N/V/C/D Flashcards
(172 cards)
1
Q
What are some causes of GI irritation? 9
A
GI irritation Motion sickness Vestibular disease Hormone disturbance Drugs and radiation Exogenous toxins Pain Psychogenic factors Intracranial pathology
2
Q
How else to N/V present clinically besides N/V
A
*Dehydration can occur as a result of vomiting(Pinching skin takes longer to go down)
Increased thirst and dry mouth.
Less frequent urination
Tachycardia
3
Q
What are 3 nonpharm therapies for NV
A
Rehydrate- Oral rehydration Solutions Avoid dairy BRAT diet- 24 hours after fluid diet Banana Rice Apple Sauce Toast (Dry)
4
Q
What are the 4 types of pharm therapy for N/V?
A
5-HT3 Antagonists
Dopamine Antagonists
Antihistamines
Cannabinoids
5
Q
Name 3 types of 5-HT3 antagonists and what is the drug of choice for NV?
A
Ondansetron (Zofran) - DOC
Granisetron (Kytril)
Dolasetron (Anzemet)
6
Q
What is the MOA of 5-HT3 antagonist?
A
Antagonism of the 5-HT3 receptor in the chemo-receptor trigger zone (CTZ)
7
Q
What are the ROA for 5-HT3 Antagonists?
A
Oral, rectal, IM, IV
8
Q
What are the 2 Indications of 5-HT3 antagonists?
A
Treatment and prevention of postoperative N/V
Chemotherapy-induced N/V
9
Q
What are the ADRs of the 4 5-HT3 antagonists?
A
HA
Dizziness
Diarrhea
Abdominal pain
10
Q
What are 3 examples of DA antagonists?
A
Metoclopramide (reglan)
Trimethobenzamide (Tigan)
Phenothiazines - Prochlorperazine (Compazine
11
Q
what are the 3 MOA of DA antagonists?
one is specific for high dose of Metoclopramide
A
Antagonist of D2 receptors in the CTZ
At higher doses metoclopramide also blocks 5-HT3 receptors
Also promote gastric emptying and small intestine peristalsis—prokinetic effects.
12
Q
5 contraind for DA Antagonists
A
GI—hemorrhage, obstruction or perforation Cautiously in patients w/depression Pheochromocytoma Seizure Use very cautiously in children
13
Q
ADRs of DA antagonists?
A
Extrapyramidal effects
Restlessness, anxiety, drowsiness, fatigue, hallucinations
CV—HTN, HPOTN, AV block, bradycardia
Agranulocytosis
14
Q
What is one antihistamine used in NV?
A
Promethazine (Phenergan)
15
Q
What are the ROA of Promethazine?
A
IV PO IM PR
16
Q
What are 2 MOA of Promethazine?
A
Block H1 effectiveness appear to be with motion sickness and vestibulochochlear disease
Antagonist of D2 receptors in the CTZ
17
Q
What are the ADRs of antihistamines?
A
dry mouth, dizziness etc.
Parkinsonian symptoms (dyskinesia, dystonias, akathisia)
Neuroleptic malignant syndrome
Blood dyscrasias
18
Q
In what conditions should you use caution in with promethazine? 3
A
BPH
Urinary retention
glaucoma
19
Q
What is a cannabinoid used in NV
A
Dronabinol (Marinol)
20
Q
What is the MOA of Dronabinol
A
Not well definded
21
Q
What are the 3 ADRs of Dronabinol?
A
Drowsiness. sedation, and increased appetite
22
Q
What 2 things does normal motility do in the intestines?
A
Acts to mix bowel contents thoroughly
To propel them in a caudal direction
23
Q
Regulation of normal intestinal motility is by? 2
A
Neuronal
Hormonal
24
Q
What nerve influences motility and what does it do?
A
The vagus nerve of the intestinal (enteric) system
Stimulates peristaltic movements
Relaxes digestive sphincters
Promotes GI secretion
25
What are the 5 classes of drugs that effect GI motility?
```
Laxatives
Antidiarrheal Agents
Prokinetic Agents
Antiemetic Agents
Antispasmodics
```
26
What is the Medical Definition of Constipation?
