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Year 1: Patho/Pharm > GI PHARM 2 > Flashcards

GI PHARM 2 Flashcards

(96 cards)

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1
Q

Define
Laxative effect

A

Produce soft, formed stool in 1 or more days

  • slower onset
  • mild effect
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2
Q

Define
Catharsis

A

Prompt fluid evacuation from rectum

  • fast onset
  • intense
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3
Q

Function of the colon

A

Absorb water and electrolytes

  • 1500mL enters the colon
  • 90% water is reabsorbed

*minimal nutrient absorption

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4
Q

Function of the colon is defined by…

A

Consistency of stool (versus stool frequency)

Soft formed stool
Minimal straining

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5
Q

Rome IV Criteria for Constipation
ADULTS

A

2 or more of the following for past 3 months, 25% of the time

  • straining
  • lumpy hard stool
  • incomplete evacuation
  • anorectal blockage
  • manual manuever required (digital, pelvic floor)
  • </= 3 BM per week
  • rarely loose and not IBS
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6
Q

Rome IV Criteria for constipation
CHILDREN

A

1 month with at least 2 criteria
Children </= 4 years

  • </= 2 BM per week
  • stool retention
  • painful hard stool
  • large diameter stool
  • 1x per week incontinence
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7
Q

Indication
Laxatives

A
  • reduce painful elimination (hemorrhoids, anal fissures, episiotomy)
  • Anthelmintic: obtain fresh stool sample (parasites); empty bowel before parasite treatment; empty colon of dead parasites
  • Empty bowel before surgery
  • Modify ileostomy/colostomy effluent
  • prevent fecal impaction bedrest
  • correct constipation (pregnancy, opioid use)
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8
Q

Non pharmacological interventions
Constipation

A
  • increase fluid
  • increase fibre
  • walk after meals
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9
Q

Laxatives
Infants pregnancy

A

Infants
- glycerin, ducosate, lactuluose

Children
- bisacodyl, mineral oil, Senna, ducosate, MgOH

Pregnancy
- caution
- can cause pre-term labour

Breastfeeding
- Senna

Older adults
- caution
- dehydration
- everything is safe

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10
Q

Laxative classification
MOA

A
  1. Bulk forming
  2. Surfactant
  3. Stimulant
  4. Osmotic agent
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11
Q

Bulk forming laxative
Example

A
  1. methylcellulose
  2. Psyllium
  3. Polycarbophil
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12
Q

Surfactant Laxative
Example

A
  1. ducosate sodium
  2. ducosate calcium
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13
Q

Stimulant laxative
examples

A
  1. Bisacodyl
  2. Senna
  3. Caster oil

*cannot be used in infants

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14
Q

Osmotic Laxative
Examples

A
  1. polyethylene glycol
  2. lactulose
  3. magnesium hydroxide, magnesium citrate, magnesium sulfate
  4. Sodium phosphate
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15
Q

Classification Laxatives
Therapeutic action

A

Group I: watery stool in 2-6 hours (bowel prep)

Group II: intermediate semi-fluid stool in 6-12 hours

Group III: slow 1-3 days, soft formed stool (chronic constipation relief)

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16
Q

Example Group I Laxatives

A

*liquid stool, 2-6 hours

High dose osmotic laxative
- Magnesium salts
- Sodium salts
- Polyethylene glycol
- Caster oil

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17
Q

Example Group II Laxatives

A

*semi-fluid stool 6-12 hours

Low dose osmotic laxative
- Magnesium salts
- sodium salts
- polyethylene glycol

Stimulant laxatives
- bisacodyl (oral)
- Senna

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18
Q

Example Group III Laxatives

A

*soft stool, 1-3 days

Bulk forming laxatives
- Methylcellulose
- Psyllium
- POlycarbophil

Surfactant laxative
- decosate sodium
- decosate calcium

Osmotic laxative
- lactulose

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19
Q

MOA
Bulk forming laxatives

A

Increase stool bulk, form viscous gel in water, increase stretch of GI, and peristalsis

Hasten transit time of stool through GI

*nutrients for GI bacteria

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20
Q

AE
Bulk forming laxatives

A

Non-digestable
Non-absorbable
*minimal systemic effects

Esophageal obstrution
GI
Patient education: take with water

obstruciton/impaction

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21
Q

Contraindications
Bulk forming laxatives

A

Narrowed GI

Dysphagia

Can cause GI obstruction and impaction

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22
Q

Indications
Bulk forming laxatives

A

Soft, formed stool, 1-3 days

Constipation

Diverticulitis

Relief of diarrhea (IBS)

colostomy/ileostomy bags

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23
Q

Surfactant Laxatives
MOA

A
  1. Lower surface tension allowing water to easily penetrate feces
  2. Prevent GI from absorbing water, Promote GI to secrete water and electrolytes into lumen
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24
Q

