DPT IV Exam 3 (tran)

MOA of antacid

neutralizes gastric fluid

MOA of alginic acid

forms highly viscous solution that serves as a protective barrier

what are antacids and alginic acids useful for?

on demand treatment of occasional symptoms

true or false: antacids and alginic acids are typically used for chronic symptoms

false

true or false: addition of alginic acid may be superior to antacids alone

true

what does are best to use of alginic acids?

those ≥ 500mg

DDI of antacids and alginic acids

cation component

tetracyclines, isoniazid, macrolides, quinolones

adverse effects of magnesium antacids

diarrhea

adverse effects of aluminum antacids

constipation

MOA of H2RAs

reversibly bind to histamine H2 receptors on gastric parietal cells

what are H2RAs useful for?

on-demand treatment of occasional symptoms (30 to 60 minutes before trigge prn)

when can tachyphylaxis occur when taking H2RAs?

within 7 to 14 days of continued treatment

consider intermittent use

dosing considerations for H2RAs

dose for OTC products tend to be lower than prescription

may require renal dose adjustment

which H2RA is available IV?

famotidine

which H2RA has significant DDIs?

cimetidine

is an inhibitor of CYP3A4, CYP2D6, and CYP1A2

adverse effects of H2RAs

headache

fatigue

dizziness

constipation or diarrhea

true or false: H2RAs may rarely cause CNS effects such as confusion, agitation, delirum, hallucinations, somnolence, and thrombocytopenia

true

MOA of PPIs

irreversibly inhibits gastric H+/K+ ATPase proton pump in gastric parietal cells

only binds to actively secreting pumps (meals stimulate pump activity)

how long may PPIs take to achieve their full effect?

a few days (~3 days)

when should PPIs be taken?

30 to 60 minutes before breakfast or biggest meal(s) of the day

true or false: the dose for OTC PPIs tend to be higher than prescription

false

what does double dose mean with PPIs?

doubling the dose

±

dosing twice daily

over the counter PPIs

L

lansoprazole

E

esomeprazole

O

omeprazole

what does optimization of PPI therapy include?

double dose

Which of the following PPIs are available over-the-counter (OTC)?

a.Omeprazole

b.Pantoprazole

c.Lansoprazole

d.Esomeprazole

e.Rabeprazole

a, c, d

formulations of PPIs

enteric coated

OR

co-formulated with sodium bicarbonate to avoid degradation from acid

when should enteric coated PPIs be given?

30 to 60 minutes before a meal

in which PPIs are the meal timings not as relevant?

omeprazole-sodium bicarbonate (as it is not enteric-coated)

dexlansoprazole (as it is a dual delayed release PPI)

you should not crush, chew, or split delayed release tablets. which PPIs does this include?

lansoprazole [OTC]

esomeprazole [OTC]

omeprazole [OTC]

pantoprazole

rabeprazole

which PPIs come as an oral suspension?

esomeprazole (packet)

omeprazole (packet)

omeprazole-sodium bicarbonate (powder)

pantoprazole (packet)

which PPIs come as an orally disintegrating tablet?

lansoprazole

which PPIs are available IV?

esomeprazole

pantoprazole

metabolism of PPIs

give 30 to 60 minutes before a meal

prodrugs, activated by acid

undergo cytochrome P450 metabolism (CYP2C19, CYP3A4)

DDIs with PPIs

inhibit CYP2C19, specifically esomeprazole and omeprazole

suppress acid

which PPIs should not be used with clopidogrel?

esomeprazole and omeprazole

when should PPis be used cautiously or avoided with?

concomitant use of medications reliant on acid for absorption or activation

What medications have you learned about that are reliant on an acidic environment for absorption or activation?

calcium

iron

vitamin B12

hepatitis C direct-acting antivirals

highly acting antiretroviral therapy (HAART)

atanazir

rilpivirine

adverse effects of PPIs

with short term use

headache

dizziness

diarrhea, flatulence

nausea

abdominal pain

with long term use

dementia

myocardial infarction

stroke

AKI

CKD

small intestinal bowel overgrowth

GI malignancy

bone fracture

pneumonia

enteric infections including C.diff

spontaneous bacterial peritontis (SBP)

magnesium deficiency

vitamin B12 deficiency

true or false: with short term use of PPIs, side effects tend to be minor

true

true or false: observational studies establish a cause-and-effect relationship

false

true or false: even though there is a risk of AKI and CKD with long-term use of PPIs, you should not routinely monitor serum creatinine

true

true or false: even though there is a risk of bone fracture with long-term use of PPIs, you should not increase calcium intake and should not routinely screen or monitor bone mineral density (BMD)

true

true or false: as there is an increased risk of infection in those with long-term use of PPIs, you should not routinely use probiotics

true

true or false: even though there is a risk micronutrient deficiency in Mg and vitamin B12, you should not increase Mg or vitamin B12 intake and you should not routinely monitor Mg or vitamin B12

true

when should you monitor Mg when taking PPIs long-term?

