PC707- Module 3 Questions With Correct Answers

Anti-Ulcer drugs help by: - Answer -altering gastric pH by decreasing acid secretion -protecting the stomach wall lining by increasing mucosal protection -eradicating harmful bacteria Ex: H. Pylori What are the main pharmacologic categories of drugs we used to manage gastric acid secretion and the effects: - Answer -antacids -H2 receptor antagonists -proton pump inhibitors (PPIs) -prostoglandin analogs -mucosal protectant sulcrafate (Carafate) What is the first OTC medication tried by patients with dyspepsia? - Answer -Antacids -->these are typically not effective for persistant GERD and PUD What are antacids? How do they work? - Answer -organic salts -neutralize the hydrochloric acid in the stomach -raises the gastric pH above 4.0 What are the main side effects of antacids? - Answer -diarrhea -constipation What are the different categories of antacids? - Answer -calcium carbonate -sodium bicarbonate -aluminum based -magnesium based -aluminum hydroxide What is important teaching for patients taking antacids? - Answer -decreasing the stomach pH can cause the decrease absorption of drugs that rely on acidic conditions -if taking enteric coated medications--reducing stomach acid can cause the medication to dissolve and absorb in the stomach instead of the intestine **always separate antacids from other medications by 2 hours** Calcium carbonate antacids: - Answer -Tums -can cause CONSTIPATION -require adequate fluid intake to dissolve -can be used in patients needing to take an antacid who also could benefit from extra calcium intake. -potential for milk "alkali" syndrome, metabolic alkalosis Sodium Bicarbonate antacids: - Answer -Alka Seltzer -contains aspirin (ASA) -potential to WORSEN GI distress. -increased risk for water retention and fluid overload -potential to cause hypertension -Contraindicated in pregnancy, children, patient with CVD* Aluminum based antacids: - Answer -Amphogel -can cause CONSTIPATION -requires adequate fluid intake to dissolve -Contraindicated in patients with renal insufficiency* Magnesium based antacids: - Answer -Milk of magnesia -suspension mixture is more effective -can cause DIARRHEA -Contraindicated in renal insufficiency* Aluminum hydroxide antacids: - Answer -may decrease the absorption of warfarin*. -can cause a chelating affect with drugs such as tetracyclines, warfarin, and digoxin—potentially decreasing their absorption & effectiveness -high affinity for phosphate—may cause hypophasphatemia What can cause heartburn in pregnancy? - Answer -hormonal fluctuations -anatomic changes Are antacids safe in pregnancy? - Answer -Yes, due to poor absorption -EXCEPT sodium bicarbonate (AlkaSeltzer) due to aspirin content, risk for fetal and maternal metabolic alkalosis, and fluid retention and overload* What are the typical order of interventions for pregnancy heartburn? - Answer -lifestyle changes then try antacids -Milk of magnesia is first line* --category B -Tums--category C -make sure to consider if she has diarrhea or constipation -if antacids fail to work--H2 receptor antagonists are next -Zantac is the most studied and deemed the safest H2 blocker in pregnancy*—however, Zantac currently is being investigated to have a carcinogen—Pepcid is a great alternative What are H2 receptor antagonists? How is it different from H1 receptor antagonists? - Answer -H2 receptors are primarily in the parietal cells of the stomach and when stimulated increase the secretion of gastric acid -H2 blockers help to competitively block the binding to these receptors--therefore decreasing acid secretion* -this is different from H1 blockers--which primarily blocks the histamine that is involved in allergic reactions What are the different types of H2 receptor antagonists? - Answer -cimetidine (Tagamet) -famotidine (Pepcid) -ranitidine (Zantac) -nizatidine (Axid) Why should cimetidine (Tagamet) be avoided whenever possible? - Answer -it is a potent CYP enzyme inhibitor causing deceased metabolism of many drugs--increasing drug levels* -many drug to drug interactions: warfarin, phenytoin, propanolol, nifidepine, chlondiapoxide, diazepam, lidocaine, tricyclic antidepressants, theophylline, metronidazole* Why is famotidine (Pepcid) a good go to drug for H2 antagonist? - Answer -least CYP inhibitor effect -fewer drug to drug