Module 6: GI Flashcards
Peptic Ulcer Disease
-4 etiological groups?
- Acid hypersecretion
- Drug induced
- “Stress” ulcers following surgery
- Infections - H. Pylori
GERD/PUD
-Management
- Cornerstone is Lifestyle modification
- Increase HOB
- Decrease Fat intake
- Smoking cessation
- Avoid lying down for 3 hours following meals
GERD/PUD Treatment
-Antacids
- Neutralize gastric acid and increase pH of gastric contents
- Indicated to relieve symptoms of duodenal ulcers
- effective for dyspepsia (aka indigestion) and heart burn - Provides immediate relieve of symptoms that lasts 20-40 minutes
- Requires Frequent dosing
GERD/PUD Treatment
-Antacid Ingredients?
- Aluminum hydroxide
- Treats increased stomach acid; used w/ kidney dz; can be constipating - Magnesium hydroxide
- Used in conjunction w/ aluminum hydroxide; can offset constipation w/ its laxative effect* - Calcium Carbonate (Tums)
- Also used to treat osteoporosis - Sodium Bicarbonate
- Systemic absorption; can have “REBOUND” effect; Can cause excess “sodium load” w/ CHF - Alginate
- “anti-refluxant” in Gaviscon; reacts w/ sodium bicarb and saliva to form protective layer; useful for GERD
GERD/PUD Treatment
-H2 Receptor Antagonists
- MOST widely used OTC anti-ulcer agents
- Inhibits 50-80% of 24 hr acid secretion
- Help to heal 70-90% of duodenal and gastric ulcers in 4-6 wks - Competitively and reversible bind to H2 receptors
- Take after meal or before bed
- Work faster than PPI’s but slower than oral antacids
GERD/PUD Treatment
-H2 Receptor Antagonist S/E & Cautions?
- S/E
- HA, constipation, diarrhea, nausea
- Cimetidine (Tagamet) can cause Dyskinesia and possible impotence - A/R’s
- Thrombocytopenia, neutropenia, bradycardia, confusion, and depression - Caution
- Cimetidine (Tagamet) w/ other medications due to interactions
- Ex: Warfarin, phenytoin, and any benzodiazepines
GERD/PUD H2 Receptor Antagonists
-Cimetidine (Tagamet)
- Can inhibit metabolism of P-450 enzyme system, enhancing other drug effects
- Takes 2-3 months to see improvement
- Can be used for wart removal in children
- GERD Adult Dose
- 1600mg/day BID-QID x 12 wks - PUD Active Ulcer Dose Adults
- 800 mg PO QHS x 4-8 wks
GERD/PUD H2 Receptor Antagonists
-3 medications?
- Cimetidine (Tagamet)
- Least Potent - Nizatidine (Axid)
- Famotidine (Pepcid)
- MOST Potent
GERD/PUD Treatment
-PPI’s
- Inhibit >90% of 24 hour acid SECRETION after a few days of therapy
- Heal more rapidly than H2 antagonists
- PUD caused by H. Pylori - USE PPI d/t proven effectiveness**
- Can cause Diarrhea
GERD/PUD Treatment
-PPI Indication and Dosing?
- Treatment of active duodenal or benign gastric ulcer for 4-8 weeks
- Maintenance of ulcer healing up to 1 yr
- GERD symptoms relief up to 4 weeks
- Erosive esophagitis for 4-8 weeks
- Maintenance of esophageal healing up to 1 year
- Massive acid hypersecretion (Ex: Zollinger-Ellison syndrome)
- Approved for children 1-11 yrs of age w/ GERD and erosive esophagitis.
GERD/PUD Treatment
-PPI Omeprazole (Prilosec)
- GERD Treatment?
