GI Mucoskeletal Material Exam Two Flashcards
Colcrys
Colchicine
Prophylaxis: 0.6 mg BID, QD if intolerant, MAX 1.6 mg/day
0.3 mg QD if CrCl <30
Flare: Day One 1.2 mg then 0.6 mg in 1 hr, Day 2 & MD 0.6 mg QD or BID
Alternative Day 1 Dosing: 0.6 mg TID MAX 1.8 mg/day
CI: Amiodarone, Verapamil, 3A4 Inhibitors Itraconazole
AE: GI Upset
Warning: Blood dysscrasias, neuromuscular toxicity
Ulcerative Colitis Meds
MILD-MOD: 5-ASA
Mod-Severe: Budesonide or Prednisone
Severe-Fulminant: IV Methylprednisolone or Hydrocortisone
Crohn’s Disease Meds
MILD-MOD: Sulfasalazine, Metronidazole (perianal), Budesonide (small bowel)
Mod-Severe: Prednisone + infliximab, adalimumab, certolizumab, methotrexate, azathioprine, mercaptopurine, or vedolizumab
Severe-Fulminant: IV hydrocortisone
Proton Pump Inhibitors
MOA: irreversibly inhibit the K+/H+ ATPase which inhibits the final step in the secretion of hydrogen ions into the gastric lumen lowering stomach acid
Indication: Erosive and Maintenance GERD therapy, H. Pylori, Ulcers
Warnings: Pneumonia, risk of C.Diff, risk of hip fracture, hypomagnesemia/vitamin b12 deficiency
AEs: HA, abdominal pain
DDIs: PLAVIX via 2C19, WARFARIN, Posaconazole, Iron Salts
PC: USE DAILY NOT PRN
Initial treatment for erosive esophagitis typically 4-8 weeks, then begin long term maintenance therapy
Aciphex
Rabeprazole
Caps/Delayed Release Tabs
Cap: 30 mins before meals
Tabs: without regard to meals
Dose: 20 mg
4-8 wk initial treatment, 20 mg daily maintenance
Nexium
Esomeprazole
Caps/Granules/IV/Tabs
60 minutes before food
Dose: 20-40 mg
4-8 wk initial treatment, 20 mg daily maintenance
Prevacid
Lansoprazole
Caps/Tabs/Oral Disintegrating Tabs
30-60 mins before meals
Food DECREASES absorption
Dose: 30 mg
8 wk initial treatment, 30 mg daily maintenance
Prilosec
Omeprazole
Tabs/Caps/Oral Suspension
30-60 mins before meals
Dose: 20-40 mg
8 wk initial treatment, 20 mg daily maintenance
Protonix
Pantoprazole
Tabs/IV/Delayed Release Oral Suspension
TAB: without regard to meals
Dose: 40 mg
8 wk initial treatment, 40 mg daily maintenance
Dexilant
Dexlansoprazole
Caps: without regard to meals
Dose: 60 mg
8 wk initial treatment, 30 mg daily maintenance
H2 Receptor Antagonists H2RAs
MOA: Reversibly complete with histamine at the H2 receptor sites in the parietal cells of the stomach to inhibit acid secretion
Indication: heartburn OTC, ulcers, MILD GERD WITHOUT esophagitis
Warnings: Vitamin B12 deficiencies
AEs:
DDIs: Benzos, Carbamazepine, BB, Phenytoin, Warfarin, and Plavix
PC: Take with food, take antacids no sooner than 2 hrs following dose
Pepcid
Famotidine
PO,IV
CAN be given with Antacids
Dose: 10-20 mg BID
Tagamet
Cimetidine
TABS
DRUG Interactions
Take with food; take antacids no sooner than 2 hrs
Zantac
Ranitidine
Withdrawal from market due to NDMA levels
Carafate
Sucralfate
MOA: forms protective coating on peptic ulcer
AE: constipation, indigestion
DDI: digoxin, warfarin, phenytoin, theophylline, levothyroxine, tetracyclines, and antacids
AVOID antacids within 30 mins before/after
Dose: 1 gram QID (before meals and at HS)
