GERD

lansoprazole

D

Prilosec

Omeprazole

Nexium

esomeprazole

Choose the correct statement/s concerning sucralfate: A It should be taken before meals. B The primary side effect is diarrhea. C The brand name is Cytotec. D It is a first-line agent for the treatment of GERD. E It is a first line treatment for the management of peptic ulcer disease.

A

The first-line regimen for H. pylori infection, according to the American College of Gastroenterology (ACG) guidelines, is: A 14-day "triple" therapy with a PPI, clarithromycin 500 mg BID, and amoxicillin 1,000 mg BID. B 7 day "quadruple" therapy with ranitidine, bismuth subsalicylate 525 mg QID, tetracycline 500 mg QID and metronidazole 250 mg QID. C 5-day "triple" therapy with a PPI, clarithromycin 500 mg BID, and amoxicillin 1,000 mg BID. D 7-day "quadruple" therapy with a PPI, bismuth subsalicylate 525 mg QID, tetracycline 500 mg QID and metronidazole 500 mg QID. E 28-day "triple" therapy with a PPI, clarithromycin 500 mg BID and either amoxicillin 1,000 mg BID or metronidazole 500 mg BID.

A

Use of a proton pump inhibitor during hospitalization can increase PR's chances of developing: Answer A Pneumonia B Stroke C Fractures D Myocardial infaction E Anemia

A

How should the pharmacist counsel LK to take Dexilant? A Take 1 capsule daily without regard to meals. B Take 1 capsule daily - 60 minutes before breakfast. C Take 1 capsule daily at bedtime. D Take 1 capsule daily on an empty stomach. E Take 1 capsule daily with a high fat meal.

A Dexlansoprazole (Dexilant) is unique among the PPIs and can be given without regard to meals. If symptoms are not well-controlled when taken without regard to meals, it can be administered before the meal.

KG has chronic constipation despite a fiber-rich diet and adequate fluids. It is "idiopathic". She has had constipation for years and says she has learned to live with it. As she is getting older, she experiences occasional heartburn after eating. Choose a good option for KG to help with the heartburn: A Milk of Magnesia B Maalox C Tums D Famotidine E Omeprazole Incorrect Milk of Magnesia (MOM) will provide benefit for both the heartburn and make the stool somewhat softer in a patient with chronic constipation.

A Milk of Magnesia (MOM) will provide benefit for both the heartburn and make the stool somewhat softer in a patient with chronic constipation.

OG enters the pharmacy asking for a recommendation for heartburn. He has just come from a party and says he gets bad heartburn when he eats spicy foods or drinks alcohol. This happens about once a week. OG takes Tums occasionally but asks if there is anything stronger he can take on a daily basis so that he doesn't have to deal with heartburn. What is the best recommendation? A Avoid bothersome foods and use an antacid or H2RA as needed. B OG can try daily use of an H2RA, such as Zantac. C Switch from calcium carbonate to Maalox. D OG can try daily use of a proton pump inhibitor, such as Prilosec. E He should ask his physician for a prescription for sucralfate.

A OG has infrequent heartburn so does not need daily medication. Tums is chewable calcium carbonate. Antacids work quickly and provide relief for 30 - 60 minutes. H2RAs take at least 30 minutes to work, but provide relief for 4 - 10 hours. If the food trigger is known, the patient can try to avoid it or take medications at the appropriate time to treat the symptoms

Sucralfate is available in the following formulation/s: (Select ALL that apply.) A Oral suspension B Oral tablet C Injectable D Transdermal patch E Nasal spray

A & B

Which of the following H2RAs are available in an IV formulation? (Select ALL that apply.) A Famotidine B Ranitidine C Nizatidine D Cimetidine E None of these are available in an IV formulation

A, B

LK's physician tells her to stop taking Pepcid Complete and start taking Dexilant. What other medications will need to be changed? (Select ALL that apply.) Medications: Norvasc 10 mg PO daily, Soltamox 20 mg PO daily, Atelvia 35 mg once weekly OTC medications: Pepcid Complete, 1-2 tablets daily, Caltrate 600+D 1 tablet BID A Atelvia B Caltrate 600+D C Norvasc D Soltamox E No other changes are necessary

A, B *Altevia is risedronate *Chronic acid-suppressing drugs like H2RAs and PPIs interact with medications that require an acidic environment for absorption. This includes Atelvia (delayed release risedronate). Other examples include: itraconazole, ketoconazole, and iron. LK is already taking calcium carbonate which has lower asborption at higher gastric pH than calcium citrate.

