Muma Drugs

Question 1

Reacts slowly to form CaCl2 and CO2 to cause belching

Answer 1

Calcium carbonate (

Question 2

Reacts with HCl to produce NaCl and CO2 which causes belching and gastric distention.

Answer 2

Sodium bicarbonate

Question 3

Reacts with HCl to form water and aluminum chloride or magnesium chloride. Magnesium salts not absorbed can cause osmotic diarrhea and aluminum salts can cause constipation so often used together.

Answer 3

Magnesium hydroxide & Aluminum hydroxide

Question 4

H2 receptor Antagonists \?

Answer 4

Cimetidine

Question 5

Pk H2 All but ____ under go? resulting in? Cleared by both?Reduction in?

Answer 5

All but nizatidine under-go first pass metabolism resulting in 50% bioavailability. Cleared by both metabolism and excretion so need for dose reduction with severe renal dysfunction.

Question 6

PD H2 antagonists Highly selective ________ ___ which inhibit___ ___ but especially basal ____ gastric acid secretion and pepsin. Inhibit ___ - ___ of acid secretion per day.

Answer 6

Highly selective H2 competitive antagonists which inhibit meal-stimulated but especially basal nocturnal gastric acid secretion and pepsin. Inhibit 60-70% of acid secretion per day.

Question 7

Uses for H2 antagonists?

Answer 7

Can be used for infrequent dyspepsia/heartburn or prophylactically before meals. Rarely used for peptic ulcers. For critically ill pts with stress-related mucosal disease and upper GI ulcers used via continuous iv infusion. Available over the counter and as prescription.

Question 8

AEs of H2 antagonsits

Answer 8

Extremely safe, < 3% diarrhea, constipation, headache fatigue, myalgias In elderly in intensive care or renal or hepatic dysfunction- mental status perturbation Cimetidine inhibits binding of dihydrotestosterone to androgen receptors and estradiol metabolism so increases serum prolactin resulting in possible male gynecomastia or impotence and female galactorrhea. Cross placenta and excreted in breast milk

Question 9

DIs for H2 Antagonists

Answer 9

Competes with creatinine and with some drugs for renal tubule secretion Cimetidine inhibits P450 drug metabolism

Question 10

PPIs

Answer 10

Omeprazole

Question 11

What type of drugs are PPIs? What type of Coating? Dissolve where? Converted to a reactive? What does it do to the enzymes?

Answer 11

Administered as a prodrug. Acid resistant coating to protect from destruction by gastric acid, dissolves in intestine where drug is absorbed (weak base) and is concentrated in parietal cell canniculus. Converted to a reactive thiophilic sulfonamide which forms a covalent bond with active proton pumps irreversibly inactivating the enzyme. If taken 1 hr before a meal drug, there is maximal activation of pumps when drug is available for inactivating the pumps. Although t1/2 = 1.5 hrs, inhibition lasts about 1 day due to synthesis of new pumps. 3-4 days for full effect due to acid inhibition as well as 3-4 days for full recovery after cessation of treatment. Absorption diminished by food so must be taken on an empty stomach.

Question 12

PD of PPIs

Answer 12

Inhibit both basal and meal-stimulated HCl secretion 90-98%/day Similar clinical efficacy among drugs in class

Question 13

Uses for PPIs

Answer 13

Gastroesophageal reflux disease (GERD)-provide symptom relief and tissue healing but symptoms often recur after discontinuation of drug resulting in the need for long term or intermittent therapy Peptic Ulcer -Rapid relief of symptoms and ulcer healing in 4-8 wks Useful for NSAID-associated ulcers and treatment of bleeding ulcers

Question 14

AEs of PPIs

Answer 14

Safe, 1-5% diarrhea, headache, abdominal pain Reduction in gastric acidity- Can reduce release of vitamin B12 from food and reduce absorption of minerals such as iron, calcium, zinc and magnesium. Associated with increase hip fracture so for those at risk, monitor bone density and provide calcium supplements. Increased risk for respiratory and enteric infections since low pH is protective against bacteria. Increased risk of chronic kidney disease and mortality from it

Question 15

DIs for PPIs

Answer 15

Alter absorption of drugs from stomach that depend on low pH

Question 16

Mucosal Protective agents Sucralfate PD and PK

Answer 16

Sucrose complexed to sulfated aluminum In water or acid forms viscous paste that binds to the ulcer forming a barrier and stimulates mucosal prostaglandin and bicarbonate secretion < 3% absorbed

Question 17

Sucralfate limited uses?

