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6020 Advanced Pharm Test 3 COMPLETE ☑️ > Module 6: GI > Flashcards

Module 6: GI Flashcards

1
Q

Peptic Ulcer Disease

-4 etiological groups?

A
  1. Acid hypersecretion
  2. Drug induced
  3. “Stress” ulcers following surgery
  4. Infections - H. Pylori
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2
Q

GERD/PUD

-Management

A
  1. Cornerstone is Lifestyle modification
    - Increase HOB
    - Decrease Fat intake
    - Smoking cessation
    - Avoid lying down for 3 hours following meals
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3
Q

GERD/PUD Treatment

-Antacids

A
  1. Neutralize gastric acid and increase pH of gastric contents
  2. Indicated to relieve symptoms of duodenal ulcers
    - effective for dyspepsia (aka indigestion) and heart burn
  3. Provides immediate relieve of symptoms that lasts 20-40 minutes
    - Requires Frequent dosing
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4
Q

GERD/PUD Treatment

-Antacid Ingredients?

A
  1. Aluminum hydroxide
    - Treats increased stomach acid; used w/ kidney dz; can be constipating
  2. Magnesium hydroxide
    - Used in conjunction w/ aluminum hydroxide; can offset constipation w/ its laxative effect*
  3. Calcium Carbonate (Tums)
    - Also used to treat osteoporosis
  4. Sodium Bicarbonate
    - Systemic absorption; can have “REBOUND” effect; Can cause excess “sodium load” w/ CHF
  5. Alginate
    - “anti-refluxant” in Gaviscon; reacts w/ sodium bicarb and saliva to form protective layer; useful for GERD
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5
Q

GERD/PUD Treatment

-H2 Receptor Antagonists

A
  1. MOST widely used OTC anti-ulcer agents
  2. Inhibits 50-80% of 24 hr acid secretion
    - Help to heal 70-90% of duodenal and gastric ulcers in 4-6 wks
  3. Competitively and reversible bind to H2 receptors
  4. Take after meal or before bed
  5. Work faster than PPI’s but slower than oral antacids
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6
Q

GERD/PUD Treatment

-H2 Receptor Antagonist S/E & Cautions?

A
  1. S/E
    - HA, constipation, diarrhea, nausea
    - Cimetidine (Tagamet) can cause Dyskinesia and possible impotence
  2. A/R’s
    - Thrombocytopenia, neutropenia, bradycardia, confusion, and depression
  3. Caution
    - Cimetidine (Tagamet) w/ other medications due to interactions
    - Ex: Warfarin, phenytoin, and any benzodiazepines
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7
Q

GERD/PUD H2 Receptor Antagonists

-Cimetidine (Tagamet)

A
  1. Can inhibit metabolism of P-450 enzyme system, enhancing other drug effects
  2. Takes 2-3 months to see improvement
  3. Can be used for wart removal in children
  4. GERD Adult Dose
    - 1600mg/day BID-QID x 12 wks
  5. PUD Active Ulcer Dose Adults
    - 800 mg PO QHS x 4-8 wks
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8
Q

GERD/PUD H2 Receptor Antagonists

-3 medications?

A
  1. Cimetidine (Tagamet)
    - Least Potent
  2. Nizatidine (Axid)
  3. Famotidine (Pepcid)
    - MOST Potent
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9
Q

GERD/PUD Treatment

-PPI’s

A
  1. Inhibit >90% of 24 hour acid SECRETION after a few days of therapy
  2. Heal more rapidly than H2 antagonists
  3. PUD caused by H. Pylori - USE PPI d/t proven effectiveness**
  4. Can cause Diarrhea
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10
Q

GERD/PUD Treatment

-PPI Indication and Dosing?

A
  1. Treatment of active duodenal or benign gastric ulcer for 4-8 weeks
  2. Maintenance of ulcer healing up to 1 yr
  3. GERD symptoms relief up to 4 weeks
  4. Erosive esophagitis for 4-8 weeks
  5. Maintenance of esophageal healing up to 1 year
  6. Massive acid hypersecretion (Ex: Zollinger-Ellison syndrome)
  7. Approved for children 1-11 yrs of age w/ GERD and erosive esophagitis.
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11
Q

GERD/PUD Treatment

-PPI Omeprazole (Prilosec)

A
  1. GERD Treatment?
    - 20 mg P0 QD x 4-8 wks; give 1 hr before meals
  2. PUD (Active)
    - 40 mg PO QD x 4-8 wks; give 1 hr before meals
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12
Q