Which of the following proton-pump inhibitors should be avoided in patients taking clopidogrel? (Select ALL that apply.) A Omeprazole B Esomeprazole C Pantoprazole D Rabeprazole E Dexlansoprazole

A, B Omeprazole and esomeprazole should be avoided in patients taking clopidogrel. They inhibit CYP2C19 and can reduce the effectiveness of clopidogrel.

Plan: Transfuse with 2 units of packed red blood cells, start an IV proton pump inhibitor. Which of the following proton pump inhibitors can be ordered for PR? (Select ALL that apply.) A Pantoprazole B Esomeprazole C Lansoprazole D Omeprazole E Rabeprazole

A, B Only two PPIs are available in injectable formulations: pantoprazole and esomeprazole (Nexium).

A medical resident asks the pharmacist why cimetidine is used less frequently than other histamine-2 receptor blockers. Which responses from the pharmacist are correct? (Select ALL that apply.) A Cimetidine can cause gynecomastia. B Cimetidine can cause impotence. C Cimetidine has more drug interactions than other agents in the class. D Cimetidine is more expensive than other agents in the class. E Cimetidine is no longer available on the U.S. market.

A, B, C

WK is going to use Pylera for a H. pylori infection. Pylera contains bismuth subcitrate potassium, metronidazole and tetracycline in one capsule. He will take three capsules four times daily (at meals and at bedtime). Which statement/s concerning Pylera is correct? (Select ALL that apply.) A A PPI should be taken twice daily during the course of treatment (such as omeprazole 20 mg BID). B An exaggerated sunburn reaction has been seen in some individuals taking tetracycline; avoid exposure to sun or tanning beds while taking this medicine. C Do not consume alcohol during treatment. D If the patient develops diarrhea during or after this course of treatment, contact a medical provider before treating with antidiarrheal medications. E Do not consume acidic beverages during treatment.

A, B, C, D

History of Present Illness: LK is a 68 year-old white female who presents to her primary care physician with a 4-week history of worsening heartburn unrelieved by OTC medications. She experiences post-meal symptoms 3-4 times per week and is sometimes awakened at night with heartburn. She has tried OTC medications for about 3 weeks without much success. LK eats three meals a day with the last meal at 6 pm. She usually has a snack about 9 pm before going to bed. What non-pharmacological recommendations should be discussed with LK? (Select ALL that apply.) A Avoid foods that can aggravate heartburn, including spicy foods, caffeine and chocolate. B Elevate the head of the bed with a wedge to help nocturnal symptoms. C Instead of snacking close to bedtime, eat one large meal late in the evening. D Losing weight could significantly improve her symptoms. E Lie down on the right side immediately after eating.

A, B, D

Which of the following statements concerning NSAID-induced ulcers are correct? (Select ALL that apply.) A Most occur in the fundus region of the stomach. B Most occur in the duodenal bulb. C Most NSAID-induced ulcers are due to chronic use of NSAIDs. D Elderly patients are at higher risk. E Antacid use (taken concurrently with the NSAID) will protect the GI lining.

A, C, D

An elderly female has hypertension, renal insufficiency (CrCl = 32 mL/min), mild memory loss and early-onset Parkinson's disease. She was started on Sinemet two weeks ago. Her movement symptoms are improved, but she is nauseated whenever she takes the medicine. She has gone to her doctor's office and presents at the pharmacy with a prescription for metoclopramide 10 mg QID. Which of the following statements is/are correct? (Select ALL that apply.) A Her Parkinson's disease symptoms will worsen. B The dose is correct, but the schedule should be three times daily. C She will experience fatigue and sleepiness. D It is safe to use as long as the dose is reduced by 50%. E Metoclopramide is a dopamine antagonist.

A, C, E Metoclopramide (Reglan) is a dopamine-blocking agent, and will worsen Parkinson's symptoms. Further, if over-dosed, the side effects of somnolence (and fatigue) will be increased. With a CrCl < 40 mL/min, the dose should be decreased by 50%, if it is used at all. Metoclopramide is not a recommended agent for nausea in the elderly, due to the poor side effect profile. It is a particularly poor choice in a patient with Parkinson's disease.

