GI Flashcards
Drugs that worsen GERD symptoms
ASA/NSAIDs
bisphosphonates
dabigatran
estrogen products
fish oil products
iron supplements
NRT
steroids
tetracyclines
GERD: initial drug tx
PPI once daily for 8 weeks
-can incr to BID if partial response or if nocturnal symptoms are present
GERD: maintenance
-PPI at the lowest effective dose
-alt: H2RA (if no erosive esophagitis)
antacids
Tums, Mylanta, Maalox, Milk of Mag, Alka-seltzers
-neutralize gastric acid by increasing gastric pH
-can accumulate with renal dysfunction
-calcium: constipation
-Aluminum: constipation
-magnesium: loose stools
-calcium containing may be preferred in pregnancy
H2RA
Famotidine (Pepcid), Ranitidine, Cimetidine
-decrease gastric acid secretion
-confusion
-cimetidine: gynecomastia, impotence (avoid)
PPI
-Esomeprazole (Nexium), Lansoprazole (Prevacid), Omeprazole (Prilosec) –> 60 min before breakfast
-Dexlansoprazole (Dexilant), Pantoprazole (Protonix)
-irreversibly bind to the gastric H/K-ATPase pump and blocking gastric acid secretion
-C.Diff associated diarrhea, hypomagnesemia, vitamin B12 deficiency with prolonged use, osteoporosis-related bone fractures with high doses or long-term use
-diminish the therapeutic effect of clopidogrel (do not use omeprazole and esomeprazole)
Metoclopramide (Reglan)
-gastroproesis
-30 min before meals and at bedtime
-CrCl < 60 mL/min decrease dose by 50%
-tardive dyskinesia, EPS
-avoid in Parkinsons disease
Drugs that require an acidic gut
-Antiretrovirals (rilpivirine, atazanavir)
-Antivirals (ledipasvir, velpatasvir/sofobuvir)
-azole antifungals (itraconazole capsules, ketoconazole, posaconazole oral solution)
-Cephalosporins (cefpodoxime, cefuroxime)
-iron products
-mesalamine
-risedronate
-TKi (dasatinib, erlotinib, pazopanib)
Drug classes that antacids bind
-antiretrovirals (INSTIs): bictegravir, dolutegravir, elvitegravir, raltegravir
-bisphosphonates
-isoniazid
-levothyroxine
-mycophenolate
-quinolones
-sotalol
-steroids
-tetracyclines
H. Pylori Treatment: bismuth quadruple therapy (first-line)
-10-14 days
-bismuth subsalicyates 300 mg QID + flagyl 250-500 mg QID + tetracycline 500 mg QID + PPI BID
-alcohol use: do not use flagyl
-pregnancy/children: do not use tetracycline
H. Pylori Treatment: concomitant therapy (if local resistance rates to clarithromycin are low and no previous macrolide exposure)
-10-14 days
-amoxicillin 1000 mg BID + clarithromycin 500 mg BID + flagyl 250-500 mg QID + PPI BID
H. Pylori treatment: clarithromycin triple therapy (if local resistance rates to clarithromycin are low and no previous macrolide exposure)
-14 days
-amoxicillin 1000 mg BID + clarithromycin 500 mg BID + PPI BID (or esomeprazole 40 mg QD)
-or 3 in 1 product Prevpac (amoxicillin + clarithromycin + lansoprazole )
NSAID induced ulcer
Sucralfate (Carafate)
-taken before meals
-constipation
-binding interactions (separate antacids by 30 in and take other drugs 2 hours before or 4 hours after)
Drugs that cause constipation
-antacids (aluminium- and calcium-containing)
-antidiarrheals
-clonidine
-colesevelam
-drugs with anticholinergic effects (antihistamines, antispasmodics, phenothiazines, TCAs, urge incontinence drugs)
-iron
-non-DHP CCB (verapamil)
-opioids
-sucralfate
OTC recommendation for constipation: most adults
fiber
OTC recommendation for constipation: iron-induced or hard stool
docusate
OTC recommendation for constipation: opioid-induced
senna or bisacodyl
OTC recommendation for constipation: pregnancy
fiber
OTC recommendation for constipation: fast relief needed
adults: bisacodyl or glycerin
Children: glycerin
Bulk-forming
psyllium (Metamucil), Calcium polycarbophil (Fibercon), Methylcellulose (Citrucel), Wheat dextrin (Benefiber)
-flatulence, abdominal, cramping, bloating
-adequate fluids are required
-separate calcium
Osmotics
Magnesium Hydroxide (Milk of Mag), polyethylene glycol (miralax), glycerin, lactulose, sodium phosphates (fleets enema)
-electrolyte imbalance, abdominal cramping
-magnesium: caution in renal dysfunction
-lactulose: hepatic encephalopathy
stimualnts
senna (Ex-Lax, Senokot) + docusate (Senna S, Senokot S)
Bisacodyl (Dulcolax)
