Exam 2 Spring 2025 Flashcards
Constipation, Diarrhea, Nausea, Vomiting, Indigestion
1
Q
Constipation is defined as having fewer than __________ bowel movements per week that is accompanied by straining and difficult passage of hard and dry stools.
A
3
2
Q
T or F: The normal bowel movements for all people is 1 time per day.
A
False. Normal varies depending on the person.
3
Q
What is the American Gastroenterology Association (AGA) definition of constipation?
A
Difficult or infrequent stool passage at time associated with straining or a feeling for incomplete defecation.
4
Q
Chronic constipation is defined as lasting longer than _________ months.
A
3
5
Q
T or F: Men are more likely to struggle with constipation.
A
False. Women are 3x more likely to experience constipation.
6
Q
T or F: Older adults are 5x more likely to experience constipation when compared to younger adults.
A
True
7
Q
__________ are the wavelike muscle contractions that move food through the digestive tract. It starts in the esophagus and continues through the large intestine.
A
Peristalsis
8
Q
What are 3 structural conditions that can lead to constipation?
A
-Colorectal/anorectal injury, inflammation, or damage
-Pelvic floor disorders
-Structural abnormalities leading to bowel obstruction (tumors, hernias, fistulas, etc)
9
Q
What are the 4 common systemic conditions that can lead to constipation?
A
-Thyroid disorders
- Diabetes
- IBS
- Postsurgical
10
Q
What are the 3 pyshcological conditions that can lead to constipation?
A
Depression, eating disorders, and situational stress
11
Q
What are the 4 common prescription medications that can cause constipation?
A
Anticholinergics, antihistamines, calcium channel blockers (verapamil), and opiates
12
Q
What are the 3 common OTC medications that can cause constipation?
A
- Antacids with aluminum and calcium
- Calcium supplements
- Iron supplements
13
Q
What are common issues that can arise from longstanding or untreated constipation?
A
Hemorrhoids, anal fissures, rectal prolapse, fecal impaction, and rectal ulcers
14
Q
T or F: Straining to poop while constipated can lead to blood pressure surges or precipitate cardiac rhythm disturbances.
A
True. Think elvis
15
Q
What are common symptoms associated with constipation?
A
Anorexia, dull headache, lassitude (tired), low back pain, bloating, farting, stress
16
Q
T or F: Straining has no connection to hemorrhoids.
A
False. Straining can lead to hemorrhoids
17
Q
The cut-off age for self-care for constipation is _______ years old.
A
2 years old
18
Q
What are the big exclusions for self-care when it comes to constipation?
A
- Severe abdominal pain or distention or cramping
- Intense flatulence
- fever, nausea, or vomiting
- Chronic medical conditions (paralyzed, IBS, UC, etc)
- Unexplained changes in bowel habits especially if accompanied by weight loss
- blood in stool or dark and tarry stool
- Change in the characteristics of the poop
- Bowel symptoms lasting longer than 2 weeks or recurring over a period of at least 3 months
- inflammatory bowel disease
- anorexia
-younger than 2 years old
19
Q
T or F: Someone with IBD presents with constipation. They are a candidate for self-treatment.
A
False. Inflammatory bowel disease is an exclusion for self-treatment for constipation
20
Q
If constipation lasts longer than ______ weeks or recurs over a period of _______ months, this person needs to be referred.
A
2 weeks
3 months
21
Q
What is black stool called?
A
Melena and it means there is likely bleeding in the stomach or esophagus
22
Q
What are the 3 goals of treatment for constipation?
A
- Relieve constipation
- Prevent recurrence
- Promote safe and effective use of laxatives
23
Q
What are some non-pharmacological recommendations for constipation?
A
Increasing water, fiber, and exercise
24
Q
T or F: Fiber intake should gradually increase over 1-2 weeks.
A
True. Too much fiber too quickly can lead to erratic bowel movements and abdominal discomfort
25
The adult daily fiber intake is ______ grams per 1000 calories.
14 grams
26
What is the daily fiber goal for women?
25 grams
27
What is the daily fiber goal for men?
38 grams
28
What is fiber?
Fiber is a carbohydrate found in plant-based food that the body cannot fully digest.
29
How does fiber help with constipation?
Fiber increases the mass of stool and normalizes the frequency of bowel movements.
30
What is the difference between soluble and insoluble fiber?
Soluble fiber dissolves in water and lowers cholesterol and blood sugar. Insoluble fiber does not dissolve in water and promotes laxation.
31
What are the 3 FDA approved bulk-forming laxatives (insoluble fiber)?
Methylcellulose (Citrucel)
Calcium polycarbophil (FiberCon)
Psyllium (Metamucil/ Konsyl)
32
If a patient is constipated, make sure they are drinking _______ ounce of water ______ times per day.
8 ounces
8 times per day
33
What is the brand name for the bulk-forming agent Methylcellulose?
Citrucel
34
What is the brand name for calcium polycarbophil?
FiberCon
35
What is the brand name for the bulk-forming agent Psyllium?
Metamucil or Konsyl
36
What are supplements that are not FDA as bulk-forming agents but are still sources of fiber?
Inulin, partially hydrolyzed guar gum, powdered cellulose, and wheat dextrin
37
What are the 6 different classes of agents for constipation available OTC?
- Bulk-forming agents
- hyperosmotic agents
- emollients (stool softeners)
- lubricants
- saline laxatives
- stimulants
38
What is the MOA for bulk-forming agents?
They mimic the body's physiological process and provide bulk and absorb water to promote peristalsis and reduce poop transit time.
39
The onset of action for bulk-forming agents is _______-______ hours and can take up to _____ hours to work.
12-24 hours
72 hours
40
What are the 3 common adverse effects seen with bulk-forming agents?
Abdominal cramping, flatulence, and distention
41
What is the main counselling point for bulk-forming agents?
Take these with lots of fluid! 8 ounces 8x per day
42
What are the two precautions for bulk-forming agents?
