Pharm exam 3 Flashcards
What medication classes can cause N/V
Anticonvulsants
Antibiotics
Chemotherapy
What is the treatment approach to N/V
remove offending agent
diet modifications
behavioral interventions
acupuncture
correct dehydration/nutritional deficiencies
How is N/V treated with pharm
often first line used empirically until cause is identified
-serotonin antagonists
May require multiple drugs with distinct MOAs
Best options for motion sickness
antihistamine
scopolamine
Best options for gastroparesis?
metoclopramide
Best options for N/V postoperative?
serotonin antagonist
scopolamine
Best option for N/V from pregnancy?
pyridoxine
antihistamines
Best options for chemotherapy induced N/V
serotonin antagonist
phenothiazines
neurokinin inhibitors
What are all the options for N/V treatment
antihistamines
scopolamine
metoclopramide
serotonin antagonists
pyridoxine
phenothiazines
neurokinin inhibitors
What are the H1 receptor antagonists
meclizine
dimenhydrinate
H1 receptor antagonist MOA?
non-selectively antagonizes H1 receptors and antagonizes cholinergic receptors
What are H1 receptor antagonists most effective for?
migraines
motion sickness
vertigo
How are H1 receptor antagonists taken
oral
What are the adverse effects of H1 receptor antagonists
anticholinergic effects:
-dry mouth
-constipation
-blurred vision
What are the serotonin 3 receptor antagonist?
odansetron (zofran)
other -setron’s
What are 5-HT3 most effective for?
CINV
PONV
How are 5-HT3s given and adverse effect?
oral or parenteral
headache
What are the phenothiazines?
promethazine (phenergan)
Prochlorperazine (compazine)
Describe phenergan
nonselective antagonist at histamine H1 receptors
anticholinergic properties
Describe compazine
selectively antagonizes Dopamine D2 receptors
What are phenothiazines most effective for
migraine
motion sickness
vertigo
CINV
PONV
How can phenothiazines be administrated and adverse effects?
oral
rectal
parenteral
Anticholinergic
EPS
What is a dopamine (3) receptor antagonist and MOA?
metoclopramide (reglan)
stimulates upper GI tract motility
Antagonizes central and peripheral dopamine receptors
What are dopamine (3) receptor antagonists most effective for? Route? ADE?
gastroparesis
oral/parenteral
EPS
What is an antimuscarinic
scopolamine transdermal (transderm Scop)
Antimuscarinic most effective? route? ADE?
motion sickness
Transdermal
Somnolence and Xerostomia
What medications can cause diarrhea?
antibiotics
laxatives
lithium
metoclopramide
What are some non pharm treatments for diarrhea?
remove causative agent
fluid and electrolyte correction
oral rehydration
BRAT diet
-bananas
-rice
-applesauce
-toast
What are the antidiarrheal agents
loperamide
diphenoxylate
bismuth salicylate (pepto-bismol)
Octreotide
Describe loperamide
gut wall opioid receptor
4mg initially, then 2mg after each unformed stool (max 16mg/day)
oral route
available OTC
may cause constipation
Describe diphenoxylate/atropine (Lomotil)
Schedule V
binds opioid receptors
may cause abdominal discomfort, N/V
Describe bismuth subsalicylates
oral
may cause stool and tongue discoloration
avoid in pregnancy/lactation
Describe octreotide
Typically used for refractory diarrhea
typically used to treat acromegaly
SubQ
Describe probiotics
variable dosing
well tolerated
prevents diarrhea associated with antibiotic use
What are the complications of diarrhea
hypovolemia
-hyponatremia when combined with increased water ingestion
metabolic acidosis
hypokalemia
What is the most critical part of treating diarrhea
volume repletion
How should volume be repleted after diarrhea
oral route is preferred
solutions containing water, sodium, glucose
commercially prepared oral rehydration
-equimolar concentrations with osmolarity between 200-310
How should oral hydration be done in mild-mod hypovolemia
5mL every 1-2 minutes by spoon or syringe
PLUS
maintenance calories and fluids administered to replace ongoing losses
When is oral rehydration therapy contraindicated?
mental status changes (aspiration)
inadequate absorption (ileus)
severe hypovolemia
persistent vomiting
How should hypovolemia be replenished IV?