4-8 wk initial course; 1 gram BID maintenance
Cytotec
Misoprostol
MOA: PGE1 Analog
Indication: Prevent NSAID induced gastric ulcers
CI: Pregnancy
AE: Diarrhea, abdominal pain
PC: Take with meals and at bedtime
Dose: QID dosing
5-Aminosalicylic Acid Derivates
MOA: Anti-Inflammatory
Indication: IBD
CIs: ASA allergy, sulfa allergy
AEs: Abdominal pain, dyspepsia, HA, nausea
Asacol
Mesalamine
Delayed Release TABS
PC: may cause constipation, do not cursh, avoid concurrent antacids
Colazol
Balsalazide
CAPS
PC: can sprinkle contents on applesauce
Dipentum
Olsalazine
CAPS
PC: may cause diarrhea; take with food
Azulfidine
Sulfasalazine
Regular and Delayed Release TABS
PC: may cause rash/anorexia, folate deficiency, hepatic necrosis, infections
Take at even intervals after meals with ample fluids
Take >3-4 wks to see effect
Monitor LFTs
Bentyl
Dicyclomine
Anticholingeric; antispasmodic
Indication: IBS
CI: glaucoma, GI obstruction, severe UC, unstable CV
PC: drowsiness, avoid alcohol
TID-QID
Levsin/Levbid
Hyoscyamine
Anticholinergic; antispasmodic
Indication: IBS
CI: glaucoma, GI obstruction, severe UC, unstable CV
PC: empty stomach 30-60 mins prior, non concomitant antacids, do not crush or chew Levbid
Levsin Dosing
Levsin 0.125 mg TAB/SL: 3-4x a day prn
Empty stomach prior to meals or prn
Levbid Dosing
Levbid 0.375 mg: BID
Extended release tablet
Lomotil
Anticholinergic and Opioid Agnist
Indication: management of diarrhea
CI: pseudomembranous colitis
ADD ATROPINE to deter abuse
2.5 mg TAB: 2 tabs or TSP QID than daily BID
Short term use, DC if no response within 10 days
Lotronex
Alosetron
5HT3 Antagonist
Indication: IBS w/Diarrhea FEMALES (REMS)
CI: constipation, IBS, Flucoxamine (DDI increase risk of serotonin syndrome)
PC: DC immediately if constipation occurs
Viberzi
Eluxadoline
Mu-Opioid Receptor Agonist
Indication: IBS w/diarrhea
CI: alcohol abuse, pancreatitis, GI obstruction, severe constipation
DDI: OAT1B1 Inhibitors (gemfibrozil)
Warning: Sphincter of Oddi Spasm and risk of pancreatitis; severe constipation
PC: take with food
Imodium
Loperamide
Peripheral Mu-Opioid Receptor Agonist/Antisecretory
Indication: Acute/Chronic Diarrhea
CI: diarrhea secondary to infection
Warning: CNS depression, nausea, constipation, cramping
PC: if siarrhea persists beyond 2 (or 10 days for people with chronic diarrhea) days call provider
Initial 4 mg then 2 mg after each loose stool
MAX 16 mg/day
What are the common/classic AEs of anticholinergic agents?
Beer List Considerations
- Blurry Vision
- Dry Mouth
- Urinary Retention
- Constipation
- CNS Impairment
- Heat Exhaustion
- Potential Pyschosis
Miralax
Polyethylene Glycol
Osmotic Laxative
Indication: relief of constipation
AE: bloating, cramping, flatulence, nausea
Powder/Packet
1 scoop 17g in 8 oz liquid once daily, use water, juice, dosa, tea, coffee
May take 48-96 hrs to see effect
CoLyte
Polyethyene Glycol
Osmotic Laxative
Indication: bowel cleansing prior to GI procedure
80z of reconsituted solution every 10 mins as directed; drink until bowel effluent clear or 4 L gone
What are the steps to counsel a patient on for CoLyte?