Those who have difficulty swallowing and those on fluid restricted diets
43
Do bulk-forming agents interact with any other medications?
They can interact with medications so separate dosing by 2 hours.
44
T or F: All the daily fiber content a person needs is present in the normal serving of bulk-forming agents.
False. Fiber will still need to be present in the diet to meet the daily goals for males and females.
45
What is the dosage form and dosing for the bulk-forming agent calcium polycarbophil (FiberCon)?
It comes in a 625 mg caplet
Dosing is 2 caplets 1-4x per day
46
What is the dosing for methylcellulose (Citrucel)?
For the powder, it is 1 rounded tablespoon up to 3x per day
47
What is the dosing for psyllium (Metamucil)?
1 rounded teaspoons in 8 ounces of liquid up to 3x per day
48
What are the two hyperosmotic agent available OTC for constipation?
Polyethylene glycol 3350 (PEG)
Glycerin
49
What is the MOA of hyperosmotic agents like Polyethylene glycol 3350 (PEG) and glycerin?
Polyethylene glycol 3350 (PEG) produces an osmotic solution the draws water into the colon or rectum to soften the stool and increase peristaltic activity.
50
The hyperosmotic agents like PEG is often use before a ___________.
Colonoscopy
51
Polyethylene glycol 3350 (PEG) takes about ________-______ hours or up to ______ hours to work.
12-72 hours
96 hours
52
The hyperosmotic agent Polyethylene glycol 3350 (PEG) can only be used in those _______ years and older?
17 years
53
What is the dosing for Polyethylene glycol 3350 (PEG)?
Use the cap which is 17g/ capful. Can use 17 g cap in 4-8 ounces of water 1 time per day.
54
What are the common adverse effects associated with Polyethylene glycol 3350 (PEG)?
Bloating, abdominal discomfort, cramping, flatulence
55
T or F: Only water can be mixed with Polyethylene glycol 3350 (PEG).
False. It can be mixed with really any liquid
56
Glycerin is used as a __________ in children experiencing constipation.
Suppository
57
What is the onset of action for glycerin?
15-30 minutes. It provides quick relief.
58
What is the active ingredient in emollients, also known as stool softeners?
Docusate sodium
59
What is the MOA for emollients (stool softeners)?
Emollients are anionic surfactants that increase wetting efficacy and facilitate a mixture of aqueous and fatty substances to soften the turd mass.
60
T or F: Emollients (stool softeners) promote peristalsis.
False. This class of medications do not promote peristalsis. It is all mush with no push needed.
61
What is the onset of action for docusate sodium (emollient)?
12-72 hours but can take up to 3-5 days
62
What is the dosing for docusate sodium in those 12 years and up?
50-300 mg in single or divided doses daily
(50 mg or 100 mg capsules)
63
What is the brand name for docusate sodium?
Dulcolax or Colace
64
What is the dosing for docusate sodium in those between 2 and 12 years old?
50-150 mg in single or divided doses daily
65
What adverse effects are associated with docusate sodium?
Well tolerated drug with no reported adverse effects
66
What is the one lubricant that can be used for constipation?
Mineral oil
67
What is the MOA of the lubricant mineral oil?
It softens fecal content by coating stool and preventing colonic absorption of fecal water.
68
T or F: The lubricant mineral oil is only available as a suppository.
False. Mineral oil is available in both a suppository and a liquid to swallow. Overall, the utility for mineral oil is questionable.
69
What is the onset of action for oral mineral oil?
6-8 hours
70
What is the onset of action for a mineral oil suppository?
5-15 minutes
71
What are some safety issues surrounding the use of the oral lubricant mineral oil?
Aspiration of mineral oil can cause lipid pneumonia and warning for use in pregnant people, immobile/older adults, children under 6 years, and those with difficulty swallowing
72
In general, lubricants like mineral oil, are generally ___________ for the treatment of constipation.
Avoided. This is due to the fact that it impairs absorption of fat-soluble vitamins and can cause leakage issues.
73
What are the typical ingredients seen in saline laxatives?
It could be magnesium citrate, magnesium hydroxide, dibasic/monobasic sodium phosphate, or magnesium sulfate.
74
Which saline laxative brand contains magnesium hydroxide?
Phillips' Milk of Magnesia and Dulcolax
75
Which saline laxative brand contains sodium phosphate?
Fleet
76
Which saline laxative brand contains magnesium citrate?
Honestly there is really no brand name. It typically just comes in a generic bottle that says magnesium citrate on it.
77
What is the MOA of saline laxatives?
They draw water into the intestine and colon via osmosis therefore increasing intraluminal pressure and promoting GI motility.
78
Typically, when are saline laxatives like magnesium citrate, etc, used?
Typically used adjunctly for acute bowel evacuation for bowel prep
79
What is the onset of action for oral saline laxatives?
30 minutes- 3 hours
80
What is the onset of action for suppository saline laxatives?
2-15 minutes
81
What are the common adverse effects associated with saline laxative use?
Abdominal cramping, nausea, vomiting, and dehydration
82
What is a key counseling point when discussing saline laxaatives?
Follow oral doses with 8 ounces of water to prevent dehydration
83
What is a precaution for saline laxatives?
They can cause electrolyte imbalances
84
What are specific contraindications and precautions associated specifically with the saline laxative, sodium phosphate?
- do not use for bowel preps
- do not exceed 1 dose in 24 hours
- Avoid in those 55 +, renal impairment, or congestive HF
85
What is the dosing for the saline laxative, magnesium citrate, for those 12 years and older?
1/2-1 bottle as directed
86
What are the two stimulant OTC products used for constipation?
Bisacodyl (Diphenylmethanes)
Senna (Anthraquinones)
87
What is the MOA for stimulants used for constipation?
They increase intestinal motility in colon by local mucosal irritation and promote peristalsis. They act on the intramural nerve plexus of intestinal smooth muscle and increase secretion of water and electrolytes in the intestines.
88
What is the onset of action for stimulants like Bisacodyl?
