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Pharm Dedo Exam3 > Constipation, Diarrhea, & IBS > Flashcards

Constipation, Diarrhea, & IBS Flashcards

1
Q

Rx meds that cause constipation

A 
opioids
anticholinergics
TCAs
CCBs *Verapamil!!
anti-Parkinson's meds
antipsychotics
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2
Q

OTC meds that cause constipation

A

antacids
Ca & Fe supplements
anti-diarrheals (including bismuth)

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3
Q

“Red Flags” that indicate further WU

A 
recent onset of constipation in pts >50yrs
obstructive sx
rectal bleeding
weight loss
FH of colon CA
Fe deficiency anemia
Heme (+) stool
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4
Q

before starting meds, pts should make sure they are optimizing _____ & _____

A

fluid & fiber intake

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5
Q

Acute/Subacute constipation options

A
  • bulk laxatives (OTC)
  • stool softeners (OTC)
  • saline laxatives (OTC)
  • stimulant laxatives (OTC)
  • hyperosmolar laxatives
  • lubricant laxatives
  • suppositories
  • enemas
  • perineal massage
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6
Q

all bulk laxatives are what type of fiber?

A

soluble fiber

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7
Q

are bulk laxatives helpful with OIC? (opioid-induced constipation)

A

nope

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8
Q

contraindications for bulk laxatives

A

obstructive sx, dysphagia, frail/bed-bound pts

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9
Q

stool softeners MOA

A

facilitates emulsification of water & fat content of stool to increase the luminal mass –> increased peristalsis

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10
Q

are stool softeners effective?

A

not really (poo just gets really mushy)

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11
Q

saline laxatives MOA

A

act as a hyperosmolar agent (draws fluid into gut) –> increases peristaltic action

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12
Q

are saline laxatives tolerated well?

A

no

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13
Q

stimulant laxatives MOA

A

alter electrolyte transport & stimulate myenteric plexus to increase peristalsis

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14
Q

what are the 2 main types of hyperosmolar laxatives?

A

lactulose & polyethylene glycol (PEG 3350)

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15
Q

when do we mainly use lactulose?

A
  • hepatic encephalopathy

- constipation (produces osmotic effect in colon)

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16
Q

when do we use PEG 3350?

A
  • bowel preps (colonoscopy)

- chronic constipation (Miralax!)

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17
Q

what is the biggest ADR associated with lubricant laxatives?

A

malabsorption of fat-soluble vitamins w prolonged use

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18
Q

MOA of suppositories?

A

induce evacuation by local rectal stimulation

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19
Q

who should NEVER get a suppository or enema?

A

pts with neutropenia or thrombocytopenia (distending the colon filled w bacteria is not a good idea for immunocompromised pts)

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20
Q

who is CIC most common in?

A

women & elderly pts

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21
Q

main sx of CIC?

A

infrequent BMs (<3/wk)
straining during defecation
lumpy/hard stools
sensation of blockage or incomplete evacuation
need for manual maneuvers to aid with defecation

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22
Q

what types of channels does Lubiprostone act on in the luminal surface of the GI tract?

A 
chloride channels
(this stimulates intestinal fluid secretion &amp; decreases transit time of feces)
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23
Q

clinical indications for Lubiprostone

A
  • CIC (ALL adults at any age)
  • IBS-C (women >18yrs)
  • OIC (chronic non-CA pain)
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24
Q

contraindications of Lubiprostone

A

pts w known or suspected mechanical obstruction OR mod-severe gatroparesis

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25
Q

Linaclotide & Plecanatide MOA

A

activate CFTR ion channel which increases the secretion of Cl & HCO3 into the lumen of intestines to accelerate transit time

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26
Q

Linaclotide & Plecanatide clinical use

A
  • CIC
  • IBS-C
  • only mildly effective though
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27
Q

Prucalopride MOA

A

selective agonist of 5HT4 receptors which stimulates secretions & increases intestinal transit time

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28
Q

Prucalopride clinical use

A

CIC ONLY!!

modestly effective

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29
Q

Options to treat CIC?

A
  • Lubiprostone
  • Linaclotide
  • Plecanatide
  • Prucalopride
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30
Q

constipation recommendations for “regular outpatients”

A

1 dietary/supplemental fiber PLUS H2O & exercise
2 add stimulants* or PEG if step 1 doesn’t work
*Bisacodyl has the most data & can be taken long term

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31
Q

constipation recommendations for “hospitalized / opiate patients”

A

PEG

*MUST start when opiate is started (especially in the elderly)

32
Q

what is the best way to treat OIC?

A

PREVENT IT!!

33
Q

clinical indications of Methylnaltrexone

A
  • OIC in pts w advanced illness who are receiving palliative care
  • OIC in pts taking opioids for chronic NON-CA pain
34
Q

Naloxegol Clinical indications

A

-OIC in NON-CA pts

35
Q

Naloxegol & Naldemedine are substrates of which CYP?

A

3A4

36
Q

Naldemedine clinical indications

A

-OIC in NON-CA pts

37
Q

1st line for constipation in pregnancy?

A

bulking laxatives (after increases fluids, fiber, & exercise)

38
Q

2nd line for constipation in pregnancy?

A

PEG (still used frequently even though C recommendation)

lactulose is a B recommendation but can cause problems for pts who are lactose intolerant

39
Q

Other options for constipation in pregnancy?

