Gastrointestinal Flashcards
What is prucalopride indicated for
Constipation
What class of drug is lubiprostone
Chloride channel agonist
When is vedolizumab used
IBD refractory to all other techniques
What counselling points are there for GI corticosteroids?
Take in the morning
Report visual disturbance
Apply sparingly
What 3 antimuscarinics are used as antispasmodics?
Dicycloverine, hyoscine and propantheline
What is the action of linaclotide?
Guanylate cyclase C receptor agonist. Causing release of cAMP and Cl. Laxative for constipation.
What is teduglutide indicated for
Short bowel syndrome
How does naloxegol exert its action for constipation
Opioid receptor antagonist. Acts on receptors in periphery so opioid central effects still occur but constipating effects blocked
What 3 classes of drugs are used in ulcer prevention and treatment?
proton pump inhibitors, h2 antagonists and prostoglandins
When and how is orlistat used?
When the BMI is over 30 and lifestyle changes are inadequate for obesity. Or over 28 with other risk factors. Max 12 weeks unless more than 5% weight loss. Taken up to 1h after meal and only if it contains fat.
Can racecadotril be mixed with food?
Yes
What additional considerations are there with sulfasalazine than with other amino salicylate?
Colours urine. Need FBC LFTs monthly for first 3 months.
What MHRA warning exists for eluxadoline?
Pancreatitis risk. Beware of worsening abdominal pain radiating to the back or shoulder.
What is given in loperamide overdose?
Naloxone
What drugs should be considered for stopping around the use of macrogol and for how long
Ace inhibitors, ARB, nsaid. Up to 72 hours after. No drugs 1h before and after
What other osmotic laxatives are there besides macrogol containing products?
Citric acid with magnesium carbonate
Lactulose
Magnesium hydroxide
sodium acid phosphate with sodium phosphate
What is the maximum amount of time before stimulant laxatives work?
12 hours
What are the common and excessive use side effects of stimulant laxatives?
Abdominal cramp common.
Diarrhoea and hypokaleamia with excessive use
Why are co-danthramer and Co-danthrusate not used commonly?
Carcinogenicity
What drugs belong to multiple classes of laxative?
Glycerol & docusate - stimulant and softening
Methyl cellulose - bulk forming and softening
Why is liquid paraffin not used much any more?
Side effects such as anal seepage, granulamatous disease, lipoid pneumonia
Why is gaviscon cautioned in hypertensive patients?
Sodium content
What are the GI side effects of antacids and how are they counteracted?
Aluminium constipating; magnesium laxative. Combine.
What proton pump inhibitor has an interaction with clopidogrel
Omeprazole
What antibiotic therapy commonly causes clostridium difficile?
Ampicillin, amoxicillin, Co amoxiclav, clindamycin, 2nd/3rd gen cephalosporins and quinolones
What can c diff be treated with?
Metronidazole, vancomycin, fidoxomycin
A high fibre diet should be given in diverticulitis. True or false
False. That and bulk forming drugs can be given in diverticular disease. Low residue diet and bowel rest given in diverticulitis
Which of these is not suitable to tell an IBS patient: eat 5 portions of fruit a day, increase physical activity, avoid sweeteners
Eat 5 portions as they should nto have more than 3
What types of cereal is gluten found in?
Wheat, barley, rye
What supplements are coeliac patients most likely to take?
Folic acid 5mg, calcium, vitamin D (risk of osteoporosis)
What should you advise to a coeliac patient requesting over the counter supplements?
Should not self medicate
What drug may be used in celiac disease?
Prednisolone (refractory)
What is the difference between diverticular disease and diverticulitis
Wihh or without inlfammation/infection
What is the most suitable treatment for uncomplicated diverticulitis
Low residue diet and bowel rest. Fibre has lacking evidence. Bulk forming laxatives may be used
If antibiotics are indicated for diverticulitis, what should be given?
IV covering Gram negative and anaerobes
A diverticular disease patient wants to buy buscopan. Is this suitable?
There is insufficient evidence to justify its role.
What differs sulfasalazine from other amino salicylate?
Combination with sulfapyridine to carry it to colonic site of action, producing more side effects. Extra testing - FBC initially and monthly for 3m and LFTs monthly for first 3m. Contact lenses may be stained.
Which form of IBD has continuous inflammation rather than interspersed?
Ulcerative colitis
What 3 options are there for chrons exacerbation, in descending order of effectiveness, if it is the patients first in 12 months?
Corticosteroid
Budesonide
Amino salicylate
What is added on to first line therapy if a patient has had 2 or more exacerbations of chrons disease in 12 months? What tests should be completed?
Azathioprine or mercaptopurine. TPMT activity - if deficit, use methotrexate
What treatment options are not used to maintain remission of chrons disease?
Corticosteroids or budesonide
What drugs are used to control diarrhoea in IBD and when are they contraindicated?
