Nausea/ vomitting/ diarrhea/constipation Drugs Flashcards
1
Q
Treatment of Nausea and vomitting-non pharmacological
A
Rehydrate, avoid dairy, BRAT diet 24 hours after strict fluid diet
2
Q
What are the 4 types of therapy for N/V
A
5-HT3 antagonists,
antihistamines,
dopamine antagonists,
cannabinoids
3
Q
5- HT3 antagonists
A
- Ondansetron-specific for CINV and PONV
- Granisetron
- Dolasetron
note: work specifically in chemo receptor trigger zone
4
Q
what are the 5-HT3 antagonist indications?
A
treatment of PONV and CINV
5
Q
What are the ADR’s of 5-HT3 antagonists?
A
- HA,
- Dizziness,
- Diarrhea,
- Abdominal Pain
6
Q
What are the 3 dopamine antagonists
A
- Metoclopramide-specifically has pro kinetic affects approved by the FDA
- trimethobenzamide
- Prochlorperazine
7
Q
What is the DA MOA
A
antagonize D2 receptors in the CTZ,
- at higher doses metoclopramidde also blocks 5-HT3 receptors
- metoclopramide also has pro kinetic affects in the gastric and small intestine
8
Q
What are the Dopamine antagonist contraindications?
A
GI hemorrhage obstruction of perforation cautious in its with pheochromocytoma seizure -caution in children
9
Q
what are the Dopamine antagonist ADRs
A
Extrapyramidal effects, Restlessness, Anxiety, drowsiness, fatigue hallucinations
Cardiovascular symptoms such as, HTN, HPOTN, Adblock, Bradycardia, AGRANULOCYTOSIS
10
Q
What is the drug used as an Antihistamine
A
Promethazine
11
Q
What is the MOA of antihistamines for N/V
A
block H1-effectiveness appears to be specifically with motion sickness and vestibulocochlear diseases, specifically antagonize d2 receptors in the CTZ
12
Q
What are the ADR;s of Antihistamines for N/V
A
- dry mouth, dizziness
- parkinsonian symptoms (dyskinesia, dystopias, akathisia
- neuroleptic malignant syndrome
13
Q
What are the contraindications of antihistamines for N/V
A
benign prostatic hypertension
urinary retention
glaucoma
14
Q
What is the function of cannabinoids in nausea and vomitting
A
canabanoids- specifically dronabinol in this case, helps to stimulate appetite and control nausea and vomitting. MOA is not well defined
15
Q
what are the side effects of dronabinol
A
-drowsiness, sedation, increased appetite.
16
Q
What are the classes of drugs that affect intestinal motility?
A
- laxitives
- antidiarrheal
- prokinetic agents
- antiemetic agents
- antispasmodics
17
Q
What is the medical definition of constipation?
A
2 or more of the following symptoms:
- straining >25% of the time
- lumpy or hard stools >25% of the time
- feeling of incomplete evacuation >25% of the time
- 2 or fewer BM in 1 week.
18
Q
What are some causes of constipation?
A
Metabotropic-hypothyroid, hypercalcemia, hypokalemia, diabetes
GI disorders-tumors, IBS, diverticulitis
Pregnancy
Neurogenic-traume to the brain/spinal chord, CNS tumor, Parkinsons
19
Q
List some meds that would cause constipation?
A
- opiates
- Ca and Al antacids
- Iron
- calcium channel blockers
- clonidine
- anticholinergics-antihistamines, antiparkinsonians, TCAs
20
Q
What are some non pharmacological treatments for constipation
A
1 best way- drink plenty of water and fluids
- Adequate excercse
- high fiber diet
21
Q
What is the purpose of laxatives?
A
Hasten the transit time in the gut and encourage defamation. They also clear the bowel prior to medical and surgical procedures
22
Q
What are all the types of laxatives listed in lecture? (5)
A
- bulk forming laxatives
- emollients and lubricants
- saline cathartics
- osmotic laxatives
5 stimulant laxatives
23
Q
What are the bulk forming laxatives?
