GI Disease Flashcards
Which of the following describes the mechanism of action of infliximab?
A. Monoclonal antibody that binds to integrin
B. Monoclonal antibody against interleukin-1
C. Monoclonal antibodythat binds to TNF
D. Monoclonal antibody that depletes CD20 B cells
E. Monoclonal antibody that inhibits T cell activation
Monoclonal antibodythat binds to TNF
Remicade
Infliximab is an anti-TNF monoclonal antibody approved for several autoimmune conditions, including inflammatory bowel disease.
Crohn’s Disease Tx
Options
Steroids (± thiopurine or MTX)
Anti-TNF ± thiopurine
Ustekinumab (Stelara)
Crohn’s Disease Tx
Mild disease of the ileum and/or right colon
Oral budesonide (Entocort EC, Uceris) for ≤ 3 months; after this course, discontinue treatment or change to thiopurine or methotrexate
Crohn’s Disease Tx
Moderate-severe disease
Anti-TNF agents
* Adalimumab (Humira)
* Infliximab (Remicade)
* Certolizumab (Cimzia)
Thiopurine (azathioprine, mercaptopurine)
Methotrexate
IL receptor antagonist
* Ustekinumab (Stelara)
Agents can be used as monotherapy or in combination
Crohn’s Disease Tx
Refractory to mod-severe treatments and/or steroid dependent
Integrin receptor antagonists:
Vedolizumab (Entyvio)
Natalizumab (Tysabri)
Integrin Receptor Antagonist
Risk, Form, & SE
Risk of Progressive Multifocal Encephalopathy (PML)
IV only
Don’t give w/ live vaccines
Hypersensitivity rxn can occur
Stop Tx after 12 + weeks of not working
Ulcerative Colitis Tx
Options
5-ASA (oral and/or rectal) ± steroids (oral or rectal)
Anti-TNF agents
Ustekinumab (Stelara)
Tofacitinib (Xeljanz)
Vedolizumab (Entyvio)
IV cyclosporine
Ulcerative Colitis Tx
Mild disease
Mesalamine (5-ASA) rectal and/or oral preferred
Ulcerative Colitis Tx
Moderate-severe disease
Anti-TNF agents
* Adalimumab (Humira)
* Infliximab (Remicade)
* Golimumab (Simponi)
Thiopurine (azathioprine, mercaptopurine)
Cyclosporine
IL receptor antagonist
* Ustekinumab (Stelara)
Ulcerative Colitis Tx
Refractory to mod-severe treatments and/or steroid dependent
Integrin receptor antagonists
* Vedolizumab (Entyvio)
Janus kinase inhibitor
* Tofacitinib (Xeljanz)
A pharmacist will counsel a patient on the correct use of Transderm Scop. Which of the following are correct counseling statements? (Select ALL that apply.)
A. Peel off the clear backing from the patch and apply it to a clean, dry, hairless area of the skin behind the ear.
B. Press firmly for at least 30 seconds to make sure the patch sticks well, especially around the edges.
C. Apply the patch 1 hour before the activity expected to cause motion sickness.
D. If motion sickness continues after 3 hours, apply a second patch behind the other ear.
E. Carefully wash hands after application and do not touch eyes if there is any medication on fingers.
Peel off the clear backing from the patch and apply it to a clean, dry, hairless area of the skin behind the ear.
Press firmly for at least 30 seconds to make sure the patch sticks well, especially around the edges.
Carefully wash hands after application and do not touch eyes if there is any medication on fingers.
An important counseling point for Transderm Scop is that it should be applied at least 4 hours before the activity expected to cause motion sickness.
As with most patches, it should not be cut.
Remove the old patch when it is time to place the next patch.
Scopolamine (Transderm Scop)
Things to remember
Alternate Ears
Can cause painful/mydriasis (dialation of pupils) if it gets in eyes
Last 3 days
Remove prior to MRI
Apply at least 4 hours before needed or the night before surgery
Press firmly for 30 secs
Proctitis refers to inflammation of the following:
A. Small intestine
B. Gall bladder
C. Liver
D. Rectum
E. Esophagus
Rectum
Proctitis is inflammation of the rectum.