- 20 mg P0 QD x 4-8 wks; give 1 hr before meals - PUD (Active)
- 40 mg PO QD x 4-8 wks; give 1 hr before meals
GERD/PUD Treatment
-PPI Zegerid
- Zegrid = omeprazole/sodium bicarb powder oral suspension
- Peak plasma reached in 30 minutes
- Good for patients who have difficulty swallowing
- Dose is based on omeprazole component
GERD/PUD Treatment
-PPI Prevacid & AcipHex
- Lansoprazole (Prevacid)
- Approved for children 1-17 yrs - Rabeprazole (AcipHex)
- Used in 7 day 3 drug regimen w/ amoxicillin and clarithromycin to treat H. Pylori *
GERD/PUD Treatment
-Pantoprazole (Protonix)
- Available as tablet or IV
2. Can cause FALSE-POSITIVE urine drug screen test for THC
GERD/PUD Treatment
-Esomeprazole (Nexium)
- Has higher and more prolonged action than omeprazole.
- Increased length of action is beneficial for GERD
- GERD dosing: 4-8 weeks
- PUD dosing: 2 wks - 6 months*
GERD/PUD Treatment
-Dexlansorprazole Dexilant
- Most similar to Prevacid
- Bind to proton pump and blocks it, preventing gastric acid from forming
- Lasts longer and can take less often - GERD = 4 weeks
- PUD = 2 weeks for h. Pylori infection
Which PPI is best?
- Nexium (esomeprazole magnesium)
- MOST EFFECTIVE for treatment of GERD & PUD - Omeprazole + sodium bicarb (Zegrid)
- Can maintain a pH >4 for 12-18 hrs
- More studies needed
GERD/PUD Treatment
-H2RA/PPI Combo Therapy?
- H-2 is taken at bedtime
- H-2’s reduce acid secretion regardless of meals or time of day - PPI works best to reduce acid secretion triggered by meals during the day
- Combo is less expensive than BID PPI’s
GERD/PUD Treatment
-Options for Nocturnal Acid Control
- Dose PPI daily prior to breakfast
- Dose PPI daily prior to dinner
- Dose PPI daily prior to breakfast & H2RA at bedtime
- Dose PPI twice daily (Prior to breakfast and dinner)
- Dose PPI twice daily (Prior to breakfast and dinner) AND H2RA at bedtime
REFER: @ PPI twice daily
Gastric Anti-secretory Agents
-PNA & C. Diff?
PPI’s and H2RA’s can
1. Increase Pneumonia
—Increase pH leads to increase in gram negative bacteria in the stomach
—If aspiration occurs, this can cause pneumonia
- Increase in C. Diff Diarrhea
- Gastric acid keeps gut flora suppressed.
- Anti-secretory agents allow increased flora and a 60% increased risk of C. Diff.
Discontinuing a PPI
-Stats
- Very difficult to D/c meds due to acid rebound hyper-secretion symptoms
- Only 1/3 of long-term PPI users will be able to successfully D/C meds
- Harder for GERD patients than PUD to D/C meds.
PPI’s and Hip Fractures?
- PPI’s may interfere w/ calcium absorption
- Increase risk when PPI is used > 1 yr; higher doses
- Men are at greater risk
NSAID Gastro-protection
-Who needs it?
- > 76 yrs old
- Significant co-morbidities
- Hx of NSAID-related GI complications
- Taking warfarin
Prevacid & Nexium are the two meds used for NSAID gastroprotection
PUD Medication
-Misoprostol (Cytotec)
- Prostaglandin analog that decreases gastric acid secretion
- Indicated for “At Risk” for GI bleed d/t NSAIDS or corticosteroids
- NOT for pregnancy; can cause ABORTION
- Can cause Diarrhea
PUD
-Sucralfate (Carafate)
- Aluminum hydroxide complex
- coating over the ulceration
- May also stimulate prostaglandins mediated mucosal protection - Used for stress ulcer prophylaxis and duodenal ulcer healing
- Given before meals and before bedtime
- Can cause constipation
- Can also be used for mouth (aphthous) ulcers**
H. Pylori
-Treatment goals?
- Relieve ulcer pain
- Heal existing ulcer
- Eradicate H. Pylori to reduce recurrence
Treatment for H. Pylori
-Triple Therapy?
