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Pharmacology for advance practice nursing 712 > WEEK 7 GASTROINTESTINAL > Flashcards

WEEK 7 GASTROINTESTINAL Flashcards

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1
Q

What are the non-pharmacologic treatment options for GERD?

A 
Lifestyle changes: 
•Lose weight
•Elevate head of the bed (6 – 10 inches – use foam wedge)
•Smaller meals
•Don’t eat 3 hours before bedtime
•Avoid foods or medications that exacerbate symptoms
•Stop smoking
•Avoid alcohol

Surgical options:
•Antireflux surgery (Nissen fundoplication)
•Bariatric surgery

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2
Q

What are the pharmacologic treatment options for GERD?

A
  • Antacids
  • Histamine-2 Receptor Antagonists (H2RAs)
  • Proton Pump Inhibitors (PPIs)
  • Prokinetic agents (metoclopramide)
  • Mucosal protectants (sulcrafate)
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3
Q

What are the non-pharmacologic treatment options for PEPTIC ULCER DISEASE (PUD)?

A
  • Dependent on type of ulcer (H. Pylori, NSAIDs, stress related mucosal damage, smoking, diet or Zollinger).
  • Often includes elimination of ulcerative source (e.g., smoking cessation, stress reduction, change in diet, etc).
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4
Q

What are the pharmacologic treatment options for PEPTIC ULCER DISEASE?

A
  • Dependent on type of ulcer (H. Pylori, NSAIDs, stress)
  • All treatment options include use of PPI
  • H. Pylori (PPI plus antibiotics)
  • NSAIDs induced (PPIs at standard doses preferred, may also use misoprostal, H2RAs, sulcralfate)
  • Stress-related (Prophylaxis in ICU setting [due to risk factors of sepsis, further organ damage, etc] therapy may differ dependent upon source of stress (e.g., thermal injury, surgery, GI bleed, etc.): H2RA or PPI)
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5
Q

What are the non-pharmacologic treatment options for NAUSEA/VOMITING?

A
  • Hydration
  • Diet
  • Bland food
  • Small frequent meals
  • Avoid triggers (e.g. fatty, spicy foods)

•Psychological

  • Avoid stress
  • Self hypnosis
  • Cognitive distraction
  • Guided imagery

•Acupressure

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6
Q

What are the pharmacologic treatment options for NAUSEA/VOMITING?

A

Anticholinergics

Antihistamines

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7
Q

What are the non-pharmacologic treatment options for DIARRHEA?

A

Removal of the diarrhea causing agent (e.g., medication).
Hydration
•Water
•Flat soft drinks, sports drinks
•Commercial rehydrating solutions (e.g. Pedialyte®)
•1 L water with 8 tsp. sugar and 1 tsp. table salt
Dietary modifications
•Avoid irritating foods
•May increase bulk if chronic

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8
Q

What are the pharmacologic treatment options for DIARRHEA?

A

Antidiarrheals:

  • Anticholinergics (Crofelemer)
  • Opiates (Lomotil, Motofen, Imodium)
  • Absorbent preparations (kaolin, pectin, bismuth subsalicylate)
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9
Q

What are the non-pharmacologic treatment options for CONSTIPATION?

A

-Increase fiber intake
•Normal: 20 – 35 grams/day PO (Max 50 grams)
-Avoid excessively processed low fiber foods
-Increase fluid intake
-Aerobic exercise
-Don’t ignore the urge to defecate
-Biofeedback may be helpful if pelvic floor dysfunction

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10
Q

What are the pharmacologic treatment options for CONSTIPATION?

A
  • Bulk forming agents (1st line)
  • Stool softeners
  • Lubricant laxatives
  • Stimulant laxatives
  • Osmotic laxatives
  • Prostaglandins: Lubiprostone (Amitiza®)
  • Opioid Antagonists
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11
Q

What are the non-pharmacologic treatment options for IRRITABLE BOWEL SYNDROME (IBS)?

A
  • Diet
  • Fluid
  • Physical activity
  • Counseling / behavioral therapy
  • Probiotics
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12
Q

What are the pharmacologic treatment options for IRRITABLE BOWEL SYNDROME (IBS)?

