n/v, constipation, diarrhea, IBS, GERD, PUD, upper GI bleed, IBD Flashcards
(208 cards)
1
Q
causes of N/V (7)
A
- general (gastroenteritis, pancreatitis)
- disorders of balance
- N/V pregnancy
- gastroparesis
- post-op N/V
- chemo and radiation induced N/V
- N/V in children
2
Q
what is gastroparesis?
A
impaired neuronal transmission –> slow stomach motility –> delayed gastric emptying
aka: food staying in the stomach for too long!
3
Q
cause of gastroparesis
A
DM!
4
Q
which causes of N/V do we start with self care?
A
GENERAL (gastroenteritis) – YES
DISORDER OF BALANCE – YES
N/V PREGNANCY – YES
gastroparesis – no
post-op N/V – no
chemo/radiation induced – no
N/V IN CHILDREN – YES
5
Q
1 cause of gastroenteritis?
A
viruses – norovirus
(other causes are bacterial – food borne)
6
Q
N/V self-care exclusions
A
- DM
- suspected food poisioning > 24 hours
- severe abdominal pain
- prolonged N/V + fever +/- diarrhea
- blood in vomit
- yellow skin/eyes + dark urine
- stiff neck +/- HA +/- light sensitivity (meningitis!!)
- head injury + N/V, blur vision, numb, tingle
- significant comorbidities
- age < 6 months
- children: lack of urination for 8-12 hours
7
Q
N/V pharm treatment options
A
- antihistamines
- phenothiazines
- serotonin antagonists (5-HT3)
- prokinetics
- corticosteriods
8
Q
antihistamine MoA
A
block H1
9
Q
antihistamine potency
A
not super potent
10
Q
antihistamine dosage form
A
all PO except scopolamine
11
Q
meclizine indication
A
ELDERLY!!! –> if > 65 years, recommend meclizine (bc of the pearls…)
12
Q
meclizine pearls
A
- less sedating
- least CNS/BBB penetration
13
Q
doxylamine formulation
A
coformulated with vitamin B6
14
Q
scopolamine dosage form
A
PATCH – transdermal, behind ear
* leave on for 3 days
15
Q
scopolamine potency
A
very potent –> hence why use for post-op n/v
16
Q
scopolamine CI
A
elderly!!
17
Q
antihistamine AE
A
- drowsiness, dry mouth, constipation
- fall risk in patients > 65 years because impairs cognition/cause confusion!
18
Q
antihistamine options
A
- meclizine
- dimenhydrinate (Dramamine)
- scopolamine
- doxylamine
- hydroxyzine
19
Q
phenothiazine options
A
- promethazine
- prochlorperazine
- chlorpromazine
20
Q
phenothiazine MoA
A
inhibit dopaminergic , histamine (H1), muscarinic receptors
21
Q
phenothiazine dosage forms
A
PO, IV, DEEP IM
22
Q
which phenothiazine comes as a rectal suppository
A
prochlorperazine
23
Q
which phenothiazine has least QT prolongation?
A
prochlorperazine
24
Q
phenothiazine AEs
A
- tissue damage –> hence DEEP IM injection
- hypotension –> hence give IV as slow IV push, patient lying down
- QTc prolongation
- dystonia: locked/rigid/frozen, like parkinson’s
- extrapyramidal symptoms (EPS): tardine dyskinesia, purposeless movements they can’t control (tongue, hand)
25
5-HT3 antagonists (serotonin antagonist) options
- ondansetron (Zofran)
- dolasetron
- granisetron
- palosetron
26
what is the most common/workhorse class of N/V?