Emollients (stool softeners)
Docusate (Colace) + senna
-preferred when straining should be avoided
Lubiprostone (Amitiza)
-CIC, OIC, IBS-C
-Cl channel acitvator
Linaclotide (Linzess)
-CIC, IBS-C
-Guanylate Cyclase C agonists
Alvimopan (Entereg)
-peripheral acting mu opioid receptor antagonists
-for hospitalized surgery [atient to decrease risk of post-operative ileus
-max 15 doses
-CI: therapeutic doses of opioids for > 7 consecutive days
methylnaltrexone (relistor)
Naloxegol (movantik)
-peripheral acting mu opioid receptor antagonists
-CI: therapeutic doses of opioids for > 7 consecutive days
Whole Bowl Irrigation
-Polyethylene glycol-electrolyte solution (Colyte, Golytely)
-Sodium phosphates (OsmoPrep)
-Sodium sulfate, potassium sulfate and magnesium sulfate (suprep bowel prep kit)
Drugs that cause diarrhea
-acetylcholinesterase inhibitors (donepezil)
-antacid containing magnesium
-abx
-antidiabetics (metformin, GLP-1 agonists)
-antineoplastics (irinotecan, capecitabine, 5-FU, methotrexate, TKis)
-colchicine
-laxatives
-misoprostol
-mycophenolate
-prokinetic drugs (metoclopramide, cisapride)
-protease inhibitors (especially nelfinavir)
-quinidine
-roflumilast
antispasmodic
dicyclomine (Bentyl)
-anticholinergic
-caution in UC can cause toxic megacolon or paralytic ileus
Crohns disease
diarrhea: bloody or non-bloody
fistulas/strictures: Common
Location: entire GI tract
Depth: transmural
Pattern: non-continous (cobble stone)
smoking: risk factor
UC
diarrhea: bloody
fistulas/strictures: uncommon
Location: colon (especially in rectum)
Depth: superficial
Pattern: continous
smoking: protective`
induction of remission for CD
steroids (+/- thiopurine or methotrexate)
anti-TNF +/- thiopurine
Ustekinumab (Stelara)
induction of remission for UC
-5-ASA +/- steroids
-anti-TNF agents
-ustekinumab (stelara)
-tofacitinib (Xeljanz)
-Vedolizumab (Entivyo)
-IV cyclosporine
maintenance of remission in CD: mild disease of the ileum and/or right colon
oral budesonide for > 3 months; after this course, discontinue tx or change to thiopurine or methotrexate
maintenance of remission in CD: moderate-severe disease
Anti-TNF agents: adalimumab (humira), infliximab (remicade), certolizumab (cimzia)
thiopurine (azathioprine, mercaptopurine)
methotrexate
IL receptor antagonist (ustekinumab (Stelara))
maintenance of remission in CD: refractory to above treatments and/or steroid dependent
integrin receptor antagonists: vedolizumab (entyvio) or natalizumab (tysabri)
maintenance of remission in UC: mild disease
mesalamine rectal and/or oral preferred
maintenance of remission in UC: moderate-severe disease
Anti-TNF agents: adalimumab (humira), infliximab (remicade), certolizumab (cimzia)
thiopurine (azathioprine, mercaptopurine)
Cyclosporine
IL receptor antagonist (ustekinumab (Stelara))
Janus Kinase Inhibitor (Tofacitinib (Xeljanz))
maintenance of remission in UC: Refractory to above treatments and/or steroid dependent
integrin receptor antagonists: vedolizumab (entyvio)
Oral steroids for CD and UC
Prednisone (Deltasone)
Budesonide (Entocort EC, Uceris)
-CD: induction and maintenance
-UC induction only
Aminosalicylates
Mesalamine ER (Pentasa, Asacol HD, Rowasa (rectal), Canasa (suppository)
-rectal is more effective than oral for distal disease/proctitis in UC
Sulfasalazine
Thiopurines
Azathipurine (Imuran)
-TPMT deficiency incr risk of myelosuppression
Natalizumab (Tysabri)
-integrin receptor antagonists
-used for CD
-IV every 4 weeks
-d/c if no response by 12 weeks
-risk of PML
-only available through REMs
Vedolizumab (Entyvio)
-integrin receptor antagonists
-injection
-used for CD and UC
-0,2, and 6 weeks then every 8 weeks
-d/c if no benefit by week 14
Scopolamine (Transderm Scop)
- 1 patch every 3 days PRN
-CI: hypersensitivity to belladonna, closed-angle glaucoma
-dry mouth, CNS effects, stinging of the eyes, pupil dilation, increase IOP
-remove patch before MRI
-avoid alcohol
Dimenhydrinate (Dramamine)
-CNS depression, increased IOP
dizziness, drowsiness, dry mouth, blurry vision
Meclizine (Dramamine All Day Less Drowsy)
-CNS, depression, increase IOP
-sedation, dry mouth, dry/burry vision
-commonly used for vertigo
