N/V, Constipation, diarrhea, pancreatic enzymes Flashcards
1
Q
Anticholinergics options for N/V
A
Scopolamine
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
3
Q
MOA of Scopolamine (anticholinergic)?
A
Blocks muscarinic/cholinergic receptors, halts signal to CNS, reduces N/V in vestibular
4
Q
AE of Scopolamine (anticholinergic)?
A
Dry mouth, drowsy, blurred vision,
Rare: dizziness, disorientation, hallucinations
5
Q
Antihistimine options for N/V?
A
Cyclizine Dimenhydrinate Diphenhydramine Hydroxyzine Meclizine Doxylamine
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
7
Q
AE of Antihistamines for N/V
A
sedation
dry mouth
constipation
Rare: confusion, blurry, urinary retention
8
Q
Phenothiazines drugs for N/V?
A
Chlorpromazine
Prochlorperazine
Promethazine
9
Q
What antiemetics can be given in a suppository?
A
Phenothiazines
10
Q
MOA of Phenothiazines drugs for N/V?
A
dopamine antagonist to D2 receptors. works in CTZ
11
Q
AE of Phenothiazines drugs for N/V?
A
sedation, lethargy, skin sensations, orthostatic hypotension
rare: CNS effects, EPS, jaundice, Hyperprolactinemia
12
Q
Phenothiazines drugs for N/V*
A
Avoid in pediatrics
13
Q
What population should avoid Phenothiazines drugs for N/V?
A
Pediatric patients
14
Q
Butyrophenones drugs for N/V?
A
- Droperidol
- Haloperidol
15
Q
MOA of Butyrophenones drugs for N/V
A
Dopamine antagonist, works in CTZ
It’s also an antipsychotic
16
Q
AE of Butyrophenones drugs for N/V
A
sedation agitation restlessness Hypotension Tachycardia
Rare: EPS, dizziness, HTN, QT prolongation
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.
18
Q
Benzamides drugs for N/V
A
Metoproclamide
Trimethobenzamide
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)
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
21
Q
Corticosteroid drugs used for N/V
A
Dexamethazone
Methylprednilosone
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.
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)
24
Q
Cannabinoids for N/V
A
Dronabinol
Nabilone
25
Why would you choose Cannabinoids for N/V Tx?
For use with Chemo patients or other serious diseases. Not first line.
26
MOA of Cannabinoids for N/V
unknown, probably central antiemetic, and is also appetite stimulant
27
AE of Cannabinoids for N/V
drowsiness, euphoria, ataxia, dizziness, somnolence, vasodilation, vision changes, dysphoria
Less common: diarrhea, flushing, tremor, myalgia
28
Benzodiazepine drugs for N/V
Lorazepam
| Alprazolam
29
MOA of Benzodiazepine drugs for N/V
maybe due to sedative, anxiolytic or amnesic properties
30
AE of Benzodiazepine drugs for N/V
sedation, amnesia
Rare: respiratory depression, ataxia, blurred vision, hallucinations
31
Serotonin Antagonist drugs for N/V
Dolasetron
Granisetron
Ondansetron
Palonesetron
32
MOA of Serotonin Antagonist drugs for N/V
selective 5HT3 antagonist block 5HT receptors, works on CTZ
33
AE of Serotonin Antagonist drugs for N/V
headache, somnolence, diarrhea, constipation, QT prolongation (except Palonesetron)
34
What do you need to monitor with Serotonin Antagonist drugs for N/V
ECG
35
What is special about Palonesetron?
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)
36
Neurokinin-1 Antagonist drugs for N/V
Aprepitant
| Netupitant (+ Palonesetron)
37
MOA of Neurokinin-1 Antagonist drugs for N/V
blocks neurokinin-1 receptors, works in CTZ
38
In what instances would you choose a Neurokinin-1 Antagonist drugs for N/V
for acute or delayed chemo-induced nausea
39
AE of Neurokinin-1 Antagonist drugs for N/V
fatigue, hiccups
Less common: dizziness, headache, insomnia
Rare: increase in hepatic transaminases
40
Interactions of Aprepitant (a Neurokinin-1 Antagonist drug for N/V)
Many! CYP3A4 drugs
41
N/V drug choices for Chemo are based on emetogenic potential. What are the low, mod, and high drug options?