- PPI + 2 antibiotics
- Clarithromycin, amoxicillin, and tetracycline - Bismuth can also be included in triple therapy
- Can cause black tongue and stool and tinnitus
Treatment for H. Pylori
-Prevpac??
- PPI + clarithromycin (Biaxin) + either amoxicillin or metronidazole **
- $290**
- 2 week duration and 90% effective
Treatment for H. Pylori
-Helidac
- BSS + metronidazole + tetracycline
- Cost $30
-2 week duration and 90% effective
Treatment for H. Pylori
-Pylera
- Biskalcitrate (Bismuth agent) + metronidazole + tetracycline
2 week duration and 90% effective
GERD Treatment
-Prokinetic Agents? Reglan?
- Metoclopramide (Reglan)
- Increases esophageal motility and gastric emptying rate - Take 30 minutes before meals for 12 weeks
- S/E
- Dystonic or tardive dyskinesia reactions - Hypotension crisis with MAOI’s
- Don’t give with alcohol or benzodiazepines
GERD Prokinetic Agents
-Baclofen (Liosresal)
- Muscle relaxant that has been shown to increase lower esophageal sphincter pressure
- S/E
- Drowsiness, hypotension, dizziness - When DC’d TAPER Medication down
Population Specific Considerations for GERD Treatment
- GERD is common in healthy infants
- Treat by thickening formula and burping - Geriatrics
- No aluminum due to constipation
- Pantoprazole works well with elderly - Women
- GERD is common in pregnancy
- DO NOT use Sodium bicarb due to alkalosis risk
Anti-Diarrheal’s
-Treatment Modalities? (4)
- Adsorbent and demulcents
- Adsorb toxins and other substances that produce diarrhea - Anti-motility/Antispasmodic
- Anticholinergic and “opiate” type effect
- Do not use if invasive bacterial diarrhea and PMC, or in preschool - Intestinal flora modifiers
- Antibiotics
Diarrhea Treatment:
-Adsorbent & Demulcents?
- Bismuth subsalicylate (Pepto-bismol)
- Non-specific diarrhea and prophylactic tx of travelers diarrhea
- Can cause black tarry stools and darkening of the tongue; tinnitus - Calcium polycarbophil (FiberCon)
- Take with 8 ounces of water
- Med is a resin that can absorb 60 times its weight in water
- Can cause contraption and “feeling full”
Diarrhea Treatment: Anti-motility/Antispasmodic
CONTRAINDICATED in children <2 yrs
- Diphenoxylate (Lomotil)
- Schedule V controlled
- Discontinue after 48 hrs if no improvement - Loperamide (Imodium)
- Difenoxin (Motofen)
- Schedule IV
Imodium Abuse?
- Imodium is an opioid agent which binds to receptors in the brain to cause a high or euphoria
- Abused due to low cost, easy access, OTC
- FDA safety warning for cardiovascular event
Intestinal Flora Modifiers?
- Lactinex
- Bacid
- Probiotics such as probiotics Try first
Travelers Diarrhea
-1st line treatment?
- Imodium + 3 day coarse of fluoroquinolone
- Relives symptoms in <24 hrs
Take Probiotic for prevention while traveling
Travelers Diarrhea
-Pregnancy Patient?
- Azythromycin (Zithromax)
Take probiotic for prevention when traveling
Travelers Diarrhea
-Prophylaxis
- Do not generally recommend prophylaxis
- Fluoroquinolone (ex: Cipro) for max of 3 wks. 90% effective
- Pepto-Bismol
- 2 tabs QID can prevent diarrhea (less effective than antibiotics
- Use 2 tabs q30 minutes up to 8 doses for TREATMENT
Population Specific Considerations for Diarrhea
- Pediatric
- Oral rehydration is key - Geriatrics
- Rehydration is paramount
- Watch interactions with meds - Women
- NO loperamide in Pregnancy
- Lomotil and loperamide are excreted in breast milk*
IBS
-Meds to Consider?
