Pharm GI Exam 2 Flashcards
Cause of nausea (Biochemical)
Cause of emesis is a defense mechanism controlled by the medulla oblongata
Receptors of the fourth ventricle in the brain are chemoreceptor zone
the chemoreceptor trigger zone contains dopamine (D2) , 5HT, opioid, ACH and substance P receptors
Stimulation of different pathways lead to emesis
In the final common pathway, substance P activates Nk-1 receptor
Emetic MOA
Drugs selectively bind to receptors in vomiting brainstem
Block signaling pathway
Inhibit stimulation of the GI tract, diaphragm and abdominal muscles
Classes and indications of
H1 antihistamines or antimuscarinics
Vestibular disturbances
vertigo or motion sickness
Classes and indications of
Dopamine receptor antagonists
Most commonly used
Post op nausea
Motion Sickness
Classes and indications of
Glucocorticoids
Chemotherapy induced nausea
Classes and indications of
5-HT3 receptor antagonists
Vomiting caused by acute gastroenteritis
Post op nausea
Go-to for radiotherapy and chemotherapy induced nausea and vomiting
Classes and indications of Neurokinin 1 (NK-1) receptor antagonists
Relatively new class of medication
Radiotherapy and chemotherapy induced nausea and vomiting
Post op nausea
Drugs by type
Antihistamine, anticholinergics
Hydroxyzine Meclizine Scopalamine Cyclizine Trimethobenzamide Dimenhydrinate
Drugs by type
Dopamine receptor antagonists (D2)
Metoclopramide Chlorpromazine Prochlorperazine Promethazine Haloperidol Droperidol
Drugs by type
Serotonin 5HT3
receptor antagonists
-setron Ondansetron Granisetron Dolasetron Ramosetron Tropisetron
Drugs by type
Neuokinin 1 receptor antagonists
-pitant
Aprepitant
Faosaprepitant
Rolapitant
Drugs by type
Other
Cannabinoids
Nabilone
Dronabinol
Nabiximol
Dexamehtasone
Netupitant/palonestetron
Drugs used for motion sickness
Meclizine
(antivert, bonine)
OTC
Meclizine
Antivert (antihistamine)
For motion sickness prophylaxis or vestibular vertigo
25-50mg 1 hour prior to motion
Warnings
Asthma, glaucoma, GI/GU obstruction, Hepatic/renal impairment
Interactions
Alcohol, tranquilizers, sedative-hypnotics potentiate CNS depression
-Setrons
5HT3 receptor antagonists
MOA
Inhibit vomiting due to vagal nerve stimulation particularly due to chemotherapy, radiotherapy, anesthesia
Blocks the serotonin receptors (5HT3) in VC, CTZ, and peripheral 5HT receptors
Ondansetron
Zofran (5ht3 receptor antagonist)
Contra
Serotonin syndrome possible with SSRI’s, SNRI’s etc
May antagonize tramadol
Adverse
Diarrhea, HA, Fever, Constipation, Fatigue, transient blindness, Serotonin syndrome (discontinue)
Metoclopromide
Reglan (dopamine 2 receptor antagonist)
Contra
History of tardive dyskinesia or dystonic reaction
Warning
Tardive dyskinesia
Promethazine
Phenergan
For motion sickness or perioperative nausea/vomiting
Adverse
Drowsiness, lowered seizure threshold, Cholestatic jaundice, anticholinergic and EP effects
Phenothiazine??
