EXAM 1- Madras

When is heartburn known as GERD?

When is heartburn known as GERD?

o ≥2 days/week

o for ≥3 months

What are some factors that promote GERD? (foods, lifestyle, meds, etc.)

• foods—> spicy, garlic, onion, chocolate, citrus/tomato juice

• alcohol

• smoking

• exercise/ heavy lifting

• MEDS—> DHP CCBs, NSAIDs, iron, bisphosphonates, KCl

Who needs referred to their PCP for GERD? (in general)

• USE COMMON SENSE!!!!!!! ANYTHING NOT NORMAL

• atypical symp

• ALARM symp

• specific pts.

What are some alarm symptoms for GERD that require referral?

• dysphagia

• odynophagia

• unexplained weight loss

• GI bleeding

What is dysphagia? What is odynophagia?

dysphagia- difficulty swallowing (think “d-d” dysphagia=difficulty)

odynophagia- painful swallowing

What are some specific patients that need referred in GERD?

• PREGNANT/nursing

• nocturnal heartburn

• < 12 YO H2RA, <18 YO PPI

• adults >45 YO and new onset

• HEARTBURN FREQUENTLY >3 months

• heartburn/dyspepsia when taking prescription PPI/H2RA

• HEARTBURN/DYSPEPSIA CONTINUES AFTER 2 weeks on OTC PPI/H2RA

What are some ways to diagnose GERD?

• barium esophagram—> doesn’t tell too much

• ENDOSCOPY************

  • invasive but can detect

The pH goal in GERD is >___.

4

WHAT ARE SOME nonpharm tx for GERD? (ex: what side do you sleep on)

• ELEVATE HEAD 6-8 INCHES with foam blocks/wedges NOT PILLOWS

• do not eat 2-3 hrs before bed

• sleep on the LEFT SIDE

• do not lie down after a meal

What is the onset and duration of ANTACIDS? (short, intermediate, long, etc.)

short onset, quick duration

What is the onset and duration of H2RAs? (short, intermediate, long, etc.)

intermediate, intermediate

What is the onset and duration of PPIs? (short, intermediate, long, etc.)

long, long

PRACTICE:

Which of the following could promote GERD?

SATA

a. Non-DHP CCBs like verapamil

b. bisphosphonate

c. garlic and onion pasta

d. brisk walking

b, c

PRACTICE:

Which of the following patients need referred for GERD?

SATA

a. 42 year old man with new symptom onset

b. 35 year old woman that’s had heartburn for 2 months

c. 47 year old pregnant woman

d. 23 year old man who has taken an OTC PPI for 4 weeks

c, d

PRACTICE:

Which of the following is a nonpharm way to help in GERD?

a. sleep on the right side

b. elevate head 4-5 inches with pillows

c. do not eat at least 4-5 hours before bed

d. do not lie down after a meal

d

What pharm tx are for mild, infrequent GERD, and which are for frequent?

mild, infrequent- Antacids, Bismuth Subsalicylate, H2RA

frequent- PPI

What are the side effects of aluminum, magnesium, calcium carbonate?

Al- constipation, Hypophosphatemia

Mg- diarrhea

CaCO3- belching, hypercalcemia

When bicarbonate is combined with calcium, what syndrome can occur?

milk-alkali syndrome

What drugs do antacids interact with?

• tetracycline

• iron

• -azole antifungals

Answer the following about Bismuth Subsalicylate (Pepto-Bismol):

• C/I

• ADRs

• BBW

• what effect on platelets?

• effect on gout?

• C/I- pregnancy, nursing, kids, teens

• ADRs- darkened tongue, black stool, tinnitus

• Reye’s Syndrome- NOT FOR KIDS/TEENS OR IF RECOVERING FROM FLU/CHICKEN POX

• antiplatelet effects

• gout attacks

Bismuth Subsalicylate can cause black stool. Does that mean there is melana (blood in stool)?

NO!!!!

Answer the following about H2RAs:

• names (brand/generic if applicable)

• method of elimination

• ADRs of the entire class

• Cimetidine (Tagamet), Famotidine (Pepcid), Nizatidine

• RENALLY cleared

• ADRs- thrombocytopenia, vit b12 deficiency

Cimetidine (Tagamet) has what endocrine like ADR? It also reduces the levels of what class of drugs?

• ADR- gynecomastia

• reduces levels of -azole antifungals

What are the brand/generics for the PPIs?

• Omeprazole (Prilosec)

• Lansoprazole (Prevacid)

• Esomeprazole (Nexium)

• Pantoprazole (Protonix)

• Rabeprazole

• Dexlansoprazole

What drug class has the greatest symptom relief and HEALING rate for GERD?

PPIs

When should PPIs be administered?

• ALL are 30-60 minutes before a meal EXCEPT esomeprazole is 60 minutes before a meal

• dexlansoprazole- can take without regard to food

Are PPIs used for immediate relief?

