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Chem and physics > Pharm 2: GI GU > Flashcards

Pharm 2: GI GU Flashcards

1
Q

Nausea & Vomiting

Causes

A

Ingestion/Admin of substance/drug
* chemo, opiates, abx, NSAIDs, hormonal therapy

GI disorders
Mechanical gastric outlet obstruction, inta-abd emergencies (appendicitis), gastroenteritis

Neuro
Cerebellar hemorrhage, tumor, hydrocephalus

Metabolic
Addisons, volume depletion, DKA, hypercalcemia

Presence of noxious stimuli

Pt specific factors that increase risk
Age (younger), previous n/v (post-op, queezy when others vomit), gender (women), obesity, anxiety

Post-op n/v: prophylactic tx

Other
Pregnancy, noxious odor, ingestion of irritant, operative procedure, septicemia, nicotine

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2
Q

N/V - Stimuli
Drugs
Ketoacidosis
Uremia

A

Agents used
Phenothiazines
Metoclopramide

Chemoreceptor trigger zone - dopamine, opiate receptors

Acts on vomiting center to:
Lower diaphragm
Contraction of abd muscles
Esophageal dilation
Reverse direction of peristalsis
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3
Q

N/V - Stimuli
Obstruction
Gastroparesis
Visceral pain

A

Agents used
Metoclopramide
Visceral pain: analgesics

Afferent impulses from periphery - dopamine, opiate receptors

Acts on vomiting center to:
Lower diaphragm
Contraction of abd muscles
Esophageal dilation
Reverse direction of peristalsis
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4
Q

N/V - Stimuli
Motion sickness
Vestibular inflammation

A

Agents used
Antihistamines
Anticholinergics

Vestibular apparatus - acetylcholine, norepi receptors

Acts on vomiting center to:
Lower diaphragm
Contraction of abd muscles
Esophageal dilation
Reverse direction of peristalsis
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5
Q

N/V - Stimuli
Higher brain stem:
emotions, sights, smells, tastes

A

Agents used
Benzodiazepines
Dronabinol
Corticosteroids

Cortical structures

Acts on vomiting center to:
Lower diaphragm
Contraction of abd muscles
Esophageal dilation
Reverse direction of peristalsis
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6
Q

N/V - Diagnostic Criteria

A

3 phases of emesis
Nausea: w/wo emesis: flushing, pallor, hyper-salivation

Retching: involuntary, synchronized labored movement of abdominal and thoracic muscles before vomiting

Vomiting: coordinated contractions of abd and thoracic muscles to expel gastric contents

Causes:
Recent travel
Hypoactive bowel sounds
Fever
Work with sick population
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7
Q

N/V - Phenothiazines

A

Prochlorperazine (Compazine)
Promethazine (Phenergan)
Mild to moderate n/v, in combo for severe

MOA
Dopamine receptor blockade in CTZ
Bind to and block cholinergic, alpha 1 adrenergic & histamine 1 receptors

C/I
Concomitant use of drugs that cause CNS depression (sedatives, hypnotics, opiates)
Exacerbation of Parkinsons s/s
Decrease sx threshold
Preg Cat C

Adverse events
Drowsiness, sedation
EPS: block central dopaminergic receptors
- drooling, tremor, inability to initiate voluntary movement, rigidity, dry mouth, urinary retention, hypotension, sedation

Interactions
ETOH and other CNS depressants
Propranolol - increased drug
Anticonvulsants - lower sz threshold
Caution in elderly
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8
Q

N/V - Antihistamines

Anticholinergics

A 
Hydroxyzine (Vistaril)
Meclizine (Antivert)
Dimenhydrinate (Dramamine)
Scopalamine (Transderm Scop)
Mild nausea, motion sickness

MOA
Interruption of visceral afferent pathways that stimulate n/v

C/I
Breastfeeding
Asthma
Glaucoma
GI/urinary obstruction
Prostatic Hypertrophy (BPH)

Adverse Events
Sedation, drowsiness, confusion
Blurry vision, dry mouth, urinary retention, tachycardia
S/s of OD: dilated pupils, tachycardia, HTN, CNS depression, flushed skin, Respiratory failure, circulatory collapse

Interactions
ETOH
Tranquilizers
Sedative hypnotics

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9
Q

N/V - Benzos

A

Lorazepam (Ativan)
Tx and prevent emesis, anxiolytics, amnesia (good for anticipatory n/v - chemo)

MOA
Hepatic or renal failure
Preg Cat D

Adverse Events
CNS depression: drowsiness, fatigue, memory impairment, impaired coordination, confusion
Paradoxical CNS stimulation
Constipation, HA, inc/dec appetite
Hypotension, bradycardia, apnea (parenteral)
Monitoring: CV, resp status, LFTs

Interactions
CNS depressants, ETOH

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10
Q

N/V - 5-HT3 receptor antagonists

Serotonin Antagonists

A

Ondansetron (Zofran)
Tx of chemo - induced n/v

MOA
Antagonize type 3 serotonin receptors centrally in CTZ and peripherally at afferent fibers upper GI tract

C/I
May harm fetus, may pass into breastmilk
Preg Cat B (may cause cleft palate later in pregnancy)

Adverse Events
HA
Diarrhea
Abd/epigastric pain
Elevated LFTs
HTN
Fatigue
Constipation
Pruritis
Fever
Arrhythmia/heart block (prolong PR, QT, wide QRS)

Interactions
Diuretics
Drugs that prolong cardiac conduction

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11
Q

N/V - Cannabinoids

A

Dronabinol (Marinol)
Only for chemo-induced n/v

MOA: unknown
Therapeutic level of THC must be in blood before admin of chemo to prevent emesis (6-12 hrs)
Pt w/ previous recreational use -> better antiemetic effect

C/I
Preg Cat D

Adverse Events
CNS effects (no driving or operating machinery)
Sedation, ataxia, dysphoria, confusion, hallucinations, anxiety, fear, orthostatic hypostatic, blurry vision, tachycardia

Indications
ETOH
CNS depressants

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12
Q

N/V - Prokinetics

A

Metoclopramide (Reglan)
Diabetic gastric stasis, post surgical gastric stasis, gastroesophageal reflux

MOA
Unknown

C/I
Gi toxicity (take w/ PO), high blood glucose levels, mood swings, depression, anxiety, aggression, psychosis, HA, restlessness, insomnia
Long term: muscle wasting, fluid/electrolyte imbalance, cataracts, osteoporosis, pathological fractures