Aprepitant
Emend
Substance P/NK1 receptor antagonist
Small intestine disorders
Appendicitis
Celiac’s
Intussusception
Obstruction
ABX for non perforated Appendix
Cefoxitin or Cefotetan 2g IV once
or
combo of cefazolin 2g <120kg, 3g >120kg plus
Metronidazole 500mg IV
Or if inpatient and allergic to penicillin
Clindamycin plus one of the following
ciprofloxacin, levofloxacin, gentamycin, aztreonam
6 elements in the management of patients with celiac disease
Consult dietician Education about disease Lifelong adherence to a gluten free diet ID and treat nutritional deficiencies Access to an advocacy group Continuous long term follow up by a multidisciplinary team
Celiacs
abnormal small intestinal mucosa that improves morphologically when treated gluten free diet and relapses when gluten is introduced
Celiac nutritional tests
Test for deficiencies Vitamins ADE (fat soluble) copper zinc carotene folic acid ferritin iron
Thiamine, B6, mag, selenium may also be deficient
Common problem with celiacs
Bone loss Usually osteopenia (less likely osteoporosis)
Usually due to secondary hyperparathyroidism
due to vitamin D deficiency
Suggested vaccine with celiacs
Pneumococcal vaccine
celiacs is associated with Hyposlenism
intussusception treatment
Nonoperative reduction can be guided by fluoroscopy or ultrasound
and either pneumatic or hydrostatic enemas may be used
Antibiotics for small bowel obstruction surgery
Cefazolin plus metronidazole 500mg
2g <120kg
3g >120kg
or Cefoxitin 2g
or Cefotetan 2g
Antibiotics for small bowel non - obstruction surgery
Cefazolin
2g <120kg
3g >120kg
Lactose intolerance
Lactase deficiency is the lack of the activity of the small intestine enzyme lactase
Lactase is required for digesting disaccharide lactose to glucose and galactose
on the microvillus membrane of the intestinal absorptive cells
Lactose intolerance education
No need to completely eliminate lactose
Restriction to 2 cups of milk daily taken in divided doses with meals is sufficient
Can also use lactase supplements
May require calcium supplements
Monitor Vitamin D
Nut allergies
Avoid eating at Asian, Mexican food places
Bakeries, ice cream places use nuts regularly
Treatment for nut allergies
Epi pen for anaphylaxis
IgE mediated food allergies
Pruritis, urticaria, flushing, lip, face, throat, swelling, nausea, vomiting, cramping, diarrhea, wheezing, lightheadedness, syncope, hypotension
Usually within minutes of eating food
Severity reaction may vary over time can go from hives to anaphylaxis
The most common types of IgE mediated food allergy in adults
Oral allergy syndrome
(pruritis of the mouth and throat)
from raw fruits, veggies
Also isolated allergies to seafood or nuts
IgE mediated food allergy treatments
Decide whether to use epi or not
food avoidance
lab tests
Migraine trigger foods
Alcohol Chocolate Aged cheese MSG Aspartame (nutrasweet) Caffeine Nuts Nitrates/nitrites
Epinephrine
Epinephrine 0.3mg (1:1000) Auto injector epipen
Anaphylaxis
(Sympathomimetic)
Warnings
CVD, HTN, Hyperthyroid, DM, Parkinson’s
Adverse
Anxiety, apprehensiveness, restlessness, tremor, weakness, dizziness, sweating, palpitations
Interactions
May be potentiated by MAOI’s, TCA’s, Synthroid, antihistamines,
May be antagonized by BB, A Blockers, ergot alkaloids,
arrhythmias possible with cardiac glycosides, diuretics, anti-arrhythmic
C Diff test - When to do
In cases of recent ABX use f health care exposure
Most critical therapy for diarrhea
Volume repletion
Preferable by oral route
With solutions of salt, water and sugar
Antibiotics in non travel community acquired diarrhea
not routinely used
Drawbacks
Cost, C-diff, bacterial resistance
Can shorten duration but pros do not outweigh the cons
Usually due to viruses anyways
Loperamide in diarrhea?
Used cautiously in patients whom fever is absent or low grade and no blood is present in stool
Causative agents of diarrhea
Stool type
Viral
Rotavirus
Watery stools
Causative agents of diarrhea
Stool type
Bacterial
E.coli, shigella, salmonella
Blood in stool
Causative agents of diarrhea
Stool type
Parasitic
Giardia
Entamoeba
Histolytica
Green stools with mucus
Tinidazole
Tindamax (500mg) (Nitroimidazole)
for giardia
Warning
risk of carcinogenicity
Interactions
Avoid alcohol during and for 3 days after use
Shigella treatment
Levo 500mg PO QD x 3 days
Cipro 500mg PO BID x 3 days
or
Cipro 750mg PO QD x 3 days
How to prevent stress ulcers in stomach
Gastric acid suppression with IV PPI
Agents poorly absorbed by activated charcoal
Cyanide Ethanol Ethylene glycol Iron Isopropanol Lithium Methanol Strong mineral acids and alkali
Activated charcoal MOA
A highly adsorbent powder made of high surface area porous organic material
(Surface area of 2000 m2/g)
