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Flashcards in GI Deck (26):
1

ANTACIDS
Metallic
Basic

Agents with highest ANC

fasting- reduce acidity for
after meal- reduced for

metallic- ca, al, mg
basic- hydroxide, bicarbonate, carbonate

Sodium bicarbonate and calcium carbonate (suspensions)

20-40 minutes
2-3 hours

2

ANTACIDS PRECAUTIONS

Ca- based

Mg-based

Al-based

ca- requires vitamin d - hypercalcemic or renal calculi

mg- renal failure

al- renal failure or dialysis- worsens dialysis osteomalacia

*sodium content for HTN CHF RENAL

3

ANTACID ADR
mg
al and ca

USE
hyperacidity
pud
gerd

diarrhea
constipation
(maalox has both neutralizes effects)

hyperacidity- QID
PUD- used after meals and bedtime, adjunct
combined anacids alum/mag
GERD- every 30-60 until subside

4

ANTIDIARRHEALS
-
-
-

Absorbent (keolin/pectin, pepto bismal)

Opiates- diphenoxylate with atropine (lomotil); difenoxin with atropine (motofen); loperamide (imodium) SCHEDULE V

Anticholinergics (atropine)

5

ANTIDIARRHEAL PRECAUTIONS/ADRS

Special populations

Bismuth salicylate

Opiods (tid or qid)

use caution with all in elderly
contraindicated in children
pregnancy category C except Imodium is B (lactation use caution)

bismuth-
reye syndrome children with flu like illness
can turn tongue black-idiosyncratic
risk of toxicity with aspirin
risk for hypoglycemia

Opioids- decrease intestinal motility can lead to toxic megacolon
diphenoxylate and difenoxin with atropine- anticholinergic and CNS effects

6

CYTOPROTECTIVE AGENTS

-_____ precautions, adrs, interactions
-


DOSING QID

carafate- binds to ulcer tissue
-no precautions, cat B
-constipation
-decreases absorption

cytotec (misoprostol)- prostaglandin analog replaces prostaglandins (NSAIDS)
- RENAL
-PREGNANCY X- DO NOT GIVE abortifacient
-diarrhea, menstrual
-mag- increase diarrhea

7

CYTOPROTECTIVE EDUCATION
misoprostol
carafate

misoprostol take with food- if diarrhea greater than a week contact provider, cat X

carafate on empty stomach, constipation prevention

8

ANTIEMETICS
-
-
-
-
-

Antihistamines (benadryl, vistaril)
Phenothiazines (compazine, phenergan)
Cannabinoids (marinol)
5ht3 receptor antagonists (SETRONS- ondansetron, palonosetron)
Misc.- tigan

9

ANTIEMETICS

antihistamine cons.

phenothiazines cons.

cannabinoids cons.

5ht3-

anticholinergic- caution in elderly

extrapyramidal reactions- do not give in parkinsons
promethazine- fatal resp depression in <2 and long term use can lead to bone marrow depression and blood dyscrasias

euphoria, depression, somnolence, CV (palp, tach, hypotension) SEIZURE LIKE ACTIVITY- contraindicated in seizure d/o; may cause behavior changes

constipation, fatigue, dizziness, diarrhea, RARE CV(tachy, brady, hypotension QT prolongation) CAN mask progressive ileus

10

ANTIEMETIC USE
n/v gastroenteritis or d/t drugs use:

motion sickness

vomiting d/t gastroparesis

5ht3- low side effect
phenothiazine (not in children) initial short term

dramamine or meclizine 1 to 2 hours before

prokinetic

11

ANTIEMETIC THINK...

additive cns or anticholinergic effects- elderly

12

Histamine2 Receptor Antagonists
-
-
-
-
-

use

TIDINE
Cimetidine
Ranitidine
Famotidine
Nizatidine

reduce gastric acid secretion NPO, GERD, prophylaxis

13

h2ra CONSIDERATIONS

caution with

Special populations

ADR


renal disease- adj needed, NIZATIDINE and RANITIDINE (possible hepatic)

Pregnancy Category B
Children- RANITIDINE AND FAMOTIDINE approved for infants and children

Antiandrogenic (gynecomastia, impotance esp. with cimetidine)
CNS (confusion, agitation, psychosis, depression, disorientation)
Hematological (rare but severe- agranulocytosis, granulocytopenia, aplastic anemia)


14

h2ras CONSIDERATIONS CONT

Interactions

USE

Education

Interactions- cimetidine CYP dont use
If long term use or high dose MONITOR LIVER

GERD BID (not infants)
PUD- not primary, step down therapy
RENAL DOSING

Take with meals
Separate antacids by 30 to hour
Drowsiness
Smoking/alcohol

15

PROKINETICS
action
ex.

