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GI/Skin Therapeutics > Exam 2: all things ass (GI & N/V) > Flashcards

Exam 2: all things ass (GI & N/V) Flashcards

1
Q

what are the risk factors for the Arfals risk score?

A
  • female gender
  • nonsmoker
  • hx of motion sickness or previous N/V post -op
  • expected use of oral opioid
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2
Q

therapies for general N/V

A
  • metoclopramide
  • phenothiazine
  • 5-HT3 serotonin antagonists (zofran)
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3
Q

therapies for disorders of balance

A

antihistamines (H1)

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4
Q

therapies for N/V in pregnancy

A

OTC: ginger, seabands
-antihistamines (doxylamine- V)
-in combo with B6/pyridoxine -N
ALT: 5-HT3 antagonists, metoclopramide, prochlorperazine

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5
Q

therapies for a risk factor score of 4

A
  • scopolamine patch –> apply 2 hrs before anesthesia
  • IV dexamethasone (given after anesthesia induction)
  • 5-HT3 antagonist - zofran (at the end of surgery)
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6
Q

therapies for a risk factor score of 2-3

A

-5-HT3 antagonist (at the end of surgery)- zofran

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7
Q

Antihistamine drugs (H1 antagonists)

A

-dimehydrinate, diphenhydramine, meclizine, doxylamine (RX diclegis or bonjesta), scopolamine (RX patch), hydroxyzine (RX)

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8
Q

what categories of N/V are antihistamines used for?

A
  • disorders of balance

- n/v with pregnancy

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9
Q

Aes of antihistamines

A

-sedation, dry mouth, constipation, kids become hyper, insomnia, irritability

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10
Q

Phenothiazines

A
  • promethazine
  • prochlorperazine (also comes in rectal)
  • chlorpromazine
  • -> all are PO, DEEP IM & IV
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11
Q

what categories of n/v are phenothiazines used for?

A

general n/v and rescue post-op

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12
Q

Aes of phenothiazines

A
  • tissue damage!
  • hypotension (of given IV- use slow push)
  • QT prolongation
  • dystonia (muscles tensing up)
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13
Q

5-HT3 antagonists

A

1: ondasteron

  • dosatron
  • guniestron
  • palonestron
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14
Q

what categories of n/v are 5-ht3 antagonists used in?

A
  • general n/v

- post operative n/v

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15
Q

Aes of 5-ht3 antagonists

A
  • constipation
  • headache
  • QT prolongation
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16
Q

when are Prokinetics used?

A

work horse for gastroparesis

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17
Q

Metoclopramide

A
  • used for general n/v

- SEs: EPS, dystonia, QT prolongation, diarrhea

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18
Q

Erythromycin

A

-can help with gastroparesis –> delayed stomach emptying in diabetic pts,
SEs: n/v, QT prolongation

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19
Q

what drugs are used to treat diarrhea?

A
  • 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
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20
Q

Self care options for diarrhea

A

(pedialyte, Gatorade, ginger ale & chicken broth)

  • loperamide (do not use < 6)
  • bismuth subsalicylate (do not use < 12)
  • probiotics
  • digestive enzymes (do not use < 4)
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21
Q

therapies for constipation : osmotics

A
  • PEG
  • Miralax
  • Lactulose
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22
Q

therapies for constipation: chronic Idiopathic constipation

A
  • lubiprostone (amtiza) : 24 mcg PO BID
  • linardotide (Linzess): 145 mcg PO QD
  • Pleccinatide (Trubulance): 3mg PO QD
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23
Q

therapies for constipation: opioid-receptor antagonists

A
  • methylnaltrexone (relstor) SQ
  • Naloxegol (morantik) PO
  • Naldemedine (symproic) PO
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24
Q

Self care options for constipation

A
  • methylcellulose
  • docusate
  • PEG, glycerin
  • senna, biscadyl
  • magnesium citrate, milk of magnesia, sodium phosphate
  • mineral oil
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25
Q

Constipation self-care therapy in pregnancy

A
  • PO docusate
  • miralax
  • PO senna, bisacodyl
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26
Q

Criteria for diagnosing IBS

A
  • 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
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27
Q

Symptoms of IBS

A
  • abdominal pain
  • altered bowel habits
  • bloating
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28
Q

IBS-C treatments

A

1- Lubiprostone (Amitiza)
1- Linaclotide (Linzess) & Piecanatide (trulance)
2- Tegaseriod (zelnorm) - if all else fails

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29
Q

Lubiprostone (amtiza) for IBS-C

A
  • approved for WOMEN only
  • 8mg BID w/ food
  • “im constipated- but some lube on me”
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30
Q

Linaclotide (linzess) & Piecancatide (Trulance) for IBS-C

A
  • lin: 290mg daily –> diarrhea!

