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Pharmacology -AM > N/V, Constipation, diarrhea, pancreatic enzymes > Flashcards

N/V, Constipation, diarrhea, pancreatic enzymes Flashcards

1
Q

Anticholinergics options for N/V

A

Scopolamine

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2
Q

How is the anticholinergic Scopolamine administered?

A

A patch that lasts 72 hours. Must apply 4 hours prior to N/V causing incident

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3
Q

MOA of Scopolamine (anticholinergic)?

A

Blocks muscarinic/cholinergic receptors, halts signal to CNS, reduces N/V in vestibular

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4
Q

AE of Scopolamine (anticholinergic)?

A

Dry mouth, drowsy, blurred vision,

Rare: dizziness, disorientation, hallucinations

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5
Q

Antihistimine options for N/V?

A 
Cyclizine
Dimenhydrinate
Diphenhydramine
Hydroxyzine
Meclizine
Doxylamine
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6
Q

MOA of Antihistamines for N/V

A

Blocks histamine 1 receptor (2nd gen don’t cross BBB, so no CNS effects) works on vestibular

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7
Q

AE of Antihistamines for N/V

A

sedation
dry mouth
constipation

Rare: confusion, blurry, urinary retention

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8
Q

Phenothiazines drugs for N/V?

A

Chlorpromazine
Prochlorperazine
Promethazine

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9
Q

What antiemetics can be given in a suppository?

A

Phenothiazines

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10
Q

MOA of Phenothiazines drugs for N/V?

A

dopamine antagonist to D2 receptors. works in CTZ

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11
Q

AE of Phenothiazines drugs for N/V?

A

sedation, lethargy, skin sensations, orthostatic hypotension

rare: CNS effects, EPS, jaundice, Hyperprolactinemia

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12
Q

Phenothiazines drugs for N/V*

A

Avoid in pediatrics

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13
Q

What population should avoid Phenothiazines drugs for N/V?

A

Pediatric patients

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14
Q

Butyrophenones drugs for N/V?

A
  • Droperidol

- Haloperidol

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15
Q

MOA of Butyrophenones drugs for N/V

A

Dopamine antagonist, works in CTZ

It’s also an antipsychotic

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16
Q

AE of Butyrophenones drugs for N/V

A 
sedation
agitation
restlessness
Hypotension
Tachycardia

Rare: EPS, dizziness, HTN, QT prolongation

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17
Q

The problem with Butyrophenones drugs for N/V

A

It has a black box warning regarding the side effects of QT prolongation, torsades de point, and sudden cardiac death

Contraindicated if pt already has QT prolongation or is at a higher risk of developing them.

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18
Q

Benzamides drugs for N/V

A

Metoproclamide

Trimethobenzamide

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19
Q

MOA of Benzamides drugs for N/V

A

Dopamine Against D2, reduces N/V in CTZ and peripherally. Some anticholinergic activity (gastric motility)

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20
Q

AE of Benzamides drugs for N/V

A

They do cross BBB, so section, restlessness, diarrhea, agitation, CNS depression

Less common: EPS, HypoTN, neuroleptic, SVT, QT prolongation, serotonin syndrome

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21
Q

Corticosteroid drugs used for N/V

A

Dexamethazone

Methylprednilosone

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22
Q

MOA of Corticosteroid drugs used for N/V

A

related to the release of 5HT, reduced permeability of BBB and reduction of inflammation.

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23
Q

AE of Corticosteroid drugs used for N/V

A

Usually only with long term use:
GI upset
insomnia
anxiety

Less common: hyperglycemia, facial flushing, euphoria, perineal itch/burn (with Dexamethazone)

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24
Q

Cannabinoids for N/V

A

Dronabinol

Nabilone

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25
Q

Why would you choose Cannabinoids for N/V Tx?

A

For use with Chemo patients or other serious diseases. Not first line.

