1. What are the three common forms of PUD?
    • Helicobacter pylori induced
    • NSAID induced
    • Stress induced
  2. What is the MOA for antacids?
    • neutralize gastic acid by raising the intragastric pH
    • inhibits conversion of pepsinogen to pepsin
    • stimulate the production of mucosal prostaglandins
    • increases LES tone
  3. Explain what antacids are used for and how they are taken
    • Used for symptomatic relief
    • NO healing power
    • in suspensions (liquids), so absorped better
  4. What side effects must you watch our for when using antacids?
    • Aluminum based = constipation
    • Magnesium based = diarrhea
  5. What are some drug interactions for Antacids that cause chelation?
    • tetracycline
    • fluoroquinolone
    • iron
  6. What is a drug interaction with antacids that cause inactivation
  7. What drug interactions with antacids cause decrease absorption?
    • H2 antagonist
    • Ketoconazole
    • Ampicillin
    • Phenytoin
  8. What are some antacid products?
    • Aluminum + Magnesium
    • Calcium carbonate
    • sodium bicarb
    • bismuth
    • *quick onset, short duration, need many doses
    • *may mask more serious problems
  9. What is the MAO for Histamine-2 Receptor antagonists (H2RA)?
    • Inhibits histamine receptors on parietal cells
    • Decreases the secretion of H+ ions
  10. When are H2RA indicated as 1st line treatment?
    • PUD
    • mild-moderate PUD or GERD
  11. What is the MAO of proton pump inhibitors?
    • Irreversible inhibition of H+/K+ ATPase on parietal cells - decrease gastric acid
    • Protonation in small bowel necessary for drug to be activated
  12. When is a PPI indicated as 1st line treatment?
    • GERD
    • Moderate-severe PUD or GERD
  13. H2RA's can also be used for...
    • H. pylori
    • Maintenance of remission
    • treatment of NSAID ulcers
    • erosive or non-erosive esophagitis
    • treatment of DU/GU
  14. PPI can also be used for..
    • Maintenance of remission
    • treatment of H. pylori
    • treatment of NSAID ulcers
    • treatment of DU/GU
    • treatment of erosive esophagitis only
  15. What is the duration of treatment for DU, GU, and GERD for both PPIs and H2RA?
    • H2RA - DU 4-8wks, GU 8wks, GERD 8wks
    • PPI - DU 4-8wks, GU 4-8wks, GERD 8wks
  16. When is the best time to take an H2RA?
    Take a larger dose before bedtime
  17. When is the best time to take a PPI?
    • Take 30-60 minutes before a meal
    • done to maximize inhibition of proton pump
  18. What are the PPI drugs?
    • Lansoprazole
    • Omeprazole
    • Rabeprazole
    • Pantoprazole
    • Esomeprazole
  19. What are the adverse effects and drug interactions of lansoprazole?
    • AE-Nausea, HA
    • Interactions - Theophylline, ketoconazole, iron, ampicillin, sucralfate
  20. What are the adverse effects and drug interactions of Omeprazole?
    • AE-nause, HA, diarrhea
    • interactions - warfarin, phenytoin, diazepam, ketoconazole, sucralfate, clopidogrel
  21. What are the adverse effects and drug interactions of Rabeprazole?
    • AE - Nausea, HA, diarrhea
    • interactions - Ketoconazole, iron, ampicillin
  22. What are the adverse effects and drug interactions of pantoprazole?
    • AE-HA, diarrhea
    • interactions - ketoconazole, iron, ampicillin
  23. What are the adverse effects and drug interactions of esomeprazole?
    • AE - HA and diarrhea
    • interactions - Ketoconazole, iron, ampicillin, clopidogrel
  24. What is sucralfate and how does it work?
    • Promotes mucosal defenses by forming reacting with hydrochloric acid to form a paste like substance and and binds to surface of ulcer
    • barrier allows ulcer to heal
    • NO acid reducing capacity
  25. How does the inhibition of COX-1 in nonspecific NSAIDS work?
    • Inhibits cyclo oxygenase which decreases prostaglandins and decreases inflammation
    • BUT by decreasing prostaglandins it decreases the protecting in GI tract
  26. Where are COX-1 inhibitors found?
    GI tract & Kidney
  27. Where are COX-2 inhibitors found?
    in sites of inflammation
  28. What is the TX of NSAID induced ulcers?
    • D/C NSAIDS if possible
    • start a PPI or H2RA
    • *if you have to continue NSAID - use a PPI
  29. How can you prevent NSAID induced ulcers and when is it indicated?
    • Use Misoprostol which causes bad diarrhea
    • Use in HIGH RISK pt w/ prior history, >60yo, high does NSAID therapy, receiving anticoag. corticosteriods
    • deal w/diarrhea with high risk patients
  30. What is the MAO of Misoprostol?
    • Prostaglandins E 1 analog
    • Stimulates production of mucous and HCO3-
    • Cytoprotection
  31. What are the adverse effects of Misoprostol?
    • Diarrhea
    • abdominal pain
    • spontaneous abortions
    • postmenopausal women-bleeding
  32. What is the one contraindication for Misoprostol use?
    Women of childbearing age!
