GI Disorders Flashcards
foods that lower LES
alcohol
caffeine
chocolate
citrus
garlic/onion
peppermint
nicotine
drugs that lower LES
alpha adrenergic agonists
calcium channel blockers
anticholinergics
theophylline
benzos
opiates
H2RA drug interactions
cimetidine worst
warfarin, theophylline, decreased absorption of antifungals
best PPI w/clopidogrel
pantoprazole
PPI drug interactions
methotrexate - increases toxicity
antifungals have decreased absorption due to lower pH
highest risk NSAIDs for GI bleed
ketorolac
indomethacin
piroxicam
highest risk in first 3 months
What can cause a false negative in H. pylori?
PPI
Antibiotics
when do you treat w/H pylori and why?
always
carcinogen
different types of H pylori tests?
serologic (blood) - can’t differentiate b/w new or old or eradication
urea breath test - can diagnose and test eradication
stool antigen - not quite as sensitive or specific
invasive tests - expensive, time consuming and difficult
1st line for H pylori?
PPI + 2 antibiotics
pantoprazole (double dose or standard) + clarithromycin 500mg BID + amoxicillin 1000mg BID + Flagyl 500mg TID
for 14 days
quadruple therapy for H pylori
Bismuth subsalicylate + Flagyl + TCN/Doxy + PPI
pantoprazole (double/standard) + bismuth subsalicylate 300mg QID/bismuth subcitrate 120-300mg QID + Flagyl 250-500mg TID-QID + TCN 500mg QID
for 10 - 14 days
sequential dosing for H Pylori
PPI (standard/double) + amoxicillin 1000mg BID x 5 - 7 days
PPI BID + Clarithromycin 500mg BID + Flagyl/tinidazole 500mg BID x 5 - 7 days
complex and not a favorite
High risk CV and High risk Bleed risk - what NSAID to use?
avoid NSAIDs and COX2 Inhibitors
High risk CV and Low/Mod Bleed risk - what NSAID to use?
naproxen and PPI
Low risk CV and low risk GI bleed - what NSAID to use?
NSAIDs ok
Low risk CV and mod risk GI Bleed - what NSAID to use?
NSAID and PPI
Low risk CV and high risk GI bleed - what NSAID to use?
COX 2 Inhibitor and PPI
why use erythromycin in endoscopy with GI bleed?
erythromycin 250mg IV 30 to 60 minutes prior will push blood distally and improve diagnostic yield
Protonix Therapy with GI bleed
Protonix 80mg IVP then 8mg/hr for up to 72 hours after surgery
BID PPI for 2 weeks after endoscopy
Indications for stress-ulcer prophylaxis inpatient
1 of following:
ventilator >48 hrs, platelets <100, INR >1.5, burns, head/spinal injury, hx of bleeds, trauma, transplant, low pH, surgery >4hr, acute lung injury
2 of the following:
sepsis, ICU stay >7 days, occult bleeding, >250mg hydrocortisone, hepatic failure, renal insufficiency, hypotension, anticoagulation
markers of inflammation
IL-1
IL-6
TNF
ulcerative colitis
(location, perfs, cancer risk, polyps, megacolon)
rectum and colon
no perfs
increased cancer risk
polyps and toxic megacolon
Crohn’s disease
(location, perfs, cancer risk, polyps, megacolon)
from mouth to anus - usually ileum
deep ulcers, fistulas, perfs
malabsorption but no cancer or polyps
Ulcerative Colitis Mild Stages
<4 poops a day
Normal ESR
topical treatment
Ulcerative Colitis Moderate Stages
> 4 poops a day
could have fever, anemia, tachycardia
treat with topicals and PO sulfasalazine then budesonide/steroids
Ulcerative Colitis Severe Stage
> 6 poops a day w/ blood
fever, HR >90, ESR>30, Hgb <75% of normal, tender abdomen, bowel edema
treat with PO Budesonide, then steroids, then TNF-a
Ulcerative Colitis Fulminant
> 10 stools a day with blood
have to have blood to be fulminant, dilated colon
treat w/methylprednisolone 40-60mg daily, if fails then do infliximab or cyclosporine
Crohn’s disease mild/moderate Stages
no systemic symptoms
can do mesalamine/sulfasalazine
minimally effective
budesonide 9mg/day
flagyl 10-20mg/kg/day
ciprofloxacin 1g/day + Flagyl
Crohn’s disease Mod/Severe Stages
sxs anemia, N/V, >10% weight loss
Prednisone 40-60mg/day or Budesonide 9mg/day if terminal ileum, TNF-a + Thiopurines
Crohn’s disease Severe Stages
no response to steroids
can have high temps, abdominal pain, vomiting, possible obstruction, abscess
treat w/ IV steroids, parenteral nutrition after 5 - 7 days, possibly cyclosporine IV
Budesonide PO is good for what GI location?