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26
Q

MOA of Cannabinoids for N/V

A

unknown, probably central antiemetic, and is also appetite stimulant

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27
Q

AE of Cannabinoids for N/V

A

drowsiness, euphoria, ataxia, dizziness, somnolence, vasodilation, vision changes, dysphoria

Less common: diarrhea, flushing, tremor, myalgia

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28
Q

Benzodiazepine drugs for N/V

A

Lorazepam

Alprazolam

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29
Q

MOA of Benzodiazepine drugs for N/V

A

maybe due to sedative, anxiolytic or amnesic properties

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30
Q

AE of Benzodiazepine drugs for N/V

A

sedation, amnesia

Rare: respiratory depression, ataxia, blurred vision, hallucinations

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31
Q

Serotonin Antagonist drugs for N/V

A

Dolasetron
Granisetron
Ondansetron
Palonesetron

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32
Q

MOA of Serotonin Antagonist drugs for N/V

A

selective 5HT3 antagonist block 5HT receptors, works on CTZ

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33
Q

AE of Serotonin Antagonist drugs for N/V

A

headache, somnolence, diarrhea, constipation, QT prolongation (except Palonesetron)

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34
Q

What do you need to monitor with Serotonin Antagonist drugs for N/V

A

ECG

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35
Q

What is special about Palonesetron?

A

It has a 40 hr half-life + receptor binding affinity, which is good for delayed nausea related to Chemo
(The other Serotonin Antagonists have a 4-9 hr half-life)

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36
Q

Neurokinin-1 Antagonist drugs for N/V

A

Aprepitant

Netupitant (+ Palonesetron)

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37
Q

MOA of Neurokinin-1 Antagonist drugs for N/V

A

blocks neurokinin-1 receptors, works in CTZ

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38
Q

In what instances would you choose a Neurokinin-1 Antagonist drugs for N/V

A

for acute or delayed chemo-induced nausea

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39
Q

AE of Neurokinin-1 Antagonist drugs for N/V

A

fatigue, hiccups

Less common: dizziness, headache, insomnia

Rare: increase in hepatic transaminases

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40
Q

Interactions of Aprepitant (a Neurokinin-1 Antagonist drug for N/V)

A

Many! CYP3A4 drugs

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41
Q

N/V drug choices for Chemo are based on emetogenic potential. What are the low, mod, and high drug options?

A

Low- Dexamethazone
Mod- Palonesetron + Dexamethazone
High- Any 5HT antagonist + Dexamethazone + Aprepitant for the first day, and then Aprepitant + Dexamethazone on days 2-4

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42
Q

N/V drugs for Post-op

A

Night before/2 hrs prior- Scolpalamine
Before anesthesia - Palonosetron, Dexamethazone, or maybe Aprepitant
After anesthesia - Droperidol, 5HT3 receptor antagonist

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43
Q

N/V drugs for motion sick or vestibular disturbances

A
  • transdermal scopolamine
  • antihistamines
  • anticholinergics
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44
Q

N/V drugs to use in pregnancy

A

1st- pyridoxine (B6)
-Doxylamine (H1B)
-Doxylamine + pyridoxine (works well, $$$)
ginger?

More severe N/V:
Promethazine
Metoclopramide
Meclizine

Hyperemesis Gravidum:
Methylprednisone- may cause cleft palate in 1st trimester, so avoid during that time

*No longer give Ondansetron -cleft palates, heart problems

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45
Q

1st choice of treatment for constipation?

A

Nonpharmocologic

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46
Q

Bulk producer options for constipation

A

Psyllium
Polycarbophil
Methycellulose

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47
Q

MOA of Bulk producer options for constipation

A

swell in GI tract and forms a gel that aids in elimination

BM occurs in 1-3 days

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48
Q

AE of Bulk producer options for constipation

A

farts and abdominal cramps

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49
Q

Important to keep in mind with Bulk producer options for constipation

A

Water!!! to avoid obstruction

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50
Q

Hyperosmotic options for constipation

A
  • Lactulose
  • sorbitol
  • glycerin
  • Polyethylene glycol (PEG) 3350
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51
Q

MOA of Hyperosmotic options for constipation

A

Brings water into the lumen of the colon

BM in 1-3 days

52
Q

AE of Hyperosmotic options for constipation

A

farts, abdominal cramping, bloating

53
Q

What is a good Hyperosmotic option for acute or persistent constipation?

