PHRD5985 Pharmacotherapy Lecture 3 - GERD Peptic Ulcer Disease GI Bleeding

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daynuhmay
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PHRD5985 Pharmacotherapy Lecture 3 - GERD Peptic Ulcer Disease GI Bleeding
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2014-02-05 02:31:01
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pharmacotherapy
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  1. condition that develops when reflux of the stomach contents causes macroscopic damage to the esophagus
    GERD (gastoesophageal reflux disease)
  2. risk factors for GERD (7)
    • 1) family history
    • 2) obesity
    • 3) smoking
    • 4) EtOH
    • 5) respiratory diseases
    • 6) diet & meds
    • 7) reflux chest pain syndrome
  3. deterioration of squamous tissue into columnar (intestine-like) in the esophagus; can lead to adenocarcinoma of esophagus
    Barrett's esophagus
  4. dynophagia
    painful swallowing
  5. 2 types of esophageal syndromes in GERD
    • 1) symptomatic syndromes
    • 2) syndroms w/ esophageal injury
  6. complications of GERD (5)
    • 1) erosive esophagitis
    • 2) stricture
    • 3) Barrett's esophagus
    • 4) adenocarcinoma
    • 5) reduction in QOL
  7. Los Angeles classification
    grades A (mild) - D (severe)
  8. Savary Miller classification
    grades I (mild) - IV (severe)
  9. What therapy is directed at (5)
    • 1) decrease acidity of refluxate
    • 2) decrease amount refluxed
    • 3) improve gastric emptying
    • 4) increase LES pressure
    • 5) protect esophageal mucosa
  10. GERD exacerbating drugs (10)
    • 1) NSAIDs
    • 2) opioids
    • 3) adrenergic agonists
    • 4) calcium channel blockers
    • 5) progesterone
    • 6) alcohol,  caffeine, nicotine
    • 7) tetracyclines
    • 8) potassium chloride
    • 9) iron salts
    • 10) bisphosphonates
  11. rx medications for moderate-severe or complicated GERD (4)
    • 1) acid suppression
    • 2) promotility agents 
    • 3) mucosal protectants
    • 4) combination tx
  12. the mainstay of GERD therapy
    acid suppression
  13. drug class of famotidine, ranitidine, nizatidine, cimetidine
    H2RA's (H2 blockers)
  14. H2RA place in therapy
    patients w/ mild-moderate non-complicated GERD
  15. drug class of esomeprazole, omeprazole, lansoprazole, rabeprazole, pantoprazole, dexlansoprazole
    proton pump inhibitors
  16. appropriate initial PPI dose for most patients
    once daily
  17. timing of PPI dose
    15-30min prior to eating
  18. drug class of metoclopramide
    promotility agent
  19. MOA of metoclopramide
    DA2 receptor antagonist
  20. duration of GERD treatment
    reassess initially w/in 2-4 weeks
  21. diration of erosive disease treatment
    continuous for 16 weeks (to forever)
  22. treatment for GERD w/ delayed upper GI emptying 
    metoclopramide
  23. treatment of new diagnosis of GERD w/ erosive esophagitis
    PPI for 16 weeks - forever
  24. PPI adverse effects (3)
    • 1) infections (community acquired pneumonia, C. diff)
    • 2) fractures
    • 3) hypomagnesemia
  25. how to manage PPIs and CDAD
    start PPIs after finishing antibiotics course
  26. relationship between PPIs and hip fracture risk
    PPIs cause decreased calcium absorption
  27. causes of peptic ulcer disease (PUD) (3)
    • 1) H. pylori
    • 2) NSAIDs
    • 3) SRMD (stress related mucosal damage)
  28. complications of PUD (3)
    • 1) bleeding
    • 2) perforation
    • 3) gastric outlet obstruction
  29. Triple therapy for H. pylori treatment
    • Triple Therapy (1st line treatment)
    • - 2 antibiotics (clarithromycin + amoxicillin) BID
    • - PPI BID

    10-14 days
  30. duration of H. pylori treatment
    10-14 days
  31. if a patient is allergic to penicillin, what do you do for H. pylori treatment?
    using triple therapy as a 1st line treatment, substitute amoxicillin with metronidazole
  32. Quadruple therapy for first line H. pylori treatment
    - PPI BID

    PLUS...

    • QID:
    • - Bismuth subsalicylate or subcitrate
    • - Metronidazole
    • - Tetracycline
  33. mechanism of NSAID-induced GI injury
    COX inhibition -> PG inhib., decr. mucus formation, decr. bicarbonate formation -> impairment of mucosal healing
  34. PUD high risk factors (2)
    • 1) hx of previous complicated ulcer
    • 2) multiple (>2) moderate risk factors
  35. PUD moderate risk factors (4)
    • 1) >65yo
    • 2) high dose NSAID tx
    • 3) previous hx of uncomplicated ulcer
    • 4) concurrent use of ASA, corticosteroids, or anticoagulants
  36. Misoprostol
    • synthetic PGE1 analog
    • used as PG replacement for PUD prophylaxis
  37. PUD prophylactic therapies (2)
    • 1) PG replacement (Misoprostol)
    • 2) PPI + NSAID
  38. duration of PPI tx for healing NSAID-induced ulcers
    8-12 weeks
  39. does enteric coating protect against GI bleeding?
    NO

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