Pharmacologic Management of Peptic Acidity and Ulcers

Question 1

Antacids (e.g., Mylanta)

Answer 1

Aluminum Hydroxide

Magnesium Hydroxide

Question 2

Nonsystemic Antacids

Answer 2

Generally not absorbed, act locally
Problems typically only with overuse
Can include hypercalcemia with calcium salts (calcium carbonate; Tums)
Complexing of aluminum with phosphate hypophosphatemia
Impair acid-dependent absorption of food and drugs

Question 3

Sucralfate (Carafate)

Answer 3

Protects mucosa from attack by acid and pepsin
Binds proteins on cell surface
Selectively binds to damaged tissue
Binds pepsin and bile salts
Suppresses growth of H. pylori
Few adverse effects

Question 4

Other mucosal protectants

Answer 4

Colloidal Bismuth Compounds 
Peptobismol
Prostaglandins
Misoprostol (Cytotect)
Activate prostaglandin receptors on parietal cells, which are protective

Question 5

Cimetidine

Answer 5

Selective H2 receptor antagonist
Blocks acid secretion from parietal cells
Inhibits cytochrome P450
Antiandrogenic effect – gynecomastia

Question 6

Ranitidine, Famotidine, Nizatidine

Answer 6

H2 receptor antagonists
Block acid secretion from parietal cells
Lack antiandrogenic effects and do not interfere with Cytochrome P450 metabolism

Question 7

Omeprazole (Prilosec)

Answer 7

Covalent binding to H+, K+ ATPase
Prodrug, activated only at low pH
Decreases H+ secretion
Irreversible, so long duration 
P450 substrate
Minimal adverse reactions

Question 8

PPI vs H2 antihistamines for GERD

Answer 8

Both PPI’s and H2 receptor antagonists are far better than placebo
PPI’s resolve esophagitis and symptoms in higher fraction of patients than do H2 receptor antagonists
Beneficial effects of doubling PPI dose are modest but significant

Question 9

Medical management of GERD case

Answer 9

1. Advise lifestyle/diet modifications
2. Begin standard dose PPI for 8-12 weeks
3. Afterwards, advise to titrate down to lowest tolerable daily dose
4. Advise use of antacids for breakthrough symptoms
5. Consider d/c PPI and try H2 antihistamine PRN
6. If poorly controlled, try doubling PPI dose then refer for endoscopy

Question 10

Helicobacter pylori

Answer 10

Gram-negative, multiflagellar microaerophile proteobacteria
Endemic incidence- disease seems mostly associated with virulent strains
Burrows below mucosa to colonize and induce epithelial inflammation directly

Question 11

Eradication of Helicobacter pylori

Answer 11

Always involves multidrug therapy!!!!
Proton pump inhibitor + Antibiotic 1 + Antibiotic 2
1st Line:
Omeprazol+amoxicillin+clarithromycin
Rescue therapy:
Omeprazol+bismuth+tetracycline+
metronidazole