- Pie: 3 mg daily

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31
Q

Tegweroid (zelnorm) for IBS-C

A

**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

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32
Q

Treatment for IBS-D

A
  • Rifaximin (Xifeaxan)
  • Eluxadoline (Viberzi)
  • Alisetron (for pts who have failed above 2)
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33
Q

Rifaximin (Xifeaxan) - IBS-D treatment

A
  • 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)
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34
Q

Eluxadoline (Viberzi) for IBS-D treatment

A
  • 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
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35
Q

Alsetron for IBS-D treatment

A
  • *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
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36
Q

treatment for any type of IBS

A
  • tricyclic antidepressants
  • fiber: soluble
  • relaxation and therapy crap
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37
Q

Tricyclic antidepressants for IBS treatment

A

-amitriptyline: 50-100mg qd
-nortriptyline: 25-75 mg qd
–> helps improve pain, global symptoms in any form of IBS
(better effects in IBS-D)

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38
Q

Fiber in IBS treatment

A

soluble: psylium, oatbran, barley & beans

- dissolves + pulls water into the gut & creates a gel that resists colonic formation = better for IBS-C

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39
Q

What are the symptoms of GERD?

A

-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

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40
Q

how can you diagnose GERD?

A

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

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41
Q

Treatment for GERD

A

-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)

42
Q

Side effects of PPIs

A
  • increase risk of infections (c diff)
  • pneumonia
  • renal injury
  • thrombocytopenia
  • decrease CNS effects
43
Q

Long term consequences of PPI use

A

-osteoporosis & fracture risk due to decreasing of absorption of calcium since acid is reduced

44
Q

Causes of PUD (4)

A
  • H. pylori
  • NSAIDS
  • alcohol use
  • critical illness
45
Q

H. pylori PUD diagnosis

A
  • 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)
46
Q

H. pylori 1st line tx : Bismuth quad therapy

A
  • PPI BID
  • bismuth subsalcylate or substrate QID
  • tetracycline 500 mg qid
  • metronidazole 250 mg QID or 500mg TID
47
Q

H. pylori 2nd line therapy: levofloxacin triple therapy

A
  • PPI BID
  • levofloxacin 500mg qid
  • amoxicillin 1 gram BID
48
Q

H. pylori last line therapy: triple antibiotic therapy

A
  • PPI bid
  • clarthromycin 500 mg BID
  • amoxicillin 1 gram BID
49
Q

Who is at risk for NSAID induced PUD?

A
  • 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
50
Q

Tx of NSAID induced PUD

A

-at least 4 weeks of PPI therapy but can go up to 8 weeks or longer

51
Q

how to prevent NSAID induced PUD

A
  • switch to APAP
  • add a PPI to NSAID regimen
  • add prostaglandin analog (misoprostol)
  • use a cox 2 selective
52
Q

PUD due to critical illness : major risk factors

A
  • respiratory failure: mechanical ventilation for at least 48 hours)
  • coagulopathy: INR > 1.5, platelets < 50
53
Q

PUD due to critical illness: minor risk factors (need at least 2+)

A
  • sepsis
  • hypotensive or are requiring pressers
  • hx of GI bleeding
  • use of high dose steroids (> 250mg/day)
54
Q

Treatment of PUD due to critical illness risk

A

-ranitidine or zantac (H2RAs)

55
Q

what are the presentations of an upper GI bleed (PUD)

A
  • hematemesis
  • melina
  • epigastric pain
  • dyspepsia
  • tachycardia
  • hypotensive
  • low hemoglobin & hematocrit
56
Q

Management of an Upper GI bleed

A
  • 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
57
Q

How to suppress acid in upper GI bleed

A
  • 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)
58
Q

Things that happen during an endoscopy with a GI bleed

A
  • epi to chock off bleeding vessels

- use targeted intact thermal therapy

59
Q

Signs & symptoms of IBD

A
  • diarrhea
  • blood in stool
  • abdominal pain
  • weight loss
  • fatigue
  • changes in daily activity
60
Q

How to diagnose IBD?

A

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

61
Q

Ulcerative Colitis (description)

A

-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

62
Q

Crohn’s Disease (description)

A

-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

63
Q

Tx of IBD: 5- ASAs

A

-acts topically to reduce inflammation in the GI tract –> decreases prostaglandins

64
Q

Tx of IBD: 5- ASAs: Sulfasalazine

A
  • 500-1500mg q6h

- ADRs: GI, rash, photosensitivity, blood dycrasias

65
Q

Tx of IBD: 5- ASAs: Osalazine

A
  • 500mg bid

- high risk of diarrhea- not used too often

66
Q

Tx of IBD: 5- ASAs: balsalazide (colazal)

A

-better tolerated than sulfa one but high pills burden: 3, 750mg caps TID

67
Q

Tx of IBD: 5- ASAs: mesalamine

A
  • oral, rectal (Rowasa), supp (Canasa)

- do not use for crohns disease

68
Q

Immunomodulators : maintenance therapy (drugs)

A
  • 6-meracaptopurine
  • azathioprine
  • methotrexate
69
Q

immunomodulators ADR/monitoring

A
  • CBC at least every 3 months: bone marrow suppression possible
  • IFTs & pancreatic enzymes, hepatotoxicity
  • lymphomas- associated with AZA alone & in combo with Infliximab
70
Q

