NAPLEX: GERD and PUD Needs Review

Patients with gERD have reduced ___ tone, which allows gastric contents to backflow into the esophagus

Lower esophageal sphincter

The big three symptoms of GERD are ___, which must occur at least ___ per week for diagnosis.

Heartburn, hypersalivation, and regurgitation of acidic contents at least twice a week

Patients with alarm symptoms such as these four things should be immediately referred to a physician

Painful swallowing, dysphagia, N/V, blood in the vomit or stool

OTC treatments should only be used for __ weeks. Then the patient should see a physician.

Two weeks

The initial drug treatment of choice is a ___ week course of a PPI

8 week

Which lifestyle modification has the best evidence for improvement of GERD symptoms

Weight loss

If symptoms return after an 8 week course of PPI, what is the next treatment?

PPI or H2RA if no erosive esophagitis and symptoms are relieved

Antacids provide relief within minutes but only last for ___ minutes

30-60 minutes

Many antacids are administered __ times per day

4-6 times per day

MOA of H2RAs

Reversibly inhibit H2 histamine receptors on gastric parietal cells, which decreases gastric acid secretion

This unique side effect can happen in patients taking H2RAs.

What are the risk factors?

Confusion

Risk factors include:

- > 50 years old,

- being severely ill

- having renal/hepatic impairment

You must decrease the dose of famotidine, nizatidine, and ranitidine when CrCl is below...

50ml/min

Which H2RA comes in IV formulations?

- Famotidine

- Rantidine

You must decrease the dose of cimetidine when CrCl is below...

30ml/min

This H2RA should be avoided entirely because of its drug interactions and side effects

Cimetidine

What is the MOA of PPIs

Irreversibly bind to the gastric H/K-ATPase pump in parietal cells, shutting down the proton pump and blocking gastric acid secretion

This PPI can be administered without regard to meals

Dexlansoprazole

This PPI in combination with sodium bicarbonate can control nocturnal symptoms if given at bedtime

Omeprazole (Zegerid)

These two PPIs are the only ones available IV

Pantoprazole and esomeprazole

All PPIs have these three warnings

- C. diff-associated diarrhea

- osteoporisis-related fractures

- hypomagnesemia

You can open capsules and sprinkle them on applesauce for every PPI but this one because it's available in a tablet

Pantoprazole (Protonix)

These two PPIs come in an ODT formulation

- Lansoprazole (Prevacid SoluTab)

- dexlansoprazole

The Beers list recommends against using PPIs in elderly patients beyond __ weeks unless there is a clear indication

8 weeks

Metoclopramide (Reglan) MOA?

-Dopamine antagonist -> stimulates motility of upper GI tract

-Enhances Ach in tissues in upper GI tract -> enhanced motility and gastric emptying

-Blocks serotonin receptors for anti-emetic action

Accelerates gastric emptying

These two agents are often used for GERD when patients have coexisting gastroparesis

- Metoclopramide (Reglan)

- erythromycin

Metoclopramide (Reglan) has a black boxed warning about ________ and should not be used for more than ___ weeks

- Tardive dyskinesia

- 12 weeks (3 months)

Metoclopramide (Reglan) is dosed QID when?

BEFORE meals and at bedtime

These are the main three side effects of metoclopramide (Reglan)

- Drowsiness

- restlessness

- fatigue

Metoclopramide (Reglan) dose should be decreased by 50% when the CrCl is less than...

< 40ml/min

Avoid use of metoclopramide (Reglan) in patients with this disease, which is related to the boxed warning

Parkinson's disease

Enteric-coated and delayed-release products require acidic/non-acidic environments for absorption

Acidic

It is important to avoid H2RAs or PPIs at any time with these three agents among others

risedronate delayed release (Atelvia), rilpivirine, Epclusa (velpatasvir/sofosbuvir)

For medications that can chelate with antacids, you should typically avoid antacids __ hours before or ___ after the chelating agent

2-4 hours before or 2-6 hours after

These 8 sets of medications require acidic gut for proper absorption

Delavirdine, rilpivirine, and atazanavir antiretrovirals

Antivirals ledipasvir and Epclusa

Azole antifungals itraconazole, ketoconazole, and posaconazole oral suspension

PO cephalosporins: cefditoren, cefpodoxime, cefuroxime

Iron products

Mesalamine

Delayed-release risedronate

Tyrosine kinase inhibitors

These 9 sets of medications can chelate with antacids

INSTIs: dolutegravir, elvitegravir, raltegravir

Bisphosphonates

Isoniazid, mycophenolate

Quinolones

Sotalol

Steroids

Tetracyclines

Thyroid products

Using H2RAs with CNS depressants is cautioned against because of additive risk of ___, especially in the elderly

Delirium, dementia, cognitive impairment

This H2RA is a moderate inhibitor of CYP450 2C19

Cimetidine

What side effects can cimetidine cause?

- Gynecomastia

- Impotence

All PPIs inhibit CYP2C19, with __ and __ being the strongest inhibitors. Do not use any PPIs with this medication

Omeprazole, esomeprazole; nelfinavir

What is peptic ulcer disease, and what are the symptoms?