Low- Dexamethazone
Mod- Palonesetron + Dexamethazone
High- Any 5HT antagonist + Dexamethazone + Aprepitant for the first day, and then Aprepitant + Dexamethazone on days 2-4
42
N/V drugs for Post-op
Night before/2 hrs prior- Scolpalamine
Before anesthesia - Palonosetron, Dexamethazone, or maybe Aprepitant
After anesthesia - Droperidol, 5HT3 receptor antagonist
43
N/V drugs for motion sick or vestibular disturbances
- transdermal scopolamine
- antihistamines
- anticholinergics
44
N/V drugs to use in pregnancy
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
45
1st choice of treatment for constipation?
Nonpharmocologic
46
Bulk producer options for constipation
Psyllium
Polycarbophil
Methycellulose
47
MOA of Bulk producer options for constipation
swell in GI tract and forms a gel that aids in elimination
BM occurs in 1-3 days
48
AE of Bulk producer options for constipation
farts and abdominal cramps
49
Important to keep in mind with Bulk producer options for constipation
Water!!! to avoid obstruction
50
Hyperosmotic options for constipation
- Lactulose
- sorbitol
- glycerin
- Polyethylene glycol (PEG) 3350
51
MOA of Hyperosmotic options for constipation
Brings water into the lumen of the colon
BM in 1-3 days
52
AE of Hyperosmotic options for constipation
farts, abdominal cramping, bloating
53
What is a good Hyperosmotic option for acute or persistent constipation?
PEG
54
Lubricant used for constipation
Mineral oil
55
MOA of mineral oil (lubricant) for constipation
coats, prevents water from leaving
BM in 1-3 days
56
Stimulant laxative options for use with constipation
- Bisacodyl
- Senna
- Castor Oil
57
MOA of stimulant laxatives
They work on intestinal smooth muscle to enhance motility
BM in 6-12 hours (fastest is rectal administration)
58
AE of Stimulant laxatives
abdominal cramping
59
Which stimulant laxative is contraindicated in pregnancy?
Castor oil- contractions
60
What is the emollient used for constipation?
Docusate
61
MOA of emollients (Docusate) used for constipation
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
In what instance would you not want to use an emollient (Docusate)?
Opioid induced constipation (though commonly prescribed)
Need something for motility and this is solely a softener
63
Saline Agent options for constipation
- Magnesium Citrate
- Magnesium Hydroxide
- Magnesium Sulfate
- other sodium and phosphate salt agents
64
MOA of Saline Agents for constipation
pull water into the lumen, increase enteral pressure
65
AE of Saline Agents for constipation
accumulate w/ renal dysfunction
With sodium -> dehydration, hypernatremia, and decrease in renal function
66
In what populations do you avoid Saline Agents for constipation
elderly, CHF patients, those with renal dysfunction
67
Intestinal Secretagogue options for constipation
Lupiprostone
| Linaclotide
68
MOA of Intestinal Secretagogues for constipation
increase in interstitial fluid secretions with increased motility
69
AE of Intestinal Secretagogues for constipation
```
loose stools (worse with high fat breakfasts & linaclotide)
nausea (lupiprostone)
diarrhea, abdominal pain, farts, abdominal distention, headache
```
70
Do you prescribe Lupiprostone or LInaclotide (Intestinal Secretagogues) to kids?
heck no
adults only, and not often given
71
When would you use Lupiprostone (Intestinal Secretagogues)?
chronic idiopathic constipation, or opioid induced
72
When would you use Linaclotide (Intestinal Secretagogues)?
