COMPLETED - GERD/PUD, RA, Osteoporosis

GERD

Causes

Lifestyle changes

Caues

• Obesity

• Bisphosphonates

• Zollinger-Ellison (hyper-secretion of acid by a tumor)

PUD Causes

Antacids

Only for…PRN

Sodium bicarb

Tums

Alternagel, Magnesium

Separate from which meds

For preg

Only for PRN use → works fast but stops working just as fast

Safe in pregnancy except for sodium bicarb, which also has concern for fluid overload

Tums (Calcium) → hypercalcemia, constipation

Magnesium → diarrhea

Alternagel (Aluminum) and Magnesium products → avoid in CKD, excreted renally

Separate 2 hrs before or 4 hrs after from

• quniolones, tetracyclines

• Levothyroxine

• ketoconazole, itraconazole, iron → needs acidic environment

Avoid sodium bicarb and magnesium products in preg

H2 blockers

Indication

ADE

Dose adjust CrCl

Preg DOC

Formulation

Used for GERD if have <2 ep/week

Can cause confusion, dizziness, headache

Can be used in pregnancy (DOC ranitidine)

All come in PO but Ranitidine and Famotidine has IV/IM formulations

Tagament

Generic, class

ADE

CYP → interactions

Cimetidine (H2 blocker), OTC

ADE: gynecomastia

CYP1A2 inhibitor → increases levels of warfarin and theophylline

Pepcid

Generic, class

Famotidine, H2 blocker, OTC

Zantac

Generic, class

For kids aged…

Ranitidine, Zantac

For kids > 1 month

PPI

MOA

When to take

ADE

Which come OTC, IV

Approved age

MOA: irreversibly blocks H+/K+ ATPase of gastric parietal cells → reduce acid production

Take it in the morning before food

Chronic use can cause

• Vitamin B12 deficiency

• C diff

• Fracture risk → low Ca, Mg

hence dont use long term

No dose adjustment

OTC: Omeprazole (Prilosec), Omeprazole/Sodium bicarb (Zegerid), Esomeprazole (Nexium 24hr), Lansoprazole (Prevacid 24 hr)

Comes IV: Pantoprazole, Esomeprazole

All approved for at least 1 yo (except Dexlansoprazole and Pantoprazole)

Prilosec

Generic, class

CYP interaction → med

Formulation, regards to food

Omeprazole, PPI

CYP2C19 inhibitor → decreases effectiveness of clopidogrel (plavix)

Zegerid (→ generic)

Omeprazole + Sodium Bicarb

Nexium

Generic, class

Formulation, regards to food

Esomeprazole, PPI

S-isomer of omeprazole

Vimovo (→ generic)

Esomeprazole + Naproxen

Prevacid

Generic, class

Formulation, regards to food

Lansoprazole, PPI

Prevpac (→ generic)

Lansoprazole

Amox

Clarithromycin

Dexilant

Generic, class

Formulation, regards to food

For kids age…

Dexlansoprazole, PPI

R-isomer of lansoprazole

Protonix

Generic, class

Formulation, regards to food

For kids age…

Pantoprazole, PPI

suspension: packets mixed only with apple sauce/juice 30 min before food

Aciphex

Generic, class

Formulation, regards to food

Age limit

Only PPI that…

Rabeprazole, PPI

Not recommended in children <1 yo

Only PPI that cannot go down the NG tube

Cytotec

MOA → indication (2)

ADE

Misoprostol, Rx

Cytoprotective agent → synthetic prostaglandin analoag that replaces protective prostaglandins NSAIDs inhibit → prevention of NSAID induced GI ulcers

Induce uterine contraction → uterine bleeding, medical abortion, pregnancy category X

Other ADE: constipation, abdominal pain

If PUD is NSAID induced…

Carafate

Sucralfate

Has Aluminum → avoid in CKD

QID on an empty stomach

ADE: constipation

Administer drugs/vitamins 2 hrs before or 6 hrs after sucralfate

DOC in pregnancy

Voquezna

Generic

MOA

Indication

CYP interaction

Vonoprazan

MOA: potassium competitive acid blocker (PCAB) → blocks both active and resting proton pumps

indicated for erosive esophagitis

Avoid with CYP3A4 inducers

• What exact diagnostic T-score threshold defines osteoporosis, and what is the preferred method to measure bone mineral density (BMD)?