Precautions

Special population

stimulate motility of GI tract without stimulating secretions
Metoclopramide (Reglan)

Black box warning- tardive dyskinesia, do not give to parkinsons
Any GI problems suspected do not give (bleed, obstruction, perforation)
History of depression- caution (possible SI)
RENAL DEPRESSION

Pregnancy Category B

16

PROKINETICS

ADRS


Interactions

Dosing consideration

tardive dyskinesia, depression dizziness, diarrhea
HYPOGLYCEMIA in diabetes
Rare- galactorrhea, amenorrhea, gynecomastia, impotence

Anticholinergics reverse action (trying to speed up motility anticholinergic is slowing it down)

Increased risk EPS with other drugs that can cause EPS

CrCl below 40 initiate at half daily dose

17

PROKINETICS EDUCATION

30 mins before meals
do not double dose
drowsy
additive cns with cns depressants (alcohol)
report involuntary movements

18

PPI

precautions
esp. special pop

antisecretory-

LIVER
PREGNANCY B or C (use caution, anomalies)
ELDERY
can mask s/s gastric cancer

Children
Esomeprazole, omeprazole, and lansoprazole approved shorte term in children >1
Pantoprazole and rabeprazole only for children >12

19

PPI cont

risk for ________
long term use ______

Interaction with ___

nutrient deficiencies (iron, b12, calcium--osteoporosis) and microbial pathogens (pneumonia, c.diff) d/t decreased acidic environment

plavix- decrease effectiveness (omeprazole)
Atazanivir, indinavir, nelfinavir- decrease effectiveness
MONITOR WARFARIN PTS

20

LAXATIVES
types

stimulants- senna cascara bisacodyl castors oil
osmotics- mag hydroxide, mag citrate, sodium phosphate, polyethylene glycol
bulk producing- psyllium, methylcellulose, and polycarbophil
lubricants- mineral oil
surfactants- docusate sodium, docusate calcium
hyperosmolar-glycerine, lactulose

21

LAXATIVES
Precautions contraindications

contraindicated in
magnesium hydroxide contraindicated in

rapid response short term use DOC

Slower response

Pregnancy?

presence n/v or abdominal pain

renal dysfunction

stimulant DOC (senna, cascara, bisacodyl, castor oil) or osmotic (mag hydroxide, mag citrate, polytethylene)

bulk forming


bulk forming

22

GERD

STEP UP THERAPY



STEP DOWN

Antacid/lifestyle
H2 receptor antagonist 4-8 weeks (if resolves cont. for 12 weeks)
PPI 4-8 weeks (if better step back down, if symptoms return start back on PPI, no improvement after this refer)

PPI and lifestyle for 8 weeks (symptom free 4 weeks step down to h2ra) if not relieved increase PPI to BID for 4-8 weeks (sx free 4 weeks step back down to once a day and reassess in 6-12 months)
if symptoms arent relieved after 8 weeks refer

23

Pediatric GERD

h2ra or PPI

24

PUD tx


1. Lifestyle OTC antacids and h2 blockers
2. H.pylori testing and PPI
3. Tx h. pylori or figure out cause


25

Tx H. pylori

Triple therapy

Quadruple therapy

Once completed therapy....

PPI plus
Clarithromycin or Metronidazole
Amoxicillin
(lansoprazole, amoxicillin, clarithromycin- prevpac)
Tx 10-14 days

PPI plus
Metronidazole
Tetracycline (except childbearing age)
Bismuth salicylate
14 days
(second line tx)

continue PPI for 8-12 weeks

26

Levofloxacin based therapy for PUD H. pylori

PPI levofloxacin amoxicillin 10-14 days (second line or rescue)