Week 4: GI products Flashcards
1
Q
What is the main symptom of GERD?
A
Heartburn
2
Q
What is heartburn?
A
Burning sensation in the stomach
3
Q
What medications can cause heart burn?
A
- Potassium
- Iron
- NSAIDs
4
Q
When would we exclude self treatment for heart burn?
A
- Frequent heartburn for more than 3 months
- While taking H2RA or PPI
- 2 weeks or while taking H2RA or PPI
- Difficulty or pain on swallowing
- Vomiting up blood/black tarry stool
- Weight loss
- Nausea, vomiting, or diarrhea
- Children
- Chest pain with sweating
- 45 YO adults with indigestion
5
Q
What are the treatment goals for heart burn?
A
- Complete relief of symptoms
- Reduce recurrence of symptoms
- Prevent/manage unwanted effects of medication
6
Q
Non pharm treatments of heartburn?
A
- Weight loss
- Non smoking
- Time
- Elevated sleeping
- Journal diet
7
Q
What are the pharm treatments for heart burn?
A
- Antacids
- H2RAs
- H2RA + antacid
- PPI
8
Q
What are antacids?
A
- Neutralizes gastric acid
- Liquid form has a faster onset
- Reevaluate if needing more than twice a week
- Most eliminated renal
9
Q
What should be avoided when taking antacids?
A
Amphetamines
10
Q
What should be avoided when taking sodium bicarbonate?
A
- Quinidine
- Salicylates (decreases salicylate response)
11
Q
What are histamine receptor antagonists?
A
- Decrease gastric secretion by blocking histamine receptors of parietal cells
- Well tolerated
- As needed drug and prevention
- Effective in relieving fasting and nocturnal symptoms
- Eliminated by a combination of renal (most important) and hepatic metabolism
12
Q
What are the side effects of H2RAs?
A
Headache, diarrhea, constipation, dizziness, drowsiness
13
Q
What should you do when taking Antacids, H2RAs, or PPIs?
A
Don’t take concurrently with antineoplastics, TKIs/
separate from antacids by several hours
14
Q
What should you avoid when taking H2RAs and PPIs?
A
Avoid taking with Concurrent Itraconazole, ketoconazole, atazanavir, iron sulfate, calcium carbonate therapy
15
Q
What is important to know about cimetidine?
A
Avoid use of cimetidine in patients taking medications metabolized by CYP enzymes
16
Q
What happens if you take citalopram with cimetidine or PPIs?
A
Citalopram dose should not exceed 20 mg per day if not used concomitantly
17
Q
What is a PPI?
A
- Inhibit hydrogen potassium ATPase, irreversibly blocking the final step in gastric acid secretion
- Increased bioavailability when daily dosing but reduced after a meal
- Relief takes 1-4 days
18
Q
What are adverse effects of PPIs?
A
Headache, abdominal pain, diarrhea, constipation, or flatulence
19
Q
What should we do about taking PPIs with Warfarin, theophylline, tacrolimus, mycophenolate, or mofetil?
A
Avoid concurrent use of check prescriber
20
Q
What should we do when taking PPIs with digoxin?
A
Check with prescriber before use
21
Q
What should we do when taking PPIs with methotrexate?
A
Avoid concurrent use of high dose methotrexate
Significant toxicity is unlikely with lower weekly doses
22
Q
What are the preventative measures of taking omeprazole and esomeprazole with clopidogrel?
A
Avoid concurrent use, clinically significant interaction is unlikely
23
Q
What is the preventative measure of taking omeprazole and esomeprazole with cilostazol or diazepam?
A
Avoid concurrent use
Lansoprazole may be a safer alternative
24
Q
What are the disadvantages of bismuth subsalicylate?
A
- Not recommended for children and be avoided in patient with salicylate sensitivity or bleeding risks
- Risk of Reyes syndrome in children
- black stool and tongue
25
What heat burn product is compatible with pregnancy?
H2RAs
Calcium and magnesium antacids
26
What heat burn product is compatible with lactation?
