PUD and GERD Flashcards
Why do NSAIDs increase risk of PUD?
- Direct or topical irritation
2. inhibition of GI prostaglandin synthesis which is needed to maintain blood flow, stim bicarb and mucous production
Which two bisphosphonates can induce ulcerations?
Alendronate (Fosamax)
Risedronate (Actonel)
*take with a full glass of water and sit up
Which infection is strongly associated with PUD?
H.pylori
H.pylori - how does it damage the gut?
produces a large amount of urease –> catalyzes the breakdown of urea to alkaline ammonia and CO2
What is the only cancer you can cure by treating the causative organism?
gastric carcinoma or B-cell lymphoma r/t h.pylori
PUD - general approach to treatmen
- stop smoking
- take NSAIDs with food
- stop or decrease NSAID dose
- Meds: misoprostol, H2RA, PPI or PPI with hs H2RA
- consider h.pylori
How long does treatment of PUD take?
6-8 weeks
Oral antacids - drugs
Amphojel, Maalox, Maalox HRF, Mylanta DS
What are oral antacids use for?
symptom relief
Oral antacids - ADE
diarrhea or constipation
Oral antacids - DDI and Why?
binds and prevents absorption or: levothyroxine, tetracyclines, iron, isoniazid, FQs
Why? binds with di valent and tri valent cations like Mg, Ca and Al
Which formula of oral antacids may be more effective?
chewable
What may be of concern in CHF patients regarding oral antacids?
Na+ content - depends on dose
*What medication provides a protective barrier in the esophagus against gastric contents…floats on surface of gastric contents but does not neutralize acid?
Gaviscon (antacid containing alginic acid)
used mostly for GERD
*What class are Ranitidine (Zantac), Famotidine (Pepcid) and Cimetidine (Tagamet) in?
Histamine Receptor Antagonist (H2RA)
*H2RA - MOA
reversibly inhibit H2 receptors on parietal cells (except famotidine which has some noncompetitive inhibition)
Of the H2RAs, which is probably “a little” better and why?
Famotidine (Pepcid) because longer t1/2 (12 hours)
Most H2RAs are BID dosing. Why do you give the 2nd dose at bedtime?
because nocturnal acid suppression is important for healing
H2RAs - ADE
thrombocytopenia (small risk), increased serum Cr and BMS
Which H2RA should be avoided in BMT patients?
Ranitidine (Zantac)
most likely to cause BMS
Which H2RA is used for prophylaxis of NSAID induced duodenal ulcers?
Famotidine (Pepcid)
How are most H2RAs cleared?
renal (adjust per CrCl)
*What class are Esomeprazole (Nexium), Lansoprazole (Prevacid), Panteprazole (Protonix) and Omeprazole (Prilosec)?
“prazoles” = PPI
*PPI - MOA
Prodrug that requires activation by acid. Irreversibly bind to H+/K+ ATPase pump on parietal cell and inhibits acid generation.
How long does it take to restore proton pumps after DC of PPI?
3-5 days
General dosing for PPI
qd
*How are most PPIs cleared?
hepatically
watch DDI…esp. CYP450
What are the long term safety concerns of PPI?
- increased risk of fractures (b/c decreased Ca absorption)
- possible hypomagnesemia
- gastric carcinoid tumors from hypergastrinemia
- pneumonia and enteric infections
Why is there an increased risk of pneumonia for the elderly on PPI?
Lower acid in the gut allows bacteria to grow and if aspirated, can cause pneumonia.
Why is there an increased risk of enteric infections on PPI?
Lower acid in the gut allows bacteria to grow (Salmonella, Shigella, Cholora)
*When is misoprostol (cytotec) used?
prophylaxis for PUD if on long term NSAID
Misoprostol (cytotec) - ADE
diarrhea and cramping
Misoprostol (cytotec) - pregnancy warning
avoid - can cause contractions
can be used to stimulate labor
*h.pylori triple therapy - PPI
PPI bid + clarithromycin 500 mg bid + AMX 1000 mg bid
80-90% eradication
at what pH does the gut heal?
> 4
ACG guidelines for maintenance of GERD
PPIs
Which drug can be given to pregnant women with N/V or HA?
Reglan
In what condition is Reglan contraindicated in?
small bowel obstruction
How is Reglan eliminated?
renal (adjust per CrCl)
“functional GERD” - peak/onset
peaks at 4 months
usually gone by 12 months
GERD - non-pharmacological treatment (infants)
hypoallergenic formula trial positioning (head up) avoid caffeine, chocolate and spicy foods (breastfeeding) weight control avoid passive smoking
GERD - non-pharmacological treatments (adult)
IBW modify diet avoid ETOH and smoking HOB up avoid tight garments
Pharmacological options - GERD
- oral antacids
- H2RA
- PPI
- Prokinetic agents
Reglan - ADEs
drowsiness, diarrhea, dystonia, EPS
What pro kinetic drug can be used to treat GERD?
Reglan
*Risk factors -PUD
NSAIDS
h.pylori
steroids
anti-coagulants
Which pathway is DDI most likely with Prilosec (PPI)?
2C19