consider monitoring Mg at baseline and then periodically

regarding the long-term side effects of PPIs, what should be considered?

side effects found are not definitive

balance benefits versus risks, consider de-prescribing as appropriate

when considering reducing or discontinuing PPI therapy, what are things to consider?

conduct a regular review of ongoing indications

if taking a double dose, consider lowering to a standard dose

indication?

when should PPIs not be considered for discontinuation in patients using them for long-term use (> 8 weeks)?

those with:

Barrett’s esophagus

severe (LA grade C or D) erosive esophagitis

esophageal strictures

use of aspirin or NSAIDs at high risk for GI bleeding

Zollinger-Ellison syndrome

Eosinophilic esophagitis

idiopathic pulmonary fibrosis

when should PPIs not be considered for discontinuation in patients using them for short-term use (≤ 8 weeks)?

those with:

uninvestigated GERD or dyspepsia

NSAID-related gastric or duodenal ulcers

Helicobacter pylori eradication

stress ulcer prophylaxis for ICU patients with risk factors

according to guidelines, when patients are taking NSAIDs + PPI, when should you not consider de-prescribing the PPI?

according to ACG

when on NSAIDs + PPI

and

moderate or high risk of upper GI bleeding (≥ 1 of the following: prior ulcer, > 65 years, high-dose NSAID therapy, aspirin use, corticosteroids, or anticoagulants

according to ACP

when on NSAIDs + PPI

and

prior ulcer bleeding on NSAID

according to guidelines, when patients are taking antiplatelet therapy + PPI, when should you not consider de-prescribing the PPI?

*according to ACCF*

when on antiplatelet therapy + PPI

and

history of upper GI bleeding OR

multiple risk factors for GI bleeding (advanced age; concomitant anticoagulant, steroid, or NSAID use; H. pylori infection)

*according to ACCP*

when on antiplatelet therapy + anticoagulant

+ PPI

and

concomitant aspirin and oral anticoagulant use

*according to ACC*

when on antithrombotics + PPI

and

use of ≥ 2 antithrombotic agents

when should PPIs be considered for discontinuation in patients using them for long-term use (>8 weeks)?

those with:

nonerosive reflux disease with no response

functional dyspepsia with no response

use of steroids WITHOUT aspirin or NSAIDs

recurrent GI bleeding from causes other than PUD

erosive esophagitis (LA grade A or B)

when should PPIs be considered for discontinuation in patients using them for short-term use (≤ 8 weeks)?

those with:

empiric treatment of laryngopharyngeal symptomatology

undifferentiated abdominal pain

nausea and vomiting unrelated to GERD or esophagitis

lower GI symptomatology

Which of the following patients has an indication for long-term PPI therapy? Select all that apply (enter each answer in the message field separated by a space).

a.Patient with prior upper GI bleed on naproxen

b.Patient with Barrett’s esophagus

c.Patient with erosive esophagitis, LA grade A

d.Patient with unresponsive functional dyspepsia

e.Patient with esophageal strictures

a, b, e

when considering de-prescribing, when should you?

when there is NO definitive indication

when there is potential for rebound acid hypersecretion (RAHS)

how should de-prescribing of PPIs be done?

limited evidence

counsel patients that they may experience upper GI symptoms at least in the short term

taper OR abruptly discontinue

consider the following to help symptoms in the short term

-on-demand PPIs

-H2RAs prn

-antacids prn

reassess symptoms in 8 weeks

gastro esophageal reflux disease (GERD)

signs and symptoms froms refluxed stomach contents into the esophagus and beyond for ≥ 2 x a week

affects well-being of patient

symptom-based GERD

heartburn, regurgitation, dysphagia

tissue injury-based GERD

esophagitis

Barrett's esophagus

esophageal strictures

esophageal adenocarcinoma

the signs and symptoms of GERD are nonspecific and may overlap with...