Cimetidine and Famotidine
Aluminum-, calcium-, or magnesium-containing antacids
27
What heat burn product is recommended for pediatrics with GI problems?
Lifestyle modifications
Antacids
28
58 y/o male with known heartburn controlled with lifestyle modifications. Friends invited him out to local chili cook-off, and he seeks advice on preventing symptoms.
What do you recommend and why?
PRN H2RA (as needed and preventative treatment)
29
46 y/o mother of 2 with a new job complains of moderate heartburn symptoms 3-4 times per week. What do you recommend and why?
1. Daily PPI
2. PRN H2RA
3. Lifestyle mod
30
54 y/o male presents complaining of severe heartburn, pounding in his chest. He appears pale, weak, diaphoretic, short of breath. Recommendation?
Refer
31
What is constipation?
Occurrence of fewer than 3 bowel movements per week accompanied by straining and difficult passage of hard, dry stools
32
What is primary constipation?
Slower than normal GI transit time or a defecatory disorder
33
What is secondary constipation?
Systemic, neurologic, and psychological disorders and/or structural abnormalities
34
What might contribute to constipation?
Inadequate dietary fiber and fluid intake
35
What are drugs that induce constipation?
1. Analgesics
2. Anatacids
3. Opiates
4. NSAIDs
36
What are the treatment goals for constipation?
1. Relieve and reestablish
2. Establish dietary and exercise habits
3. Safe and effective use of laxatives
37
What are the exclusions for self-treatment for constipation?
1. Abdominal pain and significant distension
2. Fever
3. Nausea/vomiting
4. Unexplained flatulence
5. Chronic conditions
6. Daily laxative use
7. Age
8. Abnormal stool
9. Persistant greater than 2 weeks or over 3 months
38
What are the non pharm treatments for constipation?
1. Gradual increase in fiber, 25g/day for women and 38g for men
2. Increase fluid intake 8-8 ounce glasses/day with added fibers
3. Physical activity
4. Bowel training: attempting after waking and 30 minutes after meals
39
What are bulk-forming agents?
1. Contains methylcellulose, polycarbophil, and psyllium
2. Onset of 12-24 hrs but delayed to 72 hrs
3. Absorb fluid from intestine, swell to form soft, bulky stool
40
What are the adverse effects of bulking forming agents?
1. Abdominal cramping and flatulence
2. Avoid in patients with difficulty swallowing, or esophageal structures, intestinal ulcerations, stenosis
3. Avoid in patients who are fluid restricted
4. Councel patients to take in adequate fluids
41
What are the hyperosmotic agents?
1. PEG 3350
2. Glycerin
42
What do hyperosmotics do?
1. Draw water into the colon or rectum through osmosis to stimulate a bowel movement
2. Onset 12-72hr, can take up to 96hr
43
What are the adverse effects of hyperosmotics?
Bloating, abdominal discomfort, cramping, and flatulence
No DDI
44
What is the dosage form for glycerin?
1. Suppository
2. BM within 15-30 minutes
3. Approved in all age groups
45
What are types of stimulants?
1. Sena
2. Bisacodyl
3. Castor oil-safe alternatives (no recommended)
46
What are the functions of stimulants?
1. Increases intestinal motility, increases secretion of water and electrolytes in the intestine
2. Onset 6-10 hrs for oral, 15-60mins for suppositories
47
What are the Adverse effects of stimulants?
Severe cramping, electrolyte, and fluid deficiencies, hypokalemia
48
What is the dosage form of stimulants?
Enteric coated
Should not be broken, crushed, chewed, or given with agents that increase gastric pH
49
OTC antacids?
Tums
Gaviscon
Mylanta
50
OTC H2RA?
Pepcid
Cimetidine
Zantac
51
OTC PPI?
Prilosec
Nexium
Zegerid
52
OTC bulking forming agents?
Wal-mucil
53
OTC hyper osmotic agents?
MiraLax
54
OTC stimulants?
Dulcolax
55
What are emollients (stool softeners)?