Interactions
Decrease effect of barbiturates, hydantoins, rifampin, ephedrine
Monitor: K levels when taken w/ K (depletes w/ diuretics)

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13
Q

N/V - Agent selection

A

Determine cause:
Drug induced: d/c or reverse drug

Diabetic ketoacidosis: tx with insulin, alkalosis

Hypercalcemia: IV hydration, diuretics, pamidronate

Increased ICP: surgery, steroids

EPS: tx w/ diphenhydramine or benztropine

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14
Q

N/V -

Lines of treatment

A

1st line
Phenothiazine: mild or moderate n/v (promethazine, prochlorperazine)

2nd
Antihistamine or anticholinergic: good for mild nausea when 1st isn’t effective

3rd line
Re-eval physiological cause

Education
take meds 1-2 hrs prior
long term use required monitoring: CBC, BMP, EKG

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15
Q

GERD

Causes

A 
Relaxation of lower esophageal sphincter
Increased intra-abd pressure (obesity, pregnancy)
Delayed gastric emptying
Hiatal hernia
fatty foods
chocolate, peppermint/spearmint
garlic, onions, chili peppers
ETOH, coffee/caffeine
spicy foods, citrus foods/tomato
tobacco
aspirin, iron, NSAIDs
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16
Q

GERD

Diagnosis

A

Symptoms occur after meals
Symptoms worse when reclining or lying down
Pt responds to empiric trial of acid suppression therapy

Treatment:
Relieves symptoms
Decrease frequency/duration of reflux
Heal esophageal mucosa
Prevent complications (esophagitis, esophageal ca, peptic stricture, barretts's esophagus)

Symptoms:
Heartburn
Dyspepsia
Nausea, bloating, belching, epigastric fullness/pressure/pain
Chronic cough/throat clearing
Asthma, wheezing, hoarseness, sore throat

Diagnose w/ endoscopy (with biopsy)

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17
Q

Peptic Ulcer Disease

A

Tissue injury from acid and digestive functions of GI tract

Common forms:
Helicobacter pylori-positive ulcers (chronic)
NSAID-induced ulcers (chronic)
Stress ulcers (critically ill, following major trauma/illness)

Cause:
Breakdown of gastric tissue and tissue injury from acid and digestive functions

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18
Q

Peptic Ulcer Disease

Diagnosis

A

Symptoms
Epigastric abd pain
Heartburn, belching, bloating
H. Pylori affects duodenum: pain 1-3 hrs after meal, food makes pain better
NSAIDs affect stomach: n/v, anorexia, food precipitates ulcer pain

Diagnose w/ endoscopy (with biopsy)
Cultures for H. pylori detection

Complications
GI bleeding (melena, hematemesis)
Perforation (sharp, sudden pain)
Gastric Outlet obstruction (bloating, anorexia, n/v, wt loss)

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19
Q

GERD + PUD
Treatment
Antacids

A

H. Pylori induced ulcers: combo of abx and acid suppression

Calcium Carbonate. (Tums), Mag Salts, Aluminum Salts

MOA
Neutralize HCl acid in stomach -> increase pH

C/I: none

Adverse:
Rebound acidity (mag containing antacids)
Constipation (aluminum containing antacids)

Interactions
Alter rate of absorption of iron, sulfonylureas, tetracycline, quinolone abx
Take 1-4hrs AFTER meds that alter absorption

Used for mild intermittent symptoms (less than 2x per week)
Short duration of action
Do not heal ulcers, only mask signs

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20
Q

GERD + PUD
Treatment
Histamine 2 receptor Antagonists (H2RAs)

A

Cimetidine (Tagamet)
Famotidine (Pepcid)
Ranitidine (Zantac)

MOA
Inhibit histamine 2 on gastric parietal cells -> decrease acid secretion & pepsin activation

C/I: hypersensitivity to H2RAs

Adverse events
HA, dizziness, confusion
Caution in elderly and renal disease

Interactions
Tagamet inhibits CYP450 (warfarin, phenytoin, theophylline)
Take antacids 1-2 hrs after H2RA

Effective in:
Mild GERD
Healing ulcer
H. pylori eradication
Prevention of NSAID related ulcer
Only use 1-2x daily
Onset of action 1-2 hrs after admin
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21
Q

GERD + PUD
Treatment
Proton Pump Inhibitors

A

Omezaprole (Prilosec)
Lansoprazole (Prevacid)
Pantoprazole (Protonix)
Esomeprazole (Nexium)

MOA
Inhibit gastric proton pumps located in parietal cells -> long lasting suppression of acid secretion

C/I: hypersensitivity to PPis

Adverse events
HA, diarrhea, constipation, abd pain
Long term use: hypergastrinemia, fracture, GI infection (C. diff, gastrointeritis), Vit B12 deficiency, hypomagnesemia

Interactions
Omeprazole and Lansoprazole: May affect clopidogrel (plavix)
Caution in pts taking plavix

Most potent acid suppressing agent
Onset is 5 days, most effective when taken in the morning 30-60 min BEFORE food

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22
Q

GERD + PUD
Treatment
Antibiotics

A

Amoxicillin (Amoxil)
Clarithromycin (Biaxin)
Metronidazole (Flagyl)

MOA
Used in combo w/ acid suppressing meds to eradicate H. pylori, PUD
Kills bacteria and inhibit bacteria protein synthesis

C/I:
Allergy; concomitant use w/ meds that prolong QT

Adverse events
N/v/d metallic taste

Interactions
Amoxicillin - increase effects of warfarin (increase INR)
Clarithromycin - CYP3A4 inhibitor
Metronidazole - avoid w/ ETOH and warfarin

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23
Q

GERD

Treatment

A

GERD

First line:
Mild s/s: lifestyle changes -> OTC antacids -> H2RA, PPIs
Moderate-severe: prescription acid suppression (PPIs favored)
Step up tx: lifestyle w/ gradual increase of pharm intervention; H2RA -> PPI -> surgery
Step down tx: start w/ high dose PPI -> titrate to lowest dose

Second line: for pt w/ incomplete response to acid suppression
Add H2RA at bedtime (2nd line after PPI)

Third line
Anti-reflux disease

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24
Q

GERD + PUD
Treatment
Misoprostol (Cytotec)