interactions Why is it important to document a thorough assessment of different drugs the patient has tried to relieve dyspepsia? - Answer -many insurance companies require a step-wise approach to prescribing before approving -antacids-->H2 blockers-->PPIs What are the only lifestyle changes that could reduce the symptoms of GERD? - Answer -elevation of HOB -weight loss -avoiding meals 2-3 hours before bed Plans for treating GERD begins with determining the severity of symptoms. True or false? - Answer -true -if a patient comes in with moderate-severe GERD OR erosive disease and they most likely have already tried antacids and/or H2 blockers--next step is PPIs* -if a patient comes in with mild GERD they may or may not have tried antacids, if so--try H2 blockers* It's very important to educate patients to take antacids & vitamins/iron supplements: - Answer -at least 2 hours apart -taking them together can cause little to no absorption of the vitamins/supplements and may cause deficiencies Pepto-Bismol (bismuth subsalicylate) take aways: - Answer -not known to be effective for dyspepsia -may change the color of stool to black -Contraindicated in pregnancy, lactation, and children <12 due to aspirin content* -antimicrobial, antisecretory, mild anti-inflammatory -May cause black tongue -could be used as adjunctive in tx of H. Pylori What is metoclorpramide (Reglan)? - Answer -dopamine antagonist -promotes gastric emptying (prokinetic) -tones the lower esophageal sphincter -occasionally is used in pregnancy -risk for tardive dyskinesia* BLACK BOX WARNING: Reglan - Answer -chronic use is associated with tardive dyskinesia -can be irreversible -should be avoided in all but rare cases where the benefits outweigh the risks Reglan using during lactation? - Answer -may help increase maternal prolactin release and used as a galactagogue to increase milk production significantly when effective--can work in 1-2 days! -AAP recommends avoiding use due to potential antidopaminergic effects on the infant -however, dose given & amounts actually in breastmilk is much less than standard dose given to an infant requiring the medication -must weigh risks versus benefits What is GERD? - Answer -dysfunction of the anti-reflux mechanism of the lower esophageal sphincter -goals are lifestyle changes & symptom relief What is the fastest treatment for a patient with acute gastric distress? - Answer -antacids -H2 antagonists & PPIs take more time to decrease the acid What is a GI cocktail? What must you ALWAYS rule out before giving it? - Answer -used for severe GI distress -contains Maalox/Mylanta, Lidocaine, Donnatal -Cardiac events must be ruled out--this cocktail could mask cardiac symptoms* What are proton pump inhibitors (PPIs)? - Answer -anti-secretory -stops the active production & pumping of acid out of the parietal cells by inhibiting enzymes that produces gastric acid -the strongest but takes the longest to work. -Ex: omeprazole (Prilosec)* What are the risks of taking PPIs? - Answer -decreased acid secretion can cause decreased protein digestion--potentially causing B12, calcium, and magnesium deficiencies* -risk for & pneumonia -long term use may increase risk of fractures* (more with chronic use, higher doses, multiple doses/day) -potential for precancerous lesions--leading to gastric malignancy* How do PPIs potentially set the stage for gastric malignancy? - Answer -long term use of PPIs can cause hyperplasia of the stomach lining -this is a precursor "precancerous lesion" -consider DE-prescribing whenever possible to avoid this risk* When are PPIs really useful? - Answer -those using long term NSAIDs* --->NSAIDS disrupt the mucous protection of the stomach lining which can increase the damage from acids --->PPIs help to decrease the acid that is available to damage the lining made vulnerable by NSAIDs What is important to teach patients taking PPIs? - Answer -take them 30 min-1 hour prior to meals to allow time for the medication to work before eating What are prostaglandin analogs? - Answer -anti-secretory -enhances mucosal defense -prostaglandin I & E in stomach--inhibits acid secretion & increases mucous secretion -not as effective as H2 blockers -recommended for patients with peptic ulcers on NSAIDS -recommended for ulcer prevention in patients with chronic NSAID use -Ex: misoprosotol (Cytotec)