NO

Which PPIs are capsules?

o Omeprazole rx

o Esomeprazole rx and otc

o Lansoprazole rx and otc

o Dexlansoprazole rx

Which PPIs are tablets?

o Omeprazole otc

o Esomeprazole otc

o Rabeprazole rx

o Pantoprazole rx

Which PPIs are available IV?

• pantoprazole

• esomeprazole

Which of the PPIs have a drug interaction with clopidogrel?

• omeprazole

• esomeprazole

Can I put PPIs in whatever medium I want? Like water, juice, etc.?

NO!!! must put it in whatever medium it was studied in

All PPIs but _________________ should ONLY be put in applesauce.

lansoprazole

What mediums can lansoprazole be put in?

• applesauce, yogurt, pudding, juices, lots of things

Answer the following about Zegrid:

• take how long before a meal?

• can be put in what liquid?

• don’t give in what electrolyte imbalance?

• 20 and 40 mg dose have the SAME amount of __________.

  (i don’t think she will ask on this)

• 60 min

• water

• hypernatremia

• SAME amount of Na

Can I crush/chew Vonoprazan?

no

Is sucralfate recommended in GERD? What is an ADR of sucralfate?

• not recommended in GERD

• ADR- constipation

Is Metoclopramide used as monotherapy in GERD? What is the BBW of it? What disease state should I avoid use in?

• not recom as monotherapy

• BBW- TARDIVE DYSKINESIA

• don’t use in parkinson’s

What are some causes of intestinal gas?

• Use common sense 😑

• foods

  • carbs, fruits, veggies, carbonated beverages, dairy products

• swallowing lots of air

• diseases

  • lactose intolerance, IBS, gastroparesis, celiac disease

• meds

  • opioids, cholestyramine, CCB, acarbose/miglitol, fiber

What are some nonpharm tx for intestinal gas?

• Use common sense 😑

• DIET CHANGES!!!

• do not chew gum or suck on hard candy

• avoid smoking

• do not induce burping/farting

• don’t sign, don’t drink outta straws, don’t gulp/sip, don’t lay down after a meal

• avoid tight clothes

• exercise

• avoid drugs that might cause

Is Simethicone FDA approved? Does it RELIEVE or PREVENT gas?

• FDA APPROVED

• RELIEVES gas

Is Activated charcoal FDA approved? Does it RELIEVE or PREVENT gas?

• NOT APPROVED

• NOT EFFECTIVE!!!!!!!!!

Is Alpha-galactosidase FDA approved? Does it RELIEVE or PREVENT gas?

• is a DIETARY supplement—> so not regulated by the FDA/ safety unknown

• PREVENTS gas

DO NOT use alpha-galactosidase in what 2 scenarios?

• mold allergy

• galactosemia

Does lactase enzymes RELIEVE or PREVENT gas? What is it used in?

PREVENTS gas in people that are lactose intolerant

What are some risk factors for PUD?

• H. pylori

• corticosteroids

• cocaine/smoking

• genetics

• NSAIDs

• stress

• bisphosphonates

H. pylori is a gram __________ bacteria that produces _______________.

negative, urease

What are risk factors for NSAID INDUCED ULCERS?

• > 65 YO

• previous ulcer/ anything GI

• anything to do with taking NSAIDs

• concurrent use w/ SSRI, anticoag, antiplatelet, oral bisphosphonate

• alcohol/smoking

Does abdominal pain define an ulcer?

no

What are some tests we can do to diagnose PUD?

• endoscopy

• urea breath test

• antibody detection test

• stool antigen test

For each diagnostic test for PUD, which of them can be used for an initial diagnosis? Which can be used to confirm the cure/eradication of H. pylori?

• KNOW

• endoscopy- diagnostic, confirmation

• urea breath test- diagnostic, confirmation

• antibody detection test- diagnostic, NOT FOR CONFIRMATION OF CURE

• stool antigen test- diagnostic, confirmation

Which diagnostic test for PUD is invasive and not used first?

endoscopy

WHICH DIAGNOSTIC TESTS FOR PUD CAN BE EFFECTED BY PPIs, Bismuth, or antibiotics?

• Know

• endoscopy- yes

• urea breath test- yes

• antibody detection test- NO

• stool antigen test- yes

For the antibody detection test for PUD, you have to make sure that you have not had…

PUD in the past

If I have a penicillin allergy, can I take amoxicillin?

NO (duh)

For treating H. pylori, there are many different treatment options… what are the 2 therapies with a strong recommendation?

• bismuth quadruple therapy

• concomitant therapy

What are the drugs, their dose, and their dosing for the “Bismuth Quadruple Therapy”

• MUST MEMORIZE ALL PARTS FOR THE TEST

• PPI BID

• Metronidazole 250mg QID or 500mg TID-QID

• Tetracycline 500mg QID

• Bismuth subsalicylate 300mg QID (or bismuth subcitrate 120-300mg QID)

(mnemonic: “Please Make Tummy Better”)

(think: quadruple therapy= QID (except PPI no matter the therapy is BID))

What are the drugs, their dose, and their dosing for the “Concomitant Therapy”

• MUST KNOW ALL PARTS FOR THE TEST

• PPI BID

• Clarithromycin 500mg BID

• Amoxicillin 1gm BID

• Metronidazole 500mg BID (or tinidazole 500mg BID)

(mnemonic: “Please Cure Abdominal Misery”)

(think: Concomitant= “co” and all drugs are BID)

A conditional recommendation for H. pylori tx is the “3-drug regimen”. What are the drugs, dose, and dosing of this therapy?