- 1st line Treatment
- Anti-diarrheal’s - PPI’s and H2RA can work
- Antispasmodic (Bentyl)
- Bulk forming laxatives (Metamucil)
Drugs for Hiccups?
- Chlorpromazine (Thorazine)
- Only FDA approved treatment for hiccups
Constipation
-Preferred therapy?
1. Diet and lifestyle modification Including -Increasing fiber to 20-25 grams/day -increasing exercise -Establish regular bowel regimen
Constipation Meds (Irritants or stimulants) -Biscodyl (Dulcolax)
Bisacodyl (Dulcolax)
1. Increase peristalsis through effects on smooth muscle and promoting fluid accumulation in colon/small intestine
- Onset:
- Oral 6-12 hours
- Rectal 15-60 minutes - Do not administer w/ milk or antacids
Constipation Meds (Irritants or stimulants) -Glycerin Suppositories
- Local irritating and hyperosmolar effect
- Not systemically absorbed
Constipation Meds (Irritants or stimulants) -Sennosides (Senokot)
- Start low dose and go slow
- Can easily switch to diarrhea from constipation
Constipation Meds (Irritants or stimulants) -All Meds?
- Bisacodyl (Dulcolax) (Increased peristalsis)
- Glycerin Suppositories (Hyperosmolar effect)
- Sennosides (Senokot) (Can cause diarrhea. Start slow)
Saline or Hyperosmotic Laxatives
-Info?
- Draws water into intestine through osmosis & increases intestinal motility
- MOA
- Oral 30 min - 3 hrs
- Rectal 5-15 min
Examples of Meds?
- Magnesium Hydroxide
- Miralax — 3-4 days to work. Educate to wait
- Lactulose — Also used to decrease ammonia levels (24-48 hrs for response)
SE
-Watch for DEHYDRATION
Bulk Producing Laxatives
-Info & Exemplars
- Bind to fecal contents and pull water into the stool
Onset - 12-24 hrs up to 3 days
- Exemplars
- Bran
- Metamucil
- Methylcellulose
- FiberCon
- Maltsupex - Can cause flatulence
Emollients or Stool Softeners
-Info & Exemplars
- Reduces surface tension of liquid contents of the bowel; Easier defecation
- Onset
- 1-3 days for docusate
- 6-8 hrs for mineral oil - Exemplars
-Mineral Oil — may cause lipoidal PNA if aspirated
—Absorbs fat soluble vitamines causing deficiency of Vit. A, D, E, & K.
-Docusate Sodium (Colace) - Not systemically absorbed (Good for pregnant women)
- Used for long-term use and treatment
Constipation Med
-Amitiza (Lubiprostone)
- Activates chloride channels in gut; increasing intestinal fluid secretion and improved motility
- Used for CHRONIC constipation
- Give medication with water
- Common S/E is Nausea (30%)
Constipation Med
-Linzess (Linaclotide)
- Chronic Constipation treatment
- Activates colonic neurons increasing smooth muscle contractions
- Approved for IBS-C in adults & Chronic constipation
- NOT given <6 yrs old
Common S/E
-Diarrhea
Constipation Med
-Activia
- Yogurt product w/ Probiotic
2. Insufficient evidence but may provide some relief
Constipation
-Recommended order of treatment
- First line — Bulk-forming agent — Metamucil OR Colace once daily
- Second line — Milk of magnesia OR Glycerin suppository
- Third line — Stimulant laxative OR Magnesium citrate
Special population considerations w/ Constipation?
-Pediatrics
- May need manual evacuation — can be distressing
Special population considerations w/ Constipation?
-Geriatrics
- Self reported constipation increases w/ age but bowel frequency does not decline
- Be careful with laxatives d/t fluid and electrolyte imbalances
Special population considerations w/ Constipation?
-Women
- Pregnancy = Docusate (COLACE) **
2. Be mindful of overuse of laxatives in anorexia — 10x more common in women
Bowel Prep for colonoscopy?
- Most use a large volume PEG solution (Golytely) + Laxative