• What are the specific age thresholds for routine bone density testing in women and men?

Risk factors for low bone density

testosterone deficiency

Drugs with osteoporosis risk

Premphase (→ generic)

Indication

ADE

Medroxyprogesterone + estrogen

Estrogen can cause clots

Evista

• What is the generic name, pharmacologic class, and key patient population demographic constraint?

• What are its two dual indications regarding breast cancer and bone health?

• What life-threatening cardiovascular toxicity risk does it share with tamoxifen, and what major oncologic risk does it notably not share?

• DC for how long prior to prolonged immobilization and surgery

SERM

Raloxifene (vs Tamoxifen): postmenopausal women, doesnt cause endometrial cancer

-

Prolonged immobilization: DC at least 72 hrs prior and during, restart once fully ambulatory

Surgery: stop 2-4 weeks prior

Bisphosphonates

Peridex, Periogard

• What is the exact mechanism of action, clinical treatment duration limits?

• What specific oral administration posture, fluid requirement and timing rules must be followed to avoid esophageal damage?

• What are the signature adverse effect and standard remedy protocol for dental procedures?

• Before filling medication

• DOC

• Stop bone loss by forcing osteoclasts (the cells that break down bone) to self-destruct.

• stop after 3 years for IV or 5 years for PO therapy; take with 6–8 ounces of plain water.

• Take first thing in the morning with 6-8 oz plain water before breakfast (unless Atelvia); stay upright and do not eat for at least 30 minutes (60 minutes with Boniva).

• Osteonecrosis of the Jaw (ONJ); if dental surgery is needed, use 0.12% chlorhexidine rinse (Peridex) 15 mL undiluted BID swished for 30 seconds.

• Look for if they cannot sit upright, hypocalcemia, CKD → if so dont use

• Also causes atypical femure fractures, GERD

• DOC in postmenopausal women

Fosamax

Binosto

-

Generic, Class

Formulation

Dosing in prevention, treatment

Other indication

CrCl cut off

Alendronate (bisphosphonate)

Tablets, solution

Binosto: 70 mg Q week, effervescent tablet

Osteoporosis

• Prevention: 5 mg PO QD or 35 mg PO Q week

• Treatment: 10 mg PO QD or 70 mg PO Q week

Also used in steroid-induced osteoporosis: 5 mg PO QD

Not recommended if CrCl <35

Actonel, Atelvia

Generic, class

Dosing: prevention and treatment

Atelvia note

CrCl cut off

Bisphosphonates (Atelvia only one that can be eaten with food)

Boniva

Generic, class

Unique

Formulation

Dosing

CrCl cut off

Bisphosphonates (only one that you stay upright for 60 min instead of 30 min)

Reclast

Generic, Class

Formulation

Dosing

CrCl cut off

Bisphosphonates

Reclast (for osteoporosis) vs Zometa (not for osteoporosis)

Zomesta

Generic, class

Formulation

Indication, Dosing

CrCl cut off

Bisphosphonates

Reclast (for osteoporosis) vs Zometa (not for osteoporosis)

Aredia

Generic, class

Not for what indication

Indication

Formulation, infuse over…

Pamidronate, bisphosphonates

NOT for osteoporosis

Indicated for hypercalcemia, osteolytic bone lesions associated with breast cancer and Paget’s

IV infused over 2-24 hrs to reduce renal toxicity

Prolia

Xgeva

Generic, Class

Dosing and Indication differences

ADE → take with…

Storage

Denosumab (RANK ligand inhibitors stop osteoclasts from breaking down bone)

Prolia: 60 mg SC Q6 months for osteoporosis

Xgeva: 120 mg SC Q month for prevention of skeletal related events in cancer patients

Same MOA → same ADE as bisphosphonates (hypocalcemia, osteonecrosis of jaw, atypical femur fractures)

