GI* Flashcards
Key drugs that can worsen GERD symptoms
-ASA/NSAIDs*
-Bisphosphonates*
-Dabigatran
-Estrogen products *
-Fish oil products
-Iron supplements
-Nicotine replacement therapy (gum)*
-Steroids
-Tetracyclines
Histamine -2 Receptor Antagonists (H2RAs) for GERD
–> famotidine (Pepcid) - can cause QT prolong with renal dysfunction
–> Ranitidine (Zantac) - can inc ALT
–> Nizatidine
–> Cimetidine * (avoid due to SEs & DDIs, can cause gynoclamestia and impotence)
SE: CNS effects (esp in elderly), vit B12 deficiency with prolonged use, (2 yrs), can cause agitation and vomiting in children < 1 y/o
-no need to use in combo with PPI
Proton Pump Inhibitors )PPIs) for GERD
–> Esomeprazole (Nexium) IV, OTC, suspen
–> Lansoprazole (Prevacid) OTC,ODT,suspen
–> Omeprazole (Prilosec) OTC, Rx, ODT, suspen
^^ take 30-60 mins before meals
–> Dexlansoprazole (Dexilant)
–> Pantoprazole (Protonix) IV, Rx
SE from chronic use: c. difficile associated diarrhea, osteoporosis-realted fractures, hypomagnesemia, vitamin B12 deficiency
Drugs that require an acidic gut (absorption dec by antiacids, H2RAs, PPIs)
-antiretrovirals: rilpivirine (NNRTIs), atazanavir (PI)
-Antivirals: ledipasvir, velpatasvir/sofosbuvir
-Azole antifungals: Sporanox (itraconazole caps), l=ketoconazole, posaconazole oral suspension
-Cephalosporins: cefpodoxime, cefuroxime
-iron products
-mesalamine
-risedronate delayed release
-Tyrosine kinase inhibitors: dasatanib, erlotinib, pazopanib
Oral drugs/drug classes that antacids bind
-Antiretrovirals (INSTIs): bictegravir, dolutegravir, elvitegravir
-Bisphosphonates
-Isoniazid
-Levothyroxine
-Mycophenolate
-Quinolones
-Sotalol
-Steroids (budesonide)
-Tetracyclines
PUD (H. pylori tx) 1st line Bismuth Quadruple therapy for 10-14 days
–> use 1st line especially if local resistence rates to clarithromycin are high (>15%), the pt has had a previous macrolide exposure or a penicillin allergy
–> Bismuth subsalicylate 300 mg QID +
–> Metronidazole 250-500 mg QID +
–> Tetracycline 500 mg QID +
–> PPI BID
OR
use a 3 - in - 1 combo product + PPI:
–> Pylera [bishmuth subcitrate potassium 420 mg + metronidazole 375 mg + tetracycline 375 mg] QID + PPI BID
Warnings: no alcohol with metronidazole, do not use tetracycline in children < 8yrs or pregos
Drug tx for H. pylori: concomitant therapy for 10-14 days
Use only if local resistance rates to claithyromycin are low (< 15%) and the pt has had no previous exposure to a macrolide
–> Amoxicillin 1,000 mg BID +
–> Clarithromycin 500 mg BID +
–> Metronidazole 500 mg BID +
–> PPI BID
Drug tx for H. pylori: Clarithromycin Triple THerapy: take for 14 days
use only if local resistance rates to clarithromycin are low (<15%) and the pt has had no previous exposure to macrolide
–> Amoxicillin 1000 BID +
–> Clarithromycin 500 mg BID +
–> PPI BID (or esomeprazole 40 mg daily)
-combo product = Prevpac (amoxicillin + clarithromycin + lansoprazole)
Risk factors for NSAID-induced Ulcers
-Elderly
-Hx of PUD
-high-dose NSAIDs
-Using > 1 NSAID (ibuprofen plus aspirin)
-Concomitant use of anticoagulants, steroids, SSRIs or SNRIs
Treatment of NSAID-Induced Ulcers
–> Misoprostol (Cytotec): prevention of PUD, BBW: abortifacrent (difficult to tolerate)
–> Sucralfate (Carafate): tx of PUD, SE: constipation
Drugs that are constipating
-Aluminum antacids (mag antacids can counter-effect)
-Anticholinergic drugs (TCAs, antihistamines, phenothiazines, antispasmodics, urge incontinence agents)
-NON- DHP CCBs (verapamil)
-Clonidine
-Colesevelam
-Iron *
-Opioids *
-Sucralfate (contained an aluminum complex)
What OTC product to recommend for constipation?
