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NAPLEX Review UWorld > GI Disease > Flashcards

GI Disease Flashcards

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1
Q

Which of the following describes the mechanism of action of infliximab?

A. Monoclonal antibody that binds to integrin

B. Monoclonal antibody against interleukin-1

C. Monoclonal antibodythat binds to TNF

D. Monoclonal antibody that depletes CD20 B cells

E. Monoclonal antibody that inhibits T cell activation

A

Monoclonal antibodythat binds to TNF

Remicade

Infliximab is an anti-TNF monoclonal antibody approved for several autoimmune conditions, including inflammatory bowel disease.

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2
Q

Crohn’s Disease Tx

Options

A

Steroids (± thiopurine or MTX)

Anti-TNF ± thiopurine

Ustekinumab (Stelara)

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3
Q

Crohn’s Disease Tx

Mild disease of the ileum and/or right colon

A

Oral budesonide (Entocort EC, Uceris) for ≤ 3 months; after this course, discontinue treatment or change to thiopurine or methotrexate

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4
Q

Crohn’s Disease Tx

Moderate-severe disease

A

Anti-TNF agents
* Adalimumab (Humira)
* Infliximab (Remicade)
* Certolizumab (Cimzia)

Thiopurine (azathioprine, mercaptopurine)

Methotrexate

IL receptor antagonist
* Ustekinumab (Stelara)

Agents can be used as monotherapy or in combination

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5
Q

Crohn’s Disease Tx

Refractory to mod-severe treatments and/or steroid dependent

A

Integrin receptor antagonists:

Vedolizumab (Entyvio)

Natalizumab (Tysabri)

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6
Q

Integrin Receptor Antagonist

Risk, Form, & SE

A

Risk of Progressive Multifocal Encephalopathy (PML)

IV only

Don’t give w/ live vaccines

Hypersensitivity rxn can occur

Stop Tx after 12 + weeks of not working

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7
Q

Ulcerative Colitis Tx

Options

A

5-ASA (oral and/or rectal) ± steroids (oral or rectal)

Anti-TNF agents

Ustekinumab (Stelara)

Tofacitinib (Xeljanz)

Vedolizumab (Entyvio)

IV cyclosporine

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8
Q

Ulcerative Colitis Tx

Mild disease

A

Mesalamine (5-ASA) rectal and/or oral preferred

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9
Q

Ulcerative Colitis Tx

Moderate-severe disease

A

Anti-TNF agents
* Adalimumab (Humira)
* Infliximab (Remicade)
* Golimumab (Simponi)

Thiopurine (azathioprine, mercaptopurine)

Cyclosporine

IL receptor antagonist
* Ustekinumab (Stelara)

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10
Q

Ulcerative Colitis Tx

Refractory to mod-severe treatments and/or steroid dependent

A

Integrin receptor antagonists
* Vedolizumab (Entyvio)

Janus kinase inhibitor
* Tofacitinib (Xeljanz)

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11
Q

A pharmacist will counsel a patient on the correct use of Transderm Scop. Which of the following are correct counseling statements? (Select ALL that apply.)

A. Peel off the clear backing from the patch and apply it to a clean, dry, hairless area of the skin behind the ear.

B. Press firmly for at least 30 seconds to make sure the patch sticks well, especially around the edges.

C. Apply the patch 1 hour before the activity expected to cause motion sickness.

D. If motion sickness continues after 3 hours, apply a second patch behind the other ear.

E. Carefully wash hands after application and do not touch eyes if there is any medication on fingers.

A

Peel off the clear backing from the patch and apply it to a clean, dry, hairless area of the skin behind the ear.

Press firmly for at least 30 seconds to make sure the patch sticks well, especially around the edges.

Carefully wash hands after application and do not touch eyes if there is any medication on fingers.

An important counseling point for Transderm Scop is that it should be applied at least 4 hours before the activity expected to cause motion sickness.

As with most patches, it should not be cut.

Remove the old patch when it is time to place the next patch.