cardiac disease

pulmonary disease

other GI diseases such as: rumination syndrome, achalasia, eosinophilic esophagitis, reflux hypersensitivity

typical symptoms of GERD

heartburn

burning sensation; may wax and wane

substernal, rises from upper abdomen up towards

regurgitation

return of gastric contents towards mouth

alarm symptoms of GERD

indicative of complications of GERD

dysphagia (diffiiculty swallowing)

odynophagia (painful swallowing)

bleeding

weight loss

extraesophageal manifiestations of GERD

chronic cough, hoarseness, throat clearing

laryngitis, pharyngitis, pulmonary fibrosis

asthma

Patient is a 42 year old man (72 inches, 150 kg) presenting to his primary care provider with complaints of heartburn that worsens during sleep. He occasionally also experiences backwash of food or sour liquid, especially an hour or so after eating fatty foods and drinking soda. He denies difficulty or painful swallowing or weight loss. He has used famotidine daily (over-the-counter) for the past several months with no sustained relief.

true or false: the patient is presenting with alarm symptoms

false

why may a physical exam be warranted if a patient is suspected to have GERD?

to rule out other diagnoses

upper endoscopy for GERD

evaluates esophageal mucosa for injury and complications

indicated for:

screen for Barrett’s esophagus in high-risk patients

presence of alarm symptoms

persistent or progressive symptoms

reflux monitoring for GERD

wireless telemetry capsule, transnasal catheter

measures pH, acid exposure time, number of reflux events, and symptom correlation

especially useful in patients with symptoms refractory to PPIs

esophageal monometry for GERD

evaluates presence of motor disorders and sphincter pressures

not to be used solely; no abnormality is specific for GERD

nonpharmacologic treatment for GERD may include avoiding food that may precipitate reflux. what foods may this include?

coffee

alcohol

chocolate

high fat content foods

nonpharmacologic treatment for GERD may include avoiding food that may precipitate heartburn. what foods may this include?

carbonated beverages

acidic foods

spicy foods

what behaviors may decrease esophageal acid exposure?

avoid meals or snacks 2 to 3 hours before bedtime

stay upright during and after meals

avoid sleeping right-side down

elevate head of bed by 6 to 8 inches

avoid tight-fitting clothes

lose weight (if applicable)

quit tobacco use

reduce stress

Patient is a 42 year old man (72 inches, 150 kg) presenting to his primary care provider with complaints of heartburn that worsens during sleep. He occasionally also experiences backwash of food or sour liquid, especially an hour or so after eating fatty foods and drinking soda. He denies difficulty or painful swallowing or weight loss. He has used famotidine daily (over-the-counter) for the past several months with no sustained relief.

What are some nonpharmacologic therapies that can be recommended for this patient?

true or false: if possible, you should avoid medications that may worsen GERD symptoms such as those that lower the esophageal sphincter, irritate the esophageal mucosa, or dabigatran

true

what medications lower the esophageal sphincter?

anticholinergics

dihydropyridine CCB

estrogen progesterone

caffeine

nicotine

what medications irritate the esophageal mucosa?

clindamycin

tetracyclines

bisphosphonates

NSAIDs, aspirin

potassium chloride

what is the first-line agent for "classic" GERD with no alarm symptoms?

PPIs

empiric trial of 8 weeks of single-dose PPI therapy

if adequate response, consider double dose OR alternative PPI

true or false: PPIs are superior to H2RAs, especially for moderate to severe GERD

true

true or false: there is no difference in efficacy among the PPI agents, but there is a difference in acid-suppression potency

true

PPIs in order of acid-suppression potency

rabe > esome > ome > lanso > panto

place of therapy of H2RAs in GERD treatment

mild to moderate symptoms

efficacy variable

on-demand symptom relief

adjunctive therapy with PPIs

no difference in efficacy among agents

place of therapy of antacids, antacid-alginic acid products in GERD treatment

mild to moderate symptoms

on-demand symptom relief

adjunctive therapy with PPIs

no difference in efficacy among agents

metoclopramide in GERD managment

accelerates gastric emptying

presence of motor dysfunction

limited by side effects of extrapyramidal effects, tardive dyskinesia

baclofen in GERD management

decreased number of reflux events, nocturnal reflux activity, and belching episodes

add-on to PPI

limited by side effects of dizziness, somnolence, and constipation

sucralfate in GERD management

limited studies

largely unabsorbed, no systemic toxicity

how do you monitor the efficacy of GERD treatment?