A

For pts taking high dose NSAIDs

MOA
Synthetic prostaglandin E1 analog -> inhibits acid secretion, increased mucosal defenses

C/I
Pregnancy -> uterine contractions -> AVOID

Adverse events
Diarrhea, abd pain, cramping, nausea

Interactions
Antacids may increase side effects

Used for prophylaxis against NSAID induced ulcers

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25
Q

GERD + PUD
Treatment
Sucralfate (Carafate)

A

Used for pts w/ duodenal ulcer, stress ulcer prophylaxis
Take on empty stomach

MOA
Viscous, adhesive substance that attaches to and protects ulcers from gastric contents

C/I: hypersensitivity to sucralfate

Adverse events
Constipation

Interactions
Decrease absorption of many meds
Must take 2-6 hrs before or after other meds

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26
Q

GERD + PUD
Treatment
Bismuth Subsalycylate (Pepto Bismol)

A

MOA
Suppression of acid secretion
Antimicrobial effects, salicylate provides anti-inflammatory action

C/I
Hypersensitivity to salicylates, pregnancy, lactation

Adverse events
Black stool
Darkened tongue
Constipation
Tinnitus

Interactions
Increased risk of bleeding w/ anticoagulants or antiplatelets

Effective against H. pylori when used in combo w/ abx

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27
Q

GERD

Special populations

A 
Pediatric
Spitting up, fussy around feeding
Immaturity of LES 
Respolves by 12-14 mos
Can consider Ranitidine (until pt outgrows GERD)

Women
Heartburn common during pregnancy
OTC antacids safe in moderations

Geriatric
High risk for GERD, slowed gastric motility, decreased saliva
Consider PPI bc 1x daily dosing, efficacy and tolerability
Risk for fractures (PPI)

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28
Q

GERD + PUD

Monitoring

A 
Lifestyle modifications
Wt loss
Elevate HOB
Smaller, frequent meals
Less causative foods
Avoid tight fitting clothes
Smoking cessation
ETOH

Monitor w/in 1st few weeks of initiating therapy

Allow sufficient time
6 weeks for H2RA
4 weeks for PPI

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29
Q

PUD

Agent selection

A

1st line
H.pylori + PUD: PPI + amoxicillin + clarithromycin x 7 days (triple therapy)
NSAID induced: PPI, H2RA, sucralfate (if NSAID can be d/c’d), PPI concomitantly

2nd line
PPI + bismuth subsalycylate + metronidazole + tetracycline (quad therapy)

3rd line: if pt fails 1st and 2nd line
GI for endoscopy and biopsy

PPIs and misoprostol very effective to prevent NSAID induced gastric ulcers
Consider Celecoxib if NSAID must continue - less GI side effects

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30
Q

PUD

Special populations

A

Pediatric
High rates of H. pylori in children of low socioeconomic status
Must consider triple therapy for eradicating or high risk of recurrence

Women
Misoprostol not to be given during pregnancy

Geriatric
High risk for GI malignancies - endoscopy + biopsy
High rates of tx failure with triple therapy bc of abx resistance

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31
Q

PUD

Monitoring

A

Expect improvement in 7 days w/ anti ulcer therapy

Once NSAID dc’d - improvement w/in days

Symptoms: 14 days = treatment failure -> refer to GI specialist
* educate pt on full adherence bc of possible tx failure

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32
Q

Constipation

A

Infrequent or difficult evacuation of stool -> diet, lifestyle, meds

Affects females more than males
More common in > 65 yo
Affects male and female children equally
Diet modification preferred over treatment

Causes
If primary cause present -> constipation is secondary symptom
Lifestyle - inactivity, diet; medication - iron
Chronic idiopathic constipation: slow transit constipation, reduction in propulsive capacity of colon
Opioid drugs

  • If fluid absorption in small intestine is reduced, the fluid excess leads to diarrhea
  • if there is excess fluid reabsorption, constipation occurs
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33
Q

Constipation

Lifestyle modifications

A

Diet
Increase soluble and insoluble fiber (fruits, vegetables, whole grains), water intake

Exercise

Bowel habit training: regular pattern for bathroom visits

If lifestyle modifications fail -> Medication

Goal of tx: increase H2o content of feces and increase motility of intestines using lowest dose of laxative for least amount of time

If therapy fails after 3-6 months: colon transit studies

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34
Q

Constipation

Stimulant laxatives

A

Bisacodyl (Dulcolax)
Senna (Senokot)

MOA
Increase peristalsis through direct effects on smooth muscle of intestines; promote fluid accumulation in colon and small intestine
Onset: PO 6-10 hrs, rectal 15 min - 2hrs

C/I
Acute adb, fecal impaction, obstruction, rectal fissures, hemorrhoids
severe abd pain
fevers
committing
abd distension
guarding on abd exam
hypo, absent, hyperactive bowel sounds

Adverse events
n/v, abd cramping, gas
laxative dependence

Interactions
avoid concomitant use of dulcolax w/ antacids/pH lowering agents

For short term use
Long term use -> dependence

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35
Q

Constipation

Saline laxatives

A 
Mag citrate
Mag hydroxide (milk of mag)
Mag sulfate (epsom salt)
Sodium phosphate 
Sodium biphosphate (fleet enema)

MOA
Draw water into intestines through osmosis -> increase in intraluminal pressure -> increase in intestinal motility

C/I: caution in young children & > 55 yo, renal disease
* phosphates can cause electrolyte imbalance (high phos, low K, low Ca, high Na, metabolic acidosis)

Adverse events
Dehydration

Interactions
Tetracycline and quinolone abx, antifungals

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36
Q

Constipation

Bulk forming agents

A

Methylcellulose (Citrucel)
Psyllum (Metamucil)

MOA
Work by binding to the fecal contents and pulling water into the stool; stimulate movement of intestines

C/I
Opioid induced constipation (not effective)
Hx of SBO
acute surgical abd
decreased PO intake of fluids
GI ulceration

Adverse events
Flatulence, bloating

Interactions
Gluten intolerance

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37
Q

Constipation

Lubricant laxatives

A

Mineral Oil (liquid paraffin)

MOA
Coats and softens stool; prevents reabsorption of H2O from stool by colon
Prevent straining in high risk pts (post op, L&D, CVA, hemorrhoids, hernia, MI)

C/I
DO NOT administer before bed -> aspiration

Adverse events: unpleasant taste

Interactions
Surfactant laxative -> liver toxicity
Warfarin -> decreased vitamin K levels -> increase effects of anticoagulation