Covered with a carbon based network which adorbs chemicals within minutes of contact
Preventing GI absorption and systemic toxicity
Contraindications of Activated charcoal
Not for convulsing patients unless given through NG tube and patient is intubated
Not for patients with ileus or intestinal obstruction
Not for patients who have a planned endoscopy
G6PD Deficiency
Most common inherited RBC enzymatic defect (400 million world wide)
X linked disorder
Males more likely
Heterozygous females are unaffected carriers
Kurds, Jewish, Black, sub saharan, brazil, african american, Thailand, sardinia, greece, south china, india
G6PD Clinical
Acute hemoytic anemia
(induced by medications, chemicals, foods, illness)
Oxidant injury
Fava beans, infection, henna, naphthaline
Most are intermittent hemolysis
some get life threatening jaundice or hemolytic anemia
Can cause neonate jaundice
G6PD treatment
Depends on severity and clinical setting
Preganancy is safe
Can be blood donor as long as they are not anemic
Medications that are completely unsafe for G6PD
Chlorpropamide Dabrafenib Dapsone Methylene blue Nitrofurantoin (other nitro's) Phenazopyridine Primaquine (other quines) Rasburicase and pegloticase
Paget’s disease
Osteoarthritis in nearby joints and neurologic disease are common complications
The vascularity of the pagetic bone may result in excessive bleeding during surgery on affected areas
Paget’s Disease treatment
Goal of treatment is to ease pain and normalize rate of bone remodeling
Success of treatment is assessed by periodic alkaline phosphatase
Secondary consequences of Paget disease need to be treated with other things
This includes hearing aids, analgesics for arthritis pain, physical therapy, walking aids and psychosocial issues
Side effects of bisphosphanates
acute phase response lasting several days (more common with IV meds first time use)
Can be treated with acetaminophen or NSAIDS
Rare patients are intolerant of bisphosphonates and can be treated with cacitonin
Zoledronic acid
Reclast (bisphosphanate)
Contra
Children
Hypocalcemia, CrCl <35, acute renal impairment
Adverse
Pyrexia, MSK pain, HA, Arthralgia,
Rare: osteonecrosis of jaw
Bisphosphonate MOA
Pyrophosphate analogues
2 phosphorus groups linked to C atom
Prevent loss of bone density and decrease fractures
Decreases osteoclasts mediated bone resorption
Stimulates osteoclast apoptosis
Inhibits cholesterol pathways
Decrease osteoclast number, function and bone resorption
Calcitonin
Miacalcin (hormone)
For paget disease of bone, Hyper calcemia
Interactions
May antagonize lithium (dose adjustment)
Adverse
Nausea, vomiting, local inflammation, flushing, rash
Calcitonin MOA
Lower serum calcium and phosphate by actions on bone and kidney
Calcitonin inhibits osteoclastic bone resorption
Decreases calcium and phosphate reabsorption in proximal tubules of kidney
Secretion is always determined by calcium concentration
Phenylketonuria
PKU
A deficiency of phenylalanine hydroxylase (PAH)
and if untreated
results in irreversible disability among other things
PKU
Normal
Protein gets broken down into amino acids
Phenylalanine is hydrolyzed into tyrosine
PKU
Protein gets broken down into amino acids
Phenylalanine cannot be broken down and builds up
This results in health problems
Sapropterin dihydrochloride (Kuvan) MOA
Newer FDA approved drug for PKU
A form of BH4 which is used to break down Phenylalanine
Even if it helps, it will not decrease phenylalanine to the desired amount
Must be used with PKU Diet
sapropterin
Kuvan (phenylalanine hydroxylase activator)
For PKU with a PKU diet
Reduces Phe blood levels in HPA due to BH4 in patients with PKU
Interactions
Monitor neurologic status with concomitant levodopa
Caution in drugs that inhibit folate metabolism (i.e., methotrexate)
Monitor BP with vaso-relaxors (i.e., PDE-5 inhibit)
Rickets
Inadequate intake of Vitamin D or calcium
Can result in phosphate deprivation
May occur in infants whose breast milk is the sole source of nutrition
Rickets therapy
Daily doses of D2 or D3
Vitamin A
Retinoic acid, Retinol
Night blindness xeropthalmia keratomalacia Bitot spot Follicular hyperkeratosis
Vitamin D
Cholecalciferol
Rickets
osteomalacia
craniotabes
rachitic rosary
Vitamin E
tocopherosis
Sensory and motor neuropathy
Ataxia
retinal degeneration
hemolytic anemia
Vitamin K
Phylloquinone
Hemorrhagic disease
Wernicke Korsakoff syndrome
COAT RACK C Confusion O Ophthalmoplegia A Ataxia T Thiamine Deficiency
R Retrograde amnesia
A Anterograde amnesia
C Confabulation
K Korsakoff syndrome
Wernicke Korsakoff syndrome causes
Thiamine B1 deficiency = Wernicke’s encephalopathy
Can turn into korsakoff if untreated
Chronic alcoholism
Malabsorption from stomach cancer or IBD
Which vaccination is suggested for those with celiac disease?
