IBD, N/V/D/C Flashcards
(128 cards)
1
Q
What are examples of antispasmodics?
A
Dicyclomine and hyoscyamine.
2
Q
What is the mechanism of action (MOA) of antispasmodics like Dicyclomine and hyoscyamine?
A
They are anticholinergic agents that block the action of acetylcholine at parasympathetic sites in smooth muscle, thus reducing GI motility.
3
Q
What are the indications for Dicyclomine?
A
Dicyclomine is indicated for IBS/IBD, most effective for diarrheal-type. Dosed 4x/day just before meals and at bedtime.
4
Q
What are the contraindications (CI) for antispasmodics like Dicyclomine and hyoscyamine?
A
CI include obstructive uropathy, glaucoma, severe UC, GI obstruction, and breastfeeding.
5
Q
What are the adverse drug reactions (ADRs) of antispasmodics?
A
ADRs can worsen IBD symptoms, cause dry mouth, and urinary retention.
6
Q
What are examples of aminosalicylates?
A
Mesalamine (oral, enema, suppository), sulfasalazine (prodrug), Olsalazine, and Balsalazide (colon targeted - prodrugs).
7
Q
If a patient has a sulfa allergy, which aminosalicylate should they avoid?
A
Avoid sulfasalazine.
8
Q
What patients should avoid aminosalicylates?
A
Patients with an ASA allergy.
9
Q
Which aminosalicylate is best for pediatric patients with UC?
A
Mesalamine.
10
Q
What are unique ADRs for Sulfasalazine?
A
Oligospermia (reversible), headache, diarrhea, dyspepsia, skin rash.
11
Q
What are unique ADRs for Mesalamine?
A
Pharyngitis and eructation, headache, abdominal pain, constipation, muscle or joint pain.
12
Q
What are unique ADRs for Balsalazide?
A
Intolerance syndrome, headache, abdominal pain, arthralgia, respiratory infection.
13
Q
What are unique ADRs for Olsalazine?
A
Dose-related diarrhea, abdominal pain, and cramping.
14
Q
What are examples of thiopurines?
A
Azathioprine and Mercaptopurine.
15
Q
Azathioprine is a prodrug of what?
A
6-mercaptopurine.
16
Q
What are the indications for thiopurines like Azathioprine and Mercaptopurine?
A
Maintenance for UC refractory to aminosalicylates and steroid-sparing effects, inducing remission in UC refractory to steroids.
17
Q
What are the ADRs of thiopurines?
A
Bone marrow suppression, secondary malignancy (lymphoma), hepatotoxicity, and pancreatitis.
18
Q
Thiopurines have a significant drug-drug interaction (DDI) with what medication?
A
Allopurinol; decrease the dose of thiopurines if given together.
19
Q
What testing is needed prior to starting a thiopurine?
A
TPMT testing; patients with minimal or no TPMT are at increased risk for severe toxicity at conventional mercaptopurine doses.
20
Q
What are the black box warnings (BB warnings) for TNF antagonists like Infliximab and Adalimumab?
A
Infection, malignancy, and tuberculosis.
21
Q
What screening is needed prior to starting a TNF antagonist?
A
Screen for TB and Hepatitis B.
22
Q
Can you give live vaccines to patients on TNF antagonists?
A
No.
23
Q
If a patient is on Infliximab for UC and is not responding adequately, what medication should you switch to?
A
Adalimumab.
24
Q
What are the ADRs of TNF antagonists?
A
Black box warning for infection, malignancy, tuberculosis
Positive ANA titers, demyelinating disease, infusion reactions, heart failure, hematologic disorders, risk for autoimmune hepatitis, antibody development, upper respiratory tract infections, and sinusitis.
25
Which TNF antagonist is first line?
Infliximab.
26
Which TNF antagonist is known to increase CK?
Adalimumab.
27
When is methotrexate indicated in IBD?
For moderate to severe Crohn's disease that is corticosteroid-dependent or refractory, given as a weekly IM/SQ dose.
28
What are the ADRs of methotrexate?
Hepatotoxicity, bone marrow suppression (anemia, thrombocytopenia, leukopenia), teratogenicity (category X), interstitial pneumonitis (can be lethal).
29
What testing is needed prior to starting methotrexate?
Pregnancy test, Hep B and C screening, LFTs (monitor throughout treatment).
30
What are examples of integrin-receptor antagonists?
Natalizumab and Vedolizumab.
31
Which integrin-receptor antagonist is only used in Crohn's disease?
Natalizumab.
32
What are the indications for Natalizumab?
For inducing and maintaining remission in moderately to severely active Crohn's disease who have had an inadequate response to or are unable to tolerate conventional therapies and TNF-alpha inhibitors.