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38
Q

Constipation

Surfactant laxatives

A

Docusate (Colace)

MOA
Reduce surface tension of liquid contents of bowel; promote addition of liquid to stool; softer stool, easier to defacate

C/I
Good for pts on low sodium diets; good for HTN, CHF

Adverse events
Stomach upset
cramping
diarrhea

Interactions
Liver toxicity w/ concomitant use with mineral oil

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39
Q

Constipation

Hyperosmolar laxatives

A

Lactulose (Cephulac)
Sorbitol
Polyethylene glycol (Miralax)

MOA
Metabolized to solutes in intestinal tract -> osmotic pressure -> stimulates intestinal motility and propulsion of fecal contents

C/I
Caution w/ dehydration

Adverse events
abdominal cramping and nausea

Interactions
Avoid antacids w/ lactulose (interferes w/ MOA)

Lactulose: more rapid action
Miralax: slow action

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40
Q

Constipation
Secretagogues
Chloride channel activators

A

Lubiprostone (Amitiza)

MOA
Enhance chloride rich intestinal fluid without altering serum sodium and potassium concentrations -> pulls water

C/I
Mechanism obstruction
severe diarrhea
pregnant women 
children

Adverse events
nausea

No interaction

Prescribed by GI specialist

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41
Q

Constipation
Secretagogues
Guanylate Cyclase C Agonist

A

Linaclotide (Lizess)

MOA
Stimulates secretion of chloride and bicarb into intestinal lumen -> increases fluid and decreases transit time

C/I
children < 6, mechanical obstruction

Adverse events
diarrhea, abd pain, flatulence, abd distension

Interactions: none

Prescribed by GI specialist

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42
Q

Constipation
Secretagogues
Peripherally acting Mu-opioid receptor antagonist (PAMORA)

A

Naloxegaol (Movantik)

MOA
Antagonist of opioid binding at mu-opioid receptor -> decreased constipating effects of opioid

C/I
Known or suspected GI obstruction; potential for GI performation
Can cause opioid withdrawal in pts on methadone
Preg cat C

Adverse events
Abd pain
N/v/d
flatulence
HA, hyperhidrosis
AVOID in surgical adb

Interactions
CYP34A inhibitors: Diltiazem, erythromycin, verapamil,
risk for withdrawal withdrawal in other opioid antagonists

43
Q

Constipation

Agent selection

A

1st line
Bulk forming laxative for all types of constipation (take with plenty of water)
Docusate - most effective to prevent straining

2nd line
Mag hydroxide, saline laxative, lactulose, sorbitol
More rapid onset of action

3rd line
Stimulant laxative

  • Goal is not to increase frequency of defamation -> dehydration
  • Goal is to increase comfort during defecation

Increase PO fluid -> improves efficacy
Safe when used in moderation
Chronic constipation - bulk forming are safer - take at least 3 days to work

44
Q

Constipation

Special population

A

Children
Not usually pathologic - potty training stress, painful stool
Can cause urinary incontinence and UTI
Increase fluids, bowel routine
Pharm tx not usually recommended - PEG prep, mineral oil
* NO ENEMAS < 2

Women
Docusate for pregnant women
Castor oil can stimulate contractions - AVOID

Geriatric
Bowel obsessed
Eliminate causative agents (antipsych, TCA, calcium)
High risk of electrolyte imbalance w/ laxatives
High risk for dehydration - caution

45
Q

Diarrhea

A

Increased frequency of loose, watery stool (>3x daily) over 24-48 hrs

Causative organism transferred from person to person via food and water

Can cause serious dehydration

Causes:
Meds 
Mag containing antacids
Abx
SSRI antidepressants
Cholinergic agents
Digoxin
GI stimulants
Laxatives
Metformin
Prostaglandins
Quinidine
Disorders
AIDS
Bowel rsxn
Colon ca
Diverticulitis
Enteral feeding
Gastroenteritis
Hyperthyroid
IBD
IBS
Lactose intolerance 
Malabsorption
Pheochromocytoma

Acute: lasts 1-14 days
Persistent: 14-30 days
Chronic: > 30 days

46
Q

Diarrhea

Diagnosis

A

Fecal leukocyte, lactoferrin and hem occult blood test, stool cx

Ova and parasites:
person not previously treated w/ empiric anti parasitic therapy
persistent diarrhea > 7 days
recent travel to mountainous regions, Russia or Nepal
exposure to infants at daycare centers
blood diarrhea w/ few or no fecal leukocytes
rectal sex; AIDS

Initiate therapy & evaluate inflammatory pathogen:
profuse, watery diarrhea w/ dehydration
passage of blood and mucus
fever > 101.3F

  • Prophylaxis for those that cannot comply w/ dietary restrictions
  • travelers to places w/ contaminated drinking water
47
Q

Diarrhea

Antimotility Agents

A

Diphenolxylate w/ atropine (Lomotil)
MOA: decrease GI motility

C/I:
Exacerbate infectious diarrhea-won’t excrete infectious organism
Don’t use when assoc w/ fever, bloody diarrhea, fecal leukocytosis
Caution w/ hepatic dysfunction

Adverse events:
abd discomfort, constipation, dry mouth, dry eyes, urinary retention
-drowsiness, blurry vision, dizziness
-Caution: pts w/ liver disease, fever, bloody stools, fecal leukocytosis
AVOID in children < 4yo

Interactions:
Antidepressants, ETOH, barbiturates, benzos (react w/ diphenoxylate)
HTN crisis w/ MAOIs
TCA, antipsych, antihistamines (react w/ atropine)

Loperamide (Imodium)
MOA:
Opioid receptor agonist - acts on mesenteric plexus of large intestine

C/I:
Fever, bloody, stools, fecal leukocytosis

Adverse events
Abd discomfort, constipation, drowsiness, dry mouth

Interactions
Does not cross BBB, can cause drowsiness -> warn if driving or performing activities requiring alertness

  • causes stools to be more formed, less watery
    Avoid in infectious diarrhea, traps infection in gut, makes course of infection longer
48
Q

Diarrhea
Atypical antidiarrheals
Antisecretory agents

A

Subsalicylate (Pepto Bismol), (Kaopectate)

MOA
anti-inflammatory action, antacid, antibiotic and antiviral properties

C/I
hypersensitivity to ASA
AVOID in kids w/ flu or chicken pox -> Reyes syndrome

