Pharm II - GI disorders (constipation, diarrhea, GERD, N/V

Causes of constipation - ANSWER-Low fiber Low fluid intake Inactive lifestyle Aging Diseases (IBS, Diabetes, Endocrine, neurological, cancer) Medications Name some medications that can cause constipation - ANSWER-CCBs Diuretics Iron supplements Calcium supplements Opioids Anticholinergics 1st line treatment for constipation - ANSWER-OTC laxatives What are indications for prescription constipation medications targeted to a specific diagnosis? - ANSWER-Chronic idiopathic constipation IBS w/ constipation Opiod induced constipation Docusate - ANSWER-stool softener Mineral oil - ANSWER-lubricants Psyllium - ANSWER-Fiber/bulk agent Glycerin, lactulose, sorbitol, polyethylene glycol, saline laxatives - ANSWER-Osmotic agents Bisacodyl, senna - ANSWER-Stimulant laxatives Docusate (colace) MOA - ANSWER-Surfactant laxative, increases water, fat penetration of the stool, allows for easier passage of stool Contraindications to docusate (colace) - ANSWER-Mineral oil (will increase absorption of mineral oil) Is mineral oil for long term use? - ANSWER-No, occasional constipation Precautions for mineral oil - ANSWER-Avoid long term Avoid in bedridden patients - aspiration Avoid in children, elderly, pregnancy Can decrease absorption of fat soluble vitamins Contraindications for mineral oil - ANSWER-Docusate (increase absorption of mineral oil) Fiber/bulk agents MOA - ANSWER-Adds bulk, holds water in stool, promotes peristalsis Precautions for fiber/bulk agents - ANSWER-Need to drink lots of water and move around, don't use in bedridden patients or with fluid limitations Special populations for fiber/bulk agents - ANSWER-Older adults need to continue to drink and move around Pregnancy ok with plenty of water Glycerin MOA - ANSWER-Osmotic agent that induces evacuation by local rectal stimulation Special populations for glycerin - ANSWER-Suppositiories (sizes for infants, kids, adults) Commonly used in children Can be used in pregnancy Lactulose, sorbitol MOA - ANSWER-Osmotic agents, non-absorbable sugars pull water into lumen of colon, promote peristalsis Long term use for lactulose, sorbitol - ANSWER-Prevention and treatment of chronic constipation; daily use not recommended Precautions for lactulose, sorbitol - ANSWER-Electrolyte imbalance; patients with DM (high amount of lactose) Special populations for lactulose, sorbitol - ANSWER-Daily use not recommended due to electrolyte imbalance Polyethylene glycol MOA - ANSWER-Non absorbable osmotic sugar, draws water into lumen of Colon but also contains electrolytes to prevent electrolyte shifts into colon 1st line constipation agent in hospitals , very common, safe for daily use - ANSWER-Polyethylene glycol Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) MOA - ANSWER-Non-absorbable salts pull fluid into intestines and colon; promote peristalsis Long term use for saline laxatives (Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) - ANSWER-Not for long term use (occasional) Precautions for Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) - ANSWER-Cramping, dehydration, diarrhea, electrolyte imbalance Special populations for Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) - ANSWER-Caution dehydration Renal Cardiac Bisacodyl, Senna MOA - ANSWER-Stimulant agents, directly stimulate GI tract through local mucosal irritation Special populations for bisacodyl, senna - ANSWER-For patients on chronic constipating meds, safe in older adults Are stimulant laxatives ok for long term use? - ANSWER-Yes pathophysiology of OIC - ANSWER-Options act on mu receptors in gut - Decrease motility - Increase absorption - Decrease secretion - Decrease defecation reflux Naloxegol (Movantik) MOA - ANSWER-Peripherally u-opioid receptor antagonist, does not cross BBB Place in therapy for Movantik - ANSWER-2nd line for OIC with chronic non cancer pain Dose adjustments for Movantik - ANSWER-Renal impairment Avoid in severe hepatic impairment Naldemedine (Symproic) MOA - ANSWER-Inhibit u-opiod receptors in GI tract, does not cross BBB Dose adjustments for Naldemedine (Symproic) - ANSWER-No renal dose adjustments; avoid in severe hepatic impairment Treatment for community acquired acute diarrhea - ANSWER-Oral rehydration No probiotics Loperamide Bismuth salicylate Treatment for Traveler's diarrhea - ANSWER-Rehydrate, bismuth, loperamide, ABx Prophylaxis: Bismuth, ABx, probiotics Medications that can cause diarrhea - ANSWER-ACEi Digoxin