A
- Psyllium (metamucil)- good for diabetics due to sugar free nature
- Methylcellulose
- polycarbophil
24
Q
How do bulk forming laxatives work?
A
They cause the bulk of the feces to increase by increasing water volume which distends the colon and stimulates peristaltic activity. thus increasing the rate of colonic transport time. -be careful to intake fluid vigorously while on these
25
What are bulk forming laxatives indications
1. these are considered 1st line for bed ridden its, elderly patients with chronic constipation, and pregnancy
26
Why can't bulk forming laxatives such as psyllium be used?
if a person has stenosis, these cannot be used as well as if the person has ulcerations/adhesions, and fecal obstructions
-this is because build up in these conditions would be really bad for the pt.
27
what are some of the ADR's of Bulk forming laxitives
1. flatulance
2. abdominal distinction-bulk forming duh
3. gastrointestinal obstruction
28
what are some of the drug interactions of bulk forming medications
1. bulk forming laxatives will bind to other drugs and inhibit them from working properly by reducing absorption, thus they must be separated 2 hours before other meds or 6 hours after other meds
29
Why can they also be used
they can relieve mild constipation, and relieve IBS symptoms, they can also lower cholesterol
30
What is the drug we think of as an Emollient?
docusate sodium
31
What is the purpose of an emolient
These will break up fecal material and fat by emulsifying the pooh and preventing straining in people with Recent MI, rectal surgery, on opiates, or those who are PREGNANT which can be used along side bulk forming laxitives
32
What is the MOA of an decussate sodium- an emollient?
it works mainly with surfactant by bringing water into the stool, which facilitates mixing of aqueous and fatty materials within the intestine, increasing H20 and electrolyte secretion in small/large bowels.
33
Why would you not use and emollient such as Doccusate sodium
if you already had fecal impaction or if you had signs and symptoms of appendicitis.
34
What is the lubricant we talk about the most?
Mineral oil
35
What is the main indication for mineral oil
mainly used for prevention of straining and after MI, rectal surgery, but not for chronic use
36
What is the MOA of of Lubricants such as mineral oil?
it coats the stool, allowing easier passage, and inhibits colonic absorption of water
37
Why can you not use mineral oil?
Avoid use of mineral oil in elderly, if there is an aspiration risk and watch for a decrease in the absorption of fat soluble vitamins ADEK.
38
What is a gross complication of mineral oil?
Anal leakage
39
What are the different saline cathartics?
think salts; magnesium hydroxide (milk of magnesia),
2. magnesium sulfate (epsom salts)
3. Sodium phosphate (fleets enema)
4. magnesium citrate (citrate of magnesia)
40
how do these saline cathartics like MOM work?
these salts are poorly absorbed and thus increase the water content of the bowl through osmosis
41
Do not use saline cathartics if:
the patient has impaired renal function which causes mg and NA accumulation, if CHF, and in HTN its due to their lack of sodium capacity
42
How does Castor oil work?
Home remedy, never prescribed which is metabolized to ricinoleic acid which in turn stimulates the secretory pathways. This also decreases glucose absorption, promotes intestinal motility and is not for routine use.
43
how do you use a glycerine suppository?
MOA: this has osmotic actin in the rectum only. And causes rectal irritation but is generally very safe and often used on constipated kids
44
Why and how do you use a glycerine/ hyper osmotic such as polyethylene glycol or miralax?
works as an osmotic, relatively safe and used in Kids
45
Golytely is another glycerine hyper osmotic that is used, but what is its use specifically
this is specifically used to cleanse the colon before diagnostic procedures are done. this is the one where you must drink 4 L in 3 hours and do so on the toilet. AVOID in patients with intestinal obstruction
46
There are 2 stimulant laxatives listed in the lectures; what are they?
diphenylmethane derivative: Bisacodyl
| anthraquinone laxative: Senna; increases peristalsis.