Refrigerate

Fortical

Miacalcin

Formulation

Indication

Dosing

Avoid in…allergy

Storage

Calcitonin: Directly competes for osteoclast receptors to inhibit bone resorption → lower Ca level → take with Vit D and Ca

Nasal (Fortical, Miacalcin)

• Osteoporosis

• 1 spray QD nasally (alternate nose)

• Avoid in salmon allergy

• Refrigerate, RT for 35 days, do NOT shake

IM/SC (Miacalcin): also for Paget’s disease and hypercalcemia

Forteo

Generic, class

Dosing

Only use for…

Storage, discard after…

ADE

BBW

Teriparatide, parathyroid hormone analog that stimulates bone formation (vs bisphosphonates inhibit bone breakdown)

20 mcg SC QD

Only use for total of 2 years

Always keep in fridge, discard after 28 days (vs Abaloparatide RT after first use)

ADE: orthostatic hypotension, increase uric acid and Ca (vs bisphosphonates and RANK ligand inhibitors)

Tymlos

Generic, class

Dosing

Only use for…

Storage

ADE

BBW

Abaloparatide, parathyroid hormone analog that stimulates bone formation

Treatment of postmenopausal women with osteoporosis at high risk of fracture

SC QD

Only use for total of 2 years

Fridge until RT after first use, discard after 30 days (vs Teriparatide always in the fridge)

ADE: orthostatic hypotension, increase uric acid and Ca (vs bisphosphonates and RANK ligand inhibitors)

BBW: Osteosarcoma

Evenity

Generic, class

MOA, indication

Dosing/administration

ADE

Romosozumab, Sclerostin inhibitor

Increases bone growth and decreases breakdown in postmenopausal women at high risk for fractures.

• Administer SQ once monthly in a doctor's office using two separate injections for exactly 12 doses.

• Monitor closely for major adverse cardiac events (CV risk), hypocalcemia, and osteonecrosis of the jaw → last two like bisphosphonates

Hyalgan

NeoVisc

OrthoVisc

Synvisc

(vs Restylane)

Formulation, Indication

Effects last how long

Caution in allergy to...

Osteoporosis
Meds stored in the fridge

Denosumab (Prolia, Xgeva) → RANK ligand inhibitors

Calcitonin nasal (Miacalcin) → refrigerate, RT for 35 days

Teriparatide (Forteo) → Always refrigerated, discard after 28 days

Abaloparatide (Tymlos) → Refrigerate until first opening, discard after 30 days

Anti-inflammatories in RA

DMARD

Non biologics vs Biologics

Trexall

Rasuvo

Otrexup

Formulation, Frequency

How long it takes to work

ADE

Antidote

DDI that increase MTX toxicity

Methotrexate, antimetabolite for RA/cancer

Trexqall → oral

Rasuvo, Otrexup → SC ONCE weekly

4-6 weeks before seeing effects → bridge therapy with steroids

All chemo agents cause bone marrow suppression (check CBC)

Decrease dose with xanthine oxidase inhibitors (allopurinol, febuxostat)

Caution with Bactrim (increase myelosuppression)

Arava

Generic, Class

ADE

Leflunomide, pyramidine inhibitor

• LFT monitored monthly for 6 months and then every 6-8 weeks after → avoid with MTX

• Long t1/2 → use cholestyramine 8 grams TID for 11 days to remove

Arava = Alopecia

Pregnancy Category X

Imuran

Generic, class

Indication

Prodrug of..,

DDI

Azathioprine, anti-metabolite

Chemo agent, also used in RA

Prodrug of mercaptopurine

DDI w/ xanthine oxidase inhibitors (allopurinol and febuxostat)

Plaquenil

Indication

Regards to food

ADE

Hydroxychloroquine

Used for RA, malaria, SLE

With food

ADE:

• Myopathy

• Irreversible retinopathy → avoid long term use of >400 mg

• Neurotox, Ringing in the ear → DC med

Azulfidine

Indication

Dont give in…allergy

ADE

Counseling

Sulfasalazine

Indicated for RA

Dont give in sulfa or aspirin/salicylate allergy

Any agent that has sulfa → rash

Orange urine/skin

Xeljanz, Xeljanz XR

Generic, class, formulation

Indication

Check for…

Substrate

Tofacitinib, JAK inhibitor (oral)