Colchicine Antacids PPIs T/F: Especially in Cdiff, the treatment goal of diarrhea should be to stop it as quickly as possible - ANSWER-False, need to get rid of pathogen or toxin Name two anti motility agents - ANSWER-Loperamide Diphenoxylate with atropine Loperamide Diphenoxylate with atropine MOA - ANSWER-Stimulate u-opiod receptors in gut, does not cross BBB Precautions for anti motility agents - ANSWER-Discouraged in bloody or infectious diarrhea; addiction potential (60 mg will cross BBB) Special populations for anti motility agents - ANSWER-Not recommended age 2 Weight based dosing for children up to 12 Black box warning for anti motility agents - ANSWER-QT prolongation Name an antispasmodic agent - ANSWER-Dicyclomine Dicyclomine MOA - ANSWER-Blocks ACh receptors in smooth muscle Name an anti secretory/adsorbent agent - ANSWER-Bismuth salicylate (pepto-bismol) Bismuth MOA - ANSWER-Decreases decreases, adsorbs bacteria, toxins, fluids, decreasing stool liquidity and frequency Precautions for bismuth - ANSWER-Can blacken tongue and/or stool May reduce absorption of some medications Name some probiotics - ANSWER-Bifidobacterium Lactobacillus Saccharomyces boulardi The smell of food, ingested food stimulates what 3 receptors on parietal cell - ANSWER-Histamine, gastrin, ACh Stimulation of histamine/gastrin/ACh receptors on parietal cells results in activation of - ANSWER-Proton pump (H+ combines with Cl to form HCL or stomach acid) Antacids MOA - ANSWER-neutralize acid and raise pH Drug interactions for antacids - ANSWER-Chelation (binding) - fluoroquinolones Increases pH and reduces absorption of some drugs - itraconzaole, iron Zantac 360 is brand name - ANSWER-Famotidine T/F: Ranitidine is not currently on market - ANSWER-True Drug interactions for H2RA - ANSWER-Cimetidine (most) increases levels of warfarin, phenytoin, diazepam, propranolol Special populations for H2RA - ANSWER-Require dose adjustment in moderate to severe renal impairment Avoid in elderly at high risk of delirium Precautions for proton pump inhibitors - ANSWER-May increase fracture risk May decrease oral absorption of magnesium and B12 with chronic use May increase risk of infection (C. diff) Respiratory - CAP Drug interactions for PPIs - ANSWER-Inhibitor of CYP2C19 - increase levels of clopidogrel (bleeding risk) Which PPI Is better to use with clopidogrel? - ANSWER-Pantoprazole Which neurotransmitters are associated with CINV? - ANSWER-Serotonin - 5HT3 Substance P Neurokinin NK1 receptor Dopamine - D2 Which neurotransmitters are associated with vertigo, motion sickness - ANSWER-ACh Histamine 1 Role of corticosteroids and olanzapine in CINV - ANSWER-Aid in helping antagonists Acute CINV - ANSWER-0-24 hrs after chemo Delayed CINV - ANSWER-24 hrs after chemo Patients with high (90%) chance of N/V should be treated with what agents - ANSWER-NK1 antagonist + 5HT3 antagonists + corticosteroid +/- olanzapine Patients with moderate (30-90%) chance of N/V should be treated with what agents - ANSWER-5HT3 antagonists + corticosteroid +/- olanzapine Patients with a low (10-30%) chance of N/V should be treated with what agents - ANSWER-Dopamine antagonists +/- corticosteroid Name the serotonin (5HT3) antagonists - ANSWER-Ondansetron Alosetron Granisetron Dolasetron Palonosetron Precautions for 5HT3 antagonists - ANSWER-QT prolongation, serotonin syndrome Drug interactions for 5HT3 antagonists - ANSWER-Substrate of CYP3A4 (major) Special populations for 5HT3 antagonists - ANSWER-Caution with patients at risk of arrythmia Name the NK-1 antagonists - ANSWER-Aprepitant Fosaprepitant Precautions for NK-1 antagonists - ANSWER-hypersensitivity during IV infusions Drugs interactions for NK-1 antagonists - ANSWER-Many; substrate of CYP3A4 (major); induces CYP2CP (warfarin) Use of corticosteroids in N/V - ANSWER-Improves antiemetic activity 5HT3 antagonists and NK-1 antagonists Olanzapine MOA - ANSWER-Second generation anti-psychotic with moderate antagonism of 5HT3, dopamine, histamine Use for olanzapine - ANSWER-off label acute and delayed; break through N/V Name the dopamine antagonists - ANSWER-Prochlorperazine Promethazine Use for dopamine antagonists - ANSWER-breakthrough Name two benzo's - ANSWER-Lorazepam (Ativan) Alprazolam (Xanax) Uses for benzo's in N/V - ANSWER-to prevent anticipatory N/V Special populations for scopolamine - ANSWER-Pregnancy - avoid Avoid in older adults Name the antihistamines - ANSWER-Dimenhydrinate Meclizine Uses for antihistamines - AN