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12
Q

Scopolamine (Transderm Scop)

Things to remember

A

Alternate Ears

Can cause painful/mydriasis (dialation of pupils) if it gets in eyes

Last 3 days

Remove prior to MRI

Apply at least 4 hours before needed or the night before surgery

Press firmly for 30 secs

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13
Q

Proctitis refers to inflammation of the following:

A. Small intestine

B. Gall bladder

C. Liver

D. Rectum

E. Esophagus

A

Rectum

Proctitis is inflammation of the rectum.

It can be caused by IBD, sexually transmitted diseases or radiation of certain cancers.

Patients often complain of feeling like they need to have a bowel movement constantly.

Treatment is directed at the underlying cause.

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14
Q

Ulcerative Colitis

A

Mucosal inflammation confined to rectum & colon

Superficial Ulcerations

Continuous pattern

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15
Q

Crohn’s Disease

A

Transmural inflammation in any part of the GI tract

Thickened & edematous bowel wall → narrowed, ulcerated & fibrotic w/ fistulas

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16
Q

UC & Crohn’s

Diagnosis

A

Rule out other conditions

Laboratory blood tests for inflammation

Stool testing

Imaging tests: CT or MRI

Visualization with tissue biopsy
* Colonoscopy: entire colon
* Sigmoidoscopy: end part of the intestine, closest to the rectum (only for U.C.)
* Endoscopy: upper Gl, through mouth (only for upper Gl symptoms, Crohn’s Disease)

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17
Q

UC & Crohn’s: Lifestyle Measures And Supportive Care

Diet

A

Small frequent meals

Avoid trigger foods and substances

Prevent nutritional deficiencies

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18
Q

UC & Crohn’s: Lifestyle Measures And Supportive Care

Symptom Control

A

Antidiarrheals (loperimide [Imodium])

Antispasmodics (dicyclomine [Bentyl])

Nicotine - for UC

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19
Q

UC & Crohn’s: Lifestyle Measures And Supportive Care

Natural Products

A

Probiotics

Fish oils

Peppermint, herbal teas

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20
Q

Aminosalicylates is mainly used for?

A

UC

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21
Q

Sulfasalazine breaks down into?

A

Sulfapyridine - Toxcicity

5-ASA (mesalamine) - Efficacy

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22
Q

Mesalamine Brands

A

Pentasa (ER cap)

Asacol (ER tab)

Rowasa (Enema)

Canasa (Supp)

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23
Q

What med for UC leaves a ghost tablet?

A

mesalamine (Asacol)

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24
Q

Rectal Meds are usually given when?

