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GI
Exam 1: GERD/PUD
| Question | Answer |
|---|---|
| Dyspepsia definition? | General term for symptoms from gastroduodenal region |
| When should episodic heartburn conditions raise the alarm for GERD? | If it occurs 2+ times per week |
| Pathophysiology of GERD? | Ineffective reflux barrier at esophageal junction, caused by either defective sphincter, IA pressure, reduced mucosal resistance, or abnormal clearance of GI fluids |
| What are the alarm symptoms for GERD that would require evaluation by a provider? | Dysphagia, odynophagia (pain swallowing), hematemesis, unexpected/unexplained weight loss, Dark stools (with heartburn) |
| Risk factors for GERD? | Age 50+, pregnancy, obesity, tobacco use, comorbidities (resp disease, depression, fatty liver) |
| Food triggers for GERD? | Tomatoes, spicy foods, alcohol, Citrus, garlic, coffee, carbonation, fatty meals, chocolate, etc |
| Medication triggers for GERD? | Anticholinergics, barbiturates, D-CCBs, estrogen/progresterone, nicotene, cycline antibiotics, NSAIDs, bisphosphonates, Iron/potassium supplements |
| What is the first line tx for GERD? | PPIs, assuming patient has NO alarm symptoms |
| How long is an adequate trial for PPIs? | 8 weeks |
| When would an upper endoscopy be ordered for GERD? | If alarm symptoms are present OR if failure after 8 week PPI trial |
| Goals of therapy for GERD? | Alleviate symptoms/reduce frequency Improve QOL Promote healing of mucosal injury Prevent complications |
| What are the exclusions for self care in GERD? | Heartburn 4+ times per month Heartburn continues after 2 weeks of H2RA or PPI tx Alarm symptoms Continuous N/V/D Radiating pain Children less than 2 |
| Med classes available for GERD? | PPIs H2RAs Antacids Coating agents |
| How many days a must heartburn occur to be classified as GERD? | 2+ days per week, otherwise it is episodic |
| In what severities of heartburn would we recommend non-pharm tx? | In all severities |
| At what point would PPIs be indicated for heartburn? | If it is GERD (2+ days per week with heartburn) + H2RA as needed |
| What would be indicated for mild heartburn? | Lifestyle + antacid or LOW dose H2RA |
| What would be indicated for moderate heartburn? | Lifestyle + antacid or HIGH dose H2RA |
| What is the general treatment algorithm for GERD? | Start with lifestyle changes and 8 weeks of PPI use, stop tx at 8 weeks, if symptoms return, start maintenance therapy with PPI at lowest effective dose |
| When should PPIs be taken? | Before a meal, 30-60 min |
| When would we use a PPI as BID? | If extraesophageal symptoms are also present with GERD OR if patient is not responding to QD dosing |
| Should an H2RA be used in those with erosive esophagitis? | Generally not, PPI is preferred. |
| What is the max duration of PPI use for SELF-CARE? | 2 weeks |
| When do the ACG guidelines recommend d/c PPIs? | If the patient doesnt have esophagitis or Barrett's esophagus, then we should attempt to d/c the PPI |
| Say you follow the guidelines and d/c a PPI in a patient, and their symptoms re-occur? What should you do? | Consider PRN PPI use with lowest effective dose Trial a step down with H2RA |
| Say you have a GERD patient who is not adequately responding to a PPI after 8 weeks, what do you do? | Either try a different PPI drug OR try BID dosing |
| What should you do if a patient is having persistent nocturnal symptoms of GERD? | Consider BID dosing OR consider adding bedtime H2RA |
| What would be examples of pro-kinetic agents used in GERD? | Metoclopramide Erythromycin |
| Do the guidelines recommend pro-kinetic agents? | No, unless there is evidence of gastroperesis |
| Do the guidelines recommend sucralfate for GERD? | No, unless the patient is pregnant |
| Do the guidelines recommend baclofen for GERD? | There are no instances where it is recommended |
| How fast do antacids like Tums take to work? | Less than 5 minutes |
| Onset time for H2RAs? | 30-45 minutes |
| Onset time for PPIs? | 1-3 hours |
| When are antacids indicated? | PRN for mild-moderate, episodic heartburn, for relief with certain meals |
| Which antacids are preferred in pregnancy? | Calcium based antacids, aka Tums |
| Which antacids contain aluminum? | Gaviscon, Maalox, Mylanta |
| Which antacoids contain sodium bicarb? | Alka-seltzer products |
| Which antacid contains aspirin? | Alka-Seltzer original |
| Which antacid ingredients cause constipation? | Calcium and aluminum |
| Which antacids can cause diarrhea? | Magnesium containing products |
| When would we recommend against Alka-seltzer original? | In patients with: Allergy to salicylates High bleeding risk Children under 18 with recent live vaccine or flu symptoms |
