MCP: Upper GI

Question 1

Heartburn

Answer 1

• Burning Sensation
• Discomfort behind breastbone
• Caused by acid reflux or regurgitation
• Symptom of GERD

Question 2

Dyspepsia

Answer 2

• Persistent discomfort in upper abdominal area
• Bloating
• Early satiety
• Nausea and Vomiting

Question 3

Heartburn vs. GERD

Answer 3

• Heartburn
  
  • Simple: Generally mild, associated with diet, and episodic
  • Frequent: Heartburn 2x or more/week
• GERD
  
  • Symptoms or esophageal damage that results from reflux of gastric contents into the esophagus
  • Most common symptoms of GERD: heartburn that is frequent and persistant (3 mo)

Question 4

GERD: Typical and Atypical Symptoms

Answer 4

• Typical Symptoms:
  
  • Heartburn
  • Regurgitation
  • Hyper-salivation
  • Belching
• Atypical Symptoms
  
  • Dental errosions
  • Chest pain
  • Pharyngitis
  • Hoarseness
  • Chronic Cough
  • Non-allergic asthma

Question 5

When to refer:

Answer 5

• ​Severe, recurrent, persistent symptoms
• Dysphagia: difficulty swallowing
• Chest pain
• Bleeding
  
  • Bloody stool, black and tarry
  • Coffee ground vomit
• Unexplained weightloss
• Elderly
• Consistent N/V/D

Question 6

Lifestyle Recommendations

Answer 6

• Don’t eat before bedtime/lying down
• Elevate head of bed (~6 inches)
• Weight Loss
• Smoking cessation
• Reduce portion sizes
• Avoid trigger foods
  
  • Fatty foods
  • Chocolate
  • Spicy Foods
  • Citrus
  • Coffee
  • Salt
  • EtOH
• Avoid trigger medications
  
  • NSAIDs (especially aspirin)

Question 7

Antacid: MOA

Answer 7

• Neutralizes stomach acid by increasing gastric pH

Question 8

Antacid: Indications

Answer 8

• Mild, infrequent heartburn/dyspepsia

Question 9

Antacid: Onset

Answer 9

Instant

Question 10

Antacid: Duration

Answer 10

• 20 min (empty stomach)- 3 hours (full stomach)
• What affects the duration of all antacids?
  
  • Food

Question 11

Sodium Bicarbonate

• Dissolution rate at gastric pH
• Duration
• Side effects

Answer 11

• Alka Seltzer
• rapid dissolution
• short duration
• Side effects:
  
  • Sodium overload
  • Alkalosis
  • Milk-Alkali syndrome
• Not for pregnant or elderly

Question 12

Calcium Carbonate

• Dissolution
• Duration
• Side Effects

Answer 12

• Max 2500 mg
• Slower dissolution
• Long duration
• Side Effects:
  
  • Constipation
  • Hypercalcimia
  • Milk-alkali syndrome
    
    • build up Ca²⁺, damage kidney

Question 13

Aluminum Hydroxide:

• Dissolution
• Duration
• Side Effects

Answer 13

• Slower dissolution
• longer duration
• Constipation

Question 14

Magnesium Hydroxide

• Dissolution
• Duration
• Side Effects

Answer 14

• rapid dissolution
• short duration
• diarrhea

Question 15

Antacids Cautions/Contraindications

Answer 15

• Regular use for 2 weeks
• Patients with hypercalcemia
• Toxicity with renal impairment
• Persons of advanced age, children, or pregnancy or breasfeeding women
  
  • Calcium in pregnant/breastfeed (not Nabicarb)
  • Caution with Mg in elderly
• Al containing: Caution in patients predisposed to obstruction
  
  • Elderly
  • Dehydrated
  • Reduced bowel motility (opiods)

Question 16

H2 Blockers: MOA

Answer 16

• Reversibly binds histamine 2 receptors on parietal cells, decreases acid secretion

Question 17

H2 Blockers: Indications

Answer 17

• Short-term treatment of mild-moderate heartburn/dyspepsia
• Long term prophylactic use in predisposed populations

Question 18

H2 Blockers: Onset

Answer 18

30-45 min

Question 19

H2 Blockers: Duration

Answer 19

• 4-10 hours

Question 20

H2 Blockers: Administration

Answer 20

• Take with or without food
• Long term prevention: QHS or BID before meals
• Short term prevention: take 15 min-1 hour before a heartburn inducing event
• May take along with antacids