5-HT3 antagonists --> ondansetron
27
serotonin antagonist dosage form
PO, IV, ODT
28
N/V pregnancy first line
doxylamine + vit B6
*NOT ONDANSETRON
29
serotonin antagonist AEs
- HA
- constipation
- QT prolongation (as doses inc, IV)
- well tolerated
30
prokinetic options
- metoclopramide (Reglan)
- erythromycin
31
metoclopramide MoA
- block dopamine, serotonin
- enhance Ach response --> inc gastric emptying and inc lower esophageal sphincter tone --> keeps material in stomach and moving through stomach
32
prokinetic dosage form
PO, IV
33
metoclopramide AE
- EPS, dystonia (IV and higher doses inc risk)
- QTc prolongation
- diarrhea
34
erythromycin MoA
agonize motilin receptors --> inc peristalsis (GI tract movement) in stomach and duodenum
35
erythromycin AEs
- N/V
- QTc prolongation
- diarrhea
36
corticosteroid MoA
dec prostaglandin formulation --> dec 5-HT release from gut
37
corticosteroid options
dexamethasone
38
corticosteriod AEs
- weight gain
- hyperglycemia
- insomnia
- stomach upset/irritation (inc risk (ulcer) when given with NSAIDs)
- inc BP
- agitations (hyper/manic feelings)
39
which N/V drug classes have QTc prolongation?
phenothiazines
serotonin antagonists
prokinetics
40
bismuth subsalicylate MoA
- antisecretory and antimicrobial action --> directly against bacterial and viral pathogen
41
bismuth subsalicylate limitations
- > 12 years old
- 2 day use
42
bismuth subsalicylate AEs
- fecal discoloration (black)
- tongue discoloration
- chelate with fluoroquinolone antibiotics
43
phosphorated carbohydrate solution (emetrol) limitations
- > 2 years old
- 1 hour max
44
constipation definition
less than or equal to 3 bowel movements per week
45
constipation causes
- drugs: opioids, anti-cholinergics (antihistamine, TCAs, CCBs), iron
- comorbidities: DM, pregnancy, IBS, hypothyroidism
- low fiber
- not enough water
46
constipation self care exclusions
- age < 2 years
- sudden change in bowel habits lasting > 2 weeks
- laxative use for > 7 days
- laxative use but no bowel movement
- severe abdominal pain
- N/V
- rectal bleeding
47
types of constipation and which we treat with OTC
- general constipation -- OTC
- CIC (chronic idiopathic constipation) -- OTC failed
- IBS-C -- OTC failed
- opioid-induced constipation -- OTC
48
constipation options
- bulk forming lax
- emollient lax
- hyperosmotic lax
- stimulant lax
- saline lax
- lubricant lax
- other Rx treatment
- opioid-induced treatment
49
soluble fiber products (bulk-forming lax) MoA
inc absorption of water in small and large intestine --> viscous gel
*NEED fluid!!!
50
soluble fiber products CI
CHF
51
soluble fiber products AE
cramping
52
docusate (emollient lax) MoA
surfactant/emulsifier: incorporates water --> softens stool
53
polyethylene glycol 3350 and glycerin (hyperosmotic laxative) MoA
large, poorly absorbed molecules --> draws water into colon
54
glycerin suppository AE
rectal irritation
55
sennosides, senna, and bisacodyl (stimulant lax) MoA
- directly stimulate colonic mucosa
- stimulate myenteric plexus
- inc water secretion into intestines
56
sennosides, senns, bisacodyl AE
cramping and abdominal pain
57
magnesium citrate, milk of magnesium, sodium phosphate (fleet enema) (saline lax) MoA
pulls fluid into intestines --> inc intraluminal pressure
58
mag citrate, milk of mag, sodium phosphate AEs
- abdominal cramping
- dehydration
- electrolyte imbalances
59
mineral oil (lubricant lax) MoA
- ease passage of stool by dec water absorption and lubricate intestine
- stops colon water absorption
**similar to docusate, docusate preferred
60
which OTC options do not cause cramping
- Miralax
- glycerin suppository
61
which OTC options are stool softeners
- docusate
- mineral oil enema
therefore also no cramping
62
Miralax age range
labeled indication: greater than or equal to 17 years old
could use off-label: 6 years and above
63
PEG 3350 MoA
inert substance --> pulls water into colon --> expands stool --> trigger expulsion and softenstool
**no direct stimulation --> no cramping
64
lactulose MoA
non-absorptive sugar --> causes water to be pulled into colon --> contraction
*similar to PEG
65
lactulose AE
- diarrhea
66
lactulose dosage form
syrup --> super sweet
67
osmotic agent uses
colonoscopy: PEG
hepatic encephalopathy: lactulose
68
lubiprostone MoA
works on Cl channels to inc Cl and water in colon --> improve fecal transit
69
lubiprostone AE
- diarrhea
- nausea
70
linaclotide and plecanatide MoA
- guanalyate cyclase receptor agonist (cGMP) --> inc bicarb and Cl secretion into stool --> inc fluid --> dec fecal transit time
- secretogogues
**same class --> same MoA
71
linaclotide and plecanatide AE
diarrhea
72
opioid induced constipation Rx class/MoA
mu peripheral antagonists
**opioids act on the mu receptor --> THEREFORE, the opioid will still have analgesic effects bc works in the CNS, but the GI effects will be inhibited bc they are peripheral effects
73
mu peripheral antagonist options
- methylnaltrexone
- naloxegol
- naldemedine
74
mu peripheral antagonist AEs
BBW: caution in GI wall issues (diverticulitis, IBD, colon cancer) --> can cause bowl preforations
75
diarrhea definition
greater than or equal to 3-4 stools in a 24 hour period
76
diarrhea causes
- virus (gastroenteritis --> *norovirus)
- IBD, IBS-D, celiac
- drugs --> antibiotics, metformin, chemotherpay
- food --> lactose
77
when are probiotics indicated?