47
Which stimulant laxative causes pink urine and poo
Bisacodyl
48
which stimulant laxative causes yellow and brown to red urine?
senna
49
with all stimulants overuse or long term use can do what?
cause nerve damage to the plexus resulting in atonic colon.
50
How does lubiprostone work?
MOA; lubiprostone in a chloride-channel activator and works by increasing fluid secretion locally in the small intestine by activating the CLC-2 chloride channel
51
what are some side effects of lubiprostone
nausea and diarrhea
52
When is lubiprostone contraindicated?
it is contraindicated in intestinal obstruction and in pregnancy
53
how does methyl naltrexone work?
MoA: peripheral acting antagonist of MU receptors, reduces the effects of opioids peripherally
54
What are some of the downfalls with methylnatrexone?
Methylnatrexone is expensive, it does not cross the blood brain barrier, dose must be adjust if GFR is less than 30 l/min
55
With diabetes patients with constipation, what are the best drugs to use?
psyllium due to its sugar free nature
56
With pregnancy women what is the best constipation drug to use?
lifestyle modification first, bulk forming laxatives such as psyllium (metamucil), emollients such as doccosate sodium but they CANNOT mineral oil, castor oil, or osmotics
57
people with opiate use caused constipation should do what to manage the constipation?
exercise, adequate fluid intake, and fiber
58
Elderly with constipation should manage the constipation with what?
bulk forming laxatives- psyllium
enemas
glycerin products
lactulose
they must avoid saline laxatives due to potential changes in electrolytes such as:
1. magnesium hydroxide (milk of magnesia),
2. magnesium sulfate (epsom salts)
3. Sodium phosphate (fleets enema)
4. magnesium citrate (citrate of magnesia)
59
Kids with constipation should use...
lifestyle modification, p juices, glycerin suppositories if less than 5, malt soup extracts, dark corn syrup, MOM, bisacodyl, senna and mineral oils but must AVOID stimulants and excessive use of enemas
60
What classifies as acute diarrhea and chronic diarrhe
14 days - chronic
61
Why does diarrhea occur
it is the bodies healthy response to getting rid of ingested bacteria and toxins. usually diarrhea is self limiting.
62
What is the key to acute diarrhea management?
Rehydration and electrolyte replacement!
63
What are the characteristics of rotavirus diarrhea?
watery diarrhea lasting 3-7 days
1/3 have fever
nearly every child gets it by age 5
64
what is the rotavirus vaccine?
Rotateq vaccine
65
What are the 4 types of diarrhea?
Secretory, osmotic, exudative, altered intestinal transit
66
What are some drugs that induce diarrhea?
Laxatives, antacids with mg, colchicine, NSAIDS, orlistat, antibiotics: clindamycin, broad spectrum abx
67
What is the typical diarrheal presentation ?
Nauseas/vomitting, HA, fever, chills, malaise, weight loss, dehydration.
68
what is the key to prevention of Diarrhea
Sanitation by washing hands thoroughly
69
What is the typical rehydration rate for each age group?
2 or more years- 100-200 ml after each lose stool and between if possible
continue extra fluid until diarrhea cessation
may need IV fluids for severe dehydration
70
List some anti motility drugs used in treatment of diarrhea
1. opiates and there derivatives
2. loperamide,,
3. diphenoxylate-LOMOTIL
4. paregoric
5. difenoxin
71
When using Lomitil for use of diarrhea, when should the medicine begin acting?
after 48 hours it should be working. if no change in 10 days, change therapy. -i would change sooner than that
72
why would you not use Lomitil?
lomitil would keep the infectious diarrhea such as C. diff or enterotoxin producing bacteria in contact with the GI wall longer thus making the infection grow bigger and worse.
73
When using ammonium (loperamide) how does the drug work?
loperamide acts directly on the intestinal muscles to inhibit peristalsis, prolonging the transit time.
