Chapter 59: Peptic Ulcer Disease & GERD

What is Gastroesophageal reflux disease (GERD)?

chronic condition characterized by persistent heartburn

What is the process of GERD?

1. Results when acidic stomach contents enter esophagus

2. lower esophageal sphincter weakening or relaxation occurs

3. decreased salivary secretions

4. diminished esophageal motility

What are the etiologic risk and factors associated with peptic ulcer disease?

1. infection w/ Helicobacter pylori

2. close family history of PUD

3. use of drugs

   • glucocorticoids, NSAIDs, platelet inhibitors

4. smoking tobacco

5. consumption of beverages and foods w/ excessive caffeine

6. excessive psychologic stress

What are the goals of PUD pharmacotherapy?

• relieve symptoms

• promote healing of ulcer

• prevent complications

• prevent future recurrence

What are key factors to be able to achieve the goals of PUD pharmacotherapy?

1. eradicate H. pylori

2. discontinue NSAID/other ulcer-promoting meds when possible

Whare are the major drug classes in GERD & PUD pharmacotherapy?

1. Proton pump inhibitors (PPIs)

2. H2-receptor antagonists

3. antacids

4. miscellaneous drugs

What are risk factors for H. pylori?

1. domestic crowding

2. unclean water

3. exposure to gastric content of an infected individual

What is the goal in the pharmacotherapy of H. pylori infection?

1. kill bacteria while minimizing emergence of resistance

2. PPI or histamine 2 receptor antagonist use

   *eradication rates = good w/ 10 day course AB, 14 day course AB= slightly better

What is the mechanism of action of PPIs?

• reduces acid secretion in stomach by binding to H+,K+, ATPase

• inhibits final pathway involved in acid secretion and active proton pumps

What are examples of PPIs?

1. omeprazole

2. esomeprazole (Nexium)

3. lansoprazole (Prevacid)

4. pantoprazole (Protonix)

   1. ^can be given IV

What is the therapeutic classification and use of omeprazole (Prilosec)?

• antiulcer drug

• OTC = relief of heartburn

  • prx = short-term (4-8 weeks) for active duodenal & gastric ulcers, GERD, or maintenance of erosive esophagitis

• should be taken 20-30 mins BEFORE 1st major meal of day (due to it being activated by food)

What are the adverse effects of PPIs?

*usually minor

1. headache

2. nausea

3. diarrhea

4. rash

5. abdominal pain

*DR Omeprazole = higher risk of C. diff in hospitalized pt’s

What are the drug interactions of PPI’s?

Warfarin

• may increase likelihood of bleeding

What is the mechanism of action of H2-receptor antagonists?

Blocks h2 receptors of parietal cells in stomach

• this decreases acid production

What are examples of H2-receptor antagonists?

1. famotidine (PepcidAC)

2. cimetidine (Tagamet)

What is the therapeutic classification and use of famotidine (PepcidAC)?

• antiulcer drug

• USE:

  • duodenal and gastric ulcers

  • acute stress-induced bleeding ulcers

  • hypersecretory conditions in hospitalized pt’s

  • Heartburn

  • GERD

What are the drug interactions of H2-receptor antagonists?

• Antacids should NOT be given w/in 1 hour of H2-receptor antagonists

• smoking decreases effectiveness

What is the mechanism of action of antacids?

• reacts w/ gastric acid = neutral salts/salts of low acidity

• reduces destruction of gut wall by neutralizing acid

• Caution in use w/ renal impairment

What are some examples of antiacids?

1. aluminum hydroxide (AlternaGel)

2. calcium carbonate (Titralac, Tums)

3. calcium carbonate w/ magnesium hydroxide (Rolaids)

4. Sodium bicarbonate (Alka-Seltzer)

5. magnesium trisilicate & Aluminum hydroxide (Gaviscon)

6. magnesium hydroxide & Aluminum hydroxide w/ simethicone (Mylanta)

What are the different types of antacids and their disadvantages ?

1. Sodium - fluid retention

2. Magnesium - fatigue, hypotension, dysrhythmias, interact w/ laxatives

3. Calcium - constipation, aggravated kidney stones, milk-alkali syndrome

4. Aluminum - constipation, hypophosphatemia

5. Bicarbonate - metabolic acidosis, bloating, belching

What are 2 miscellaneous drugs use for PUD & GERD?

1. bismuth compounds (Kaopectate, Pepto)

2. sucralfate (Carafate)

What is the mechanism of action of bismuth compounds?

• stimulates mucosal bicarb and prostaglandin production

• inhibits H. pylori from attaching to tissue

• NOT used for kids if salicylate is contained

• CAN cause black stools!

What is the mechanism of action of sucralfate ?

• stimulates mucus, bicarb, and prostaglandin secretion

• creates effective protective barrier (up to 6 hours)

• requires 4 daily dosing @ each meal & bed time

• CAN cause constipation

• MAY interfere w/ sucralfate