Adverse events
black stool, dark tongue, tinnitus

Interactions: meds that interact w/ ASA
Aspirin
Warfarin

49
Q

Diarrhea

Adsorbents & Absorbents

A

Adsorbent: Kaolinite (Kaopectate)
Absorbent: Polycarbophil (Fibercon)

MOA
Adsorbent: bind to bacteria -> solidification of of loose stools (add dose after each BM)
Abdorbent: water is absorbed in GI tract -> less watery stools

C/I: none

Adverse events:
Constipation and feeling of fullness
Stomach upset, bloating and gas

Interactions
Not selective: may absorb other meds & nutrients -> take separately from other meds and food

50
Q

Diarrhea

Semisynthetic Abx

A

Rifaximin (Xifaxin)

  • for non-invasive strains of E. coli
  • best for travelers diarrhea

MOA
Blocks transcription of bacteria -> inhibits bacterial synthesis and growth

C/I
hypersensitivity to Rifaximin

Adverse events
Peripheral edema, nausea, dizziness, fatigue, muscle spasms, HA

Interactions
Poorly absorbed into bloodstream -> low risk for interactions

51
Q

Diarrhea

Agent Selection

A

1st line
Loperamide - more effective than adsorbents (drowsiness - may not be tolerated as first line)
Travelers diarrhea: Ciprofloxacin, Levofloxacin, Rifaximin

2nd line
Adsorbent or antisecretory agent

3rd line
Lomotil (schedule 5; causes anticholinergic effects + CNS effects)
Zithromycin

52
Q

Diarrhea

Special Populations

A

Children
Oral hydration is priority
Antidiarrheal agents not recommended

Women
Loperamide NOT given bc not studied
Absorbents = 1st line

Geriatric
Rehydration is priority
Diphenoxylate/loperamide -> sedation when combined w/ benzos, antidepressants, anticholinergics, antipsych

53
Q

Diarrhea

Monitoring

A 
All patients at risk for:
dehydration
hypotension
tachycardia
orthostatic hypotension
poor skin turgor

Monitor serum electrolytes

54
Q

Irritable Bowel Syndrome

A

Functional bowel disorder w/ abd discomfort and alteration in bowel pattern

Classic symptoms: 
abd pain 
bloating
constipation
diarrhea

Causes
Dysregulation btw brain and gut
increased and abnormal contractions on intestinal tract -> either diarrhea OR constipation
onset over weeks to months
worse during physical and emotional stress -> sexual/physical abuse
Food can be trigger
Meds may be required only intermittently

55
Q

Irritable Bowel Syndrome

Diagnosis

A 
Abd pain
Change in consistency of stools -> relieved w/ defecation
Young adulthood onset
Wt loss
rectal bleeding
fever
acute onset
onset > 50 yo unusual

ROME III criteria for IBS
Recurrent abd pain 3 days/mo in the last 3 months with 2 of the following:
-Improvement w/ defecation
-Onset assoc w/ change in frequency of stool: more or less frequent
-Onset assoc w/ change in appearance of stool: formed vs liquid

56
Q

Irritable Bowel Syndrome

Treatment

A

Mild symptoms:
Responsive to dietary and lifestyle changes
- Avoid cereals, spicy food, lactose, caffeine, beans, cabbage, fatty foods, ETOH)
- Maintain daily diary of food intake
-Biofeedback: relaxation; good for stress induced IBS
-Incorporate exercise into daily activities

57
Q

Irritable Bowel Syndrome

Medication tx

A 
Bulk-forming Laxatives 
Hyperosmotic Laxatives
Stimulant Laxatives
Surfactant Laxatives
Antidiarrheal Agents (Lomodil, Immodium)
Semi-synthetic Antibiotic
58
Q

Irritable Bowel Syndrome

Antispasmodics (Anticholinergics)

A

Dicyclomine (Bentyl)

Mechanism of action
Direct relaxation of the smooth muscle of the GI tract

Contraindications
Glaucoma, unstable CAD, GI/GU obstruction, paralytic ileus, severe ulcerative colitis

Adverse Events
Drowsiness, anticholinergic effects, paradoxical excitement

Interactions
Antacids inhibit absorption
Additive anticholinergic effects with anticholinergics, antihistamines, narcotics, tricyclic antidepressants, narcotics

59
Q

Irritable Bowel Syndrome

Agent Selection

A

1st line
IBS-Constipation:
linaclotide or lubiprostone
osmotic laxative to avoid incidence of diarrhea

IBS-Diarrhea:
Loperamide- fewest CNS complications
Dicyclomine for pain, gas, bloating

2nd line
IBS-C 
Osmotic laxatives 
IBS-D 
diphenoxylate HCl for short term use
Rifaximin for long term

3rd line
IBS-C
stimulant laxatives for resistant cases- short term only

60
Q

Irritable Bowel Syndrome

Special Populations

A

Pediatric
No tx criteria established
Antidiarrheals, antispasmodics and fiber

Women
More likely to have IBS
Hx of verbal and sexual abuse has been linked to IBS

Geriatric
Presence > 50 yo rare
Consider abd pain as more concerning clinical symptom

61
Q

Irritable Bowel Syndrome

Monitoring

A

Re-eval within 3-6 weeks of initial evaluation

Psychological counseling may also be helpful

Mild to intermittent s/s can be managed by PCP

Exacerbations and remissions:
Can achieve recovery within 12-18 mo (70% of the time)
May consider GI referral

62
Q

Irritable Bowel Disease

Crohn’s and Ulcerative Colitis

A

IBD: describes two main chronic inflammatory conditions of GI tract:

Crohn’s Disease:
Chronic inflammatory disease characterized by transmural lesions located at any point in the GI tract

Ulcerative Colitis:
Chronic disease of mucosal inflammation limited to the colon and rectum

63
Q

Irritable Bowel Disease

Causes

A

Dysregulation of immunologic mechanisms- thought to be autoimmune

Genetic predisposition

Defect in mucosal barrier > enhanced permeability > increased uptake of proinflammatory molecules/infectious agents

Differentiate by endoscopic findings only

64
Q

Irritable Bowel Disease

Diagnosis

A

Diagnosed with endoscopy

Physical exam, abdominal exam, recent use of abx, international travel, diet hx, use of laxatives vs antidiarrheals, family history

