GI Flashcards
Drugs that can worsen GERD symptoms
ASA/NSAIDs
Bisphosphonates
Dabigatran
Estrogen products
Fish oil products
Iron supplements
Nicotine replacement therapy
Steroids
Tetracyclines
Initial treatment for GERD
Lifestyle modification
PPI once daily x8 weeks
Examples of antacids
Calcium carbonate
Magnesium hydroxide
Bicarb/ASA/citric acid (alka-seltzer)
Key points for antacids
Al and Mg can accumulate with renal dysfunction
Ca and Al = constipation
Mg = loose stools
Ca based antacids preferred in pregnancy
Examples of histamine-2 receptor antagonists
Famotidine
Ranitidine
Cimetidine
Key points for H2RAs
Warnings for confusion (elderly, renal impairment, etc.), B12 deficiency w/ long use
Cimetidine = gynecomastia, impotence, many DDIs
Onset ~60 min
Can be used in pregnancy
Examples of proton pump inhibitors
Esomeprazole
Omeprazole
Lansoprazole
Pantoprazole
Dexlansoprazole
Key points for PPIs
Take 30-60 min before breakfast
Warnings for C. diff, low Mg, vit B12 def, osteoporosis
Cannot take clopidogrel with (es)omeprazole
Only pantoprazole and esomeprazole available as IV
Should only be used for 8 weeks in elderly pts unless demonstrated need or chronic NSAID use
What drug class is metoclopramide?
Dopamine antagonist
Key points for metoclopramide
Can cause tardive dyskinesia, EPS, parkinson-like symptoms, drowsiness
Avoid in pts with parkinson’s disease
Decrease dose by 50% if CrCl <60 mL/min
Drugs that require an acidic gut (affected by antacids/PPIs/H2RAs
Antiretrovirals (rilpivirine, atazanavir)
Antivirals (ledipasvir, velpatasvir)
Azoles
Cefpodoxime, cefuroxime
Iron products
Mesalamine
Risendronate DR
TKIs (dasatanib, erlotinib, pazopanib)
Drugs that antacids bind with (chelate)
Antiretrovirals (bictegravir, dolutegravir, elvitegravir, raltegravir)
Bisphosphonates
Isoniazid
Levothyroxine
Mycophenolate
FQ
Sotalol
Steroids (esp. budesonide)
Tetracyclines
Cimetidine inhibits which enzymes?
CYP2C19, CYP3A4, and CYP1A2
What enzyme do PPIs inhibit?
CYP2C19
3 most common causes of PUD
H. pylori
NSAID use
Stress ulcers
Duodenal ulcers are associated with pain when _______
Not eating (2-3 hours after eating)
(Eating lessens the pain)
Gastric ulcers are associated with pain when _________
Eating
Which drugs must be held for 2 weeks prior to H. pylori testing?
PPIs
Bismuth
Abx
1st line H. pylori treatment when >15% resistance rates to macrolides
Bismuth subsalicylate 300 mg QID +
Metronidazole 250-500 mg QID +
Tetracycline 500 mg QID +
PPI BID
Duration 10-14 days
1st line H. pylori treatment when <15% resistance rates to macrolides
Amoxicillin 1g BID +
Clarithromycin 500 mg BID +
PPI BID
Duration 14 days
Cytoprotective drugs that can be used to help prevent NSAID-related ulcers
Misoprostol
Sucralfate
Drugs that can cause constipation
Al and Ca antacids
Antidiarrheals
Clonidine
Colesevelam
Anticholinergics
Iron
Non-DHP CCBs
Opioids
Sucralfate (contains Al)
Examples of PAMORAs
Alvimopam (Entereg)
Methylnaltrexone (Relistor)
Naloxegol (Movantik)
Key points for PAMORAs
Must be on opioids >7 days to use
Potential risk of MI w/ long term use
Drugs that cause diarrhea
Acetylcholinesterase inhibitors (donepezil)
Mg antacids
Antibiotics
Antidiabetics
Antineoplastics
Colchicine
Laxatives
Misoprostol
Mycophenolate
Metoclopramide
Protease inhibitors
Quinidine
Roflumilast
OTC, what is the max time loperamide can be used for?
48 hours
Max doses for loperamide (OTC and Rx)
OTC = 8 mg/day
Rx = 16 mg/day
Clinical features of UC vs CD
UC
- Bloody diarrhea
- Fistulas/strictures uncommon
- Located in colon
- Superficial
- Continuous pattern
- Smoking is protective
CD
- Non-bloody diarrhea
- Fistulas/strictures common
- Located anywhere in GI tract
- Transmural
- Non-continuous pattern
- Smoking is RF
What foods should pts with UC or CD avoid?
Fats and dairy
Caffeine
Alcohol
What drugs are used to treat acute CD/UC flares?
Steroids
Tapered off over 8-12 once remission is achieved
Treatment options for UC
5-ASA
Anti-TNF agents
Ustekinumab (Stelara)
Tofacitinib (Xeljanz)
Vedolizumab (Entyvio)
IV cyclosporine
Treatment options for CD
Steroids (budesonide for 3 mo) +/- thiopurine/methotrexate
Anti-TNF +/- thiopurine
Ustekinumab (Stelara)
Examples of anti-TNF agents used for UC/CD
Adalimumab (Humira)
Infliximab (Remicade)
Certolizumab (Cimzia) - CD
Golimumab (Simponi) - UC
What enzyme is budesonide a substrate of?
CYP3A4
What is the primary form of 5-ASA in the US?
Mesalamine
Examples of 5-ASAs
Mesalamine
Sulfasalazine
Balsalazide
Olsalazine
Key points for 5-ASAs
Mesalamine suppositories (1-3 hrs) and enemas (overnight) must be retained
CI w/ allergies to salicylates (+sulfa w/ sulfasalazine)
More SE w/ sulfasalazine
Balsalazide capsule beads can stain teeth/tongue
ER forms can leave ghost tablet
Formulations + names of mesalamine
ER capsules = Pentasa
ER tablets = Asacol
Enema = Rowasa
Suppository = Canasa
Examples of thiopurines
Azathioprine
Mercaptopurine
Key points for thiopurines
Causes immunosuppression
Should perform TPMT gene testing - deficiency = increased risk of myelosupression
Azathioprine is prodrug of mercaptopurine
What is the frequency of methotrexate when used for CD?
IM/subq once weekly
Examples of integrin receptor antagonists
Natalizumab (Tysabril)
Vedolizumab (Entyvio)
Key points for integrin receptor antagonists
For induction and remission of IBD
Natalizumab: risk of progressive multifocal leukoencephalopathy (PML), REMS program, d/c if no response by 12 weeks, for CD only
Vedolizumab: for UC and CD, d/c if no response by 14 weeks
DOC for motion sickness
Scopolamine – Anticholinergic
Benadryl, dimenhydrinate (Dramamine), meclizine (Bonine) – Antihistamines
Which antiemetics are not effective for motion sickness
Metoclopramide
5HT-3 antagonists
When should a scopolamine patch be applied?
4 hours before needed or night before surgery
Lasts for 3 days