Adults: fiber (metamucil)
–> on opioids: Senna or a biscodyl suppository
–> on iron or stool is very hard: docusate
–> need to go soon but needs something gentle: glycerin suppository
Children: glycerin suppository
Pregnancy: fiber
*if no improvement in 7 days, go to MDO
What drugs are approved for IBS-C and chronic idiopathic constipation?
-Lubiprostone
-Linaclotide
-Plecanatide
Bulk forming agents
–> Psyllium (Metamucil)
–> Calcium polycarbophil (Fibercon)
–> Methylcellulose (Citrucel)
-onset of 12-72 hrs
-take 2 hrs before/after other drugs
SE: gas, bloating
Osmotic Laxatives
–> Magnesium hydroxide (MOM) - 30 min to 6hr onset
–> Polyethylene glycol (Miralax) - 24-96 hr onset
–> Glycerin (Supp) - works stat
–> Lactulose (Constulose) - also for hepatic encephalopathy
–> Sodium phosphates (Fleet enema)
SE: electrolyte imbalance
Stimulants
-Senna (Senokot)
-Bisacodyl (Dulcolax) - fast acting supp
-6+ hours to work, can give QHS to have BM in the am
SE: cramping, electrolyte imbalance
Emollients (stool Softeners)
–> Docusate sodium (colace)
-can be used for Iron-Induced constipation
-takes about 12-72 hrs orally, 2-15 mins rectally
Osmotic for whole bowel Irrigation
–> Polyethylene glycol solution (GaviLyte-G)
–> Sodium phosphates (fleet enema)
BBW: nephropathy
CI: severe renal impairment
onset: 1-6 hrs
-can only drink “clear liquid diet”
CANNOT have foods with red/blue/purple food coloring, no milk/cream, tomatoe, orange juice
Lubiprostone (Amitiza)
-indicated for chronic idiopathic constipation, opioid induced constipation and IBS-C
SE: nausea (take with food and water)
Linaclotide (Linzess)
-guanylate cyclase C agonist
–> used for chronic idiopathic constipation and IBS-C
BBW: do not use in peds, high risk of dehydration that can cause death
SE: diarrhea
Alvimopan (Entereg)
-peripherally-acting MU-opioid receptor antagonist
-used for post-surgical patients to decrease risk of post-operative ileus (REMS drug)
BBW: potential risk of MI w/ long term use max 15 doses
Select drugs that can cause diarrhea
-acetylcholinesterase inhibitors (donepezil)
-antacids containing magnesium
-antibiotics
-antidiabetics (metformin, GLP-1)
-Antineoplastics (Irinotecan, capecitabine, fluorouracil, methotrexate, TKIs)
-Colchicine
-Drugs used fro constipation (laxatives)
-Misoprostol
-Mycophenolate
-Prokinetic drugs (metoclopramide, cisapride)
-Protease inhibitors (esp nelfinavir)
-Quinidine
-Roflumilast
Treatment for diarrhea associated w/ IBS (IBS-D)
–> most cases: Loperamide works
-Rifaximin (Xifaxan): abx w/ approved for IBS-D, relapse often occurs within several months of tx
-Alosetron (Lotronex): useful for women only, but has restricted use due to the risk of ischemic colitis
Antidiarrheals: Bismuth Subsalicylates (Pepto-Bismol)
SE: black tongue/stool, salicylate toxicity (tinnitus)
-caution in pts on aspirin therapy + anticoagulants
-can cause Reye’s syndrome in children + teens who are recovering from a viral infection (due to the salicylate use)