```
2 or more of the following:
Straining > 25% of time
Lumpy or hard stools > 25% of time
Feeling of incomplete evacuation > 25% of time
2 or fewer BM in 1 week
```
27
What Metabolic diseases may cause constipation? 4
Hypothyroid, hypercalcemia, hypokalemia, diabetes
28
What 3 GI d/o may cause constipation?
Tumors, IBS, Diverticulitis
29
what 3 neurogenic d/o may cause constipation?
Trauma to brain/spinal cord, CNS tumor, Parkinson’s
30
What 6 meds may cause constipation?
```
Opiates
Ca and Al antacids
Iron
Calcium channel blockers
Clonidine
Anticholinergics (Antihistamines, antiparkinsonians, TCA)
```
31
what are the 3 best ways to prevent constipation?
Drink plenty of water and fluids (“P” juices (pear, prune, peach))
Adequate exercise (Do not hold it (water will be reabsorbed and stools will harder))
High fiber diet (insol and sol) -
32
What does insol fiber do for constipation? 2 ex
Insoluble-shorten intestinal transit time and increase stool bulk.
Whole grains
Bran
33
What does sol fiber due for constipation
more moist stool and less effect on transit time.
Fresh fruits
Fresh vegetables
34
what do laxatives do? (2)
Drugs used to hasten transit time in the gut and encourage defecation.
Drugs are also used to clear the bowel prior to medical and surgical procedures.
35
what are 6 types of laxatives?
```
Bulk-Forming Laxatives
Emollients and Lubricants
Saline Cathartics
Osmotic Laxatives
Stimulant Laxatives
```
36
what are 3 times of bulk-forming laxatives?
Psyllium (Metamucil), Methylcellulose (Citrucel), Polycarbophil (Fibercon)
37
when is bulk-forming laxative onset time?
2-3days
38
what is the MOA of bulk-formong laxatives? (what is very imp to do along with these)
Increases the volume of the non-absorbable solid residue with water, distending the colon and stimulating peristaltic activity increasing the rate of colonic transit
(Adequate fluid intake is very important with these agents)
39
what is the 1st line for bedridden or geriatric with chronic constipation, and in Pregnancy?
bulk forming laxatives
40
What are the 3 contraindications for bulk-forming laxatives?
Patients with stenosis
Ulceration or adhesions
Fecal obstruction
41
what are the ADRs of Bulk forming laxatives? 3
flatulence, abdominal distension, gastrointestinal obstruction
42
What are drug interactions with bulk forming laxatives? what is the proper way to take other meds and bulk-forming lax?
Binds drugs & reduces absorption—separate from other medication administration.
take med 1st-wait 2 hrs then lax
take lax 1st-wait 4 hrs to take med
43
What are 3 other uses of bulk forming laxatives?
The ability of these agents to absorb water makes them useful for relieving symptoms of mild diarrhea.
Several months use can relieve symptoms of irritable bowel syndrome
Lowering cholesterol
44
what is one example of an emollient?
Docusate sodium (Colace)
45
what are the indications for emollients? DOC for?
To avoid straining
After MI, rectal surgery, opiates
1st line Pregnant women (along with bulk forming)
46
Onset of emollient is?
1-3 days
47
What is the MOA of emollients?
surfactant brings water into stool, facilitates mixing of aqueous and fatty materials within intestine, increase H20 and electrolyte secretion in small/ large bowel
48
what are contraindications for emollients?
Fecal Impaction
| Signs and symptoms of appendicitis
49
What is an example of Lubricant used for constipation?
Mineral Oil
50
What is discouraged for mineral oil?
Chronic Use
51
What is Mineral Oil used for?
mainly for prevention
To avoid straining
After MI, rectal surgery
52
What is the Onset of mineral oil?
6hr-3days
53
what is the MOA of mineral oil?
coats stool (allows easier passage), inhibits colonic absorption of water
54
what are the cautions of mineral oil use? 4
Avoid in elderly, aspiration risk and decrease absorption of fat-soluble vitamins (DEAK)
May leak from anal sphincter
55
What are 2 examples of osmotic agents used for constipation?
Lactulose and sorbitol
56
What is lactulose's MOA
disaccharide that is metabolized by bacteria in the colon to low-molecular weight acids = osmotic effect
57
what is lactulose NOT considered?
