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Therapeutics Fall 2016 > Module 1 - GI Disorders > Flashcards

Module 1 - GI Disorders Flashcards

1
Q

Symptoms associated with N/V

A

pallor, tachycardia, diaphoresis

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2
Q

CTZ

A

Chemoreceptor Trigger Zone

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3
Q

NTS

A

Nucleus of the Tractus Solitarius (vomiting center)

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4
Q

Which medication should not be used in children and why?

A

promethazine; respiratory depression

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5
Q

Serotonin Antagonists at CTZ, NTS, and GI tract

A
  1. ondansetron
  2. granisetron
  3. palonosetron
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6
Q

Aloxi (brand)

A

palonosetron (generic)

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7
Q

Butyrophenones MOA

A

Dopamine inhibition at CTZ

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8
Q

Compazine (brand)

A

prochlorperazine (generic)

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9
Q

Maalox, Mylanta

A

Aluminum Hydroxide, Magnesium Hydroxide, Simethicone

antacid

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10
Q

Zantac (brand)

A

ranitidine (generic)

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11
Q

Phenothiazines MOA

A

Dopamine inhibition at CTZ

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12
Q

Drugs with SE of EPS

A
  1. Phenothiazines (promethazine, eg)
  2. Butyrophenones (droperidol, eg)
  3. Benzamides (metoclopramide, eg)
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13
Q

hyperemesis gravidarum

A

complication of pregnancy characterized by severe n/v such that weight loss and dehydration occur

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14
Q

Assessment of NV

A
  1. # of episodes
  2. Onset
  3. Duration of sx
  4. Severity of nausea (0-10)
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15
Q

Which drug used to tx NV has a BB Warning for the risk of EKG abnormalities (QT prolongation)?

A

droperidol (Inapsine)

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16
Q

Which drug is excellent for breakthrough NV?

A

olanzapine

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17
Q

List 3 Neurokinin-1 Antagonists

A
  1. aprepitant (PO)
  2. fosaprepitant (IV)
  3. rolapitant (PO)
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18
Q

Marinol (brand)

A

dronabinol (generic)

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19
Q

Emend (brand)

A

aprepitant (generic)

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20
Q

Cesamet (brand)

A

nabilone (generic)

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21
Q

Cannabinoids

A

dronabinol (CIII)

nabilone (CII)

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22
Q

Which drug class is especially useful for anticipatory NV?

A

Benzodiazepines (lorazepam, alprazolam, eg)

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23
Q

Reglan (brand)

A

metoclopramide (generic)

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24
Q

metoclopramide dose for NV

A

(pre-tx with Benadryl to prevent EPS), then:

20-50 mg

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25
Q

About how long is the onset for an IM dosage form in tx of NV?

A

~30 minutes

ODT, IV, PR faster

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26
Q

When to apply scopolamine patch? Duration of action?

A

Appy 6-8 hrs before needed;

Duration 72 hrs

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27
Q

When to take dimenhydrinate or meclizine to tx motion sickness?

A

30-60 min before needed (PO)

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28
Q

Dramamine (brand)

A

dimenhydrinate (generic)

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29
Q

Bonine (brand)

A

meclizine (generic)

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30
Q

PONV treatment of highest risk pts

A

Always use 2 agents:

  1. 5-HT3 antagonist
  2. dexamethasone, droperidol, aprepitant, or metoclopramide
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31
Q

CINV Acute Emesis (onset, max, resolution)

A

After chemo administration–
Onset: 1-2 hrs
Max: 5-6 hrs
Resolve: 12-24 hrs

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32
Q

CINV Delayed Emesis (onset, max, resolution)

A

After chemo administration–
Onset: post 24 hrs
Peak: 48-72 hrs
Resolve: gradual over 1-3 days

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33
Q

Most difficult type of CINV to tx

A

Delayed Emesis

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34
Q

Highly emetogenic drugs

A 
#1. cisplatin
2. cyclophosphamide + doxorubicin
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35
Q

Prevention of Acute CINV (high emetic risk)

A

3 drug approach over 2-4 days:

  1. 5-HT3 antagonist
  2. dexamethasone
  3. aprepitant or olanzapine
  4. (+/-) lorazepam
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36
Q

Prevention of Acute CINV (moderate emetic risk)

A
  1. 5-HT3 antagonist (palonosetron preferred)

2. dexamethasone

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37
Q

Prevention of Acute CINV (low emetic risk)

A

*dexamethasone,

metoclopramide, prochlorperazine, ondansetron, granisetron

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38
Q

ROA for Acute vs Breakthrough CINV

A

Acute: PO whenever possible
Breakthrough: IV/PR often required

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39
Q

Tx of Acute Breakthrough CINV

A

Agent from different drug class

  1. prochlorperazine
  2. nabilone
  3. metoclopramide (+ benadryl)
  4. haloperidol
  5. olanzapine
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40
Q

Acute constipation

A

Less than 3 BM/week

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41
Q

Chronic constipation

A

Sx > 6 weeks

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42
Q

Disease states that slow down GI motility

A
  1. Diabetes
  2. Parkinson’s
  3. CNS/spinal cord injury
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43
Q

Constipation referral

A

Sx > 2 weeks w/o significant relief

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44
Q

How much fiber recommended per day?

