GI Flashcards
GI drug selection therapy is based on…
Identifying disease treatment in context of the patient’s medical history and organ function
Noting drug allergies
Reconciling meds (Rx and OTC)
Name that class:
Bismuth Subsalicylate (Pepto-Bismol)
Cytoprotective
Anti-diarrheal
Name that class:
Ondansetron (Zofran)
Antiemetic
Name that class:
Ranitidine (Zantac)
H2 blocker
Name that class:
Calcium carbonate (Tums)
Antacid
Name that class:
Magnesium hydroxide
Laxative
Name that class:
Famotidine
H2 blocker
Name that class:
Promethazine (Phenergan)
Antiemetic
Name that class:
Esomeprazole (Nexium)
PPI
Name that class:
Pantoprazole (Protonix)
PPI
Name that class:
Lansoprazole (Prevacid)
PPI
Name that class:
Prochlorperazine (Compazine)
Antiemetic
Name that class:
Diphenoxylate/atropine (Lomotil)
Antidiarrheal
Name that class:
Omeprazole (Prilosec)
PPI
Name that class:
Magnesium hydroxide/Aluminum hydroxide (Maslow)
Antacid
Name that class:
Metoclopramide (Reglan)
Prokinetic
Name that class:
Adalimumab (Humira)
Anti-inflammatory
Name that class:
Lubiprostone (Amitiza)
Anti-constipation
Name that class:
Linaclotide (Linzess)
Anti-constipation
Name that class:
Dicyclomine (Bentyl)
Antispasmodic
Name that class:
Misoprostol (Cytotec)
Cytoprotective
Name that class:
Infliximab (Remicade)
Anti-inflammatory
Name that class:
Polyethylene glycol (Miralax)
Laxative
Name that class:
Loperamide (Imodium)
Anti-diarrheal
Name that class:
Senna (Senokot)
Laxative
Name that class:
Lab tulles
Laxative
What are the alarm features for GERD?
Dysphagia Hematemesis Melena Anemia Unintentional weight loss Personal Hx of cancer Inadequate response to therapy
What should your plan be for a patient with GERD in the absence of alarm features?
Discuss dietary, lifestyle, behavior mods
Consider pharmacological therapy (Antacid vs H2 blocker vs PPI)
• Ranitidine (Zantac) first line
What are the benefits of using H2 blockers for GERD?
Quick onset, appropriate for ON-DEMAND RELIEF
Most effective for decreasing NOCTURNAL acid formation
What are some causes of esophagitis other than reflux?
Infectious (ie Candida)
Eosinophilic
Pill-induced
What medications can lead to pill-induced esophagitis
BISPHOSPHONATES
Iron supplements
NSAIDs/Aspirin
Potassium
Tetracycline
Which medication is most appropriate for the treatment of reflux esophagitis?
Omeprazole (Prilosec) or any other PPI
How long do PPIs take to work?
Relief of symptoms generally takes 2-5 days
Best given in the morning, 30 min before breakfast
What is the rebound effect with PPIs?
Acid hypersecretion with abrupt d/c
Consider taper therapy
What are the possible risks associated with chronic PPI therapy?
Nutrient malabsorption (Ca, Mg, B12, Fe)
Osteoporosis related fractures (consider bone density scans)
C. difficile/other enteric infections
Kidney disease
Use lowest effective dose for shortest duration possible
Which antacid:
SE = diarrhea
Magnesium
Which antacid:
Hypermagnesemia risk (caution in patients with renal insufficiency)
Magnesium
Which antacid:
SE = constipation
Aluminum hydroxide
Which antacid:
Hypercalcemia risk
Calcium carbonate (tums)
Which antacid:
Risk of sodium/fluid retention (caution in patients with edema, cirrhosis, HF, renal impairment)
Sodium Bicarbonate
What non-invasive tests can help diagnose H. pylori infection?
Urea breath test
Stool antigen
What is the first-line therapy for a patient with H. pylori?
Quadruple therapy - PPI, Bismuth, Metronidazole, Tetracycline
Why is eradication testing necessary for patients treated for H. pylori?
Risk of PUD, Fe deficiency anemia, and gastric malignancy
Which meds should be d/c prior to H. pylori testing and in what timeframe?
PPI 1-2 weeks prior to testing
Bismuth/antibiotics 4 weeks prior to testing
“Burning, gnawing” epigastric pain aggravated by meals (sx 30 min after meal)
Partial relief with Zantac
No vomiting, hematemesis, melena, weight loss
Takes ibuprofen 600 mg TID for past year
Probable PUD secondary to chronic NSAID use
What are some common causes of PUD?
H. pylori
ZES
Physiologic stress
NSAID use
What is the most appropriate diagnostic test for PUD?
EGD
What complications do you worry about with PUD and how would you recognize them?
Hemorrhage (hematemesis, melena, heme (+) stool)
Penetration/perforation (peritoneal signs, free air under diaphragm)
Obstruction (succussion splash)
In addition to NSAIDs, concomitant use of what meds can complicate PUD?
Anticoagulants
Aspirin
Steroids
As a general rule, active duodenal ulcers should be treated for ______ and gastric ulcers for _______
Duodenal - 4 weeks
Gastric - 8 weeks
In the setting of NSAID induced PUD we would advise the patient to d/c NSAID. If patient needs to keep using them, what would you recommend?
Maintenance PPI therapy
What cytoprotective medication can be used to prevent NSAID-induced ulcers in non-pregnant patients?
