GERD

Question 1

When LES pressure is low, it is ___ for stomach contents to flow back into the esophagus.

Answer 1

easier

this is bad

Question 2

Which of the following mechanisms is known to cause or increase the risk of developing GERD?
A) faster gastric emptying
B) higher LES pressure
C) increase in esophageal mucosal resistance
D) acid pocket formation

Answer 2

acid pocket formation

Question 3

extraesophageal symptoms
* ___ cough
* laryngitis
* wheezing
* ___

Answer 3

• chronic
• asthma

Question 4

i

immediate medical attention
* dysphagia (difficulty ___ )
* odynophagia
* bleeding
* ___ % unexplained weight loss

automatic referal

Answer 4

• swallowing
• 5%

Question 5

Rx therapy for GERD should last for ___ weeks

Answer 5

8

Question 6

OTC therapy for GERD should last ___ weeks

Answer 6

2

Question 7

diagnostic tests

upper ___ - preferred for assessing mucosal injury and complications

Answer 7

endoscopy

Question 8

diagnostic tests

___ pH test (+ impedance) - useful for patietns not respodning to acid suppression after normal endoscopy

Answer 8

reflux

Question 9

diagnostic tests

manometry (+/- impedance) - useful for patients who failed 2 trials of ___ with normal endoscopy findings to identify motor dysfunction

Answer 9

PPIs

looking for functions of the esophagus

Question 10

diagnostic tests

___ radiography - lacks sensitivity + specificity; not routinely recommended

Answer 10

Barium

Question 11

Complications of GERD

• ___ esophagitis
• Stricture ( ___)
• ___ esophagus
• ___ (cancer)

Answer 11

• erosive
• narrowing
• Barrett’s
• adenocarcinoma

Question 12

prn medications for GERD

Answer 12

• antacids
• H2RAs

Question 13

scheduled medications for GERD

Answer 13

• H2RAs
• PPIs

Question 14

GERD treatment steps

1. lifestyle modifications
2. OTC treatments
3. Rx treatment (___ weeks )
4. If Rx fails, ___
5. Surgery

Answer 14

• 8 weeks
• switch

Question 15

REFER

• ___ symptoms
• OTC trial longer than ___ days with no relief

Answer 15

• alarm
• 14

Question 16

Antacids

• ___ relief
• make intragastic pH > ___
• decrease activation of pepsinogen to ___
• increased ___ pressure

Answer 16

• immediate
• 4
• pepsin
• LES

Question 17

T or F: only antacids increase LES pressure

Answer 17

True

Question 18

antacids

caution in patients with ___ impairment taking ___ or ___ containing products

Answer 18

• renal
• calcium
• aluminum

Question 19

Side effects of antacids

Calcium
* constipation
* ___ - alkali syndrome
Magnesium
* ___
* accumulation
Aluminium
* consitpation
* ___/neurotoxicity

Answer 19

• milk
• diarrhea
• confusion

Question 20

Antacid Drug Interactions

affects ___ of :
* fluroquinolones
* tetracyclines
* azole antifungals
* levothyroxine
* Fe
* steroids
* digoxin
* HIV meds
* select oral antineoplastics

Answer 20

absorption

Question 21

antacid drug interactions

take medications ___ hours before or ___ hours after antacids

Answer 21

• 2 hrs
• 4-6 hrs

Question 22

single element containing antacids (2)

Answer 22

• Tums (calcium carbonate)
• Milk of Magnesia (magnesium hydroxide)

Question 23

mixed antacids (4)

Answer 23

• Al + Mg: Maalox and Gaviscon (+ alginate acid)
• Al + Mg + simethicone: Mylanta, Maalox advanced max strength
• Ca + Mg: Rolaids, Mylanta Ultra
• Ca + simethicone: Alka-Seltzer heart burn + gas, Tums gas relief

Question 24

Brand name

sodium bicarbonate + ASA + citric acid

Answer 24

Alka-Seltzer

Question 25

# Brand name bismuth subsalicylate

Answer 25

Pepto-Bismol

Question 26

# Brand name simethicone

Answer 26

Gas-X

Question 27

T or F: Alka-Selzer is approved for children < 12 years

Answer 27

FALSE; ASA can cause Reye's syndrome

Question 28

# H2RAs MOA: ___ inhibition of histamine receptors in ___ cells

Answer 28

* reversible * parietal

Question 29

Tums dosing: ___ tablets PRN up to 4x/day Max: ___ tabs/day

Answer 29

* 2-4 * 16

Question 30

Milk of Magnesia dosing: ___ mL PRN up to 4x/day Max: ___mL/day

Answer 30

* 5-15 * 60

Question 31

Maalox dosing: ___ mL PRN or at meals + bedtime up to 4x/day Max: ___ mL/day

Answer 31

* 10-20 * 80

Question 32

Gaviscon dosing: ___ tablets or ___ mL at meals + bedtime 4x/day Max: ___ tabs/day