6-10 hours and can take up to 24 hours
89
What are common adverse effects associated with stimulants for constipation like bisacodyl and senna?
Abdominal cramping, nausea, vomiting, diarrhea
90
What are key counseling points for stimulants for constipation?
-Senna may discolor urine pink to red
- Senna may cause reversible melanotic pigmentation of the clonic mucosas
- enteric coated bisacodyl prevent irritation of gastric mucosa
91
What 4 medications/products interact with OTC stimulants for constipation?
Antacids, H2RAs, PPIs, and some milk products
Separate dosing by 1 hour
92
What is the dosage form and dosing for the stimulant, Senna?
Tablet of 8.6 mg
Start with 2 tablets daily
Max dose of 4 tablets BID
93
What is the dosage form and dosing for the stimulant, Bisacodyl?
Tablet of 5 mg
1-3 tablets once daily
94
_______% of patients taking opioids experience constipation.
40%
95
T or F: Patients taking opioids develop a tolerance after a period of time to the opioids and no longer experience the constipation.
False. Tolerance is not acquired with opioids in terms of constipation. It requires a long-term laxative regimen with first-line being stimulant laxatives (Senna, Bisacodyl) or PEG 3350.
96
T or F: Stool softeners alone are enough to treatment opioid-induced constipation.
False. Stool softeners like docusate sodium are not enough.
97
For the OTC treatment of constipation, what is the product selection order?
1. Bulk-forming agents (fibers)
2. PEG 3350
3. Stimulants (if both ineffective)
Obviously non-pharm as well
98
Patients who fail to achieve a therapeutic response after ________ days on self-treatment for constipation require a medical referral.
7 days
99
For pregnancy and breastfeeding, what are the 4 different products that are safe to use for constipation?
Bulk-forming agents, docusate (stool softener), short-term use of stimulants (senna, bisacodyl), and PEG 3350
100
For children between the ages of 2-6, what are the appropriate treatments for constipation?
1. Oral docusate sodium (stool softener) or magnesium hydroxide (saline laxative)
2. Rectal glycerin suppository
101
For children between the ages of 6-12, what are the appropriate treatments for constipation?
1. Oral bulk-forming agents, docusate sodium (stool softener) or magnesium hydroxide (saline laxative)
2. Rectal glycerin or bisacodyl suppositiories
102
___________ and _______ are the first-line choices for constipation in adults.
Bulk-forming agents and PEG 3350
103
Diarrhea is defined as more than ______ bowel movements with loose stool in 24 hours.
3
104
What are other symptoms associated with diarrhea?
Nausea, bloating, abdominal cramps, pain
105
Persistent (14 days-4 weeks) and chronic diarrhea (more than 4 months) is often caused by what?
Comorbid conditions or medical conditions
106
Diarrhea will typically improve within _____-_____ hours.
24-48
107
If diarrhea lasts longer than ________ hours, refer to PCP.
48 hours
108
Diarrhea is categorized as acute if it lasts shorter than ________ days.
14 days
109
Diarrhea is most common in what population?
Those under 5 years old
110
Diarrhea can be infectious or noninfectious. It can also be inflammatory (dysentery) or noninflammatory. What is often the cause and description of inflammatory diarrhea?
It is often caused by invasive or toxin-producing pathogens. Blood or mucus will be present in the stool. Needs to be referred.
111
Diarrhea can be infectious or noninfectious. It can also be inflammatory (dysentery) or noninflammatory. What is often the cause and description of noninflammatory diarrhea?
It is often caused by decreased water reabsorption and the diarrhea is typically vert watery.
112
What are two viruses that are often responsible for infectious diarrhea?
Rotavirus and Norovirus (24 hour stomach bug)
113
T or F: No vaccine is available for rotavirus.
False. There is a vaccine available for rotavirus for children
114
What are the three bacteria that are often responsible for infectious diarrhea?
Salmonella, E. Coli, and C.dif
115
C.Dif is often described as _________ associated diarrhea.
Antibiotic
116
What is 1 common protozoa that is often responsible for infectious diarrhea?
Giardia Intestinalis. This is treated with antimicrobial therapy
117
What prescription medications often cause diarrhea?
Antibiotics, chemotherapy agents, cholinergic agents, metformin, and SSRIs
118
What OTC medications often cause diarrhea?
Laxatives, magnesium, orlistat, and PPIs
119
T or F: Traveler's diarrhea is not contagious.
False. Traveler's diarrhea is very contagious.
120
Traveler's diarrhea effects up to ____% of travelers and can to effect up to _____ days after exposure.
70%
10 days
121
Traveler's diarrhea typically subsides in 3-7 days. However, _______ and _________ may be used as prophylaxis and treatment.
Antibiotics and Antidiarrheals
122
What are the many exclusions for self-treatment for diarrhea?
- Younger than 6 months
- **persistent fever greater than 102.2 (little lower than normal)**
- Blood, pus, or mucus in stool
- high output of poop
- persistent vomiting
- signs of severe dehydration (no tears, no urination, hypotension, etc)
- Severe abdominal pain
- **Pregnancy**
- Chronic or persistent diarrhea
- No response to oral replacement solutions that have been given
- Risk for significant complications
Bolded are ones I keep forgetting
123
If a person has lost more than ______% of their body weight from diarrhea, they need to be referred ASAP.
10%
124
If a person has only lost less than ______% of their body weight from diarrhea they can be treated OTC with oral replacement solutions.
9%
125
What is really the only non-pharmacological option for diarrhea?
Oral rehydration solutions (ORS) to prevent dehydration and electrolyte loss
126
In order for a 'beverage' to be considered an ORS, it must meet specific _______ and _______ concentrations.
Electrolyte and carbohydrate
127
T or F: Oral replacements solutions are not as effective as IV replacement therapy.
False. They are equally as effective in preventing dehydration and electrolyte loss.
128
There are two phases when using oral rehydration solutions. This includes the _______ phase and ________ phase.
Rehydration phase
Maintenance phase
129
What is occuring in the rehydration phase with oral replacement solutions?
