Exam 2: all things ass (GI & N/V) Flashcards
what are the risk factors for the Arfals risk score?
- female gender
- nonsmoker
- hx of motion sickness or previous N/V post -op
- expected use of oral opioid
therapies for general N/V
- metoclopramide
- phenothiazine
- 5-HT3 serotonin antagonists (zofran)
therapies for disorders of balance
antihistamines (H1)
therapies for N/V in pregnancy
OTC: ginger, seabands
-antihistamines (doxylamine- V)
-in combo with B6/pyridoxine -N
ALT: 5-HT3 antagonists, metoclopramide, prochlorperazine
therapies for a risk factor score of 4
- scopolamine patch –> apply 2 hrs before anesthesia
- IV dexamethasone (given after anesthesia induction)
- 5-HT3 antagonist - zofran (at the end of surgery)
therapies for a risk factor score of 2-3
-5-HT3 antagonist (at the end of surgery)- zofran
Antihistamine drugs (H1 antagonists)
-dimehydrinate, diphenhydramine, meclizine, doxylamine (RX diclegis or bonjesta), scopolamine (RX patch), hydroxyzine (RX)
what categories of N/V are antihistamines used for?
- disorders of balance
- n/v with pregnancy
Aes of antihistamines
-sedation, dry mouth, constipation, kids become hyper, insomnia, irritability
Phenothiazines
- promethazine
- prochlorperazine (also comes in rectal)
- chlorpromazine
- -> all are PO, DEEP IM & IV
what categories of n/v are phenothiazines used for?
general n/v and rescue post-op
Aes of phenothiazines
- tissue damage!
- hypotension (of given IV- use slow push)
- QT prolongation
- dystonia (muscles tensing up)
5-HT3 antagonists
1: ondasteron
- dosatron
- guniestron
- palonestron
what categories of n/v are 5-ht3 antagonists used in?
- general n/v
- post operative n/v
Aes of 5-ht3 antagonists
- constipation
- headache
- QT prolongation
when are Prokinetics used?
work horse for gastroparesis
Metoclopramide
- used for general n/v
- SEs: EPS, dystonia, QT prolongation, diarrhea
Erythromycin
-can help with gastroparesis –> delayed stomach emptying in diabetic pts,
SEs: n/v, QT prolongation
what drugs are used to treat diarrhea?
- diphenoxylate (w/ atropine): dont use in pts with bacterial infections, used in IBD (reduce abuse potential)
- octerotide: gets used for intestinal carcinoid tumors & chemo-induced diarrhea
Self care options for diarrhea
(pedialyte, Gatorade, ginger ale & chicken broth)
- loperamide (do not use < 6)
- bismuth subsalicylate (do not use < 12)
- probiotics
- digestive enzymes (do not use < 4)
therapies for constipation : osmotics
- PEG
- Miralax
- Lactulose
therapies for constipation: chronic Idiopathic constipation
- lubiprostone (amtiza) : 24 mcg PO BID
- linardotide (Linzess): 145 mcg PO QD
- Pleccinatide (Trubulance): 3mg PO QD
therapies for constipation: opioid-receptor antagonists
- methylnaltrexone (relstor) SQ
- Naloxegol (morantik) PO
- Naldemedine (symproic) PO
Self care options for constipation
- methylcellulose
- docusate
- PEG, glycerin
- senna, biscadyl
- magnesium citrate, milk of magnesia, sodium phosphate
- mineral oil
Constipation self-care therapy in pregnancy
- PO docusate
- miralax
- PO senna, bisacodyl
Criteria for diagnosing IBS
- recurrent abdominal pain at least 1 day per week, in the last 3 months AND (at least 2 of the following):
- needs to be associated with deification
- a change in the frequency of stool
- a change in the form/appearance
Symptoms of IBS
- abdominal pain
- altered bowel habits
- bloating
IBS-C treatments
1- Lubiprostone (Amitiza)
1- Linaclotide (Linzess) & Piecanatide (trulance)
2- Tegaseriod (zelnorm) - if all else fails
Lubiprostone (amtiza) for IBS-C
- approved for WOMEN only
- 8mg BID w/ food
- “im constipated- but some lube on me”
Linaclotide (linzess) & Piecancatide (Trulance) for IBS-C
- lin: 290mg daily –> diarrhea!
