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NAPLEX 2024 > 73. Constipation + Diarrhea > Flashcards

73. Constipation + Diarrhea Flashcards

1
Q

Medical conditions that can cause constipation

A

IBS (constipation-predominant)
Anal disorders (fissures, fistulae, rectal prolapse)
Multiple sclerosis
CV events
Parkinson disease
Spinal cord tumors
DM
Hypothyroidism

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2
Q

When constipation persists for several weeks or longer, and cause is unknown, it is termed ____

A

chronic idiopathic constipation (CIC)

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3
Q

Idiopathic constipation a/w chronic or recurrent abdominal discomfort that is relieved by defecation is termed ____

A

IBS with constipation (IBS-C)

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4
Q

T/F: Non-drug treatments are preferred for constipation

A

True

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5
Q

What are non-drug treatments for constipation?

A

Increasing fluid intake (64oz daily recommended)
Limiting caffeine and alcohol intake (to avoid dehydration)
Increasing physical activity
Eating foods high in fiber is useful

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6
Q

Common side effects of drugs used for constipation

A

Diarrhea and abdominal cramping

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7
Q

What type of drug is first-line for constipation?

A

Bulk forming drugs (e.g. fiber like psyllium)

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8
Q

What type of drug is treatment of choice for constipation in pregnant pts?

A

Bulk forming drugs (e.g. fiber like psyllium)

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9
Q

How do osmotics work for constipation?

A

contain large ions or molecules that are poorly absorbed, draw fluid into bowel which distends the colon and increases peristalsis

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10
Q

Why are stimulants and stool softeners often given together in pts using opioids?

A

Opioids cause constipation
Stimulants = push
Stool softener like docusate = makes easier to push

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11
Q

Why are pts on iron supplements also on docusate?

A

Iron supplements make stool hard, docusate softens stool

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12
Q

How do lubricants like mineral oil work for constipation?

A

Coat bowel and stool with waterproof film, keeps moisture in the stool and makes pooping easier

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13
Q

Key drugs that are constipating

A

Antacids (aluminum, calcium containing)
Antidiarrheals
Clonidine
Colesevelam
Anticholinergic drugs: antihistamines (e.g. diphenhydramine), antispasmodics (e.g. baclofen), phenothiazines (e.g. prochlorperazine), TCAs (e.g. amitriptyline), incontinence drugs (e.g. oxybutynin)
Iron
Non-DHP CCBs (esp verapamil)
Opioids
Sucralfate (contains aluminum complex)

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14
Q

Which OTCs do you recommend for constipation in most adults?

A

Fiber

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15
Q

Which OTCs do you recommend for iron-induced/hard-stool constipation?

A

Stool softener (e.g. docusate) or bulk-forming drug

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16
Q

Which OTCs do you recommend for opioid-induced constipation?

A

Stimulant (e.g. senna, bisacodyl) or osmotic (e.g. PEG) laxative

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17
Q

Which OTCs do you recommend for constipation in pregnant pts?

A

Fiber

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18
Q

Which OTCs do you recommend for constipation in pts that need fast relief?

A

Adults: bisacodyl or glycerin (more gentle) suppository)
Children: glycerin suppository

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19
Q

Examples of bulk forming drugs used for constipation

A

Psyllium (Metamucil)
Calcium polycarbophil (FiberCon)
Methylcellulose (Citrucel)
Wheat dextrin (Benefiber)

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20
Q

Side effects of bulk forming drugs used for constipation

A

Flatulence, abd cramping, bloating

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21
Q

what is a counseling point for bulk forming drugs used for constipation?

A

adequate fluids are required

FiberCon has calcium, caution with binding drug interactions

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22
Q

Examples of osmotic drugs used for constipation

A

Magnesium hydroxide (Milk of Magnesia)
Polyethylene glycol 3350 (MiraLax)
Glycerin
Lactulose (Constulose, Enulose)
Sodium phosphates (Fleet Enema)

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23
Q

Side effects of osmotic drugs used for constipation

A

Electrolyte imbalance, abd cramping

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24
Q

What is a concern with use of magnesium hydroxide (Milk of Magnesia)?

A

Caution with renal impairment and do not use if severe renal impairment

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25
Q

Lactulose is commonly used for ____

A

hepatic encephalopathy

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26
Q

Examples of stimulant drugs used for constipation

A

Senna (Senokot, Ex-Lax)
Bisacodyl (Dulcolax)

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27
Q

When should oral stimulants used for constipation be taken?

A

Bedtime to induce bwoel movement int he morning

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28
Q

Emmolients (stool softeners) like docusate (Colace) is often preferred when straining should be avoided (e.g. ____)

A

postpartum, post-MI, anal fissures, hemorrhoids

29
Q

How does lubiprostone (Amitiza) work for constipation?

A

Chloride channel activator, acts on chloride channels in gut, leading to increased fluid and peristalsis

30
Q

How does linaclotide (Linzess) work for constipation?

A

Guanylate cyclase C agonist, increase chloride and bicarbonate secretion into the lumen of the intestines, increasing speed of GI transit and reducing abdominal pain

31
Q

How does alvimopan (Entereg) work for constipation?