Answer 17

Upper Gi bleeding in critically ill and stress related bleeding

Question 18

AEs of Sucralfate

Answer 18

Constipation in 2% due to aluminum Not absorbed systemically so no systemic adverse effects

Question 19

Mucosal Protective Agents Prostaglandin analog Misoprostol analog of? PK and PD

Answer 19

Pharmacokinetics Orally available, rapidly absorbed and metabolized to active form t1/2 < 30min so 3-4 doses/day Pharmacodynamics Stimulates mucus and bicarbonate secretion Enhances mucosal blood flow Binds to prostaglandin receptors on parietal cells to reduce histamine-stimulated acid production

Question 20

Uses for Misoprostol

Answer 20

Prophylactic use for NSAID induced ulcers

Question 21

Misoprostol AEs and DIs

Answer 21

10 -20% diarrhea and cramping Causes uterine contractions so contra-indicated during pregnancy No significant drug interactions

Question 22

Mucosal Protective Agents Bismuth compounds PK and PD

Answer 22

PK- Salicylate rapidly dissociates and is absorbed Bismuth excreted in the stool PD- Bismuth coats ulcers for physical protection Stimulates prostaglandin, mucus and bicarbonate secretion Direct antimicrobial effects, binds enterotoxins Antimicrobial effects against Helicobacter pylori Reduces stool frequency and liquidity in acute infectious diarrhea

Question 23

Bismuth uses

Answer 23

Treatment of dyspepsia and acute diarrhea and prophylactically against traveler’s diarrhea Used in combination with antibiotics and proton pump inhibitors for H. pylori infection

Question 24

Bismuth AEs

Answer 24

Extremely safe Harmless blackening of stool and if liquid formulation also tongue

Question 25

Abx for the Tx of H. Pylori only need to know 2

Answer 25

Clarithromycin and Metronidazole

Question 26

Natural laxative product 1 What is it?

Answer 26

Psyllium- Indigestible hydrophobic colloid that absorb water to form a bulky gel that distends the colon and advances peristalsis, bacteria in colon can cause bloating and fart from nat product

Question 27

Stool softener only one How does it work?

Answer 27

Docusate Surfactants allowing water and lipids to penetrate stool

Question 28

Osmotice laxatives Mg Oxide Should be used in patients with?

Answer 28

should not be used in pts with renal insufficiency due to hypermagnesemia

Question 29

Balanced polyethylene glycol What is it? Whats in it? No change in? Not associated with? Used for what?

Answer 29

Inert non-absorbable sugar balanced with isotonic solution of sodium sulfate, sodium chloride, sodium bicarbonate, potassium chloride No change in intravascular volume or electrolyte balance Not associated with cramps or flatus Used for colonic cleansing before GI endoscopic procedures and chronically for constipation at lower doses

Question 30

Stimulant laxatives Diphenylmethane derivatives Biscodyl- Used for?

Answer 30

used for acute and chronic constipation, and in conjunction with PEG for colonic cleansing prior to endoscopy

Question 31

Chloride channel activator?

Answer 31

Lubiprostone

Question 32

Lubiprostone MOA? Used for?

Answer 32

Stimulates type 2 chloride channels in small intestine. Used for the tx of chronic constipation and IBS with constipation

Question 33

Opioid receptor Antagonists

Answer 33

Methylnaltrexone

Question 34

Methylnaltrexone Selective for? does cross? Used for?

Answer 34

alvimopan and naloxegol are selective mu opioid antagonists that do not cross the blood brain barrier. Used for the treatment of opioid-induced constipation and post-operatively.

Question 35

Opioid agonists

Answer 35

Loperamide

Question 36

Loperamide Doesnt?

Answer 36

cross the BBB

Question 37

Bile salt binding resins

Answer 37

Cholestryamine

Question 38

Cholestryamine PD

Answer 38

Conjugated bile salts are absorbed in the terminal ileum. Diseases of terminal ileum such as Crohn’s disease or surgical resection disturb bile salt absorption and may cause colonic secretory diarrhea. Bile salt binding resins bind bile salts to decrease diarrhea due to excess fecal bile acids.

Question 39

Cholestryamine AEs

Answer 39

Bloating, flatulence, constipation, fecal impaction Further removal of bile acids may cause fat malabsorption

Question 40

Cholestyramine DIS

Answer 40

Cholestryanine and colestipol may bind other drugs and decrease their absorption, so do not take other drugs within 2 hrs. Colesevelam does not alter absorption of other drugs.