A

20-30 g fiber/day

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45
Q

Metamucil (brand)

A

psyllium (generic)

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46
Q

Citrucel (brand)

A

methylcellulose (generic)

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47
Q

Fibercon (brand)

A

calcium polycarbophil (generic)

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48
Q

Which bulk laxative produces less gas?

A

methylcellulose (Citrucel)

-mix with cold water

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49
Q

Which bulk laxative produces less gas?

A

methylcellulose (Citrucel)

-mix with cold water

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50
Q

Surfactant (stool softner)

A

docusate (Colace)

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51
Q

Saline Laxatives

A
  1. MOM
  2. Mg Citrate
  3. Fleet’s Saline Enema
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52
Q

Hyperosmotic Agents

A
  1. Sorbitol
  2. Lactulose
  3. PEG
  4. Glycerin supp.
  5. Karo Corn Syrup
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53
Q

Stimulant Laxatives

A
  1. Senna
  2. Bisacodyl
  3. Castor Oil
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54
Q

Stimulant Laxative MOA

A

Locally irritates nerves which stimulates motility

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55
Q

Cl- Channel Activator for idiopathic constipation or IBS-C

A

lubiprostone (Amitiza)

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56
Q

Amitiza (brand)

A

lubiprostone (generic)

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57
Q

lubiprostone (Amitiza) dosing

A

Take with food and water:
24 mcg BID (constipation)
8 mcg BID (IBS-C)
*avoid in pregnancy

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58
Q

Guanylate Cyclase Activator for idiopathic constipation or IBS-C

A

linaclotide (Linzess)

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59
Q

Linzess (brand)

A

linaclotide (generic)

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60
Q

linaclotide (Linzess) dosing

A

Empty stomach, 30 min before breakfast:
145 mcg daily (constipation)
290 mcg daily (IBS-C)

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61
Q

Mu opioid receptor antagonists for constipation tx

A
  1. methylnaltrexone (Relistor): 8-12 mg SC QOD

2. naloxegol (Movantik): 25 mg PO daily on empty stomach

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62
Q

Relistor (brand)

A

methylnaltrexone (generic)

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63
Q

Movantik (brand)

A

naloxegol (generic)

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64
Q

alvimopan (Entereg) indication

A

tx of post-op ileus (leads to constipation)

-restricted-access program; high risk pts only

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65
Q

GI Prep: tx classes

A

Hyperosmotics or Saline Laxatives

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66
Q

Classifications of diarrhea (acute, persistent, chronic)

A

Acute: less than 2 weeks
Chronic: greater than 1 month

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67
Q

Most common infectious cause of diarrhea in adults?

A

Rotavirus

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68
Q

4 types of diarrhea pathophysiologies?

A
  1. Secretory: ion transport
  2. Osmotic: poorly absorbed substances
  3. Exudative: IBD
  4. Altered Intestinal Transit: decreased exposure time (bowel resection, promotility meds, etc); anything that speeds up intestine
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69
Q

Which diarrhea pathophysiologies are characterized by large stool volumes (> 1 L/day)?

A

Secretory and Exudative

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70
Q

Which diarrhea pathophysiology resolves if patient stops eating?

A

Osmotic

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71
Q

Prevention of Traveler’s Diarrhea?

A

Pepto-Bismol 1-4 x daily, prophylactically

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72
Q

Antimotility drugs MOA

A

Activate Mu opioid receptors on bowel smooth muscle to: reduce peristalsis and increase segmentation (mixing)

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73
Q

List 4 antimotility agents

A
  1. Loperamide
  2. Diphenoxylate
  3. Difenoxin
  4. Codeine
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74
Q

Imodium (brand)

A

loperamide (generic); OTC

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75
Q

Lomotil (brand)

A

diphenoxylate/atropine (generic); Rx-only

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76
Q

Motofen (brand)

A

difenoxin/atropine (generic); Rx-only

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77
Q

loperamide dosing

A

4mg (2 tabs) initially, then 2mg (1 tab) after each loose stool
Max: 16 mg/day (8 tablets)

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78
Q

diphenoxylate/atropine dosing

A 
5 mg (2 tabs) 4 x daily
Max: 20 mg/day (8 tablets)
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79
Q

Absorbents MOA

A

Use in chronic diarrhea; oral non-absorbed agents absorb excess fluid to help form solid stools

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80
Q

List 2 Absorbents used to treat diarrhea

A
  1. polycarbophil (Fibercon)

2. psyllium (Metamucil) – powder formulation absorbs more water than tablet

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81
Q

Which antisecretory treatment of diarrhea also has antimicrobial and anti-inflammatory effects?