1st line agent in constipation
58
What are ADRs of lactulose?
May result in flatulence, cramps, electrolyte imbalances
59
What is lactulose more commonly used for (other than const)
More commonly used in patients with hepatic encephalopathy
60
what is the onset of lactulose
Oral dose softens stool in 1-3 days
61
what is sorbitols MOA
monosaccharide creates an osmotic gradient when used as a 70% solution
62
what is an ADR of sorbitol
hyperglycemia
63
what is the onset for sorbitol?
1-3days
64
What are 4 examples of saline cathartics used for diarrhea?
Magnesium hydroxide (Milk of Magnesia), magnesium sulfate (Epsom salts), sodium phosphate (Fleets Enema), magnesium citrate (Citrate of Magnesia)
65
What is the onset of saline cathartics?
30min-6hr (oral), 5-30min (rectal)
66
What is the MOA of cathartics?
Mg++ or Na+ salts are poorly absorbed; they increase the water content of the bowel through osmosis
67
What are 3 contraindications for cathartics
impaired renal function Mg and Na accumulation, CHF, no sodium for HTN pts
68
What is the MOA of glycerin suppository?
osmotic cation in rectum
69
Onset of glycerin suppository?
<30mins
70
What might glycerin suppository cause?
Rectal irritation
71
Indications for glycerin suppository
Very safe laxative/ Can be used in children
| Intermittent use
72
Example are 2 ex of glycerin/hyperosmotic?
Polyethylene glycol (Miralax) (PEG, GoLYTELY)
73
How do you use Miralax
17g mixed in water or juice, usually 2 weeks duration, chronic use OK
74
what is the onset of miralax?
1-3days
75
what is the MOA of miralax?
osmotic
76
what is the indication for miralax?
Relatively safe and OK in children
77
What is the indication for PEG, GoLYTELY
for colonic cleansing before diagnostic procedures
78
what is the onset of action of PEG, GoLYTELY
1hr after initiation
79
what is the MOA of PEG, GoLYTELY
osmotic agent that causes retention of water resulting in softer stool and more frequent defecation
80
how do you take PEG, GoLYTELY
4 liters over 3 hrs (8oz glass every 10 minutes), not for chronic use
81
what pts should avoid use of PEG, GoLYTELY
Avoid in patients with intestinal obstruction
82
what are 2 stimulant laxatives?
```
Diphenelymethane deriv (bidacodyl (dulcolax))
Anthraquinone lax (senna (senokot))
```
83
what is the MOA of Bisacodyl (Dulcolax)
MOA stimulate nerve plexus of colon
84
who may take Bisacodyl (Dulcolax)
>12y/o
85
what is the onset of Bisacodyl (Dulcolax)
Onset: 6-8hr (PO); 1-6h (PR)
86
when should you not take Bisacodyl (Dulcolax)
Should not take within 1 hour of antacids, milk or milk products
87
what are 3 ADRs of Bisacodyl (Dulcolax)
Intestinal cramps
Can cause fluid and electrolyte inbalance.
Pink colored urine and feces
88
what can long term use of Bisacodyl (Dulcolax) cause?
Could cause damage to the nerve plexi
Resulting in deterioration of intestinal function
Atonic colon
89
what is Senna (Senokot)?
Anthraquinone laxative
90
what is the MOA of Senna (Senokot)
Increased peristalsis
91
what is Senna (Senokot) coformulated with
docusate
92
who can take Senna (Senokot)
>12y/o
93
what is the onset of Senna (Senokot)
6-12 hr
94
what are the ADRs of Senna (Senokot) 2
Yellow-brown to red colored urine
| Large doses can produce nephritis
95
what can long term use of Senna (Senokot) cause?