A

PEG

54
Q

Lubricant used for constipation

A

Mineral oil

55
Q

MOA of mineral oil (lubricant) for constipation

A

coats, prevents water from leaving

BM in 1-3 days

56
Q

Stimulant laxative options for use with constipation

A
  • Bisacodyl
  • Senna
  • Castor Oil
57
Q

MOA of stimulant laxatives

A

They work on intestinal smooth muscle to enhance motility

BM in 6-12 hours (fastest is rectal administration)

58
Q

AE of Stimulant laxatives

A

abdominal cramping

59
Q

Which stimulant laxative is contraindicated in pregnancy?

A

Castor oil- contractions

60
Q

What is the emollient used for constipation?

A

Docusate

61
Q

MOA of emollients (Docusate) used for constipation

A

increase surface wetting action to soften and reduce friction, makes passing the stool easier

BM in 72 hrs

This option is better for prophylaxis

62
Q

In what instance would you not want to use an emollient (Docusate)?

A

Opioid induced constipation (though commonly prescribed)

Need something for motility and this is solely a softener

63
Q

Saline Agent options for constipation

A
  • Magnesium Citrate
  • Magnesium Hydroxide
  • Magnesium Sulfate
  • other sodium and phosphate salt agents
64
Q

MOA of Saline Agents for constipation

A

pull water into the lumen, increase enteral pressure

65
Q

AE of Saline Agents for constipation

A

accumulate w/ renal dysfunction

With sodium -> dehydration, hypernatremia, and decrease in renal function

66
Q

In what populations do you avoid Saline Agents for constipation

A

elderly, CHF patients, those with renal dysfunction

67
Q

Intestinal Secretagogue options for constipation

A

Lupiprostone

Linaclotide

68
Q

MOA of Intestinal Secretagogues for constipation

A

increase in interstitial fluid secretions with increased motility

69
Q

AE of Intestinal Secretagogues for constipation

A 
loose stools (worse with high fat breakfasts & linaclotide)
nausea (lupiprostone)
diarrhea, abdominal pain, farts, abdominal distention, headache
70
Q

Do you prescribe Lupiprostone or LInaclotide (Intestinal Secretagogues) to kids?

A

heck no

adults only, and not often given

71
Q

When would you use Lupiprostone (Intestinal Secretagogues)?

A

chronic idiopathic constipation, or opioid induced

72
Q

When would you use Linaclotide (Intestinal Secretagogues)?

A

for IBS-C or chronic idiopathic constipation

73
Q

What do you need to monitor with Lupiprostone or LInaclotide (Intestinal Secretagogues)?

A

fluid/electrolyte loss

74
Q

Peripherally-acting Mu-opioid receptor antagonist drug options for constipation

A
  • methylnaltrexone bromide

- naloxegol

75
Q

MOA of Peripherally-acting Mu-opioid receptor antagonist drug options for constipation

A

antagonize mu-receptor inhibits opioid-induced decrease in motility/transit time

76
Q

AE of Peripherally-acting Mu-opioid receptor antagonist drug options for constipation

A

abdominal pain, cramping farts, diarrhea

-methylnaltrexone bromide- dizziness, hyperhidrosis

naloxegol- GI perforation, n/v, headache

77
Q

When would you choose to use a methylnaltrexone bromide or naloxegol?

A

short-term, special situations. Only pts on opioids and nothing else has worked

78
Q

When are methylnaltrexone bromide or naloxegol contraindicated?