  33. What is the treatment of NSAID induced ulcers?
    • stop NSAID therapy when ulcer occurs
    • PPI - agent of choice when NSAIDS must be continued
    • Tx H.pylori when pt. taking NSAIDS who have ulcers and are infected with the organism
  34. How do you treat H. pylori?
    • Combine 2 antibiotics plus a PPI or H2RA
    • Bismuth + metro + tetracycline x 2 weeks
    • Lansoprazole + clarithro + amoxicillin x 10 days
    • Omeprazole + clarithro + amoxi x 10 days
    • Esomeprazole + clarithro + amoxi x 10 days
    • Rabeprazole + clarithro + amoxi x 10 days
  35. What is the duration of treatment for H. pylori?
    • The 2 antibiotics should be continued for 7-14 days
    • The PPI or H2RA should be continued for 2-5 weeks after anbx stops
  36. What is bismuth based quadruple therapy?
    • Special therapy for H. pylori
    • uses a PPI or H2RA with bismuth, metro, and tetra for 10-14 days
  37. What are the combination products used to treat H. pylori?
    • Ranitidine bismuth citrate - Tritec
    • lansoprazole, amoxicillin - Prevpac
    • Bismuth subsalicylate, metro, tetracycline - Helidac
  38. What are four complications of GERD?
    • Esophagitis
    • Barrets
    • Adenocarcinoma
    • Strictures
  39. What is the Non-Pharm treatment of GERD?
    • Diet, avoid exercise, tight clothing, smoking
    • pregnancy
    • Avoid nicotine, iron, potassium, alcohol, and narcotics
  40. What is the empiric treatment of GERD?
    • OTC antacids - OTC H2blockers or OTC PPI
    • Rx H2 blockers or PPI
    • Metoclopramide
  41. When do you use an antacid for GERD?
    • infrequent mild sx
    • adjunctive therapy
  42. What is H2RA's role in treatment of GERD?
    • 1st line for chronic, mild-moderate GERD
    • Non-erosive esophagitis

    must monitor sx and AE's
  43. What is PPI's role in the treatment of GERD?
    • 1st line in moderate to severe GERD
    • when other agents fail
    • must not chew, take 30-60 minutes before meal

    most monitor for sx and AE's
  44. What is the MAO for metoclopramide?
    • Stimulates motility in upper GI
    • considered prokinetic
    • Increases LES tone
    • increases antral contractions
    • increases perstalsis
  45. What are the AE's for Metoclopramide?
    • Galactorrhea
    • Diarrhea
    • extrapyramidal symptoms
    • depression
    • drowsiness
  46. When is Metoclopramide contraindicated?
    • Parkinson's disease
    • obstruction
  47. What are some drug interactions with Metoclopramide?
    • Anticholinergics
    • MAO inhibitors
    • Levodopa
  48. What should you monitor Metoclopramide for?
    • Renal fucntion
    • adverse effects
  49. What drug classes are used in the treatment of Ulcerative Colitis (UC) and Crohns?
    • Aminoglycosides
    • Corticosteriods
    • Immunosupressants
    • misc. antibiotics
    • monoclonal antibodies
  50. What is the MAO for aminosalicylates (ASA)?
    • 1st line for UC and Crohns
    • reduce prostaglandin & leukotriene production
    • inhibits bacteria-induced chemotaxis
  51. What are the agents classified as Aminosalicylates?
    • Sulfasalazine
    • mesalamine
    • olsalazine
    • balsalazide
  52. What do all Aminosalicylates do?
    • They are cleaved into products that provide anti-inflammatory activity in the colon/rectum
    • effects are primarily topical
    • Split products include 5-aminosalicyclic acid (5-ASA)