74
How long should loperamide immodium take to work)?
48 hours
75
When would you not use Imodium?
1. patients with a fever
2. acute ulcerative colitis
3. antibiotic associated colitis
4. children under 2
76
What are the 3 absorbents used in diarrhea?
kaolin-pectin, polycarbophil, also used in constipation, and attapulgite
77
what is the MOA of absorbents?
they do exactly what they sound like, absorb nutrients, toxins, and drugs, as well as digestive juices
-the problem with these is that the effectiveness is unproven
78
One absorbent does not fit with the others in its class because it absorbs bile salts and C. diff toxin. what is this drug?
cholestryamine (questran)
79
Pepsi bismol is a bismuth subsalicylate. How long should it take to work?
80
How does pep bismol work?
stimulates absorption of fluid and electrolytes across the intestinal wall making it antisecretory, anti inflammatory, and antibacterial.
81
Why can't you use pep in kids under 12?
They could get reyes syndrome due to the derivative of the drug being closely related to aspirin
82
what are some side effects of pepto bismol?
blackened tongue and stools, salicylism, and gout attacks in susceptible patients
83
pepto bismol is known to interact with some drugs, what are they?
anticoagulants, tetracycline, and will interfere with radiologic studies due to its absorbent capacity
84
Octreotide is an antisecretory medication. how does it work?
octreotide blocks the release of serotonin, directly inhibiting the motility and facilitating water absorption from the gut.
85
what is octreotide's official indication?
it is specifically used for metastatic vasoactive intestinal peptide-secreting tumor associated diarrhea, but off label is used to treat refractory diarrhea, last resort only!!!!!!
86
Octreotide has some ADR's which are....
bradycardia and hyperglycemia.
87
Atropine, an anticholinergic, is used in diarrhea. How does it work?
it blocks vagal tone and prolongs the gut transit time. do not use this in glaucoma and BPH or with other anticholinergics as it will enhance the effects
88
Often times when a person gets diarrhea, they suffer from losing the GI flora. what is a medication you could use to restore the GI flora
Lactobacillus which is a pro biotic works great for restoring go flora. The only problem is when gut flora increases, the bi product made from their living produces flatus in the patient, making this an adr.
89
why can you not use lactobacillus?
if a person is immune compromised, you cannot use lactobacillus due to the lack of an immune system which could make person sicker.
90
Lactose-intolerance is a big problem in many. What is the reason and the treatment
these people lack the lactase enzyme needed to break down lactose from milk. Thus replacing the lactose enzyme with lactic, allows them to consume milk products again.
91
Travelers diarrhea such as montezuma's revenge is a problem for those who like to travel, especially in third world countries. What are the 3 forms?
1. classic-passage of 3 or more unformed stools in 24 hour periods plus at leas 1 of the following: nausea, vomiting, ab pain, and cramps, fever, blood in stool
2. moderate-passage of 1 to 2 unformed stools in 24 hours plus at least one of the afore mention problems or more than 2 unformed stools without other symptoms.
3. mild-1 or 2 unformed stools in 24 hours without other symptoms
92
how is travelers diarrhea treated?
often symptomatically without culture. workup would be done if fever and colitis symptoms of bloody stools or abdominal cramping. Most often campylobacter or shigella spp is the big reason or Enterohemoryhagic e.coli and shiga toxin.
93
workup if:
-predominant upper GI symptoms
94
if antibiotic are given for prophylaxis, why do you need to monitor the persons stool.
C. diff is a common concern for those with antibiotic use.
95
Why should travel location be considered?
To determine if they have acquired a type of bacterial infection resistant to antibiotics. -asia
96
What can you use as prophylaxis of diarrhea while abroad?
pepto is a big prophylaxis due to its absorbent qualities. antibiotics are effective but irresponsible prophylaxis.
97
How do you treat Travelers diarrhea?