AK is going to use Prevpac for a H. pylori infection. She will take four pills twice daily. Which statement/s concerning Prevpac are correct? (Select ALL that apply.) A This medication may make birth control pills less effective, which may result in pregnancy. B Prevpac does not include the proton pump inhibitor needed for triple or quadruple therapy. C This medication should not be used if the patient is allergic to amoxicillin. D This medicine cannot be used with alcohol, or the patient will have severe nausea and vomiting. E This medicine can cause a "metallic" taste in the mouth. Next

A, C, E Prevpac contains lansoprazole, amoxicillin and larithromycin. Clarithromycin may cause diarrhea, nausea and abnormal metallic taste (each ~3%). Antibiotics may make birth control pills less effective.

A middle-aged gentleman has reflux symptoms. He has been diagnosed with GERD and told to purchase Prilosec OTC. The patient reports that he will use the medicine whenever he gets symptoms, which occur 3-4 times per week. Choose the correct counseling statement/s: A This medication works best when taken as-needed. B This medication is best taken daily, before the morning meal. C This medication should be started twice daily. D This medication should be taken before bedtime. E This medication should be taken immediately after eating.

B

Alarm symptoms in GERD that may warrant additional testing include: A Cough, chest pain, bloody stools B Unintentional weight loss, dysphagia, hematemesis C Hypersalivation, cough, sore throat D Regurgitation, heartburn, choking E Cough, hypersalivation, acid taste

B

What is the mechanism of action of magnesium hydroxide when used for heartburn? A Neutralizes pepsin in the stomach via hydroxylation B Neutralizes acid in a buffering reaction (producing salt & water) C Inhibits (reversibly) the histamine-2 receptors on gastric parietal cells D Irreversibly binds to the H+/K+-ATPase pump in gastric parietal cells E Blocks the first step in acid production high up in the pathway.

B

What risk factors does MS have for H2RA-associated confusion? History of Present Illness: MS is an 87 year-old female admitted to the hospital on 5/15 for a hip fracture. She has multiple medical problems including osteoporosis, hypertension, Alzheimer's disease, atrial fibrillation, and stroke. Despite this, she is in good spirits and her family is at her bedside after her surgery. She has required minimal pain medications and her surgical team is being cautious with opioids due to her age. A Age > 80 and recent surgery B Age > 50 and renal impairment C Renal impairment and hepatic impairment D Renal impairment and recent surgery E Recent surgery and hepatic impairment

B Confusion from H2RAs is usually reversible when they are discontinued. Risk factors are age > 50 and renal or hepatic impairment. MS meets two of these criteria. Decrease the dose of famotidine, ranitidine, and nizatidine when CrCl is < 50 mL/min.

Allergies: Penicillin (rash), ciprofloxacin (numbness) Past Medical History: None Medications: Has tried self-treating the pain with OTC Prilosec with no improvement Tests: Urea breath test (negative) SD is diagnosed with H. Pylori via endoscopy sampling. Choose the most appropriate therapeutic regimen for SD. (Select ALL that apply.) A Lansoprazole 30 mg BID + Amoxicillin 1,000 mg BID + Clarithromycin 500 mg BID x 14 days B Lansoprazole 30 mg BID + Clarithromycin 500 mg BID + Metronidazole 500 mg BID x 14 days C Lansoprazole 30 mg BID + Bismuth subsalicylate 525 mg QID + Metronidazole 500 mg QID + Tetracycline 500 mg QID x 7 days D Lansoprazole 30 mg BID + Bismuth subsalicylate 525 mg QID + Metronidazole 250 mg QID + Tetracycline 500 mg QID x 14 days E Lansoprazole 30 mg daily + Amoxicillin 1,000 mg BID + Metronidazole 500 mg BID x 14 days

B & D

SH uses omeprazole daily for heartburn. She is elderly and frail. Which of the following questions should the pharmacist ask SH that is important to know when using chronic PPI therapy? A Does she get enough vitamin E? B Is she experiencing diarrhea? C Does she consume dairy products and/or take calcium/vitamin D supplements? D Does she have unusual headaches? E Does she use zolpidem for sleep?

B, C If a patient is taking long-term acid-suppression therapy (especially PPIs), ensure that calcium and vitamin D intake is optimal as long-term use increases the risk for fractures. PPIs can also increase the risk of C. difficile associated diarrhea.

