GI Pharm

Question 1

Antacids used for the treatment of what?

Answer 1

ulcers

Question 2

What meds are antacids? 3

Answer 2

1. Aluminum salts
2. Magnesium hydroxide
3. Calcium carbonate

Question 3

MOA: Antacids

1. In general how do they work?
2. How do they do this? 4

Answer 3

1. In general work by neutralizing gastric acid
2. • Protect gastric mucosa against acute chemical injury
   • Bind bile acids and inhibit peptic activity
   • Promote angiogenesis in injured mucosa
   • Heavy metals suppress H. pylori

Question 4

1. What substances are in magnesium salts?
2. Brand names? 5
3. Common side effects? 5
4. Caution with what?

Answer 4

1. Magnesium hydroxide/aluminum hydroxide
2. Brand names
   - Maalox,
   - Alamag,
   - Mag-Al,
   - Mag-Al Ultimate,
   - Mylanta
3. Common side effects:
   - Diarrhea,
   - constipation,
   - abd cramps,
   - N/V
   - Hypermagnesemia
4. Caution with renal insufficiency

Question 5

Aluminum salts

1. Caution with what?
2. Can block the intestinal absorption of what?
3. Brand names? 2

Answer 5

1. Caution in renal insufficiency
2. Can block the intestinal absorption of phosphate
3. • Acid gone
   • Gaviscon

Question 6

Calcium carbonate

1. Brand names? 6
2. Indications? 2
3. Most common side effects? 6
4. Separate from other meds by what?

Answer 6

1. Brand names
   - Tums,
   - Maalox regular chewable,
   - Calci-chew,
   - Rolaids,
   - Chooz,
   - Alka-Mints
2. Indications:
   - Acid indigestion,
   - heartburn
3. Most common side effects:
   - constipation,
   - bloating,
   - gas,
   - N/V,
   - abdominal pain,
   - xerostomia
4. Separate from other meds by 2 hours

Question 7

H2 Blockers indications

3

Answer 7

1. Treatment and maintenance therapy of peptic ulcer disease
2. Treatment of GERD
3. Management of dyspepsia

Question 8

1. MOA of H2 blockers?

2. When should we take these?

Answer 8

1. Inhibit acid secretion by blocking histamine H2 receptors on the parietal cell
2. Generally dosed to take 30-60 min prior to a meal (if using for acid suppression with meals)

Question 9

H2 blocker side effects?

2

Answer 9

1. Rare, severe adverse events, such as renal and hepatic toxicity
2. Myelosuppression

Question 10

H2 blocker SE: Myelosuppressio. What will you see on the CBC?
4

Answer 10

1. Thrombocytopenia
2. Neutropenia
3. Anemia
4. Pancytopenia

Question 11

Rare CNS side effects with H2 blockers?

Rare cardiac side effects?

Answer 11

Can cause confusion, restlessness, somnolence, agitation, headaches, and dizziness and, with prolonged therapy, hallucinations, focal twitching, seizures, unresponsiveness, and apnea (primarily in the elderly with concomitant renal and/or hepatic failure)

Sinus bradycardia, hypotension, AV block, prolongation of the QT interval, and sinus and cardiac arrest have occurred with the rapid infusion

Question 12

Cimetidine has some unique side effects such as?

5

Answer 12

1. Can rarely cause gynecomastia and impotence
2. Polymyositis
3. Interstitial nephritis
4. Cleared through the P450 system so has multiple drug interactions
5. Giving rapidly IV can cause cardiac arrhythmias and hypotension

Question 13

Absorption and distribution
of H2 blockers:
1. How well is it absorbed?
2. Peak serum concentrations occur when?
3. Absorption is reduced by 10-20% if taken with what?

Answer 13

1. Well absorbed after oral dosing
2. Peak serum concentrations occur within one to three hours
3. antacids

Question 14

What are the H2 blockers?

4

Answer 14

1. Cimetidine (Tagamet)
2. Ranitidine (Zantac)
3. Famotidine (Pepcid)
4. Nizatidine (Axid)

Question 15

What are the Proton pump inhibitors?

6

Answer 15

1. Omeprazole (Prilosec, Zegrid)
2. Lansoprazole (Prevacid)
3. Pantoprazole (Protonix)
4. Esomeprazole (Nexium)
5. Dexlansoprazole (Kapidex)
6. Rabeprazole (AcipHex)

Question 16

PPI: Indications?

5

Answer 16

Treatment of all acid-related disorders

1. peptic ulcer disease
2. gastroesophageal reflux disease
3. Zollinger-Ellison syndrome
4. Treating and preventing nonsteroidal anti-inflammatory drug (NSAID)-associated gastroduodenal mucosal injury
5. Eradication of Helicobacter pylori infection

Question 17

PPIs MOA

Answer 17

Block acid secretion

irreversibly binds to and inhibits the hydrogen-potassium ATPase pump on the parietal cell membrane

Question 18

PPIs MOA
1. What need to be active for PPIs to work so don’t give other antisecretory meds at the same time?