A

-stimulant laxatives (bisacodyl&raquo_space;Senna)
long-term use is not recommended (C recommendation)
-stool softeners (docusate; C recommendation)
^be careful, already contained in some prenatal vitamins!

40
Q

constipation agents that are contraindicated in pregnancy?

A

Lubricants

  • mineral oil (C)
  • castor oil (X)
41
Q

most common type of pediatric constipation

A

functional or withholding constipation

42
Q

functional constipation:

A

constipation w/o an organic cause

43
Q

what is the main cause of functional constipation?

A

a painful BM that leads the child to voluntary withholding (bad cycle continues)

44
Q

what are the 2 categories of pharmacologic tx for functional constipation?

A
  • disimpactions

- maintenance (dietary & medications)

45
Q

Disimpaction can be performed ___ or ____

A

manually or pharmacologically

46
Q

how do you begin disimpactions for pediatrics?

A

start with oral PEG, NOT enemas or digital disimpaction

–being PEG with a big loading dose (1-1.5g/kg/day) x3 days then decrease to maintenance levels

47
Q

maintenance dose of PEG for peds?

A

0.4-1 g/kg/day

titrate as needed for 1-2 soft stools/day

48
Q

how long should PEG maintenance continue?

A

at least 6 months (need to break the cycle of holding stools out of fear of pain)

49
Q

most acute diarrhea is infectious or non-infectious?

A

infectious

50
Q

what are the two types of infectious diarrhea?

A

inflammatory and non-inflammatory

51
Q

what is the OTC version of bismuth subsalicylate

A

Pepto Bismol

52
Q

MOA of bismuth subsalicylate

A

anti-secretory, anti-inflammatory, & antimicrobial action (against GI bacterial & viral pathogens)

53
Q

clinical indications of bismuth subsalicylate

A
  • sx tx of mild, nonspecific diarrhea

- prevention & control of traveler’s diarrhea (MUST be non-inflammatory!)

54
Q

how old should kids be before they can have bismuth subsalicylate?

A

at least 12yrs…worry about Reye’s syndrome (ASA derivative!)

55
Q

ADRs of bismuth subsalicylate:

A
  • darkening of tongue & stool
  • constipation&raquo_space; impaction (dose-dependent)
  • effects of ASA
56
Q

Loperamides MOA

A

acts on intestinal muscles via opioid receptors to decrease peristalsis & increase transit time of fevels.
(additionally it increases viscosity an decreases fecal volume and flui/electrolytes)
*it is a poorly absorbed opioid!!

57
Q

loperamide clinical indications:

A

acute nonspecific NON-INFLAMMATORY diarrhea

also uncommonly used for IBS-D

58
Q

what happens when OTC loperamide is abused?

A

serious arrhythmias & death

can cross BBB at very high doses so patient can get high on opioid-like effects

59
Q

contraindications to loperamide?

A

acute IBD or inflammatory infectious diarrhea

60
Q

2nd line tx for diarrhea (not OTC)

A

diphenoxylate & atropine

61
Q

diphenoxylate is an “opioid”. what is its MOA?

A

inhibits excessive GI motility & propulsion

62
Q

what discourages abuse of diphenoxylate c/t loperamide?

A

subtherapeutic amounts of atropine (unpleasant ADRs if too much is taken)

63
Q

diarrhea management in pregnancy:

A

generally try to avoid medications d/t safety concerns

64
Q

is IBS m/c in males or females?

A

females (2-2.5x more common)

65
Q

IBS definition:

A

chronic, intermittent abd pain accompanied by altered bowel habits (dx of exclusion!)

66
Q

what are the 4 types of IBS?

A

IBS w constipation (IBS-C)
IBS w diarrhea (IBS-D)
IBD w mixed sx (IBS-M)
IBS unclassified (IBS-U)

67
Q

physiologic considerations of IBS:

A
  • change in the gut microbiome
  • stress response
  • sensory & motor fnx of gut
  • host genetic factors
68
Q

since the exact cause of IBS is unknown, the goal of tx is…

A

symptom control!

69
Q

bc most IBS tx are only “modestly effective” we should use…

A

a combined treatment approach

70
Q

IBS management strategies:

A

1 stress reduction (v important!)
2 exercise (also v important)
3 diet education/modification (Low FODMAPs?)
4 dietary/supplementary fiber
5 laxatives? (IBS-C; PEG, stool softeners, colonic stimulants)
6 antidiarrheals? (IBS-D)
7 antispasmotics? (help tx abd pain)

71
Q

recommended (SOLUBLE) fiber intake for adults:

A

20-40 g/day

72
Q

when is the best time to take antispasmotic drugs?

A

PRN for acute attacks of pain or before meals if pts have postprandial sx

73
Q

Other IBS meds for refractory pts (just know at an awareness level, GI will be managing this!):

A
  • Lubiprostone
  • Linaclotide & plecanatide
  • Tegaserod
  • Tenapanor
  • Eluxadoline
  • Alonsetron
  • Rifaximin
  • Antidepressants (TCAs&raquo_space;>SSRIs)
  • probiotics
  • peppermint oil
  • CBT
74
Q

which drug alters the gut microbiota & reduce mucosal inflammation?

A

Rifaximin

-VERY costly w just a small benefit

75
Q

peppermint oil MOA?

A

antispasmotic properties d/t Ca channel blockade

Pharm Dedo Exam3 (3 decks)

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