Tx various minor ailments Flashcards
NonPharms prevention constipation (5)
Fibre
fluid -1.5L/day
toilet routine
- bowel schedule
- stool to put feet on
bowel retraining
exercise
nonpharms for tx of constipation (4)
increased fluid
bowel retraining
manual manipulation
prebiotics/probiotics
- activia
- bioGaia tabs
- bisbiome
- yakult liquid
5 classes of laxatives (nonRx pharm)
bulk forming
osmotic agents
stool softeners
saline laxatives
stimulant laxatives
bulk forming (nonRx pharm)
psyllium
- Lax A day / metamucil
- 70% soluble fibre 30% insoluble
- DO NOT INHALE POWDER
wheat dextran vs inulin
- (USA = wheat dextran CAN = inulin)
- Benefiber
- soluble fibre dissolves in liquid
Low level evidence
- sterculia gum
- polycorbophil
- methylcellulose
osmotic agents (nonRx pharm)
- MoA
- evidence
- 4 kinds
- how use to avoid diarrhea
- purgative/lavage
non-absorbed ions or mols break down gut flora –> acidic env osmotic gradients within intestinal lumen retaining water
ONLY laxative family with evidence shown to improve constipation
- glycerin suppository (only works in last few inches of rectum)
- lactulose (can use in diabetics bc no systemic abs)
- sorbitol 70% solution (syrup)
- PEG 3350 powder
+restoralax, miralax, lax a day
+good for pediatrics and adults
+onset 3 days
TO AVOID DIARRHEA
-start low and work way up
Purgative/lavage
- PEG with electrolytes
- much higher dose
- should be closely supervised by physician or caregiver
Stool softeners (nonRx pharm)
- MoA
- names 2
- lubricant/purgative (2)
-EVIDENCE/EFICACIOUS?
act as surfactants and soften stool by allowing mixing of aq and fatty substances
docusate sodium
docusate calcium
LUbricant/purgative
- mineral oil oral
- mineral oil enema
Saline Laxatives (nonRx pharm)
- MoA
- avoid in who
- oral (3)
- enemas (6)
- ENEMA NOTE
create osmotic gradient through electrolyte imbalance
avoid in children and elderly
Oral
- Mg(OH)2
- MgCitrate
- NaPO4 oral
Enemas
- tap water
- soap suds
- Mg enema
- Phosphate soda
- saline enema
- mineral oil
ENEMA NOTE
-can damage rectum, only use as pretense to remove impaction
Stimulant laxatives (nonRx pharm)
- MoA
- concern
- 4 types
- how use
produce rhythmic contractions in intestines
dependency with overuse, talk about reduction in those using lot
DO NOT CAUSE MELANOSIS
senna tablets/suppository
- can be used in children as liquid and may be used in pregnancy
- herbal, tablet, liquid -> probs swallowing
Bisacodyl tablets/suppository
cascara sagrada
-NOT commonly used
Castor oil
HOW USE
- take at night then shit for the next 12 days
- some patients complain about cramping
Complimentary and homeopathic and herbal agents
- evidence
- found in OTC prep
- 11 worthless hunks of plant
NO EVIDENCE, JUST EAT GRASS
senna and psillium –> use OTC bc thats where evidence
slippery elm Fennei seed aloe vera papaya acacia gum psyllium husk pepermint leaves triphala buckthorn bark senna leaves ginger root
Oral forms for laxatives (acute)
PEG 3350 1.5g/kg/day
- evidence for disimpaction
NO EVIDENCE BUt USED IN PRACTICE Mg(OH)2 MgCitrate lactulose sorbitol senna bisacodyl
Rectal laxatives (acute)
EVIDENCE FOR DISIMPACTION -phosphate soda enema - saline enema - mineral oil enema followed by phasphate \+ need medical supervision
MOST EVIDENCE IN ELDERLY
- bisacodyl suppository
- glycerin suppository
NOT RECOMMENDED tox and irrit
- soap suds enema
- tap water enema
- Mg enema
glycerin suppository (acute)
fastest onset
less effective if stool dry and hard
fast acting in nec to get relief before oral osmotic agent works in 48 hours
saline laxatives (acute)
- evidence
- onset
- admin with what
- taste
- concern
- CI
lack evidence to supp effectiveness
fast acting and effective
administer with enough fluid avoid dehydration
tastes v chalky
electrolyte disturbances
- esp in LT use
- -> diarrhea
CONTRAINDICATIONS
- renal failure
- CHF worse due to Mg
- Neg mortality at 3 yrs
bulk laxatives (acute)
- when do not use
- how administer
- good for what constipation
- bad in what constipations
do not use if patient is
- dehydrated
- fluid restricted
- impacted
administer with at least 250mL water or juice to prevent impaction
improves normal transit constipation
poor in slow colonic transit or pelvic floor disorder
stool softeners
- chronic constipation use?
- AEs?