  53. When are Corticosteriods used and what is a contraindiction?
    • Used for short-term use
    • Contra - LT use see cushing-like condition
  54. What are the corticosteriods used in the treatment of IBD?
    Prednisone, methyprednisone, hydrocortisone
  55. What is the specific agent used in the treatment of UC and IBD?
    • Budesonide -
    • high oral potency in UC use
    • Low bioavailabity - released in ileum for disease affecting ileum or ascending colon
  56. What is the dosing of corticosteriods?
    • for MODERATE acute exacer - 40-60mg q24h
    • *prednisone is drug of choice
    • for SEVERE exacer - IV therapy
    • *Methylprednisone is drug of choice
    • taper does when withdrawing
  57. Hydrocortisone is used in the treatment of UC and IBD
    • Oral or topical use
    • enema is more effective than suppository or foam
    • Foam - greater system absorption
  58. What is Budesonide and how does it work?
    • Enteric coated oral product that allows drug to be released in the ileum and ascending colon
    • exerts local anti-inflammatory effect
    • Induces remission in mild-moderate Crohns disease of ileum and ascending colon
  59. What are some AE's of corticosteriod use?
    • Hyperglycemia
    • HTN
    • electrolyte imbalance
    • Increased apetite
    • insomnia
    • psychosis
    • anxiety, tremors
    • Increased fluid retention
  60. What do we need to monitor corticosteriods for when treating IBD?
    • Acute- BP and Glucose
    • Chronic - Lipids, fasting glucose, Electrolytes, Bone density
  61. What are the pros and cons of using Immunsuppresives to treat IBD?
    • Pros - maintain remission, reduce steriod use
    • Cons - very slow onset (3-12 months), Lots of AE's, Cost
  62. What are the immunosuppresive agents used for treating IBD?
    • Azathioprine
    • 6-Mercaptopurine
    • Methotrexate
    • Cyclosporine
  63. what is the MAO for Azathioprine/6-Mercaptopurine?
    • Inhibits purine synthesis
    • Inhibits DNA synthesis
    • Decreases cell replication
  64. What is the time of onset for Azathioprine/6-Mercaptopurine and was are some side effects?
    • Time of onset - 3-6 months
    • SE's - lots of hemotologic effects 'penias', pancreatitis
  65. What are some contraindications for the use of Azathioprine/6-mercaptopurine?
    • Allopurinol
    • Warfarin
  66. What are contraindictions to the use of Azathioprine/6-Mercaptopurine?
    • Active liver disease
    • Pregnancy
    • Caution with severe renal impairment
  67. What is the MAO for Methotrexate?
    • Inhibits dihydrofolate - important in folic acide production
    • Decreases further cell replication
  68. What is the time of onset for Methotrexate?
    time of onset - 12-16 weeks
  69. What are the adverse effects of Methotrexate?
    • Most serious are hemotological
    • Anemia
    • leukopenia
    • N/V/D
    • Heptatoxicity
    • Renal dysfunction
    • Folic acid def.
    • *Contraindicated in Pregnacy
  70. What is the MAO for cyclosporine?
    • Binds to cyclophilin receptor
    • inhibits T-cell activation
    • decreases cytokine production
  71. What is the time of onset for cyclosporine?
    time of onset - 2-3 days IV
  72. What are some AE's of Cyclosporine?
    • Nephrotoxicity **
    • Tremor
    • HTN
    • Pancreatitis
    • Heptatoxicity
    • Seizure
    • infection
  73. When are antibiotics used to treat IBD?
    • Used in Crohns disease only
    • used when microorganisms is suspected but not proven
  74. What are the antibiotics used to treat Crohns disease?
    • Ciprofloxacin
    • Metronidazole
    • rifaxamin
  75. What are the Monoclonal antibodies used in treating IBD?
    • Infliximab
    • Adalimumab
    • Natalizumab
  76. What is the MAO for infliximab?
    • Neutralizes activity of soluble TNF alpha by binding to TNF alpha receptors and inhibit receptor binding
    • Reduces infiltration of inflammatory cells and TNF alpha production
    • Reduces mononuclear cell ability to express TNF alpha and interfero
  77. How is infliximab dosed?
    • Given every week or every 2 weeks and slowly progress to give it every 8 or 9 weeks as maintenance
    • this treatment continues forever
  78. What are some AE's to infliximab?
    • Sepsis
    • Serum-sickness
    • HA
    • N/V/D
    • liver toxicity
    • Arthalgia, myalgia
    • dyspepsia
    • rash
    • lymphomas
  79. What can infliximab produce if used inproperly?
    • TB
    • Histoplasmosis
    • Listeriosis
    • Pneumocystosis
    • Pneumonia
    • Hep B
  80. Information about other Monclonal antibodies
    • Adal - TNF alpha blocker, similar AE to inflix
    • Nata - leukocyte blocker for pt. who cant tolerate TNF blocker, careful of JC virus may lead to death
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