8 week cycles best, not long term
for ileum and ascending colon
have rectal foam for descending colon
antispasmodics for colonic disease
dicyclomine
propantheline
hyoscyamine
cholestyramine for colonic disease
sequesters bile acid to decrease diarrhea after ileal resection
aminosalicylates
sulfasalazine - activated in the colon, ADR hemolytic anemia, hepatotoxicity, bone marrow suppression, pancreatitis, decreases sperm production
remove sulfa - mesalamine, olsalazine, balsalazide - could cause nephrotoxicity
location of action for aminosalicylates in colonic disease
colon only, activated there
corticosteroids for colonic disease
budesonide is 15x more potent than prednisone
takes 2 weeks to transfer from prednisone to budesonide
Mercaptopurine
azathioprine
TPMT metabolizes azathioprine to mercaptopurine
pancreatitis, bone marrow suppression, N/V/D, rash, hepatotoxicity, T-Cell lymphoma esp if male and adds TNF-a
methotrexate
bone marrow suppression, N/V/D, pulmonary toxicity, hepatotoxicity
tofacitinib
oral JAK inhibitor for moderate to severe UC
10mg PO BID
if no relief after 16 weeks then discontinue
D/C - renal impairment, mod hepatic failure, 3A4/2C19 inhibitor, stop if ANC < 0.5, interrupt if Hgb <8 or drops >2, infection
ADR - URTI, increase CPK, rash, HA, diarrhea, herpes zoster, TB, neutropenia, low Hgb, lymphocytopenia, malignancies, GI perf
can cause DVT, PE, and thrombosis with RA if >50 yo and CVD if higher than recommended doses given
biologics for UC/Crohn’s
infliximab - combine w/azathiopurine for induction, increases HF, antibodies, bone marrow suppression, cancer risk, and CNS effects
adalimumab** - 2nd line, less antibodies
certolizumab** - most effective agent if CRP > 10
golimumab** - only once others have failed or steroid dependent
natalizumab - must test for antibodies, increased cancer risk a lot, no combo therapy
vedolizumab - similar to natalizumab but less cancer risk
ustekinumab - IL-12 and IL-23 last line essentially
octreotide dosing for varices
octreotide 50mcg IVP then 50mcg/hr for 3 to 5 days
vasopressin for variceal bleeding
0.2 - 0.4units/min + nitroglycerin 40-400mcg/min x 3 - 5 days
must use combination therapy
beta blockers for varicese
non-selective
propranolol, carvedilol, nadolol
goal resting HR is 55-60 or 25% reduction from baseline
medication that increased risk of death in variceal bleeding
isosorbide will decrease HR but increased risk of death in primary prophylaxis
bacteria in spontaneous bacterial peritonitis
E coli, Klebsiella, Strep pneumo, Rarely MSSA
albumin dosing in spontaneous bacterial peritonitis
albumin 1.5g/kg on admission
albumin 1g/kg on day 3 reduced mortality and renal failure
prophylaxis for bacterial peritonitis
ciprofloxacin or Bactrim DS 5 days a week
hepatorenal failure and peritoneal issues
vasoconstrictors for BP (levophed) or midodrine
and octreotide
hepatitis A exposure
Immune globulin 0.1ml/kg IM within 2 weeks of exposure
chronic liver disease gets a vaccine and the IG