• PPI BID

• Clarithromycin 500mg BID

• Amoxicillin 1gm BID

  OR

• PPI BID

• Clarithromycin 500mg BID

• Metronidazole 500mg TID

A conditional recommendation for H. pylori tx is the “Levofloxacin Triple Therapy”. What are the drugs, dose, and dosing of this therapy?

• PPI BID

• Levofloxacin 500mg once daily

• Amoxicillin 1gm BID

  or

• PPI BID+ amoxicillin 1gm BID for 5-7 days followed by: PPI BID, amoxicillin BID, Levofloxacin 500mg once daily, metronidazole 500mg BID(or tinidazole 500mg for 5-7 days)

What is the duration of tx for all therapies for H. pylori?

10-14 DAYS FOR ALL OF THEM!!!!!! (3-drug regimen is 14 days)

What 2 questions do we need to ask in order to determine what therapy to use for H.pylori?

1. Do you have a penicillin allergy?

2. Do you have previous macrolide exposure?

   (a macrolide is anything with “-mycin” like clarithromycin)

If a patient has NO penicillin allergy and NO macrolide exposure, what tx can we use?

• bismuth quadruple therapy

• concomitant therapy

If a patient has NO penicillin allergy and HAS HAD macrolide exposure, what tx can we use?

• bismuth quadruple therapy

• levofloxacin triple therapy

If a patient HAS a penicillin allergy and NO macrolide exposure, what tx can we use?

• bismuth quadruple therapy

• 3-drug regimen with metronidazole

If a patient HAS a penicillin allergy and HAS HAD macrolide exposure, what tx can we use?

• bismuth quadruple therapy

If you have resistance to macrolides >___% tx as if you have had macrolide exposure.

15

When do you test for H. pylori eradication?

4 weeks after antibiotic completion, and after holding PPI for 2 weeks

For NSAID induced ulcers, what can we use to tx them? What can be used to reduce the risk?

• tx options: PPI, H2RA, sucralfate

  • PPI IS PREFERRED, I REPEAT PPI IS PREFERRED

• reducing the risk: misoprostol, PPI

Does misoprostol cause constipation or diarrhea?

diarrhea

What are some exclusions to self-tx for n/v?

• pregnant/nursing

• not if you have head injury/hit your head

• not if you have glaucoma

• if it’s DRUG INDUCED

  • ex: antibiotics, digoxin, opioids

• others: if severe n/v for >48 hrs, blood in vomit, abdominal pain, high ketones, severe food poisoning for >24 hrs

If you are pregnancy what are some nonpharm and pharm tx?

• NO OTC ANTIEMETIC FOR n/v IS APPROVED FOR PREGNANCY!!!! NONE!!!!!!

• NONPHARM ONLY!!!

  • fresh air

  • eat light/bland food

  • avoid greasy meals

What are some nonpharm ways to prevent motion sickness?

• stay hydrated

• sit by the window

• don’t read/look at screen

• look straight ahead

• don’t eat/drink a lot when traveling

• sit where there’s not much motion

• drive if appliable

• sit in forward-facing seats on bus/train

For nonpharm tx of motion sickness you can use wristbands. What are their names? How many wrists are they put on? Do they have power?

1. Sea-Band- 2 wrists, no power

2. BioBand- 1 wrist, no power

3. ReliefBand- 1 wrist, power

Wristbands for motion sickness are all contraindicated if you have a _____________.

pacemaker

What wristband is made of latex and you need to watch if you have a latex allergy?

ReliefBand

With what wristband should you apply a gel on the arm before use?

ReliefBand

What antihistamines can be used for n/v? What are the main ADRs of antihistamines?

• Meclizine, Dimenhydrinate, diphenhydramine

• ADR- anticholinergic (dry eyes, mouth, urinary retention, constipation)

Answer the following about Scopolamine:

• is it OTC or rx?

• where is the patch applied

• how many hours is it good for?

• rx

• applied behind ear to hairless area

• good for 72 hrs

What are the main ADRs of promethazine?

anticholinergic

Answer the following about Phosphorated Carbohydrate Solution:

• what is it a mixture of?

• What is the max # of doses in 1 hr?

• What disease states should it not be used in?

• Can it be diluted? If so what can it be diluted in?

• How long should you not drink other liquids before/after use?

• mix of fructose, glucose, and phosphoric acid

• max of 5 doses in 1hr

• do not use in diabetes/fructose intolerance

• do not dilute

• do not drink before or 15 min after