EXAM 2 COMBINED

“upper” GI refers to what?

lips to duodenum

Peptic ulcer disease

ulcers formed in the muscular mucosa in the wall of the GI tract

Main causes of peptic ulcer disease

• helicobacter pylori infection

• use of non-steroidal anti-inflammatory drugs (NSAIDS)

• stress-related mucosal damage (physiologic stress)

What plays an important role in maintaining the layers of mucosa protection?

prosteglandin

3 factors of mucosa protection

• mucus secretion

• bicarbonate secretion

• microcirculation

microcirculation

takes away the damaging things & brings in repair cells

mucus secretion

thin membrane to protect epithelial cells

bicarbonate secretion

neutralizes acid before it gets to the cells

What is the root cause of ulcers?

helicobacter pylori

Where does H. pylori reside?

between mucus layer and surface epithelial cells

How is H. pylori transmitted?

fecal-oral & oral-oral

First line for H. pylori eradication

optimized bismuth quadruple therapy

optimized bismuth quadruple therapy has how many drugs in it?

4

Helidac + PPI

optimized bismuth quadruple therapy

Pylera + PPI

optimized bismuth quadruple therapy

What is inside of Helidac + PPI & Pylera + PPI?

• bismuth (subsalicylate or subcitrate)

• metronidazole

• tetracycline

What properties do the two components of optimized bismuth quadruple therapy drugs have?

antibiotic and an acid-blocker

What do NSAIDS do?

decrease production of prostaglandins

Why can using NSAIDS be dangerous?

it decreases the production of prostaglandins we do want such as bicarbonate, mucosa, and microcirculation

What is GERD?

retrograde flow of stomach contents back into esophagus

What is the most common GI disorder among adults in the U.S.?

GERD

What does the lower esophageal sphincter control?

controls the flow of stomach material

Typical signs & symptoms of GERD

• heartburn

• acid regurgitation

• belching

• abdominal bloating

• early satiety

• nausea

Common lifestyle modifications for GERD

• lose weight

• smaller meals & avoiding low-fat food

• avoid acidic food & beverages

• avoid laying down for 2-3 hours after eating

• smoking cessation

• elevate head of bead

• avoid tight clothing

antacids (types)

• aluminum hydroxide

• magnesium

• calcium carbonate

• sodium bicarbonate

• combinations

antacids

upper GI drug

Antacids MOA

neutralize gastric acid so it causes less damage

Onset of action for antacids

rapid (immediate relief)

Duration of action for antacids

20-40 min if fasting, up to 3 hours if taken after meals (SHORT)

ALternaGEL

aluminum hydroxide

Amphojel

aluminum hydroxide

aluminum hydroxide

upper GI drug

ADRs for aluminum hydroxides

• constipation

• phosphate depletion (helps bone mineralization)

• osteoporosis

• hyperaluminemia (in renal insufficiency)

magnesium

upper GI drug

ADRs for magnesium

• diarrhea

• hypokalemia

• hypermagnesemia (in renal insuffiency)

Tums

calcium carbonate

Chooz

calcium carbonate

calcium carbonate

upper GI drug

ADRs for calcium carbonate

• calcium stone formation

• acid rebound (body releases more acid)

• milk-alkali syndrome (too much calcium)

Alka-Seltzer

sodium bicarbonate

baking soda

sodium bicarbonate

Which of the 4 classes of antacids are systemically absorbed?

sodium bicarbonate

ADRs for sodium bicarbonate

• systemic alkalosis

• acid rebound

• sodium overload

Rolaids

calcium carbonate + magnesium hydroxide (combinations)

Mylanta, Maalox

magnesium hydroxide + aluminum hydroxide

Common drug-drug interactions of antacids

• direct complexation

  • tetracycline

  • bisphosphonates

• increased gastric pH decreases absorption

  • ketoconazole

  • iron supplements

Patient education for taking antacids

• take 1 and 3 hours after meals and at bedtime

• take 1 hour before or 2 hours after other medications

• shake liquid preps before each dose

• refrigerate liquids to minimize bad taste

• no calcium antacids with milk or vitamins

• chew tablets completely

What is alginic acid added to?