20mL/kg rapid infusion of isotonic saline
convert to oral rehydration therapy when patient is stable
What medications cause constipation
antihistamines
antidiarrheal agents
diuretics
opioids
tricyclic antidepressants
When should constipation be treated?
when it reduces patients quality of life
How to treat constipation non-pharm
identify medication related causes
-switch or remove
increase hydration (8-8ounce cups)
increase fiber to 20-30g
increase physical activity
Describe bulking agents
increase water content of stool
onset in 3 days
Psyllium (metamucil)
increase stool frequency
ADE: bloating
Describe stimulants
stimulate mucosal nerve plexus of colon
may alter fluid/electrolyte transport
Senna (senokot)
Bisacodyl (dulcolax)
onset in 8-12 hours
Describe osmotics
lactulose
polyethylene glycol (miraLAX)
nonsabsorbable disaccharide
results in colon retaining fluid
onset 2-3 days
ADE: flatulence
Describe polyethylene glycol
an osmotic
minimal ADE
onset 1-3 days
OTC
safe in pregnancy
Describe emollients (stool softeners)
increase stool moisture content - easier to pass stool
prevention of constipation
Docusate (colace)
Describe glycerin
intermittent constipation or fecal impaction
suppository
onset in 30-60 minutes
Describe lubiprostone
Rx
approved for:
-idiopathic chronic constipation
-opioid induced constipation
bowel movement occurs within 24-48 hours of use
expensive
contraindicated in patient with obstruction
Describe linaclotide
Rx
approved for:
-idiopathic constipation
-IBS C
What meds should be used for IBS constipation?
laxative
linaclotide
lubiprostone
What meds should be used for IBS diarrhea?
loperamide
alosetron
What meds should be used for bloating (IBS)
Rifaximin
probiotics
What meds should be used for IBS pain
antispasmodics
antidepressants
What type of laxative is not recommended for IBS-C
stimulants
but can use psyllium and polyethylene glycol
What type of population can use lubiprostone for IBS-C
adult women
What does lubiprostone treat for IBS-D
just reduces frequency not pain or other symptoms
Who can use alosetron to treat IBS-D
women with severe IBS-D unresponsive to other meds
What meds can be used for any IBS subtype for bloating
Rifaximin for bloating
-nonabsorbable antibiotic
What meds can be used for any IBS subtype for pain
antispasmodics
-short term relief for abdominal pain
-dicyclomine/hyoscyamine
Antidepressants
-TCA
-SSRI*
What is considered mild UC
<4 stools/day
no systemic signs of toxicity
what is considered moderate UC
> 4 stools/day
minimal signs of toxicity
What is considered severe UC
> 6 stools/day + blood
systemic signs of toxicity
What is considered fulminant UC
> 10 stools/day with continuous bleeding
blood transfusion may be needed
colonic dilation
What is considered mild-mod crohn’s
CDAI 150-220
ambulatory
no:
-dehydration
-systemic toxicity
-abdominal tenderness/mass
-obstruction
What is considered mod-severe Crohn’s
CDAI 220-450
failed treatment for mild-mod
fever
abd tenderness/pain
vomiting
weight loss
What is considered fulminant crohn’s disease
CDAI >450
persistent symptoms despite OP therapy
High temp
persistent vomiting
obstruction/abscess
What are the goals of IBD therapy and types?
symptoms reduction
prevent relapse
decrease CRC risk
induction therapy - control acute symptoms
maintenance therapy once acute attack is under control
What is the step-up approach to IBD
start with 5-ASA, topical corticosteroids
immunomodulators and biologics:
-reserved for maintenance
-failure of therapy
-relapses
What is the top-down approach to IBD
early therapy with immunomodulators or biologics
transition then to standard conventional agents
may help with mucosal healing and prevent complications to start with aggressive therapy early
How to start induction therapy for mild-mod UC if distal location
Standard:
-topical mesalamine
-oral sulfasalazine or mesalamine
-topical corticosteroids
-aminosalicylates
Additional options:
-oral corticosteroids
-infliximab
How to start induction therapy for UC if severe disease
not hospitalized:
-infliximab
-oral aminosalicylate if previously taking
hospitalized:
-IV corticosteroid
What is the maintenance therapy for mild-mod UC if distal location
standard:
-topical mesalamine
-oral sulfasalazine or aminosalicylate
-topical + oral aminosalicylate
Additional options:
-thiopurines
-infliximab
What is the maintenance therapy for UC if severe disease?
continue what provided symptom improvement
Corticosteroids: taper to lowest effective dose
How should induction therapy be done with mild-mod UC that is located distal to the splenic flexure? maintenance?
first line for both:
-aminosalicylates
What are not effective for maintenance therapy for mild-mod distal UC?
topical corticosteroids
-hydrocortisone
-budesonide
What should be done for induction therapy for extensive UC disease that is proximal to the splenic flexure? maintenance?