A

For pain:
Antispasmodics, Antidepressants, Antibiotics

Diarrhea:
•Antidiarrheal agents: loperamide, atropine/diphenoxylate
•Alosetron (Lotronex®) 0.5 mg PO BID for 4 weeks (max 2 mg/day)

Constipation:
•Bulk forming agents, osmotic laxatives
•Lubiprostone (Amitiza®) 8 mcg PO BID
 -Place in therapy: IBS-C in females ≥18 years
•Linaclotide (Linzess®) 290 mcg daily
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13
Q

Prokinetic agents

A

•Metoclopramide 10-15 mg by mouth up to 4 doses/day

MOA: enhances esophageal peristalsis and gastric emptying

  • Inferior efficacy and adverse effect profile (CNS effects)
  • BBW for tardive dyskinesia – irreversible movement disorder
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14
Q

1st line treatment options for H. Pylori peptic ulcer disease

A

•Bismuth quadruple therapy (10-14 days)

  • -Standard dose PPI PO BID
  • -Clarithromycin 500 mg PO BID
  • -Amoxicillin 1 g PO BID OR metronidazole 500 mg PO TID

•Concomitant therapy (duration 10-14 days)

  • -Standard dose PPI PO BID
  • -Clarithromycin 500 mg PO BID
  • -Amoxicillin 1000 mg PO BID
  • -Metronidazole 500 mg PO BID

•Triple therapy (duration 14 days)

  • -Standard dose PPI PO BID
  • -Clarithromycin 500 mg PO BID
  • -Amoxicillin 1 g PO BID OR metronidazole 500 mg PO TID
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15
Q

Antimobility agents

A
  • Common agents and dosing:
  • Loperamide (Imodium®) 4 mg PO after 1st loose stool, then 2 mg after each subsequent loose stool
  • Diphenoxylatewith atropine (Lomotil®)•MOA: slows intestinal motility

Place in therapy:
•Do NOT use in bacterial or viral gastroenteritis

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16
Q

Considerations/Precautions with antimobility agents

A 
Adverse effects:
•Abdominal cramping
•Constipation
•Nausea 
•Dizziness

Contraindications:
•Children <2 years of age
•Bloody diarrhea and high fever

Precautions:
•Abuse potential (opioid receptor activity at high doses)
•Risk of serious cardiac adverse reactions (Black Box Warning)
•Syncope, ventricular tachycardia, torsades de pointes
•Avoid in patients with risk factors for QT prolongation

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17
Q

Considerations/Precautions with Anti-secretory agents.

A

Adverse effects:
•Headache
•Fecal discoloration

Contraindications:
•Ulcers

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18
Q

Anti-secretory agents

A

Bismuth subsalicylate (Pepto-Bismol®) 535 mg PO q30-60 min as needed (max 4,200 mg/day x 2 days)

MOA:
•Antisecretory, antimicrobial, and anti-inflammatory effects

Place in therapy:
•Diarrhea and dyspepsia

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19
Q

Alternative 1st line treatment options for H. Pylori peptic ulcer disease

A

•Sequential therapy

  • -1st 5 days: standard dose PPI PO BID + amoxicillin 1 g PO BID
  • -Next 5 days: standard dose PPI PO BID + clarithromycin 500 mg PO BID + metronidazole 500 mg PO BID

•Hybrid Therapy

  • -1st 7 days: standard dose PPI PO BID + amoxicillin 1 g PO BID
  • -Next 7 days: above + clarithromycin 500 mg PO BID + metronidazole 500 mg PO BID

•Fluoroquinolone triple – PPI, amoxicillin, levofloxacin (“PAL”) [Duration 10-14 days]

  • -Standard dose PPI PO BID
  • -Amoxicillin 1 g PO BID
  • -Levofloxacin 500 gm PO daily

•Fluoroquinolone sequential

  • -1st 5 days: standard dose PPI PO BID + amoxicillin 1 g PO BID
  • -Next 5 days: standard dose PPI PO BID + levofloxacin 500 mg PO daily + metronidazole 500 mg PO BID

