N/V/D/C/IBS Flashcards
What are some causes/types of nausea and vomiting?
- general (gastroenteritis, pancreatitis)
- balance disorder (motion, vertigo, dizzy)
- pregnancy
- post operative
- gastroparesis (DM induced nerve damage)
How do you determine planned therapy for postoperative nausea?
Apfel risk score
Apfel risk score determinants (4)
+1 female
+1 nonsmoker
+1 hx motion sickness or previous PONV
+1 expected to use post-op opioids
Apfel score = 4
- Before surgery: scopolamine patch 2hr prior
- Right before: IV dexamethasone after anesthesia induction (b4 surgery)
- Post-op: 5HT3 antagonist
Score
Apfel score = 2-3
5HT3 antagonist post OP
Apfel score ≤1
no planned therapy
can give rescue therapy if PONV signs develop
Rescue pONV
- 5HT3 antagonist
+/- drug from other class
>Metoclopramide (pro-kinetic)
>Phenothiazine (antipsychotic)
Whether you change therapy or not depends on the DOA of drug
General N/V treatment
- 5HT3 antagonist (ondansetron, etc)
- Metoclopramide (Reglan) IV/PO Q6H
- Phenothiazines (Promethazine, Prochlorperazine (rectal), Chlorpromazine) //PO/IV/deep IM
Balance N/V treatment
Antihistamines (OTC)
- Meclizine (least sedating)
- Dimenhydrinate (Dramamine)
- Doxyalamine (Unisom, +B6=diclegis)
- scopolamine (transderm)
- Hydroxyzine
NVP treatment
1st line
- Doxyalamine + B6
2nd line
- 5HT3 antagonist
- Metoclopramide
Self-care
- Ginger
- acupressure
- fresh air
- dry crackers
Gastroparesis treatment
- metoclopramide
- erythromycin
Post OP N/V treatment
based on Apfel score
- scopolamine patch
- IV dexamethasone
- 5HT3 antagonists
Treating N/V in pediatrics
Must replenish fluids and electrolytes
(not required for adults)
Antihistamines ADR
Drowsy, sedation
Constipation, dry mouth
Increased fall risk in older patients (confusion, impaired cognition)
Phenothiazines ADR
Tissue damage if given IV (opt for deep IM instead)
Hypotension (need slow IV push, lie down during/30 min after)
QT prolongation
Dystonia/EPS (rigid, locked, sustained muscle contraction)
5HT3 antagonist ADR
Constipation
Headache
QT prolongation (more likely with higher doses)
Prokinetics ADR - metoclopramide
Dystonia, EPS (more likely with IV high dose)
QT prolongation
Diarrhea
Prokinetics ADR - Erythromycin
Nausea/vomiting (can be counterintuitive)
diarrhea
QT prolongation
Corticosteroids ADR
Agitation (manic, hyper)
Insomnia
Increased appetite
Hyperglycemia
Hypertension
Decrease PG formation
- Less GI irritation/ulceration with short course (NSAID DDI)
How to handle QTc prolongation risk?
Try to avoid QT-prolonging agents >450 msec
Get EKG, if QTc >450 msec, cry - hard to treat
>Compazine (prochlorperazine)
>Low dose Zofran when absolutely have to
>Antihistamines once in a while
If you start antiemetic, but then:
QTC >500 msec = D/C
Increase QTc >60 = D/C or decrease dose
//Pancreatitis patients will often have QT-prolonging agents on board
Goals for QTc prolongation risk monitoring
Potassium > 4
Magnesium > 2
Diarrhea classification
≥3-4 stools in a day (24hr)
Constipation definition
≤ 3 bowel movements a week (7 days)
Diarrhea causes
Gastroenteritis (norovirus)
Food intolerance
Celiac
IBD (UC, Crohn’s)
IBS-D
Medications (abx, chemo, metformin)
Constipation causes
Low fiber diet (dehydration)
Comorbidities (pregnancy, IBS, DM, hypothyroidism)
Medication (opioids, iron, anticholinergics: antihistamines, TCA, CCB)
Chemo-induced diarrhea treatment
Somatostatin analog
- Octeotride (SQ QD then IM depo Q 4 wk)
Diarrhea treatment
Mild-mod noninfectious diarrhea: PO Loperamide
Severe Inflammatory IBD 10-12 watery stools, hgb<6: Diphenoxylate/atropine* (Lomotil)
//*atropine prevents abuse
Chemo diarrhea or intestinal carcinoid tumor
- octreotide SQ,IM
Irritable IBS-D
- SIBO = Rifaximin
- Eluxadoline
- Alostren
Diarrhea Severe IBD (UC) treatment
10-12 watery stools: Diphenoxylate/atropine*
//*atropine prevents abuse
Constipation treatment
Gentle but takes a while: Osmotics
- PEG: inert, pulls water, well tolerated
- Lactulose: sugar, may cause diarrhea, taste bad
- Good for pt with hepatic encephalopathy (cirrhosis)
Opioid-induced constipation treatment
Peripheral Mu antagonist
- Methylnaltrexone SQ (Relistor)
- Naloxegol PO (Movantile)
- Naldemedinen PO (Symproic)
Chronic idiopathic constipation treatment
(and also IBS-C)
- Lubiprostone (CL channel activator)
- Linaclotide (Linzess)
- Plecanatide (Trulance)
Osmotic laxative ADR
Lactulose may cause diarrhea due to sugar alcohols
Miralax rather tame, may take a while
Chronic Idiopathic Constipation drugs ADR
CL channel activators: work too well cause diarrhea, nausea
Guanyl Cyclase C agonist: diarrhea, (Trulance has less diarrhea)
peripheral opioid receptor antagonists ADR
Severe abdominal pain and diarrhea (D/C)
WARNING: bowel perforation in patients with GI malignancies
Which drug class has warning for bowel performation?