A

Bismuth subsalicylate (Pepto-Bismol)

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82
Q

Pepto-Bismol dosing

A

2 tabs or 30 mL every 30-60 min PRN
(up to 8 doses/day)
AVOID in pts who shouldn’t take salicylates

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83
Q

4 subtypes of IBS

A

IBS-C, IBS-D, IBS-M, IBS-U

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84
Q

Lotronex (brand)

A

alosetron (generic)

5HT-3 antagonist for IBS-D

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85
Q

alosetron (Lotronex) classification and dosing

A

5HT-3 antagonist for IBS-D
Initial: 0.5 mg BID x 4 weeks
*REMS d/t severe constipation in overdose (ischemic colitis)

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86
Q

tegaserod (Zelnorm) classification and indication

A

5HT-4 agonist for IBS-C

*restricted use only d/t risk of CV disorders

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87
Q

Bentyl (brand)

A

dicyclomine (generic)

Antispasmotic and anticholinergic for IBS

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88
Q

dicyclomine (Bentyl) classification and indication

A

Antispasmotic and anticholinergic for IBS

take 30-60 minutes before meals

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89
Q

hyoscyamine (Levsin) classificaiton and indication

A

Anticholinergic for IBS

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90
Q

rifaximin (Xifaxan) indication and dosing

A

IBS with diarrhea

550 mg TID x 14 days

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91
Q

eluxadoline (Viberzi) classification and indication

A

Mu-opioid agonist, Delta-opioid antagonist (C-IV)
MOA: slows motility and relieves pain
IBS with diarrhea

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92
Q

Pathophysiology of GERD (6 factors)

A
  1. Defective LES pressure
  2. Anatomic factors (hiatal hernia, eg)
  3. Delayed gastric emptying
  4. Esophageal clearance
  5. Mucosal resistance
  6. Refluxate composition (pH, volume)
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93
Q

Causes of defective LES pressure (6 factors)

A
  1. spontaneous LES relaxations
  2. increased abdominal pressure
  3. atonic LES
  4. pregnancy
  5. foods
  6. medications
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94
Q

3 causes of delayed gastric emptying

A
  1. high-fat meals
  2. smoking
  3. diabetic gastroparesis
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95
Q

Atypical GERD sx

A

(aka extraesophageal sx)

  1. chronic cough
  2. hoarseness
  3. non-allergic asthma
  4. dental enamel erosions
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96
Q

Alarm GERD sx

A
  1. dysphagia
  2. odynophagia
  3. bleeding
  4. unexplained weight loss
  5. continual pain
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97
Q

Best diagnostic tool for GERD

A

PPI trial of 8 weeks

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98
Q

Type of cell that produces acid in the stomach?

A

Parietal cell

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99
Q

Indication for antacids as first line tx?

A

PRN for intermittent GERD sx

sx LESS THAN twice weekly

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100
Q

Only acid suppressing therapy appropriate for erosive GERD?

A

PPI

NOT antacids or H2RAs

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101
Q

Antacid adverse effects: Mg vs. Al vs. Ca

A

Magnesium: diarrhea
Aluminum: neurotoxicity, anemia, constipation
Calcium: Milk-Alkali syndrome (HA, nausea, irritability)

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102
Q

Antacid DDI causes

A
  1. reduced absorption of other drugs d/t higher pH (digoxin, iron, ketoconazole)
  2. chelation and adsorption to some antibiotics

**separate antacids 2 hours before/4 hours after other drugs

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103
Q

PPIs with IV formulations

A

pantoprazole

esomeprazole

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104
Q

PPI capsules you can open and sprinkle in applesauce or down NG tube (4)

A
  1. omeprazole
  2. esomeprazole
  3. lansoprazole
  4. dexlansoprazole
105
Q

PPI with ODT formulation

A

lansoprazole

106
Q

PPI with instructions NOT to crush

A

pantoprazole

rabeprazole

107
Q

In what type of pts would you consider using a H2RA over a PPI?

A
  1. pt with recent antibiotic use d/t increased risk of C diff with PPI
  2. pt on HIGH DOSE, IV methotrexate d/t increased risk of toxicity
108
Q

Which PPIs should be avoided d/t inhibition of CYP 2C19?