1. Act in the small and large intestine to increase the wetting efficiency of intestinal fluid
2. Facilitates mixture of aqueous and fatty substances to soften the fecal mass
3. Commonly used in combination with stimulants
56
OTC emollients?
Colace
57
Example of emollient active ingredient?
Docusate
Onset: 12-72hr delay 3-5 days
Well tolerated, limited adverse effects
58
Example of lubricants?
Mineral oil
59
What are lubricants?
1. softens fecal content by coating stool and preventing colonic absorption of fecal water
2. Onset 6-8hr as liquid, rectal 5-15 minutes
60
What are the counseling points for lubricants?
1. Should not be taken before lying down
2. Should not be used in children <6, pregnant, bedridden or geriatrics, individuals with difficulty swallowing
3. Due to risks associated with use of mineral oil, it is a last resort
61
What is a saline laxatives?
1. Magnesium sulfate or sodium phosphate
2. Draw water into the small and large intestine by osmosis
3. Increase intraluminal pressure and promote GI motility
4. Oral (30-min - 3hr) or rectal (2-15min)
62
What are the adverse effects of saline laxatives?
Abdominal cramping, nausea, vomiting, dehydration
63
What are the adverse effects of saline laxatives?
Abdominal cramping. nausea, vomiting, dehydration
64
What are the risks of using saline laxatives?
1. Higher DDI and drug disease
2. Caution in renal impairment, newborns, older adults
65
What should you avoid using with docusate salts?
Mineral oil
Avoid concurrent use
66
What should you avoid using with magnesium citrate?
Fluroquinolone and tetracycline antibiotics
Avoid oral magnesium citrate within 1–3 hours of ingestion of oral tetracyclines or fluoroquinolones
67
What should you avoid using with bisacodyl?
Avoid Milk products or drugs that raise gastric pH within 1 hr before or after ingestion
68
Rank the GI treatment in terms of speed (fastest to slowest)
1. Enemas
2. Suppositories
3. Lubricants
4. Salines
5. Stimulants
6. Osmotics
7. Stool softeners
8. Bulk
69
Rank the GI treatment in terms of comfort (most to least)
1. Stool softeners
2. Bulk
3. Osmotic
4. Stimulants
5. Salines
6. Lubricants
7. Suppositories
8. Enemas
70
What products for constipation are recommended for pediatrics?
1. Lifestyle changes and diet
2. 2-6 years: oral decussate, magnesium OH, senna
3. 6-12: oral–methylcellulose, psyllium powder, docusate, mineral oil , bisacodyl, senna, mag citrate, mag hydroxide, mag sulfate
rectal – glycerin suppositories, mineral oil, sodium phosphate, and bisacodyl
71
What products for constipation are recommended for geriatrics?
Bulk-forming laxatives or PEG 3350
Life style mod
Stool softener
72
What products for constipation are recommended for pregnancy?
1. Supplements
2. Lifestyle and diet
3. Bulk-forming
4. short term use of senna or bisacodyl is considered low risk
5. Avoid castor oil, mineral oil, and saline laxatives
73
What products for constipation are recommended for lactation?
1. Senna, bisacodyl, PEG 3350, and docusate are considered compatible
2. Avoid castor oil and mineral oil
74
24 y/o male recently left military service and entered 4-year college. Complains of straining to pass small, hard stools only a few times a week compared to his usual bowel habits.
Gradually increasing fiber
Bulk-forming laxative
Stool softener
Stimulant laxative
Osmotic laxative
75
36 y/o male, opiate user (chronic pain), has not had a bowel movement in 6-7 days. Complains of severe abdominal pain and distension, bowel sounds absent. What do you recommend and why?
Refer
76
What is diarrhea?
abnormal increase in stool frequency, liquidity, weight or volume
77
What is abnormal diarrhea?
3 BM per day
78
What are the risk factors of diarrhea?
1. Attendance or employment at day cares
2. Food handlers or caregivers
3. Congregate living conditions
4. Consumption of unsafe foods
5. Diverticulitis, immunocompromised
79
What is viral gastroenteritis?