Rehydrate, rehydrate, rehydrate! Antibiotics in moderate to severe forms. fluoroquinolone preferred unless asia travel was recent. Capri or azithromyacin. if Fluoroquinolone not available, give rifaxamin.
-antimotility agents are also effective but use cautiously with antimicrobial therapy
98
C. diff is the classic nosocomial diarrhea. What would make you concerned about c. diff?
recent hospitalization or recent abx, use. Make sure to hand wash more!!!
99
TX of c diff. -hint you got this wrong on the quiz
Metronidazole or vancomycin
100
IBS is the most common diagnosis in clinical gastroenterology. what are some of the symptoms of IBS?
lower abdominal pain, disturbed defamation, and bloating with absence of structural or biochemical explaining factors. other symptoms include. bloating and distention, Diarrhea with extreme urgency and mucus passage, Constipation, depression, urinary symptoms, fatigue, and dyspareunia.
101
Generally, what are the diagnostic criteria for IBS?
manning criteria: abdominal pain for 6 months and 2 or more of the following: ab pain associated with more frequent stool, ab distention, incomplete evacuation, mucus, abdominal pain relieved by defamation.
Rome III criteria: recurrent abdominal pain or discomfort >3 days /moth in the last 3 months associated with 2 or more of the following: Relieved with defamation, onset associated with change in freq of stool, onset associated with change in form of stool
102
what are the 2 types of IBS
IBS c- constipation predominant and IBS-D diarrhea predominant.
103
what type of medication can be used for both types for moderate relief of symptoms?
TCA's-global relief of either type
104
What medication should not be used in both?
SSRI's
105
For IBS-C what are dome lifestyle modifications that could be done to improve severity of symptoms?
1. Stress management
2. Increase dietary fiber and fluid
3. Pharmacotherapy
106
3 specifically mentioned medications for IBS-C are:
Linaclotide, lubiprostone, PEG laxatives
107
Linaclotide is a medication specifically recommended to treat IBS-C. What is it's MOA?
linaclotide and an active metabolite will bind and agonize guanylate cyclase C on the luminal surface of intestinal epithelium resulting in subsequent chloride and bicarb secretion into the intestinal lumen (thus increasing intestinal fluid and increasing GI transit time.
108
With linaclotide, one of the key features is faster transit time. know this what is one of the ADR's of Linaclotide?
Diarrhea is the ADR for linaclotide.
109
LUbiprostone is another medication used for IBS-C and has the same MOA as linoclotide but can only be used for females. what is the MOA
It increases the intestinal transit time, problem is that this medication is expensive! if cost is an issue, use alternative medication.
110
What is lowest cost option for IBS C-
Peg laxatives are typically the best medication due to their low cost and low ADRs.
111
IBS-D is the predominantly diarrhea governed IBS. What are some Lifestyle modifications you could use to manage this problem
Stress management and patient education
lactose and caffeine free diet as well as avoiding other food that cause diarrhea
Pharmacotherapy per guidelines
112
For this there are 3 specific medication listed to treat IBS-D. What are they?
Rifaximin, loperamide, and alosetron
113
Rifaximin is the first medication addressed in the lectures. What is the MOA of rifaximin?
Rifaximin inhibits bacterial RNA synthesis by binding to bacterial DNA dependent RNA polymerase.
114
Why is rifaximin recommended for some patients?
It is cheap and is recommended for infectious and irritable bowel problems combined.
115
What are some of the ADR's of Rifaximine
peripheral edema, dizziness, and fatigue.
116
the next drug addressed in lecture is Alosetron. what is this drugs MOA?
Alosetron is a potent selective 5-HT3 antagonist which may reduce pain, abdominal discomfort, urgency, and diarrhea, but is only FDA approved in women. One of the ADR's of this medication is constipation that is dose related.
117
The last drug mentioned for IBS-d is loperamide. What is the problem with loperamide.
Loperamide, due to lack of clinical significance is recommended conditionally as an adjunctive therapy only.