It can be caused by IBD, sexually transmitted diseases or radiation of certain cancers.
Patients often complain of feeling like they need to have a bowel movement constantly.
Treatment is directed at the underlying cause.
Ulcerative Colitis
Mucosal inflammation confined to rectum & colon
Superficial Ulcerations
Continuous pattern
Crohn’s Disease
Transmural inflammation in any part of the GI tract
Thickened & edematous bowel wall → narrowed, ulcerated & fibrotic w/ fistulas
UC & Crohn’s
Diagnosis
Rule out other conditions
Laboratory blood tests for inflammation
Stool testing
Imaging tests: CT or MRI
Visualization with tissue biopsy
* Colonoscopy: entire colon
* Sigmoidoscopy: end part of the intestine, closest to the rectum (only for U.C.)
* Endoscopy: upper Gl, through mouth (only for upper Gl symptoms, Crohn’s Disease)
UC & Crohn’s: Lifestyle Measures And Supportive Care
Diet
Small frequent meals
Avoid trigger foods and substances
Prevent nutritional deficiencies
UC & Crohn’s: Lifestyle Measures And Supportive Care
Symptom Control
Antidiarrheals (loperimide [Imodium])
Antispasmodics (dicyclomine [Bentyl])
Nicotine - for UC
UC & Crohn’s: Lifestyle Measures And Supportive Care
Natural Products
Probiotics
Fish oils
Peppermint, herbal teas
Aminosalicylates is mainly used for?
UC
Sulfasalazine breaks down into?
Sulfapyridine - Toxcicity
5-ASA (mesalamine) - Efficacy
Mesalamine Brands
Pentasa (ER cap)
Asacol (ER tab)
Rowasa (Enema)
Canasa (Supp)
What med for UC leaves a ghost tablet?
mesalamine (Asacol)
Rectal Meds are usually given when?
QD HS
What is the physical (mechanical) cause of gastroesophageal reflux disease?
A. The histamine receptors over-secreteacid.
B. The parietal cells over-secrete acid.
C. Food gets stuck in the esophagus.
D. Lower esophageal sphincter tone is reduced.
E. The gastric muscle contracts suddenly.
Lower esophageal sphincter tone is reduced.
Gastroesophageal reflux disease (GERD) occurs when the stomach contents leak backward, through the lower esophageal sphincter (LES), into the esophagus.
Key drugs that can worsen GERD
ASA/NSAIDs
Bisphosphonates
Dabigatran
Estrogen products
Fish oil products
Iron supplements
Nicotine replacement therapy
Steroids
Tetracyclines
A pregnant female is asking the pharmacist for a recommendation for heartburn symptoms. The symptoms began during the third month of the pregnancy (she is currently 14 weeks pregnant). She states that whenever she eats anything, she has heartburn. She takes a daily prenatal vitamin. She gets adequate calcium from the vitamin and a cheese stick she eats with lunch. Choose the most appropriate recommendation.
A. Tagamet
B. Protonix
C. Tums
D. Misoprostol
E. Metoclopramide
Tums
Calcium antacids are considered first-line in pregnancy.
Cimetidine (Tagamet)
Antacids are ___ & ___ acting
Fast & shorting acting
Antacids Concerns
Al & Mg
Accumulation w/ severe renal dysfunction
Not Rec CrCl < 30
Antacids Concerns
Alka Seltzer Original
Contains Na & ASA
> 500 mg Na per tab → edema in pts w/ HF or cirrhosis
Risk of bleeding w/ ASA
Antacids
Tums
Calcium carbonate
Antacids
Mylanta Supreme
Calcium carbonate + Mg
Antacids
Maalox Advanced Maximum Strength
Calcium carbonate + simethicone (anti-gas)
Antacids
Milk of Magnesia (MOM)
Magnesium hydroxide
Antacids
Maalox, Mylanta Max
Magnesium hydroxide + Aluminum
Maalox & Mylanta Classic: + simethicone
Antacids
Alka-Seltzer
Sodium bicarbonate + ASA + citric acid
Antacids
SE
Unpleasant taste
Antacids SE
Calcium
Constipation
Bloating
Belching
Antacids SE
Aluminum
Constipation
Hypophosphatemia
Antacids SE
Magnesium
Loose stools
Use w/ Al may counter-balance
A patient asks the pharmacist if there is anything over-the-counter that she could take for car sickness. Which of the following would be appropriate? (Select ALL that apply.)
