ALWAYS REFER
What are common risk factors of PUD?
- Stress
- Cigarette Smoking
- NSAIDs
- Caffeine
- Spicy Foods
- Alcohol
What are the risk factors for H.Pylori Induced Ulcers?
- Colonization, close contacts
- Active H.Pylori infection in susceptible host
What are the risk factors for NSAID Induced Ulcers?
- Regular use or High Dose NSAIDs, Corticosteroids, and ASA
- Slow release, prodrugs, enteric coats do not decrease likelihood of PUD
What are the risk factors for Stress Related Induced Ulcers?
- Respiratory Failure
- Coagulopathy
- HTN
- Sepsis
- Hepatic/Renal Failure
- Trauma
- Prolonged ICU admin
What are the Antacids and their place in therapy?
- Calcium
- Aluminum
- Magnesium
- Sodium
Intermittent Dyspepsia
What is the action of Antacids?
Quick acting, Short duration, topical buffering
What drugs are bound by antacids and have a decreased absorption?
- Fluoroquinolon antibiotics
- Tetracyclines
- Nitrofurantoin
- Isoniazid
What drugs require an acidic environment and have a decreased absorption when used with antacids?
- Iron
- Ketoconazole
- Itraconazole
- Sucralfate
- Calcium Carbonate
- Levothyroxine
What is the AE of Calcium and Aluminum?
Constipation
What is the AE of Magnesium?
Diarrhea
What is the AE of Sodium?
Fluid retention
What combination has the BEST BALANCE between onset and duration?
H2RA + ANTACID
Can PPIs be used as needed?
NO
What is the MOA of H2RAs?
Reversible competitive binding vs histamine at H2 receptors
Should you recommend H2RAs in acute management of upper GI bleeding?
NO
What drugs are have inhibited metabolism when used with Cimetidine?
- Theophylline
- Phenytoin
- Warfarin
What drugs require an acidic environment and have a reduced absorption when used with Cimetidine, Famotidine, and PPIs?
- Ketoconazole
- Itraconazole
- Sucralfate
- Iron
- Calcium Carbonate
- Levothyroxine
What are the AEs of Cimetidine?
- CNS
- Hematologic
- Gynecomastia
- Increase EtOH
Does Famotidine have CYP450 Interactions?
NO
What are the AEs of Famotidine?
- CNS
- Hematologic
When would a H2RA be preferred over PPI?
SRMD prevention in hospitals
What is the PK of PPIs?
Irreversibly bind to K-H-ATPase, inhibits final step of hydrogen ion secretion
What is the MOA of PPIs?
Noncompetitive, irreversible binding to sulfhydryl group of H/K Atpase
What is the AE risk with prolonged use of PPI?
- Hypomagnesemia and B12 deficiency
- Hypergastrinemia-gastric carcinoid tumors
When are PPIs preferred for treatment?
Severe PUD
Mod/Severe Esophagitis
What are the drugs that can cause an interaction with PPIs?
- Clopidogrel
- Benzos
- SSRIs: Citaloprama nd Escitalopram
- Cyclosporine
- Methylphenidate
- Methotrexate
- Phenytoin
- Vit K Antagonists: Warfarin
What is the recommendation for H.pylori negative ulcers?
QD with PPI or H2RAs for 4-8 weeks
When should you administer antacid drugs?
Separate administration of all other drugs by at least 2 hrs
When should you administer PPI drugs?
Before meal to improve efficacy
Recommended treatment for severe peptic ulcer bleeding includes what?
- IV PPI loading dose
- 72-hr continuous infusion
- Maintain intragastric pH >6
If you had to use clopidogrel with a PPI which PPI would you recommend?
Pantoprazole
What are typical symptoms of PUD?
- Dyspepsia
- Duodenal Ulcer: pain 1-3 hrs after meal
- Gastric Ulcer: pain enhanced with food
What are alarm symptoms of PUD?
- Bleeding
- Unintentional weight loss
- Choking
- Dysphagia
- Odynophagia
What is the PK of Misoprostol?
Cyctoprotective, inhibits acid secretion
Misoprostol is the only drug approved for what?
Prevention of NSAID induced ulcers
What are the AEs of Misoprostol?
GI Effects common, diarrhea
CI in WOMEN with childbearing potential
What are the AEs of Sucralfate?
- Severe Constipation
- Accumulation in renal impaired
- Liquid form CLOGS feeding tubes w/enteral food
What are the drug interactions for Sucralfate?
Binds
1. Fluoroquinolone antibiotics
2. Tetracycline
3. Nitrofurantoin
4. Isoniazid
What is the dosing for Sucralfate?
QID dosing, large tablet size, very constipating
What is the place of therapy for Prokinetic Agents?
ADJUNCT for GERD
Reserved for patients with underlying hypo-motility disorders
What are the AEs of Metoclopramide Prokinetic Agent?
- Somnolence
- Increased Prolactin
- Extrapyramidal Symptoms
What are other pro kinetic agents?
Erythromycin and Domperidone
When is treatment clearly indicated for Eradication of H.Pylori?
- Gastric and Duodenal Ulcer
- MALT
- Endoscopic Gastric Cancer
- Uninvestigated Dyspepsia
What is first line treatment in H.Pylori?
Bismuth Quadruple therapy
What is the 4-Drug Therapy first line therapy?
- PPI or H2RA
- Bismuth Subsalicylate
- Metronidazole
- Tetracycline
What is the 3-Drug Therapy?
- PPI or H2RA
- Clarithromycin
- Amoxicillin/Metronidazole
What is LOAD Therapy?
- Levofloxacin
- Omeprazole
- Alinia (Nitazoxanide)
- Doxycycline
What is secondary treatment after initial failure for H.Pylori?
Avoid antibiotics previously used
Bismuth quadruple or LOAD or Clarithromycin
How do you manage NSAID Induced Ulcer?
- DC NSAID
- Add protective agent: Misoprostol, H2RA, and PPI
PPI co therapy reduces risk of NSAID Induced Ulcers the same as what and better than what?
Same as Misoprostol
Better than H2RA
Standard PPI and Nonselective NSAID have as similar efficacy as that when reducing risk of NSAID induced ulcers?
Celecoxib?