Question 21

H2 Blockers: Side Effects

Answer 21

• GI pain
• N/V/D
• Constipation
• Headache
• Dizziness
• Agitated/Confused

Question 22

H2 Blockers: Cautions/Contraindications

Answer 22

• Decrease activity of drugs that require acidic pH for absoprtion
  
  • Have OJ when taking med
  • Ketoconazole
  • Fe supplement
• Decrease dose in renal or hepatic impairement
• Caution in pregant/breastfeeding/elderly patients/children

Question 23

H2 Blockers: Generic, Brand Name, OTC/RX

Answer 23

• Cimetidine
  
  • Tagamet
  • Careful in drug interaction screen
  • Oldest in class
  • OTC: 200mg
• Famotidine
  
  • Pepcid
  • OTC: 10mg
  • Rx: 20mg
• Ranitidine
  
  • Zantac
  • OTC: 25, 75, 150mg

Question 24

Proton Pump Inhibitor: MOA

Answer 24

• Irreversibly inhibits proton pumps (proton-potassium ATPase) on parietal cells
• Decrease acid secretion

Question 25

PPI: Indications

Answer 25

* Frequent heartburn/dyspepsia more than 2 days per week * GERD * Peptic Ulcers * In combo with antibiotics to treat ulcers

Question 26

PPI: Onset

Answer 26

* 2-3 hours; several days (1-4) for complete relief

Question 27

PPI: Duration

Answer 27

* 12-24 hours

Question 28

PPI: Administration

Answer 28

* Take 30-60 minutes before a meal * May open capusles and sprink on soft food/liquids * Duration: GERD 4-8 weeks, gastric/duodenal ulcer 8-12 weeks * Note: OTC PPI's not for long term use, not to exceed 14 days every 4 months

Question 29

PPI: Side Effects

Answer 29

* Headache * Diarrhea * Constipation

Question 30

PPI: Caution/Contraindications

Answer 30

* Decrease activity of drugs that require acidic pH for absorption * Renal or hepatic impairement * Caution in pregnant/breastfeeding/elderly patients * **Potential drug interations due to CYP450** **2C19**** enzyme metabolism** * **Thought to potentially interact with clopidogrel (especially omeprazole/esomeprazole)** * Not absolute, run by cardiologist

Question 31

PPI: Long Term Use May Result In...

Answer 31

* Vitamin B12 deficiency * Weakness, tiredness, increased HR, neuropathy * Hypomagnesmia * Careful with other meds that lower magnesium (BP meds) * Baseline magnesium levels consideration for patients on long term PPI * Increased risk of hip, spine, and wrist fractures in patients \> 50 yo * Recommend Ca²⁺ citrate * Rebound hyper-secretion upon d/c * taper off slowly * Increased risk of infection (controversial) * C-dificile associated diarrhea * pneumonia

Question 32

PPI: Generic, **Brand Name**, OTC/Rx

Answer 32

* Esomeprazole magnesium (new: sodium) * **Nexium** * Rx and OTC * 20-40 mg orally once daily * Lansoprazole * **Prevacid** * Rx and OTC * 15-30 mg orally once daily * Omeprazole * **Prilosec** * Rx and OTC * 20-40 mg oraly once daily * Pantoprazole * **Protonix** * Rx * 40 mg orally once daily * Rabeprazole * **Aciphex** * Rx * 20 mg orally once daily

Question 33

Antacids * Line of therapy * Indiactions * Onset * Duration

Answer 33

* 1st line of therapy * mild, infrequent heartburn/dyspepsia * instant onset * 20-30 min duration

Question 34

H2 Blockers * Line of Therapy * Indication * Onset * Duration

Answer 34

* 2nd line of therapy * mild-moderate epidsodic heartburn/dyspepsia * onset: 30-45 min * duration: 4-10 hours

Question 35

PPIs: Line of Therapy, Indication, Onset, Duration

Answer 35

* 3rd line of therapy * frequent heartburn/dyspepsia 2+ days per week, GERD, peptic ulcers * Onset: 2-3 hours, several days for complete relief * Duration: 12-24 hours