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GI/Hepatic > Constipation and IBS > Flashcards

Constipation and IBS Flashcards

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1
Q

What is the definition of constipation?

A

Described by < 3 bowel movements per week, stool size or consistency, or sensation of incomplete defecation

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2
Q

What are the mechanical causes of constipation?

A

Colorectal cancer
Colon, rectal or anal stricture
Intestinal pseudo-obstruction
Megacolon

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3
Q

What are the neurologic disease causes of constipation?

A

Spinal cord lesion
Stroke
Parkinson’s disease
MS

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4
Q

What are the metabolic disturbance causes of constipation?

A 
Hypercalcemia
Hypokalemia (severe)
Hypomagnesemia
Hypothyroidism (severe)
Uremia
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5
Q

What medications can cause constipation?

A 
Opioids
Anticholinergics
Ca Channel blockerws
Anticonvulsants
Antidepressants
Antispasmodics
Antihistamines
Antiemetics (zofran)
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6
Q

What is acute constipation?

A

Usually treatable with lifestyle changes (diet, fluid intake, exercise) and OTC treatment

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7
Q

What is chronic constipation?

A

Often requires Rx treatment if patient does not respond to lifestyle changes and OTC treatment

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8
Q

What is opioid induced bowel dysfunction?

A

constellation of GI symptoms including N/V, OIC (most common), abdominal cramping, bloating, and abdominal pain

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9
Q

What is OIC?

A

Opioid induced constipation

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10
Q

What are the nonpharmacological therapies for treatment of constipation?

A 
Increase fiber in diet (25-40g/day)
Increase fluid intake (6-8 glasses of water per day)
Increase exercise (3-5d/wk)
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11
Q

How does insoluble fiber work?

A

Insoluble fiber reduces the risk of colon cancer by increasing transit through the colon and decreasing the time carcinogens are in contact with the mucosa. It also dilutes the carcinogenic substance

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12
Q

How does soluble fiber work?

A

Soluble fiber has been shown to decrease cholesterol by binding to bile acids in the intestines
It also regulates blood glucose by slowing stomach emptying resulting in a steadier rate of carb absorption in the small bowel

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13
Q

What are the saline osmotic laxatives?

A

Mag Citrate
Mag hydroxide
Mag Sulfate
Sodium phosphate

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14
Q

What is the onset of action for saline osmotic laxatives?

A

Fast (15min - 3 hours)

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15
Q

What are osmotic laxatives?

A

Glycerin
Lactulose
PEG

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16
Q

What is the onset of action for glycerin?

A

Fast (w/in 1 hour)

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17
Q

What is the onset of action for lactulose?

A

1-2 days (may require multiple doses)

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18
Q

What is the onset of action for PEG?

A

1-3 days

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19
Q

What are stimulant laxatives?

A

Bisacodyl

Senna

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20
Q

What is the onset of action for bisacodyl?

A 
6-12 hours (oral)
1 hour (supp.)
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21
Q

What is the onset of action for senna?

A

6-12 hours

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22
Q

What are the bulk forming laxatives?

A

Psyllium
Wheat dextrin
Calcium polycarbophil
Methylcellulose

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23
Q

What is the onset of action for bulk-forming laxatives?

A

12-72 hours

Less effective in drug-induced constipation

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24
Q

What is a stool softener?