| Which meds should be separated with antiacids? | Tetracyclines, FQs, Levothyroxine, Anti-retrovirals, bisphosphonates, mycophenolate, sotalol, separate by 2-4 hours |
| Indication for H2RAs? | Mild-moderate episodic heartburn |
| Which drugs would fall into the H2RA category? | Cimetidine, Famotidine, Nizatidine |
| Which H2RA has an IV formulation? | Famotidine |
| Why are H2RAs not recommended for long term daily/maintenance use? | Tachyphylaxis after 2 weeks of scheduled use |
| ADRs of H2RAs? | CNS symptoms (headache, sedation, depression, agitation, confusion) Cimetidine can cause antiandrogenic effects |
| Which medications can lower platelets and WBCs? | H2RAs |
| Which GERD medication is particularly concerning in terms of DDIs? Why? | Cimetidine, inhibits CYP1A2, 3A4, 2C19, 2D6, has a LOT of interactions |
| Should PPIs be used for immediate relief of heartburn? | No |
| Short term ADEs of PPIs? | Headache, abdominal pain/nausea, diarrhea/constipation, flatulence, rebound hypersecretion |
| What are the serious ADRs for PPIs? | Acute interstitial nephritis, DILE (drug induced lupus erythematosus IV pantoprazole: Thrombophlebitis, severe skin rash, SJS/TEN |
| Which drug class should NOT be used for immediate relief of heartburn? | PPIs |
| Which medication for GERD/PUD has a dual delayed release formulation? | Dexlansoprazole |
| How would you counsel a patient on when to take their PPI? | Before breakfast OR before the biggest meal of the day, never take with food |
| For most PPIs they shouldnt be taken PRIOR to meal and not with meals, what are the exceptions to this rule? | Dexlansoprazole or any enteric coated tablet formulation |
| Should PPIs be chewed? | No, but they can be sprinkled into apple sauce or juice |
| Based on the meta-analysis used in the ACG guidelines, what is a proven long term risk of PPI use? | Enteric infections |
| Which GERD medications are inhibitors of CYP-2C19? Why is this important to know? | Omeprazole and esomeprazole, can decrease elimination of phenytoin, warfarin, diazepam, and carbamazepine |
| The ACG guidelines recommend AGAINST routine monitoring for what during PPI use? | BMD, SCr, Mg, Vitamin B12, |
| In what situations would monitoring be appropriate for Mg or B12? | For patients on high doses or >1 year of therapy |
| In what situations would monitoring for bone density be appropriate? | If the patient has other risk factors for osteoporosis or bone fractures |
| Aside from potential effects on CYP enzymes, what is another potential cause for DDIs in GERD medications? | May lower absorption of drugs that require acidic pH in the stomach |
| What would be the restrictions of GERD medications in pregnant patients? | No restrictions on PPIs or H2RAs For antacids, use calcium based |
| In pediatrics, how would we deal with GERD? | Must be 12+ months old, try non-pharm first, if non-pharm doesnt help, PPI is first-line |
| Which GERD medications are preferred in geriatrics? Why? | PPIs are preferred, since H2RAs and pro kinetic drugs like metoclopramide have CNS side effects |
| Common causes for PUD? | H pylori, NSAIDs, Stress-related mucosal damage (SRMD) |
| Risk factors for PUD? | Smoking, alcohol use, gastric hypersecretion, non-adherence to medicatons |
| What would be the potential complications of PUD? | Upper GI bleeds, perforation, gastric outlet obstruction |
| What symptoms of PUD would help differentiate it from GERD? | In PUD, pain will be relieved AFTER meals, no acid regurgitation, feelings of abdominal fullness or cramping |
| Which patients should be tested for H pylori? | Pretty much any patient with active PUD, a history of PUD, gastric cancer, or MALT lymphoma |
| Non-pharm treatments for PUD? | Decrease smoking/drinking, stress reduction (controversial) |
| Risk factors for H pylori? | Close contacts within household Low income status Living in developing country |
| Potential complications of H pylori infection? | PUD (most common complication) MALT lymphoma, Gastric cancer (both of which are rare) |
| Pros and cons of Endoscopic tests for H pylori? | Pros: Better able to distinguish active vs eradicated H pylori Cons: expensive, invasive, requires mucosal biopsy |
| Pros and cons of non-endoscopic tests for H pylori? | Pros: less invasive/expensive, more convenient Cons: Less likely to differentiate active vs eradicated |
| When should confirmation of eradication be done for H pylori? | 4 weeks after finishing ABs AND 2 weeks after stopping PPIs |
| What would be some examples of Non-endoscopic tests for H pylori? | Urea breath test Fecal antigen Anti-body detection |
| What is the test of choice to confirm post-treatment cure of H pylori? | Urea breath test |