A

Omeprazole and Esomeprazole

109
Q

Promotility agent most commonly used in diabetic gastroparesis

A

metoclopramide (Reglan); increases gastric emptying and LES tone

110
Q

Nexium (brand)

A

esomeprazole (generic)

111
Q

Dexilant (brand)

A

dexlansoprazole (generic)

112
Q

Pepcid (brand)

A

famotidine (generic)

113
Q

Prilosec (brand)

A

omeprazole (generic)

114
Q

Protonix (brand)

A

pantoprazole (generic)

115
Q

Prevacid (brand)

A

lansoprazole (generic)

116
Q

Tagamet (brand)

A

cimetdine (generic)

117
Q

Axid (brand)

A

nizatidine (generic)

118
Q

Zantac (brand)

A

ranitidine (generic)

119
Q

famotidine dosing- GERD and active PUD

A

OTC: 10 mg BID
GERD: 20 mg BID
PUD: 20 mg BID, or 40 mg at bedtime

120
Q

ranitidine dosing- GERD and active PUD

A

OTC: 75 mg BID
GERD: 150 mg BID
PUD: 150 mg BID, or 300 mg at bedtime

121
Q

cimetidine dosing- GERD and active PUD

A

OTC: 200 mg BID
GERD: 400 mg BID
PUD: 400 mg BID, 300 mg QID, or 800 mg HS

122
Q

omeprazole dosing- GERD and active PUD

A

OTC: 20 mg daily x 14 days Q 4 months
Nonerosive GERD: 20 mg daily
Erosive GERD: 20 mg BID
PUD: 20-40 mg daily/BID

123
Q

pantoprazole dosing- GERD and active PUD

A

Nonerosive GERD: 40 mg daily
Erosive GERD: 40 mg BID
PUD: 40 mg daily/BID

124
Q

lansoprazole dosing- GERD and active PUD

A

OTC: 15 mg daily x 14 days Q 4 months
Nonerosive GERD: 15-30 mg daily
Erosive GERD: 30 mg BID
PUD: 15-30 mg daily/BID

125
Q

esomeprazole dosing- GERD and active PUD

A

OTC: 20 mg daily x 14 days Q 4 months
Nonerosive GERD: 20 mg daily
Erosive GERD: 40 mg daily
PUD: 20-40 mg daily/BID

126
Q

Sucralfate MOA

A

Mucosal protectant for duodenal ulcer

MOA: breaks down to insoluble aluminum/sucrose paste and adheres to ulcer to allow protection and healing

127
Q

sucralfate dosing

A

1 g QID, or 2 g BID

*administer on empty stomach; separate from other meds 2 hours before or 4 hours after

128
Q

misoprostol MOA

A

synthetic prostaglandin E1 (replaces PGs inhibited by NSAIDs); mucosal protectant

129
Q

misoprostol adverse effects

A

TERATOGENIC

significant GI effects (diarrhea, abdominal pain); use-limiting

130
Q

Treatment of Non-NSAID/H. pylori PUD

A

H2RA or sucralfate x 6-8 weeks

PPI x 4 weeks

131
Q

PPI based regimen for H. pylori PUD

A
  1. Clarithromycin 500 mg BID
  2. Amoxicillin 1 g BID, or Metronidazole 500 mg BID
  3. PPI, BID: Omeprazole 20 mg, Lansoprazole 30 mg, Pantoprazole 40 mg, Esomeprazole 20 mg (or 40 mg daily), or Rabeprazole 20 mg
132
Q

Bismuth based regimen for H. pylori PUD

A
  1. Bismuth
  2. Metronidazole
  3. Clarithromycin, Amoxicillin, or Tetracycline
  4. PPI or H2RA: Omeprazole, Lansoprazole, Pantoprazole, Esomeprazole, Rabeprazole, Cimetidine, Ranitidine, Famotidine, Nizatidine
133
Q

Treatment of NSAID induced PUD

A
  1. if NSAID discontinued: PPI, H2RA, or sucralfate x 6-8 weeks
  2. if NSAID continued: PPI x 8-12 week, (or as long as NSAID is required)
134
Q

Antiplatelet induced PUD prophylaxis

A
  1. PPI preferred but if taking clopidogrel, then choose Pantoprazole d/t DDI with esomeprazole and omeprazole
  2. Famotidine 20 mg BID
135
Q

pH goal in management of PUD in ED/ICU

A

Maintain pH > 6

136
Q

4 complications that designate “clinically important bleeding” in SRMB

A
  1. hemodynamic instability
  2. decreased Hgb
  3. necessity of RBC transfusions*
  4. increased ICU length of stay
137
Q

How does SRMD differ from PUD?

A
  • SRMD: multiple, superficial lesions primarily in the stomach with more congestion and bleeding.
  • PUD: few, deeper lesions primarily in the duodenum with perforations being more common.
138
Q

4 factors that lead to development of an acute stress ulcer

A
  1. reduced HCO3 secretion
  2. reduced mucosal blood flow
  3. decreased GI motility
  4. acid back diffusion
139
Q

2 major risk factors for development of a stress ulcer

A
  1. Respiratory failure: mechanical ventilation for ≥ 48 hours
  2. Coagulopathy: plt count 1.5, or PTT > 2x control value
140
Q

Indication for SRMD prophylaxis (ICU only)