Question 41

Antiemtic Drugs 5-HT3 receptor antagonists

Answer 41

Palonosetron

Question 42

Palonosetron PK and PD

Answer 42

Anti-emetic actions through blockade of 5-HT3 receptors on extrinsic intestinal vagal and spinal afferent nerves and perhaps on the vomiting center and chemoreceptor trigger zone.

Question 43

Palonosetron- 2nd generation with a?

Answer 43

longer t1/2 and higher binding affinity Selective- no antagonism at dopamine or cholinergic muscarinic receptors May slow colon transport but no effect on esophageal or gastric motility.

Question 44

Palonosetron uses

Answer 44

Anti-emetic effects for emesis due to vagal stimulation such as post-operative or chemotherapy. Chemotherapy induced emesis- primary agents for use alone but can also be used in combination with dexamethasone or NK1 antagonist Used for nausea and vomiting induced by radiation therapy to the abdomen or whole body and post-operatively.

Question 45

1. 5-HT3 Receptor Antagonists AEs

Answer 45

Well-tolerated and generally safe Most common side effects are headache, dizziness and constipation.

Question 46

Corticosteroids Antiemetics

Answer 46

Dexmethasone

Question 47

Neurokinin 1 receptor antagonists PK PD Uses AEs DIs

Answer 47

Aprepitant

Pharmacokinetics

Aprepitant has 65% oral bioavailability.

Fosaprepitant is an iv infusion formulation that is rapidly converted to aprepitant.

Rolapitant- long half-life prolongs therapeutic effects

Pharmacodynamics

Selective neurokinin 1 receptor antagonist with antiemetic properties via central blockade of receptors in the area postrema.

Uses

Prevent and treat post-operative and chemotherapy-related nausea & vomiting

Less effective for motion sickness related nausea & vomiting

Used alone or in combination with 5-HT₃ receptor antagonist and dexamethasone (corticosteroid).

Adverse effects

Safe, well tolerated, few adverse effects reported but include fatigue, dizziness and diarrhea.

Drug interactions

Inhibit P450 metabolism (CYP3A4) and metabolism of drugs including some chemotherapeutic agents.

Question 48

1. Dopamine 2 receptor antagonists

Answer 48

Prochlorperazine

Question 49

D2 receptor antagonists

PD

uses

AEs

Answer 49

Pharmacodynamics

Antipsychotics with antiemetic effects via dopamine & muscarinic receptor antagonism (phenothiazines) or for butyronphenones via central dopaminergic antagonism.

Sedative effects via antihistamine activity

Uses

In the past, used extensively for post-operative antiemetic and sedative effects.

Adverse effects

Extrapyramidal effects and hypotension

Question 50

1. Substituted benzamides

Answer 50

Metoclopramide

Question 51

Substituted Benzamides

Pd

And
AEs

Answer 51

Pharmacodynamics

Mechanism of antiemetic effect- dopamine receptor antagonisms

Trimethobenzamide also has weak antihistamine effects

Adverse effects

Via central dopaminergic antagonism- restlessness, dystonia, parkinsonism

Question 52

H1 antihistamine anticholinergics

PD

Uses

AEs

Answer 52

Diphenhydramine

Hyoscine (scopolamine)

Pharmacodynamics

Diphenhydramine and dimenhydramine have both antihistamine and anticholinergic properties

Meclizine has antihistamine effects but limited anticholinergic effects so less sedating.

Hyoscine is a muscarinic antagonist.

Uses

Used to prevent and treat motion sickness.

Diphenhydramine and dimenhydramine used in combination with other agents for treatment of chemotherapy caused emesis.

Meclizine is used for preventing motion sickness and treatment of vertigo caused by labrynth dysfunction.

Hyoscine in a transdermal patch used extensively for motion sickness.

Adverse effects

Use limited by side effects- sedation, dizziness, confusion, dry mouth, cycloplegia, urinary retention

Question 53

BZDs

Answer 53

Lorazepam

Enhance GABAergic neurotransmission

Used to reduce vomiting associated with anxiety or anticipatory vomiting related to chemotherapy

Question 54

Cannabinoids

Answer 54

Dronabinol

Uses

Used as an appetite stimulant and antiemetic

Used with other antiemetics, synergistic with phenothiazines and decrease adverse effects of both drugs.