Flu vaccine
Pneumococcal vaccine
Herpes-Zoster vaccine
Hepatitis B vaccine
Pneumococcal vaccine
Which of the following is not a precaution for EPIPEN?
Hypothyroidism
DM
HTN
Cardiovascular disease
Hypothyroidism
What is the boxed warning for the giardia drug tinidazole?
Pregnancy
Carcinogenicity
Atrial fibrillation
Suicidal thoughts in younger patients
Carcinogenicity
Which of the following is not usually associated with bloody stools?
Giardia
Salmonella
E.coli
Shigella
Giardia
Which of the following vitamins is not a fat-soluble vitamin?
Vitamin C
Vitamin D
Vitamin A
Vitamin E
Vitamin C
There have been many controversies involving the administration of vaccines allegedly causing various diseases/disorders. Which of the below controversies is the most well-known in the medical community?
MMR vaccine and dementia MMR vaccine and Parkinson's Disease MMR vaccine and ADHD MMR vaccine and autism spectrum disorder None of the above
MMR vaccine and autism spectrum disorder
How many days should a patient wait before receiving another live, attenuated vaccine, if him or her received the same type of vaccine within the past 4 weeks?
14 days 28 days 42 days 64 days 100 days
28 days
Which of the below diagnoses is associated with all 50 U.S. States in allowing students to possess self-administered emergency medication?
cardiovascular disease diabetes mellitus hypertension asthma ADHD
asthma
Which of the following complementary and alternative therapies (CAM) is not in the top 5 of all CAM involved with the pediatric population?
Tai chi homeopathy guided imagery vitamins None of the above
guided imagery
Which of the following factors is not considered a factor that affects the pharmacokinetics and pharmacodynamics of a pediatric patient?
gastric pH intestinal transmit time activity of bile fluid activity of CSF none of the above
activity of CSF
How many drugs were available for PEDS before the FDA’s pediatric program?
20%
Factors that affect children and medications
oral bioavailability
Gastric pH Emptying time intestinal transit time immaturity of secretion activity of bile and pancreatic fluid
Medications that specifically act differently in peds
Stimulants and non stimulants
Stimulantsare the best-known and most widely used ADHD medications.
Between 70-80% of children with ADHD have fewer ADHD symptoms when taking these fast-acting medications
Nonstimulantswere approved for the treatment of ADHD in 2003.
They do not work as quickly as stimulants, but their effect can last up to 24 hours.
Medications can affect children differently and can have side effects such as decreased appetite or sleep problems.
One child may respond well to one medication, but not to another.
Medications that specifically act differently in pregnant women
ACE Inhibitors
ACE inhibitors-May cause kidney damage in the fetus when used in II and III trimester, decrease in the amount of amniotic fluid and deformities of face, limbs and lungs
Medications that specifically act differently in pregnant women
Cough syrup
If you have a cough, Mucinex, Robitussin, and other medications containing guaifenesin can increase the risks of neural tube defects in infants if taken during the first trimester of pregnancy.
Medications that specifically act differently in pregnant women
Misc
NSAIDs & Aspirin and other Salicylates-Delay in start of labor, premature closing of ductus arteriosus, jaundice, brain damage in the fetus and bleeding problems in the woman during and after delivery and in the newborn.
Antibiotics- Tetracycline- Slowed bone growth, permanent yellowing of the teeth and increased susceptibility to cavities in the body.
Ciprofloxacin-Possibility of joint abnormalities (seen in animals)
Alcohol and miscarriage
Alcohol in any amount can cause miscarriage
Where to find medication info
Always use Epocrates, Uptodate, or other evidence-based medical databases to look up the latest information.
Breastfeeding women and meds
Breastfeeding women should avoid aspirin and products containing aspirin (this includes Pepto Bismal taken for an upset stomach), as well as products containing naproxen (Aleve).
In contrast, acetominophen (Tylenol) and ibuprofin (Motrin, Advil) are not known to have any negative effects on nursing babies.
Accidental poisoning and drug toxicity in infants and children
Most common things
medicines sold over the counter, such as Tylenol, cough and cold remedies, iron tablets, antihistamines and anti-inflammatory drugs;
prescription medicines, such as antidepressants, narcotics and analgesics;
recreational drugs, such as cannabis and cocaine;
household products – such as bleach, disinfectants, detergents, cleaning agents,
cosmetics and vinegar;
pesticides – including insecticides, rodenticides and herbicides;
poisonous plants; animal or insect bites.