A
  1. Mechanical ventilation ≥ 48 hours
  2. Coagulopathy
  3. Hx of GI ulcer/bleeding within 1 year of admission and at least 2 of the following 4 factors:
    - sepsis, ICU > 1 week, occult bleeding ≥ 6 days, or high-dose corticosteroids
141
Q

Notable ADE of H2RA vs. PPI

A

H2RA: tachyphylaxis (tolerance)
PPI: risk of Clostridium difficile colitis

142
Q

Neonate

A

0-28 days

Term + 28 days (if born premature)

143
Q

Infant

A

1-12 months

144
Q

Child

A

1-12 years

145
Q

Adolescent

A

13-18 years

146
Q

1 oz to mL

A

1 oz = 30 mL

147
Q

1 tablespoon to mL

A

1 T. = 15 mL

148
Q

Bedside Schwartz equation

A

eGFR (mL/min per 1.73 m2) = 0.413 x (ht in cm/SCr)

149
Q

Peds: ranitidine dosing

A

IV: 1-2 mg/kg Q 8-12 hrs
PO: 2-4 mg/kg BID

150
Q

Peds: famotidine dosing

A

IV: 0.5 mg/kg 1-2 times daily
PO: 0.5 mg/kg BID

151
Q

Peds: lansoprazole dosing

A

PO: 1 mg/kg/day

152
Q

Peds: omeprazole dosing

A

PO: 1 mg/kg/day

153
Q

Encopresis definition

A

(fecal incontinence)
repeated passage of feces into inappropriate places

-often secondary to soft stool leaking around large mass of stool in rectum

154
Q

What age is bowel continence expected by?

A

Age 4; otherwise termed delayed bowel training

155
Q

Circular smooth muscles (2) that are part of the physiology for a bowel movement

A
  1. internal anal sphincter

2. rectum

156
Q

Skeletal muscles (2) that are part of the physiology for a bowel movement

A
  1. external anal sphincter

2. puborectalis muscle

157
Q

Diarrhea definition (#/day)

A

3 or more loose or liquid stools per day

158
Q

Chronic diarrhea

A

Lasting 14 or more consecutive days

159
Q

Peds: calculating fluid requirements (per 24 hours)

A

Up to 10 kg: 100 mL/kg
10-20 kg: 1000 mL + (50 mL/kg x kg over 10)
>20 kg: 1500 mL + (20 mL/kg x kg over 20)

160
Q

Common complication of TPN long term in SBS

A

Cholestasis: reduction or stoppage of bile flow from the liver to the duodenum
-can lead to liver failure (PNALD)

161
Q

Medication used to prevent or treat PNALD

A

Ursodiol

MOA: minor component of bile acid; helps to solubilize cholesterol. PO administration.

162
Q

Cytokines increased in CD vs UC

A

CD: increased Th1 cytokine activity
UC: increased Th2 cytokine activity
both: TNF-alpha plays key role

163
Q

Two types of IBD

A 
Ulcerative colitis (UC)
Crohn's disease (CD)
164
Q

Smoking effects in UC vs CD

A

UC: protective; fewer flare-ups
CD: increased frequency and severity

165
Q

local complications of UC

A

hemorrhoids, anal fissures, perirectal abcesses

common during flares

166
Q

severe, life-threatening complication of UC

A

Toxic megacolon

-colonic dilation/distention, increased depth of ulceration; s/sx of systemic toxicity

167
Q

difference in complications btwn UC and CD

A

UC: increased bleeding, carcinoma risk, and rectal involvement
CD: fistulas, strictures, and perianal disease common

168
Q

What markers distinguish IBD from IBS?

A

fecal calprotectin
fecal lactoferrin
(specific to inflammation in GI tract)

169
Q

What antibodies distinguish UC vs CD?

A

UC: (+) perinuclear antineutrophil cytoplasmic antibodies (pANCA)
CD: (+) anti-Saccharomyces cervisiae antibodies (ASCA)

170
Q

UC: proctitis

A

involving the rectal area

171
Q

UC: proctosigmoiditis

A

involving rectum and sigmoid colon

172
Q

UC: pancolitis

A

involving majority of colon

173
Q

UC: distal

A

(left-sided); distal to splenic flexure

descending colon, sigmoid colon, rectum

174
Q

UC: extensive

A

extending proximal to splenic flexure

175
Q

UC: mild disease

A
  • less than 4 stools/day (+/- blood)
  • no systemic disturbance
  • normal ESR
176
Q

UC: moderate disease

A
  • greater than 4 stools/day

- minimal systemic disturbance

177
Q

UC: severe disease

A
  • greater than 6 stools/day with blood

- systemic disturbance (fever, tachycardia, anemia, or ESR > 30 mm/h)

178
Q

UC: fulminant disease

A
  1. greater than 10 stools/day with continuous bleeding
  2. toxicity (severe systemic disturbance)
  3. abdominal tenderness
  4. need for transfusion
  5. colonic dilation
179
Q

splenic flexure

A

curvature on the left side of the colon between the transverse colon and descending colon

180
Q

fulminant definition

A

severe and sudden in onset

181
Q

What is the difference between hematochezia and melena?