1. Norovirus in adults
2. Transmitted by contaminated water or food, people, surfaces
3. Rotavirus in infants and children (seasonally and 2 oral vaccines)
80
What is bacterial gastroenteritis?
1. Food borne transmission
2. Campylobacter, E.coli, Salmonella
3. Extremely watery diarrhea or bloody diarrhea depending on the pathogen
81
What is protozoal diarrhea?
1. Not rx treatments are not available, refer
82
What is foodborne gastroenteritis?
1. Noravirus
2. Linked to poor sanitation and manufacturing practices in food facilities
83
What is traveller's diarrhea?
1. Acquired mainly by ingestion of contaminated food or water
2. Fruit, veggies, raw meat, seafood, water, ice cubes
84
What is food induced diarrhea?
Provoked by food intolerance
85
What are the meds that may cause diarrhea?
1. Cimetidine
2. Magnesium containing antacids
3. NSAIDs
4. Osmotic laxatives
5. PPIs
6. St. Johns wort
7. Stimulant laxatives (senna, bisacodyl)
86
What are the exclusions for diarrhea?
1. Children
2. Persistent fever and vomiting
3. Blood and pus and mucus in stool
4. High output
5. Severe dehydration and abdominal pain/distress
6. Chronic med
87
What are exclusions for diarrhea self treatment for pregnancy?
Chronic or persistent
Suboptimal response to oral rehydration solution already administered
88
What are the treatment goals of diarrhea?
1. Prevent or correct fluid and electrolyte loss
2. Controls symptoms
3. Identify and treat the cause
4. Prevent acute morbidity and mortality
5. Focus should be on fluid and electrolyte replacement by oral rehydration solutions
89
What are fluid and electrolyte management for diarrhea?
1. Rehydration using ORS
90
What are the 2 phases of rehydration?
Rehydration: over 3-4 hrs quickly replaces water and electrolyes to restore normalcy
Maintenance: maintain normal body composition until adequate dietary intake is reestablished
91
What is dietary management for diarrhea?
Early referring in combination with ORS improves outcomes
92
What are the preventative measures for diarrhea?
Hand washing, cleaning contaminated surfaces
93
What is the function loperamide?
1. Synthetic opioid agonist that lacks central nervous system effects
2. Slows intestinal motility and allows absorption of electrolytes and water
3. Helps reduce daily fecal volume, increased viscosity and bulk volume, and reduced fluid and electrolyte loss
4. Labeled for use in children 6 years and older
94
What are Adverse effects of loperamide?
1. Dizziness and constipation
2. Few DDI
3. Not for invasive bacterial diarrhea
95
OTC loperamide
Imodium
96
What is bismuth subsalicylate?
1. Reduce frequency of unformed stools, increase stool consistency, release abdominal cramping, decrease nausea and vomiting
2. Caution in patients taking aspirin
3. Approved for acute diarrhea in children 12 years and older
97
What is the bismuth subsalicylate adverse effect?
1. Children recovering from chicken pox, risk of Reyes
2. Black staining of stool
3. Antibiotic DDI
98
OTC bismuth subsalicylate?
Pepto bismol
99
Diarrhea recommendation for pediatrics?
1. Antidiarrheal medications are not recommended
2. Pre-mixed solutions are preferred
3. If symptoms persist, recommend PCP
100
Diarrhea recommendation for geriatrics?
Diarrhea is more likely to be severe or possibly fatal in these patients, should be recommended to PCP
101
Diarrhea recommendation for pregnancy?
Recommend to PCP
BSS is contraindicated during pregnancy
102
Diarrhea recommendation for lactation?
BSS should be avoided
103
38 y/o female recently diagnosed with T2DM and started on metformin. Now reports 2-3 loose stools per day and mild cramping abdominal pain.
Refer
104
Pham medications for constipation?
1. bulk
2. Hyperosmotic
3. Stimulants
4. Emollients
5. Lubricants
6. Saline laxatives
105
Pharm meds for diarrhea?
1. Loperamide
2. BSS