•Fluoroquinolone quadruple [duration 10-14 days]

  • -Double dose PPI PO BID
  • -Nitazoxanide 500 mg PO BID
  • -Levofloxacin 250 mg PO daily
  • -Doxycycline 100 mg PO daily
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20
Q

Salvage Therapy for treatment of H. Pylori peptic ulcer disease

A

•Bismuth quadruple therapy [10-14 days]

  • -Standard dose PPI PO BID
  • -Tetracycline 500 mg PO QID
  • -Metronidazole 250 mg PO QID
  • -Bismuth subsalicylate 525 mg PO QID

•Concomitant therapy [10-14 days]

  • -Standard dose PPI PO BID
  • -Clarithromycin 500 mg PO BID
  • -Amoxicillin 1000 mg PO BID
  • -Metronidazole 500 mg PO BID

•Fluoroquinolone triple – “PAL” [10-14 days]

  • -Standard dose PPI PO BID
  • -Amoxicillin 1 g PO BID
  • -Levofloxacin 500 gm PO daily

•Rifabutin-based triple therapy [10-14 days]

  • -Standard dose PPI PO BID
  • -Amoxicillin 1 g PO BID
  • -Rifabutin 300 mg PO daily

•High-dose dual therapy [14 days]

  • -Standard/double dose PPI PO BID
  • -Amoxicillin 1 g PO TID or 750 mg PO QID
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21
Q

Misoprostol

A

NSAID Induced PUD
Misoprostol 400-800 mcg/day in divided doses

MOA: prostaglandin analog which replaces the protective prostaglandins consumed with prostaglanding-inhibiting therapies (e.g. NSAIDs)

Onset of action: 30 minutes; duration: 3 hours

Adverse effects: diarrhea, abdominal pain

Precautions: Pregnancy category X

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22
Q

Antimobility agents

A

Common agents and dosing:
•Loperamide (Imodium®) 4 mg PO after 1st loose stool, then 2 mg after each subsequent loose stool
•Diphenoxylatewith atropine (Lomotil®)•MOA: slows intestinal motility

Place in therapy:
•Do NOT use in bacterial or viral gastroenteritis

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23
Q

Considerations/Precautions with Anti-secretory agents.

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A

Adverse effects:
•Headache
•Fecal discoloration (Pt’s should be warned about gray/black stools and black tongue from bismuth use. They should be educated this is to be expected and that it does not indicate GI Bleeding).

Contraindications:
•Ulcers

24
Q

Anticholinergics

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A

Common agents and dosing:
•Scopolamine (Transderm Scop®) 1.5 mg transdermal patch – 1 patch behind ear at least 4 hours prior to exposure and every 3 days as needed

MOA: block acetylcholine at the H1 receptor •Onset: 6-8 hours, duration: 72 hours (patch)