A

hematochezia: gross blood per rectum; indicates lower GI bleeding (sign of CD)
melena: black tarry stools; indicates upper GI bleeding

182
Q

sulfasalazine chemistry and indication

A
  1. sulfapyridine (inactive, associated with ADRs, but prevents systemic absorption in small intestine)
    • mesalamine (5-ASA, active, anti-inflammatory effects)
      Indication: mild IBD
183
Q

Advantages/disadvantages of budesonide

A

Pros: extensive first pass metabolism so minimal systemic absorption (can take PO for 8 weeks); well tolerated

Cons: CYP3A substrate so DDI with inhibitors increase systemic exposure

184
Q

Mercaptopurine (6-MP) metabolism

A

AZA (prodrug) > 6-MP > inactive metabolite or active toxic metabolite (TGN)
TMPT: metabolizes 6-MP to inactive metabolite
TGN: accumulation results in bone marrow suppression

185
Q

Azathioprine (AZA) and Mercaptopurine (6-MP) indication

A

induction and maintenance of remission in UC and CD

  • after failure of 5-ASA tx
  • slow onset (3-6 months)
  • long term tx
186
Q

Cyclosporine indication

A

induction of remission in refractory IBD

  • bridge therapy; not for long term use
  • better data in UC
187
Q

Methotrexate indication

A

induction and maintenance of remission in CD

  • add folic acid 1 mg daily to prevent bone marrow suppression
  • teratogenic (pregnancy CI)
188
Q

Remicade (brand)

A

infliximab (generic)

189
Q

Humira (brand)

A

adalimumab (generic)

190
Q

Simponi (brand)

A

golimumab (generic)

191
Q

Cimzia (brand)

A

cerolizumab pegol (generic)

192
Q

TNF-alpha antagonists

A

induction and maintenance therapy

  1. infliximab (Remicade)
  2. adalimumab (Humira)
  3. golimumab (Simponi)
  4. certolizumab pegol (Cimzia)
193
Q

Anti-Adhesion biologics

A
  1. natalizumab (Tysabri)

2. vedolizumab (Entyvio)

194
Q

Biologic(s) only used for CD

A
  1. certolizumab pegol

2. natalizumab

195
Q

Biologic(s) only used for UC

A

golimumab (Simponi)

196
Q

Biologics used for CD and UC

A
  1. infliximab (Remicade)
  2. adalimumab (Humira)
  3. vedolizumab (Entyvio)
197
Q

TNF-alpha antagonists: Class ADRs

A
  • increase risk of serious infections
  • injection site reactions
  • risk of malignancy/demyelinating disease
  • hepatosplenic T-cell lymphoma (HSTCL) risk
  • may exacerbate CHF
198
Q

Baseline monitoring for TNF antagonists

A

PPD, CXR, Hep B/C
-ensure no latent infection that could be reactivated
(live vaccines CI during and 3 months after tx)

199
Q

Biologics administered via IV infusion

A
  1. infliximab (2 hour infusion)
  2. natalizumab (1 hour infusion)
  3. vedolizumab (30 min infusion)
200
Q

Which biologic is associated with PML?

A

natalizumab (Tysabri)

-must test for JC antibody prior to initiation

201
Q

First-line treatment in mild-moderate active UC

A

if extensive disease: need systemic tx (PO)
-oral sulfasalazine or mesalamine

if distal disease: within reach (topical)
-mesalamine enema or suppository

202
Q

Alternatives for mild-moderate active UC

A
  1. Budesonide CR
  2. Prednisone 40-60 mg/day if refractory to ASAs
  3. topical corticosteroids for distal disease
  4. AZA or 6-MP if refractory to ASAs
203
Q

Moderate-Severe active UC

A
  1. systemic corticosteroids (PO prednisone 40-60 mg daily)

2. TNF-alpha inhibitors if unresponsive

204
Q

Severe-Fulminant active UC

A
  1. parenteral corticosteroids (IV: methylprednisolone or hydrocortisone)
    2-3. TNF-inhibitor or cyclosporine (similar efficacy)

*transition cyclosporine to 6-MP or AZA for maintenance to

205
Q

Agents that can be used in UC maintenance

A
  1. ASA (mesalamine > sulfasalazine)
  2. AZA or 6-MP
  3. TNF-alpha antagonist

NOT corticosteroids or cyclosporine

206
Q

Mild-Moderate active CD

A
  1. 5-ASA (minimal efficacy in CD)
  2. Budesonide CR (distal/right-sided disease)
  3. Antibiotics (perianal disease)
207
Q

Moderate-Severe active CD

A
  1. systemic CS (PO prednisone 40-60 mg/day)
  2. MTX
  3. TNF-antagonist

*AZA/6-MP not rec for induction tx d/t slow onset (can maintain remission after induction with steroids)

