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49 Cards in this Set
- Front
- Back
Dyspepsia = recurrent persistent pain or discomfort around midline of _____ abdomen for > than ___ weeks.
Causes of dyspepsia= 3., 4., 5. and others |
1. upper
2. 2 weeks 3. NUD- ulcer undetectable by endoscapy 4. PUD- ulcer px 5. GERD |
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Endoscopy is necessary in pts w/ dyspepsia if the pt is >__, and if pt pxs w/ GI bleeding, anemia, unexplained wt loss, recurrent vomiting, dysphagia, abdominal mass, and/or jaundice
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- 45
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NUD- recurrent, and is there evidence usually of organic dz? Is H. pylori pathophys in this dz?
There is ___ clear tx for this dz. |
- no evidence of organic dz
- H. pylori may be px but usually has not has a role in the dz - no clear tx for NUD |
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PUD is caused by imbalance of defensive and aggressive factors, what are some defensive factors(3)?
What are some aggressive factors? |
1. Prostaglanding
2. Mucus bicarb layer 3. blood q and cell renewal 4. H pylori 5. NSAIDs 6. Smoking 7. Acid, pepsin, bile salts |
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90% chance of recurrence of PUD if ___ is not eradicated.
What are some lifestyle modifications helpful w/ PUD? |
1. H. pylori
2. STOP SMOKING 3. Elim ulcerogenic meds-- NSAIDs, corticosteroids 4. Minimize EtOH intake |
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Antacids- MOA
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- reduces acidity by neutralizing secreted gastric acid, reacts w/ stomach acid to form salt and water
- inhibits proteolytic activity of pepsin if pH is > 4 - increases LES tone |
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Sodium bicarb- Class, Caution/CI
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Class: Antacids
Caution: not recommended for long term use b/c it can produce SYSTEMIC alkalosis CI: increases Na load-- CHF, Htn, and renal pts |
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Calcium Carb- Class, Caution
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Class: antacids
Caution: may produce hypercalcemia, w/ v. high chronic dosing or w/ use of THIAZIDE diuretics |
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MgSalts--AE
AlSalts- AE |
1. Mg Salts-- diarrhea
2. Al Salts-- constipation - combo may be effective |
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Antacids- DI
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DI: quinolones, tetracylines, bisphosphonates- may result in failure of abx tx
- increase in gastic pH-- may interfere w/ absorption of itraconazole, ketoconazole, digoxin, phenytoin, and isoniazid |
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Antacids- Use, When to give?
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Use: prn for breakthrough sx-- rapid onset but SHORT duration of action requiring frq dosing
- Give 1 HOUR after meal for maximal efficacy |
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H2RA belong to what larger class?
H2RA- MOA |
- antisecretory meds
- competitive inhibition of histamine at H2 receotors of the gastric parietal cells, inhibiting both BASAL and food stimulated acid secretion - inhibition of cAMP dep pathway-- decreased proton pump activity |
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Cimetidine, famotidine, nizatidine, and ranitide- Class
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H2RA
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H2RA- Use (types of tx)
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- acute tx to heal ulcers--4-6 wks for DU, 8-12 wk for GU
- maintenance tx- for pts in whom h pylori has not been eradicated, if H pylori not eradicated then NO NEED for maintenance tx - combo w/ bismuth citrate and 2 abx to eliminate H pylori |
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H2RA- AE, DI
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- rare- hepatitis, hemat tox, and dystonia esp in elderly w. reduced renal clearance
- CIMETIDINE- can cross BBB DI: can decrease absorption of drugs that require acidic environment-- i.e. ketoconazol,e fluconazole, itraconazole, and protease inhibitors |
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Cimetidine- AE, Class
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Class: H2RA
AE: Cimetidine has higher incidence of SE b/c it can cross the BBB- can cause nightmares, hallucination - Long term use ass. w/ anti androgenic SE- gynecomastia, impotence, and decreased sperm count |
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Cimetidine- DI
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DI: inhibits cytochrome P450 enzymes-- decrease metabolism & increases serum concentration of THEOPHYLLIN, phenytoin, warfarin, PROPRANOLOL, and diazepam
- also in GEN for H2RA-- reduced absorption of ketoconazole, fluconazole, itraconazol,e and protease inhibitors b/c of increase in gastric pH. |
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PPI- MOA
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- binds to proton pump (H=/K+ ATP pump) of parietal cell irreversibly inhibiting secretion of H+ ions into gastric lumen
- MOST POTENT class of meds |
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Omeprazole, esomeprazole, lansoprazole, raberprazole- Class
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- PPI
- lansoprazole adn omeprazole= OTC and 1/5 of prescription costs |
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- prazole- Class, Use, AE
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Class: PPI
Use: more rapid relief of pain adn healing rates AE: some increased risk of aspiration pneumonia in mechanically ventilated pts, also some increased risk of hip fractures so council to get enough calcium |
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PPI- DI
Omeprazole- DI |
- Gen DI for all PPIs-- decreased bioavailability of drugs that depend on GI acidity for absorption- ketoconazole, itraconazole, and protease inhibitors
Omeprazole- inhibits cytochrome P450- increases levels of warfarin, phenytoin, digoxin, and diazepams |
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PPI- Use/PK
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- slightly faster healing than w/ H2RA
- can use as part of multi drug regimen for H pylori eradication - use PPI only at lowest effective dose to min risk of aspiration pneumonia and c. diff colitis - take 30-60 min before meals-- drug starts off inactivated and is activated in acidic env - usually BID |
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Cytoprotective Agents- MOA, drug name
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- Sucralfate and Bismuth (peptobismol)- drug
- complex salt of sucros sulfate and AlOH -- Al dissociates-- leaving highly polar anion which binds to positively charged proteins in normal & diseased mucosa - forms viscous adhesive protective barrier on ulcer crater- protects gastric lining against peptic acid, pepsin, and bile salts - may increase secretion of local prostaglandins |
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Sucralfate- AE/DI
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AE: constipation
DI: binds to other drugs and impairs absorption of phenytoin, digoxin, theophyliin, warfarin, quinolones, and tetracyclines |
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Sucralfate- Use
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- requires multiple daily doses and is not as effective as PPI or H2RA for pain
- doubles the cost of tx - ADVANTAGES--good for preggers b/c no systemic absorption - NO increased risk of aspiration pneumonoia- good for pts on mech ventilators |
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Bismuth subsalicylate- Use, Class, Caution, Pt education
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- H. pylori eradication-- multidrug regiment-- mild antimicrobial
Class: cytoprotective agents Caution: in children b/c Reyes syn Pt education- may turn stool grayish black- benign |
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H pylori increases the incidence of ___ and ___
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1. MALT ass. lymphoma
2. adenocarcinoma |
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Methods to detect H pylori?