- Add water and shake well to dissolve powder
- Can chill after reconsitution to improve taste
- Do NOT eat wtihin 3-4 hrs prior to starting prep
- Follow physician directions for when to start prep
- Meds within 1 hr prior to prep may not be absorbed
- Drink glasses quickly
- No food or drink after completion of bowel prep
Senokot
Senna
Stimulant Laxative
Indication: constipation
AE: abdominal cramp, diarrhea, N/V
ONSET: within 6-24 HRS
PC: Take once (or BID) daily doses at bedtime, adminster 2 hrs before or after other medications
Colace
Docusate
Stool Softener
Indication: Relief/Prevention of constipation
PO or Rectal
DDI: do NOT combine with mineral oil
PC: more effective for prevention than treatment
ONSET: 12-72 HRS
QD or BID, take with full glass of water
Chronulac
Lactulose
Osmotic Effect
Indication: constipation, portal system encephalopathy PSE
PSE: TITRATE TO 2-3 STOOLS/DAY
PO/Packet/Solution/Rectal
AE: gas, abdominal discomfort
ONSET: MAY TAKE 24-48 HRS TO PRODUCE BOWEL MOVEMENT
Amitiza
Lubiprostone
Prosecretory Agent
Indication: IBS w/constipation in FEMALES
CI: GI obstruction
DDI: METHADONE
AE: Nausea
PC: Administer with food and water to decrease nausea
Linzess
Linaclotide
Prosecretory Agent
Indication: IBS w/constipation
CI: GI ostruction or Use in <6 yrs
AE: Diarrhea
PC: Empty stomach 30 mins prior to 1st meal
PAMORAs
Peripheral Mu Opioid Receptor Antagonist
METHYLNALTREXONE/RELISTOR
MOA: peripherally acitng mu-opioid receptor antagonists
DOSE ADJUST RELISTOR in renal impairment
Warning: Risk of GI Perforation
NEVER USE IN CONFIRMED OR SUSPCTED GI OBSTRUCTION
AVOID in impaired integrity of GI wall
Monitoring: symptoms of opioid withdrawal
Prucalopride
Motegrity
Selective 5-HT Agonist
Warning: avoid if risk of Gi perforation
AE: HA, dizziness, fatigue, diarrhea, SUICIDAL IDEATION
Monitoring: mood and frequency of bowel movements
What are the AEs of Dopamine Receptor Antagonists?
Movement Disorders
What are the AEs of Serotonin Antagonists?
- Serotonin Syndrome
- HA
- Constiaption
- Fatigue
- OTc Prolongation
Compazine
Prochlorperazine
MOA: Dopamine Antagonist central
Indication: severe N/V
CI: CNS Depressants and Children <2 yrs <20lbs
AE: Drowsiness, dizziness, and blurred vision
Phenergan
Promethazine
Dopamine Antagonist
Indication: ACUTE N/V
Dosing: IV/IM/SQ avoided due to risk of tissue injury
AE: drowsiness, anticholinergic
Zofran
Ondansetron
Serotonin Antagonist
Indication: prevention of chemotherapy/post-operative induced N/V
AE: HA, fatigue, constipation
QTc Prolongation w/high doses
8-16 mg/day and pre-medicate with 1st dose up to 30 mins before chemo
Reglan
Metoclopramide
Dopamine and Serotonin Antagonist
Indication: GERD, diabetic gastroparesis, prevention of chemo N/V
CI: GI obstruction
BBI: risk of TARDIVE Dyskinesia, limit use to <12 weeks
AE: drowsiness, fatigue, movement disorders, OTc PROLONGATION
PC: QID take 30 minutes prior to food
NSAIDs
MOA: reversibly bind and inhibit COX enzymes, preventing synthesis of prostanoids and prostaglandins
Analgesic/Antipyretic/Anti-Inflammatory
Indication: OA, RA, GOUT
BBI: increased risk of CV events/stroke/GI ulceration/bleeding/perforation
PC: take with food/milk to minimize GI upset and avoid/limit alcohol intake
What risk factors increase the risk of a GI Bleed when on NSAIDs?
- Long duration of use
- Higher doses
- Age above 60
- History of PUD
- Alcohol abuse
- Concomitant glucocorticoids and/or anticoagulants
What are the Class DDIs of NSAIDs?
- Warfarin 2C19 w/Celecoxib
- All Anticoagulants
- Probencid: decrease NSAID excretion
- Lithium: increased lithium levels
- Anti HTN Agents: NSAIDs decrease their effect
- Loop Diuretics: NSAID reduce their efficacy
- ACE Inhibitors: nephrotoxicity due to additive effects
- High dose Methotrexate
- Systemic Steroids
- ASA: reduced cardioprotective effect, bleed risk
How can NSAIDs cause an AKI when used with ACE Inhibitors?