Place in therapy:
•Motion sickness
•Migraine
•Vertigo

25
Considerations/Precautions with Anticholinergics:
Adverse effects: Sedation Urinary retention Blurred vision Precautions: Caution in patients with CV disease, open-angle glaucoma, and and GI obstruction
26
Antihistamines
Common agents and dosing: •Meclizine (Dramamine®) 25-50 mg PO 1 hour prior to travel MOA: competes with histamine for H1 receptor sites Place in therapy: •Motion sickness •Vertigo •Available over the counter
27
Considerations/Precautions with Anticholinergics:
Adverse effects: Sedation Urinary retention Blurred vision Precautions: Caution in patients with CV disease, open-angle glaucoma, and and GI obstruction
28
Antihistamines
Common agents and dosing: •Meclizine (Dramamine®) 25-50 mg PO 1 hour prior to travel MOA: competes with histamine for H1 receptor sites Place in therapy: •Motion sickness •Vertigo •Available over the counter
29
Considerations/Precautions with Antihistamines
Adverse effects:•Drowsiness•Fatigue•Anticholinergic effects•Precautions:•May cause CNS depression•OTC products may contain ginger and dimenhydrinate – read label
30
Dopamine antagonists - Butyrophenones
Common agents and dosing: •Droperidol (Inapsine®) 2.5 mg IM, IV initial dose, then 1.25 mg as needed MOA: •Blocks dopamine stimulation of the chemoreceptor trigger zone Place in therapy/efficacy: •Postoperative nausea/vomiting
31
Considerations/Precautions with Dopamine antagonists - Butyrophenones
•Adverse effects:•Anticholinergic effects•Sedation•Dizziness•Extrapyramidal symptoms•Orthostatic hypotension•Precautions:•Black Box Warning for prolonged QT interval and/or torsade de pointes
32
Considerations/Precautions with Dopamine antagonists - Butyrophenones
•Adverse effects:•Anticholinergic effects•Sedation•Dizziness•Extrapyramidal symptoms•Orthostatic hypotension•Precautions:•Black Box Warning for prolonged QT interval and/or torsade de pointes
33
Chemotherapy-induced nausea/vomiting (CINV)
* Corticosteroids (e.g. dexamethasone) * Neurokinin 1 Receptor Antagonists (aprepitant, fosaprepitant) * 5-HT3 receptor antagonists (dolasetron, ondansetron) * Olanzapine * Thalidomide * Dronabinol (cannabinoid)
34
Bulk Forming Agents
Common agents and dosing: •Psyllium (Metamucil®) 2.5-30 g/day PO in divided doses •Calcium polycarbophil (FiberCon®) 1,250 mg PO 1-4 times daily •Methylcellulose (Citrucel® powder or tablet) 2 tablets (500 mg) up to 6 times/day or 2 g (1 Tbsp) powder up to TID MOA: •Soluble fiber which absorbs water in the intestine to add bulk to the stool and promote peristalsis Place in therapy: •1st line agent •Drug of choice in pregnancy
35
Considerations/ Precautions with Bulk Forming Agents
Adverse effects: •Gas •Bloating Contraindications: •Fecal impaction •GI obstruction (psyllium)
36
Considerations/ Precautions with Bulk Forming Agents
Adverse effects: •Gas •Bloating Contraindications: •Fecal impaction •GI obstruction (psyllium)
37
Stool Softeners (AKA emollient laxatives)
Common agents and dosing: •Docusate (Colace®) 50-360 mg PO daily or in divided doses MOA: reduce surface tension of oil-water interface of the stool Place in therapy: •Preferred when straining should be avoided
38
Considerations/ Precautions with Stool Softeners (AKA emollient laxatives)
Adverse effects: •Mild GI cramping •Well tolerated
39
Lubricant laxatives
Common agents and dosing: •Mineral oil – dose varies with product MOA: •Coats the bowel to ease passage of stools
40
Considerations/ Precautions with Lubricant laxatives
``` Adverse effects: •Abdominal cramps •Diarrhea •Nausea •vomiting ``` ``` Contraindications: •Children <6 years of age •Pregnancy •Bedridden patients •Elderly •Use longer than 1 week •Difficulty swallowing ``` Precautions: •Do not take with docusate •Aspiration risk – do not lie down for 30-60 minutes •May decrease absorption of fat-soluble vitamins
41
Stimulant laxatives
Common agents and dosing: •Bisacodyl (Dulcolax®) 5-15 mg PO daily, 10 mg rectally daily •Senna (Senokot®) 15 mg PO daily MOA: •Stimulate peristalsis by direct action on the intestinal mucosa Place in therapy: •Chronic opioids often require a stimulant laxative
42
Considerations/ Precautions with Stimulant laxatives