A

with a GI obstruction, or with CYP3A4 (mod-strong), or with other opioid antagonists -> CV event risk

79
Q

Absorbents/Bulk agent options for diarrhea

A
  • calcium polycarbophil
  • psyllium
  • methylcellulose
80
Q

MOA of absorbents/bulk agent options for diarrhea

A

absorb water, form gel and enhance stool formation

no systemic absorption

psyllium and methylcellulose help reduce fluid in stool

81
Q

What do you need to be conscious of with calcium polycarbophil (Absorbents/Bulk agent) used for diarrhea

A

It may interfere with absorption of other meds

82
Q

Antiperistaltic meds for diarrhea

A
  • Loperamide
  • Diphenoxylate (+ atropine)

Diphenoxylate is an opioid receptor, so Atropine is added as an abuse deterrent

83
Q 
MOA of Antiperistaltic meds (Loperamide
and Diphenoxylate (+ atropine) for diarrhea
A

prolong transit time which means more fluid is reabsorbed

84
Q

When would you choose a Antiperistaltic meds (Loperamide and Diphenoxylate (+ atropine) for diarrhea

A

Only with non-infectious diarrhea

85
Q 
AE of Antiperistaltic meds (Loperamide
and Diphenoxylate (+ atropine) for diarrhea
A

constipation

86
Q

Antisecretory meds for diarrhea

A
  • Bismuth subsalicylate (PO- OTC)

- Octreotide (SubQ or IV)

87
Q

MOA of Antisecretory meds (Octreotide and Bismuth subsalicylate) for diarrhea

A

prevents secretions, so reduction in fluid in the stool

88
Q

When would you choose to use Bismuth subsalicylate (antisecretory)

A

for acute diarrhea

Caution- risk of salicylic

89
Q

When would you choose to use Octreotide (antisecretory)

A

with chemo induced, HIV, DM, gastric resection, GI tumors, reduced hepatic portal vein pressure

90
Q

AE of Antisecretory meds (Octreotide and Bismuth subsalicylate) for diarrhea

A

Black stools with Bismuth

Nausea, bloating, gallstones with Ocreotide

91
Q

MOA of Probiotics for use with diarrhea

A

It stimulates the immune response and suppresses inflammation response. It also enhances the normal microflora of GI tract

92
Q

When would you use Lactase for diarrhea?

A

To prevent diarrhea in patients who are lactose intolerant so they can break it down

93
Q

What antibiotic options would you consider for use with infective diarrhea?

A
  • Ciprofloxacin
  • Levoflaxacin
  • Azithromycin
  • Rifaximin
94
Q

Antispasmodics used for diarrhea

A
  • Dicylomine
  • Hyoscyamine
  • Propantheline
  • Clidinium + chlordiazepoxide
  • Hyoscyamine/scopalamine/atropine/phenobarbital
  • peppermint oil
95
Q

MOA of Antispasmodics used for diarrhea

A

reduce spasms of intestines and reduces cramping

96
Q

AE of Antispasmodics used for diarrhea

A

drowsiness (w/ peppermint oil), blurry vision, constipation, urinary retention

rare: psychosis

97
Q

Other meds used for IBS related diarrhea

A
  • Eluxadoline

- Alosetron

98
Q

MOA and AE of Eluxadoline used for IBS diarrhea

A

MOA: Mu-opioid receptor agonist, reduces bowel contractions
AE: constipation, nausea, abdominal pain

99
Q

MOA, indications, and cautions of using Alosetron for IBS diarrhea

A

MOA: blocks serotonin (5HT3) receptor

Indications: Only for women with severe IBS-D. They must sign a consent

Caution- risk of ischemic colitis

100
Q

3 stages of N/V

A

nausea
retching
vomiting

101
Q

areas in vomiting center that are triggered and causes emesis

A 
GI tract
chemoreceptor trigger zone (CTZ)
cerebral cortex
vestibular apparatus
pharynx (gag)
102
Q

Vomiting center that is outside the BBB; stimulated by uremia, acidosis, and circulating toxins (like chemo);
has many type 3 serotonin (5HT3), neurokinin-1 (NK1) and dopamine (D2) receptors that respond to GI distention, mucosal irritation, and infection.