antacid

Gaviscon

antacid + alginic acid (aluminum & magnesium antacids)

How do alginic acids work?

forms a foam that floats on the liquid present in the stomach

Types of drugs that decrease gastric acid production

• histamine2-receptor antagonists (H2RA)

• proton pump inhibitors

What is alginic acid used for?

control of reflux symptoms

nizatidine (Axid)

H2RAs

cimetidine (Tagamet)

H2RAs

famotidine (Pepcid)

H2RA

famotidine (Zantac 360)

H2RA

MOA of H2RA

decreases the histamine-mediated release of acid from the gastric parietal cells by about 70%

ADRs of H2RAs

• hormonal ADRs with Tagamet

  • antiandrogenic effects and prolactin activity

  • menstrual irregularities & gynecomastia

-prazole

PPIs

MOA of PPIs

produce profound and long-lasting decrease in gastric acid through inhibition of the enzyme responsible for secreting gastric acid

PPIs decrease gastric acid secretion by how much?

80-95%

Long term risks with PPIs

• pneumonia

  • gastric acid won’t kill bacteria in stomach anymore and it can be aspirated

• osteoporosis

Vonoprazan

novel PPI

Carafate

miscellaneous upper GI drug

upper GI drugs

• antacids

• H2RAs

• PPIs

• Carafate

• Simethicone

• anticholinergic agents

• serotonin antagonists

• dopamine antagonists

• cannabinoids

• corticosteroids

• neurokinin antagonists

MOA of Carafate

forms a protective barrier at the ulcer site (needs pH <4)

ADRs of Carafate

constipation (bc it has aluminum)

Cautions for using Carafate

renal failure

Mylicon

simethicone

Gas-X

simethicone

Mylanta Gas

simethicone

MOA of simethicones

defoaming agent used to relieve intestinal gas (prevents formation of large gas bubbles)

What negative effects come with increased vomiting?

• dehydration

• metabolic alkalosis

• loss of electrolytes

• esophageal damage

Drug classes for anti-emetics

• anticholinergic agents

• serotonin antagonists

• dopamine antagonists

• cannabinoids

• corticosteroids

• neurokinin antagonists

Uses for anticholinergics

• simple nausea

• motion sickness

Transderm-Scop

anticholinergic

Antivert

anticholinergic

Dramamine

anticholinergic

-setron

serotonin receptor antagonists

Uses of serotonin receptor antagonists

• acute nausea and vomiting

• chemotherapy-induced nausea and vomiting

Phenergan

dopamine antagonist

Reglan

dopamine antagonist

Uses for dopamine antagonists

• acute nausea and vomiting

• good general-purpose drugs

Why don’t we typically use dopamine antagonists?

the side effect (abnormal involuntary reactions) can be irreversible

Marinol

cannabinoids

Cesamet

Cannabinoids

Uses for cannabinoids

• mild-moderate nausea with minimal vomiting (constant nausea)

• less effective in most patients

Decadron

corticosteroid

Solu-Medrol

corticosteroid

Uses for corticosteroid

• chemotherapy-induced nausea and vomiting

• post-surgical nausea and vomiting (cannot use for more than a few days)

Emend

neurokinin antagonist

Uses for neurokinin antagonist

• chemotherapy-induced nausea and vomiting

• post-surgical nausea and vomiting

Which has less side effects, corticosteroid or neurokinin antagonist?

neurokinin antagonist

What is considered lower GI anatomically?

colon and down to rectum

Drugs that commonly cause constipation

• opioids

• calcium channel blockers

• iron supplements (pregnancy)

• antacids with aluminum

• anticholinergics

Red flag symptoms of constipation

• blood in stool

• weight loss

• fever

• anorexia

• nausea and vomiting

Classes of laxatives

• bulk forming

• stool softeners

• stimulants

• osmotic

• lubricants

Metamucil

bulk forming laxative

Citrucel

bulk forming laxative

FiberCon

bulk forming laxative