pediatric, shorten duration of gastroenteritis and symptoms
*NOT adult c. diff prevention!
78
diarrhea self care exclusions
- pregnancy
- age < 6 months
- severe abdominal pain
- recent antibiotic use
- diarrhea > 14 days
- severe dehydration
- protracted vomiting
- blood, mucus, pus in stool
- DM, CHF
- immunosuppression
- high fever (>102.2 F)
79
diarrhea oral rehydration indication
ESSNETIAL in children (N/V and diarrhea) --> higher doses for diarrhea
80
bismuth subsalicylate MoA
bismuth: antimicrobial effects
salicylate: antisecretory effects
**both work on pathogen!!
81
bismuth subsalicylate age
> 12 years
82
what is child's pepto bismol?
calcium carbonate --> antacid
NOT TREAT DIARRHEA!!
83
adult pepto AEs
black staining of tongue and stool
chelate with fluoroquinolones
84
probiotic MoA
dec symptoms and duration of infectious diarrhea IN CHILDREN ONLY
- mixed data on if prevent antibiotic associated c. diff!
85
digestive enzyme MoA
lactaid: lactase enzyme replacement
86
loperamide MoA
opioid derivative without central activity (only peripheral activity) --> therefore, slows transit time and dec chloride secretion --> locks you up
this makes sense --> opioids cause constipation --> therefore this is the peripheral opioid effect!
87
loperamide age limit
6 years or older
88
loperamide pearl
opioid derivative/mu peripheral agonist --> can make you high if take enough!
89
loperamide CI
bacterial cause of diarrhea --> do not want to lock in the bacteria --> bad!
90
mu peripheral agonist MoA
works in gut --> cause constipation essentially
91
diphenoxylate + atropine MoA
diphenoxylate: similar to meperidine (opioid) --> inhibit excessive GI motility and propulsion
atropine: strong anticholinergic --> AE: hot, dry, blind --> DISCOURAGES ABUSE!
92
octreotide
inhibit serotonin, gastrin secretion, secretin, motilin, insulin, glucagon ----> overall dec intestinal motility and secretion
- a somatostatin (hormone) analog
93
octreotide dosing
SQ daily --> IM depot q 4 weeks
94
octreotide indications
- intestinal carcinoid tumors
- chemo-induced diarrhea
95
diphenoxylate + atropine indication
- IBD-UC
- adjunctive therapy (add on when so much stool even after treatment)
96
digestive enzymes age
greater than or equal to 4 years old
97
IBS definition
chronic abdominal pain with altered bowel habits
98
IBS Dx
- chronic abdominal pain for 1 day/week for 3 months
AND
- atleast 2 of following: associated with -- defecation, change in stool frequency, change in stool consistency
99
IBS patho
no functional changes but still symptoms --> Dx of exclusion
gut hypersensitivity: mismatch between what is happening in gut, and what is signaled to brain
100
IBS symptoms
- change in bowel habits
- global symptoms: pain, bloating
**today we treat both
101
what is IBS associated with?
