What does GERD stand for

Gastroesophageal reflux disease

Parietal cells in the epithelial lining of the stomach secrete

hydrochloric acid (HCl) through the H+/K+ -adenosine triphosphatase (ATPase) pump known as the proton pump

The pump, and secretion of HCl, is stimulated by histamine, ACh and the hormone gastrin which has the added role of

stimulating stomach muscle contracentrations to aid in digestion

How is acidic gastric contents normally prevented from backflow into the esophagus

by a protective ring of muscle fibers called lower esophageal sphincter (LES)

Patients with GERD have reduced

LES pressure (muscle tone), and gastric contents can backflow into the esophagus

GERD symptoms

heartburn (daytime or nocturnal), hypersalivation and regurgitation of acidic contents into the mouth or throat

How is GERD diagnosed

based on patient-reported symptoms: duration, daytime and/or nocturnal occurrence, frequency ≥ 2 times/week and risk factors (family history, diet and eating habits)

Drugs that can worse GERD

aspirin/NSAID, bisphosphonates, dabigatran, estrogen products, fish oil products, iron supplements, nicotine replacement therapy, steroids, tetracyclines

Patients should be referred for further evaluation if

they do not respond to lifestyle modifications and/or 2 weeks of OTC self treatment

For frequent (≥ 2 times/week) or severe GERD, what is the initial treatment

8 week course of a PPI

Maintenance treatment of GERD

PPI at the lowest effective dose

(alternative: H2RA, if there is no erosive esophagitis)

MOA of antacids

works by neutralizing gastric acid (producing salt and water) which increases gastric pH

Since antacids do not require systemic absorption, they provide relief within

minutes but the duration of relief is short (30- 60 mins)

Brand name of calcium carbonate

Tums

Brand name of calcium carbonate + magnesium

Mylanta Supreme

Brand name of calcium carbonate + simethicone

Maalox Advanced Maximum Strength

Brand name of magnesium hydroxide

Milk of Magnesium

Brand name of magnesium hydroxide + aluminum + simethicone

Mylanta Maximum Supreme

Brand name of sodium bicarbonate/aspirin/citric acid

Alka-Seltzer

Aluminum and magnesium can

accumulate with severe renal dysfunction (not recommended if CrCl < 30 mL/min)

Side effects of calcium

constipation, bloating, bleching

Side effects of aluminum

constipation, hypophosphatemia

Side effects of magnesium

loose stools

MOA of H2RA

reversibly inhibit H2 receptors on gastric parietal cells which decrease gastric acid secretion

Brand name for famotidine

Pepcid AC

Brand name for cimetidine

Tagamet HB

Onset of relief for H2RA

within 60 mins, duration 4-10 hours

Which H2RA was removed from the market in 2020

ranitidine (Zantac)

MOA of PPIs

irreversibly bind to the gastric H+/K+ ATPase pump in parietal cells

(this shuts down the pump and blocks gastric acid secretion)

Which PPIs do you take before breakfast

esomeprazole, lansoprazole, omeprazole

Brand name for esomeprazole

Nexium

Brand name for lansoprazole

Prevacid

Brand name for omeprazole

Prilosec

Brand name for dexlansoprazole

Dexilant

Brand name for pantoprazole

Protonix

Brand name for rabeprazole

Aciphex

PPIs may diminish the therapeutic effect of which medication

clopidogrel

Side effects of IV Protonix

thrombophlebitis, severe skin reactions (SJS/TEN)

Onset of PPIs

1-3 hours, duration > 24 hours

Which PPIs are available IV

pantoprazole and esomeprazole

Which PPIs capsules can be opened, mixed in applesauce and swallowed immediately

dexlansoprazole, esomeprazole, lansoprazole, omeprazole and rabeprazole

(everyone but pantoprazole)

What vitamin deficiency can occur with long-term PPI use

vitamin B12

Which PPIs come in ODT formulation

lansoprazole, omeprazole

Which H2RA comes in an injection

famotidine

MOA of metoclopramide

dopamine antagonist

PPIs inhibit what enzyme

CYP2C19

PPIs can increase the levels of

citalopram, phenytoin, tacrolimus, voriconazole and warfarin

How does peptic ulcer disease (PUD) occur

occurs when there is mucosal erosion within the GI tract

Where does peptic ulcer usually occur

in the duodenum

(small percentage occur in the stomach)

Three most common causes of PUD

H. pylori, NSAIDs and stress ulcer

What is H. pylori

a spiral-shaped, pH-sensitive, gram-negative bacterium that lives in the acidic environment of the stomach

Primary symptom of PUD

dyspepsia, a gastric pain that can feel like a gnawing or burning sensation in the middle or upper stomach

If the ulcer is in the duodenal, what are the symptoms

pain is typically worse 2-3 hours after eating, eating food or taking antacids lessens the pain

With gastric ulcers, what are the symptoms

eating generally worsens the pain

Diagnostic test for H. pylori

urea breath test (UBT)

First line treatment for H.pylori

quadruple therapy

When is triple therapy treatment for H.pylori considered first-line

only if clarithromycin resistance rates are low (<15%) and the patient has no previous history of taking a macrolide antibiotic for any reason

What medications are in the quadruple therapy treatment

bismuth subsalicylate 300 mg QID + metronidazole 250-550 mg QID + tetracycline 500 mg QID + PPI BID

(take for 10-14 days)

What drugs does Pylera contain

bismuth subcitrate potassium 420 mg + metronidazole 375 mg + tetracycline 375 mg

What drugs are in concomitant therapy for H.pylori

amoxicillin 1000 mg BID + clarithromycin 500 mg BID + metronidazole 500 mg BID + PPI BID

(take for 10-14 days)

What drugs are in clarithromycin triple therapy

amoxicillin 1000 mg BID + clarithromycin 500 mg BID + PPI BID

(take for 14 days)

What drugs are in Prevpac

amoxicillin + clarithromycin + lansoprazole

How does NSAIDs cause ulcers

direct irritation of the gastric epithelium and systemic inhibition of prostaglandin synthesis

Risk factors for NSAID induced ulcers

age > 60 y/o, history of PUD, high-dose NSAID, using > 1 NSAID, concomitant use of anticoagulants, steroids, SSRIs or SNRIs

Brand name of naproxen/esomeprazole

Vimovo

Brand name of ibuprofen/famotidine

Duexis

Brand name of diclofenac/misoprostol

Arthrotec

Brand name of misoprostol

Cytotec

MOA of misoprostol

prostaglandin E1 analog that replaces the gastro-protective prostaglandins removed by NSAIDs

MOA of sucralfate

sucrose-sulfate-aluminum complex and can interact with albumin and fibrinogen to form a physical barrier over an ulcer

Brand name of sucralfate

Carafate

Side effects of misoprostol

diarrhea, abdominal pain

Side effects of sucralfate

constipation