Many concomitant symptoms:
Arthritis, fever, diarrhea, weight loss, rectal bleeding, abdominal pain

65
Q

Irritable Bowel Disease

Aminosalicylates

A

Sulfasalazine (Azulfidine)
mesalamine (Asacol, Rowasa, Pentasa)

Mechanism of Action
Decrease inflammation in the GI tract by inhibiting prostaglandin synthesis (quick onset- 1 week)

Contraindications
ASA allergy, sulfa allergy, G6PD Deficiency

Adverse Events
Nausea, HA, abd pain, diarrhea

Interactions
Sulfasalazine decreases effect of warfarin

  • Gold standard for mild-moderate Crohn’s and Ulcerative Colitis
66
Q

Irritable Bowel Disease

Corticosteroids

A 
Prednisone
methylprednisolone
hydrocortisone
dexamethasone
budesonide

Mechanism of Action
Immunosuppression and prostaglandin inhibition when disease fails to respond to aminosalicylates

Contraindications
Active GI bleeding

Adverse Events
Hyperglycemia, increased appetite, insomnia, anxiety, tremors, HTN, fluid retention, electrolyte imbalances, decreased bone density

Interactions
Many are P450 34A substrates and should be used cautiously
Decrease efficacy of antidiabetic and anti-HTN medications

  • Intermittently used to treat IBD exacerbations only
  • Can be used in combo w/ all other IBD meds
  • Cyclosporine is for severe, acute exacerbations of UC
67
Q

Irritable Bowel Disease

Immunosuppressive agents

A

Azathioprine (Imuran)
cyclosporine
6-mercaptopurine (Purinethol)
methotrexate (rheumatrex)

Mechanism of Action
Decrease production of various inflammatory mediators

Contraindications
Pregnancy, liver disease, bone marrow suppression

Adverse Events
Pancreatitis, fever, arthralgias, rash, hepatotoxicity, cirrhosis, neutropenia, nausea, diarrhea, HTN

Interactions
Cyclosporine P450 34A cytochrome. Grapefruit juice increases blood levels and risk of side effects

68
Q

Irritable Bowel Disease

Antibiotics

A

Metronidazole (Flagyl)
ciprofloxacin (Cipro)

Mechanism of Action
Link between IBD and infectious cause
Abx that act against gram (-) and Mycobacterium organisms with low side effect profile

Contraindications
Liver failure, renal failure, pregnancy, seizure disorder, no Cipro to children < 12 (also, risk of tendon rupture)

Adverse Events
Nausea, diarrhea, dizziness, photosensitivity

Interactions
No Flagyl + ETOH
Cipro inhibits theophylline metabolism

69
Q

Irritable Bowel Disease
Biological Agents - Tumor Necrosis Factor Inhibitors
(TNF-a inhibitors)

A

Infliximab (Remicade)
adalilimumab (Humira)
certolizumab pegol (Cimzia)

Mechanism of Action
Overexpression of immunologic cytokines including TNF seen in Crohn’s
TNF inhibitors neutralize soluble forms of TNF and inhibit its binding to TNF receptors

Contraindications
Active TB , heart failure, hep B,

Adverse Events
Opportunistic infections (TB, fungal, bacterial, viral), lymphoma, lupus-like syndrome, injection site reactions

Interactions
not to be given with live vaccines

  • For severe, refractory Crohn’s disease
  • Maintain remission of Crohn’s disease;
  • Treat Ulcerative Disease and Crohn’s disease
70
Q

Irritable Bowel Disease
Biological agents-
Selective adhesion molecule inhibitors

A

Natalizumab (Tysabri)
vedolizumab (Entyvio)

Mechanism of Action
Prevent migration of inflammatory lymphocytes into the gut mucosa

Contraindications
Active TB, Hep B, active progressive multifocal leukoencephalopathy (PML)

Adverse Events
Opportunistic infections (TB, fungal, bacterial, viral), lymphoma, lupus-like syndrome, injection site reactions, PML

Interactions
not to be given with live vaccines

  • Reserved for pts who have inadequate response or are unable to tolerate conventional Crohn’s therapies and TNF inhibitors
71
Q

Irritable Bowel Disease
Agent selection
Crohn’s

A

Mild: oral/rectal aminosalicylate OR rectal corticosteroid

Moderate: oral AND rectal aminosalicylate AND short term steroids

Severe: IV corticosteroid AND/OR IV Cyclosporine

Fulminant: IV corticosteroid, AND/OR IV cyclosporine, IV infliximab or SC adalimumab

Also, supportive care including IV fluids, bowel rest, parenteral nutrition

For UC anf Crohn’s there is no 1st, 2nd, 3rd line tx
Tx based on location and inflammation, severity, and extent of disease
Consider pt tolerance to therapy, compliance, and cost

72
Q

Irritable Bowel Disease
Agent selection
Ulcerative Colitis

A

Mild: combination oral AND rectal aminosalicylates

Moderate: aminosalicylates + corticosteroids

Severe: require hospitalization, DC oral/topical agents, add corticosteroids

If no resolution of symptoms in 7-10 days consider IV cyclosporine, IV infliximab, SC adalimumab, IV vendolizumab

  • Surgery for pts who fail to respond to drug therapy
73
Q

Irritable Bowel Disease

Special Populations

A

Pediatrics
IBD diagnosed early in life
Must limit nutritional deficiencies > stunted growth, malnutrition, anemia
No long term steroids
Infliximab (CD, UC) and Adalimumab (UC) > 6yo for inducing and maintaining remission

Women
Increased rates of abortions
stillbirths
developmental defects seen with active disease
Treat aggressively to prevent dehydration, anemia, nutritional deficiencies

74
Q

Irritable Bowel Disease

Monitoring

A

Monitor nutritional parameters: weight, albumin, vitamin B12, iron levels & transferrin

Mental health and quality of life: social interactions, attendance at work, completion of ADLs

Monitoring drug toxicities: CBC, LFTs, renal function

Biologics: monitor for heart failure, TB, infection, hepatotoxicity, lupus-like syndrome

75
Q

UTI

Causes

A

Broad term used to describe inflammation of the urethra, bladder and kidney

Bacteria, yeast or chemical irritants can cause inflammation of urinary tract

Women:men 30:1, after age 65 1:1
Peak incidence 18-24 yo

Shorter urethra, closer to rectum, sexual intercourse is contributing factor

Men cannot have uncomplicated infections
Distance between end of urethra and bladder
Incomplete bladder emptying- stagnant urine