208
Q

Severe-Fulminant active CD

A
  1. parenteral corticosteroids x 3-7 days then PO (methylprednisolone or hydrocortisone)
  2. Biologic (infliximab, eg)
  3. Cyclosporine (limited data, last resort)
209
Q

Agents used in CD maintenance of remission

A
  1. AZA or 6-MP (first-line)
  2. MTX
  3. TNF-antagonist or other biologic
    (or infliximab + AZA or 6-MP)
210
Q

Pro/Con of combination therapy: TNF antagonist + AZA

A

Pro: more effective in preventing development of anti-drug antibodies (ADAs)
Con: increase risk of HSTCL

211
Q

What vessels comprise the Hepatic Portal Triad that supplies blood to the liver?

A
  1. Bile duct
  2. Hepatic artery
  3. Portal vein
212
Q

AST and ALT normal values

A 
Aspartate Aminotransferase (AST): 0-50 IU/L
Alanine Aminotransferase (ALT): 5-60 IU/L
213
Q

ALP normal value

A 
Alkaline Phosphatase (Alk Phos):
35-130 IU/L
214
Q

GGT normal value

A

Gamma Glutamyl Transferase (GGT):

0-85 IU/L

215
Q

Bilirubin normal value

A

Bilirubin: 0-1.4 mg/dl

Direct/Conjugated Bilirubin: 0-0.3 mg/dl

216
Q

Albumin normal level

A

Serum albumin: 3.6-5 g/dl

(LOW in liver disease) - b/c created by liver

217
Q

BUN normal values

A

Blood Urea Nitrogen (BUN): 10-20 mg/dl

(LOW in liver disease) - b/c created by liver

218
Q

Components of LFTs

A
  1. albumin
  2. bilirubin
  3. cholesterol
  4. BUN
  5. INR
219
Q

Components of LITs

A
  1. AST
  2. ALT
  3. Alk Phos
  4. GGT
220
Q

Modes of transmission for Hep A, B, and C

A

HepA: fecal-oral
HepB: sexual, parenteral, perinatal
HepC: parenteral

221
Q

Centrilobular Necrosis- definition and drug cause(s)

A

direct/metabolite-related hepatotoxicity; damage spreads outward from middle of a lobe
-Acetaminophen

222
Q

Nonalcoholic Steatohepatitis (NASH)- definition and drug cause(s)

A

accumulation of fatty acids in hepatocytes

  • Tetracycline
  • Valproate
223
Q

Phospholipidosis- definition and drug cause(s)

A

accumulation of phospholipids in hepatocytes
-Amiodarone
(long half-life)

224
Q

Generalized Hepatocellular Necrosis- definition and drug cause(s)

A

drug induction of innate immune response (auto-immune type)

-Isoniazid

225
Q

Toxic Cirrhosis- definition and drug cause(s)

A

scarring effect of hepatitis (mild, undetected) leads to cirrhosis

  • Methotrexate
  • Vitamin A
226
Q

Cholestatic Injury- definition and drug cause(s)

A

accumulation of toxic bile acids in liver

  • Chlorpromazine
  • Amoxicillin-Clavulanic Acid
  • Carbamazepine
227
Q

Liver Vascular Disorder- definition and drug cause(s)

A

development of large, blood-filled lacunae

  • Androgens, Estrogens
  • Tamoxifen
  • Azathioprine
228
Q

Hepatocellular Injury examples (4)

A
  • damage directly to hepatocytes
    1. Centrilobular Necrosis
    2. Steatohepatitis
    3. Phospholipidosis
    4. Generalized Hepatocellular Necrosis
229
Q

Three main histological phases of Alcoholic Liver Disease?

A
  1. Steatosis/fatty liver
  2. Acute alcoholic hepatitis
  3. Cirrhosis
230
Q

Most common cause of cirrhosis?

A

Alcoholic Liver Disease

231
Q

Interpreting Maddrey’s Score

A

Acute Alcoholic Hepatitis (AAH) assessment
Score > 32
-poor prognosis
-threshold for starting corticosteroids or pentoxifylline

232
Q

Pentoxifylline indication and MOA

A

Anti-inflammatory and vasodilator used to treat alcoholic hepatitis
MOA: PDE inhibitor and TNF-alpha modulator
Dose: 400 mg PO TID

233
Q

ETOH Withdrawal treatment

A
  1. fluid resuscitation
  2. thiamine 100 mg daily
  3. folic acid 1 mg daily
  4. multivitamins daily
  5. benzodiazepines
234
Q

Complications of Cirrhosis (7)

A
  1. portal HTN
  2. varices
  3. ascites
  4. hepatic encephalopathy (HE)
  5. coagulation defects
  6. spontaneous bacterial peritonitis (SBP)
  7. hepatorenal syndrome (HRS)
235
Q