- Pie: 3 mg daily
Tegweroid (zelnorm) for IBS-C
**only use in women w/o cardiac hx and < 65 y/o
-6mg PO BID- d/c in no benefit in 4-6 weeks
CIs: HTN, smoking, BMI > 30, diabetes, hyperlipidemia & age > 65
Treatment for IBS-D
- Rifaximin (Xifeaxan)
- Eluxadoline (Viberzi)
- Alisetron (for pts who have failed above 2)
Rifaximin (Xifeaxan) - IBS-D treatment
- abx that mainly stays in the GI tract, SIBI & positive breath test
- 14 day course of therapy, 550mg TID, can be repeated up to 2 more times (within a year)
Eluxadoline (Viberzi) for IBS-D treatment
- inhibits bowel contraction
- can cause sphincter of oddi dysfunction/spasm
- CIs: pts w/ hx of pancreatitis, w/o a gallbladder, hx of alcoholism or current pts who inject 3 or more alcoholic beverages/day
Alsetron for IBS-D treatment
- *for pts who have failed all 3 treatments!
- part of a REMS program
- for WOMEN who have have failed conventional therapy with severe IBS-D
- d/c therapy if no effect in 4 weeks
- ischemic colitis
treatment for any type of IBS
- tricyclic antidepressants
- fiber: soluble
- relaxation and therapy crap
Tricyclic antidepressants for IBS treatment
-amitriptyline: 50-100mg qd
-nortriptyline: 25-75 mg qd
–> helps improve pain, global symptoms in any form of IBS
(better effects in IBS-D)
Fiber in IBS treatment
soluble: psylium, oatbran, barley & beans
- dissolves + pulls water into the gut & creates a gel that resists colonic formation = better for IBS-C
What are the symptoms of GERD?
-heartburn that lasts for 3+ months with refractory to OTC therapies (omeprazole)
Heartburn: (substernal chest pain): can be either occasional & be treated in an OTC setting
Dyspepsia: discomfort in the epigastric –> burning pain, fullness, gnawing pain associated with bloating, early satiety
how can you diagnose GERD?
1) symptoms: heartburn for 3+ months that can start a trial therapy- then if their symptoms go away, they are diagnosed w. GERD
2) endoscopy: happens if they describe pain when swallowing
Treatment for GERD
-PPI for 8 weeks qd
Chronic PPI therapy: if pt has complications, pts who have symptoms return when they stop the therapy –> try to titrate to the lowest effective dose (3 times a week or PRN)
Side effects of PPIs
- increase risk of infections (c diff)
- pneumonia
- renal injury
- thrombocytopenia
- decrease CNS effects
Long term consequences of PPI use
-osteoporosis & fracture risk due to decreasing of absorption of calcium since acid is reduced
Causes of PUD (4)
- H. pylori
- NSAIDS
- alcohol use
- critical illness
H. pylori PUD diagnosis
- endoscopy (if pt has black stool or low hemoglobin
-blood tests: to pick up antibodies, breath test: to pick up on CO2 and fecal antigen test
(last 2 are used more for eradication)
H. pylori 1st line tx : Bismuth quad therapy
- PPI BID
- bismuth subsalcylate or substrate QID
- tetracycline 500 mg qid
- metronidazole 250 mg QID or 500mg TID
H. pylori 2nd line therapy: levofloxacin triple therapy
- PPI BID
- levofloxacin 500mg qid
- amoxicillin 1 gram BID
H. pylori last line therapy: triple antibiotic therapy
- PPI bid
- clarthromycin 500 mg BID
- amoxicillin 1 gram BID
Who is at risk for NSAID induced PUD?