- inc bacteria in colon (SIBO)
- gastroenteritis
- physchological stress
102
treatment goals for IBS
- improve global symptoms
- improve QoL
- improve stools
- improve bloating
103
how do we classify IBS?
type of stool
104
types of IBS
IBS-C: hard stool > 25% of time
IBS-D: liquid stool > 25% of time
IBS-M: mixed stool, C > 25% time and D > 25% time
105
lubiprostone IBS indication
ONLY WOMEN with IBS
106
lubiprostone AE
diarrhea, N --> reduce by taking with food
107
lineclitide and plecanatide additional effects
some pain receptor effects in colon
108
lineclitide and plecanatide AEs
diarrhea
109
tegaserod MoA
- inc GI secretion and motility
- dec visceral pain (gut pain)
- 5-HT4 agonist (NOT 5-HT3 SEROTONIN!)
110
tegaserod indication
women, < 65 years, no history of CV ischemic event (stroke, TIA, angina, heart attack/MI)
**REMS --> bc cardiac event causes
111
when to D/C tegaserod?
if no effect in 4 weeks --> bc and increased cardiac event risk so want to stop if not working
112
tegaserod AE
- HA
- diarrhea
- cardiac events
- well tolerated
113
tenapanor MoA
- GI Na/H exchanger isoform III --> dec sodium and phosphate absorption into body --> inc water secretion into stool
- GI pain receptor effect
114
tenapanor AE
diarrhea
115
IBS-C options
- lubipristone (women)
- lineclitide
- plecanantide
- tegaserod (women, <65, no ischemic Hx)
- tenapanor
116
IBS-D options
- rifaximin
- eluxadoline (Vibrezi)
- alosteron
117
rifaximin MoA
poorly absorbed antibiotic --> therefore stays in gut
INDICATION: SUSPECT BACTERIAL OVERGROWTH!
118
rifaximin dosage
550mg TID PO x 14 days
- can repeat twice prn
119
does rifaximin have systemic AE?
not really bc it stays in the gut --> no systemic absorption
120
eluxadoline MoA
mu, delta, kappa agonist --> inhibit bowel contraction
*makes sense bc acts like an opioid
121
eluxadoline main AE
**sphiner of oddi dysfuntion (the muscle valve that connects the bile duct/pancreatic duct to the small intestine
- can cause sphincter spasm --> back up of bile and stuff --> pancreatitis
122
eluxadoline CI
- Hx pancreatitis
- Hx alcoholism
- drink 3 drinks/day
123
eluxadoline AE
- N
- andominal pain
- constipation
124
alosetron MoA
serotonin antagonist (like ondansetron) --> dec transit time, inc water absorption --> dec stool liquidity
125
alosetron AE
- SEVERE CONSTIPATION
- ischemic colitis
therefore --> REMS!
126
alosetron indication
women with severe IBS-D
127
which 3 IBS agents are only for women?
- lubipristone -> IBS-C
- tegaserod -> IBS-C
- alosetron -> IBS-D
128
which IBS agents are on REMS?
- tegaserod -> IBS-C
- alosetron -> IBS-D
129
other IBS options
- TCA antidepressants
- soluble fiber
130
TCA MoA for IBS
- help with brain-gut miscommunication
- TCAs>>>SSRIs for IBS --> but due to AEs, providers often do SSRIs
effect:
- improve pain
- global IBS of bloating and pain s/s
131
TCA options
- amitriptyline
- nortriptyline
132
TCA AEs
**anticholinergic --> dry, sedation, CONSTIPATION!!
- therefore take at night
133
which TCA is for IBS-D? why?
amitriptyline
- older, more AE --> constipation is an AE --> therefore use with diarrhea
134
which TCA is for IBS-C? why?
nortriptyline
- newer, fewer AE --> constipation is an AE --> therefore since already have constipation, want to dec that effect!