- mineral oil risk
- AVOID IN WHO
insufficient data to use in chronic
AEs equal to placebo
mineral oil risk of lipid aspiration and binding fat soluble drugs
Avoid in pediatric and elderly
timeframe to eliminate cramping and bloating
1 day
timeframe to reduce pain
1-2 hours
timeframe to prevent future constipation
3-4 days
-get >3shits/wk
bulk laxatives for chronic
- safety LT use
- avoid in who
- admin with what
safest drug for LT use
avoid in dehydrated or fluid restricted
admin with 250mL water or juice to prevent impaction
osmotic laxatives (chronic)
- what one use in children
- lactulose and PEG
- low dose
FIRST LINE in pediatric = PEG
lactulose
- abdominal pain
- 80% effective
PEG
-least straining and greatest efficacy and tolerability
low dose
- stops bloating, cramping, flatulence, and electrolyte imbalance
saline laxatives (chronic)
- evidence
- onset
- admin with what
- compliance consideration
- risks
- lack evidence to supp effectiveness
fast acting and effective
admin withe nough fluid prevent dehydration
compliance prob: chalky taste
RISKS
- multiple electrolyte disturbances esp in LT use
- diarrhea
Stimulant laxatives (chronic)
- evidence
- opioid induced
- when admin/onset
- RISKS
- insufficient evidence
- best with opioid induced constipation (combo with osmotic agent may work better)
- admin at bedtime
- onset 6-12hr
RISKS -concern dependence \+ limit use when possible \+use if other classes innefective -abdominal discomfort and some electrolyte imbalance
for an acute episode of constipation
saline laxative, glycerin suppository, and/or enemas if no BM for 3 consecutive days
when follow up to check if shit
24-48hr
when follow up again after initial shit check
1mo
steps to care
educate patient, lifestyle modification, diet
fibre supplement and/or bulk forming laxatives
osmotic laxatives or saline laxatives orally
emolients and stimulants
- limit to st use
- use if fail other agents/narcotic load
opioid induced constipation: methylnaltrexone
methylnaltrexone
- blocks miu receptor in gut
- used for opioid induced constipation
laxatives covered on ODB and most private plans on Rx
Relistor (brandname) not covered
oxycodone and naloxone
opioid induced constipation: naloxegol (movantik BN)
oral tablet
indication
- opioid induced, non-cancer pain in adults
- do not use if risk GI obstruction
dose
- 25mg daily if cramp and pain restart at 12.5mg
- hod regular laxatives for 3 days
administration
- take on empty stomach
- avoid grapefruit juice
Chronic idiopathic constipation: linaclotide (constella BN)
class secretagogue: guanylate cyclase C agonist 2C
good for chronic idiopathic constipation and Irritable bowel disease
activates c-GMP to activate chloride channels in cells of luminal surface of intestine
drives water into intestinal lumen
not effective if ++ diarrhea
prokinetic agents
increase peristaltic movement
prokinetic: prucalopride
Class prokinetic: seretonin 5=HT4 receptor
indication:
- trials, mainly women
- chronic idiopathic constipation, secondary to parkinsons, opioids
- ileus
- refractory gastroparesis
- intestinal pseudo-obstruction
prev drugs in this class removed from market but no safety risk vs placebo for CV risks
mild-moderate acute infections diarrhea - resolution? - What therapy \+what type \+reverse what \+replenish what \+as effective as what \+when CI
WHEN RECOMMEND
- mild to moderate acute infectious diarrhea should be self limiting to 7-10 days
Oral rehydration therapy (ORT)
+inexpensive sugar salt solution
+reverses secretory diarrhea
+replenishes fluid and electrolyte losses - glucose enhances Na Abs
+ as effective as IV rehydration for mild to moderate dehydration
+contraindicated in protracted vomiting
RECOMMEND BEFORE DEHYDRATION
why homemade ORS typically not recommended
measurement errors
what avoid as ORS (4)
- why
- what risks (2)
- what CAN substiture
plain water, fruit juice, sports drinks, carbonated beverages
- plain water can cause hyponatremia
- others may worsen osmotic diarrhea
apple juice half diluted with water is reasonable alt until suitable ORS can be obtained
ORS administration
- dosage
- what if vomiting
- what if unpalatable (3)
- how long use
15mL/kg/hr OR 60mL/kg for 4hr
if vomiting give small volumes frequently until vomiting resolves
-ex. 15mL q10min
if unpalatable give by spoon or oral syringe or administer frozen
cts until diarrhea resolves
should patients use BRAT for diarrhea
NO - eat whatever (so long as not trigger)
acute diarrhea in breast fed children
breast / bottle feeding cts (+ORS)
- some patients with giardia lamblia will dev temp Lactose intolerance so temp milk avoidance may help
what food portions during diarrhea
small food protions until diarrhea improves
When should you use zinc in diarrhea tx
- how long