Answer 32

* 2-4 * 10-20 * 16

Question 33

# H2RAs Famotidine (___) OTC: 10-20 mg up to ___ (Max ___ mg/day) Rx: ___ BID prn ___ minutes before trigger foods * if symptoms persist after 2-4 weeks, increase to ___ mg BID for ___ weeks; if symptoms improve, may continue therapy if needed * onset: ___ hours * Duration ___ hours * CrCL < 50 mL/min: give ___% of dose

Answer 33

* Pepcid OTC: BID, 40 mg/day Rx: 10 mg, 10-60 min * 20 mg, 2 weeks * 1-3 hrs * 10-12 hrs * 50%

Question 34

# H2RAs Cimetidine (___) OTC/Rx: ___ mg daily up to ___ min prior to trigger foods (Max: ___ mg/day) * onset: ___ hr * duration: ___ hrs * only adjust dose with ___ renal impairment * MANY drug reactions via ___ * not commonly used

Answer 34

* Tagamet * 200 mg, 30 min, 400 mg/day * 1 hr * 4-5 hrs * severe * CYPs

Question 35

# H2RAs Nizatidine (___) Rx only: ___ mg BID * adjust dose in renally impaired patients * Onset: ___ hrs * Duration: ___ hrs * not readily available/commonly used. Small revival after ___ was pulled from the market

Answer 35

* Axid * 150 mg * 0.5-3 hrs * 5-10 hrs * ranitidine

Question 36

# H2RA Side Effects * Headache * dizziness/fatigue * constipation or diarrhea * Somnolense Confusion/___ * agitation * ___ deficiency (long term use) | Increased with risk if > 50 years with renal/hepatic impairment

Answer 36

* delirium * B12 | B12 is absorbed and activated in the stomach

Question 37

# H2RAs: Pearls * ___ occurs with long term use * ___ Criteria - avoid in patients with/high risk of ___ * used alone or in combination with other classes to treat mild to moderate GERD * NOT as efficacious as ___ * all H2RAs are considered equally efficacious * useful in treatment of ___ symptoms

Answer 37

* tachyphylaxis * Beer's, delirium * PPIs * nocturnal

Question 38

Which H2RA has the most concern for lots of drug-drug interactions? A) ranitidine B) famotidine C) cimetidine D) nizatidine

Answer 38

cimetidine

Question 39

T or F: H2RAs are equally as efficacious as PPIs

Answer 39

False; PPIs are stronger bc they almost completely inhibit acid production

Question 40

# PPIs MOA: ___ inhibition of proton/potassium ATPase in ____ cells

Answer 40

* irreversible * parietal

Question 41

T or F: PPIs do NOT require renal dose adjustments

Answer 41

True

Question 42

# PPIs Dexlansoprazole (___) * NO complications: ___ mg daily * Complications: ___ mg daily for ___ weeks then ___ mg indefinitely * Onset: ___ hr, then ___ hr * Duration: ___ hr * ___ formulation allows 2 different onsets * can be taken without regard to ___

Answer 42

* Dexilant * 30 mg * 60 mg, 8 weeks, 30 mg * 1-2 hrs, 4-5 hrs * 16-18 hrs * dual * meals

Question 43

# PPIs Lansoprazole ( ___ ) * Rx: __ mg daily * OTC: ___ mg daily for ___ days; may repeat in ___ months if needed * Onset: ___ hrs * Duration: ___ days * can open contents of capsule and mix in ___ only * ___ tablet available * administer ___ minutes before a meal

Answer 43

* Prevacid * 15-30mg * 15 mg, 14 days, 4 months * 1-3 hrs * >1 day * water * oral disuntegrating tablet * 30-60 minutes

Question 44

# PPIs Omeprazole ( ___ ) * OTC: ___ mg daily for ___ days; may repeat in ___ months if needed * Rx: ___ mg daily * when combined with ___, product becomes the only immediate release PPI * administer ___ min before a meal * metabolzed by CYP ___ * Onset: ___ hr * Duration: up to ___ hrs

Answer 44

* Prilosec * 20 mg, 14 days, 4 months * 10-40 mg daily * sodium bicarbonate * 30-60 min * CYP2C19 * 1-3 hr * 72 hrs

Question 45

# PPIs Pantoprazole ( ___ ) * PO Rx: ___ mg daily * IV Rx: ___ mg daily * tablet cannot be ___ or ___ * administer ___ min before a meal * most common PPI found on hospital formularies * Onset PO: ___ hrs * Onset IV: ___ min * Duration: ___ hrs