135
soluble fiber options
- psyllium (metamucil)
- barley
- oatbran
- beans
136
soluble fiber MoA
soluble: pull water into gut and make a gel
vs
insoluble: not digested, fermented in colon -> gasey
137
GERD disease differences
heartburn: burning in substernal chest, moves up, taste acid
GERD: heartburn that occurs 1-2 times/wk, 3 or more months, not respond to OTC therapy
VS
dyspepsia: discomfort, pain, burning, gnawing, early satiety in epigastrium
gastritis/duodenitis: superficial inflammation of stomach mucosa lining
PUD: inflammation to submucosa
138
GERD complications
barrett's esophagus
esophageal adenocarcinoma
139
self-care exclusions for GERD
- symptoms > 3 months
- age < 2 years
- symptoms despite PPI or H2RA OTC for 2 weeks
- difficulty/pain when swallowing
- vomiting blood, black/tarry stools
- chronic hoarseness, choking
- unexplained weight loss
- continuous N/V/D
- chest pain + sweating, radiating to shoulder/arm
- SOB
- pregnant/nursing
140
alarm symptoms --> need a GI or other workup FIRST
- substernal pain: cardiac
- suspected GI bleed --> coughing up blood
- unexplained weight loss
- dysphagia --> hurts to swallow
- anorexia: not want to eat
141
antacid MoA
neutralize stomach acid (buffer)
- Mg --> diarrhea
- Al and Ca --> constipation
142
H2RA MoA
inhibit histamine receptor on parietal cell --> dec acid produciton i think
143
PPI MoA
inhibit parietal cell H/K ATP pump --> prevent stomach acid secretion i think
144
which do you take on an empty stomach?
PPIs
30min before first meal --> if forget, do 30 min before second meal
145
H2RA age limit
12 years old
146
PPI age limit
18 years old
147
how long is heartburn/GERB/dyspepsia OTC treatment??
14 days ONLY
148
most potent OTC for gerd?
PPI
149
why does barrett's need lifelong PPI?
dec risk esophageal adenocarcinoma!
150
which indications for long term PPI?
- barrett's
- GERD complications: severe erosive esophagitis, narrowing/strictures
151
long term PPI AEs
- bone fracture, hip fracture
- B12 deficiency
- dementia
- CKD from AIN
- c. diff, gastroenteritis
152
why do we limit PPI use?
stomach acid helps with absorption and killing so don't want to suppress it forever!!
153
PPI long term monitoring
- kidney as usual
- daily recommendations of B12, D, and Ca
154
gastritis/duodenitis
inflammation of top layer - muscosa only
155
ulcer
inflammation down to submucosa
* >5mm in size
**more blood vessels therefore more GI bleed risk, life-threatening
156
major complication of PUD
GI bleeding
157
causes of PUD
#1 cause: H. pylori
#2 cause: NSAIDs
158
h pylori pud duration of treatment
14 days
159
h pylori pud 1st line
quad therapy --> QID
ppi bid
+
bismuth subsalicylate
+
tetracycline
+
metronidazole
160
h pylori pud 2nd line
triple therapy --> bid
ppi bid
+
azithromycin
+
amoxicillin or metronidazole
161
which h pylori pud treatment needs eradication confirmation?
triple therapy
*wait 4 weeks AFTER TREATMENT ENDS to confirm testing
162
NSAID PUD risk factors
- age > 65 years
- using steriods concurrently
- non-COX selective use
- anticoagulants
- antiplatelets
- previuos Hx PUD
- high dose NSAID
- multiple NSAIDs
163
if you have a NSAID ulcer and can stop the NSAID, how long PPI?
4-8 weeks
164
why are COX-2 NSAIDs prefered?
less impact on GI prostaglandins --> less PUD risk
165
COX-2 selective nsaids
- celecoxib
- nabumetone, meloxicam, etodolac
166
PUD NSAID patho
NSAID --> COX inhibition --> dec PG (to dec pain) --> ALSO inc acid secretion, dec proliferation of cells, dec bicarb --> epithelial cell damage --> ulcer
167
upper GI bleed s/s
- melena (black stool)
- hematemesis (throwing up blood)
- lightheaded
- HA
- inc HR
- dec BP, Hgb, Hct
168
why do we treat upper GI bleed with PPI asap?
stomach acid will reduce activity of platelets and clotting factors --> we need those to be working in order to clot the bleeding spot
169
upper GI bleed PPI treatment breakdown
step 1: 80mg IV bolus
step 2: 40mg IV bolus BID OR 8mg/hr continous IV
****step 1 + 2 = 72 hours (3 days)*******
step 3: oral PPI x 2 weeks
step 4:
- h pylori: add the antibiotics for 2 weeks oral ppi totoal
- NSAID: continue so total oral ppi either 4-8 weeks or conituous
170
what two categories of patho does IBD impact?