- infant dose <6mo
- infant dose >6mo
for children at risk
- use for 10-14 days
- 10mg daily for infants <6mo
- 20mg daily for infants >6mo
when use pharm options in addition to ORT (diarrhea)
when needed for QoL or if sx’s not improved in 48hrs
what diarrhea pharm tx d/c in can
attapulgite
what do if patient does not improve from ORT + bismuth subsalicylate OR psylium
+time frame
+what do
if do not improve in 48 hours try loperamide for 24 hours
- if no imp refer
if improvement with ORT +/- Pharm tx what do (diarrhea)
cts until resolves then consider stop
Psylium (metamucil) [DIARRHEA tx]
- used for what
- action
- safety (SE/guidance)
- adherance (dosage forms)
- dosing
- used for mild diarrhea
- Bulking agent
+ abs fluid to make stool less watery
-cramping and flatulence
+ take sep from other meds by 2hrs
+give with enough water
- powder avail in mult flavours as well as capsules
DOSE
TID to QID
bismuth subsalicylate (pepto-bismol) {Diarrhea]
- what kind diarrhea
- action
- safety (avoid in [4], SE)
- adherance
- dose
- used for mild to moderate diarrhea
- antisecretory agent
+stimulates reabsorption of electrolytes and water
- SAFETY \+black tongue and stools \+ causes tinnitus \+ AVOID IN: -children -anticoagulants -subcylates - history of ulcer
liquid available in mult flavours
chewable tablets
easy to swallow capsules
DOSE
130-60min PRN with daily maximum
loperamide
- what types diarrhea
- action
- safety (4SE, 1CI, avoid[2])
- adherence
- dosing
- used for moderate to severe diarrhea
- antimotility agent
+ binds to opioid receptor to slow peristalsis - cramping, drowsiness, dizziness, dry mouth
- contraindicated in children <3yrs
- avoid in patients with fever or bloody diarrhea
capsule, liquid, tablet
initial dose followed by dose after each BM with daily max
PEP in children younger than 12yrs pregnant or lactating, evidence of active lyme disease
- what drug/dose
- endpoint/time period
doxycycline 200mg x 1 dose
0.4% incidence (relative to 3.2% placebo) of (endpoint) development of erythema migrans at site of tick bite (at 3wks and 6wks)
doxycycline drug interactions (3)
oral anticoagulants
hepatic enzyme inducers
isotretinoin
doxycycline MoA
-what consideration/counsil point
binds to divalent cations (ex. Ca, Fe)
forms non-absorbable complex
- wait 2hrs before/after dosing doxy with Ca and Fe (and other divalent cation) supplements
doxycycline AEs
allergy
superinfection
photosensitivity (LD higher in summer –> photosensitivity inconvenient)
N/V
esophagitis and esophageal ulcer (only if LT use)
NOT HUGE DEAL BC ONLY ONE DOSE DOXY FOR LD
Rx doxycycline 200mg po x 1 dose
-what about in children
in children
- 4mg/kg po x 1 dose (maximum 200mg)
Non-pharm strategies NBI (3)
reduce symptoms
- gently remove crusts with warm water or mild soap and water
- warm saline compress x 10-15min TID-QID (dec itch)
prevent spread (other areas of body and other ppl)
- no scratch
- wash b4/aft touch
- cover draining lesion w/ clean/dry bandage
- no share towel
- wash linens sep from other ppl
- discard used compress/bandages imm OR wash in hot water
- stay home from school until 24hrs antimicrobial therapy OR lesions dry
prevent recurrence
- trim fingernails
- manage pruritis appropriately
- wash cuts, scrapes, and insect bites ASAP and cover w/ bandage
Topical antimicrobial therapy for mild uncomplicated non-bullous impetigo (3)
mupirocin 2%
fusidic acid 2%
ozenoxacin 1%
mupirocin 2% (4)
- effectiveness
- dose
- type of topical (problematic?)
- expense
impetigo
- as effective as oral antibiotics with fewer SEs
- TID x 5-7 days
ointment or cream available
- ointment
+ not good for oozing lesions
+ kids touch a lot and fingerprint all you shit - least expensive
Fusidic acid 2%
- effectiveness
- dose
- type of topical
- expense
NBI
- as effective as oral antibiotics with fewer side effects
TID x 5-7 days
- ointment or CREAM (use cream bc ointment probs)
- intermediate in price range to ozenoxacin 1%, mupirocin 2%
Ozenoxacin 1%
- effectiveness
- dose
- type of topical
- cost
Superior to placebo, hasnt been studies vs other antibiotics (drawback)
BID x 5-7 days
cream
most expensive
What are the non-pharmacologic options for the treatment of dermatitis? (6)
- keep environment temperate (mild) with moderate humidity
- choose swimming as a sport
- wear loose-fitting cotton or cotton blend clothing
- bathe using lukewarm water and a mild soap/soapless cleanser
- do NOT restrict diet in absence of a confirmed food allergy
- use wet dressings
What are the 3 types of wet dressings that can be used to treat dermatitis and when are they indicated?
- Compresses –> when oozing and crusting is present
- Soaks –> when hardened crusts and scaling are present (chronic)
- Wraps –> moderate to severe AD and/or resistant cases