- age > 65
- previous hx of ulcers
- using steroids at the same time (use COX 2 selective when you can: Celebrex, nabumetone, meloxicam, etodolac)
- pt is using anticoagulant
- pt is using anti platelet
Tx of NSAID induced PUD
-at least 4 weeks of PPI therapy but can go up to 8 weeks or longer
how to prevent NSAID induced PUD
- switch to APAP
- add a PPI to NSAID regimen
- add prostaglandin analog (misoprostol)
- use a cox 2 selective
PUD due to critical illness : major risk factors
- respiratory failure: mechanical ventilation for at least 48 hours)
- coagulopathy: INR > 1.5, platelets < 50
PUD due to critical illness: minor risk factors (need at least 2+)
- sepsis
- hypotensive or are requiring pressers
- hx of GI bleeding
- use of high dose steroids (> 250mg/day)
Treatment of PUD due to critical illness risk
-ranitidine or zantac (H2RAs)
what are the presentations of an upper GI bleed (PUD)
- hematemesis
- melina
- epigastric pain
- dyspepsia
- tachycardia
- hypotensive
- low hemoglobin & hematocrit
Management of an Upper GI bleed
- need IV isotonic bolus (4-5L of NS or lactated ringer)
- restore blood loss: packed red blood cells (get hemoglobin above 7!)
- give O2 (92%)
- reverse anticoagulation: give vit K or FFP
How to suppress acid in upper GI bleed
- start before endoscopy
- high dose IV short term Bolus followed by infusion –> 80mg bolus of pantpropazole or emopropazole followed by an 8mg/hr infusions for 72 hrs)
Things that happen during an endoscopy with a GI bleed
- epi to chock off bleeding vessels
- use targeted intact thermal therapy
Signs & symptoms of IBD
- diarrhea
- blood in stool
- abdominal pain
- weight loss
- fatigue
- changes in daily activity
How to diagnose IBD?
1- symptoms: peaks ~15-30 years old, can see weight loss & fatigue
2- lab tests: inc ESR & CRP (non-specific markers of inflammation)
3- lactoferrin + calprotectin: stool studies
4- endoscopy or CT scan/MRI
Ulcerative Colitis (description)
-confined to the rectum and colon
–> Proctitis: rectum only
–> left sided/distal colitis: comes up to the descending colon at splenic flexure
–> pan colitis: extensive damage- past the flexure
depth: confined to the mucosa
Risk: toxic mega colon, colon cancer
Crohn’s Disease (description)
-any where from mouth to anus
-most common for inflammation to show up in the terminal ileum
-have more perianal involvement = fistulas
Depth: deep! can go thru all the layers of the intestinal wall- inflammation is patchy: cobblestone appearance, high risk of requiring a colectomy
-risks: malnutrition, vitamin deficiency, strictures, fistulas
Tx of IBD: 5- ASAs
-acts topically to reduce inflammation in the GI tract –> decreases prostaglandins
Tx of IBD: 5- ASAs: Sulfasalazine
- 500-1500mg q6h
- ADRs: GI, rash, photosensitivity, blood dycrasias
Tx of IBD: 5- ASAs: Osalazine
- 500mg bid
- high risk of diarrhea- not used too often
Tx of IBD: 5- ASAs: balsalazide (colazal)
-better tolerated than sulfa one but high pills burden: 3, 750mg caps TID
Tx of IBD: 5- ASAs: mesalamine
- oral, rectal (Rowasa), supp (Canasa)
- do not use for crohns disease
Immunomodulators : maintenance therapy (drugs)
- 6-meracaptopurine
- azathioprine
- methotrexate
immunomodulators ADR/monitoring
- CBC at least every 3 months: bone marrow suppression possible
- IFTs & pancreatic enzymes, hepatotoxicity
- lymphomas- associated with AZA alone & in combo with Infliximab
Corticosteroid use in IBD
- works quickly to decrease inflammation
- Budesonide
Budesonide entocort
-formulated to release in terminal ileum
Budesonide ulceris
-formulated to release throughout colon (use in UC)
Budesonide dosage
-to induce remission: 9mg PO qd for 8 weeks
CD (maintain remission): after 8 weeks may be continued at 6mg po qd for 3 months
biologics to treat CD only
- certolizumab
- natalizumab
biologics to treat UC only
- golimumab
- tofacitinib
biologics to treat CD & UC
- infliximab
- adalimumab
- vedolizumab
- ustekinumab
biologics acute infusion reaction & tx
-chest pain, cough, dyspnea, itching
TX: premedication with: 1000mg APAP, 50 mg IV/PO diphenhydramine +/- 50 mg iV hydrocortisone
