NAPLEX / Gastrointestinal disorder

Answer E. The diagnosis of Zollinger-Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH < 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages.
Reference:
The role of proton pump inhibitors in the treatment of Zollinger–Ellison syndrome. Available from: https://www.researchgate.net/publication/7339146_The_role_of_proton_pump_inhibitors_in_the_treatment_of_Zollinger-Ellison_syndrome [accessed Apr 16, 2017].
Jensen RT, Gardner JD, Raufman JP, Pandol SJ, Doppman JL, Collen MJ. Zollinger-Ellison syndrome: current concepts and management. Ann Intern Med. 1983;98:59–75

Answer A,B,C,D. Use proton pump inhibitors (PPIs) in patients with or who have risk factors for osteoporosis cautiously. PPIs have been associated with a possible increased risk of bone fractures of the hip, wrist, and spine. Daily treatment with a gastric acid-suppressing medication over a long period of time may lead to hypomagnesemia. Vitamin B12 deficiency has been reported with long term use of PPIs in the literatures. The use of PPIs, may increase the risk of enteric infection by encouraging the growth of gut microflora and increasing susceptibility to organism including Clostridium Difficile. There are recent FDA warnings regarding C. Diff infection with use of PPIs. H. Pylori infection is not a complication of PPIs. PPIs in combination with certain antibiotics are used to treat H. pylori Infections.
Reference:
Targownik LE, Lix LM, Metge CJ, et al. Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ 2008;179:319—26.
Howden CW. Vitamin B12 levels during prolonged treatment with proton pump inhibitors. J Clin Gastroenterol. 2000;30:29–33.
Haag S, Andrews JM, Katelaris PH, et al. Manage¬ment of reflux symptoms with over-the-counter pro-ton pump inhibitors: issues and proposed guidelines. Digestion 2009;80:226-34.

Answer C. Omeprazole is CYP2C19 inhibitor which can prolong the elimination of warfarin, particularly R-warfarin. R-warfarin is partially metabolized by CYP2C19. The combined use of omeprazole and warfarin has been associated with reports of increased INR and prothrombin time (PT).
Reference:
Prilosec (omeprazole) package insert. Wilmington, DE: AstraZeneca; 2016 Dec.

Answer A, C, E. Non-pharmacological measure that may control symptoms of gastroesophageal reflux disease are: Avoid aggravating foods/beverages that may reduce LES pressure alcohol, citrus juices caffeine, garlic, onions or cause direct irritation such as spicy foods or tomato juice should be avoided. Reduce fat intake, remain upright after meals, avoid meal before bedtime. Avoid tight fitted cloths, decrease intra-abdominal pressure. Discontinue nicotine use. Reduce intake of food or beverage that may reduce lower esophageal sphincter tone.
Reference:
American Gastroenterological Association Institute. Medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 2008;135:1383-91.

All of the above medications has reported cases of pancreatitis.
Reference:
Acute Pancreatitis. UpToDate. 2016. Available at: https://www.uptodate.com/contents/etiology-of-acute-pancreatitis . Accessed September 29, 2016.
Management of Acute Pancreatitis, Am J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013

Patients with very high triglyceride levels (i.e., 500mg/dL or higher) usually require drug therapy in addition to therapeutic lifestyle changes. Fibrates or niacin is practical first0line choices for these patients. The initial goal is to decrease the risk of acute pancreatitis, especially if triglyceride levels are above 1,000mg/dL. Fibrate therapy can reduce triglyceride level by 20-50%, whereas nicotinic acid can reduce triglycerides at a much lower dose ~ 15-25%. Thus, A is incorrect. For patients with a triglyceride level below 500 mg/dL (5.7 mmol/L) in whom pharmacologic therapy is indicated, we suggest treatment with a statin rather than an agent targeted at reduction of triglycerides. Thus, D is incorrect. Insulin therapy is initiated for acute pancreatitis treatment, thus C is incorrect.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.