- GI mucosa
- GI pathogen recognition
171
unique s/s of IBD
- blood in stool
- weight loss
- abdominal pain
- cramping
172
IBD Dx
- stool studies: leukocytes, LACTOFERRIN, CALPROTECTIN (non-invasive) (both bowel inflammatory markers)
- colonoscopy with small-bowel follow thru
- inc ESR, inc CRP --> non-specific markers of inflammation
- CT scan, MRI --> penetration into other tissues
173
main mode of IBD Dx
colonoscopy!
174
UC complications
- toxic megalocolon
- colon cancer
- colectomy
175
CD complications
- malnutrition, vit deficiency
- strictures
- fistulas
176
which IBD do we have a cure for?
UC --> colectomy
177
what OTC do we avoid in IBD?
NSAIDs --> induce flares!
178
5-ASA MoA
locally inhibit COX enzymes --> reduce prostaglandins --> reduce inflammation and pain
179
5-ASA absorption
rapidly absorbed into the SI but want it to stay in GI --> THEREFORE need a carrier to keep it in GI (targetted drug delivery)
180
sulfasalazine AE
rash/allergy
181
sulfasalazine carrier
sulfa
182
balsalazide carrier
inert
183
mesalamine carrier
many product that bring to diff part of GI!! ohhhhh
184
mesalamine suppository (Canasa)
rectum
185
mesalamine enema (Rowasa)
rectum + distal colon
186
mesalamine oral DR (Asacol)
terminal ileum --> CD
187
mesalamine oral (Pentasa)
jejunum --> CD
188
immunomodulator MoA
immunosuppressant properties
189
which immomodulators are related?
azathioprine (prodrug) --> 6-mercaptopurine
190
why do we use azathioprine with biologics or steriods?
aza...
- takes 3 months to work
- inc efficacy, dec ADA formation
- steriod sparing
191
azathioprine monitoring
- CBC q3months --> bone suppression
- LFTs
- pancreatic enzymes
192
azathioprine BBW
lymphoma risk inc when use with biologic!!!
193
methotrexate dosage form
IM/SQ ---> PO when stable
194
corticosteroid MoA
dec immune response, dec inflammation
195
why is budesonide good for IBD?
high first-pass effect --> therefore, more stays in GI --> less systemic effect, very effective in GI
*poor systemic absorption
15x more potent than prednisone bc local effect
196
which budesonide oral is for UC?
Uceris --> colon
197
which budesonide oral for CD?
Entocort --> terminal ileum
198
duration for budesonide treatment?
8 weeks
199
antibiotic indication
CD --> perianal disease (fissures, fistulas)
200
antibiotic options
**enteric gram (-) (e coli, protese)
**anaerobes
these are what is most present in GI tract!
metronidazole
ciprofloxacin
3rd gen cephal
201
which biologic has best evidence?
infliximab
202
anti-TNF BBWs
1) infection --> TB, invasive fungal, bacterial, viral, opportunistic
- therefore: PPD, chest x-ray, HBV, HCV, HIV baseline
- HOLD when sick
2) malignancy --> lymphoma
- when + azathioprine
- but inc efficacy with azathioprine
203
natalizumab MoA
inhibit leukocyte trafficking and T cells (everywhere)
204
natalizumab BBW
PML --> CNS infection
**REMS
THEREFORE WE PREFER VEDOLIZUMAB
205
vedolizumab MoA
inhibit T-cells tagged/going to GI tract
206
JAKi BBWs
- cancer
- cardiac events
- thrombosis
- death
- infection
207
JAKi indication
bc so many BBW...
failed 1 or more TNF inhibitors
208
how to give mesalamine enema
at night in bed as retention enema
- wear adult diaper