Immediately life-threatening complications of cirrhosis

A
  1. acute variceal bleeding

2. spontaneous bacterial peritonitis (SBP)

236
Q

Risk factors for variceal bleeding

A
  1. poor liver function
  2. large varices
  3. alcoholic etiology of cirrhosis
  4. red wale markings
237
Q

Complications of cirrhosis mainly d/t Portal Hypertension

A
  1. varices/variceal bleeding
  2. ascites
  3. encephalopathy
238
Q

Complications of cirrhosis mainly d/t Liver Insufficiency

A

(lack of hepatic enzymes/function)

  1. encephalopathy
  2. coagulopathies
239
Q

Octreotide MOA and dosing

A

MOA: selectively vasoconstricts splanchnic vasculature thereby decreasing portal BP
Dosing: 50-100mcg IV load, then 25-50mcg/hr continuous IV infusion x ~5 days

240
Q

splanchnic vasculature defintion

A

vasculature that flows into hepatic portal vein

-mesenteric, gastric, splenic, pancreatic veins

241
Q

PPI treatment in variceal bleeding

A

Esomeprazole or Pantoprazole

dose: 80 mg IV load, then 8 mg/hr continuous infusion
* high dose oral PPI x 4 weeks post-bleed

242
Q

prophylactic antibiotics during acute variceal bleed

A

-to prevent SBP (serious infection)
Short course (max 7 days):
1. Cephalosporin- ceftriaxone 1g IV q 24 hours
2. Fluoroquinolone- ciprofloxacin 400mg IV BID

243
Q

Comprehensive Treatment for Variceal Bleed

A
  1. volume resuscitation
  2. PPI
  3. Octreotide IV (~5 days)
  4. EVL (banding procedure)
  5. 3rd gen. cephalosporin (~7 days)
    * secondary prophylaxis: nonselective BB
244
Q

Prevention of variceal bleeding- drug(s) and dosing

A

Non-selective beta blocker

  1. Propanolol 10mg BID or TID
  2. Nadolol 20mg daily
    - titrate to HR goal: 55-60 bpm
245
Q

most common complication of cirrhosis

A

ascites

-fluid accumulation in peritoneal space

246
Q

Serum Ascites Albumin Gradient (SAAG)

A

-determines cause of ascites

Albumin (serum) - Albumin (ascites) = SAAG

SAAG > 1.1 g/dl = d/t portal HTN

247
Q

Ascites Treatment

A
  1. Spironolactone** 25-50 mg daily
  2. Furosemide 20-40mg daily
    * *most effective b/c aldosterone antagonist that counteracts RAAS activation that causes ascites
248
Q

Spironolactone : Furosemide ratio

A

100: 40
- maintain at all times to ensure K+ balance
- max: 400mg/160mg

249
Q

Volume expander needed along with Paracentesis for large volume/refractory Ascites

A

Albumin infusion: 8g per L of ascitic fluid removed

if tap >5L

250
Q

SBP mechanism

A

bacterial translocation through intestines to peritoneal fluid; “spontaneous” infection of ascitic fluid

251
Q

Diagnosis of SBP

A

PMN > 250 cells/mm3

PMN = WBC x %neutrophils

252
Q

Treatment of SBP

A

Choose one for empiric coverage (x 5 days):
1. Ceftriaxone 2g IV q 24 hours
2. Zosyn 3.375g IV q 6 hours
3. Ciprofloxacin
*If SCr >1, BUN >30, or bilirubin >4:
Albumin infusion: 1-1.5 g/kg to prevent HRS

253
Q

Primary/Secondary Prophylaxis of SBP

A

Choose one for life (if secondary):

  1. Cipro 500-750mg PO daily
  2. TMP/SMX 1 DS tab PO daily
  3. Norfloxacin 400mg PO BID
254
Q

Asterixis

A

Hand flapping tremor (“waving goodbye”); symptom of HE

255
Q

Normal ammonia level

A

normal: less than 35 umol/L
-NOT diagnostic of HE if elevated
AMS + cirrhosis = HE

256
Q

Treatment of HE

A
  1. Lactulose 45 mL/hr until catharsis, then maintenance titrated to 3-4 soft BMs daily
  2. Metronidazole 250mg q 6-12 hrs
  3. Rifaximin 400mg TID x 5-10 days, then 550mg BID for prevention
  4. Flumazenil (no long term benefit)
257
Q

Treatment of HRS

A

(Discontinue diuretics)

  1. albumin + octreotide + midodrine
  2. liver transplant

albumin 1g/kg x 1 day, then 20-40g daily
octreotide 100mcg SQ TID
midodrine 5-7.5mg PO TID

258
Q

Pain management in Cirrhosis

A
  1. Acetaminophen
  2. Tramadol
  3. Fentanyl
  4. Hydromorphone
    * Avoid NSAIDs

Therapeutics Fall 2016 (4 decks)

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