Which of the following proton pump inhibitors come in capsules that can opened and mixed in applesauce if a patient cannot swallow pills? (Select ALL that apply.) A Pantoprazole B Lansoprazole C Esomeprazole D Dexlansoprazole E Omeprazole

B, C, D, E

A pregnant female is asking the pharmacist for a recommendation for heartburn symptoms. The symptoms began during the third month of the pregnancy (she is currently 14 weeks pregnant). She states that whenever she eats anything, she has heartburn. She takes a daily prenatal vitamin. She gets adequate calcium from the vitamin and a cheese stick she eats with lunch. Choose the most appropriate recommendation. A Tagamet B Protonix C Tums D Misoprostol E Metoclopramide

C

HL, a pregnant 33 year-old female, comes to your pharmacy with a prescription for Pylera. Her medication profile consists of a Citranal DHA prenatal vitamin. The patient has a noted allergy for codeine and iodine. The patient is symptomatic and the prescriber confirms that treatment will be used. Which of the following components of Pylera could cause tooth discoloration of the baby's teeth and can interfere with bone development? A Bismuth subcitrate potassium B Metronidazole C Tetracycline D All of them can do this E None of these agents are likely to do this

C

What is the mechanism of action of famotidine? A Neutralizes pepsin in the stomach via hydroxylation B Neutralizes acid in a buffering reaction (producing salt & water) C Reversibly inhibits the histamine-2 receptors on gastric parietal cells D Irreversibly binds to the H+/K+-ATPase pump in gastric parietal cells E Blocks the first step in acid production high up in the pathway

C

What is the mechanism of action of sucralfate? A Dopamine blocker B Prokinetic agent C Provides a protective barrier for the gut D Prostaglandin analog E Phosphodiesterase inhibitor

C

Which of the following are possible complications if a H. pylori infection if left untreated? A C. difficile infection B GERD C Gastric cancer D Cirrhosis E Pancreatitis

C

LK is a 68 year-old white female who presents to her primary care physician with a 4-week history of worsening heartburn unrelieved by OTC medications. She experiences post-meal symptoms 3-4 times per week and is sometimes awakened at night with heartburn. She has tried OTC medications for about 3 weeks without much success. LK eats three meals a day with the last meal at 6 pm. She usually has a snack about 9 pm before going to bed. In addition to lifestyle modification, which of the following is the best recommendation to manage LK's symptoms? A LK should be referred for endoscopy. B LK should be treated empirically with famotidine for 6 weeks. C LK should be treated empirically with esomeprazole for 8 weeks. D LK should be treated empirically with sucralfate for 2 weeks. E LK should take scheduled antacids indefinitely.

C An 8-week course of a PPI is recommended for this patient because she has GERD (by definition, symptoms occur at least twice weekly). Lifestyle measures can be helpful and should be used in conjunction with drug therapy. Symptoms should be re-evaluated after 8 weeks

History of Present Illness: MS is an 87 year-old female admitted to the hospital on 5/15 for a hip fracture. She has multiple medical problems including osteoporosis, hypertension, Alzheimer's disease, atrial fibrillation, and stroke. Despite this, she is in good spirits and her family is at her bedside after her surgery. She has required minimal pain medications and her surgical team is being cautious with opioids due to her age. 48 hours later, MS is confused and her family is very concerned. She has no other new symptoms. Though MS has Alzheimer's disease, this is very different behavior for her. What is the most likely cause of this new-onset confusion? Plan (5/15): Start cefazolin 1 gm IV Q12H, famotidine 20 mg IV BID, and heparin drip after surgery and no sooner than next scheduled dose of rivaroxaban. Pain management orders per surgery team. A Acute renal failure B Cefazolin C Famotidine D Stroke E Alzheimer's disease

C H2RAs can cause CNS side effects. Beers Criteria recommends avoiding use in select populations, especially in those with dementia or cognitive impairment. The CT scan is negative for stroke. Acute renal failure does not cause neurological side effects usually unless the BUN is extremely elevated (e.g., close to 100).

GH has had GERD for many years. She tried OTC products with no relief and finally went to her primary care doctor. Her PCP prescribed 8 weeks of Protonix and counseled her on lifestyle modifications. Her symptoms completely went away. She has been off Protonix for 3 weeks. Today she reports to her PCP that some of her symptoms have returned but they aren't as bad or as frequent as before. She has GERD symptoms after eating late at night and immediately going to bed, which she knows she should not do. She has also had symptoms during the day that do not seem to be related to meals. This happens 5-6 days per week. What recommendation is most appropriate for GH at this time? A OTC antacids as needed B OTC H2RA as needed C Her PCP should prescribe an H2RA D Her PCP should prescribe maximum dose PPI E Her PCP should prescribe metoclopramide

C Options for maintenance therapy include lowest effective dose of PPI or H2RAs (if they provide relief of symptoms). GH's symptoms (5-6 days per week) are too frequent to manage with OTC products. If the H2RA does not control her symptoms, she may require chronic PPI therapy.