Rehydration over 3-4 hours with 70-90 mEq/L of sodium (1,600-2,000 mg of sodium)
130
What is occuring in the maintenance phase with oral replacement solutions?
45-50 mEq/L of sodium after the first 3-4 hours (another 1,000-1,150 mg of sodium)
131
What are the 3 approved oral rehydration solutions?
Hydralyte, Pedialyte, and Enfamil
132
T or F: Excessive carbohydrates from gatorade or soda drinks can increase diarrhea.
True. Try to avoid 'at-home' rehydration
133
What is the BRAT diet? Is it recommended?
The BRAT diet is a diet including bananas, apple sauce, rice, and toast. It provides insufficient calories, protein, and fat and is therefore not recommended during diarrhea.
134
What are some foods to avoid during episodes of diarrhea?
Fatty foods, foods rich in simple sugars, spicy foods, and caffeine containing things.
135
What is the MOA of loperamide (Imodium AD)?
It is an opioid agonist that reduces peristalsis and slows intestinal motility. It reduces fecal volume, increases bulk, and diminishes fluid and electrolyte loss.
136
What is the brand name for Loperamide?
Imodium AD
137
Loperamide is only approved for use in those _______ years and older.
6 years
138
What is the dosing for Loperamide?
4 mg initially followed by 2 mg after each loose stool. The maximum is 8 mg per day
139
What is the maximum amount of time that loperamide should be used?
48 hours
140
What is the actual indication for use for loperamide?
Acute noninfectious diarrhea with no fever. It can also be used for traveler's diarrhea and chronic diarrhea associated with IBS and IBD
141
What is the pediatric dosing for loperamide?
2 mg initially followed by 1 mg after each loose stool
142
What are the 2 common adverse effects associated with loperamide?
Dizziness and constipation
143
What is a precaution associated with loperamide use?
It has a potential to be abused as at very high doses it can act on CNS mu opioid receptors to include euphoria.
144
What are the 2 boxed warnings associated with loperamide?
Torsades de pointes and sudden death
145
P-glycoprotein inhibitors as well as ______ and _______ inhibitors can increase the concentration of loperamide.
CYP3A4 and CYP2C8
146
T or F: Loperamide can be used in those with bacterial diarrhea and those with C.diff.
False. Do not use in these patients can cause toxic megacolon.
147
What are the 3 bismuth subsalicylate products available OTC for diarrhea?
Kaopectate, Maalox, and Pepto-Bismol
148
What is the MOA for bismuth subsalicylate products?
The salicylate moiety has antisecretory effects and the bismuth exerts antimicrobial effects for bacterial and viral GI pathogens.
149
Bismuth subsalicylate products like Kaopectate, Maalox, and Pepto-Bismol are not to be used in those under _________ years of age.
12 years
150
What is the dosing for bismuth subsalicylate products?
525 mg every 30-60 minutes PRN with maximum of 8 doses per day (4,200 mg)
151
What are the indications for use for bismuth subsalicylate products like Kaopectate, Maalox, and Pepto-Bismol?
Acute non-infectious diarrhea with no fever. Additional uses include indigestion, traveler's diarrhea, and H-pylori associated PUD.
152
What are 4 common adverse effects associated with bismuth subsalicylate products like Kaopectate, Maalox, and Pepto-Bismol?
Black stools and tongue, constipation, and tinnitus
153
What is the main counselling point for bismuth subsalicylate products like Kaopectate, Maalox, and Pepto-Bismol?
Brush your teeth after taking this medication and drink lots of water
154
What are the precautions associated with bismuth subsalicylate products like Kaopectate, Maalox, and Pepto-Bismol?
Reye's syndrome. Do not give within 6 weeks of a viral infection.
155
What are the drug interactions with bismuth subsalicylate?
Salicylate interacts with lots of things while bismuth not as much. Seperate the dosing of medications by at least 2 hours.
156
What is the brand name for the probiotic supplement containing Bifidobacterium?
Align
157
What is the brand name for the probiotic supplement containing Lactobacillus?
Culturelle
158
T or F: Probiotics may reduce the severity and duration of diarrhea symptoms.
True
159
What is nausea defined as?
Feeling a need to vomit
160
What are the 4 different causes of nausea and vomiting?
- Motion sickness
- Morning sickness
- Acute viral gastroenteritis
- Upset stomach from either overeating or indigestion
161
What are the many exclusions for the self-treatment of nausea and vomiting?
- High blood glucose levels
- Suspected food poisoning
- Severe abdominal pain or right upper quadrant pain
- Fever or diarrhea present
- Blood in vomit
- Yellow skin or eyes
- Stick neck with/without headache
- **Pregnancy and breastfeeding**
- Chemotherapy
- Drug-induced nausea and vomiting
- Psychogenic nausea and vomiting (bulimia)
- Chronic-disease induced nausea and vomiting
Bolded are the ones I keep forgetting
162
What is the first-line treatment for nausea and vomiting?
Oral rehydration solutions
163
For minimal dehydration in children greater than 10 kg (22 lbs), how much rehydration do they need per N/V episode?
120-240 mL per episode
164
For minimal dehydration in children less than 10 kg (22 lbs), how much rehydration do they need per N/V episode?
60-120 mL per episode
165
For mild-moderate dehydration in all children, how much rehydration do they need per N/V episode?
50-100 mL/kg over 3-4 hours
166
For mild-moderate dehydration in adults, how much rehydration do they need per N/V episode?
2-4 Liters over 3-4 hours
167
What is the utility of antihistamines in terms of nausea and vomiting?
Antihistamines can prevent nausea, vomiting, and dizziness associated with motion sickness.
168
What is the MOA of first-generation antihistamines?
They inhibit H1 receptors in the CNS mainly
169
What are the 4 different antihistamines that are commonly used for N/V associated with motion sickness?
Dimenhydrinate
Diphenhydramine
Meclizine
Doxylamine
170
What is the dosing for Meclizine?