A

Peripherally-acting mu-opioid receptor antagonist (PAMORAs) act on mu-opioid receptors in the GI tract, decreasing constipation

32
Q

Luubiprostone (Amitiza) indications

A

CIC, IBS-C, OIC

33
Q

Linaclotide (Linzess), plecanatide (Trulance) indications

A

CIC, IBS-C

34
Q

Alvimopan (Entereg) indications

A

Surgery - for hospitalized surgery pts to decrease risk of post-op ileus

35
Q

Prucalopride indications

A

CIC

36
Q

Methylnaltrexone (Relistor), Naloxegol (Movantik)

A

OIC

37
Q

Side effects of lubiprostone (Amitiza)

A

Nausea
Others: diarrhea, abd pain, abd distension, HA

38
Q

Side effects of linaclotide (Linzess)

A

Diarrhea, abd pain, flatulence

39
Q

Contraindications of Alvimopan (Entereg)

A

Therapeutic dose of opioids for > 7 consecutive days immediately prior to use

40
Q

Prucalopride (Motegrity) warnings

A

suicidal ideation

41
Q

Although usually safe and well-tolerated, laxatives for colonoscopy can cause ____, especially oral sodium phosphates such as ___

A

fluid and electrolyte losses
OsmoPrep

42
Q

Use extra caution in pts with ______ or taking _____ before starting laxatives used for whole bowel irrigation

A

CVD, renal insufficiency
Taking loop diuretics (d/t additional fluid loss) or NSAIDs

43
Q

Boxed warning for OsmoPrep (sodium phosphates)

A

Nephropathy

44
Q

Contraindication for OsmoPrep (sodium phosphates)

A

Acute phosphate nephropathy, gastric bypass, or stapling surgery

45
Q

When are doses of bowel prep regimens typically given?

A

Evening before colonoscopy and morning of coloscopy

46
Q

Before a colonoscopy, be on a clear liquid diet. Do NOT consume ___

A

sold or semi-solid floods, anything with red or blue/purple food coloring, milk, cream, tomato, orange or grapefruit juice, alcohol, cream soups

47
Q

Brand name for polyethylene glycol-electrolyte solution (for bowel prep)

A

Colyte, GoLytely

48
Q

Brand name for sodium phosphates (for bowel prep)

A

OsmoPrep

49
Q

Brand name for sodium sulfate, potassium sulfate, and magnesium sulfate (for bowel prep)

A

Suprep Bowel Prep Kit

50
Q

Drugs that can cause diarrhea

A

ACEi (e.g. donepezil)
Antacids containing magnesium
Abx (esp broad-spectrum), diarrhea may be infectious (e.g. C. diff)
Antidiabetics (e.g. metformin, GLP-1RA)
Antineoplastics (e.g. irinotecan, capecitabine, fluorouracil, methotrexate, TKIs)
Colchicine
Drugs used for constipation (e.g. laxatives)
Misoprostol
Mycophenolate
Prokinetic drugs (e.g. metoclopramide, cisapride)
Protease inhibitors (especially nelfinavir)
Quinidine
Roflumilast

51
Q

T/F: Most cases of diarrhea are bacterial

A

False - viral

52
Q

___ is the most common bacterial cause of diarrhea

A

E. coli

53
Q

Recurrent idiopathic diarrhea a/w chronic or reoccurring abdominal discomfort that is relieve by defecation is termed ____

A

IBS with diarrhea (IBS-D)

54
Q

Non-drug management of diarrhea includes ____

A

fluid and electrolyte replacement with oral rehydration solutions (ORS) such as Pedialyte, Enfamil Enfalyte, Gatorade

55
Q

Most patients with non-infectious diarrhea who require symptomatic relief can use short-term ____ or ___ as needed

A

Bismuth subsalicylate (Pepto-Bismol) or Loperamide

56
Q

___ and ___ are antimotility drugs that slow intestinal motility, prolonging time for water absorption

A

Loperamide and diphenoxylate

57
Q

MOA eluxadoline (Viberzi)

A

Mixed mu-opioid receptor agonist (in contrast to PAMORAs which are antagonist)

58
Q

Contraindications for bismuth subsalicylate (Pepto-Bismol)

A

Salicylate allergy, taking other salicylates (e.g. aspirin), GI ulcer, bleeding problems, black/bloody stool

59
Q

Concern with use of Pepto-bismol with anticoagulants or antiplatelets or NSAIDs

A

increased risk of bleeding

60
Q

Loperamide (Imodium A-D) Dosing

A

4mg PO after the first loose stool, then 2 mg after each subsequent loose stool

Max: 8mg/day (Self-care) or 16mg/day (healthcare supervision)

61
Q

Contraindications for loperamide (Imodium A-D)

A

acute dysentery (bloody diarrhea + high fever)
Pseudomembranous colitis (C. diff), bacterial enterocolitis
Others: abd pain without diarrhea, acute ulcerative colitis

62
Q

Boxed warnings for loperamide (Imodium A-D)

A

TdP, cardiac arrest and sudden death with higher doses than max dose (do NOT exceed)
Do not use in children < 2yo

63
Q

Contraindications for Diphenoxylate/atropine (Lomotil)

A

Risk of respiratory and CNS depression in children
Do not use if <2 yo, or < 6yo for tablets)

Others: diarrhea caused by enterotoxin-producing bacteria or C.diff, obstructive jaundice

64
Q

Liquid formulation of Diphenoxylate/atropine (Lomotil) is recommended in children ___

A

<13 yo

65
Q

Anticholinergic effects of Lomotil come from the ___compontent

A

Atropine

66
Q

Dicyclomine (Bentyl) warnings

A

Anticholinergic, caution in pts ≥ 65yo (Beer’s Criteria) and mild-moderate ulcerative colitis (can cause toxic megacolon or paralytic ileus)

67
Q

Side effects of dicyclomine (Bentyl)

A

Dizziness, dry mouth, nausea, blurred vision, somnolence, weakness, nervousness

68
Q

Contraindications of Eluxadoline (Viberzi)

A

Pts without a gallbladder

69
Q

What are some oral medications for diarrhea that are used less commonly?

A

Antibiotics (Rifaximin) - for IBS without constipation; costly and relapse often occurs
Serotonin 5HT-3 receptor agonist (Alosetron) - approved for women only, but restricted use d/t risk of ischemic colitis

NAPLEX 2024 (74 decks)

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