Loperamide or codeine. Not in active UC as can cause toxic megacolon
What are the treatment options in fistulating chrons?
Metronidazole, ciprofloxacin
Azathioprine, mercaptopurine
Infliximab
Surgery if not perianal
What is proctitis and proctosigmoiditis? What are the drugs of choice here?
Inflammation of the rectum. Inflammation of rectum and sigmoid colon.
Amino salicylate - rectal more effective.
Rectal corticosteroid or oral prednisolone if can’t use above or subacute
What is left sided and extensive ulcerative colitis? What are the drug choices here?
Involving colon distal to splenic flexure. Involving colon proximal to splenic flexure.
High induction oral amino salicylate plus rectal AC or oral beclometasone if necessary
Oral prednisolone if can’t give above or subacute
How long are amino salicylate given to work and what should be given if they fail?
After 4 weeks, add prednisolone. After another 2-4 weeks consider tacrolimus or budesonide
What is given in acute severe ulcerative colitis?
IV corticosteroid or ciclosporin. Combination. Surgery. Infliximab.
What is and isn’t suitable for maintaining remission in ulcerative colitis?
Amino salicylate
Azathioprine and mercaptopurine if 2 or more exacerbations in 12 months
Not corticosteroids
What symptoms should patients taking amino salicylate be advised to look out for?
Unexplained bleeding, bruising, purpura, sore throat, fever, malaise.
Diarrhoea in a breast fed infant.
Explain how to administer pentasa and salofalk
Pentasa tablets can be split or dispersed in water but should not be chewed. Granules are placed on the tongue and washed down with water or orange juice without chewing.
Solofalk granules washed down with water
What 2 things should be ensured before starting vedolizumab? What 3 things should be monitored for?
Screened for tuberculosis Effective contraception (and a for at least 18 weeks after)
Hypersensitivity
Infection
Neurological signs and symptoms
What diet and lifestyle advice should be given to IBS patients?
Increase physical activity, eat regularly without missing meals or leaving long gaps, no more than 3 portions of fresh fruit daily, soluble fibre (oats) not insoluble (bran). Increase fluid intake to at least 8 cups. Reduce caffeine, alcohol and fizzy drinks. Avoid sorbitol. Try probiotics for at least 4 weeks.
Which of these is not suitable for an IBS patient; fybogel, lactulose, colpermin, spasmonal
Lactulose. Can cause bloating.
When is linaclotide indicated?
Moderate to severe IBS with constipation for at least 12 months not responding to laxatives
What type of drugs can be used for discomfort in IBS if they are unresponsive to first line therapies?
Antidepressants (TCAs or SSRIs)
Eluxadoline; indication, action and MHRA alert
IBS with diarrhoea
Acts on gut opioid receptors reducing contractility and fluid secretion
Cases of pancreatitis; especially if undergone cholecystectomy or in biliary disorders. Advised to avoid alcohol and stop treatment if experience abdominal pain that may radiate to the back or shoulder, with or without nausea and vomiting.
Can colpermin capsules be opened?
No peppermint oil may irritate mouth or oesophagus
What drugs are commonly incompletely absorbed in small bowel syndrome?
Levothyroxine, warfarin, oral contraceptives and digoxin.
Enteric coated or modified release, especially with ileostomy.
What deficiency is common in short bowel syndrome and what problems can treatment arise?
Hypomagnesemia. Oral magnesium can cause diarrhoea
What 3 advantages does loperamide have over codeine for antidiarrhoeal purposes?
Not sedative, does not cause dependance or fat malabsorption
Why is co-phenotropes use restricted?
Crosses blood brain barrier fo CNS effects. Potential for dependance and anticholinergic effects.
When is coles tyramine indicated in short bowel syndrome and what is monitored?
Intact colon with less than 100cm of ileum resected . Monitor for fat malabsorption or fat soluble vitamin deficiencies.
What cautions should be taken with teduglutide use?
Tetracycline hypersensitivity
On discontinuing May cause dehydration
Patients with cardiovascular disease should seek medical attention it they notice sudden weight gain, swollen ankles or dyspnoea
What is advised with osmotic laxatives?
Maintain adequate hydration.
Abdominal pain is usually transient and can be reduced by taking preperations slower.
Renal function at baseline in those at risk of fluid and electrolyte disturbance (also ECG and electrolytes if ascorbic containing)
What dietary advice is given regarding the lead up to bowel cleansing?
Low residue or fluid only diet (water, fruit squash, clear soup, black tea or coffee) and copious intake of clear fluids. Specifically no solid food for 2 hours before starting.
What are red flag symptoms that may accompany constipation?
Anaemia, abdominal pain, weight loss, blood in stool
What dietary advice should be given for patients with constipation ?
Balanced diet with whole grain, fruit and veg. Increase fluid and exercise. Increase fibre gradually. Can take 4 weeks to see difference. Sorbitol.
What electrolyte imbalance may laxative abuse cause?