Indication
Surfactant laxatives

A

Group III laxative
soft BM in 1-3 days

Full glass of water

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25
Stimulant Laxatives MOA
1. Stimulate GI motility 2. increase water and electrolyte secretion into lumen (and reduce absorption) Group II Semi-fluid stool in 6-12 hours
26
SE & Contraindications Bisacodyl
Contraindications - do not crush the pill (gastritis) - do not administer with milk (wait 1 hour) - not safe in infants SE - proctitis
27
SE & Contraindications Senna
Contraindications - not safe in infants SE - yellow, brown or pink urine
28
Caster oil MOA
Stimulant laxative Group I: liquid stool in 2-6 hours Acts on the small intestine, rapid evacuation Intestinal lipase converts to ricinoleic acid 1. surfactant 2. stimulate motility 3. increase secretion water, electrolytes into GI (prevent absorption)
29
MOA Osmotic laxatives
High dose laxative salts are poorly absorbed Draw water into lumen, fecal swelling, stimulation peristalsis with GI wall stretch
30
Dosage and MOA Osmotic laxative salts
Low dose Group II semi-fluid stool 6-12 hours High dose Group I Fluid stool 2-6 hours
31
AE Osmotic Laxative Salts
Magnesium toxicity Sodium stimulated fluid volume overload: HF, HTN, edema Kidney failure, HTN, Heart failure, Edema Dehydration
32
Contraindications Osmotic Laxative salts
Dehydration Kidney failure Heart failure HTN Edema ACE inhibitors, diuretics, ARBs --> dehydration --> Kidney failure
33
SE Polyethylene glycol
not absorbed systemically Nausea abdominal bloating cramping flatulence diarrhea at high dose
34
Indication PEG
osmotic laxative chronic constipation 17g daily in 4-8oz of water
35
Lactulose MOA
Group III: Osmotic laxative disaccharide of galactose and fructose *not absorbed or digested by GI enzymes Digested by colon bacteria Conversion to lactic acid, formic acid, acetic acid pull water into intestine, soft, formed stool, 1-3 days excrete ammonia
36
Lactulose Indications
Group III: osmotic laxative, soft stool, 1-3 days Chronic liver disease: hepatic encephalopathy, excretion ammonia
37
Contraindiciations Laxatives
- appendicitis - enteritis - c diff - diverticulitis - ulcerative colitis, Crohn’s disease - acute abdominal surgery - fecal impaction - bowel obstruction - caution pregnancy - magnesium and sodium salts: kidney disease, heart disease
38
Patient instructions Laxatives
lowest dose, shortest duration can diminish deification reflex drink water
39
Laxative abuse Cycle
Laxative clears bowel takes 2-5 days for another BM *think constipated and repeat the dosage
40
Diarrhea Definition
Increase 1. volume 2. frequency 3. fluidity of stool
41
Diarrhea Causes
1. infectious 2. malabsorption 3. Inflammation 4. Bowel disorders (IBS, IBD) 5. Drugs
42
Management of Diarrhea
1. diagnose cause (infectious, malabsorption, inflammation, disorder) 2. Treat cause 3. reverse dehydration, electrolyte imbalances 4. reduce passage of stools 5. reduce cramping
43
Two types of anti-diarrheal drugs
1. Specific - treat the cause 2. Non-specific - treat the frequency of passage of stools - Ex. opioids
44
Opioid Anti-Diarrheal Examples
- Diphenoxylate (lomotil) - Loperamide (Imodium)
45
Opioid anti-diarrheal MOA
1. Bind mu receptors in GI tract, slow motility, increase Sphincter tone, decrease secretions, increase absorption water, electrolytes, decrease stool volume and frequency 2. Promote absorption water and electrolytes in small intestine (prevent excretion water, electrolytes)
46
SE Opioid anti-diarrheals
1. Toxic megacolon IBD 2. High dose = morphine like effects 3. Prevent passage of infection (increase duration disease) High doses diphenoxylate Equate to morphine CNS supression Respiratory suppression constipation urinary retention Euphoria hypotension, bradycardia *Atropine included in diphenoxylate (lomotil) to prevent abuse
47
Why is loperamide not regulated
It is too large to cross the BBB
48