Other causes:
Pregnancy, DM, constipation, sickle cell disease, structural defects of the urinary system

76
Q

UTI

Pre-disposing factors

A 
Female sex
Pregnancy
Diabetes 
Chronic degenerative neurological conditions 
Paralysis
Recurrent UTI 
Ineffective bladder emptying 
Estrogen deficiency
Constipation 
Delayed post coital micturition
Sickle cell disease
Renal transplant
77
Q

UTI

Diagnosis

A

Most pathogens enter the urinary tract > ascend the urethra > in the bladder bacteria multiply

Triad of symptoms:
Urgency, frequency, dysuria

Uncomplicated: premenopausal, sexually active, non pregnant woman without recent UTI

Complicated: man, postmenopausal, pregnant, urinary structural defects, neurologic lesions, catheter, symptoms > 7 days

History, physical exam, lab studies including urinalysis and culture

Tx: abx

  • 25-42% uncomplicated acute cystitis resolve without intervention
  • All symptomatic UTIs treated
78
Q

UTI

Treatment

A

Trimethoprim-sulfamethoxazole (Bactrim)

Adverse events: N/V, anorexia, megaloblastic anemia, hallucinations, depression, seizures

Contraindications: megaloblastic anemia, pregnancy (Cat C), breastfeeding

Nitrofurantoin (Macrobid)

Adverse Events: Nausea, pulmonary allergic reaction, dizziness, hemolytic anemia, diarrhea, vaginitis, rhinitis, HA

Contraindications: anuria, oliguria, pregnancy at term, breastfeeding mother
Take with food to increase absorption

Ciprofloxacin (Cipro)

Adverse events: nausea, diarrhea, altered taste, dizziness, drowsiness, HA, insomnia, agitation, confusion
SERIOUS: pseudomembranous colitis, SJS

Contraindications: Allergy to fluoroquinolones, <18 yo, pregnancy, renal disease, breast feeding mothers

Interactions: increases serum levels of theophylline, food slows absorption

79
Q

UTI

Urinary analgesics

A

Methenmamine (Urised)
phenazopyridine (Pyridium)

Mechanism of Action
Topical analgesic on the mucosa of the urinary tract

Adverse Events
Rash, GI upset, headache, difficulty urinating, urine discoloration

Contraindications
Glaucoma, patients < 6 yo, renal insufficiencies, pregnancy/lactation

  • Not to be used for more than 2 days for pain relief in setting of UTI
80
Q

UTI
Agent selection
Uncomplicated Cystitis

A

1st line
Bactrim (3 days vs 7 days) OR nitrofurantoin (7 days)

2nd line
Bactrim 7 days, 7 days: cipro-, levo-, o-, norfloxacin

3rd line
Culture and sensitivity testing
Treat based on results

Tx when pt has dysuria, urinary urgency, frequency

If flank pain, n/v, CVA tenderness, fever >38C ->cx for pyelonephritis

81
Q

UTI

Special populations

A

Children
Treat quickly- high risk for renal scarring
< 3 yo need renal US
1st line: Augmentin, Bactrim, cefpodoxime

Geriatric
Usually asymptomatic, consider UTI if change in mental status
Usually r/t incontinence, malnutrition, incomplete bladder emptying
No nitrofurantoin in elderly

Pregnancy
UTI > prematurity and still birth
Amoxicillin, cephalexin, nitrofurantoin (through 2nd trimester)

82
Q

Overactive Bladder

A

Symptoms
Urinary urgency accompanied by frequency (voiding > 8x/24 hrs)
Nocturia (>2 night wakings to void) with or without urge urinary incontinence (UUI)

Multifactorial: anatomic, physiologic, comorbidity-related

Bladder fills with urine > urge to void at ~ 75% capacity > neural control defers urination

83
Q

Overactive Bladder

Diagnosis

A

Assess degree of impairment/annoyance

Behavioral interventions: bladder training, pelvic floor muscle exercises, weight loss

Anticholinergic: 1st line

Goals of therapy: resolution of symptoms, cessation of incontinence episodes, return to previous level of social functioning

Dx is difficult
Grossly under-reported due to embarrassment

Reduce fluid consumption
Reduce alcohol consumption
Reduce caffeine consumption
Bladder training
Pelvic floor exercises
84
Q

Overactive Bladder

Treatment

A

Oxybutynin (Detrol)
trospium (Sanctura)
solifenacin (VESIcare)

Mechanism of Action
Increase bladder capacity, decrease intensity and frequency of bladder contractions, delay initial urge to void

Adverse Events
Anticholinergic response- dry mouth, constipation, urinary retention

Contraindications
Glaucoma, renal impairment

Interactions
Prolonged QTc, CYP34A inhibitors/inducers

85
Q

Overactive Bladder

Beta-Adrenoreceptor Agonists

A

Mirabigron (Myribetriq)

Mechanism of Action
Promotes relaxation during filling phase, Increases bladder capacity and decreases frequency of micturition

Adverse Events
Less cases of dry mouth, constipation, urinary retention

Contraindications
Can elevate BP in some cases, otherwise less anticholinergic response than other meds

Interactions
Low potential for drug interactions

86
Q

Overactive Bladder

Agent Selection

A

1st line
Behavioral therapy
Anticholinergics

2nd line
Add second anticholinergic medication

87
Q

Overactive Bladder

Special Populations

A

Pediatric
Usually secondary to deficits in learned neural control, fecal impaction or underlying structural abnormalities
Oxybutynin IR & ER have been approved

Women
Postmenopausal symptomatology- vaginal atrophy, urogenital changes
Antimuscarinic 1st line

Geriatric
Usually anatomic, physiologic, age-related
Many side effects including impaired cognition
Antimuscarinic 1st line

88
Q

Prostatitis

Causes

A

Most common urological infection in adult men:
Category I: Acute bacterial
Category II: chronic bacterial
category III: chronic nonbacterial
category IV: asymptomatic inflammatory
Chief organisms are E. coli & Pseudomonas

Acute bacterial:
Ascending infection up the urinary tract (can affect younger men)

Chronic, non-bacterial:
Inflammatory response: eosinophil infiltration; granulomatous inflammation by macrophages

Diagnostic criteria:
Abd pain, urinary retention, fever, painful ejaculation, rectal/perineal pain,
Need prostatic urine culture to dx: urine collected after prostate massage and after full bladder void

