NAPLEX GERD/Acid Reflux

What is the pump that secretes hydrochloric acid in the stomach?

H+/K+ ATPase pump (aka the proton pump)

What neurotransmitters (3) activates/stimulates the secretion of acid?

Histamine, Acetylcholine, and Gastrin

What are some medications that are harmful to the stomach lining/esophagus?

Asprin, NSAIDs, bisphosphonates, dabigatran, estrogen, fish oil, iron, nicotine, steroids, tetracyclines

Should an endoscopy be considered in diagnosing all cases of GERD?

No, should be considered if alarm symptoms are present (vomiting, black/bloody stool/vomit)

What is the treatment of choice for infrequent (<2x/week) heartburn?

OTC antacid or H2RA as needed

When do you refer to a provider for GERD treatment?

If symptoms don’t resolve after 2 weeks

What is the initial drug treatment for GERD?

PPI once daily for 8 weeks (can increase to 2x/day if partial response)

What is the maintenence treatment for GERD?

Discontinue PPI, treat mild recurring symptoms with an OTC antacid or H2RA, or PPI as needed

If indefinite treatment is needed, use the lowest effective dose

When would aluminum and magnesium antacids not be recommended?

In renal dysfunction (CrCl <30) due to mineral accumulation

What is an important safety reminder with aspirin containing antacids?

Risk of bleeding

Why might we not want to use alka-seltzer in patients with heart failure or cirrhosis?

Can worsen edema due to sodium content in the tablets

What is a group where H2RAs are not recommended?

Elderly patients (Beers List)

What is a unique side effect associated with high doses of cimetidine?

Gynecomastia

What vitamin deficiency is common with prolonged use of H2RAs?

Vitamin B12

What dose reduction is important to know with famotidine?

Dose decrease if CrCl <60

What is an important disease-state to look out for with PPIs?

C.diff

What are some warnings associated with PPIs?

Hypomagnesemia, Vitamin B12 deficiency with prolonged use, risk of bone fractures

What is the trademark drug interaction to be aware of with omeprazole?

Omeprazole & Clopidogrel - DO NOT TAKE TOGETHER

Reduces effect of clopidogrel

How should PPIs be taken?

30-60 minutes before a meal

Dexlansoprazole can be taken without regard to meals

What is the MOA of vonoprazan?

It is a potassium-competitive acid blocker (PCAB) that inhibits the potassium channel of the H+/K+ ATPase pump

In addition to being expensive, what safety issues are associated with vonoprazan?

Same as PPIs

What types of products need an acidic gut for absorption?

Enteric coated tablets or delayed-release products

H2RAs should be completely avoided with which medication?

Delayed release risendronate

PPIs should be avoided with which antivirals?

Rilpivirine, Velpatasvir, Ledipasvir

When using H2RAs and CNS depressants together, what should be kept in mind?

Risk of additive delirium, dementia, and cognitive impairment in the elderly

What CYP enzyme do PPIs mainly inhibit?

CYP 2C19

What are some drugs that require an acidic gut?

Antiretrovirals, azole antifungals, cephalosporins, iron, risendronate

What are some drugs that antacids bind to?

INSTIs, bisphosphonates, isoniazid, levothyroxine, fluoroquinolones, steroids, tetracyclines

What are the preferred GERD treatments in pregnancy?

Lifestyle modifications first

Antacids or sucralfate