A

QD HS

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25
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.
Lower esophageal sphincter tone is reduced. ## Footnote Gastroesophageal reflux disease (GERD) occurs when the stomach contents leak backward, through the lower esophageal sphincter (LES), into the esophagus.
26
Key drugs that can worsen GERD
ASA/NSAIDs Bisphosphonates Dabigatran Estrogen products Fish oil products Iron supplements Nicotine replacement therapy Steroids Tetracyclines
27
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
Tums | Calcium antacids are considered first-line in pregnancy. ## Footnote Cimetidine (Tagamet)
28
Antacids are ___ & ___ acting
Fast & shorting acting
29
# Antacids Concerns Al & Mg
Accumulation w/ severe renal dysfunction | Not Rec CrCl < 30
30
# Antacids Concerns Alka Seltzer Original
Contains Na & ASA ## Footnote > 500 mg Na per tab → edema in pts w/ HF or cirrhosis Risk of bleeding w/ ASA
31
# Antacids Tums
Calcium carbonate
32
# Antacids Mylanta Supreme
Calcium carbonate + Mg
33
# Antacids Maalox Advanced Maximum Strength
Calcium carbonate + simethicone (anti-gas)
34
# Antacids Milk of Magnesia (MOM)
Magnesium hydroxide
35
# Antacids Maalox, Mylanta Max
Magnesium hydroxide + Aluminum ## Footnote Maalox & Mylanta Classic: + simethicone
36
# Antacids Alka-Seltzer
Sodium bicarbonate + ASA + citric acid
37
# Antacids SE
Unpleasant taste
38
# Antacids SE Calcium
Constipation Bloating Belching
39
# Antacids SE Aluminum
Constipation Hypophosphatemia
40
# Antacids SE Magnesium
Loose stools | Use w/ Al may counter-balance
41
A patient asks the pharmacist if there is anything over-the-counter that she could take for car sickness. Which of the following would be appropriate? (Select ALL that apply.) A. Diphenhydramine B. Meclizine C. Promethazine D. Dimenhydrinate E. Loratadine
Diphenhydramine Meclizine Dimenhydrinate ## Footnote Diphenhydramine (Benadryl), dimenhydrinate (Dramamine) and meclizine (Bonine) are antihistamines with anticholinergic side effects, making them useful for preventing motion sickness. Non-sedating, second-generation antihistamines (e.g., loratadine) are not helpful for motion sickness. Promethazine (Phenergan) is available by prescription only.
42
How long before the activity expected to cause motion sickness should OTC motion sickness meds be taken?
30-60 mins
43
Transderm Scop vs OTC motion sickness
Does not work better but Transderm Scop last longer
44
# Thiopurines Drugs
Azathioprine (Azasan, Imuran) Mercaptopurine (Purixan)
45
Thiopurines Effects
Not safe in pregnancy Myelosuppression Steroid Sparing (helps w/ excessive need for steroids)
46
Which of the following are short-term adverse effects of prednisone?  A. Cataracts and poor wound healing  B. Osteoporosis and immunosuppression  C. Fat deposits in the face and adrenal suppression  D. Cushing's syndrome and growth retardation  E. Insomnia and mood changes
Insomnia and mood changes ## Footnote A patient started on steroids short-term may experience elevated blood pressure, changes in mood, insomnia and elevated blood glucose, among other adverse effects. The remaining choices are long-term adverse effects of corticosteroids.
47
# IBD Steroids
Use for Short Duration Route - IV/PO/PR Adverse Effects * Short term * Long term
48
# IBD: Steroids Adverse Effects: Short term
↑ appetite Wt gain Fluid Retention Emotional instability Insomnia
49
# IBD: Steroids Adverse Effects: Long term
Cushingoid Effects Immunosuppression Impaired wound healing
50
# IBD Which med do you not crush?
Entocort EC - for CD Uceris - for UC
51
# IBD: Steroids Drug Intxn
Avoid w/ antacids CYP3A4 inhibitors
52
A patient beginning treatment with Amitiza should be counseled on which common side effect?  A. Constipation  B. Hyponatremia  C. Hypertension  D. Somnolence  E. Nausea
Nausea | Amitiza (lubiprostone)
53
lubiprostone | Brand, Most common SE, Indication
Amitiza Nausea For Constipation Take w/ food & water to ↓ nausea
54
Constipation
Osmotic Laxatives Bulk-Forming Laxatives Emollient/Stool Softener Stimulant Laxatives Calcium-Channel Activator
55
Bulk-Forming Laxatives | Examples
Psyllium (Metamucil) Calcium polycarbophil (FiberCon) Methylcellulose (Citrucel) Wheat dextrin (Benefiber)
56
Osmotics
Mg Hydroxide (Milk of Magnesia [MOM]) Polyethylene glycol 3350 (Miralax) Glycerin Lactulose (RX) Sodium phosphates (Fleet Enema)