Hypokaleamia
A patient describes their constipation as small hard stools. What laxative is the best option and what do you advise?
Bulk forming. Onset may take up to 72 hours. Symptoms of flatulence, bloating and cramping may be exacerbated. Maintain adequate fluid intake.
Why are anthraquinone group laxatives limited in use?
Carcinogenicity and genotoxicity. Only in terminally I’ll.
What faecal softener is least used and why?
Liquid paraffin due to anal seepage and granulomatous disease
Which osmotic laxative may be used in hepatic encephalopathy and why?
Lactulose as produces low faecal pH and discourages proliferation of ammonia producing organisms.
In what order are the laxative classes generally recommended and when does this change?
Bulk forming, then osmotic laxative, then stimulant.
Bulk forming should be avoided if opioid induced. May also try naloxegol and methylnaltrexone.
Faeceal impaction starts with macrogol (hard stools) or stimulant. Rectal bisacodyl or glycerol may be tried, or enema.
Macrogol first line in children. Then stimulant.
If 2 laxatives have been used for at least 6 months what are the further options for constipation treatment?
Prucalopride in women (4 weeks for effect) or lubiprostone (2 weeks)
Is senna safe in pregnancy and breastfeeding
Yes. Breastfeeding in over 1 month.
What should be advised with bulk forming laxative use in the elderly
Supervise to ensure fluid intake. Also if narrowing intestines decrease motility or debilitated.
When should loperamide be avoided?
Bloody or suspected inflammatory diarrhoea (including with significant abdominal pain)
What antibiotic is used occasionally for prophylaxis of travellers diarrhoea?
Ciprofloxacin
What are alarm features for dyspepsia?
Bleeding, dysphagia, recurrent vomiting, weight loss, over 55yo if unexplained and unresponsive
What are the treatment stages of dyspepsia
Antacid
Proton pump inhibitor for 4 weeks
Test for h pylori
How may antacids change stool consistency?
Magnesium may be laxative and aluminium constipation.
Which antacids should not be used in infants and why?
Aluminium containing as accumulation may occur
What is the recommended initial treatment therapy for h pylori
PPI (BD) , clarithromycin (250mg BD if with metronidazole 400mg BD, or 500mg BD if with 1g BD amoxicillin)
When should the c urea test not be conducted?
Within 4 weeks of antibacterial treatment or 2 weeks of antisecretory treatment
Who is at risk of nsaid gastrointestinal complications?
Over 65yo, history of peptic ulcer, other GI side effect drugs, Co morbidity (cvd, diabetes, impairment)
What drug class might cause someone to develop skin lesions on their lower arms and what would you advise them?
PPIs. Avoid skin exposure to sunlight and consider discontinuing
Which proton pump inhibitor can be used in pregnancy?
Omeprazole
A patient is taking an antimuscarinic for IBS and is experiencing sedation. Which are they most likely taking, why and what can be given instead?
Dicycloverine lipid soluble (also atropine)) so crosses blood brain barrier Hyoscine and propantheline don't.
What is the drug of choice on cholestatic pruritus? What other options are there?
Colestyramine
Ursodeoxycholic acid - especially in preganancy
Rifampicin
Sertraline, naltrexone
What should be advised for a patient taking cholic acid and experiencing diarrhoea?
Need to have investigations for overdose
What drugs are known to cause weight gain?
Atypical antipsychotic, beta blockers, insulin, lithium, valproate, sulphonylureas, thiazolidinediones and tricyclic antidepressantss
What BMI should a patient have before considering an anti obesity drug?
- Or 28 with risk factor
When will discontinuation of orlistat be considered
If weight loss not exceeded 5% after 12 weeks
How should someone be advised to take orlistat?
Immediately before, during or up to 1 hour after each main meal. If a meal is missed or contains no fat, omit dose.
What laxatives can be used with anal fissure?
Bulk forming or osmotic
If an anal fissure has been present for more than 6 weeks, what can be given?
Glyceryl trinitrate rectal ointment
Topical diltiazem or nifedipine have less adverse effects
How should pancreatin patients be advised to eat and use their medicine?
Distribute food intake through 3 mains meals and 2-3 snacks. Avoid difficult to digest food such as legumes and high fibre. Avoid alcohol.
Take pancreatin with food and don’t heat if mix. Mix gr granules with slightly acidic food and swallowed immediately. Can open capsules.
What formulations are unsuitable in stomas?
Enteric coated or modified release, particularly in ileostomy
Are sugared or sugar free products more suitable for stoma patients?
Sugared. Sorbitol is unsuitable as laxative
Are proton pump inhibitors suitable in stoma patients?
Yes. Advised due to increased acid secretion.
When should stoma patients be given potassium supplements?
When taking digoxin - high risk of hypokaleamia. Also when other diuretics used.
What are the most suitable laxatives in stoma patients?
Bulk forming or small dose stimulant. But avoid if at all possible.