Corticosteroid use in IBD

A
  • works quickly to decrease inflammation

- Budesonide

71
Q

Budesonide entocort

A

-formulated to release in terminal ileum

72
Q

Budesonide ulceris

A

-formulated to release throughout colon (use in UC)

73
Q

Budesonide dosage

A

-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

74
Q

biologics to treat CD only

A
  • certolizumab

- natalizumab

75
Q

biologics to treat UC only

A
  • golimumab

- tofacitinib

76
Q

biologics to treat CD & UC

A
  • infliximab
  • adalimumab
  • vedolizumab
  • ustekinumab
77
Q

biologics acute infusion reaction & tx

A

-chest pain, cough, dyspnea, itching

TX: premedication with: 1000mg APAP, 50 mg IV/PO diphenhydramine +/- 50 mg iV hydrocortisone

78
Q

biologics delayed infusion reaction & tx

A
  • myalgias, arthralgias, fever, rash, itching, urticaria, headaches
    tx: may reside on its own or a short course of corticosteroids
79
Q

antibiotics used in IBD

A
  • best for perianal fistulas or fissures (CD)
  • metronidazole 500mg tid or 20 mg/kg/day
  • ciprofloxacin 400 mg IV or 500 mg PO bid
80
Q

Crohn’s Disease mild-moderate

A

-no symptoms really, have kept weight loss less than 10%

81
Q

Crohn’s Disease moderate-severe

A
  • failed mild-moderate therapies
  • may have fever present (>38C)
  • significant weight loss
  • abdominal pain
  • N/V w/ no obstructions
  • have anemia
82
Q

Crohn’s Disease severe- fulminant

A
  • 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
83
Q

Crohn’s Disease - active therapy for mild-moderate disease

A

1) po budesonide - 8 week course of therapy

2) IF theres colonic involvement: use 5-ASA –> sulfasalazine

84
Q

Crohn’s Disease - active therapy for moderate - severe disease

A

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

85
Q

Crohn’s Disease - active therapy for severe-fulminant

A

(has tried several biologic therapies)

  • needs surgery
  • IV steroids: hydrocortisone, methylprednisolone
  • for pts not improving use: Infliximab IV
  • should also give IV fluids
86
Q

Crohn’s Disease - active therapy for perianal disease

A
  • fistulas or fissures
  • metronitazole or cipro
  • -> fistulas can also use Infliximab
87
Q

Crohn’s Disease - maintenance therapy

A

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!

88
Q

Ulcerative colitis remission

A
  • asymptomatic- having formed stools
  • no blood in stool
  • normal hemoglobin
  • normal ESR & CRP
  • fecal calprotectin levels on the lower end
89
Q

Ulcerative colitis mild

A
  • < 4 stools/day
  • having intermittent blood in stool
  • normal hemoglobin
  • CRP is elevated & fecal calprotectin > 150
90
Q

Ulcerative colitis moderate- severe

A
  • > 6 stools/day
  • frequent blood in stools
  • hemoglobin < 75% of normal
  • ESR + CRP is elevated
  • FC > 150
91
Q

Ulcerative colitis fulminate

A
  • > 10 stools/day
  • continuous blood in stools, requiring blood transfusions
  • HgB < 8
  • ESR, CRP & FC is elevated
92
Q

Ulcerative colitis Active therapy: mild distal disease (left sided)

A

1) topical mesalamine preps
2) PO 5-ASA: used if ppl dont want rectal - combo PO + PR therapies
3) budesonide (Uceris)

93
Q

Ulcerative colitis active therapy: extensive mild disease (in transverse colon)

A

PO 5- ASA: consider adding budesonide in the form of uceris x 8 weeks

94
Q

Ulcerative colitis active therapy for moderate to severe

A
  • budesonide
  • presinosone: 40-60 mg PO
  • biologics: Infliximab (may be paired with 6-MP/AZA in IC)
95
Q

Ulcerative colitis active therapy for fulminant

A
  • IV steriods ASAP
  • IV Infliximab
  • IV cyclosporine
  • surgery
96
Q

Ulcerative colitis maintenance therapy for mild distal

A
  • topical 5- ASA (mesalamine)

- PO 5-ASA preps (sulfa?)

97
Q

Ulcerative colitis maintenance therapy for mild extensive disease

A

-oral 5- ASA (sulfasalazine)

98
Q

Ulcerative colitis maintenance therapy for moderate to fulminant

A
  • 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
99
Q

______ has a BBW warning against ______ which is caused by ______
(cautionary for ______)

A

1- natalizumab
2-PML
3- JC polyvirus
4- vedolizumab

100
Q

which drugs hold a BBW for infections & malignancy?

A
  • infliximab
  • adalimumab
  • golimumab
  • tofacitinib
  • certolizumab
  • natalizumab
101
Q

pros of azathioprine therapy

A
  • reduce antibody formation

- enhance the rate of biologics

102
Q

cons of azathioprine therapy

A
  • can be potassium sparing
  • can take 4 months to work
  • can cause lymphomas

GI/Skin Therapeutics (3 decks)

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