Management of Infectious Diarrhea
Majority self limiting - resolve in 24 hours Anti-diarrheals prolong disease Infections requiring antibiotics: - Salmonella (gram negative) - Shiegella (gram negative) - Campylobacter (gram negative) - Clostridium dificile (+ anaerobe) - sometimes E. coli
49
Traveller's Diarrhea Etiology
E. coli (gram negative bacilli) Most common Usually self limiting - drinking water - eating local unwashed food - do not take anti-diarrheal if moderate or severe
50
Prevention Traveller's Diarrhea
- boil, cook, peel or forget it - avoid raw, uncooked meat, fish, seafood, dairy - don't drink tap water, ice cubes - ground grown greens, vegetables, fruits (untreated water) - street vendors unless hot
51
Anti-biotic treatment in Thailand, India, Nepal, Indonesia
Azithromycin *resistance to fluroquinolones is high
52
Definition and Treatment Mild to Moderate Traveller's Diarrhea
E. coli. up to 3 BM per day No blood No fever First line Loperamide (opioid) Bismuth subsalicylate (antibiotic) Should resolve 24 hours
53
Definition and Treatment Moderate to Severe Traveller's Diarrhea
Moderate 3-5 BM per day no blood or fever Severe 3-5 BM per day blood and/or fever First line Fluroquinolones: norfloxacin, ciprofloxacin, levofloxacin Second line Azithromycin (first line children, pregnant) Rifaximin (no blood, not pregnant)
54
Indications Prophylaxis treatment Traveller's Diarrhea
Anti-biotics: start day 1 high risk area continue 1-2 days upon return home maximum: 3 weeks Probiotics - lactobacillus - Saccharomyces Vaccination (Dukoral) - high risk, short term travel - children > 2 years - chronic illness - greater risk (hypochlorhydria, immunocompromised, history repeat travellers diarrhea)
55
Non pharmacological treatments Traveller's Diarrhea
Fluid - clear fluid - salted crackers - electrolyte solutions - pedialyte (children)
56
Contraindications Moderate to Severe Traveller's Diarrhea
Anti-motility agents increase curation of infection
57
Clostridium Difficile Diarrhea
Gram positive anaerobic bacteria Spore forming Toxin A and B attack GI mucosal membrane inflammation, edema, pus
58
Complications Clostridium Difficile Infections
Mild infection - abdominal pain, nausea, vomiting, anorexia, diarrhea, fever Severe infection - toxic megacolon, pseudomembranous colitis, colon perforation, sepsis, death
59
Treatment Clostridium Difficile Infections
1. ORAL 2. Antibiotic therapy - Vancomycin OR - Metronidazole 30% Re-occurance rate 1. Vancomycin, QID, 10 days 2. Rifaxamin TID, 20 days
60
Etiology Clostridium Difficile
- fluroquinolones - tetracyclines - cephalosporins - PPIs * can occur up to 6 weeks after D/C - proton pump inhibitors - ingestion spores
61
MOA Fluroquinolones
Inhibit DNA gyrase (supercoils DNA for replication) and DNA topoisomerase (daughter strands cannot separate)
62
Indication Fluroquinolones
Indication moderate-severe traveller's diarrhea Abx. Spectrum Gram positive, gram negative, pseudomonas
63
SE/AE Fluroquinolones
Prolonged QT interval C. Diff infections: N/V/D Phototoxicity Tendon ruptures - greater risk elderly, glucocorticoids, children, transplants Teratogenic
64
MOA Azithromycin
Macrolide antibiotic Inhibits 50S ribosomal subunit, bacteriostatic, prevents replication
65
Indication Azithromycin
Moderate-Severe Travellers diarrhea Antibiotic spectrum Gram positive and gram negative bacteria
66
SE/AE Azithromycin
Prolonged QT interval N/V/Metallic Taste in mouth Ototoxicity
67
MOA Vancomycin
Binds cell wall precursors, preventing synthesis of cell wall bacteria cell lysis and death results
68
Indication Vancomycin
Gram positive bacteria and MRSA C. diff infection
69
SE/AE Vancomycin
Nephrotoxic Ototoxicity Bleeding risk *safe in pregnancy
70
MOA Metronidazole
Antibiotic spectrum anaerobic bacteria - convert prodrug into active form which damages DNA
71
Indication Metronidazole