A

Chemoreceptor Trigger Zone (CTZ)

103
Q

Vomiting center that when stimulated, causes motion sickness; and has many histamine (H1) and muscarinic cholinergic receptors

A

Vestibular system (vestibular apparatus)

104
Q

Vomiting center that is affected by sensory input: sights, smells, emotions; and is also involved in anticipatory n/v associated with chemo

A

Cerebral cortex

105
Q

1st things to try with treating n/v

A
  • identify and treat underlying cause (ie. AE of meds)
  • adjust eating habits (frequent small meals)
  • try nonpharmacologic (ginger, acupressure)
  • then pharmacologic
106
Q

Antiemetics that work with the vestibular system

A

anticholinergics

antihistamines

107
Q

Antiemetics that work with the chemoreceptor trigger zone(CTZ) -dopamine antagonists

A

Phenothiazines
Butyrophenones
Benzamides

108
Q

Antiemetics that work with the chemoreceptor trigger zone (CTZ)

A

Serotonin antagonists
Neurokinin-1 antagonists
Corticosteroids (maybe related to 5HT release?)

109
Q

Antiemetics with an unknown MOA

A

Cannabinoids

Benzodiazepines (maybe depresses vomiting center?)

110
Q

Extrapyramidal Symptoms (EPS)

A

Dystonia -involuntary muscle contractions
Tardive dyskinesia - irreversible and permanent involuntary movements
Akathisia - motor restlessness or anxiety

  • these are all rare
  • risk factors with Butyrophenones and Benzamides
111
Q

Nonpharmacologic therapy for constipation

A
  • don’t hold it
  • increase dietary fiber
  • increase fluids
  • increase exercise
  • maybe probiotics?
  • maybe biofeedback?
  • surgery is last resort
112
Q

What things should you be aware of before using meds for constipation?

A
  • if elderly, avoid mineral oil
  • children
  • pregnant/nursing
  • colostomy
  • DM (due to sugar content of some products)
  • Heart disease (due to Na content of some products)
  • Kidney disease (may cause build-up of some electrolytes/products)
  • Swallowing difficulty (bulk formers may cause esophageal obstruction)
113
Q

Cause of diarrhea

A
  • Infection or non-infetious
  • changes in osmotics
  • increased secretion of ions into lumen
  • inflammation
  • increased motility (less reabsorption)
  • meds
114
Q

What are the concerns with diarrhea

A

with elderly or young children, or if severe

concern for electrolyte disturbances, metabolic acidosis, CV collapse

Most diarrhea is self limiting and lasts less that 3-4 days, causes no complications or significant dehydration, and can be self treated

115
Q

Primary treatment of diarrhea

A

fluid/electrolyte replacement, dietary modifications, drug therapy

116
Q

Nonpharmacologic therapy for diarrhea

A

Fluid and electrolytes

Food (basic stuff)

117
Q

What is an inflammatory process that causes impaired endocrine and exocrine function?

A

chronic pancreatitis

118
Q

As exocrine function decreases in chronic pancreatitis, what can’t be absorbed from the diet?

A

lipids and protein

  • which causes wt. loss, malnutrition, fat-soluble vitamin deficiency
  • fat or protein-containing stools occur
  • carb absorption is usually fine
119
Q

What are the treatment goals with chronic pancreatitis

A
  • relief of acute/chronic abdominal pain- analgesics (non-opioid preferred)
  • correction of dietary malabsorption with exogenous pancreatic enzymes
  • Tx of endocrine insufficiency and associated diabetes (can develop glucose intolerance)
120
Q

What are the components of pancreatic enzymes

A

Amylase
Lipase
Protease

121
Q

When are pancreatic enzymes indicated?

A
  • symptomatic patients with steatorrhea
  • chronic pancreatitis
  • cystic fibrosis
122
Q

MOA of pancreatic enzymes

A

delivers exogenous pancreatic enzyme to duodenum and allows proteins and fats to be absorbed

must be taken immediately before meals and snacks

123
Q

How do you select what pancreatic enzyme product to use

A

consult a specialist! many options with different ratios

They are often based on body weight, symptoms, stool fat content

124
Q

What does the half life of pancreatic enzymes depend on?

A

how much fat is in the intestines

pts should consider reducing dietary fat consumption to extend efficacy of pancreatic enzymes

125
Q

What may need to be prescribed along with pancreatic enzymes

A

H2 blocker or PPI if delayed gastric emptying or non-enteric coated products

126
Q

Caution with lipase >10,000/day

A

risk of colonic stricture and fibrosis

Pharmacology -AM (4 decks)

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