Pharm GI Exam 1 Flashcards
Treatment for acute cholecystitis
Initial treatment is supportive care IV fluids Electrolyte correction pain meds (NSAIDS) (can use opioids) Ketorolac (NSAID) Morphine, diluadid, Demerol (no longer meperidine)
Acute calculous cholecystitis Tx
Admit Initial treatment is supportive care IV fluids Electrolyte correction pain meds IV ABX Fasting NG tube if vomiting
Acute cholecystitis IV ABX
Continue IV ABX until gallbladder removed
or cholecystitis resolves
Empiric abx for Acute cholecystitis
Cover most pathogens of
Enterobacteriaceae family
including gram negative rods
and anaerobes
The most frequent isolates from the gall bladder and common bile duct are…
Ecoli 41%
Enterococcus 12%
Klebsiella 11%
Enterobacter 9%
Single agent regimens of low risk, and hospital-acquired intra-abdominal infections
Ertapenem 1 G IV QD
Piper Taz 3.375 G IV Q6h
Single agent regimens of high risk, and hospital-acquired intra-abdominal infections
Imipenem 550mg IV Q6h
Meropenem 1 G IV Q8h
Doripenem 500mg IV Q8H
Piper Taz 4.5 G IV Q6H
Health care acquired intra abdominal infections
Empiric therapy coverage for Streptococci Enterococci Enterobacteriaceae resistant to 3rd gen cef Pseudomonas Anaerobes
Cholangitis S/S Charcot
Charcot’s triad
Fever
Jaundice
RUQ pain
50-75% of patients have all 3
Most common is fever and abdominal pain
Cholangitis S/S Reynolds
Reynolds
Fever
Jaundice
RUQ pain
Plus
Hypotension
AMS
Other misc symptoms can include: Hepatic abscess, MSOD, shock, sepsis,
Acute cholangitis in elderly on glucocorticoids
Hypotension may be only symptom
Charcot’s triad
Fever
Abdominal pain
Jaundice
Should suspect Acute cholangitis
Acute cholangitis treatment
Biliary drainage is required
Infectious Esophagitis CMV
treatment
Ganciclovir
Infectious Esophagitis HSV
treatment
Acyclovir
Infectious Esophagitis Candida
treatment
Fluconazole or ketoconazole
Medication induce esophagitis
meds that can cause it
ABX eg tetracycline Aspirin NSAIDS potassium chloride quinidine iron bisphosphonates
Medication induce esophagitis
factors that affect it
size of med position of patient amount of fluid ingested with it rate of esophageal transit prolonged caustic contact altered esophagus anatomy increased age
GERD treatment criteria
frequency
severity
presence or absence of erosive esophagus
or Barrett’s esophagus on upper gi
GERD Tx
mild/intermittent
with no previous treatments
and no evidence of Barrett’s or erosion
lifestyle and diet changes
low dose histamine 2 receptor antagonists
(H2 blockers)
Antacids or sodium alginate
(for symptoms less than once a week)
If more than once a week
Increase to standard dose H2blockers
BID for minimum of 2 weeks
GERD Tx
Persistent GERD
lifestyle and diet changes
Stop H2 blockers
Start PPI once a day at low dose
increase to standard dose if symptoms persist
once controlled,
should be continued for minimum of 8 weeks
GERD tx
with erosive esophagitis
lifestyle and diet changes
Initial acid suppression therapy with
Standard dose PPI
Once a day
GERD in Pregnancy
lifestyle and diet changes
TX with
antacids
sucralfate
Avoid antacids with sodium bicarb
and
mag trisilicate
move on to H2 blockers
and PPI’s
if antacids don’t work
Systemic antacids
Sodium bicarbonate
sodium citrate
Non systemic antacids
Magnesium hydroxide Mag trisilicate aluminum hydroxide gel magaldrate calcium carbonate
Antacid MOA
Usually contain combination of
Magnesium hydroxide
Mag trisilicate
calcium carbonate
this neutralizes gastric pH
This decreases exposure of esophageal mucosa to acid during reflux
Antacid onset/duration
Usually work within 5 minutes
short duration of
30-60 minutes
Calcium carbonate
Tums
Warning
Hypoparathyroidism
interactions
Calcium blocks absorption of tetracyclines
Antacid misc info
NSAIDS should be taken with antacids
MOA - neutralizes gastric HCL
should not lower pH below 5 due to rebound hyperacidity
Foam is produce which can result in esophageal burning
give with simethicone (anti foam)
sucralfate
Carafate (aluminum sucrose sulfate)
for short term tx of active duodenal ulcers and maintenance of healed ulcers
up to 8 weeks (tabs only)
Interactions
avoid antacids with 30 mins of taking
may reduce absorption
(cimetidine, ranitidine)
A surface agent that promotes healing protects form injury and adheres to mucosal surface
limited to GERD in pregnancy due to short acting compared to PPI
sucralfate MOA
thought to form ulcer adherent complex at the ulcer site protecting it from further injury from stomach acid
sodium alginate
a poly saccharide derived from seaweed that forms a viscous gum that floats in the stomach and neutralizes the post prandial acid pocket in the proximal stomach
Histamine 2 receptor antagonists
decrease the secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cells
Cimetidine
Tagamet (H2 blocker)
Warnings
impaired renal/hepatic function, elderly, debilitated, immunocompromised,
Preg Cat B,
not recommended for nursing mothers
interactions
Antacids within 1 hour of taking
Adverse
HA, diarrhea, dizziness, somnolence