for IBS-C or chronic idiopathic constipation
73
What do you need to monitor with Lupiprostone or LInaclotide (Intestinal Secretagogues)?
fluid/electrolyte loss
74
Peripherally-acting Mu-opioid receptor antagonist drug options for constipation
- methylnaltrexone bromide
| - naloxegol
75
MOA of Peripherally-acting Mu-opioid receptor antagonist drug options for constipation
antagonize mu-receptor inhibits opioid-induced decrease in motility/transit time
76
AE of Peripherally-acting Mu-opioid receptor antagonist drug options for constipation
abdominal pain, cramping farts, diarrhea
-methylnaltrexone bromide- dizziness, hyperhidrosis
naloxegol- GI perforation, n/v, headache
77
When would you choose to use a methylnaltrexone bromide or naloxegol?
short-term, special situations. Only pts on opioids and nothing else has worked
78
When are methylnaltrexone bromide or naloxegol contraindicated?
with a GI obstruction, or with CYP3A4 (mod-strong), or with other opioid antagonists -> CV event risk
79
Absorbents/Bulk agent options for diarrhea
- calcium polycarbophil
- psyllium
- methylcellulose
80
MOA of absorbents/bulk agent options for diarrhea
absorb water, form gel and enhance stool formation
no systemic absorption
psyllium and methylcellulose help reduce fluid in stool
81
What do you need to be conscious of with calcium polycarbophil (Absorbents/Bulk agent) used for diarrhea
It may interfere with absorption of other meds
82
Antiperistaltic meds for diarrhea
- Loperamide
- Diphenoxylate (+ atropine)
Diphenoxylate is an opioid receptor, so Atropine is added as an abuse deterrent
83
```
MOA of Antiperistaltic meds (Loperamide
and Diphenoxylate (+ atropine) for diarrhea
```
prolong transit time which means more fluid is reabsorbed
84
When would you choose a Antiperistaltic meds (Loperamide and Diphenoxylate (+ atropine) for diarrhea
Only with non-infectious diarrhea
85
```
AE of Antiperistaltic meds (Loperamide
and Diphenoxylate (+ atropine) for diarrhea
```
constipation
86
Antisecretory meds for diarrhea
- Bismuth subsalicylate (PO- OTC)
| - Octreotide (SubQ or IV)
87
MOA of Antisecretory meds (Octreotide and Bismuth subsalicylate) for diarrhea
prevents secretions, so reduction in fluid in the stool
88
When would you choose to use Bismuth subsalicylate (antisecretory)
for acute diarrhea
Caution- risk of salicylic
89
When would you choose to use Octreotide (antisecretory)
with chemo induced, HIV, DM, gastric resection, GI tumors, reduced hepatic portal vein pressure
90
AE of Antisecretory meds (Octreotide and Bismuth subsalicylate) for diarrhea
Black stools with Bismuth
Nausea, bloating, gallstones with Ocreotide
91
MOA of Probiotics for use with diarrhea
It stimulates the immune response and suppresses inflammation response. It also enhances the normal microflora of GI tract
92
When would you use Lactase for diarrhea?
To prevent diarrhea in patients who are lactose intolerant so they can break it down
93
What antibiotic options would you consider for use with infective diarrhea?