Adverse effects: •Abdominal cramps •Diarrhea •Nausea/vomiting
43
Osmotic laxatives
Common agents and dosing: •Polyethylene glycol (Miralax®) 17 g (1 dosing cup) PO in 4-8 ounces of water daily •Magnesium hydroxide (Milk of Magnesia) 2.4-4.8 g PO once daily •Lactulose (Enulose®) 10-20 g PO daily MOA: •Causes water retention in the stool to increase stool frequency
44
Considerations/ Precautions with Osmotic laxatives
Adverse effects: •Diarrhea •Flatulence •Nausea Precautions: •Electrolyte imbalance •Avoid use in patients with bowel obstruction
45
Constipation Prostaglandins
•Lubiprostone (Amitiza®) 24 mcg PO BID MOA: •Activates chloride channels in gut to increase fluid and peristalsis Place in therapy: •Chronic idiopathic constipation •Irritable bowel syndrome •Opioid-induced constipation
46
Considerations/ Precautions with Constipation Prostaglandins
Adverse effects: •Headache •Nausea •Diarrhea Contraindications: •GI obstruction Precautions: •Dyspnea •Hypotension •Reserved for experts in GI
47
Considerations/ Precautions with Constipation Prostaglandins
Adverse effects: •Headache •Nausea •Diarrhea Contraindications: •GI obstruction Precautions: •Dyspnea •Hypotension •Reserved for experts in GI
48
Opioid Antagonists
•Naloxegol (Movantik®) 25 mg PO once daily MOA: peripherally acting opioid antagonist •Blocks opioid-induced GI effects, but does not affect analgesic activity (does not cross the BBB)
49
Considerations/ Precautions with Opioid Antagonists
* Adverse effects: * Abdominal pain * Diarrhea * Headache Precautions: •Contraindicated in patients with risk of GI obstruction •Reserved for specialist prescribing
50
IBS PAIN: Antispasmodics
Antispasmodics: •Dicyclomine 10-20 mg PO q4-6 hours prn •Hyoscyamine 0.125 – 0.25 mg PO or sublingual q4 hours prn MOA: blocks action of acetylcholine at parasympathetic sites in smooth muscle Place in therapy: •As needed and/or in anticipation of stressors
51
Considerations/ Precautions with Antispasmodics
Adverse effects: •Dizziness, dry mouth, blurred vision, drowsiness Precautions: •CNS effects •Delirium in elderly Contraindications: obstruction of GI tract, severe ulcerative colitis, glaucoma, infants <6 months of age
52
IBS PAIN: Antidepressants
Antidepressants: •Amitriptyline: 10-75 mg PO once daily at bedtime MOA: analgesic properties in addition to anticholinergic properties, which may slow the intestinal tract Place in therapy: •Use cautiously in patients with constipation (anticholinergic effects)
53
Considerations/Precautions with Antidepressants for IBS Pain
Adverse effects: •Sedation •Dry mouth Precautions: •Contraindications: coadministration with MAOIs •BBW for suicidal thinking/behavior
54
IBS PAIN: Antibiotics
Antibiotics: •Rifaximin(Xifaxan®) 550 mg PO TID x 14 days, may retreat up to 2 times MOA: semisynthetic antibiotic with low systemic absorption Place in therapy: •Not routinely recommended •Moderate to severe IBS without constipation •Failed other therapies
55
Considerations/Precautions with Antibiotics for IBS PAIN.
Adverse effects: •Peripheral edema, dizziness, fatigue, nausea, headache Precautions: •C. difficile infection
56
IBS Diarrhea: Antidiarrheal
Alosetron (Lotronex®) 0.5 mg PO BID for 4 weeks (max 2 mg/day) MOA: selective 5-HT3 receptor antagonist – decreases colonic motility and secretion Place in therapy: •Severe IBS-D, female patients; symptoms >6 months; failed to respond to all other conventional treatment Adverse effects: •Constipation, fatigue, headache, nausea, GI pain, UTI Precautions: •Contraindications: constipation, intestinal obstruction, Crohn disease •BBW: risk of ischemic colitis and serious complications of constipation•Reserved for specialist prescribing
57
IBS CONSTIPATION
•Linaclotide (Linzess®) 290 mcg daily MOA: agonist of guanylate cyclase C, which increases chloride and bicarbonate secretion into the intestinal lumen, increasing intestinal fluid and GI transit. Adverse effects: diarrhea, headache, abdominal pain, upper respiratory tract infections Precautions: - -Contraindications: <6 years (BBW); mechanical GI obstruction - -Severe diarrhea

Pharmacology for advance practice nursing 712 (24 decks)

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