Antidiarrheals: Loperamide (Imodium A-D)
BBW: Torsades de pointes, arrest and sudden death with doses higher than recommended
OTC MAX: 8 MG/DAY
RX MAX: 16 MG/DAY
-self tx should not be > 48hrs
- do not use in children < 2 y/o
Antidiarrheals: Diphenoxylate/atropine (Lomotil)
SE: sedation, constipation
Max: 20 mg/day
Antidiarrheals: Eluxadoline (Viberzi)
-C-IV
–> peripherally-acting Mu-opioid receptor agonists
CI: pts w/o a gallbladder
Crohn’s Disease facts
-bloody or non bloody diarrhea
-common to have fistulas/strictures
-located in entire GI tract
-transmural (deep depth)
-cobble stone pattern
-smoking is a risk factor
Ulcerative Colitis facts
-bloody diarrhea
-uncommon to have fistulas/strictures
-located in colon (esp. the rectum)
-superficial depth
-continuous pattern
-smoking is protective
Drug tx for induction of remission: Crohn’s Disease
-steroids +/- thiopurine or methotrexate
-anti-TNF +/- thiopurine
-Interleukin receptor antagonist
Drug tx for induction of remission: Ulcerative Colitis
-steroids - Uceris (oral/rectal) +/- 5-ASA or thiopurine
-anti-TNF +/- thiopurine
-IV cyclosporine
-Tofacitinib (Xeljanz)
Crohn’s Disease TX: Mild disease of the ileum and/or right colon
–> oral budesonide (Entocort EC) for < 3 months, after this course, d/c tx or change to thiopurine (azathiopurine, mercoaptopurine) or methotrexate
Crohn’s Disease TX: Moderate to Severe Disease
–> anti-TNF agents: Adalimumab (humira), Infliximab (Remicade), Certolizumab (Cimzia)
–> Thiopurine: azathioprine, mercaptopurine
–>methotrexate
–> IL receptor antagonist: Ustekinumab (stelara)
Crohn’s Disease TX: Refractory to other tx and/or steroid dependent
–> Integrin receptor antagonists:
Vedilozumab (Entyvio)
Natalizumab (Tysabri)
Ulcerative Colitis TX: Mild disease
-mesalamine (5-ASA)
Ulcerative Colitis TX: Moderate to severe disease
–> Anti-TNF agents: Adalimumab (Humira), Infliximab (Remicade), Bolimumab (Simponi)
–> thiopurine: azathioprine, mercaptopurine
–> cyclosporine (IV)
–> IL receptor antagonist: Ustekinumab (Sterlara)
Ulcerative Colitis TX: refractory and/or steroid dependence
–> Integrin receptor antagonists: vedolizumab (Entyvio)
–> Janus Kinase Inhibitor
Tofacitinib (Xeljanz)
Treatment for motion sickness: OTC
-meclizine (bonine)
-cyclizine (Marcezine)
-diphenhydramine (benadryl)
-dimenhyrinate (Dramamine)
Scopolamine (Transderm-scop) patch for motion sickness
–> for N/V due to motion sickness or anesthesia/surgery
-apply at least 4 hr before needed or the night before surgery
-press firmly to skin for 30 secs
-try to avoid placing the patch over hair or when the patch is removed
-lasts 3 days; if another patch is needed, place behind the other ear
-painful/mydriasis if gets in eye
-remove prior to MRI
**do not drive: high level of sedation, dizziness, confusion (worse in elderly)
Meclizine (Bonine, Dramamine)
Warnings: CNS depression, inc intraocular pressure
SE: sedation, dry mouth, dry/blurry vision