33
What is the BB warning for Natalizumab?
Increases the risk of progressive multifocal leukoencephalopathy (PML); patients must be enrolled in the REMS TOUCH program.
34
What are the ADRs of Natalizumab?
Hepatotoxicity, herpes infections (including meningitis and encephalitis), increased risk of other infections, hypersensitivity reactions (rare), headache, fatigue, depression, arthralgias, respiratory tract infections.
35
When is it recommended to discontinue Natalizumab if a patient is on a steroid?
If the patient cannot be tapered off oral corticosteroids within 6 months of therapy initiation or if corticosteroids are needed for more than 3 months in addition to Natalizumab.
36
What is the MOA of Vedolizumab?
Inhibits the migration of memory T-lymphocytes across the endothelium into inflamed GI parenchymal tissue.
37
What is the clinical use of Vedolizumab?
For moderate to severe Crohn's disease or UC, administered via IV infusion.
38
When is it recommended to discontinue Vedolizumab?
If no benefit is observed by week 14.
39
What is an example of an interleukin 12/23 inhibitor?
Ustekinumab.
40
What are the clinical uses of Ustekinumab?
For treating moderately to severely active Crohn's disease in adults who have failed or were intolerant to immunomodulatory or corticosteroid therapy, but never failed TNF antagonist therapy.
41
What are the ADRs of Ustekinumab?
Activation of latent TB, antibody formation that can decrease drug levels or treatment response, nasopharyngitis, respiratory tract infections, increased risk of infection and malignancy (non-melanoma skin cancer), reversible posterior leukoencephalopathy syndrome.
42
When are steroids indicated for IBD?
During flares, both topical or oral.
43
What is the clinical use of steroids in IBD?
Topical First line for mild-moderate distal disease,
Iv for severe extensive disease
oral steroids can induce remission in mild-moderate distal or extensive disease.
44
Which form of budesonide is used for Crohn's disease vs UC?
Crohn's = enteric coated (released in ileum and right colon); UC = extended release (released throughout entire colon).
45
Is tapering required for budesonide?
Not required for foam or suppositories; can taper quickly if concern based on symptoms.
46
When are antibiotics indicated for IBD and what would you use?
For fistulizing Crohn's, use metronidazole, ciprofloxacin, or rifaximin.
47
What are examples of bulk laxatives?
Psyllium and Polycarbophil.
48
What are examples of emollients (stool softeners)?
Docusate.
49
What are examples of lubricants?
Glycerin.
50
What are examples of stimulant laxatives?
Sennosides (senna) and Bisacodyl.
51
What are examples of osmotic laxatives?
Polyethylene glycol, lactulose, sodium phosphates, magnesium citrate/milk of magnesia.
52
What are examples of peripheral opioid antagonists?
Methylnaltrexone and Naloxegol.
53
When should you recommend a patient contact you regarding medication for constipation?
Prior to use if N/V or stomach pain are present, sudden change in bowel habits that persists over 14 days, rectal bleeding occurs, bowel movement fails to occur, or use needed for more than 7 days.
54
What types of laxatives would you recommend for use in chronic constipation?
Bulk laxatives, stool softeners, and osmotics.
55
What types of laxatives would you recommend for use in acute constipation?
Stimulant laxatives, suppositories, or enemas, and lubricants.
56
What is the safest form of laxative?
Bulk laxatives; they work the slowest and must be taken with water.
57
What is the MOA of bulk laxatives?
Fiber forms a soft-textured mass to help prevent the formation of hard, dry stools that are difficult to pass.
58
Which bulk laxative is safe in pregnancy because it is not systemically absorbed?
Psyllium.
59
What is the MOA of docusate?
Reduces surface tension of the oil-water interface of the stool, enhancing the incorporation of water and fat for stool softening.
60
What is the MOA of glycerin?
Osmotic dehydrating agent that increases osmotic pressure, drawing fluid into the colon and stimulating evacuation.
61
What is the MOA of stimulant laxatives like Sennosides and Bisacodyl?
Stimulate peristaltic activity in the intestine by direct action on intestinal mucosa or nerve plexus, increasing motility.
62
What are the ADRs of stimulant laxatives?
Diarrhea, abdominal pain, and N/V.
63
What are therapeutic considerations for stimulant laxatives?
Will cause bowel movement within 12-24 hours; administer at bedtime.
64
What is the common MOA of osmotic laxatives?
Draws water into the gut by causing retention, aiding peristaltic activity.
65
What are sodium phosphates used for and what is their CI?
Used for constipation or bowel prep for colonoscopy; CI in patients with kidney disease.
66
What is magnesium citrate/milk of magnesia used for? Caution in who?
Given orally, only one dose; safe in children 2 and older; caution in low salt diet/renal impairment.