89
Q

Prostatitis
Diagnosis
Agent Selection

A

Non-bacterial forms are treated without use of antibiotics
Antibiotics are treatment of choice:
Course is 4-6 weeks, up to 12 weeks, in duration

1st line: fluoroquinolones- (Cipro) best tissue concentration followed by Bactrim (more resistance in US)

2nd line: Doxycycline, azithromycin, clarithromycin

Sitz baths, analgesics, stool softeners, antipyretics, rest

Goals of therapy: eradicate causative organism and restore prostate health

Monitor creatinine clearance in older men taking fluroquinolones

Should begin to elicit results after 1st week of therapy (sometimes 2 weeks)

90
Q

Prostatitis

Trimethorpim-Sulfamethoxazole (Bactrim)

A

Mechanism of action
Affects the production of proteins and nucleic acids of bacteria at prostate; inhibits growth of bacteria

Adverse events
GI distress, rash

Contraindications
Allergy to sulfa

Interactions
Dilantin, hypoglycemic, Coumadin levels- monitor for seizures, BG and PTT

91
Q

Prostatitis

Fluoroquines

A

Mechanism of action
Decrease the growth and replication of bacteria by inhibiting bacterial DNA during synthesis
1st choice when allergic to sulfa

Adverse events
Headache, diarrhea, nausea, drowsiness, altered taste, insomnia, agitation, confusion, pseudomembranous colitis, Stevens-Johnson syndrome

Contraindications
Pregnancy/lactation, allergy to macrolides, caution in liver and kidney disease

Interactions
Absorption is reduced by milk, antacids, iron and sucralfate
Can increase levels of systemic theophylline and warfarin (may need to lower the dosages of these medications)

92
Q

Prostatitis

Doxycycline

A

Mechanism of action
Inhibits protein synthesis

Adverse events
GI distress, potential acute hepatotoxicity and nephrotoxicity

Contraindications
Pregnancy/lactation, hypersensitivity to tetracyclines

Interactions
Interact with metal ions: aluminum, calcium, iron, magnesium and zinc- must separate meds by 2 hours

93
Q

BPH

A

Most common prostate problem in men older than age 50

Cause is not well understood

Overgrowth of normal cells in the stromal and epithelial tissues of the prostate gland

Blood levels of testosterone < and estrogen > as men age, lower levels of testosterone and higher levels of estrogen thought to contribute to hyperplasia of prostate cells

94
Q

BPH

Diagnosis

A

Digital rectal exam and PSA
AUA symptom scale > 7

Eval for post-void residual- > 100mL is considered significant

Symptoms of BPH stem from obstruction:
Problems with urination (hesitancy, weak stream, urgency, retention, frequency, dysuria, incontinence)

Goal of tx:
Reduce bladder outlet obstruction
improved quality of life
fewer symptoms and decreased residual urine volume

95
Q

BPH

Alpha-Adrenergic Blocker

A 
Terazosin (Hytrin)
doxazosin (Cardura)
tamsulosin HCl (Flomax)

Mechanism of action
Better for men with smaller (still enlarged) prostate or who need a fast result
Relax smooth muscle in prostate and bladder neck and decrease bladder resistance to urinary outflow

Adverse events
Orthostatic hypotension, somnolence, dizziness

Contraindications
tachyarrhythmias, HTN, pregnancy/lactation, cardiac, renal, hepatic insufficiency, orthostasis, priapism, impotence

Interactions
Take at bedtime to avoid hypotension

96
Q

BPH

5-a-Reductase Inhibitor

A

Finasteride (Proscar)
dutasteride (Avodart)

Mechanism of action
Reduce prostate size by 20-40% after 6 mo use
Block 5-a-reductase- enzyme that activates testosterone in the prostate

Adverse events
Impotence, decreased libido, hypotension, priapism, increased risk for prostate CA

Contraindications
Not to be handled by pregnant women, sensitivities to sulfonamides

Interactions
May take up to 6 mo to work

97
Q

BPH

Phosphodiesterase 5 Inhibitor

A

Tadalafil (Cialis) used for erectile dysfunction, also approved for BPH

98
Q

BPH

Agent selection

A

1st line- no medical treatment is recommended if AUA score < 7

2nd line > 3rd line- initiate when AUA score > 7; a-adrenergic blocker > + 5-a-reductase inhibitor when symptoms are moderate to severe

4th line- referral to urology to discuss surgical options

99
Q

BPH

Monitoring

A

AUA score

Monitor patients BP within first 2 weeks of initiating treatment

Lifestyle changes:
Decrease fluid intake several hours before bed, avoid diuretics and ETOH, anticholinergics, antihistamines and antidepressants

100
Q

Erectile Dysfunction

A

Most common sexual problem in men – repeated inability to achieve or maintain and erection that is firm enough for sexual intercourse (total inability, inconsistent ability or brief erection)

Causes: usually secondary to a decline in testosterone levels, psychological/ psychiatric problems, damage to nerves/arteries/smooth muscles/fibrous tissue

Risk factors: age, CVD, smoking, DM, HTN, high cholesterol, obesity, sedentary lifestyle

101
Q

Erectile Dysfunction

Diagnosis

A

Medical conditions, medications, sexual function, cardiac history

Fasting glucose levels, lipid panel, TSH, morning total testosterone level

Goal: achieve sexual satisfaction and achieve/maintain an erection

102
Q

Erectile Dysfunction

Phosphodiesterase 5 inhibitor (PDE5)

A

Tadalafil (Cialis)
vardenafil (Levitra)
sildenafil (Viagra)

Mechanism of action
Inhibit the breakdown of one of the messengers involved in the erectile response > facilitate and maintenance of an erection

Adverse events
Headache, flushing, GI disturbance, nasal congestion, rash, priapism- vasodilatory

Contraindications
Nitrates, a-blockers within 4 hours of use

Interactions
Potent CYP3A4 inhibitor

103
Q

Erectile Dysfunction

A

1st line
Lifestyle changes, modify meds that are contributory
PDE5 inhibitor

2nd line
Urology consult

Pt w/ BP <170/110

  • lifestyle changes + PDE5 inhibitor
  • if successful, continue
  • if unsuccessful, refer to urologist

BP > 170/110
Stabilize pt, then start PDE5 inhibitor

Chem and physics (8 decks)

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