A

Doc sodium

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25
What is the onset of action for doc sodium?
1-6 days
26
What is a chloride channel activator?
Amitiza
27
What is Amitiza's MOA?
Activates chloride channels in colon to draw fluid into colon
28
What is Amitiza FDA approved for?
CIC in adults IBS-C Chronic OID
29
What is the onset of action for amitiza?
w/in 24 hours
30
What preg category is amitiza?
C but animal studies suggest the potential for fetal death | Women should have (-) test prior to starting and should use BC while taking
31
What are common ADRs of Amitiza?
HA Diarrhea Nausea Dyspnea
32
What is a guanylate cylase-C agonist?
Linzess | Trulane
33
What is the MOA of Linzess and Trulance?
Increases chloride secretion into intestinal lumen increasing intestinal fluid and decreases transit time (also decreases visceral pain by inhibiting afferent nerve activity)
34
What is Linzess FDA approved for?
CIC in adults | IBS-C
35
What is the onset of action for Linzess?
w/in 1-2 days
36
What is Linzess/Trulance contraindicated for?
Peds up to age 6 (avoid 6-17yo)
37
What are ADRs for Linzess?
GI (diarrhea, flatulence, ab distension) | HA
38
What is Trulance FDA approved for?
CIC in adults
39
What is the onset of action for Trulance?
1-2 days
40
What are the ADRs for Trulance?
GI (diarrhea, flatulence abdominal distension)
41
What are the peripheral opioid antagonists?
Methylnaltrexone Naloxegol Alvimopan Naldemedine
42
What is the MOA of peripheral opioid antagonists?
Blocks opioid binding to the mu, kappa, and gamma receptors in the periphery - Does not cross BBB - Does not affect opioid analgesic effects or induce opioid withdrawal
43
What is methylnaltrexone FDA approved for?
Chronic OIC in both cancer and noncancer pain
44
What is the onset of action for methylnaltrexone?
30-60 minutes in responding patients
45
What enzyme metabolizes methylnaltrexone?
Substrate of CYP 2D6 (minor)
46
What are the ADRs of methylnaltrexone?
GI (ab pain, flatulence, nausea)
47
What is naloxegol FDA approved for?
Chronic OIC in noncancer pain
48
What is the OOO for naloxegol?
6-12 hours
49
How is naloxegol metabolized?
Substrate for CYP 3A4 and P-gp resulting in several drug interactions
50
What is are the ADRs for naloxegol?
GI (ab pain, diarrhea, flatulence, N/V, HA
51
What is alvimopan FDA approved for?
Treatment of post-op ileus
52
What is the OOO of alvimopan?
4-7 hours
53
What are the ADRs for alvimopan?
Hypokalemia | Dyspepsia
54
What is naldemedine FDA approved for?
Tx of Chronic OIC in noncancer pain
55
What is the OOO of naldemedine?
4-24 hours
56
How is naldemedine metabolized?
Subwstrate of CYP 3A4 (major) and P-gp resulting in potential for several drug interactions
57
What are the ADRs for naldemedine?
Ab pain Diarrhea Nausea
58
What is a combination peripheral opioid antagonist and opioid agonist?
Targinig ER (Oxycodone/Naloxone)
59
What is the MOA of Targinig ER?
Naloxone which has a high affinity for opioid receptors in the GI tract, displaces oxycodone from GI tract opioid receptors making oxycodone available for transport to the brain where it exerts its opioid effect. With less opioid binding in the GI tract there will be less opioid inducing constipation
60
What is Targinig ER FDA approved for?
Treatment of moderate to severe pain requiring daily, around the clock, long term opioid treatment
61
Can Naloxone cross the BBB?
Yes - while it has very high first pass hepatic metabolism it still crosses the BBB and can reverse the analgesic effects of opioids
62
What is IBS?
Characterized by altered bowel habits AND abdominal pain for at least 3 months
63
What are the types of IBS?
IBS-constipation predominant (IBS-C) IBS-diarrhea dependent (IBS-D) IBS-mixed constipation/diarrhea
64
When is IBS prevalent?
3-4th decade | Usually resolves 6-7th decade
65
What are the physiologic abnormalities in IBS?
Altered GI reactivity (motility, secretion) to luminal (food, distention, inflammation, bacteria) or environmental (psychosocial stress) stimuli, resulting in diarrhea and/or constipation Hypersensitive GI tract with enhanced visceral perception and pain Dysregulation of the brain-GI axis
66
What is encompassed by the brain-GI axis?
Enteric nervous system (including afferent and efferent innervation) CNS HPA axis Serotonin - 80% of all serotonin found in GI tract; increases peristalsis and secretory reflexes
67
How do we diagnose IBS?
Symptom based criteria since there is no diagnostic test
68
What are alarm symptoms?
``` Rectal bleeding Anemia Weight loss Fever FH of colon cancer Onset of sx after age 50 Major change in sx ```
69
What do we do if there are alarm sx present?
Rule out other dz | Always test for celiac dz
70
What are the non-pharma and CAM treatment for IBS?
``` Exclude dietary triggers Exercise for 30-60min 5 d/wk Psychological treatment (hypnosis, cognitive behavioral therapy, psychotherapy) Acupuncture Chinese, indian, tibetan herbs Peppermint oil - anispasmodic; Melatonin ```
71
What are the Pharm tx for IBS?
Treat gut dysmotility AND pain
72
What is the MOA of antispasmodic agents?
Inhibit muscarinic cholinergic receptors on smooth muscle
73
What are the ADRs for antispasmodic agents?
Anticholinergic
74
What are antispasmodic agents?
Hyoscyamine Dicyclomine Clindinium chlordiazepoxide
75
What is the MOA of TCA's?
Reduce sensitivity of peripheral nerves or to changes that occur in the brain (anticholinergic) Reduce pain and normalize GI transit time
76
What is an example of TCAs?
Amitriptyline
77
When will benefits be seen for TCAs?
w/in 2 weeks - if not seen by 4 weeks DC
78
How long should TCAs be used to treat IBS?
at least 6 months
79
When should TCAs not be used for IBS?
IBS-C or mixed d/t the consitpating effects of TCAs
80
What is the potential MOA of SSRIs on IBS?
Decreases visceral hypersensitivity
81
What are ADRs of SSRIs?
Zoloft/prozac: diarrhea Paxil: constipation or diarrhea Celexa/Lexapro: useful for all IBS
82
What are SNRIs shown to be effective for in IBS?
Cymbalta and Effexor have been shown to be effective in reducing pain in other chronic conditions, but data is lacking
83
What do 5-HT3 receptor antagonists treat?
IBS-D for both diarrhea and pain
84
Which 5-HT3 receptor antagonist is only approved for women with severe IBS-D?
Lotronex
85
What are two 5-HT3 receptor antagonists used for IBS-D?
Lotronex | Zofran
86
What is the peripheral mu-opioid receptor agonist?
Viberzi
87
What is the MOA of Viberzi?
Mixed locally acting, kappa-opioid agonist, and a delta-opioid receptor antagonist (very little oral absorption)
88
What is Viberzi approved for?
IBS-D to improve diarrhea with ab pain
89
How is Viberzi metabolzied?
Substrate of several enzymes Inhibits P-gp Several potential drug interactions
90
What are the ADRs for Viberzi?
Nausea Constipation Rare pancreatitis (EtOH drinkers)
91
What antibiotic is used for IBS?
Xifaxan
92
What is Xifaxan FDA approved for?
IBS-D
93
What is Xifaxan used off-label for?
Tx of C. diff colitis
94
What are other FDA indications for Xifaxan?
Traveler's diarrhea | Hepatic encephalopathy prophylaxis
95
What are probiotics most useful for?
Bloating

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