57
Stimulants
Senna (Ex-Lax, Senokot) Biscodyl (Dulcolax)
58
Emollients
Docusate sodium (Colace)
59
Senna + docusate
Senna S, Senokot S
60
Lubricants
Mineral Oil
61
Chloride Channel Activator
Lubiprostone (Amitiza)
62
Guanylate Cyclase C Agonists
linaclotide (Linzess) ## Footnote Plecanatide (Trulance)
63
Peripharally-Acting Mu-Opioid Receptor Antagonists (PAMORAs)
Alvimopan (Entereg) Methylnatrexone (Relistor) Naloxegol (Movantik) ## Footnote naldemedine (Symproic)
64
Non-Drug Tx for Constipation
65
Drugs that cause constipation
Antacids (aluminum- and calcium- containing) Antidiarrheals Clonidine Colesevelam Drugs with anticholinergic effects: * Antihistamines (e.g., diphenhydramine) * Antispasmodics (e.g., baclofen) * Phenothiazines (e.g., prochlorperazine) * TCAs (e.g., amitriptyline) * Incontinence drugs (e.g., oxybutynin) Iron Non-DHP calcium channel blockers (especially verapamil) Opioids Sucralfate (contains an aluminum complex)
66
PPI MOA
Irreversibly bind to the gastric H/K-ATPase pump
67
PPI Drugs
Esomeprazole (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec) Dexlansoprazole (Dexilant) Pantoprazole (Protonix) ## Footnote Rabeprazole (Aciphex)
68
Omeprazole + sodium bicarbonate
Zegerid
69
When to take PPI
Generally 30-60 minutes before meals
70
Which PPI can be taken w/out regard to meal?
Dexlansoprazole (Dexilant) Pantoprazole (Protonix) - tablets Rabeprazole (Aciphex) - tablets
71
Which PPI comes IV?
exomeprazole (Nexium) pantoprazole (Protonix)
72
PPI SE | Chronic Use
C.difficile associated diarrhea Osteoporosis-related fractures (≥ 1 yr) Hypomagnesemia Vit B12 deficiency (use ≥ 2 yrs) ## Footnote Long term use can ↑ risk of infection
73
Esomeprazole + naproxen
Vimovo
74
What drug does omeprazole & esomeprazole diminish the therapeutic effect of?
Clopidogrel | They inhibit CYP2C19 ## Footnote rabeprazole or pantoprazole have less risk
75
# Non-Steroidal Anti-iniflammatory Drug-induced Ulcers Cytoprotective Drugs
Misoprostol (Cytotec) **Sucralfate** (**Carafate**) ## Footnote Misoprostol + diclofenac (Arthrotec)
76
# Cytoprotective Drugs Misoprostol ## Footnote Non-Steroidal Anti-iniflammatory Drug-induced Ulcers
Prostaglandin E1 analog Boxed Warning: Abortifacient SE: Diarrhea, abdominal pain ## Footnote Arthrotec: NSAID ↑ risk of serious GI events (bleeding & ulceration & CV disease (eg, MI, stroke)
77
# Cytoprotective Drugs Sucralfate ## Footnote Non-Steroidal Anti-iniflammatory Drug-induced Ulcers
Sucrose-sulfate-aluminumb complex, interacts w/ albumin & fibrinogen to form a **physical barrier** over an open ulcer Take **before** meals SE: **Constipation** Notes: **binding interactions** - separate from other drugs ## Footnote Arthrotec: NSAID ↑ risk of serious GI events (bleeding & ulceration & CV disease (eg, MI, stroke)
78
Which PPI does not come in a capsule form?
Pantoprazole
79
Which of the following statements concerning NSAIDs is correct? (Select ALL that apply.) A. All NSAIDs can cause gastric ulcers when used chronically. B. COX-2 selective NSAIDs have an increased risk of gastrointestinal side effects. C. All NSAIDs should be used cautiously in patients with a history of cardiovascular or renal disease. D. COX-2 selective NSAIDs have an increased risk of causing cardiovascular events. E. Patients with high risk for GI bleeding should preferably use sucralfate concurrently with an NSAID.
All NSAIDs can cause gastric ulcers when used chronically. All NSAIDs should be used cautiously in patients with a history of cardiovascular or renal disease. COX-2 selective NSAIDs have an increased risk of causing cardiovascular events. ## Footnote All NSAIDs should be used with caution in patients with existing cardiovascular or renal disease. The COX-2 selective drugs have less GI risk but increased cardiovascular risk. All NSAIDs increase the risk for gastric ulcers.
80
Which medication/s can be prescribed for irritable bowel syndrome with constipation in a 35-year-old female if OTC treatment options have failed? (Select ALL that apply.) A. Linzess B. Methylnaltrexone C. Amitiza D. Eluxadoline E. Bentyl
Linzess Amitiza ## Footnote Linaclotide (Linzess) and lubiprostone (Amitiza) are approved for the treatment of various types of constipation, including IBS-C.

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