2. The amount of H-K-ATPase present in the parietal cell is greatest after when?
3. PPIs should be administered when?

Answer 18

1. Parietal cells
2. a prolonged fast
3. before the first meal of the day

Question 19

PPIs:

1. Onset of action?
2. Peak concentration?

Answer 19

1. About 1 hour

2. Peak concentration in about 2 hours

Question 20

PPI’s side effects

3

Answer 20

1. Diarrhea
2. Headache
3. Plus flatulence with Protonix

Question 21

Drug interactions

1. Which PPI has the lowest drug interaction?
2. Which drugs are metabolized largely via CYP2C19, and the potential for interactions thus appears to be the greatest among the PPIs?

Answer 21

1. Pantoprazole (Protonix)
2. • Omeprazole (Prilosec, Zegrid)
   • Esomeprazole (Nexium)

Question 22

What is the omeprazole?

Answer 22

Significant interaction between omeprazole and clopidogrel

black box warning

Question 23

Long term administration of PPIs may increase the incidence of what? 3

Answer 23

1. Infections
2. Fractures
3. Malabsorption issues

Question 24

PPIs

1. Which infections does it increase incidence of?
2. Which fracturs?
3. What kind of Malabsorption issues? 3

Answer 24

1. Infections
   - C. difficile
   - pneumonia
2. Fractures
   - Hip,
   - wrist,
   - spine
3. Malabsorption of
   - B12 (check levels)
   - Magnesium (check levels esp. with diuretics and digoxin administration)
   - Iron

Question 25

PPI administration: 1. Take when? 2. What if twice daily dosing is needed?

Answer 25

1. Take 30-60 min before first meal of the day | 2. If twice daily dosing is needed then take second dose 30-60 min prior to the last meal of the day

Question 26

Sulcralfate (Carafate) 1. What substances are in this drug? 2. Prevents what? 3. Heals what?

Answer 26

1. Sucrose octasulfate-aluminum hydroxide 2. Prevents chemical induced mucosal damage 3. Heals chronic ulcers

Question 27

1. Sulcralfate (Carafate) MOA? | 2. Binds to the ulcer base best at a pH below ___ so should be administered 30-60 min prior to meals

Answer 27

1. Stimulates angiogenesis and formation of granulation tissue likely due to growth factor binding 2. 3.5

Question 28

Sulcralfate (Carafate) Cautions? | 2

Answer 28

1. Due to the combination with aluminum hydroxide do not administer with aluminum containing antacids in patients with renal failure 2. Do not administer with citrate containing compounds – increases aluminum absorption by 50X in normal renal function

Question 29

1. Bismuth suppresses what? | 2. However, not helpful in the treatment of what?

Answer 29

1. Suppresses H. pylori infection | 2. Not helpful in treatment of non H pylori induced ulcers

Question 30

Bismuth MOA? | 4

Answer 30

1. Inhibition of peptic activity but not pepsin secretion 2. May bind to ulcer craters 3. Recruits macrophages to the edge of the ulcer crater to promote healing 4. May increase mucosal prostaglandin production and mucus bicarbonate secretion

Question 31

Misoprostol (Cytotec) 1. INdicated for what? 2. Preg cat? 3. What class of drug? 4. MOA? 2 NOT A FIRST LINE THERAPY

Answer 31

1. Indicated for the prevention and treatment of NSAID induced ulcers 2. Pregnancy category X 3. Prostaglandin E1 analog 4. Enhances mucosal defenses and promote ulcer healing Not a first line therapy

Question 32

Black box warning for misoprostol

Answer 32

[U.S. Boxed Warning]: Use of misoprostol during pregnancy may cause abortion, birth defects, or premature birth. It is not to be used to reduce NSAID-induced ulcers in a woman of childbearing potential unless she is capable of complying with effective contraceptive measures and is at high risk of developing gastric ulcers and/or their complications.

Question 33

WHat drug is the Prokinetic?

Answer 33

Metaclopramide

Question 34

Metaclopramide (Reglan) 1. First line therapy for what? 2. MOA?

Answer 34

1. First line therapy for gastroparesis for no longer than 12 weeks unless benefits outweigh risks 2. Improves gastric emptying by increasing gastric antral contractions and decreasing postprandial fundus relaxation

Question 35

Metaclopramide 3 different drug classes it falls under. What are they?

Answer 35

1. Dopamine receptor antagonist 2. 5-HT4 agonist 3. Weak 5-HT3 receptor antagonist

Question 36

Metaclopramide (Reglan) | 7

Answer 36

1. Anxiety 2. Restlessness 3. Depression 4. Hyperprolactinemia 5. QT prolongation Extrapyramidal side effects 6. Dystonia 7. Tardive dyskinesia

Question 37

Dangerous drug interactions to avoid with metoclopramide | 5

Answer 37

1. Antispsychotics 2. Droperidol (Inapsine) 3. Promethazine (Phenergan) 4. Tetrabenazine (Xenzine) - Huntington’s chorea 5. Trimetazidine (Vastarel MR) - Antianginal

Question 38

More drug interactions to avoid with metoclopramide? | 4

Answer 38

1. SSRIs 2. TCAs 3. Atovaquone (Mepron) - Antimalarial 4. Metyrosine (Demser) - Tx symptoms of pheochromocytoma