Adverse effects

Euphoria, dysphoria, sedation, hallucination, dry mouth, increased appetite, tachycardia, orthostatic hypotension

Question 55

Drugs for the Tx of IBS with diarrhea

7

Answer 55

1. Anti-diarrheal agents especially loperamide
2. Mu and kappa opioid agonist, delta opioid antagonist

Eluxadoline

Decreases abdominal pain and diarrhea

Adverse effects: constipation, nausea, abdominal pain

1. Tricyclic anti-depressants at low doses

Reduce pain

Normalize GI motility and secretions to reduce frequency and volume

No effects on mood

1. 5-HT₃ receptor antagonists

Alosetron approved for treatment of women with severe IBS with diarrhea

Efficacy of other 5-HT₃ antagonists not examined

5-HT₃ receptors in GI modulate visceral pain and intestinal motility

Alosetron- rare but serious GI toxicity limits use to women refractory to other therapies

1. Bile salt binding resins

About 1/3 of people with IBS-D have bile acid malabsorption and can be treated with bile salt binding resins

1. Antispasmodics

Hyoscine

Used to reduce colon muscle spasms and pain

1. Antibiotic

Rifaximin- GI specific broad spectrum antibiotic

Question 56

Drugs for tx of IBS with Constipation

3

Answer 56

1. Polyethylene glycol and osmotic laxatives used to soften stools and increase frequency, but no impact on pain.
2. Guanylate cyclase agonist

Linaclotide

Adverse effects

diarrhea, upper respiratory tract infection, abdominal pain or distention, flatulence, headache

1. Chloride channel activators

Lubiprostone

Stimulates type 2 chloride channels in small intestine, low systemic absorption

Used for the treatment of chronic constipation and women with IBS with constipation

Adverse effects

Nausea (29%),< 12 % headache, diarrhea, stomach pain or bloating, gas, vomiting, dizziness, swelling of the hands, feet, ankles, or lower legs, discomfort in chest, tiredness

Question 57

Drugs for the Tx of IBD

6

Answer 57

1. Aminosalicylates

5-aminosalicylic acid differs from salicylic acid by addition of an amino group at the 5 position

Mechanism of action uncertain but thought to alter inflammation and immune responses.

Thought to work topically in the GI mucosa so several formulations used to limit absorption and aid in delivery to small bowel or colon.

Azo compounds

Sulfasalazine

Olsalazine

Balsalazide

An aza bond to another 5-aminosalicylate or inert compound reduces absorption until drug reaches the terminal ileum and colon where an azoreductase cleaves the azo bond to achieve high concentrations of active compound at site of action.

Mesalamine compounds

Pentasa

Asacol

Lialda

Rowasa

Canasa

Formulations designed to deliver 5-aminosalicylic acid to various segments of the small and large bowel.

Uses

Mild to moderate ulcerative colitis and Crohn’s disease.

Adverse effects

Sulfasalazine has high incidence of adverse effects especially in slow acetylators due to sulfapyridine, up to 40% cannot tolerate.

Olsalazine causes stimulatory diarrhea in 10% of pts.

Some of the common side effects of aminosalicylates include abdominal pain, diarrhea, headaches, heartburn, nausea and vomiting.

1. Glucocorticoids

Pharmacokinetics

Prednisone and prednisolone are the most commonly used oral glucocorticoids.

Hydrocortisone enemas, foam and suppositories used to maximize colon effects and diminish systemic absorption.

Budesonide is a high affinity synthetic prednisolone analog with high first pass effect, available in controlled release formulation for delivery to distal ileum and colon.

Pharmacodynamics

Via interaction with glucocorticoid receptors:

Decrease production of inflammatory cytokines and chemokines.

Decrease inflammatory cell adhesion molecules.

Decrease transcription of nitric oxide synthase, phospholipase A₂, cyclooxygenase-2 and NFB.

Uses

Treatment of moderate to severe IBD.

Budesonide for mild to moderate Crohn’s disease since slightly less effective but with significantly fewer adverse effects.

Adverse effects

For treatment less than 2 weeks, very well tolerated, occasional peptic ulcer, and rare pancreatitis.