~8 week trial

symptoms

mucosal healing

prevention of complications (esophagitis, strictures, Barrett's esophagus, and esophageal adenocarcinoma)

course of therapy if patient presents with typical systems of GERD without resolution

empiric PPI trial x 8 weeks

↓ (if there is partial or no response)

optimize PPI therapy x 8 weeks

↓ (if there is partial or no response)

upper endoscopy ± reflux monitoring

course of therapy if patient presents with typical systems of GERD with resolution

empiric PPI trial x 8 weeks

↓ (resolution of symptoms)

wean to lowest effective dose

what should you do if a patient's symptoms return with discontinuation of PPI or if a patient presents with alarm systems or isolated extra-esophageal symptoms?

upper endoscopy ± reflux monitoring

Patient is a 42 year old man presenting to his primary care provider with complaints of heartburn (worsens during sleep) and regurgitation. He has used famotidine daily (over-the-counter) for the past several months with no sustained relief.

Medication list:

•Atorvastatin 80 mg PO daily

•Aspirin 81 mg PO daily

•Clopidogrel 75 mg PO daily

•Furosemide 40 mg PO daily prn leg swelling

•Metoprolol succinate 25 mg PO daily

•Potassium 20 mEq PO daily

Which of the following medications is likely to precipitate or exacerbate the patient’s GERD symptoms? Select all that apply (enter each answer in the message field separated by a space).

a.Atorvastatin

b.Aspirin

c.Clopidogrel

d.Furosemide

e.Metoprolol succinate

f.Potassium

b,f

Patient is a 42 year old man presenting to his primary care provider with complaints of heartburn (worsens during sleep) and regurgitation. He has used famotidine daily (over-the-counter) for the past several months with no sustained relief.

Explain why famotidine was ineffective.

Patient is a 42 year old man presenting to his primary care provider with complaints of heartburn (worsens during sleep) and regurgitation. He has used famotidine daily (over-the-counter) for the past several months with no sustained relief.

Medication list: atorvastatin, aspirin, clopidogrel, furosemide, metoprolol succinate, potassium

The patient prefers tablets. His insurance does NOT cover empiric PPI therapy. Which of the following is the most appropriate treatment option at this time?

a.Dexlansoprazole

b.Omeprazole

c.Lansoprazole

d.Pantoprazole

c

The patient returns to clinic 2 weeks later with continued complaints of heartburn and regurgitation.

Which of the following is the most appropriate treatment option at this time?

a.No changes, continue same PPI

b.Increase PPI dose from daily to twice daily

c.Switch PPIs

d.Add H2RA

a

The patient has now completed 8 weeks of therapy and is NO longer experiencing any GERD-related symptoms. His past medical history is significant for myocardial infarction and obesity.

Medication list: atorvastatin, aspirin, clopidogrel, furosemide, metoprolol succinate, potassium

Which of the following is the most appropriate treatment option at this time?

a.Continue PPI, the patient has an indication for long-term PPI therapy

b.Discontinue PPI abruptly

c.Increase PPI dose from daily to twice daily

d.Decrease PPI dose from daily to every other day

b, d

peptic ulcer disease

occurs in the stomach duodenum and the ulcer is ≥ 5 mm extending into muscularis mucosa

what are common causes of PUD?

H.pylori

NSAIDs

stress-related mucosal damage

describe the variability of signs and symptoms in PUD

asymptomatic

common signs and symptoms

abdominal pain

heartburn, belching, bloating

nausea, vomiting

anorexia, weight loss

complications

bleeding

perforation

penetration

obstruction

signs and symptoms of PUD caused by H.pylori

symptoms

epigastric pain

GI bleeding

+

site of damage

duodenum > stomach

ulcer depth

superficial

signs and symptoms of PUD caused by NSAIDs

symptoms

asymptomatic

GI bleeding

++

site of damage

stomach > duodenum

ulcer depth

deep

signs and symptoms of PUD caused by stress related mucosal damage (SRMD)

symptoms

asymptomatic

GI bleeding

++

site of damage

stomach > duodenum

ulcer depth

superficial

endoscopic tests for H. pylori

histology

microbiologic examination

gold standard

results are not immediate

biopsy (rapid) urease

urease generates ammonia = color change

rapid results (within 24 hours)