- Ciprofloxacin
- Levoflaxacin
- Azithromycin
- Rifaximin
94
Antispasmodics used for diarrhea
- Dicylomine
- Hyoscyamine
- Propantheline
- Clidinium + chlordiazepoxide
- Hyoscyamine/scopalamine/atropine/phenobarbital
- peppermint oil
95
MOA of Antispasmodics used for diarrhea
reduce spasms of intestines and reduces cramping
96
AE of Antispasmodics used for diarrhea
drowsiness (w/ peppermint oil), blurry vision, constipation, urinary retention
rare: psychosis
97
Other meds used for IBS related diarrhea
- Eluxadoline
| - Alosetron
98
MOA and AE of Eluxadoline used for IBS diarrhea
MOA: Mu-opioid receptor agonist, reduces bowel contractions
AE: constipation, nausea, abdominal pain
99
MOA, indications, and cautions of using Alosetron for IBS diarrhea
MOA: blocks serotonin (5HT3) receptor
Indications: Only for women with severe IBS-D. They must sign a consent
Caution- risk of ischemic colitis
100
3 stages of N/V
nausea
retching
vomiting
101
areas in vomiting center that are triggered and causes emesis
```
GI tract
chemoreceptor trigger zone (CTZ)
cerebral cortex
vestibular apparatus
pharynx (gag)
```
102
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.
Chemoreceptor Trigger Zone (CTZ)
103
Vomiting center that when stimulated, causes motion sickness; and has many histamine (H1) and muscarinic cholinergic receptors
Vestibular system (vestibular apparatus)
104
Vomiting center that is affected by sensory input: sights, smells, emotions; and is also involved in anticipatory n/v associated with chemo
Cerebral cortex
105
1st things to try with treating n/v
- identify and treat underlying cause (ie. AE of meds)
- adjust eating habits (frequent small meals)
- try nonpharmacologic (ginger, acupressure)
- then pharmacologic
106
Antiemetics that work with the vestibular system
anticholinergics
| antihistamines
107
Antiemetics that work with the chemoreceptor trigger zone(CTZ) -dopamine antagonists
Phenothiazines
Butyrophenones
Benzamides
108
Antiemetics that work with the chemoreceptor trigger zone (CTZ)
Serotonin antagonists
Neurokinin-1 antagonists
Corticosteroids (maybe related to 5HT release?)
109
Antiemetics with an unknown MOA
Cannabinoids
| Benzodiazepines (maybe depresses vomiting center?)
110
Extrapyramidal Symptoms (EPS)
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
Nonpharmacologic therapy for constipation
- don't hold it
- increase dietary fiber
- increase fluids
- increase exercise
- maybe probiotics?
- maybe biofeedback?
- surgery is last resort
112
What things should you be aware of before using meds for constipation?
- 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
Cause of diarrhea
- Infection or non-infetious
- changes in osmotics
- increased secretion of ions into lumen
- inflammation
- increased motility (less reabsorption)
- meds
114
What are the concerns with diarrhea
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
Primary treatment of diarrhea
fluid/electrolyte replacement, dietary modifications, drug therapy
116
Nonpharmacologic therapy for diarrhea
Fluid and electrolytes
| Food (basic stuff)
117
What is an inflammatory process that causes impaired endocrine and exocrine function?
chronic pancreatitis
118
As exocrine function decreases in chronic pancreatitis, what can't be absorbed from the diet?
lipids and protein
- which causes wt. loss, malnutrition, fat-soluble vitamin deficiency
- fat or protein-containing stools occur
- carb absorption is usually fine
119
What are the treatment goals with chronic pancreatitis
- 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
What are the components of pancreatic enzymes
Amylase
Lipase
Protease
121
When are pancreatic enzymes indicated?
- symptomatic patients with steatorrhea
- chronic pancreatitis
- cystic fibrosis
122
MOA of pancreatic enzymes
delivers exogenous pancreatic enzyme to duodenum and allows proteins and fats to be absorbed
must be taken immediately before meals and snacks
123
How do you select what pancreatic enzyme product to use
consult a specialist! many options with different ratios
They are often based on body weight, symptoms, stool fat content
124
What does the half life of pancreatic enzymes depend on?
how much fat is in the intestines
pts should consider reducing dietary fat consumption to extend efficacy of pancreatic enzymes
125
What may need to be prescribed along with pancreatic enzymes
H2 blocker or PPI if delayed gastric emptying or non-enteric coated products
126
Caution with lipase >10,000/day
risk of colonic stricture and fibrosis