67
What is the MOA of polyethylene glycol (PEG)?
Increases water retention in the stool to increase stool frequency.
68
What are the ADRs of polyethylene glycol? CI?
Abdominal pain, N/D, bloating, flatulence; prolonged use can lead to electrolyte disturbances; CI in patients with bowel obstruction.
69
What is the MOA of lactulose?
Produces an osmotic effect in the colon with resultant distention promoting peristalsis.
70
What is lactulose used for and what are its ADRs?
Used for constipation and hepatic encephalopathy; ADRs include abdominal cramps, N/D, flatulence, and electrolyte disturbances.
71
What is the mechanism of action (MOA) of lactulose?
Produces an osmotic effect in the colon with resultant distention promoting peristalsis.
72
What are the uses of lactulose?
Used for constipation and hepatic encephalopathy.
73
What are the adverse drug reactions (ADRs) of lactulose?
Abdominal cramps, nausea/vomiting/diarrhea/constipation, flatulence, bloating, electrolyte disturbances.
74
What patient education should be provided for lactulose?
It has a bad taste and can be given as a retention enema.
75
What is the mechanism of action (MOA) of lubiprostone?
Chloride channel activator that acts locally on the apical membrane of the GI tract to increase intestinal fluid secretion and improve fecal transit.
76
What are the clinical uses of lubiprostone?
Used for chronic idiopathic constipation, IBS with constipation, and opioid-induced constipation.
77
What are the contraindications (CI) for lubiprostone?
CI if suspected or actual bowel obstruction.
78
What is the mechanism of action (MOA) of linaclotide?
Agonizes cGMP on luminal surface of epithelium, increasing chloride and bicarbonate in intestinal lumen, leading to increased intestinal fluid and decreased GI transit time.
79
When should linaclotide be administered?
Give 30 minutes before the first meal of the day; better if the meal is high in fat.
80
What are the clinical uses of linaclotide?
Chronic idiopathic constipation, IBS with constipation, opioid-induced constipation.
81
What is the black box warning for linaclotide?
Severe dehydration in pediatric patients; contraindicated in patients < 6 years of age; avoid use if < 18.
82
What is the mechanism of action (MOA) of methylnatrexone and naloxegol?
Peripheral acting opioid antagonist used for opioid-induced constipation.
83
What are the contraindications (CI) for methylnatrexone?
Known or suspected GI obstruction or at risk for recurrent GI obstruction.
84
What is recommended to do prior to starting methylnatrexone?
Discontinue all maintenance laxatives before starting.
85
What should you do if a patient develops severe diarrhea while on methylnatrexone?
Discontinue.
86
What are the contraindications for Naloxegol?
Strong 3A4 inhibitors.
87
Which laxatives are most commonly abused?
Stimulants.
88
What are the consequences of laxative abuse?
Severe electrolyte disturbances, dehydration that can cause organ damage, tolerance leading to lazy colon, IBS, and risk of colon cancer.
89
What laxatives are safe in pregnancy?
Bulk forming and docusate.
90
What laxatives should be avoided in the elderly?
Avoid stimulants; use osmotics cautiously.
91
What laxatives are recommended for opioid-induced constipation?
Stimulants or PAMORAs (Peripheral Acting Mu-Opioid Receptor Antagonists, methylnaltrexone, naloxegol)
92
What is the mechanism of action of bismuth subsalicylate?
The salicylate moiety provides an antisecretory effect, and the bismuth exhibits antimicrobial activity directly against bacterial and viral gastrointestinal pathogens.
93
What are the uses and adverse drug reactions (ADRs) of bismuth subsalicylate?
Used in diarrhea, traveler's diarrhea, and eradication of H. pylori. ADRs include black tongue and stool, tinnitus if salicylate toxicity occurs.
94
When should bismuth subsalicylate be avoided?
In children with viral infections due to the risk of Reye's syndrome and in those with a history of PUD.
95
What is the mechanism of action of Loperamide?
Acts on intestinal muscles (through opioid receptor) to inhibit peristalsis and slow intestinal motility.
96
What are the uses and contraindications of Loperamide?
Used for acute or chronic diarrhea, traveler's diarrhea, and chemotherapy-induced diarrhea (do not use > 2 days). Avoid in infectious diarrhea and contraindicated in children < 2 years old.
97
What is the black box warning for Loperamide? What other ADR?
Risk of cardiac death (QTc prolongation) in patients who take higher doses than recommended.
Risk for toxic mega colon
98
What is the mechanism of action of Diphenoxylate with Atropine (Lomotil)?
Diphenoxylate inhibits GI motility and atropine discourages abuse.
99
What are the adverse drug reactions (ADRs) for Diphenoxylate with Atropine (Lomotil)?