biologics delayed infusion reaction & tx
- myalgias, arthralgias, fever, rash, itching, urticaria, headaches
tx: may reside on its own or a short course of corticosteroids
antibiotics used in IBD
- best for perianal fistulas or fissures (CD)
- metronidazole 500mg tid or 20 mg/kg/day
- ciprofloxacin 400 mg IV or 500 mg PO bid
Crohn’s Disease mild-moderate
-no symptoms really, have kept weight loss less than 10%
Crohn’s Disease moderate-severe
- failed mild-moderate therapies
- may have fever present (>38C)
- significant weight loss
- abdominal pain
- N/V w/ no obstructions
- have anemia
Crohn’s Disease severe- fulminant
- persistent symptoms despite steroids of biologic therapy
- –> fever, abdominal pain
- often needing to be treated in the hospital b/c they have high fever
- persistent N/V, intestinal obstruction that needs surgical intervention, they cant eat, have some intestinal inflammation in the form of abscesses
Crohn’s Disease - active therapy for mild-moderate disease
1) po budesonide - 8 week course of therapy
2) IF theres colonic involvement: use 5-ASA –> sulfasalazine
Crohn’s Disease - active therapy for moderate - severe disease
a. systemic steroid: prednisone 40-60 mg qs x 2 weeks
b. biologic: 1- Infliximab
(if doesn’t work use: cetero or nata) –> 2-4 weeks will see symptom relief
c. Azathioprine ( 6-MPS): use as an add on- good to reduce the immune system response but takes ~ 4 months to work
Crohn’s Disease - active therapy for severe-fulminant
(has tried several biologic therapies)
- needs surgery
- IV steroids: hydrocortisone, methylprednisolone
- for pts not improving use: Infliximab IV
- should also give IV fluids
Crohn’s Disease - active therapy for perianal disease
- fistulas or fissures
- metronitazole or cipro
- -> fistulas can also use Infliximab
Crohn’s Disease - maintenance therapy
1) 6-MP/AZA/MTX: takes 4 months to see full effect
(other options)
-budesonide: can be useful for additional 3 months
-biologics: continue whatever one was working
**do not use 5-ASA!
Ulcerative colitis remission
- asymptomatic- having formed stools
- no blood in stool
- normal hemoglobin
- normal ESR & CRP
- fecal calprotectin levels on the lower end
Ulcerative colitis mild
- < 4 stools/day
- having intermittent blood in stool
- normal hemoglobin
- CRP is elevated & fecal calprotectin > 150
Ulcerative colitis moderate- severe
- > 6 stools/day
- frequent blood in stools
- hemoglobin < 75% of normal
- ESR + CRP is elevated
- FC > 150
Ulcerative colitis fulminate
- > 10 stools/day
- continuous blood in stools, requiring blood transfusions
- HgB < 8
- ESR, CRP & FC is elevated
Ulcerative colitis Active therapy: mild distal disease (left sided)
1) topical mesalamine preps
2) PO 5-ASA: used if ppl dont want rectal - combo PO + PR therapies
3) budesonide (Uceris)
Ulcerative colitis active therapy: extensive mild disease (in transverse colon)
PO 5- ASA: consider adding budesonide in the form of uceris x 8 weeks
Ulcerative colitis active therapy for moderate to severe
- budesonide
- presinosone: 40-60 mg PO
- biologics: Infliximab (may be paired with 6-MP/AZA in IC)
Ulcerative colitis active therapy for fulminant
- IV steriods ASAP
- IV Infliximab
- IV cyclosporine
- surgery
Ulcerative colitis maintenance therapy for mild distal
- topical 5- ASA (mesalamine)
- PO 5-ASA preps (sulfa?)
Ulcerative colitis maintenance therapy for mild extensive disease
-oral 5- ASA (sulfasalazine)
Ulcerative colitis maintenance therapy for moderate to fulminant
- 6-MP derivative (aza): if tx induced with steroid
- continue biologic if tx was induced with biologic (use 6-mp or AZA)
- use 6-mP/AZA or verdolizuman if tx is induced by IV cyclosporine
______ has a BBW warning against ______ which is caused by ______
(cautionary for ______)
1- natalizumab
2-PML
3- JC polyvirus
4- vedolizumab
which drugs hold a BBW for infections & malignancy?
- infliximab
- adalimumab
- golimumab
- tofacitinib
- certolizumab
- natalizumab
pros of azathioprine therapy
- reduce antibody formation
- enhance the rate of biologics
cons of azathioprine therapy
- can be potassium sparing
- can take 4 months to work
- can cause lymphomas