Proton pump inhibitors
To be used in patients who fail twice daily H2 blockers
Patients with erosive esophagitis
frequent or sever GERD (2 or more times per week)
PPIs are the most potent inhibitors of gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium (H-K) ATPase pump
PPIs should be administered daily rather than on-demand because continuous therapy provided better symptom control, quality of life, and higher endoscopic remission rates
PPI Onset
PPIs are most effective when taken 30 minutes before the first meal of the day because the amount of H-K-ATPase present in the parietal cell is greatest after a prolonged fast
Omeprazole indications
Prilosec
Used in triple therapy or dual therapy for H. Pylori in duodenal ulcer disease Short term active benign gastric ulcer active duodenal ulcer erosive esophagitis maintenance of erosive esophagitis Symptomatic GERD pathologic hypersecretory conditions
Omeprazole
Prilosec
PPI
Warnings
Gastric malignancy
Adverse
HA, abdominal pain, N/V/D, flatulence
Omeprazole dosage (low)
10mg QD
Cimetidine dosage (low)
200mg BID
Foods that worsen GERD by lowering LES pressure
Fatty meals Mints Chocolate coffee tea garlic onions chili peppers
Meds that worsen GERD by lowering LES pressure
Anticholinergics Barbs Caffeine Dihydropyridine CCB Dopamine Estrogen Ethanol Nicotine Nitrates Progesterone Tetracycline Theophylline
Foods that worsen GERD by direct irritation
Spicy foods
Juices (tomato, orange)
Coffee
Meds that worsen GERD by direct irritation
Alendronate Aspirin NSAIDS Iron Quinidine Potassium chloride
Mallory Weiss syndrome tx
IV PPI BID (initial)
(for all patients suspected of upper GI bleed)
prior to endoscopy
Continue standard therapy for 2 weeks
Omeprazole 20mg QD
after endoscopy
These promote hemostasis by neutralizing gastric acid and stabilizing blood clots
PPI and antiemetics
Antiemetics are for persistent nausea and vomiting
For patients with disorders of esophageal hyperperistalsis and GERD symptoms
PPI BID
For patients with no GERD (or well controlled GERD) but have dysphagia
tx
Peppermint oil (2 altoids taken sublingually before each meal)
if no improvement, CCB (diltiazem 60-90 mg QID
If CCB not effective, low dose TCA
(imipramine 25mg at bed time)
Esophageal strictures
tx
After esophageal dilation
PPI
Omeprazole 20mg BID x 1 year
Esophageal varices
vasoactive meds tx
Med to be started at time of presentation and not held pending diagnosis
Vasoactive meds decrease portal blood flow and have shown to decrease mortality and improve hemostasis with acute variceal bleeding
(octreotide, terlipressin, somatostatin)
Esophageal varices
BB Tx
Goal of treatment is to decrease portal venous inflow
Non selective beta blockers block the adrenergic dilatory tone in mesenteric arterioles
This results in unopposed alpha adrenergic mediated vasoconstriction and therefore decrease venous inflow
Propranolol and nadolol
Esophageal varices
Acute management
Hemodynamic resuscitation Octreotide Banding Sclerotherapy Prophylactic ABX (ceftriaxone)
Esophageal varices
Chronic management
Beta blockers
Endoscopic variceal ligation
Hep A vaccine
Havrix (inactivated)
Contraindications
Neomycin allergy
Interactions
immunosuppressives may reduce efficacy
Hep B Diagnoses
Based on detection of Hep B surface antigen (HBsAG)
and IgM antibody to hepatitis B core antigen
Treatment is mainly supportive
The decision to start treatment is based on presence of cirrhosis, ALT and HBV DNA level
Hep B Tx
Treatment is mainly supportive
The decision to start treatment is based on presence of cirrhosis, ALT and HBV DNA level
for treatment naïve patients
nucleotide analogue
we recommend tenofir or entecavir
Tenofovir alafenamide 25mg QD
tenofovir disoproxil fumarate 300mg QD
tenofovir alafenamide
Vemlidy 25mg
Nucleoside analogue (reverse transcriptase inhibitor)
Chronic Hep B Virus in patients with compensated liver disease
Warning
Post treatment severe acute exacerbation of Hep B
tenofovir MOA
Nucleotide analogue of AMP
Inhibits HBV polymerase
First approved for treatment of HIV
emtricitabine MOA
Nucleoside analog of cytosine active against HIV and ABV
Hep B Vaccine
Recombivax HB
Contra
yeast hypersensitivity
HCV infected patient education
HCV-infected patients should be counseled on measures to decrease the risk of transmission and correcting factors associated with accelerated liver disease, including alcohol use, obesity and insulin resistance, and marijuana use.
Substance use treatment is also an important element of care in patients who have ongoing illicit drug use.
Protease inhibitors Meds
Telaprevir boceprevir asunaprevir simeprevir faldaprevir MK-5172r
Translation and polyprotein processing
NNPI Meds
Deleobuvir filibuvir setrobuvir tegobuvir VX-222
RNA replication
Hep D tx
Optimal treatment is uncertain
Treatment of choice for chronic Hep D is interferon Alfa (IFNa)
Mainstay of treatment for Hep D is vaccination against Hep B
Hep E Tx
12 week course of ribavirin monotherapy to certain non pregnant patients with chronic Hep E