WEEK 7 GASTROINTESTINAL Flashcards
What are the non-pharmacologic treatment options for GERD?
Lifestyle changes: •Lose weight •Elevate head of the bed (6 – 10 inches – use foam wedge) •Smaller meals •Don’t eat 3 hours before bedtime •Avoid foods or medications that exacerbate symptoms •Stop smoking •Avoid alcohol
Surgical options:
•Antireflux surgery (Nissen fundoplication)
•Bariatric surgery
What are the pharmacologic treatment options for GERD?
- Antacids
- Histamine-2 Receptor Antagonists (H2RAs)
- Proton Pump Inhibitors (PPIs)
- Prokinetic agents (metoclopramide)
- Mucosal protectants (sulcrafate)
What are the non-pharmacologic treatment options for PEPTIC ULCER DISEASE (PUD)?
- Dependent on type of ulcer (H. Pylori, NSAIDs, stress related mucosal damage, smoking, diet or Zollinger).
- Often includes elimination of ulcerative source (e.g., smoking cessation, stress reduction, change in diet, etc).
What are the pharmacologic treatment options for PEPTIC ULCER DISEASE?
- Dependent on type of ulcer (H. Pylori, NSAIDs, stress)
- All treatment options include use of PPI
- H. Pylori (PPI plus antibiotics)
- NSAIDs induced (PPIs at standard doses preferred, may also use misoprostal, H2RAs, sulcralfate)
- Stress-related (Prophylaxis in ICU setting [due to risk factors of sepsis, further organ damage, etc] therapy may differ dependent upon source of stress (e.g., thermal injury, surgery, GI bleed, etc.): H2RA or PPI)
What are the non-pharmacologic treatment options for NAUSEA/VOMITING?
- Hydration
- Diet
- Bland food
- Small frequent meals
- Avoid triggers (e.g. fatty, spicy foods)
•Psychological
- Avoid stress
- Self hypnosis
- Cognitive distraction
- Guided imagery
•Acupressure
What are the pharmacologic treatment options for NAUSEA/VOMITING?
Anticholinergics
Antihistamines
What are the non-pharmacologic treatment options for DIARRHEA?
Removal of the diarrhea causing agent (e.g., medication).
Hydration
•Water
•Flat soft drinks, sports drinks
•Commercial rehydrating solutions (e.g. Pedialyte®)
•1 L water with 8 tsp. sugar and 1 tsp. table salt
Dietary modifications
•Avoid irritating foods
•May increase bulk if chronic
What are the pharmacologic treatment options for DIARRHEA?
Antidiarrheals:
- Anticholinergics (Crofelemer)
- Opiates (Lomotil, Motofen, Imodium)
- Absorbent preparations (kaolin, pectin, bismuth subsalicylate)
What are the non-pharmacologic treatment options for CONSTIPATION?
-Increase fiber intake
•Normal: 20 – 35 grams/day PO (Max 50 grams)
-Avoid excessively processed low fiber foods
-Increase fluid intake
-Aerobic exercise
-Don’t ignore the urge to defecate
-Biofeedback may be helpful if pelvic floor dysfunction
What are the pharmacologic treatment options for CONSTIPATION?
- Bulk forming agents (1st line)
- Stool softeners
- Lubricant laxatives
- Stimulant laxatives
- Osmotic laxatives
- Prostaglandins: Lubiprostone (Amitiza®)
- Opioid Antagonists
What are the non-pharmacologic treatment options for IRRITABLE BOWEL SYNDROME (IBS)?
- Diet
- Fluid
- Physical activity
- Counseling / behavioral therapy
- Probiotics
What are the pharmacologic treatment options for IRRITABLE BOWEL SYNDROME (IBS)?
For pain:
Antispasmodics, Antidepressants, Antibiotics
Diarrhea:
•Antidiarrheal agents: loperamide, atropine/diphenoxylate
•Alosetron (Lotronex®) 0.5 mg PO BID for 4 weeks (max 2 mg/day)
Constipation: •Bulk forming agents, osmotic laxatives •Lubiprostone (Amitiza®) 8 mcg PO BID -Place in therapy: IBS-C in females ≥18 years •Linaclotide (Linzess®) 290 mcg daily
Prokinetic agents
•Metoclopramide 10-15 mg by mouth up to 4 doses/day
MOA: enhances esophageal peristalsis and gastric emptying
- Inferior efficacy and adverse effect profile (CNS effects)
- BBW for tardive dyskinesia – irreversible movement disorder
1st line treatment options for H. Pylori peptic ulcer disease
•Bismuth quadruple therapy (10-14 days)
- -Standard dose PPI PO BID
- -Clarithromycin 500 mg PO BID
- -Amoxicillin 1 g PO BID OR metronidazole 500 mg PO TID
•Concomitant therapy (duration 10-14 days)
- -Standard dose PPI PO BID
- -Clarithromycin 500 mg PO BID
- -Amoxicillin 1000 mg PO BID
- -Metronidazole 500 mg PO BID
•Triple therapy (duration 14 days)
- -Standard dose PPI PO BID
- -Clarithromycin 500 mg PO BID
- -Amoxicillin 1 g PO BID OR metronidazole 500 mg PO TID
Antimobility agents
- Common agents and dosing:
- Loperamide (Imodium®) 4 mg PO after 1st loose stool, then 2 mg after each subsequent loose stool
- Diphenoxylatewith atropine (Lomotil®)•MOA: slows intestinal motility
Place in therapy:
•Do NOT use in bacterial or viral gastroenteritis
Considerations/Precautions with antimobility agents
Adverse effects: •Abdominal cramping •Constipation •Nausea •Dizziness
Contraindications:
•Children <2 years of age
•Bloody diarrhea and high fever
Precautions:
•Abuse potential (opioid receptor activity at high doses)
•Risk of serious cardiac adverse reactions (Black Box Warning)
•Syncope, ventricular tachycardia, torsades de pointes
•Avoid in patients with risk factors for QT prolongation
Considerations/Precautions with Anti-secretory agents.