Could cause damage to the nerve plexi
Resulting in deterioration of intestinal function
Atonic colon
96
what are the contraind of Senna (Senokot) -2
Pregnancy and acute intestinal inflammation
97
what is the MOA if Lubiprostone (Amitiza)
chloride-channel activator…works by increasing fluid secretion locally in the small intestine by activating the ClC-2 chloride channel
98
what are the ADRs of Lubiprostone (Amitiza)
Nausea and diarrhea
99
what is the onset of Lubiprostone (Amitiza)
1d-1wk or more
100
what are the contraind of Lubiprostone (Amitiza)
Intestinal obstruction, Pregnancy
101
what is the MOA of Methylnaltrexone
Peripherally acting antagonist of mu
| Reduces effects of opioids peripherally- Not centrally
102
what do you need to do if CrCl <30 for Methylnaltrexone
renal dose adj
103
does Methylnaltrexone cross the BBB?
No
104
who gets constipation
Diabetics, pregnant, opiate users
105
how do you treat diabetic related constipation?
Sugar-free products (Metamucil)
106
how do you treat pregnancy constipation?
bulk formers or emolients
107
what is contrind for preg constipation
mineral oil, castor oil, and osmotics
108
how do you treat opiate related constipation
exersice, adequate fluid, fiber, methylnaltrexone
109
what is best to use in elderly with constipation
Bulk-forming laxatives, enemas, glycerin, lactulose (especially good for bed-ridden patients)
“P” juices (peach, pear, prune)
110
what is best to avoid in elderly with constipation
Best to avoid saline laxative due to potential changes in electrolytes
111
how do you treat kids with constipation
“P” juices (peach, pear, prune)
<5yrs: glycerin suppositories, malt soup extract (mix with juice or breast milk), dark corn syrup, MOM, bisacodyl
Senna or mineral oil
112
what should you avoid using in kids with constipation?
stimulants and excessive use of enemas
113
why do kids get constipated?
diet and habits
114
how many days is considered acute diarrhea? Chronic
14 days is chronic
115
when should try not to use antimotility agents for diarrhea? why>
NO ANTIMOTILITY AGENTS IN DYSENTERY OR IF C.Diff IS POSSIBLE
| Diarrhea is usually a healthy response
116
what does rotavirus cause?
Watery diarrhea lasting 3-7 days, 1/3 have fever
117
what are the 4 types of diarrhea?
secretory, osmotic, exudative, altered intestinal transit
118
what is secretory diarrhea? Does fasting help? whats the characteristic of stool?
excess H2O and electrolytes
NO
Clinically recognized by large stool volume > 1L/day with normal ionic contents/osmolality
119
what is osmotic diarrhea?
| does fasting help?
substances that draw intestinal fluids
Poorly absorbed substances lead to retention of intestinal fluids = diarrhea
Clinically recognized if diarrhea stops when patient does not eat
120
what is exudative diarrhea?
d/t inflammatory disease of GI that discharge mucus, serum proteins, and blood into gut
121
3 alterations of the transit of colon
Reduced contact time in small intestine
Premature emptying colon
Bacterial Overgrowth
122
what causes reduced contact time in sm int
Intestinal Resection or Bypass Surgery
123
what causes premature emptying of the colon?
Metoclopramide
| Erythromycin
124
what can lead to bacterial overgrowth in the colon?
Increased time of exposure can lead to bacterial overgrowth
125
drugs that induce diarrhea? lots...
```
Laxatives
Antacids containing Mg
Antineoplastics
Colchicine
NSAIDs
Orlistat
Antibiotics: Clindamycin, Broad spectrum ABX
Antihypertensives- ACEI,
Cardiac Agents-digoxin
Cholinergics
PPIs-esomeprazole
H2-Blockers-famotidine
```
126
how does diarrhea present?
N/V, abdominal pain, HA, fever, chills, malaise
Weight Loss
Dehydration
127
4 ways to treat diarrhea nonpharmacologically
Discontinue consumption of solids and dairy for 24 hours (osmotic)
With N/V: mild low residue diet, as BM decrease begin bland diet
Rehydrate: Oral Rehydration Solutions, LR, D5W, NS
Maintain electrolytes
128
4 examples of antimotility agents
Diphenoxylate
Loperamide
Paregoric
Difenoxin
129
3 examples of absorbents used in diarrhea
Kaolin-pectin mix
Polycarbophil
Attapulgite
130
example of antisecretory used in diarrhea?