CNS depression, urinary retention, flushing, dryness of skin/mucous membranes, respiratory depression, may worsen fluid and electrolyte imbalances due to fluid retention in intestines.
100
What relays messages to the vomiting center in the forebrain?
Chemoreceptor trigger zone, which receives messages from vestibular stimuli.
101
What are examples of Neurokinin 1 (NK1) Receptor Antagonists?
Aprepitant/Fosaprepitant and Netupitant.
102
What are examples of 5HT-3 receptor antagonists?
Ondansetron (Zofran), Dolasetron, Granisetron, Palonosetron (second generation).
103
What are examples of cannabinoids?
Dronabinol and Nabilone.
104
What are examples of phenothiazines?
Prochlorperazine and Promethazine.
105
What are examples of 1st generation anticholinergics?
1st generation antihistamines such as meclizine.
106
What is the mechanism of action of 5-HT3 Serotonin Receptor Antagonists?
Selective 5-HT3-receptor antagonist, blocking serotonin both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone.
107
What is an adverse reaction of 5-HT3 Serotonin Receptor Antagonists?
QTc prolongation; Palonosetron has the lowest risk.
108
What is the mechanism of action of Phenothiazines like Prochlorperazine and Promethazine?
Blocks postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the brain (CTZ).
109
What are the precautions with Phenothiazines?
Risk increases with concomitant antipsychotics, hypotension & extravasation concerns (IV), altered cardiac conduction (QT prolongation), and risk of seizures.
110
What is the mechanism of action and use of Metoclopramide?
Blocks dopamine and serotonin receptors in the CTZ; enhances the response to acetylcholine in the upper GI tract, causing enhanced motility and accelerated gastric emptying; increases lower esophageal sphincter tone. Used for diabetic gastroparesis.
111
What is the black box warning for Metoclopramide?
Tardive dyskinesia risk increases with total cumulative dose; avoid treatment for greater than 12 weeks; increased risk in elderly patients.
112
What is the mechanism of action of Fosaprepitant/Aprepitant?
Neurokinin-1 antagonist; receptors present in CTZ and NTS.
113
What are the dosage forms of Fosaprepitant/Aprepitant?
Aprepitant (PO) and Fosaprepitant (IV); Fosaprepitant is a prodrug of aprepitant. A single dose of fosaprepitant provides coverage up to 72 hours post-chemo.
114
What are the adverse drug reactions (ADRs) of Fosaprepitant/Aprepitant?
Neutropenia, fatigue, diarrhea, and changes effects of 5-HT3 antagonists.
115
What is the mechanism of action of Netupitant?
Selective substance P/neurokinin (NK1) receptor antagonist, which augments the antiemetic activity of 5-HT3 receptor antagonists and corticosteroids to inhibit acute and delayed chemotherapy-induced emesis; only comes in combo with palonosetron; 90-hour half-life.
116
What is the mechanism of action of Dronabinol/Nabilone?
Synthetic THC; most effects are due to activation of CB1 receptors.
117
What is the clinical use for Dronabinol/Nabilone?
CINV and appetite stimulation in AIDS patients.
118
What are the adverse drug reactions (ADRs) of Dronabinol/Nabilone?
CV effects: hypotension, syncope; CNS effects: sedation, cognitive impairment, euphoria, paranoia, worsening of psychiatric disorders.
119
What is the mechanism of action and use of Droperidol?
Butyrophenone antipsychotic; antiemetic effect is a result of blockade of dopamine stimulation of the chemoreceptor trigger zone; used for post-op N/V.
120
What is the black box warning for Droperidol?
QT prolongation.
121
When should you refer patients for constipation or diarrhea?
Constipation: >7 days without improvement; Diarrhea: >48 hours or signs of dehydration.
122
What drugs are used for motion sickness?
1st generation antihistamines such as diphenhydramine and dimenhydrinate.
123
What is the mechanism of action of 1st generation antihistamines like diphenhydramine and dimenhydrinate?
Blocks chemoreceptor trigger zone, diminishes vestibular stimulation, and depresses labyrinthine function through its central anticholinergic activity.
124
In a 25-year-old female with distal ulcerative colitis presenting with rectal bleeding, which formulation of mesalamine is most appropriate?
Rectal suppository.
125
Which test should be performed before initiating thiopurine therapy?
TPMT enzyme activity.
126
In an 82-year-old woman with mild dementia presenting with constipation, which agent is safest?
PEG; well-tolerated in the elderly and avoids electrolyte shifts.
127
In a 6-year-old presenting with fever, bloody diarrhea, and abdominal pain, should loperamide be used?
No; risk of toxic megacolon and masking serious infections in children.
128
Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease?
Sulfasalazine.