25-50 mg before travel in those 12 years and older
171
What is the pregnancy dosing for doxylamine?
10-12.5 mg every 8 hours
172
What is the dosing for dimenhydrinate?
50-100 mg Q4-6H in those 12 years and older. Maximum 400 mg/day
173
Which antihistamine can be used in those 2-6 years?
Dimenhydrinate (12.5-25 mg Q6-8H max 75mg). Diphenhydramine can be used in those 6+ while meclizine and doxylamine are only used in those 12+.
174
Which antihistamine can be used for nausea in pregnancy?
Doxylamine (10-12.5 mg Q8H)
175
What is phosphorate carbohydrate solution and what is it used for?
This is a solution that contains dextrose, levulose, and phosphoric acid. It can be used for nausea associated with overeating.
176
What is the suspected MOA of phosphorate carbohydrate solutions?
It is believed to relieve nausea and vomiting by decreasing smooth muscle contraction and delay gastric emptying.
177
What are the adverse effects associated with antihistamines?
Dry mouth, confusion, dizziness, constipation, drowsiness (anticholingeric effects)
178
How soon before a nausea triggering event should antihistamines be administered?
60 minutes before event
179
What is a supplement that can be used during pregnancy to reduce episodes of nausea and vomiting?
Vitamin B6
180
A supplement that may aid in nausea and vomiting is _________.
Ginger
181
Frequent heartburn occurs ______ or more times per week.
2
182
GERD is defined as what?
Heartburn that is frequent and persistent
183
GERD often last __________ or more months.
3
184
What are 4 common things that can exacerbate heartburn?
spicy foods, poor lifestyle, medications, and health conditions
185
What are common food that can increase heartburn?
Fatty foods, garlic, onion, spicy foods, peppermint, chocolate, caffeine, citrus, tomatoes, and alcohol.
186
Foods like coffee, spicy foods, and tomato juice are actually __________ __________ of the esophagus.
Direct irritants. All the other just lower the pressure of the lower esophageal sphincter
187
What 4 medications are direct irritants and can precipitate heartburn?
Bisphosphonates, chemotherapy, NSAIDs (aspirin too)l and potassium chloride.
188
What are common medications that increase heartburn by relaxing the lower esophageal sphincter?
Anticholinergics, barbs and benzos, CCBs, dopamine, hormones, opioids, nitrates, theophylline, TCAs, and zidovudine
189
What are 4 health conditions that can exacerbate heartburn?
Hiatal hernia
Scleroderma
Motility disorders like gastroparesis
Zollinger-Ellison Syndrone
190
What is the typical clinical presentation of heartburn?
Burning chest pain beginning at the breastbone and moving up to the throat. Can also feel like food or acid is coming up into the back of the throat or mouth.
191
What are the alarm symptoms associated with heartburn that should signal an immediate referral to the PCP?
1. Dysphagia
2. Odynophagia (painful swallowing)
3. Chest pain
4. Upper GI bleeds
5. Persistent N/V, diarrhea
192
What are the exclusions for self-treatment for heartburn?
- Lasted longer than 3 months
- Severe or nocturnal heartburn
- Chronic hoarseness, wheezing, coughing
- 2 years and younger
- Unexplained weight loss
- Heartburn continuing after TX
- Heartburn that occurs when taking RX H2RAs or PPIs
- Any symptom alarm signs
193
Those ______ years and younger cannot be treated OTC for heartburn.
2
194
T or F: Pregnant and breastfeeding individuals cannot be treated for heartburn OTC.
False
195
What are some evidence based non-pharmacological options for heartburn?
GERD pillow, reduce alcohol intake, limit triggering foods and beverages, lose weight, stop smoking, do not eat 3 hours before bedtime. Can also maybe eat smaller meals, reduce stress, eat slower, etc.
196
What are the different antacids options for heartburn?
Calcium carbonate
Sodium Bicarbonate
Aluminum hydroxide
magnesium hydroxide
197
What are the proton pump inhibitors that are OTC for heartburn?
Omeprazole, Esomeprazole, lansoprazole
198
What are the histamine-2 receptor antagonists available OTC for heartburn?
Famotidine and Cimetidine
199
What is the MOA of antacids for heartburn?
Antacids neutralize gastric pH
200
What is the onset of action for antacids?
Less than 5 minutes
201
Antacids should not be used in those _______ years and younger. However, there are children TUMS available that can be used for those between the ages of 2-11.
12
202
T or F: Antacids are only to be used to relieve episodic and infrequent symptoms related to heartburn.
True
203
Antacids can be taken multiple times a day, but are only indicated for use for up to ______ weeks.
2
204
What are the adverse effects associated with antacid use?
Diarrhea (magnesium one), constipation (calcium followed by aluminium), electrolyte disturbances, and metabolic alkalosis
205
What is an anal abscess?
This is a collection of pus causing obstruction of anal glands often resulting in a bacterial infection. May result on sepsis if not caught early.
206
What is an anal fistula/groove?
This is an abnormal internal opening that connects with an external opening. It basically connects areas that should not be connected. Surgical repair is required.
207
What is an anal fissure?
This is a slit-like ulcer in the anal canal that results from a trauma tear during passage of a large stool or explosive diarrhea.
208
What is an anal neoplasm?
Abnormal growth of tissue in and around the anus that can bening or cancerous.
209
What is the dentate line?
This is a line in the body that divides external and internal hemorrhoids.
210
T or F: Hemorrhoids above the dentate line are very painful while those below the dentate line are painless.
False. Hemorrhoids above the dentate line are typically painless while those below are painful.
211
What is a hemorrhoid?
Hemorrhoids are conglomerations of inflamed and swollen blood vessels and tissue that project into the bowel lumen during defecation.
212
What are the general characteristics of an internal hemorrhoid?
Above the dentate line, painless, and typically blood is present. If there is only a small amount of blood in stool and patient is being treated by the doctor, can technically treat them OTC.
213
A person can use _______ days worth of OTC treatment for hemorrhoids before they need to be referred to a provider.