A. Diphenhydramine
B. Meclizine
C. Promethazine
D. Dimenhydrinate
E. Loratadine
Diphenhydramine
Meclizine
Dimenhydrinate
Diphenhydramine (Benadryl), dimenhydrinate (Dramamine) and meclizine (Bonine) are antihistamines with anticholinergic side effects, making them useful for preventing motion sickness.
Non-sedating, second-generation antihistamines (e.g., loratadine) are not helpful for motion sickness.
Promethazine (Phenergan) is available by prescription only.
How long before the activity expected to cause motion sickness should OTC motion sickness meds be taken?
30-60 mins
Transderm Scop vs OTC motion sickness
Does not work better but Transderm Scop last longer
Thiopurines
Drugs
Azathioprine (Azasan, Imuran)
Mercaptopurine (Purixan)
Thiopurines Effects
Not safe in pregnancy
Myelosuppression
Steroid Sparing (helps w/ excessive need for steroids)
Which of the following are short-term adverse effects of prednisone?
A. Cataracts and poor wound healing
B. Osteoporosis and immunosuppression
C. Fat deposits in the face and adrenal suppression
D. Cushing’s syndrome and growth retardation
E. Insomnia and mood changes
Insomnia and mood changes
A patient started on steroids short-term may experience elevated blood pressure, changes in mood, insomnia and elevated blood glucose, among other adverse effects.
The remaining choices are long-term adverse effects of corticosteroids.
IBD
Steroids
Use for Short Duration
Route - IV/PO/PR
Adverse Effects
* Short term
* Long term
IBD: Steroids
Adverse Effects: Short term
↑ appetite
Wt gain
Fluid Retention
Emotional instability
Insomnia
IBD: Steroids
Adverse Effects: Long term
Cushingoid Effects
Immunosuppression
Impaired wound healing
IBD
Which med do you not crush?
Entocort EC - for CD
Uceris - for UC
IBD: Steroids
Drug Intxn
Avoid w/ antacids
CYP3A4 inhibitors
A patient beginning treatment with Amitizashould be counseled on which common side effect?
A. Constipation
B. Hyponatremia
C. Hypertension
D. Somnolence
E. Nausea
Nausea
Amitiza (lubiprostone)
lubiprostone
Brand, Most common SE, Indication
Amitiza
Nausea
For Constipation
Take w/ food & water to ↓ nausea
Constipation
Osmotic Laxatives
Bulk-Forming Laxatives
Emollient/Stool Softener
Stimulant Laxatives
Calcium-Channel Activator
Bulk-Forming Laxatives
Examples
Psyllium (Metamucil)
Calcium polycarbophil (FiberCon)
Methylcellulose (Citrucel)
Wheat dextrin (Benefiber)
Osmotics
Mg Hydroxide (Milk of Magnesia [MOM])
Polyethylene glycol 3350 (Miralax)
Glycerin
Lactulose (RX)
Sodium phosphates (Fleet Enema)
Stimulants
Senna (Ex-Lax, Senokot)
Biscodyl (Dulcolax)
Emollients
Docusate sodium (Colace)
Senna + docusate
Senna S, Senokot S
Lubricants
Mineral Oil
Chloride Channel Activator
Lubiprostone (Amitiza)
Guanylate Cyclase C Agonists
linaclotide (Linzess)
Plecanatide (Trulance)
Peripharally-Acting Mu-Opioid Receptor Antagonists (PAMORAs)
Alvimopan (Entereg)
Methylnatrexone (Relistor)
Naloxegol (Movantik)
naldemedine (Symproic)
Non-Drug Tx for Constipation
Drugs that cause constipation
Antacids (aluminum- and calcium- containing)
Antidiarrheals
Clonidine
Colesevelam
Drugs with anticholinergic effects:
* Antihistamines (e.g., diphenhydramine)
* Antispasmodics (e.g., baclofen)
* Phenothiazines (e.g., prochlorperazine)
* TCAs (e.g., amitriptyline)
* Incontinence drugs (e.g., oxybutynin)
Iron
Non-DHP calcium channel blockers (especially verapamil)
Opioids
Sucralfate (contains an aluminum complex)
PPI MOA
Irreversibly bind to the gastric H/K-ATPase pump
PPI Drugs
Esomeprazole (Nexium)
Lansoprazole (Prevacid)
Omeprazole (Prilosec)
Dexlansoprazole (Dexilant)
Pantoprazole (Protonix)
Rabeprazole (Aciphex)
Omeprazole + sodium bicarbonate
Zegerid
When to take PPI
Generally 30-60 minutes before meals
Which PPI can be taken w/out regard to meal?