Misoprostol (Cytotec)
We don’t use in pregnancy b/c it’s an abortifacient
If a patient has T2DM and complains of early satiety, post-prandial nausea, and intermittent vomiting, especially after large fatty meals, what should you suspect?
Diabetic Gastroparesis
Be sure to r/o PUD or gastric cancer too though
What dietary recommendations should you make to a patient with diabetic gastroparesis?
Reinforce small frequent low fat, low residue meals
What is the best long-term treatment option for gastroparesis?
Improved glucose control
But if you want to give them a med, you can give them Metoclopramide (Reglan)
How should Metoclopramide (Reglan) be used for patients with gastroparesis?
Advise lowest effective dose for shortest duration possible due to risk of extrapyramidcal symptoms and tardive dyskinesia
Contraindications: obstruction, perforation, GI hemorrhage
Educate pt about possible abdominal cramping and diarrhea
What are the cautions for Ondansetron (Zofran)
Caution with cardiac arrhythmias and QT interval prolongation
Risk of serotonin syndrome (caution in combo with other serotonergic drugs)
What are the precautions for Promethazine (Phenergan) and Prochlorperazine (Compazine)
Sedating
Drug-induced parkinsonism
Generalized abdominal pain, alternating diarrhea/constipation
Sx worse with food and stress
What you think?
Irritable Bowel Syndrome
What is a good initial medication to suggest to a patient with IBS?
Antispasmodic meds (ie Dicyclomine - Bentyl)
Has anticholinergic properties, use with caution in elderly patients
When would you consider Amitriptyline for a patient with IBS?
Psychosocial component and relief of abdominal pain
When would you consider Eluxadoline (Viberzi) for patients with IBS?
If they have IBS-D
What recommendations should be made for patients with chronic constipation?
Reconcile meds, identify hypomotility agents
Ensure adequate fiber and fluid intake
Encourage exercise
Consider pharmacological therapy
What medications can exacerbate constipation?
Anti-psychotics Aluminum hydroxide Dicyclomine (Bentyl) Antidepressants Opioids
Which meds are bulk-forming laxatives?
Psyllium (Metamucil)
Methylcellulose (citrucel)
Polycarbophil (FiberCon)
Benefited
SE for bulk-forming laxatives
Flatulence, bloating
Need to take with FLUID
SE of stool softeners (ie Docusate)
GI cramping
Which meds are osmotic laxatives?
Polyethylene glycol (Miralax)
Milk of magnesia
Mag citrate
Lactulose
SE of osmotic laxatives
GI discomfort
Bloating
Caution with Mg-containing laxatives and hypermagnesemia in patients with renal insufficiency
Which meds are stimulant laxatives
Bisacodyl (Dulcolax)
Senna (Senokot)
SE of stimulant laxatives
GI cramping
Rare electrolyte disturbances
Melanosis coli
Which laxatives are available by Rx only
Lubiprostone (Amitiza)
Linaclotide (Linzess)
Plecanatide (Trulance)
Contraindications for use of laxatives
Acute abdomen Intestinal obstruction Perforation Toxic megacolon Unexplained abdominal pain
Overuse of laxatives can lead to…
Laxative dependency
Fluid/electrolyte imbalance
Alterations in bowel function
When would you consider the use of Methylnaltrexone (Relistor)?
Opioid-induced constipation with advanced illness (palliative care) or in chronic noncancer pain
What meds are known to cause/aggravate diarrhea?
Mg Reglan Augmentin Metformin Colchicine
If a patient was recently on Clindamycin for a dental infection and is now presenting with diarrhea, how would you approach care?
Consider C. difficile infection
Order C. diff stool test, treat empirically with oral vancomycin or metronidazole
What are the precautions/contraindications for anti-diarrheal use?
Bloody or suspected infectious diarrhea High fever/toxicity Pseudomembranous colitis Acute ulcerative colitis Use caution in patients with hx of drug abuse
What are some possible adverse reactions from anti-diarrheal use?
Ileus
Toxic megacolon
What is the most common adverse effect of pesto-bismol?
May cause temporary harmless black tongue, mouth, stool
Why should you avoid using pepto-bishop in children?
Contains salicylate - risk of Reye Syndrome (like aspirin)
CT with contrast shows your patient has diverticulitis. What is the most appropriate treatment?
Flatly + Cipro
Follow up with colonoscopy 6-8 weeks after resolution of Sx to exclude concomitant colon cancer or IBD
How do you diagnose IBD?
Colonoscopy
Which med is most appropriate in managing a patient with newly diagnosed IBD-UC?
Mesalamine (Lialda)
In the event a patient with IBD develops an acute flare, which class of meds may be helpful to reduce remission but are not appropriate for maintenance therapy?
Corticosteroids
Reasonable to provide short burst in tapering doses
What are the side effects/risks of chronic steroid therapy?
Increased appetite and weight gain Increased risk of infection Low bone density/osteoporosis Worsening diabetes PUD Cataracts Adrenal insufficiency
Always have an exit strategy when prescribing them
When are abx appropriate for IBD patients
Perinatal Crohn Disease (Cipro and Flagyl)
Side effect of Cipro?
Tendon rupture
Side effect of Flagyl
Disulfiram-like reaction with EtOH
Immunomodulators and biologists require frequent monitoring of which labs?
CBC
LFTs
Be cautious with infections, hepatotoxicity, and malignancies