7 days
214
What are the 7 exclusions for self-treatment for OTC hemorrhoid treatment?
1. Less than 12 years
2. GI disease diagnosis
3. Family history of colon cancer
4. Presence of abscesses, fistulas, fissures, malignancy
5. Anorectic signs and symptoms with severe pain, bleeding, seepage, prolapse, thrombosis, or black tarry stool
6. Does not respond to TX in 7 days
215
What are common non-pharmacological options to help prevent hemorrhoids?
Avoid lifting heavy objects and foods that aggravate symptoms like alcohol, caffeine, citrus, and fatty foods. Increase water and fiber intake, limit time on toilet to 3-5 minutes, don't ignore urge to poop. avoid straining, avoid excess wiping, and consider a warm sitz bath 2-4x per day for 10-15 minutes.
216
Which product is only used for external hemorrhoid application?
Local anesthetics like benzocaine, lidocaine, or pramoxine.
217
What is the brand name for the external application only of the topical anesthetic lidocaine?
Preparation H
218
What type of hemorrhoid products are preferred in pregnancy?
External products only like topical anesthetics and/or protectants like glycerin.
219
What are the 7 product types that can be used for hemorrhoids?
- Local anesthetics (benzocaine, lidocaine, pramoxine)
- Vasoconstrictors (Phenylephrine, epinephrine, etc)
- Protectants (glycerin, cocoa butter, mineral oil, petrolatum, zinc oxide)
- Astringents (calamine, zinc oxide, witch hazel)
- Keratolytics
- Analgesics, anesthetics, and antipruritics (Menthol and camphor)
- Corticosteroids (hydrocortisone)
220
Should witch hazel (astringent) be applied internally or externally?
Externally only for witch hazel.
221
What are the 3 categories of hemorrhoid products that are approved for intrarectal use (internal use)?
Vasoconstrictors like phenylephrine
Protectants (NOT glycerin)
Astringents (NOT witch hazel)
222
Hemorrhoid cream vasoconstrictors should be avoided in what 5 medical conditions?
Diabetes, HTN, thyroid disease, enlarged prostate, and cardiac diseases
223
What is the mainstay therapy for nausea, vomiting, and diarrhea?
Oral rehydration solutions
224
What two medications may help on acute diarrhea?
Loperamide or bismuth subsalicylate
225
What are the 4 classes of heartburn medications?
- Antacids
- H2RAs
- PPIs
- Miscellaneous (Bismuth subsalicylate and alginic acid)
226
What is the duration of relief seen with antacids?
1-2 hours and can be up to 3 hours if taken with food.
227
For what duration of time can antacids be used for?
Up to 2 weeks of use. Antacids can be used multiple times per day.
228
T or F: Antacids for children (2-11 years) do not exist.
False. Children's pepto contains 400mg of calcium carbonate and Tums Kids contains 750mg of calcium carbonate.
229
Antacids should only be used for __________ heartburn.
Infrequent (less than 2 times per week)
230
What are the common adverse effects seen with antacids?
Dose-related diarrhea (magnesium antacid), dose-related constipation (calcium more than aluminum antacid), electrolyte disturbances, and metabolic acidosis.
231
Dose-related diarrhea as an adverse effect is mainly seen with _____________ containing antacids.
Magnesium
232
Dose-related constipation as an adverse effect is mainly seen with _____________ and ___________ containing antacids.
Calcium > aluminum
233
Electrolyte disturbances as an adverse effect on seen in those with renal dysfunction mainly with ________ and _________ containing antacids.
Aluminum and Magnesium. Avoid use of these in those with renal dysfunction.
234
Antacids products containing ________ _________ have high sodium content and should be avoided in what types of patients?
Sodium bicarbonate
Fluid overload pts with congestive heart failure, renal failure, and/or cirrhosis
235
Metabolic alkalosis as an adverse effect can be seen mainly with __________ _________ containing antacids.
Sodium bicarbonate
236
T or F: Antacids have no drug interactions.
False. Antacids inhibit the absorption of other drugs indirectly through increasing pH and directly by binding medications.
237
What 3 medications are not absorbed due to increased pH with antacids?
Intraconazole, ketoconazole, and iron
Take 2 hours apart
238
What 3 classes of medications are not absorbed due to antacids binding them?
Tetracyclines. azithromycin, and fluoroquinolones
Take 2 hours apart
239
What is the brand name of the antacid that contains magnesium hydroxide?
Phillips Milk of Magnesia Original
240
What is the dosing for Phillips Milk of Magnesia Original Antacid (Magnesium Hydroxide)?
1-3 tsp Q4H
(5ml= 1tsp= 400mg mag hydroxide)
241
What is the brand name for the antacid medication that contains calcium carbonate and magnesium hydroxide?
Rolaids Antacids
242
What is the dosing for Rolaids Antacids (calcium carbonate and magnesium hydroxide)?
Chew 2-4 tablets every hour PRN (max 12 tablets)
243
What is the maximum amount of tablets that can be taken per day for Rolaids Antacids?
12 tablets
244
What is the brand name for the antacid that solely contains calcium carbonate?
Tums, Alka-Mints, and Maalox (quick dissolve regular strength tablet)
245
What is the dosing for Tums?
Chew 2-4 tablets PRN
Max 10 tablets for extra strength (750mg) and max 15 tablets for regular strength (500mg)
246
What is the brand name for the antacid that contains aluminum hydroxide, magnesium hydroxide, and simethicone?
Maalox
247
What is the dosing for Maalox with only calcium carbonate in it?
Chew 1-2 tablets per symptoms maximum 12 tablets
248
What is the dosing for Maalox that contains magnesium hydroxide, aluminum hydroxide, and simethicone?
2-4 tsp QID (max 12 tsps)
5ml= 1tsp=200mg of aluminum, 200mg of magnesium, and 20 mg of simethicone
249
What is the dosing for Alka-Mints?