ACE: efferent dialate
NSAID: afferent constrict
= lower pressure and lower filtration = reduced eGFR
Naprosyn/Aleve
Naproxen
LONG ACTING
Do not crush
500-1000 mg/day
Daily dose usually split BID; may rarely increase to 1500 mg/day
Motrin/Advil
Ibuprofen
SHORT ACTING
1200-1300 mg/day
Daily dose split 3-4x a day
Lodine
Etodolac
SHORT ACTING
Do not crush
Voltaren
Diclofenac
SHORT ACTING
Oral/Ophthalmic/Topical Gel
Up to 200 mg/day
Clinoril
Sulindac
Prodrug
LONG ACTING
Feldene
Piroxicam
LONG ACTING
PO QD
Indocin
Indomethacin
SHORT ACTING
Take w/food, milk, or antacids
Up to 200 mg/day
Daily dose usually split 2-3x a day
ER: Up to 150mg/day
Toradol
Ketorolac
ORAL can only be given after first receiving a parenteral dose
5 DAY LIMIT ON DOSING DUE TO INCREASED ADEs
CI: Pentoxifylline/Probenecid = severe renal impairment
SHORT ACTING
IM = 60 mg once, than 30 mg q 6h
IV = 30 mg once, than 30 mg q 6h
PO = 20 mg, then 10 mg q 4-6h
Lower doses for those >65 yrs and/or <50 kg
Relafen
Nabumetone
Prodrug
LONG ACTING
Celebrex
Celecoxib
SHORT ACTING
DDI: Warfarin, 2C19 Fluconazole
OA: 200 mg/day, either QD or BID
RA: 200-400 mg/day, BID
Mobic
Meloxicam
LONG ACTING
7.5-15 mg PO QD
Disalcid
Salsalate
Inhibits prostaglandin synthesis
Lacks effect on platelet function
Zyloprim
Allopurinol
100-800 mg daily
Doses >300 mg may be given in divided doses
CI: HLAB5801 positive
DDI: Azathioprine
Methotrexate
Folate Antagonist
IM/SQ/PO
RA, once weekly dosing
BBW: bone marrow suppression, hepatotoxicity, infection, etc.
CI: pregnancy
DDI: NSAIDs
AE: N/V, diarrhea, photosensivity
Monitor: CBC, LFTs, SCr/BUN
Plaquenil
Hydroxychloroquine
SLE, RA
Warning: cardiomyopathy, bone marrow suppression, retinal toxicity
AE: GI Upset
Monitoring: CBC and opthalmologic
PC: take with food or milk, watch for vision changes, do not crush
200-400 mg QD or BID
MAX 400 or >5mg/kg/day whichever one is lower
JAK Inhibitors
Warning: serious infections (zoster), lymphoma, malignancies, thrombosis (DVT/PE), and tuberculosis
XELJANZ/Tocacitinib
Humira
Adalimumab
TNFa Inhibitor
CD, UC, RA, and Psoriasis
Muscle Relaxants
CI: Concomitant CNS Depressants
Primarily for short term use
Flexeril
Cyclobenaprine
Indication: painful MS conditons
CI: CHF, arrhythmias, acute MI
AE: drowsiness, dizziness, dry mouth, fatigue
Robaxin
Methocarbamol
Indication: painful MS conditons
AE: drowsiness
3-4 g/day
QID
Doses of 6g/day for the first 2-3 days up to 8g
Norflex
Orphenadrine
Indication: Painful MS conditions
CI: conditions aggravated by anticholinergic effects (glaucoma or GI obstruction)
AE: drowsy, dizzy, dry mouth
Do not crush or chew
Skelaxin
Metaxalone
Painful MS Conditions
CI: impaired hepatic/renal function
AE: drowsy, dizzy, nausea
Warning: serotonin syndrome
Soma
Carisoprodol
Painful MS Conditions
AE: drowsy, nausea
WARNING: SEIZURES or Central Depressant Activity (abuse)
Zanaflex
Tizanidine
RENAL DOSE ADJUST
CI: Fluvoxamine or Cipro 1A2 inhibitors
AE: hypotension and abnormal LFTs
Lioresal
Baclofen
RENAL DOSE ADJUST
CI: do not DC abruptly = hallucinations/seizures
DDI: CNS depressants
AE: URINARY RETENTION