Both:
-oral sulfasalazine OR aminosalicylate
What should be used for induction therapy for UC in severe disease that is refractory to aminosalicylates?
hospitalized:
-IV corticosteroids for 7-10 days
not hospitalized:
-infliximab
What should be used for MAINTENANCE therapy for UC in severe disease that is refractory to aminosalicylates?
Switch from IV formulation of corticosteroids and taper to lowest effective dose
If IV cyclosporine, transition to oral
Last line - colectomy
Meds for induction therapy of mild-mod crohn’s?
oral aminosalicylate
Meds for induction therapy of mod-severe Crohn’s?
oral corticosteroids
Meds for induction therapy of severe-fulminant crohn’s?
IV corticosteroids
IV Cyclosporine
consider surgical intervention
Crohns mod-severe maintenance treatment
corticosteroid taper
infliximab
based off therapy that achieved remission
Crohn’s severe-fulminant maintenance therapy
corticosteroid taper/transition to oral therapy
Crohn’s mild-mod maintenance treatment
budesonide
What does sulfasalazine target
the colon
It is a 5-ASA
What forms does mesalamine come in?
suppository
enema
enteric-coated
delayed release
extended release
it is a 5-ASA
5-ASA (aminosalicylates) are first line for?
mild-moderate IBD
What may be beneficial to allow drug to target a specific location?
prodrug
How do prodrugs work?
have carrier that facilitate specific actions at a particular location
-drug release only at specific spot
5-ASA routes?
oral
enemas
suppositories
When are 5-ASA not used?
acute severe cases of IBD
What should be done if treatment fails with 5-ASA
discontinue and do not transition to another 5-ASA
In treating mild to mod UC, how should 5-ASA be used?
Use prodrug formulations to allow targeted release in the colon
What is a limitation of sulfasalazine (5-ASA)?
cannot be used in patients with a sulfa allergy
How should corticosteroids be used in treatment of IBD?
Used for induction then taper
If needed maintenance, oral prednisone 20-60mg/day
IV hydrocortisone or methylprednisolone
Place in therapy:
-induction for IBD
-symptoms control not achieved with alt. agents
-severe illness
What are the immunomodulators used in IBD treatment
thiopurines:
-6-mercaptopurine
-azathiprine
methotrexate
calcineurin inhibitors
-cyclosporine
-tacrolimus
thiopurines MOA
inhibit purine synthesis
apoptosis of T cells
*used for maintenance therapy
ADE of thiopurines
dose dependent:
-nausea
-hepatitis
-infection risk
long term:
-increased risk of lymphoma; often the benefit outweighs the risk
Describe methotrexate in IBD treatment
inhibits DNA synthesis, repair, replication
-reduced folates
IM or SC weekly
increased risk of infection/malignancy and myelosuppression
NOT EFFECTIVE in UC; only crohn’s
Calcineurin inhibitor MOA
suppress synthesis of pro-inflammatory cytokines
What are the anti-TNF alpha therapies and MOA?
infliximab (remicade)
adalimumab (humira)
elevated TNF alpha levels found in patients with Crohn’s and UC
Describe infliximab
Induction is IV weeks 0, 2, 6
maintenance is IV every 8 weeks
administer over 2 hours
premedicate with
-antihistamine
-acetaminophen
-corticosteroids
contraindicated with active infection
ADE: increased infection/malignancy risk
Describe adalimumab
SubQ injection on days 1, 15, and 29
-doses go 160, 80, then 40
after day 29, continue 40mg every other week
ADE: increased risk of malignancy/infection
Describe certolizumab
weeks 0,2,4 then every 4 weeks maintenance
ADE: increased infection and malignancy risk
Key points of anti-TNF alpha therapies
infection risk with all agents - risk vs benefit
prior to starting, screen:
-TB
-HBV
-HCV
Pt ed: avoid live vaccines during therapy
What anti TNF alpha therapies can be used for crohn’s?
all agents
What anti TNF alpha therapy can be used for UC
infliximab
What is an Anti-a4 integrin antibody
Natalizumab (Tysabri)
What is natalizumab useful for?
inducing remission and for maintenance in moderate to severe crohn’s and UC
natalizumab ADE and CI?
increased infection
increased malignancy risk
CI:
-use with other immunosuppressants or anti TNF alpha agents
-hepatic disease
What is rotavirus
virus that spreads quickly among infants and children
-watery diarrhea
-dehydration
-hospitalization
What are the rotavirus vaccines available
RotaTeq (RV5) 2,4,6 months
Rotarix (RV1) 2,4 months
Given by putting drops in infant’s mouth
Is it ok to give rotavirus vaccine when infant is ill?
mild illness - acceptable
mod-severely ill - wait until recovery