Chew 1-2 tablets Q2H PRN maximum 9 tablets
250
What is the MOA for Histamine 2 Receptor Antagonists?
They block histamine 2 receptors on the parietal cells in the stomach therefore decreasing acid secretion.
251
What is the onset of action of H2RAs?
30-45 minutes
252
What is the duration of relief for H2RAs?
6-12 hours
253
What is the indication for use for H2RAs?
- Treatment of mild-moderate, infrequent, or episodic heartburn
- Prevention of heartburn associated with indigestion
- Postprandial heartburn (+ antacid)
254
H2RAs can also be used to prevent heartburn. How long before meals should they be taken for this to work?
30-60 minutes before a meal
255
For postprandial heartburn, H2RAs should be paired with an_______________.
Antacid
256
H2RAs can not be used in those under ________ years old.
12 years old
257
Dosing for H2RAs is up to ________ per day for up to ______ weeks.
2/day
2 weeks
258
T or F: Tachyphylaxis does not occur with H2RAs.
False. Tachyphylaxis can occur if these medications are used daily
259
What duration of time can H2RAs be used as OTC TX?
2 weeks
260
Even though H2RAs are fairly well tolerated, what are the some common adverse effects that are reported?
Headache, diarrhea, constipation, dizziness, and drowsiness
261
Which H2RA is never used as it has many drug interactions?
Cemetidine
262
What is unique about cemetidine?
It has weak anti-androgenic effects leading to decreased libido, impotence, and gynecomastia. It also inhibits CYP enzymes 3A4, 2D6, 1A2, and 2C9 therefore increasing concentrations of drugs metabolized by those enzymes like phenytoin, warfarin, theophylline, and more.
263
How do H2RAs like famotidine interact with other medications?
They indirectly inhibit absorption of medications that need a low pH like intraconazole, ketoconazole, and iron. Famotidine also can inhibit CYP enzymes at high doses (not at OTC doses though).
264
What is the brand name for the H2RA cimetidine (even though we do not use it)?
Tagament HB
265
What is the brand name for Famotidine?
Pepcid
266
What is the typical dosing for Pepcid (Famotidine)?
10-20 mg with a glass of water (max 2 tablets per day)
There is also a chewable tablet and you just chew and swallow 1 tablet maximum 2 tablet
267
What is the maximum dosing for Pepcid (Famotidine)?
Can be dosed twice per day so the total is maximum 2 tablets
268
What is the MOA of Proton Pump Inhibitors (PPIs)?
They irreversibly inhibit the H+/K+ ATPase pump therefore decreasing acid secretion into the stomach.
269
What is the onset of action for PPIs?
2-3 hours
270
When should all PPIs be taken?
30-60 minutes before a meal as it only works on ACTIVE proton pumps in the stomach.
271
How long does it take for the full effect of PPIs?
1-4 days
272
What is the duration of relief for PPIs?
24 hours
273
What is the indication for use of PPIs?
Treatment of frequent heartburn in patients who have symptoms 2 or more days per week. It is not for immediate relief as it takes time to exert its full effects.
274
PPIs can not be used in those younger than __________ years old.
18 years old
275
T or F: PPIs are a type of heartburn medication that is used for immediate heartburn relief.
False. This medication is not for immediate relief. It is for those with heartburn symptoms 2 or more times per week.
276
What is the OTC dosing for PPIs?
Take once per day 30-60 minutes before first meal for up to 2 weeks. If heartburn persists after 2 weeks, refer to PCP.
277
A course of PPIs (2 weeks) can be repeated every ________ months if the heartburn returns.
4 months
If it returns sooner than 4 months after using a course of PPIs, patient must be referred.
278
What are the common adverse effects seen with PPIs?
Headache, diarrhea, and constipation
279
What are adverse effects associated with long term use of PPIs?
Hip fractures, C.diff, and pneumonia
280
PPIs inhibit what CYP enzyme?
CYP2C19. Clinically significant interactions are not common though.
281
PPIs indirectly increase stomach pH by blocking proton release into the stomach. How does this effect certain medications?
It inhibits absorption of medications that need an acidic environment like intraconazole, ketoconazole, and iron.
282
T of F: Omeprazole (PPI) can inhibit the activation of clopidogrel.
True. Clopidogrel is a prodrug that needs to be metabolized into its active form. This conversion may be blocked when used in combination with omeprazole.
283
What is the brand name for the PPI omeprazole?
Prilosec OTC
284
What is the brand name for the PPI esomoprazole?
Nexium
285
What is the brand name for the PPI Lansoprazole?
Prevacid 24HR
286
What is the brand name for Omeprazole and sodium bicarbonate combination?
Zegerid
287
What is the amount of omeprazole in a dose of Prilosec OTC?
20 mg
288
What is the amount of esomeprazole in a dose of Nexium?
20 mg
289
What is the amount of lansoprazole in Prevacid 24Hr?
15 mg
290
What is Zegerid?
This is a medication that contains both omeprazole 20mg and sodium bicarbonate 1100mg. The idea is that sodium bicarbonate raises the stomach pH immediately therefore increasing the absorption rate of omeprazole. However, there is no evidence shower quicker symptom relief.
291
What is the MOA of bismuth subsalicylate?
The mechanism is which is decreases heartburn is unknown but it may exert topical effects on the stomach mucosa.
292
What are the 5 indication for bismuth subsalicylate?
Heartburn, upset stomach, indigestion, nausea, and diarrhea
293
What is the OTC dosing for heartburn for bismuth subsalicylate?
262-525 mg (1-2tbsp) Q0.5-1Hr PRN
Max 8 doses per day
294
What is the maximum doses per day of bismuth subsalicylate?
8 doses per day
295
What is the MOA of alginic acid?
This medication forms a mechanical foam barrier which floats on the surface of the gastric contents. The idea is that the foam will stop the stomach acid from reaching the esophagus.
296
Is alginic acid an active or inactive ingredient?
It is considered an inactive ingredient
297
Are PPIs safe to use in those breastfeeding?
No. Use antacids or H2RAs.