Caution of detection? |
1. endoscopy- urease activity of h pylori is tested
2. serology- looks for IgG against h pylori 3. Urea breath test 4. stool antigen test - FALSE NEGATIVES may occur in pts taking antisecretory agent or abx except for w/ serology tests |
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What is the usual tx for H. pylori?
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- one anti secretory (PPI OR H2RA) and two abx- amoxacillin, clarithromycin, metronidazole, and tetracycline, and levofloxacin= ABs effective against H. pylori- cant really substitute other abx b/c these are the ones that are stable in acid environment
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Is one abx treatment regimen appropriate for H. pylori?
If first course of tx doesn't work fo rH pylor then what can be used? |
- No b/c low cure rate
- use DIFFERENT abx b/c pt might be resistant to the failed abx-- abx that work-- amox, clarithromycin, metronidazole, tetracycline- CMTA |
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Quadruple therapy for H. pylori?
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Bismuth subsalicylate, metronidazole, tetracycline, and A PPI for 14 days has highest rate of efficacy (> 90%)
- good for pts allergic to penicillin |
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What is the idal tx for preggers?
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- Sucralfate
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NSAIDs are the other major cause of GI ulcers, about __ % of pts w/ prolonged NSAIDs use have ulcers.
NSAIDs weaken gastroprotective factors by inhibition of ___? |
- 20%
- COX1 |
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Should COX 2 inhibitors be used instead of COX 1 to protect stomach?
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- no, not really b/c INCREASED CV risk and COX 2 selective shoul dbe avoided if pt has CAD
- celecoxib CI in pts w/ sulfonamide allergies - use of Celecoxib w/ ASA- negates any GI protective advantage |
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Test for H. pylor before placing pts on long term ___ therapy. If pt is positive for H pylori then first treat H. pylori ____ beginning regimen.
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- NSAID
- before |
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WHat is DOC when 1. NSAID must be continued in presence of ulcer dz, 2. if ulcer is large, or 3. there is sig upper GI bleeding?
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- Omeprazole (PPI) at high dose
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What is an effective prophylactic therapy for NSAID induced GU & PU?
What drugs are INEffective as prophylactic tx for NSAID induced ulcers? |
- MIsoprostol (PGE1 analog)
- PPI - H2RA and sucrlafate- NOT effective |
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Misoprostol- CI, MOA
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MOA: stable PGE1 analog that replenishes prostaglandin-- increases bicarb, mucus and mucosal blood flow
CI: women of child bearing age that may want to get pregnant-- is abortive agent |
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Stress induced ulcers are different from PUD b/c they are not ____
- these occur in untreated critically ill pts w/ in 24 to 48 hrs |
1. recurrent
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What is the tx for stress ulcers?
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1. Treat underlying condition
2. Give antisecretory agents (h2RA, PPI)and agents that increase protective factors (sucrlfate (particularily good) , antacid) |
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GERD- when is endoscopy necessary?
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- pts greater than 45 w/ alarming sx- dysphagia, bleeding, unexplained wt loss, choking, chest pain
- present for >5 yrs - lower threshold for males b/c much mroe likely fro Barretts esophagus |
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Controversy w/ H pylori and GERD?
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- may be protective
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Besides antiescretory agents(PPI, H2RA) and acid neutralizing agents (antacids), what class of meds can be given to GERD pts?
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- Promotility agents such as metoclopromide, bethanecol, and cisapride
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Which method should be followed w/ GERD pts- step down or step up?
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- both depending on severity of sx
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Which of the antisecretory agents is better for GERD?
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- PPI over H2RA
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Promotility agents in GERD- MOA, drug names
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- Drugs- metaclopramide, bethanechol, & cisapride
- Metoclopramide--Antagonizes central and peripheral dopamine receptors - Bethanechol- Sensitizes receptors in GI tract to acetylcholine - increases LES tone and improves gastric motility |
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Metoclopramide in GERD-AE
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- extrapyramidal sx w/ high dose
- avoid in pts w/ PD-antagonizes effects of dopaminergic agents |
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Betahnecol- MOA, CI
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MOA: stimulates cholinergic receptors, ↑ GI motility & ↑ LES tone to relieve SYMPTOMS of reflux
CI: PUD, asthma SE: cholinergic SE |
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When is H2RA goood for pts w/ GERD?
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- for nighttime sx
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