Bismuth susalicylate
131
anticholinergic used in diarrhea
atropine
132
what is a bacterial replacement used in diarrhea
Lactobacillus
133
enzymes used in treatment of diarrhea
lactase
134
antibiotics to treat diarrhea
metronidazole and vancomycin
135
what is the MOA of antimotility drugs in diarrhea?
Slow intestinal transit
Prolong contact and absorption
Increase gut capacity
136
what can antimotility agents do if diarrhea is infectious?
Make it worse
137
what is lomotil?
diphenoxylate
138
what is the onset of lomotil and when should you change if not working?
Clinical benefit usually within 48 hours
| If no benefit within 10 days, change therapy
139
what is the contraindications for lomotil?2
Cdiff or entertoxin-producing bacteria
140
what is the MOA of loperamide?
Acts directly on intestinal muscles to inhibit peristalsis, prolonging transit time
141
what is the onset of loperamide?
w/in 48 hrs
142
what are the contraind of loperamide? 4
Patients w/a fever exceeding 101 F (38.3C)
Acute ulcerative colitis
Antibiotic associative colitis
Children under
143
what is the MOA of absorbents?
absorb nutrients, toxins, drugs, and digestive juices
144
what is Cholestryamine (questran)
An absorbent for bile salts and C.diff
145
what is the MOA of pepto-bismol
Stimulates Absorption of Fluid and Electrolytes Across the Intestinal Wall
Antisecretory, anti-inflammatory, and antibacterial effects
146
what can pepto-bismol cause in kids under 12
reye's syndrome
147
what are the ADRs of pepto-bismol - 3
Blackened stools and tongue
Salicylism
Can induce gout attacks in susceptible patients
148
what are the drug int with pepto-bismol? 3
Anticoagulants and tetracycline; May interfere with radiologic studies
149
what is the onset of pepto-bis
<48 hrs
150
what is octreotide (sandostatin)
an antisecretory for diarrhea
151
what is the moa of octreotide (sandostatin)
Blocks the release of serotonin, Direct inhibitory effects
| Reduces motility and facilitates water absorption from the gut
152
what is the official indication of octreotide (sandostatin)
control symptoms in pts with metastic vasoactive intestinal peptide-secreting tumor associated diarrhea
153
what is the offlabel use of octreotide (sandostatin)
Treatment of refractory diarrhea
154
what is the onset of octreotide (sandostatin)
1-3 days up to a week
155
what are the 2 adr's of octreotide (sandostatin)
bradycardia, hyperglyc
156
what is the MOA of atropine in diarrhea
blocks vagal tone and prolongs gut transit time
157
what is ADR of atropine
anticholinergic
158
contraindications of atropine
Glaucoma, prostatic hypertrophy
159
what is the MOA of lactobacillus
Restores normal flora and intestinal function
160
what is the contraindication for lactobacillus
immuno-compromised pts
161
what is the lactase enzyme used for?
lactose intolerance
162
what is Zn used for in diarrhea?
adjunct to ORS
Reduction of stool output
Reduction of diarrhea duration
163
what is the proposed MOA of Zn
possibly action on intestinal ion transport
164
what is travelers diarrhea typically?
4-5 loose/watery stools per day with cramping, +/- fever, lasting 3-4 days without treatment
>80% bacterial
>90% occur in 1st two weeks of travel
165
what are risks associated with travelers diarrhea?
Ingestion of contaminated food or drink
meals eaten at home
166
what foods are at risk and may cause traveler's diarrhea?
undercooked veggies, unpeeled fruit, raw/undercooked meat
167
3 prophylaxis for traveler's diarrhea?
Dietary counseling
Bismuth subsalicylate (PeptoBismol)
Antibiotics
-Effective but irresponsible prophylaxis
168
what is problem with prophyl and abx
-Gives false sense of security
Resistance huge problem
Cipro 500mg daily is 95% effective in some areas
Campylobacter in Thailand 84% resistance within 4 year
169
if someone traveled to thialand and got diarrhea what might they have been infected with?
campylobacter
170
how do we treat travelers diarrhea - 2
Rehydration is key
Antibiotics
Cipro 500mg BID X 3 days
Azithromycin 1gm X1 or 500mg daily x 3 days
171
who gets C.Diff
Hospitalized or recently on abx
172
how do we treat c.diff?
metronidazole and vanco