Generally, PPIs are taken within 60 minutes before a meal. What is the rationale behind this direction? A The drug must be present in the gut prior to the entry of food. B The drug is not well-absorbed on an empty stomach. C PPIs inhibit proton pumps that are actively secreting acid. D PPIs require gastric acid for absorption. E It takes a long time for the beads to dissolve in the stomach.

C Since PPIs only inhibit proton pumps that are actively secreting acid in response to a meal, they are most effective when taken 30-60 minutes before a meal. This provides sufficient time for the drug to reach the site of action.

Question The provider suspects SD has H. Pylori. What is the best indicator that his suspicions are correct based on the information provided? A H. pylori occurs more frequently in patients with flouroquinolone allergies B Negative urea breath test C Eating lessens the pain D Eating worsens the pain E H. pylori occurs more frequently in patients with penicillin allergies

C Usually, with H. pylori infection, the pain will be lessened by eating, especially if the ulcer is in the duodenum. Although SD has a negative urea breath test, he has been using a PPI which can cause a false negative result. PPIs, antibiotics and bismuth products must be discontinued 2 weeks prior to testing.

The provider suspects SD has H. Pylori. What is the best indicator that his suspicions are correct based on the information provided? A H. pylori occurs more frequently in patients with flouroquinolone allergies B Negative urea breath test C Eating lessens the pain D Eating worsens the pain E H. pylori occurs more frequently in patients with penicillin allergies

C Usually, with H. pylori infection, the pain will be lessened by eating, especially if the ulcer is in the duodenum. Although SD has a negative urea breath test, he has been using a PPI which can cause a false negative result. PPIs, antibiotics and bismuth products must be discontinued 2 weeks prior to testing.

Which of the following proton pump inhibitors comes in a combination drug with aspirin? A Pantoprazole B Esomeprazole C Omeprazole D Dexlansoprazole E Rabeprazole

C Yosprala is a new combination tablet that includes omeprazole and aspirin (81 or 325 mg). It is indicated for patients with high GI risk who require aspirin for prevention of cardiovascular events.

A patient who suffers from heartburn was using an OTC H2RA. He went to his physician complaining of continuing heartburn symptoms. The physician suggested trying OTC omeprazole. He told the patient that omeprazole is stronger than the medicine he has been taking. What is the mechanism of action of omeprazole? A Neutralizes pepsin in the stomach via hydroxylation B Neutralizes acid in a buffering reaction (producing salt and water) C Reversibly inhibits the histamine-2 receptors on gastric parietal cells D Irreversibly binds to the H+/K+-ATPase pump in gastric parietal cells E Blocks the first step in acid production high up in the pathway

D

An endoscopy is performed and a tissue sample is taken to test for H. Pylori. Choose the statement that best describes this organism: A It is an invasive fungi B It is a protozoal organism C It is a gram positive cocci seen in pairs D It is a spiral-shaped gram negative bacterium E It is an oblong shaped viral organism

D

CA comes into the pharmacy with a prescription for Pylera, which has been on back-order from the supplier for two weeks. The pharmacist contacts the prescribing physician to inform him that the medication is not in stock. The physician states that the patient must start this medication today and asks if the components that make up Pylera are in stock. Which medications should be selected to fill the Pylera prescription? Answer A Lansoprazole, Amoxicillin, Metronidazole B Lansoprazole, Amoxicillin, Clarithromycin C Bismuth subsalicylate, Metronidazole, Minocycline D Bismuth subcitrate potassium, Metronidazole, Tetracycline E Bismuth subsalicylate, Metronidazole, Amoxicillin

D

What is the mechanism of action of misoprostol? A Prokinetic agent B Coats the stomach with a protective lining C Histamine-2 receptor antagonist D Prostaglandin analog E Proton pump inhibitor

D

What is the physical (mechanical) cause of gastroesophageal reflux disease? A The histamine receptors over-secrete acid. B The parietal cells over-secrete acid. C Food gets stuck in the esophagus. D Lower esophageal sphincter tone is reduced. E The gastric muscle contracts suddenly.