GERD/PUD Treatment

-PPI Zegerid

A
  1. Zegrid = omeprazole/sodium bicarb powder oral suspension
  2. Peak plasma reached in 30 minutes
    - Good for patients who have difficulty swallowing
    - Dose is based on omeprazole component
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13
Q

GERD/PUD Treatment

-PPI Prevacid & AcipHex

A
  1. Lansoprazole (Prevacid)
    - Approved for children 1-17 yrs
  2. Rabeprazole (AcipHex)
    - Used in 7 day 3 drug regimen w/ amoxicillin and clarithromycin to treat H. Pylori *
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14
Q

GERD/PUD Treatment

-Pantoprazole (Protonix)

A
  1. Available as tablet or IV

2. Can cause FALSE-POSITIVE urine drug screen test for THC

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15
Q

GERD/PUD Treatment

-Esomeprazole (Nexium)

A
  1. Has higher and more prolonged action than omeprazole.
  2. Increased length of action is beneficial for GERD
  3. GERD dosing: 4-8 weeks
  4. PUD dosing: 2 wks - 6 months*
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16
Q

GERD/PUD Treatment

-Dexlansorprazole Dexilant

A
  1. Most similar to Prevacid
    - Bind to proton pump and blocks it, preventing gastric acid from forming
    - Lasts longer and can take less often
  2. GERD = 4 weeks
  3. PUD = 2 weeks for h. Pylori infection
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17
Q

Which PPI is best?

A
  1. Nexium (esomeprazole magnesium)
    - MOST EFFECTIVE for treatment of GERD & PUD
  2. Omeprazole + sodium bicarb (Zegrid)
    - Can maintain a pH >4 for 12-18 hrs
    - More studies needed
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18
Q

GERD/PUD Treatment

-H2RA/PPI Combo Therapy?

A
  1. H-2 is taken at bedtime
    - H-2’s reduce acid secretion regardless of meals or time of day
  2. PPI works best to reduce acid secretion triggered by meals during the day
  3. Combo is less expensive than BID PPI’s
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19
Q

GERD/PUD Treatment

-Options for Nocturnal Acid Control

A
  1. Dose PPI daily prior to breakfast
  2. Dose PPI daily prior to dinner
  3. Dose PPI daily prior to breakfast & H2RA at bedtime
  4. Dose PPI twice daily (Prior to breakfast and dinner)
  5. Dose PPI twice daily (Prior to breakfast and dinner) AND H2RA at bedtime

REFER: @ PPI twice daily

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20
Q

Gastric Anti-secretory Agents

-PNA & C. Diff?

A

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

  1. 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.
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21
Q

Discontinuing a PPI

-Stats

A
  1. Very difficult to D/c meds due to acid rebound hyper-secretion symptoms
  2. Only 1/3 of long-term PPI users will be able to successfully D/C meds
  3. Harder for GERD patients than PUD to D/C meds.
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22
Q

PPI’s and Hip Fractures?

A
  1. PPI’s may interfere w/ calcium absorption
  2. Increase risk when PPI is used > 1 yr; higher doses
  3. Men are at greater risk
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23
Q

NSAID Gastro-protection

-Who needs it?

A
  1. > 76 yrs old
  2. Significant co-morbidities
  3. Hx of NSAID-related GI complications
  4. Taking warfarin

Prevacid & Nexium are the two meds used for NSAID gastroprotection

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24
Q

PUD Medication

-Misoprostol (Cytotec)

A
  1. Prostaglandin analog that decreases gastric acid secretion
  2. Indicated for “At Risk” for GI bleed d/t NSAIDS or corticosteroids
  3. NOT for pregnancy; can cause ABORTION
  4. Can cause Diarrhea
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25
Q

PUD

-Sucralfate (Carafate)

A
  1. Aluminum hydroxide complex
    - coating over the ulceration
    - May also stimulate prostaglandins mediated mucosal protection
  2. Used for stress ulcer prophylaxis and duodenal ulcer healing
  3. Given before meals and before bedtime
  4. Can cause constipation
    - Can also be used for mouth (aphthous) ulcers**
26
Q

H. Pylori

-Treatment goals?

A
  1. Relieve ulcer pain
  2. Heal existing ulcer
  3. Eradicate H. Pylori to reduce recurrence
27
Q

Treatment for H. Pylori

-Triple Therapy?