Anaerobic bacterial infections and protozoa C. difficile Quadruple therapy for PUD Amox/meteonidazole + clarithromycin/levooxacin + ppi Bismuth + tetracycline + metronidazole + ppi
72
SE/AE Metronidazole
N/V/HA/Dizziness Disulfram reaction with alcohol Inhibits aldehyde dehydrogenase Hepatitis
73
Crohn's Disease Treatment Pathways
1. Mild Disease - Induction and maintenance remission 5-ASA (sulfasalazine, methalazine) 2. Mild-Moderate Disease - Induction remission budesonide - maintenance remission 5-ASA 3. Moderate to severe disease - Induction and maintenance remission Tumour necrosis factor alpha (infliximab, adalimumab) + Methotrexate OR Thiopurine (Azathiopurine/Mercaptopurine)
74
5-ASA Examples
1. Sulfasalazine (metbaolized to 5-ASA and sulfapyridine) 2. Mesalazine (no sulfa moiety, less SE)
75
5-ASA MOA
1. Inhibit COX formation of prostaglandins 2. Inhibit migration of inflammatory cells to site of action
76
5-ASA Indication
Induction and maintenance of remission mild-moderate IBD
77
5-ASA SE/AE
Locally acting Inactivated by first pass effect Sulfa moiety: nausea, fever, rash, arthralgia
78
5-ASA Prescriber considerations
Safe in pregnancy and breast feeding Monitor CBC and diff
79
Budesonide MOA
Anti-inflammatory and immunosupression Prevents transcription of inflammatory genes and inhibits formation of cytokines (TNF, IL) Inhibits activation of pro-inflammatory cells: macrophages, neutrophils, T cells, dendrites, etc.
80
Budesonide INdication
Enterocort EC release in ileum and cecum induction of remission in mild-moderate collitis not responsive to first line 5-ASA
81
Budesonide SE/AE
Minimal systemic effects inactivated by first pass effect
82
Anti-Tumour Necrosis Factor alpha (TNF alpha) Examples
Infliximab Adalimumab
83
Anti-TNF alpha MOA
Block the effect of TNF alpha pro-inflammatory cytokine responsible for recruitment inflammatory cells and immune response (fever)
84
Anti TNF alpha SE/AE
BLACK BOX WARNING: - increase risk for serious and fatal infections - bacterial - fungal - TB and HBV Infusion reactions: - flu like symptoms - fever, HA, chills, dyspnea, hypotension, anaphylaxis Rare: - heart, liver failure - cancer - allergic reactions
85
Prescriber considerations anti TNF alpha
- no live vaccinations - screen for opportunistic infections (HBV, TB)
86
Methotrexate Indication
Induction and maintenance of remission with anti-TNF alpha therapy of moderate-severe CDM
87
Methotrexate MOA
folate anatonist inhibition of B and T cells onset: 3-6 weeks
88
Methotrexate SE/AE
Hepatic fibrosis bone marrow supression pneumonitis GI ulceration Teratogenic Reduced life expectancy: CVE, cancer, infection
89
Prescribing considerations Methotrexate
Monitor - CBC and diff - Kidney and liver function - lung function - screen for pregnancy - screen for TB, HBV, infections - no live vaccines - no alcohol
90
Thiopurines Examples
1. Azithioprine (pro drug) 2. Mercaptopurine (active drug)
91
Thiopurine Indication
Maintenance of remission with anti-TNF alpha, moderate to severe disease Onset delayed: 6 months
92
Thiopurine SE/AE
hepatitis blood dyscaria malignancy
93
Ulcerative Colitis (UC) Treatment Pathways
1. Mild disease Induction 5-ASA rectal suppository: proctitis enema: L sided colitis oral: pancolitis 2. Mild-moderate disease Induction 5-ASA with oral budesonide MMX Second line: prednisone systemic corticosteroid 3. Moderate-Severe Disease Induction and maintenance: anti-TNF alpha + Thiopurines Induction and maintenance: Vedolizumab (integrin blocker, monoclonal antibody) + thiopurine
94
Which drug is not used in Ulcerative Colitis
Methotrexate
95
5-ASA is more effective in which disease?
Ulcerative colitis
96
Special population UC and CD treatment in pregnancy
Continue 5-ASA and suppliment with folic acid Methotrexate is teratogenic Budesonide has minimal systemic effect and is safe Infliximab and adalimumab are safe in pregnancy

Year 1: Patho/Pharm (45 decks)

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