Pharm - GERD/PUD Flashcards
What are the pharmacologic agents that may cause LES relaxation?
Anticholinergics (diphenhydramines)
Beta adrenergic agonists (albuterol)
Benzodiazepines (diazepam)
What can cause increased esophageal pressure?
Obesity
pregnancy
What are the typical symptoms of GERD
Heartburn
Dyspepsia
What is an atypical symptoms of GERD
Burning throat
What are some symptoms that require an immediate referral to GI
Anemia
Chest pain
GI bleeding
If given a PPI trial for GERD, what should be done if no improvement after 8 weeks?
refer to GI
If given a PPI trial for GERD, what should be done is improvement after 8 weeks?
Taper PPI to lowest effective dose and eventually therapy discontinuation is possible
What should be recommended along with PPI trial for initial GERD treatment?
lifestyle changes
-stop smoking
-weight loss
-avoid late/large meals
-elevate head of bed
What are the 3 GERD pharm treatment options
Antacids
Histamine 2 receptor antagonists
Proton pump inhibitors
What are examples of antacids
Maalox
Mylanta
TUMS
Antacids MOA
neutralize acid and raise intragastric pH
Antacids clinical pearls
- quick symptom relief
- first line for mild, intermittent symptoms
- breakthrough symptoms for those take H2 or PPI
-mild intermittent = less than twice weekly symptoms - NOT appropriate for chronic symptoms
Dosing concern for antacids
take 1-3 hours after meals and other medications to avoid potential drug interactions
Common ADE of antacids
constipation
chalky taste
long term use may cause renal dysfunction
What are the H2RAs
famotidine (pepcid)
cimetidine
nizatidine
ranitidine is withdrawn from market
H2RA MOA
blocked parietal cell acid secretion by reversible H2RA blockade
H2RA clinical pearls
- mild, troublesome GERD symptoms
- maintenance therapy - patient W/O erosive disease with intermittent symptoms
- Less effective than PPIs in healing erosive esophagitis
H2RA dosing
- OTC typically 50% dose of prescription formulations
- Not ideal to use > 2 weeks
- Renal impairment - requires dose reductions
H2RA drug interaction relating to pH
drugs that require low pH for absorption = reduced absorption
-ketoconazole
-itraconazole
-HIV protease inhibitors
H2RA cimetidine drug interaction
inhibitor of CYP450
-cyclosporine
-theophylline
-warfarin
What are the PPIs
all -prazole ending
Brand:
Nexium
Prilosec
Protonix
PPI MOA
irreversibly interacts with the hydrogen potassium adenosine triphosphate (H-K-ATPase) pump - results in long-lasting impairment of acid secretion
PPI clinical pearls
- empiric therapy for patients experiencing frequent, continued symptoms
-once daily for 8 weeks - most potent inhibitors of acid suppression
- Superior to H2RAs
-moderate to severe GERD
-Erosive esophagitis
-GERD-related complications - Symptom relief is delayed compared to H2RAs
- Not indicated for intermittent episodic symptoms
PPI clinical pearl for maintenance therapy
persistent symptoms in patients with complications (erosive esophagitis, Barrett’s esophagus)
Long term therapy - lowest effective dose
PPI clinical pearl for partial response/incomplete response
increase dosing to twice daily
Switch to a different PPI
PPI administration considerations
- Do not administer with H2RAs
-cumulative effects on acid suppression - Acceptable to use with H2RAs when time interval between dose is sufficient
What are the IV formulation for PPI
Esomeprazole and Pantoprazole
What patient education given with PPI
- most products take 30-60 minutes before a meal
- Capsules and tablets are delayed release
-do not crush or chew - patients with swallowing difficulties
-open delayed release capsules and sprinkle on applesauce
- liquid formation are available for some products
PPI adverse effects
Rebound hypersecretion
-reappearance of acid related symptoms when therapy is discontinued for 2 weeks or more
-advise tapering off
Complications with chronic acid suppression (PPI use)
Fractures
Hypomagnesemia
Increased incidence of C. diff
PPI drug interactions
Ketoconazole/itraconazole/HIV PIs - altered absorption
Clopidogrel - avoid combo with:
-omeprazole
-esomeprazole
-lansoprazole
What should be used for refractory GERD
Metoclopramide
Dopamine antagonist
What to note about metoclopramide
> 12 weeks is not recommended due to risk of irreversible tardive dyskinesia
Where is PUD most common
Stomach and upper duodenum
What are the most common causes of PUD
H. pylori
NSAIDs
What are the symptoms of PUD
Heartburn
Epigastric pain
Anorexia
Weight loss
Complications of PUD
GI bleeding
Perforation
What is the main symptom of gastric ulcer
indigestion of food
What are the main symptoms of duodenal ulcers
pain 1-3 hours post ingestion
pain relieved by food
What is the treatment goal of H. pylori
Eradication
relieve symptoms
heal and prevent ulcers
Primary treatment of H. pylori
Clarithromycin based triple therapy
PPI + Clarithromycin + Amoxicillin
sub metronidazole for amoxicillin allergy
-first line
10-14 days
What is the secondary (quadruple) therapy for PUD and when to used it
PPI
Bismuth
metronidazole
tetracycline
For failed triple therapy
Adverse effect of PUD combo therapy treatment
Diarrhea
Metronidazole - disulfuram-like reaction with alcohol intake
Bismuth - darkening of tongue and stool
What is the most important predictor of treatment failure for PUD (h. pylori)
Lack of adherence and antibiotic resistance
What should be done in the case of NSAID induced PUD
discontinue if possible
What are the GI risks for NSAID ulcers
- history of PUD
- Age >60
- Concominant meds
-anticoags
-corticosteroids
-other NSAIDs (aspirin)
GI risk low vs high
low = 0 risk factors
high - 3+ risk factors
What are the NSAID ulcer CV risks?
Requirements for low dose aspirin
-Prior CV events
-diabetes
-Hyperlipidemia
What to note about CV risk
High arbitrarily defined as a requirement for low dose aspirin
Low CV risk + Low GI risk
NSAID alone ok
High CV risk + high GI risk
AVOID NSAID or COX-2 inhibitors
What is the best option for high CV risk
Naproxen
What is the best option for high GI risk
Celecoxib
What should be done if high GI and high CV risk
Avoid NSAIDs altogether
What is the most COX-2 selective NSAID
celecoxib
What are the top 3 most non selective NSAID
Aspirin (#1)
ibuprofen
naproxen
What to remember about GERD/heartburn in pregnancy?
- Heartburn is the predominant symptom
- symptoms are worst during last trimester
- Dietary triggers
-fatty foods
-spicy foods
-caffeine - typically resolves after delivery
How to treat GERD during pregnancy?
Antacids
-magnesium/calcium considered safe
H2RA
-Famotidine
PPI (Cat C)
-AVOID omeprazole in first trimester