Hep B Treatment
Treat if ALT >2x ULN and DNA load is >20k
Pegylated interferon (Pegasys) 180mcg SC weekly x yr - initially increases ALT
Pegasys
pegylated interferon given 180mcg SC qweekly x 48 weeks Hep B
is a cytokine w/antiviral, antri-proliferative, and anti-immune activity
can cause bone marrow suppression, leukopenia, thrombocytopenia, CNS effects, seizures, psychosis, flu, thryoid issues, alopecia, CVA
Hep B Reverse Transcriptase Inhibitors
Entecavir 1mg daily
Tenofovir
can also do lamivudine or telbivudine but not as good, has resistance, BBW for lactic acidosis, hepatomegaly, osteoporosis
Hepatitis C Drugs
Zepatier (elbasvir/grazoprevir) PO daily 12 weeks
Mavyret (glecaprevir/pibrentasvir) PO daily 8-16 weeks
Interferon/Peg-interferon
Ribavirin PO BID x 12 wks
Sofosbuvir daily x 12 weeks, has combo w/velpatasvir +/- voxilaprevir but still needs ribavirin
Heb B Vaccines
Heplisav “saves” a dose (2)
Engerix (give 4th dose if HD)
Twinrix is only for adults who are unvaccinated
drug interactions with antiretrovirals
PPI’s decrease [x]
anticonvulsants, rifampin, St Johns Wort
amodiodarone
statin [x] is increased
drugs that can cause pancreatitis
amiodarone
azathioprine
cannabis
diuretics
estrogen
exenatide
mesalamine
sulfasalazine
sitagliptin
TCN
Bactrim
Depakote
pain killer to avoid with pancreatitis
demerol
pancreatic enzyme replacement dose
40k units/meal and 1/2 for snacks
500-1000u/kg/meal
DOC for HIV ART diarrhea
crofelemer, octreotide
DOC for short bowel syndrome diarrhea
teduglutide (GLP2)
constipation meds that increase fluid secretion and help transit time
linaclotide 290 for IBS
linaclotide 145 for idiopathic
plecanatide 3mg daily
opioid induced constipation drugs
methylnaltrexone
naldemedine
naloxegol
drugs for idiopathic constipation
linaclotide 145
prucalopride (suicide ADR)
lubiprostone 24mcg BID w/meals
drugs for IBS
linaclotide 290mcg
lubiprostone 8mcg
tenapanor
lubiprostone
take w/meals
24mcg BID for idiopathic constipation
8mcg BID for IBS
need neg pregnancy test before use
IBS anticholinergic contraindications
GI obstructions
myasthenia gravis
glaucoma
drugs for IBS-diarrhea
SSRIs and TCAs
eluxadoline
alosetron
rifaximin
tegaserod
for IBS constipation in women <65 and low cardiovascular risks
may cause ischemic bowel but works - use 2nd line behind lubiprostone and linaclotide
phenothiazine drugs and ADRs
promethazine, prochlorperazine
EPS, injection site reactions, anticholinergic, anti-dopamine
serotonin antagonist drugs and ADR
ondansetron, dolasetron, granisetron, palonosetron
QTc prolongation
correct mag and k
haloperidol/droperidol side effects for N/V
Extrapyramidal side effects
QTc prolongation
NK1 antagonists
fosaprepitant, neupitant/aloxi, rolapitant
emend is only inj. others tabs
reduces birth control pill and warfarin
rolapitant has 7 days 1/2 life
CYP 3A4 interactions
Diclegis / Bonjesta
doxylamine and pyridoxine 10/10mg for pregnancy if all others fail
Category A