CYP3A4 and 2C19 substrate

Kineret

Generic, Class

Formulation, frequency

Dont give with…

Anakinra, IL-1 receptor antagonist

SQ QD (very often) → make sure to switch sites to avoid irritation

Can cause neutropenia → check CBC

Enbrel

Generic, class, indication

Formulation, Frequency

Injection where…

Etanercept, TNF receptor blocker

SC once weekly, preferably in the thigh

Erelzi

Generic

Etanercept-szzs

Biosimilar of Enbrel (TNF alpha blocker)

TNF alpha blockers

Indications

ADE

Avoid with what other RA meds

Used for RA, psoriasis

Heart failure, hepatotoxicity

Avoid with Abatacept and Anakinra

Remicade, Inflectra

Unique formulation

Administration

Infliximab, TNF inhibitor

IV with NS (usually TNFi given SC)

Begin infusion within 3 hrs of reconstitution

Infused at least 2 hrs and premedicated with tylenol/steroids/antihistamine

Humira

Generic, class

Dosing

Adalimumab, TNF alpha inhibitor

Simponi-SC

Simponi Aria-IV

Generic, class

Formulation

Golimumab, TNF alpha blocker

Comes both SC and IV

Cimzia

Generic, class

Certolizumab, TNF-alpha blocker

Orencia

Indication

Generic, class

Formulation, frequency

ADE

Dont use with

Use when MTX and TNF blockers dont work for RA

Rituxan

Generic, class

Formulation

Pretreat with…

Avoid…

Rituximab, monoclonal antibody to CD20 antigen

IV

Pretreat with acetaminophen and antihistamine

Avoid with live vaccines

Actemra

Generic, class

Formulation, frequency (2)

Screening, dont give with

Don’t start if

Tocilizumab, IL-6 inhibitor

IV diluted in NS monthly

SQ once a week

PPD test screen, dont give live vaccines

Do not start if

• ANC <2000

• Platelets <100,000

• ALT/AST >1.5xULN

Kevzara

Generic, class

Formulation, frequency

Screening, dont give with

Don’t start if

Sarilumab, IL-6 inhibitor

SC once every 2 weeks

PPD test screen, dont give live vaccines

Do not start if

• ANC <2000

• Platelets <100,000

• ALT/AST >1.5xULN

Olumalant

Generic, class, formulation

Watch out for

Baricitinib, JAK inhibitors, oral

watch out for clots

Rinvoq

Generic, class, formulation

Watch out for

Upadacitinib, JAK inhibitors, oral

watch out for clots

Cuprimine

Generic

MOA → Indications (3), DDI

Regards to food

Dosing

Avoid in…

Most common ADE

D-penicillamine

Lowers IgM rheumatoid factor →

• Used for RA (last resort)

Chelates to lead, copper, mercury to excrete them as stable complex in urine →

• Lead poisoning, Wilson's disease (binds to excessive copper)

• Separate 1 hr apart from other meds, milk, antacids, zinc or iron containing products

Empty stomach

Start low and titrate, maintenance at 1,000 mg QD

Avoid in myasthenia gravis

Most common ADE: rash → temporarily discontinue the drug and restart it at a much lower dose alongside an oral antihistamine or low-dose steroid

Non-Biologic DMARD for RA

Name summary

Biologics for RA

Name summary

Always check…and avoid…

Always check for infection and TB (PPD test) and avoid live vaccines

RA

Appropriate vs not appropriate combinations

Can do: non-biologics + (biologics or JAKi)

Can’t do: biologics + (biologics or JAKI)

IV formulations of RA

(All others if injections are SC)

Tocilizumab (Actemra): IV Q monthly, SC Q weekly

Rituximab (Rituxan): IV

Abatacept (Orencia): IV Q monthly, SC Q weekly

Infliximab (Remicade): IV with NS

Golimumab: IV and SC