peripheral mu receptor antagonists
- patients with GI malignancies or GI wall problems
- IBD, diverticulitis, colon cancer
IBS presentation
Chronic abdominal pain + altered bowel habits
Women < 50 y/o
Global symptoms: bloating, abdominal pain, change in BM
Diagnosing IBS
Exclusion - rule out everything else
ROME4 Criteria
ROME4 criteria
Recurrent abdominal pain (QW) in last 3 mon:
+2 of the below:
- pain due to defecation
- change in stool frequency
- change in stool consistency
Causes of IBS
Gut hypersensitivity
Acute gastroenteritis (transient)
SIBO (small intestine bacteria overgrowth)
Psychological stress
Types of IBS
25% time or more
IBS-C
IBS-D
IBS-M
IBS-C constipation treatment
1st: 2022 guidelines –> Linzess (linacoltide)
1st WOMEN only: lubiprostone (CL channel PO)
Women <65 w/o CV hx: Tegaserod (d/c if no effect in 4 wks)
Tenapanor (IBSrela) – new drug, reduces Na/phosphate absorption, effect on GI pain receptor
Lubiprostone ADR
20% Diarrhea
Nausea (take w/ food to reduce ADR)
//only for IBS-C if women
//approved for chronic constipation for all
Secretagogue ADR
Diarrhea w/ linzess (linaclotide)
//ibs-c
less diarrhea with trulance (Plecanatide)
Tegaserod ADR
(Zelnorm)
<5%
Diarrhea
Risk of cardiac event
Tenapanor ADR
(IBSrela)
Diarrhea 15%
//IBS-C
IBS-D Diarrhea treatment
1st line
>SIBO: Rifaximin 550mg TID (abx 14 days) - ok repeat twice
>Eluxadoline (Viberzi) - mu/delta/kappa agonist
2nd line
> Severe IBS, fail tx: Alosetron (5HT3 antagonist)
Rifaximin ADR
Antibiotic, careful of C.diff
Well tolerated, no systemic ADR
DO NOT SUB
*for IBS-D
Eluxadoline (Viberzi) ADR
u agonist, delta antagonist, kappa agonist
Generally well tolerated
- constipation, nausea, abdominal pain
Can cause sphincter of oddi dysfunction (spasm, enzyme backup)
Contraindicated:
- history of pancreatitis
- No gallbladder
- Alcoholism
- 3+ drinks/day
Alostren (Lotronex) ADR
5HT3 antagonist - IBS-D
Can cause severe constipation
Some cases of ischemic colitis –> REMS program
IBS-general treatment theory
Visceral hypersensitivity due to brain/gut mismatch
= can also target the brain, not just the gut
1. Antidepressants improve pain/global IBS sx
- SNRI, SSRI (better tolerated)
- TCA (best data, more ADR) QHS
> Nortriptyline (fewer ADR, good for IBS-C)
> Amitriptyline (older, better for IBS-D)
2. Non-pharm
- Soluble fibers form a gel in GI (TITRATE)
- More time with provider (mental)
- Relaxation, stress relief
Anticholinergics ADR
tachycardia
Dry mouth
Constipated
Sedating
Examples of soluble fiber
Psyllium (metamucil)
Oat bran
Barley
Beans
helps resist colonic fermentation
Causes of IBS
Gut hypersensitivity
Acute gastroenteritis (transient)
SIBO (small intestine bacteria overgrowth)
Psychological stress