| Which non-endoscopic tests can be negatively affected by use of antibiotics or GERD meds? | Fecal antigen and urea breath test |
| Which non-endoscopic test does NOT confirm active or cured? | Antibody detection |
| What is the gold standard test for DIAGNOSIS of H pylori infection? | Endoscopic test with biopsy |
| What is the first line therapy regimen for H pylori? | BQT (Bismuth Quadruple Therapy), Includes PPI, metro, tetracycline, bismuth for 14 days (remember Please Make Tummy Better) |
| Which H pylori regimen is able to be used in a true penicillin allergy? | BQT |
| What are the dosing frequencies for BQT? | PPI - BID Metro- TID-QID Tetracycline- QID Bismuth- QID |
| For the agents in BQT, when should they be taken? | Antimicrobial agents: With meals + bedtime PPI: 30-60 min before meal |
| How would you change BQT in a patient with a salicylate allergy? | Switch from bismuth subsalicylate to bismuth subcitrate |
| What are the other first line regimen options for H pylori? | Rifabutin triple therapy PCAB dual therapy PCAB triple therapy |
| What would an alternative regimen if none of the first line options were viable (for H pylori)? | Levofloxacin triple therapy |
| What are the treatment durations for all 4 of the first line regimen options for H pylori? | They are all 14 days |
| What is Rifabutin triple therapy regimen? | Omeprazole 40, Amoxicillin 1g, Rifabutin 50mg, all taken TID |
| What is the PCAB dual therapy regimen? | Vonoprazan 20 mg BID + Amoxicillin 1g *TID |
| What is the PCAB. triple therapy regimen? | Vonoprazan 20 + Amoxicillin 1 *BID + Clarithromycin 500 BID |
| Say you dont have antibiotic susceptibilities for an H pylori infection, what antimicrobials should not be used? | Clarithromycin and levofloxacin, do not use unless you have susceptibilities |
| When treating H pylori, why are PPIs preferred over H2RAs? | PPI use shows a higher eradication rate vs H2RAs. |
| Say you like a certain drug regimen for H pylori treatment, but you want to swap out one of the drugs in that regimen, is this allowed? | NO, do not substitute any drugs within a regimen |
| What should you do if a patient has a penicillin allergy and failed BQT therapy? | Consider allergy testing, refer to gastroenterologist |
| When should a patient be referred to a gastroenterologist for H pylori? | If they failed any of the first line tx regimens |
| What is the levofloxacin triple regimen? | PPI BID + Levo 500 QD + (Amoxicillin 1g BID OR Metro 500 BID) |
| ADRs of bismuth preparations? | Black stool/tongue Increased risk of bleeding/bruising |
| MOA of Vonoprazan? | PCAB (Potassium competitive acid blocker), inhibits H+/K+ ATPase by competing at K+ site, more potent than PPIs |
| Which antibiotics can cause metallic taste? | Metro and Clarithromycin |
| Mechanisms of NSAID induced ulcers? | NSAIDs act as topical irritants They systemically inhibit COX-1 |
| Risk factors for NSAID induced ulcers? | Age > 65, h/s of PUD, high dose NSAIDs, using multiple NSAIDs, Selection of NSAID (non-selectives), aspirin (even low dose) |
| Concomitant use of what drugs can increase risks of NSAID-induced ulcers? | Low dose aspirin, oral bisphosphonates, corticosteroids, anticoagulant/antiplatelet agents, SSRIs |
| What is the treatment for NSAID induced ulcers? | PPI daily for 8 weeks + stop offending NSAID *also test for H pylori |
| Once NSAID induced ulcers are resolved, can a patient resume their NSAIDs? | Only if it is required and it must be continued with a PPI or another GERD agent (like Misoprostol) Or try a COX-2 selective drug |
| MOA of misoprostol (Cytotec)? | analog of prostaglandin E1, increases mucosal blood flow + stimulates gastric mucous/bicarb secretion |
| Common ADRs of misoprostol? | Abdominal cramping and diarrhea |
| BBW for misoprostol? | Uterine rupture (dont use in pregnant patients, requires pregnancy testing + contraception) |
| How can we void DDIs with sucralfate? | Give interacting medication 2 hours before or 4 hours after sucralfate Avoid with FQs |
| Most common ADR with sucralfate? | Constipation |
| Caution should be taken when using sucralfate in what patient populations? Why? | Those with renal failure, may cause accumulation of aluminum and cause seizures |
| For stress-related mucosal bleeding prophylaxis, what agents should be used? | Either a low dose PPI or H2RA, do not use sucralfate |
| What are the main indications for stress ulcer prophylaxis? | Coagulopathy, chronic liver disease, shock |
| What are the subtypes of Upper GI bleeds? | Variceal - Associated with cirrhosis Nonvariceal- chronic peptic ulcers or SRMD |
| What is the main pharmacologic treatment for Upper GI bleeds? | High dose PPI for 3 days after endoscopic treatment, then continue PPI for 2 weeks BID |
Created by:
cdaughtry