Adverse effects:
•Headache
•Fecal discoloration
Contraindications:
•Ulcers
Anti-secretory agents
Bismuth subsalicylate (Pepto-Bismol®) 535 mg PO q30-60 min as needed (max 4,200 mg/day x 2 days)
MOA:
•Antisecretory, antimicrobial, and anti-inflammatory effects
Place in therapy:
•Diarrhea and dyspepsia
Alternative 1st line treatment options for H. Pylori peptic ulcer disease
•Sequential therapy
- -1st 5 days: standard dose PPI PO BID + amoxicillin 1 g PO BID
- -Next 5 days: standard dose PPI PO BID + clarithromycin 500 mg PO BID + metronidazole 500 mg PO BID
•Hybrid Therapy
- -1st 7 days: standard dose PPI PO BID + amoxicillin 1 g PO BID
- -Next 7 days: above + clarithromycin 500 mg PO BID + metronidazole 500 mg PO BID
•Fluoroquinolone triple – PPI, amoxicillin, levofloxacin (“PAL”) [Duration 10-14 days]
- -Standard dose PPI PO BID
- -Amoxicillin 1 g PO BID
- -Levofloxacin 500 gm PO daily
•Fluoroquinolone sequential
- -1st 5 days: standard dose PPI PO BID + amoxicillin 1 g PO BID
- -Next 5 days: standard dose PPI PO BID + levofloxacin 500 mg PO daily + metronidazole 500 mg PO BID
•Fluoroquinolone quadruple [duration 10-14 days]
- -Double dose PPI PO BID
- -Nitazoxanide 500 mg PO BID
- -Levofloxacin 250 mg PO daily
- -Doxycycline 100 mg PO daily
Salvage Therapy for treatment of H. Pylori peptic ulcer disease
•Bismuth quadruple therapy [10-14 days]
- -Standard dose PPI PO BID
- -Tetracycline 500 mg PO QID
- -Metronidazole 250 mg PO QID
- -Bismuth subsalicylate 525 mg PO QID
•Concomitant therapy [10-14 days]
- -Standard dose PPI PO BID
- -Clarithromycin 500 mg PO BID
- -Amoxicillin 1000 mg PO BID
- -Metronidazole 500 mg PO BID
•Fluoroquinolone triple – “PAL” [10-14 days]
- -Standard dose PPI PO BID
- -Amoxicillin 1 g PO BID
- -Levofloxacin 500 gm PO daily
•Rifabutin-based triple therapy [10-14 days]
- -Standard dose PPI PO BID
- -Amoxicillin 1 g PO BID
- -Rifabutin 300 mg PO daily
•High-dose dual therapy [14 days]
- -Standard/double dose PPI PO BID
- -Amoxicillin 1 g PO TID or 750 mg PO QID
Misoprostol
NSAID Induced PUD
Misoprostol 400-800 mcg/day in divided doses
MOA: prostaglandin analog which replaces the protective prostaglandins consumed with prostaglanding-inhibiting therapies (e.g. NSAIDs)
Onset of action: 30 minutes; duration: 3 hours
Adverse effects: diarrhea, abdominal pain
Precautions: Pregnancy category X
Antimobility agents
Common agents and dosing:
•Loperamide (Imodium®) 4 mg PO after 1st loose stool, then 2 mg after each subsequent loose stool
•Diphenoxylatewith atropine (Lomotil®)•MOA: slows intestinal motility
Place in therapy:
•Do NOT use in bacterial or viral gastroenteritis
Considerations/Precautions with Anti-secretory agents.
Adverse effects:
•Headache
•Fecal discoloration (Pt’s should be warned about gray/black stools and black tongue from bismuth use. They should be educated this is to be expected and that it does not indicate GI Bleeding).