Mucosal erosion within the GI tract that causes ulcers that extend deep into the mucosa. Dyspepsia, gastric pain in the middle or upper stomach

What are the three main causes of PUD?

Helicobacter pylori, NSAID-induced ulcers, and stress ulcers that occur in critical illness and ventilated patients

H. pylori is this shape and gram positive/negative

Spiral-shaped gram negative

If an ulcer is duodenal (usually caused by H. pylori), eating will alleviate/aggravate symptoms.

If the ulcer is gastric (primarily NSAIDs), eating will alleviate/aggravate pain

Duodenal = H. pylori = food alleviate

Gastric = NSAIDs = food aggravate

In order to do a urea breath test to determine the presence of H. pylori, these three medications must be discontinued for two weeks prior

Why?

- PPIs

- bismuth

- antibiotics

They will cause a false negative breath test (esp PPIs)

This type of therapy is recommended first line for H. pylori treatment

Quadruple therapy

Triple therapy for H. pylori can only be used if clarithromycin resistance rates are <__

15%

What are the four components of quadruple therapy including dosing?

- PPI BID (or Nexium 40mg QD)

- Bismuth subsalicylate 300mg QID

- Metronidazole 250-500mg QID

- Tetracycline 500mg QID

tx duration x 10-14 days

What are the four components of concomitant therapy, which is an alternate first-line treatment to quadruple therapy

- PPI BID or Nexium 40mg QD

- Amoxicillin 1,000mg BID

- Clarithromycin 500mg BID

- Metronidazole 250-500mg QID

tx duration x 10-14 days

What is included in triple therapy?

- PPI BID (or Nexium 40mg)

- Amoxicillin 1,000mg BID

- Clarithromycin 500mg BID

If a patient has a penicillin allergy, what do you do with the triple therapy regimen?

Replace amoxicillin with metronidazole TID

Tx duration x 14 days

What are the five risk factors for NSAID-induced ulcers?

Over 60 years old, history of PUD, high-dose NSAIDs, using more than one NSAID, and concimittant anticoagulants, steroids, or SSRIs

This NSAID selectively inhibits COX-2, which decreases GI risk, but increases cardiovascular risk

Celecoxib

These four NSAIDs are closer to the selectivity of celecoxib but aren't as detrimental as far as cardiovascular disease is concerned

Meloxicam, nabumetone, diclofenac, and etodolac

What does Maalo contain?

Aluminum

Mg hydroxide

What happens in pt taking Maalox with poor renal funtion?

Accumulation which results in toxicities:

- Aluminum - neurotoxin

- Mg hydroxide - arrhythmias and seizures

NSAIDs should be used in caution in any person with these two diseases

Cardiovascular or renal disease

Avoid non-selective and COX-2 selective NSAIDS in patients with...

High GI and high CV risks

How do you treat an NSAID induced ulcer?

PPI for 8 weeks and discontinue NSAIDs

What is Yosprala?

Aspirin + omeprazole

Allows patients with hx of NSAID ulcers to still take aspirin for CV health

Misoprostol has a black box warning for this

Abortifacient - causing abortion

Avoid in women of child bearing potential

What are the two main side effects of misoprostol

- Diarrhea

- abdominal pain

How does sucralfate work?

Binds to the surface of the ulcer (attaching to exposed proteins) and coats the ulcer.

Protects the ulcer and prevent further injury by acid and pepsin

Is sucralfate taken before or after meals?

Before

What is the main side effect of sucralfate? Keep in mind that it is an aluminum complex

Constipation

Magnesium-containing antacids can cause ___, while aluminum-containing antacids can cause ___

Magnesium = diarrhea

Aluminum = constipation

Milk of Magnesia (MOM)

saline laxative and an antacid

What ingredient in antacid causes constipation?

- Al

- Ca

The use of PPI in hospital can increase risk of?

PNA

What is the problem with short term use PPI?

Long term use?

- Short-tern use: PNA

- Long-term use: fractures

In pt with high risk of GI bleed, but must take an NSAID, should take _______ PPI concomitantly?

PPI

_________ for pain has the lowest CV risk for pt with hx of cardiac disease?

Naproxen

Celecoxib (Celebrex) should not be used in?

- hx of CVD

- allergy to sulfa

which PPI are IV

- esomeprazole (Nexium)

- pantoprazole (Protonix)

What are the counseling points for PPIs?

- Take before meal

- Take on regular bases (does not work well on a prn basis)

- QD: taken before breakfast

- BID: before breakfast and dinner

Pylera

Bismuth subcitrate potassium, metronidazole, and tetracycline

Counseling points:

- Alcohol should not be used during tx or 3 days afterwards

- PPI should be used BID

- Excessive diarrhea, contact PCP

______ is a poor choice to use in patient with Parkinson Disease

Meoclopramide (Reglan) is a dopamine antagonist

Will worsen Parkinsons syndrome

Should decrease 50% in dose when CrCl <40

Which class is the most potent of acid-supressing agents?

PPIs