Dexlansoprazole (Dexilant)
Pantoprazole (Protonix) - tablets
Rabeprazole (Aciphex) - tablets
Which PPI comes IV?
exomeprazole (Nexium)
pantoprazole (Protonix)
PPI SE
Chronic Use
C.difficile associated diarrhea
Osteoporosis-related fractures (≥ 1 yr)
Hypomagnesemia
Vit B12 deficiency (use ≥ 2 yrs)
Long term use can ↑ risk of infection
Esomeprazole + naproxen
Vimovo
What drug does omeprazole & esomeprazole diminish the therapeutic effect of?
Clopidogrel
They inhibit CYP2C19
rabeprazole or pantoprazole have less risk
Non-Steroidal Anti-iniflammatory Drug-induced Ulcers
Cytoprotective Drugs
Misoprostol (Cytotec)
Sucralfate (Carafate)
Misoprostol + diclofenac (Arthrotec)
Cytoprotective Drugs
Misoprostol
Non-Steroidal Anti-iniflammatory Drug-induced Ulcers
Prostaglandin E1 analog
Boxed Warning: Abortifacient
SE: Diarrhea, abdominal pain
Arthrotec: NSAID ↑ risk of serious GI events (bleeding & ulceration & CV disease (eg, MI, stroke)
Cytoprotective Drugs
Sucralfate
Non-Steroidal Anti-iniflammatory Drug-induced Ulcers
Sucrose-sulfate-aluminumb complex, interacts w/ albumin & fibrinogen to form a physical barrier over an open ulcer
Take before meals
SE: Constipation
Notes: binding interactions - separate from other drugs
Arthrotec: NSAID ↑ risk of serious GI events (bleeding & ulceration & CV disease (eg, MI, stroke)
Which PPI does not come in a capsule form?
Pantoprazole
Which of the following statements concerning NSAIDs is correct? (Select ALL that apply.)
A. All NSAIDs can cause gastric ulcers when used chronically.
B. COX-2 selective NSAIDs have an increased riskof gastrointestinal side effects.
C. All NSAIDs should be used cautiouslyin patients with a history of cardiovascular or renal disease.
D. COX-2 selective NSAIDs have an increased risk of causing cardiovascular events.
E. Patients with high risk for GI bleeding should preferably use sucralfate concurrently with an NSAID.
All NSAIDs can cause gastric ulcers when used chronically.
All NSAIDs should be used cautiouslyin patients with a history of cardiovascular or renal disease.
COX-2 selective NSAIDs have an increased risk of causing cardiovascular events.
All NSAIDs should be used with caution in patients with existing cardiovascular or renal disease.
The COX-2 selective drugs have less GI risk but increased cardiovascular risk.
All NSAIDs increase the risk for gastric ulcers.
Which medication/s can be prescribed for irritable bowel syndrome with constipation in a 35-year-old female if OTC treatment options have failed? (Select ALL that apply.)
A. Linzess
B. Methylnaltrexone
C. Amitiza
D. Eluxadoline
E. Bentyl
Linzess
Amitiza
Linaclotide (Linzess)and lubiprostone (Amitiza) are approved for the treatment of various types of constipation, including IBS-C.
