H pylori often leads to _____ ulcer, while NSAID induced is more often ____ ulcer
Duodenal
Stomach
What are defensive factors that prevent PUD from developing?
Mucus
Bicarbonate
Blood flow
Prostaglandins
What are aggressive factors that could lead to PUD?
H pylori
NSAIDs
Acid
Pepsin
Smoking
True/false: Duodenal ulcer, pain is elicited usually after ingestion of food
False; duodenal ulcer, pain is relieved by food.
What’s the H pylori treatment regimen?
Two antibiotics + one antisecretory drug (PPI)
Or two antibiotics + one ant secretory drug and bismuth
What are the antibiotics used to treat H pylori?
Clarithromycin
Amoxicillin
Metronidazole
Tetracycline
Bismuth (yes, pepto bismol has topical antibacterial effects apparently)
True/false: Abx substitutions not recommended
True
True/false: H2 blockers could be used instead of PPIs
True, but not necessarily recommended
MOA of amoxicillin?
Inhibits cell wall biosynthesis
MOA of clarithromycin?
Inhibits RNA-depended protein synthesis
MOA of metronidazole?
Inhibits nucleic acid synthesis
MOA of Tetracycline?
Inhibits protein synthesis
Adverse effect of amoxicillin?
Diarrhea, rash, allergic reaction
Adverse effect of Clarithromycin?
Diarrhea, N/v, taste changes, QT prolongation
Adverse effect of Metronidazole?
N/v, HA, taste changes
Adverse effect of Tetracycline?
Upset stomach, flatulence, tooth discoloration
Adverse effect of bismuth subsalicylate?
Blackened stools, blackened tongue
Which abx used to treat H pylori could cause QT prolongation?
Clarithromycin
Which antibiotics should you reduced the dosage for if creatinine clearance is less than 30?
Amoxicillin
Clarithromycin
Tetracycline
(Gotta ACT when CrCl < 30 yo!)
Drugs with -tidine stem is _______. Drugs with -prazole stem is _______
H2 receptor antagonist
PPI (Prazole = PPI)
What is the MOA of PPI?
Directly inhibit the H+/K+ ATPase on the apical membrane
_____ has inhibitory effect on cAMP, which ultimately leads to decreased H+ secretion
Prostaglandin
What are adverse effects of PPI?
HA, Nausea, abd pain
Chronically, drug interactions, and could increase gastric pH overtime (yes, increase)
True/false: PPIs inhibits CYP2Cp and CYP2C19
True
Which PPI has an immediate release when taken with sodium bicarb/ magnesium hydroxide?
Omeprazole
True/false: all PPI are formulated as immediate release
False; they are all formulated as delayed release (enteric coated)
True/false: H2 receptor antagonist are better used for bleeding ulcers
False; PPIs are most likely superior for bleeding ulcers
In bleeding ulcers, which drug (PPI/ H2RA) would you use?
PPI
What is the MOA of H2RA?
Blocks the histamine receptor on the basolateral membrane, so histamine could not bind, and cAMP would therefore not be stimulated. Ultimately, decreased H+ secretion
Adverse effects of H2RA?
HA, dizziness
Chronically, could potentially cause thrombocytopenia, and also could increase gastric pH over time
What is the usual daily dose for PPI? H2RA?
Once a day for PPI
Twice daily for H2RA
True/false: some H2RA have CYP interactions
True
True/false: H2RA and PPIs have equal efficacy for non-bleeding ulcers, stress ulcer prophylaxis
True
Which COX isoform produces protective prostaglandin, and plays the primary role in how NSAID could cause peptic ulcers?
COX-1
What is the treatment strategy for NSAID induced peptic ulcer?
discontinue NSIAD if possible and start PPI/H2RA / sucralfate
Or decrease dose of NSAID and start PPI/ H2RA/ sucralfate/ misoprostol
What is the MOA of Misoprostol?
Prostaglandin receptor agonist.
Misoprostol is a synthetic analog of PGE 1
When is Misoprostol used to treat ulcers?
when it is NSAID induced, and you can’t completely discontinue NSAID, so you add misoprostol in treatment
Which drug can form a complex of albumin/fibrinogen at ulcer site creating a protective barrier?
sucralfate
True/false: you have to take sucralfate on an empty stomach
True
True/false: misoprostol can increase PGE2
False; Sucralfate increases PGE 2, misoprostol is an PGE 1 analog
True/false: Misoprostol should be taken with food
true
When is misoprostol use contraindicated?
in pregnancy because it stimulate uterine contractions
What is stress related mucosal damage?
acute erosive gastritis that occurs in response to physiologic stress, mostly in critically ill patients
What are way that critical illness can lead to acute stress ulcer?
can lead to hypovolemia which leads to decreased cardiac output
increase proinflammatory cytokine release
Increased in catecholamines which leads to vasoconstriction
And all these leads to splanchnic hypoperfusion and ultimately leads to acute stress ulcer
Which drugs are used to prevent SRMD?
PPIS
H2Ras
Antacids
Prokinetic agents
True/false: Antacids are usually used for PUD
False; antacids like TUMS are not usually used for PUD, they are more often used for episodic heartburn
What is an alumni based antacid?
Mylanta
What is a magnesium based antacid?
Maalox
Milk of magnesia
What is calcium based antacid?
Calcium carbonate (tums)
True/false: pepto bismol is an antacid
True; but remember it can also have some antibacterial effects
What are adverse effects of antacids?
Flatulence, diarrhea.
Aluminum: constipation
Magnesium: diarrhea
What are prokinetic agents?
Azithromycin
Cisapride
Metoclopramide
Bethanechol
What is the MOA of prokinetic agents?
Increase gastric emptying
Which prokinetic agent agonizes motilin receptors?
Azithromycin
Which prokinetic agent works by increasing Ach?
Cisapride
Metoclopramide
Which prokinetic agent works by directly stimulating muscarinic receptors?
Bethanechol
Which prokinetic agent should not be used due to QT prolongation/ Torsades
Cisapride
Which prokinetic agent blocks dopamine and 5HT2 receptors?