A
  1. PPI + 2 antibiotics
    - Clarithromycin, amoxicillin, and tetracycline
  2. Bismuth can also be included in triple therapy
    - Can cause black tongue and stool and tinnitus
28
Q

Treatment for H. Pylori

-Prevpac??

A
  1. PPI + clarithromycin (Biaxin) + either amoxicillin or metronidazole **
  2. $290**
    - 2 week duration and 90% effective
29
Q

Treatment for H. Pylori

-Helidac

A
  1. BSS + metronidazole + tetracycline
  2. Cost $30

-2 week duration and 90% effective

30
Q

Treatment for H. Pylori

-Pylera

A
  1. Biskalcitrate (Bismuth agent) + metronidazole + tetracycline

2 week duration and 90% effective

31
Q

GERD Treatment

-Prokinetic Agents? Reglan?

A
  1. Metoclopramide (Reglan)
    - Increases esophageal motility and gastric emptying rate
  2. Take 30 minutes before meals for 12 weeks
  3. S/E
    - Dystonic or tardive dyskinesia reactions
  4. Hypotension crisis with MAOI’s
    - Don’t give with alcohol or benzodiazepines
32
Q

GERD Prokinetic Agents

-Baclofen (Liosresal)

A
  1. Muscle relaxant that has been shown to increase lower esophageal sphincter pressure
  2. S/E
    - Drowsiness, hypotension, dizziness
  3. When DC’d TAPER Medication down
33
Q

Population Specific Considerations for GERD Treatment

A
  1. GERD is common in healthy infants
    - Treat by thickening formula and burping
  2. Geriatrics
    - No aluminum due to constipation
    - Pantoprazole works well with elderly
  3. Women
    - GERD is common in pregnancy
    - DO NOT use Sodium bicarb due to alkalosis risk
34
Q

Anti-Diarrheal’s

-Treatment Modalities? (4)

A
  1. Adsorbent and demulcents
    - Adsorb toxins and other substances that produce diarrhea
  2. Anti-motility/Antispasmodic
    - Anticholinergic and “opiate” type effect
    - Do not use if invasive bacterial diarrhea and PMC, or in preschool
  3. Intestinal flora modifiers
  4. Antibiotics
35
Q

Diarrhea Treatment:

-Adsorbent & Demulcents?

A
  1. Bismuth subsalicylate (Pepto-bismol)
    - Non-specific diarrhea and prophylactic tx of travelers diarrhea
    - Can cause black tarry stools and darkening of the tongue; tinnitus
  2. 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”
36
Q

Diarrhea Treatment: Anti-motility/Antispasmodic

A

CONTRAINDICATED in children <2 yrs

  1. Diphenoxylate (Lomotil)
    - Schedule V controlled
    - Discontinue after 48 hrs if no improvement
  2. Loperamide (Imodium)
  3. Difenoxin (Motofen)
    - Schedule IV
37
Q

Imodium Abuse?

A
  1. Imodium is an opioid agent which binds to receptors in the brain to cause a high or euphoria
  2. Abused due to low cost, easy access, OTC
  3. FDA safety warning for cardiovascular event
38
Q

Intestinal Flora Modifiers?

A
  1. Lactinex
  2. Bacid
  3. Probiotics such as probiotics Try first
39
Q

Travelers Diarrhea

-1st line treatment?

A
  1. Imodium + 3 day coarse of fluoroquinolone
    - Relives symptoms in <24 hrs

Take Probiotic for prevention while traveling

40
Q

Travelers Diarrhea

-Pregnancy Patient?

A
  1. Azythromycin (Zithromax)

Take probiotic for prevention when traveling

41
Q

Travelers Diarrhea

-Prophylaxis

A
  1. Do not generally recommend prophylaxis
  2. Fluoroquinolone (ex: Cipro) for max of 3 wks. 90% effective
  3. Pepto-Bismol
    - 2 tabs QID can prevent diarrhea (less effective than antibiotics
    - Use 2 tabs q30 minutes up to 8 doses for TREATMENT
42
Q

Population Specific Considerations for Diarrhea

A
  1. Pediatric
    - Oral rehydration is key
  2. Geriatrics
    - Rehydration is paramount
    - Watch interactions with meds
  3. Women
    - NO loperamide in Pregnancy
    - Lomotil and loperamide are excreted in breast milk*
43
Q

IBS

-Meds to Consider?