Over-the-counter and alternative therapies in children
Natural products Chiropractic or osteopathic manipulation Yoga, Tai chi, Qui gong Deep breathing Homeopathy
Social issues that may prohibit or hinder treatment plans.
One study found higher adherence rates in clinics located in suburban areas compared to inner city clinics among adolescents who were taking oral contraceptives.
This could be due to lack of transportation, access to pharmacies, or funds to purchase medications.
Use of and legal requirements for the use of medications in the school system
As of October 2014, all 50 states and the District of Columbia have laws or statutes allowing students with a diagnosis of
asthma or life-threatening allergic reactions
to possess and self-administer emergency medication.
Antitoxin Definition
Antitoxin.
A solution of antibodies against a toxin. Antitoxin can be derived from either human (e.g., tetanus immune globulin) or animal (usually equine) sources (e.g., diphtheria and botulism antitoxin). Antitoxins are used to confer passive immunity and for treatment.
Immune globin Definition
Immune globulin.
A sterile solution containing antibodies, which are usually obtained from human blood.
Antigen vs antibody
Antigen
A substance that can induce the immune system to produce antibodies against it
Has combinations of polysaccharides
Can be cells
Act as the key
2 main types (self antigens and non self antigens)
Antibody
Antibody is a protective protein produced by the B cells of the immune system in order to attack antigens
Purely made of proteins
Not cells
Act as the lock
Five main categories (IgA, IgD, IgE, IgG, IgM)
Antigen
Antigen
A substance that can induce the immune system to produce antibodies against it
Has combinations of polysaccharides
Can be cells
Act as the key
2 main types (self antigens and non self antigens)
Antibody
Antibody
Antibody is a protective protein produced by the B cells of the immune system in order to attack antigens
Purely made of proteins
Not cells
Act as the lock
Five main categories (IgA, IgD, IgE, IgG, IgM)
Vaccines
Vaccines train our immune system to defend against disease
Live attenuated vaccines
use a living virus that has been weakened to the point that iti is incapable of causing disease.
Inactivated vaccines
contain a virus that has been killed and is completely incapable of causing disease
Subunit vaccine
contain purified pieces of virus to create the vaccine
Conjugate vaccines
Connect outer sugar like coatings found on bacteria to proteins to induce an immune response
Toxoid vaccines
contain inactivated toxins no longer capable of causing harm or disease
Live attenuated vaccines
Live attenuated vaccines
use a living virus that has been weakened to the point that iti is incapable of causing disease.
Inactivated vaccines
Inactivated vaccines
contain a virus that has been killed and is completely incapable of causing disease
Subunit vaccine
Subunit vaccine
contain purified pieces of virus to create the vaccine
Conjugate vaccines
Conjugate vaccines
Connect outer sugar like coatings found on bacteria to proteins to induce an immune response
Toxoid vaccines
Toxoid vaccines
contain inactivated toxins no longer capable of causing harm or disease
Resources for immunizations
Primarily Centers for Disease Control and Prevention (CDC) websites!
When is a live vaccine contraindicated
From CDC:
A person who received either live, attenuated influenza vaccine or an injectable live-virus vaccine (e.g., MMR-II, Varivax) in the past 4 weeks should wait 28 days before receiving another live vaccine.
Inactivated vaccines may be administered at the same time or at any time before or after a live vaccine.
Severely immunocompromised persons and pregnant females should not receive live vaccines!
Vaccine safety surveillance systems
The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program run by CDC and the Food and Drug Administration (FDA).
VAERS serves as an early warning system to detect possible safety issues with U.S. vaccines by collecting information about adverse events (possible side effects or health problems) that occur after vaccination.
VAERS was created in 1990 in response to theNational Childhood Vaccine Injury Act.
Vaccine controversies
Distrust of the scientific ‘establishment’ who generally promotes vaccination, albeit based on careful risk-benefit analyses,
suspicion that those conducting vaccine safety studies are in the pay of the pharmaceutical industry
sincerely held personal belief that their child was damaged by a vaccine
pseudoscientific beliefs such that vaccination is unnatural and it is better for a child to experience the real disease or that giving several vaccines to a young child can ‘overload the immune system
Best well-known controversy was the unfounded MMR vs autism report.