D

When a pharmacist is dispensing Pylera they are careful to counsel the patient that they may notice a temporary and harmless darkening of the tongue and/or black stool. What is causing this effect? A The PPI they are taking concurrently B Metronidazole C Tetracycline D Bismuth E A breakdown product from the H. pylori

D

GG is a 70 year-old patient who has seen a television commercial for Dexilant SoluTab and subsequently asked his doctor for a prescription. He has had reflux symptoms for years, but was using chewable calcium tablets when he felt enough discomfort. GG's insurance plan will not cover Dexilant SoluTab until he had failed two trials of the PPIs that are available as generics. This is upsetting to GG. Choose the correct statement: Answer A The best PPI, with the highest documented symptom relief, is AcipHex Sprinkle. B The best PPI, with the highest documented symptom relief, is Nexium. C Due to his age, GG should be using metoclopramide instead. D Dexilant SoluTab is not more effective than other PPIs. E Due to his age, GG should be using famotidine instead.

D All PPIs are considered equivalent although a patient may respond better to one agent than another. This is why most insurance plans require the patient to fail trials of generics first. Metoclopramide and famotidine has risks associated with use in elderly patients.

At discharge, PR and his wife ask what the best options are for pain management. Which of the following is an appropriate recommendation given PR's history? A Arthrotec B Fentanyl patch C Celebrex D Vimovo E Indomethacin

D In patients at high-risk of GI bleeding who must take an NSAID, a PPI should be given concomitantly. Naproxen has the lowest CV risk in patients with a history of cardiac disease. Celecoxib should not be used in patients with a history of cardiovascular disease and/or a sulfa allergy.

An elderly patient is purchasing several large bottles of Maalox. Her medications include sertraline, furosemide, carvedilol, lisinopril and Epogen. Her conditions include depression, hypertension, heart failure, renal insufficiency and anemia secondary to renal insufficiency. Which of the following recommendations should be made? A This medicine should not be used in patients with depression. B This medicine contains a salicylate and should be avoided in patients with aspirin allergies. C This medication should be separated from the patient's furosemide. D This medicine can accumulate in patients with kidney dysfunction. E This medicine can increase the patient's blood pressure.

D Maalox contains aluminum and magnesium hydroxide. A small amount is absorbed, which is excreted renally. This usually poses no health risks and antacids are considered a safe class of medications. However, in patients with poor renal function, both aluminum and magnesium can accumulate when used excessively. This can cause significant toxicities (magnesium can cause arrhythmias and seizures; aluminum is a neurotoxin).

A female patient is using naproxen 250 mg twice daily for Achilles' tendon pain. She was a long distance runner, but was forced to stop due to the painful heel injury. After using the medication for about a month, she began to experience stomach upset, and her physician prescribed misoprostol 100 mcg QID. The physician stated that he did not wish to begin chronic acid suppression therapy in a young female patient due to recent reports of increased fracture risk. Which of the following statements is correct? A The primary side effects of misoprostol are headache and peripheral edema. B Misoprostol works by coating the stomach with a protective lining. C Misoprostol is safe to use in pregnancy. D The primary side effects are diarrhea and abdominal pain. E The brand name of misoprostol is Arthrotec.

D Patient adherence to misoprostol therapy is very poor, due to significant diarrhea and cramping. Misoprostol can induce abortion, and has a boxed warning for being an abortifacient. It is safest to avoid misoprostol in women of childbearing age.

LF approaches the pharmacist for assistance with OTC GERD treatments. She has been taking Pepcid AC Max Strength twice daily for 3 weeks, though she knows the directions say not to take it longer than 2 weeks. The pharmacist should suggest the following: A Switch to a proton pump inhibitor, such as omeprazole, taken daily (30 minutes before breakfast). B Switch to an histamine-2 receptor antagonist, such as ranitidine. C Reduce the Pepcid dose to once daily. D Make an appointment to see a doctor. E Use regular enemas to cleanse the bowel.

D Patients self-treating with OTC products who do not find improvement should be referred for medical evaluation.

OTC medications: Pepcid Complete, 1-2 tablets daily, Caltrate 600+D 1 tablet BID Which over the counter medication has LK been using to self-treat her symptoms? A Famotidine B Famotidine + simethicone C Famotidine + omeprazole D Famotidine + calcium carbonate E Famotidine + calcium carbonate + magnesium hydroxide

E

Protonix

pantoprazole

zantac

ranitidine