A
  1. 1st line Treatment
    - Anti-diarrheal’s
  2. PPI’s and H2RA can work
  3. Antispasmodic (Bentyl)
  4. Bulk forming laxatives (Metamucil)
44
Q

Drugs for Hiccups?

A
  1. Chlorpromazine (Thorazine)

- Only FDA approved treatment for hiccups

45
Q

Constipation

-Preferred therapy?

A 
1. Diet and lifestyle modification
Including
-Increasing fiber to 20-25 grams/day
-increasing exercise
-Establish regular bowel regimen
46
Q 
Constipation Meds (Irritants or stimulants)
-Biscodyl (Dulcolax)
A

Bisacodyl (Dulcolax)
1. Increase peristalsis through effects on smooth muscle and promoting fluid accumulation in colon/small intestine

  1. Onset:
    - Oral 6-12 hours
    - Rectal 15-60 minutes
  2. Do not administer w/ milk or antacids
47
Q 
Constipation Meds (Irritants or stimulants)
-Glycerin Suppositories
A
  1. Local irritating and hyperosmolar effect

- Not systemically absorbed

48
Q 
Constipation Meds (Irritants or stimulants)
-Sennosides (Senokot)
A
  1. Start low dose and go slow

- Can easily switch to diarrhea from constipation

49
Q 
Constipation Meds (Irritants or stimulants)
-All Meds?
A
  1. Bisacodyl (Dulcolax) (Increased peristalsis)
  2. Glycerin Suppositories (Hyperosmolar effect)
  3. Sennosides (Senokot) (Can cause diarrhea. Start slow)
50
Q

Saline or Hyperosmotic Laxatives

-Info?

A
  1. Draws water into intestine through osmosis & increases intestinal motility
  2. 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

51
Q

Bulk Producing Laxatives

-Info & Exemplars

A
  1. Bind to fecal contents and pull water into the stool
    Onset
  2. 12-24 hrs up to 3 days
  3. Exemplars
    - Bran
    - Metamucil
    - Methylcellulose
    - FiberCon
    - Maltsupex
  4. Can cause flatulence
52
Q

Emollients or Stool Softeners

-Info & Exemplars

A
  1. Reduces surface tension of liquid contents of the bowel; Easier defecation
  2. Onset
    - 1-3 days for docusate
    - 6-8 hrs for mineral oil
  3. Exemplars
    -Mineral Oil — may cause lipoidal PNA if aspirated
    —Absorbs fat soluble vitamines causing deficiency of Vit. A, D, E, & K.
    -Docusate Sodium (Colace)
  4. Not systemically absorbed (Good for pregnant women)
    - Used for long-term use and treatment
53
Q

Constipation Med

-Amitiza (Lubiprostone)

A
  1. Activates chloride channels in gut; increasing intestinal fluid secretion and improved motility
  2. Used for CHRONIC constipation
  3. Give medication with water
    - Common S/E is Nausea (30%)
54
Q

Constipation Med

-Linzess (Linaclotide)

A
  1. Chronic Constipation treatment
  2. Activates colonic neurons increasing smooth muscle contractions
  3. Approved for IBS-C in adults & Chronic constipation
  4. NOT given <6 yrs old

Common S/E
-Diarrhea

55
Q

Constipation Med

-Activia

A
  1. Yogurt product w/ Probiotic

2. Insufficient evidence but may provide some relief

56
Q

Constipation

-Recommended order of treatment

A
  1. First line — Bulk-forming agent — Metamucil OR Colace once daily
  2. Second line — Milk of magnesia OR Glycerin suppository
  3. Third line — Stimulant laxative OR Magnesium citrate
57
Q

Special population considerations w/ Constipation?

-Pediatrics

A
  1. May need manual evacuation — can be distressing
58
Q

Special population considerations w/ Constipation?

-Geriatrics

A
  1. Self reported constipation increases w/ age but bowel frequency does not decline
  2. Be careful with laxatives d/t fluid and electrolyte imbalances
59
Q

Special population considerations w/ Constipation?

-Women

A
  1. Pregnancy = Docusate (COLACE) **

2. Be mindful of overuse of laxatives in anorexia — 10x more common in women

60
Q

Bowel Prep for colonoscopy?

A
  1. Most use a large volume PEG solution (Golytely) + Laxative

6020 Advanced Pharm Test 3 COMPLETE ☑️ (7 decks)

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