GERD/PUD (NAPLEX)

Patients who have GERD have reduced ____ pressure

lower esophageal sphincter

Diagnosis of GERD is frequency which is ≥ ___ times per week

2

Drugs that can worsen GERD symptoms (10)

BEN AND FIST

Bisphosphonates

Estrogen products

NRT

Aspirin

NSAIDs

Dabigatran

Fish oil

Iron supplements

Steroids

Tetracyclines

OTC exclusions & should be referred (2)

no response to 2 weeks of OTC treatment

Alarm symptoms (odynophagia, dysphagia, n/v, hematemesis, black/bloody stools, unintentional weight loss)

Infrequent heart burn (<2x/wk) treatment (2)

Antacids prn

H2RA prn

GERD TX algorithm *

INITIAL: PPI daily for 8 weeks (can inc to BID if partial response or nocturnal sxs present)

Maintenance: lowest effective dose PPI

ALTERNATIVES: H2RA if no erosive esophagitis and relieves sxs

Do not use metoclopramide or sucralfate

Mylanta Supreme components

Calcium carbonate + magnesium

Maalox Advanced Max Strength components

Calcium carbonate + simethicone

Mylanta Max Strength components

Magnesium hydroxide + aluminum + simethicone

Alka-Seltzer components

Sodium bicarbonate + aspirin + citric acid

Can cause loose stools

A. Calcium

B. Aluminum

C. Magnesium

C. Magnesium (Massive Diarrhea)

calcium and aluminum can cause constipation

_______ containing antacids may be preferred in pregnancy

A. Calcium

B. Aluminum

C. Magnesium

A. Calcium

Antacids warnings (2)

Aluminum and magnesium can accumulate with severe renal dysfunction

Risk of bleeding with aspirin containing products (Alka-Selzter)

Zantac 360 generic

Famotidine

Famotidine renal adjust with CrCl < ___ mL/min

<60

H2RA's can cause confusion in what patients (3)

elderly

critically ill

renally impaired

Cimetidine at high doses can cause ______ and ______

gynecomastia and impotence

PPIs ______ inhibit H/K/ATPase

A. Irreversible

B. Reverisble

A. Irreversible

T/F: If using PPI's for maintenance use the lowest effective dose

True

PPI warnings (4)

C diff

HypoMg

Vitamin B12 deficiency (>2yr)

Osteoporosis (>1yr)

Which PPI's are CYP2C19 and should be avoided with clopidogrel?

Omeprazole

Esomeprazole

Vimovo components

Esomeprazole + naproxen

PPI's available IV (2)

Pantoprazole

Esomperazole

T/F: You can crush PPI tablets

False - Do not crush, cut, or chew tablets or capsules. Only capsules can be opened (not crushed) and mixed in applesauce

PPI's that should be taken 60 min before breaky (3)

lansoprazole

esomeprazole

omeprazole

Which PPI's can be taken without regards to meals (2)

Dexlansoprazole

Pantoprazole TABLET (suspension must be taken 30 mins before meal)

Which PPI oral suspension must be taken 30 minutes before a meal?

Pantoprazole

Write out the H2RA & PPI formulations to know (studygal :()

OTC

ODT

SUSPENSION

INJECTION

When is metoclopramide used for GERD?

Only with coexisting gastroparesis

Metoclopramide MOA

dopamine antagonist. increases motility, accelerated gastric emptying, increase LES tone

Metoclopramide dosing

10-15mg QID 30 min before meals and at bedtime

Metoclopramide is dose reduced by 50% with CrCl < ___ mL/min

<60mL/min to avoid CNS effects/EPS

Metoclopramide BW (1)

Tardive dyskinesia

Metoclopramide warnings (2)

EPS

Parkinsonian like symptoms

What patient population should you avoid metoclopramide in?

Parkinsons

Medications that need an acidic gut & therefore have DDI with our GERD meds (6) studygal

aacdir

Antiretrovirals (NNRTI, PI)

Azoles

Cephalosporins (PO)

Direct acting antivirals (ledipasvir)

Iron products

Risedronate delayed release

Oral drugs that antacids bind to & therefore have DDI with GERD meds (9) study gal

ibilmfsst

INSTI's (BCRED)

Bisphosphonates

Isoniazid

Levothyroxine

Mycophenolate

FQ

Sotalol

Steroids (esp budesonide)

Tetracycline

Which H2RA is a CYP450 inhibitor?

Cimetidine

PUD causes (3)

H. pylori

NSAIDs

Stress (critically ill vented)

What kind of bug is H. pylori?

Spiral shaped gram negative

Where is PUD pain located?

Middle or upper stomach

Eating causes pain

A. H pylori caused PUD

B. NSAID caused PUD

C. Stress caused PUD

B. NSAID caused PUD

Pain is worse 2-3 hours after eating

A. H pylori caused PUD

B. NSAID caused PUD

C. Stress caused PUD

A. H pylori caused PUD

H. Pylori PUD diagnosis (1) & what causes false results (2)

Urea breath test (UBT)

PPIs stop 2 weeks prior

Bismuth and ABX stop 4 weeks prior

H PYLORI PUD TX REG ***

Bismuth Quadruple therapy (preferred and only option for PNC allergy)

“Please take my bacteria”

PPI BID

Tetracycline 500mg QID

Metronidazole 500mg TID or QID

Bismuth 300mg QID

Rifabutin Triple Therapy (Alternative)

Rifabutin 500mg TID

Amoxicillin 1000mg TID

Omeprazole 40mg TID

DURATION 14 DAYS

H. Pylori PUD treatment duration for all regimens is ___ days

14 days

Risk factors for NSAID induced ulcers (5)

>60 yo

Hx of PUD

High dose NSAIDs

Using >1 NSAID

Use of AC, steroids, SSRI, SNRI

TX options for NSAID PUD (2)

Misoprostol

Sucralafate

Misoprostol MOA

Prostaglandin E1 analog that replaces gastroprotective prostaglandins inhibited by NSAIDs

Arthrotec components

Misoprostol + diclofenac

Misoprostol BW

Abortifacient

Sucralafate is taken ____ meals

before

GERD during pregnancy preferred TX

Antacids or sucralfate

Alternative: H2RA

Mod-Sev sxs only: PPI

MOA of PPI's

A. Binds protons released from hydrochloric acid

B. Inhibits active and inactive H+/K+-ATPase pumps

C. Inhibits active H+/K+-ATPase pumps

D. Inhibits histamine-2 receptors on parietal cells

E. Replaces gastroprotective prostaglandins

C. Inhibits active H+/K+-ATPase pumps