NBME 23 Area labeled ‘B’ (NBME Answers)

Retired NBME 23 Answers

nbme23/Block 2/Question#33 (reveal difficulty score)
A 68-year-old man who has been treated for ...
Area labeled ‘B’ 🔍 / 📺 / 🌳 / 📖
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+16 upvote downvote
submitted by ∗thotcandy(131)

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Everyone asking why not PPIs?

if you give NSAIDs which decrease PGs so you get GERD, the simplest way to fix it is to bring those PGs back, so misoprostol.

Just simply -PGs --> +PGs

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hungrybox This is the best explanation IMO Also makes me feel like an absolute idiot +9

guber also per FA, misoprostol is used specifically for prevention of NSAID_induced peptic ulcers +4

cuteaf I think the key to answering this question is to remember the specific side effects associated with misoprostol -> severe diarrhea. No other GERD medications in the answer choices have this side effect. Antiacids could also cause diarrhea (MgOH) but not in the answer choices +4

deathcap4qt Actually one of the side effects of PPI use is diarrhea (and other GI issues). Not in FA but emphasized in AMBOSS and Sketchy. I got this Q wrong for that reason but I see now why Misoprostol is the better answer. +3

veryhungrycaterpillar That's wild. I take PPIs like candy and I've never had diarrhea, but I chose histamine blocked because Pepcid/Famotidine gives me the WORST diarrhea ever. +

an1 I changed my answer from PG to PPI because I recall sketchy saying PPI was the best for an ulcer, adn they both had diarrhea in the sketch. but I realized why im wrong Why isn’t this PPI (E)? because PPI’s INHIBIT the pump (should have been a dotted line) Also, PPI’s increase the risk for C.Diff which can lead to diarrhea, they don’t directly cause diarrhea unline PG misoprostol PPI RF’s include osteoporosis, lung decline, increased risk for AI Nephritis, and reduced absorption of Fe, Mg, and Ca (not the best choice for an old guy) +1

kcyanide101 NBME [redacted] HAS A VERY SIMILAR Q THAT THEY CHOSE PPI over PG analog for NSAID induced stomach issue! Really annoying how they flip! +1

+5 upvote downvote
submitted by emh(11)

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Prostaglandins increase GI motility due to peristalsis. It's the same reason why the uterus contracts during menstruation.

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samsam3711 Also Misoprostol is used for the prevention for NSAID induced peptic ulcers +1

+2 upvote downvote
submitted by ∗mousie(272)

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Not sure I am understanding this question - the patient got an NSAID for RA and this decreased her prostaglandins so she developed GERD... Doc added Misoprostol to counteract the decreased Prostaglandins I the gut and an adverse reaction of Misoprostol is diarrhea .. Correct?

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chris07 Yes. Diarrhea is a side effect of misoprostol. +3

+1 upvote downvote
submitted by xw1984(8)

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English is not my first language.

I think the reason that not using PPI is the Q mentions other adverse effects than gastric burning:

"... has severe gastric burning and discomfort... THESE adverse effectS".

Therefore, I guess PPI can relieve gastric burning but not discomfort, so we give the patient what he is lack of.

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+1 upvote downvote
submitted by dubchak7(1)

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They suggest Misoprostol to counteract NSAIDs... Why not PPIs?

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hayayah PPI's don't have many side effects! If the question didn't involve the diarrhea side effect the answer would have been to give her a PPI. +3

tsarcoidosis I guess one takeaway is that PPIs don't directly cause diarrhea, but they do increase the risk for C-diff, which causes diarrhea. +19

usmleuser007 PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium) +2

temmy The patient got severe gastric burning and discomfort as an effect of the drug. My logic was since the patient was taking an NSAID it had to be a COX 1 inhibitor that destroys the protective barrier of the GI mucosa due to inhibition of prostaglandin so we needed to treat with a drug that will regenerate prostaglandin and prostaglandin is a vasodilation which might be the reason for the diarrhea. +1

+1 upvote downvote
submitted by ∗donttrustmyanswers(74)

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I just realized there were solid arrows and dashed arrows in the image. Is there a significant to the dashed arrows vs the solid arrows?

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faus305 The solid lines are the correct answers. lol jk but not really +

+1 upvote downvote
submitted by ∗hhsuperhigh(49)

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My guess for not choosing PPI is because the duration of drug-using. PPI increases the risk of C. diff by long-term using which considered as over 1 year of using. This pt should have used the second drug less than 4 weeks according to the question. So PPI is unlikely to cause C. diff diarrhea within this short period of usage, especially when this pt is not immunocompromised, or using antibiotics.

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+0 upvote downvote
submitted by ∗criovoly(17)

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The first drug given was an NSAID (prostaglandins inhibitor) this caused GERDS/ulcer because of decrease mucosal protection.

The second drug was misoprostol which gives mucosa protection and a common side effect is diarrhea.

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+0 upvote downvote
submitted by ∗handsome(3)

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FA 2020 pg 399

misoprostol clinical use - prevention of NSAID induced peptic ulcers

MOA: PGE1 analog in effect causes decrease acid production and increase secretion of gastric mucous barrier.

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-2 upvote downvote
submitted by ∗usmleuser007(464)

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PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium)

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imnotarobotbut That's not the right answer tho, the answer is the binding of PGE to it's receptor +

tinydoc Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1

maxillarythirdmolar Keep it simple, stupid. +1

roaaaj @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +

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