Answer 45

Protonix * 20-40 mg * 40 mg * crushed, altered * 60 min * 2.5 * 15-30 min * 24 hrs

Question 46

# PPIs Rabeprazole ( ___ ) * Rx: ___ mg daily * can open contents of capsule, but cannot crush tablet * administer ___ min before a meal * Onset: ___ * Duration: ___

Answer 46

AcipHex * 10-20 mg * 30 min * 1 hr * 24 hrs | Rx only

Question 47

# PPI drug interactions biggest interactions from ___ and ___ * Increase effect (3) * Decrease effect (4)

Answer 47

omeprazole and esomeprazole * methoytexate, phenytoin, warfarin * iron, bisphosphonates, HIV/HCV drugs, clopidogrel

Question 48

# PPIs Short Term Side Effects * headache * dizziness * diarrhea * flatulence * nausea * abdominal pain * enteric infections ( ___ ) * community-acquired ___

Answer 48

* C. diff * pneumonia

Question 49

# PPIs Long Term Side Effects * hypomagnesemia ( due to less ___ ) * bone density decrease/fractures ( less ___ absorption) * vitamin ___ deficiency * chronic ___ disease

Answer 49

* absorption * Ca2+ * B12 * kidney

Question 50

Which PPI interacts wih clopidogrel and may decrease its effectiveness (meaning it should be avoid if at all possible). A) Omeprazole B) Lansoprazole C) Pantoprazole D) Dexlansoprazole

Answer 50

Omeprazole

Question 51

# Prokinetic Drugs * metoclopramide and ___ * used as adjunct therapy is known ___ defect * problems: these have ___ side effects and are not as effective as ___ suppression therapy * ___ is NOT recommended * Sucralfate - NOT useful in GERD management unless ___ reflux GERD present

Answer 51

* bethanechol * motility * undesireable, acid * baclofen * nonacid

Question 52

# Combination Therapy antacids + H2RAs * helpful for heartburn after ___ * Pepcid AC = ___ PPIs + H2RAs * nighttime administration of a single H2RA dose can help with ___ acid production * ___ can also help with ___ heartburn

Answer 52

* eating * famotidine + calcium carbonate and magnesium * nocturnal * H2RAs, breakthrough

Question 53

# PPI Clincal Pearls * ___ formulation is just as effective as PO * All PPIs are considered equally efficacious * patients who do not respond to an initial PPI trial should be switched to a different PPI with ___ effective dose * ___ dosing for patients who faily once daily max tolerated dose PPIs * when discontinuing after long term theraly, consider ___ due to risk of ___ * Beer's Criteria

Answer 53

* IV * lowest * BID * tapering, rebound hyperacidicty

Question 54

# Surgery * anti-reflux surgery focuses on restoring normal ___ pressure indicated if : * long term therapy is undesireable * persistent symptoms or damage despite appropriate therapy * presence of ___ hernia

Answer 54

* LES * hiatal

Question 55

# Special Populations: Pregnancy First line: lifestyle recommendations First line meds: antacids or ___ Second line: ___ Last line: ___ reserved for complications of GERD or treatment failure (exception: ___)

Answer 55

* sucralfate * H2RAs * PPIs, omeprazole

Question 56

# Special Populations: Lactation * ___ and ___ are present in breastmilk * low risk to infants at standard doses * stick to ___

Answer 56

* PPIs and H2RAs * antacids

Question 57

T of F: GERD symptoms occur in 2/3 of pregnancies

Answer 57

True

Question 58

# Special Populations: Kiddos Symptoms/Signs * refusing to eat * wheezing/coughing * ___ erosion * recurrent ___ or belching irritability Alarm Symptoms * Weight loss * fever * seizure * persistent vomiting/diarrhea

Answer 58

* dental * regurgitation

Question 59

# Pediatric GERD Non-Pharm Options * ___ formula/foods * ___ volume of intake * ___ free diet * ___ therapy

Answer 59

* thickening * decrease * milk * positioning

Question 60

# Pediatric Meds for GERD PPIs and H2RA's * treat for ___ weeks * only for diagnosed GERD or ____ Simethicone and Probiotics: safe ___ Herbal options: ___ , ___ , or ___ Antacids * should not use ___ * do not use ___ or ___ in children < 12

Answer 60

* 4-8 weeks * esophagitis * OTC * peppermint, ginger, chamomile * aluminum or bismuth subsalicylate

Question 61

T or F: Children's Pepto is safe to use in kids under 12 years old

Answer 61

True! children's "pepto" is just calcium carbonate