298
Which types of antacids are recommended in breastfeeding?
Magnesium, calcium, or aluminum containing antacids
299
What can be recommended for pregnant people experiencing mild-moderate heartburn?
Calcium or magnesium containing antacids only. H2RAs and PPIs only if PCP says it is okay but we can't just recommend them.
300
What are some non-pharm therapies for intestinal gas pain?
Eat slowly, chew food, avoid using straws, avoid gas-producing foods, avoid foods with air whipped into them, and avoid carbonated beverages
301
What is the indication for simethicone?
Relief of pressure and bloating commonly referred to as gas.
302
What is the MOA for simethicone?
It acts to reduce surface tension of gas bubbles allowing them to break and be eliminated more easily.
303
What is unique about simethicone?
It is not systemically absorbed so it can be given to basically anyone even neonates.
304
What is the dosing for simethicone?
It is generally just taken PRN after meals and at bedtime. Slides just say to refer to bottle for maximum doses.
305
Lactose intolerance can result in intestinal gas. What medication can be given prior to eating lactose to prevent intestinal gas for those with a lactose intolerance?
Lactase enzyme also known as Lactaid
306
What is Beano?
Beano is used for those with oligosaccharide intolerances. It contains the enzyme alpha-galactosidase
307
What two medications can be taken prior to a meal to prevent gas symtpoms?
Lactaid and Beano
308
T or F: Beano and Lactaid are regulated as medications.
False. They are regulated like they are dietary supplements.
309
T or F: Point-of-care/ home testing should not replace routine visits with a healthcare provider.
True
310
What is sensitivity in terms of testing reliability?
Sensitivity is the ability for a test to correctly identify patients with a condition. It is a true positive.
311
What is specificity in term of testing reliability?
Specificity is the ability of a test to correctly identify patients without the condition. It is a true negative
312
T or F: It is okay to change medications or dosages based on a home-use test without consulting a healthcare provider.
False. Do not change medications or dosages based on home testing.
313
How does the COVID-19 test work in terms of antibodies and antigens?
The control line binds all antigens present while the test line binds only COVID antigens.
314
What is the approximate level of HCG that is considered positive for pregnancy?
25. Pregnancy levels of HCG are detectable 12-14 days following conception.
315
When should patients test their urine for pregnancy?
Morning
316
Which pregnancy test is most accurate?
They all have equal accuracy
317
What day of the menstrual cycle does ovulation typically occur?
Day 14
318
What hormone do ovulation tests detect for?
Luteinizing hormone
319
Is a false positive or false negative more common with pregnancy tests?
False negatives are much more common. Advise person to continue taking pregnancy tests.
320
When does LH surge prior to ovulation?
24-36 hours prior to ovulation
321
Infertility is defined for those younger than 35 as being unable to get pregnant after ________ years of trying.
1 year
322
Infertility is defined for those older than 35 as being unable to get pregnant after ________ months of trying.
6 months
323
What do UTI strips detect for?
Leukocyte esterase and nitrates
324
What do yeast infection strips detect?
pH changes. Yeast infection should result in no pH change. A pH strip that changes color could be a UTI or BV which needs to be referred.
325
If a patient tests positive for a UTI, what should you do as a provider?
Refer to PCP
326
How does a drug test work?
If there is a positive test, only the control line will show up. If the test is negative, both the drug and control line will show up.
327
How long does it take for HIV antibodies to develop?
3-6 months
328
What does an HIV test detect?
HIV tests detect the presence of antibodies to HIV produced by the human body.
329
When should adults begin regular colon disease testing?
45 years old
330
What do colon disease tests test for?
Blood in poop
331
What medications should be avoided during a colon disease screening at home test?
NSAIDs, steroids, and possibly anticoagulants
332
What HbA1c % is considered diabetes?
6.5% and greater
333
Define urinary urge.
Frequent urgency (more than 8 times per day) to urinate with a large amount of urine lost. Typically 1 or more nocturia events.
334
Define urinary stress.
Occasional urgency to urinate. Leakage can be caused by activity. Nocturia is rare.
335
Define urinary overflow.
This is difficulty or hesitancy to urinate. Nocturia is frequent here.
336
What are the 3 exclusions for self-treatment for urinary incontinence?
- UTI symptoms
- Women who do not have PCP or urologist
- Men who do not have PCP or urologist
337
What is the 1st line treatment for urinary incontinence?
Non-pharmacological/ behavioral techniques
338
What are the behavioral techniques/ non-pharm methods to help with urinary incontinence?
Bladder training, toilet assistance, and pelvic floor muscle training. Pads, briefs, or shields can be placed in undergarments to catch any leakage. Bladder support for women is also available which is a tampon-like device inserted into the vagina that closes the urethra to prevent leakage.
339
What is the only OTC treatment available for urinary incontinence?
Oxybutynin (Oxytrol for women)
340
What is the MOA for oxybutynin?
It is an anticholingeric medication. It blocks muscarinic receptor activation preventing urinary release.
341
How is oxybutynin used?
It is applied to a dry and smooth area of the skin every 4 days.
342
What is a supplement often used by patients experiencing overactive bladder but it is not recommended?
Saw Palmetto
343
What body provides immunization recommendations?
Advisory Committee on Immunization Practices (ACIP)
344
What body approves immunization recommendations?
CDC
345
What two populations is the shingles vaccine (RZV vaccine called Shingrix) recommended for?
- 50+
- 19-49 with immunosuppression
346
What two populations are the pneumonia vaccines recommended for?
- 50+
- 19-49 with underlying medical conditions
347
What is the best time to give an RSV vaccine?
Late summer and early fall
348
What 3 populations are recommended to get the RSV vaccine?
- 75+
- 60-74 with increased risk for RSV
- Pregnant people between 32-36 weeks
349
What 3 populations are recommended to get the Tdap vaccine?
- 11-12 years (1 dose then every 10 years)
- Pregnant people weeks 27-36
- patients with contaminated wounds if more than 5 years since last dose