Extensive adverse effects for treatment lasting longer than 2 weeks

1. Immune Modulators

Purine analogs

Azathioprine

6-mercaptopurine (6-MP)

Pharmacokinetics

Bioavailability of azathioprine better than 6-MP, azathioprine converted to 6-MP

Short half-life but active 6-thioguanine nucleotide metabolites have a long half-life and are concentrated in cells

Pharmacodynamics

Immunosuppressive properties through an unknown mechanism

6-thioguanine inhibits purine nucleotide metabolism and DNA synthesis and repair leading to decreased cell division and proliferation

Uses

Induction & maintenance of remission of ulcerative colitis and Crohn’s disease

Help maintain remission in up to 80% of pts

Used to reduce dose or eliminate glucocorticoid treatment

Adverse effects

Nausea, vomiting, hepatotoxicity, bone marrow suppression

Monitoring of complete blood count and liver function tests needed

Leukopenia and liver dysfunction usually reverse with dose reduction

Hypersensitivity characterized by fever, rash, pancreatitis, diarrhea & hepatitis in 5%

Drug interactions

Reduce the dose of azathioprine and 6-MP by half in patients taking allopurinol because

allopurinol reduces purine analog catabolism.

Methotrexate

Anti-metabolite used for a number of chronic inflammatory diseases.

Pharmacodynamics

Primary mechanism of action is inhibition of dihydrofolate reductase, an enzyme important in production thymidine and purines.

Uses

Induce and maintain remission of IBD

Adverse effects

At high doses- bone marrow suppression, megaloblastic anemia, alopecia and mucositis.

At doses used for IBD, uncommon but if occur, reduce dose

Folate supplements reduce the risk of adverse effects without reducing anti-inflammatory effects.

1. Anti-Tumor Necrosis Factor (TNF) therapy

Infliximab

Adalimumab

Certolizumab

Golimumab

Pharmacokinetics

Due to a long half-life, these drugs are given at bi-weekly or longer intervals for induction and maintenance of remission.

Pharmacodynamics

Monoclonal antibodies to human TNF approved for the treatment of IBD.

TNF is a pro-inflammatory cytokine dysregulated via TH1 T cell response in IBD, esp. Crohn’s disease.

Uses

Acute and chronic treatment of moderate to severe Crohn’s disease with inadequate response to other therapies.

Infliximab approved for acute and chronic ulcerative colitis with inadequate response to other therapies.

Median clinical response time is 2 weeks.

Adverse effects

Serious adverse effects occur in 6% of pts

Infection due to suppression of TH1 inflammatory response such as pneumonia & sepsis, fungal infections, viral infections, reactivation of latent TB and other opportunistic infections.

Acute adverse infusion reactions in ~10% characterized by fever, chills, pruritis, urticaria, cardiopulmonary symptoms, dyspnea or hemodynamic instability

Antibody production against the antibodies which eliminate the clinical response and increase the risk for infusion reactions.

Delayed(1-2 wks) infusion reaction in 1% characterized by myalgia, arthralgia, fever, rash, urticaria and edema. Usually requires discontinuation of therapy.

Rare adverse effects include hepatic failure, demyelinating disorders, hematological reactions congestive heart failure in pts with heart disease and lymphoma

1. Anti-Integrin therapy

Natalizumab

Vedolizumab

Pharmacodynamics

Integrins are adhesion molecules that allow circulating leukocytes to enter tissue

Natalizumab is a monoclonal antibody against α4 integrin that prevents circulating leukocytes from entering tissues targeting brain and gut.

Vedolizumab humanized monoclonal antibody directed against α4β7 integrin. The α4ß7 integrin is expressed on the surface of a discrete subset of memory T-lymphocytes that preferentially migrate into the GI tract providing increased selectivity.

Uses

Approved for the treatment of moderate to severe Crohn’s refractory to other treatments.

Adverse effects

Natalizumab

Acute infusion reactions and opportunistic infections.

Progressive multifocal leukoencephalopathy a rare infection of the brain that cannot be treated, prevented, or cured and that usually causes death or severe disability. The risk for PML is higher with one or more of the following risk factors: treatment for longer than 2 years, previous treatment with immunosupressants (azathioprine, cyclophosphamide, methotrexate, mitoxantrone, and mycophenolate mofetil), exposure to JC virus.

Hepatotoxicity with jaundice in 0.1% -discontinue if occurs

Vedolizumab- no PML reported

1. Antibiotics

Metronidazole

Ciprofloxacin

Used to treat infections resulting from IBD

Question 58

Tx of Celiac Disease

Answer 58

Life-long gluten-free diet accomplished by excluding wheat, rye and barely from the diet, oats should also be excluded due to contamination issues.

Initial supplements with iron, calcium, phosphorous, folate, B12 and fat-soluble vitamins as needed.

Refractory disease can be treated with corticosteroids such as budesonide or anti-inflammatory drugs such as azathioprine.

Untreated celiac disease damages the small intestine and interferes with nutrient absorption.

Without treatment, people with celiac disease can develop complications such as osteoporosis, anemia, and cancer.