Contraindications:
•Ulcers
Anticholinergics
Common agents and dosing:
•Scopolamine (Transderm Scop®) 1.5 mg transdermal patch – 1 patch behind ear at least 4 hours prior to exposure and every 3 days as needed
MOA: block acetylcholine at the H1 receptor •Onset: 6-8 hours, duration: 72 hours (patch)
Place in therapy:
•Motion sickness
•Migraine
•Vertigo
Considerations/Precautions with Anticholinergics:
Adverse effects:
Sedation
Urinary retention
Blurred vision
Precautions:
Caution in patients with CV disease, open-angle glaucoma, and and GI obstruction
Antihistamines
Common agents and dosing:
•Meclizine (Dramamine®) 25-50 mg PO 1 hour prior to travel
MOA: competes with histamine for H1 receptor sites
Place in therapy:
•Motion sickness
•Vertigo
•Available over the counter
Considerations/Precautions with Anticholinergics:
Adverse effects:
Sedation
Urinary retention
Blurred vision
Precautions:
Caution in patients with CV disease, open-angle glaucoma, and and GI obstruction
Antihistamines
Common agents and dosing:
•Meclizine (Dramamine®) 25-50 mg PO 1 hour prior to travel
MOA: competes with histamine for H1 receptor sites
Place in therapy:
•Motion sickness
•Vertigo
•Available over the counter
Considerations/Precautions with Antihistamines
Adverse effects:•Drowsiness•Fatigue•Anticholinergic effects•Precautions:•May cause CNS depression•OTC products may contain ginger and dimenhydrinate – read label
Dopamine antagonists - Butyrophenones
Common agents and dosing:
•Droperidol (Inapsine®) 2.5 mg IM, IV initial dose, then 1.25 mg as needed
MOA:
•Blocks dopamine stimulation of the chemoreceptor trigger zone
Place in therapy/efficacy:
•Postoperative nausea/vomiting
Considerations/Precautions with Dopamine antagonists - Butyrophenones
•Adverse effects:•Anticholinergic effects•Sedation•Dizziness•Extrapyramidal symptoms•Orthostatic hypotension•Precautions:•Black Box Warning for prolonged QT interval and/or torsade de pointes
Considerations/Precautions with Dopamine antagonists - Butyrophenones
•Adverse effects:•Anticholinergic effects•Sedation•Dizziness•Extrapyramidal symptoms•Orthostatic hypotension•Precautions:•Black Box Warning for prolonged QT interval and/or torsade de pointes
Chemotherapy-induced nausea/vomiting (CINV)
- Corticosteroids (e.g. dexamethasone)
- Neurokinin 1 Receptor Antagonists (aprepitant, fosaprepitant)
- 5-HT3 receptor antagonists (dolasetron, ondansetron)
- Olanzapine
- Thalidomide
- Dronabinol (cannabinoid)
Bulk Forming Agents
Common agents and dosing:
•Psyllium (Metamucil®) 2.5-30 g/day PO in divided doses
•Calcium polycarbophil (FiberCon®) 1,250 mg PO 1-4 times daily
•Methylcellulose (Citrucel® powder or tablet) 2 tablets (500 mg) up to 6 times/day or 2 g (1 Tbsp) powder up to TID
MOA:
•Soluble fiber which absorbs water in the intestine to add bulk to the stool and promote peristalsis
Place in therapy:
•1st line agent
•Drug of choice in pregnancy
Considerations/ Precautions with Bulk Forming Agents
Adverse effects:
•Gas
•Bloating
Contraindications:
•Fecal impaction
•GI obstruction (psyllium)
Considerations/ Precautions with Bulk Forming Agents
Adverse effects:
•Gas
•Bloating
Contraindications:
•Fecal impaction
•GI obstruction (psyllium)
Stool Softeners (AKA emollient laxatives)
Common agents and dosing:
•Docusate (Colace®) 50-360 mg PO daily or in divided doses
MOA: reduce surface tension of oil-water interface of the stool
Place in therapy:
•Preferred when straining should be avoided
Considerations/ Precautions with Stool Softeners (AKA emollient laxatives)
Adverse effects:
•Mild GI cramping
•Well tolerated
Lubricant laxatives
Common agents and dosing:
•Mineral oil – dose varies with product
MOA:
•Coats the bowel to ease passage of stools
Considerations/ Precautions with Lubricant laxatives
Adverse effects: •Abdominal cramps •Diarrhea •Nausea •vomiting
Contraindications: •Children <6 years of age •Pregnancy •Bedridden patients •Elderly •Use longer than 1 week •Difficulty swallowing
Precautions:
•Do not take with docusate
•Aspiration risk – do not lie down for 30-60 minutes
•May decrease absorption of fat-soluble vitamins
Stimulant laxatives
Common agents and dosing:
•Bisacodyl (Dulcolax®) 5-15 mg PO daily, 10 mg rectally daily
•Senna (Senokot®) 15 mg PO daily
MOA:
•Stimulate peristalsis by direct action on the intestinal mucosa
Place in therapy:
•Chronic opioids often require a stimulant laxative
Considerations/ Precautions with Stimulant laxatives
Adverse effects:
•Abdominal cramps
•Diarrhea
•Nausea/vomiting
Osmotic laxatives
Common agents and dosing:
•Polyethylene glycol (Miralax®) 17 g (1 dosing cup) PO in 4-8 ounces of water daily
•Magnesium hydroxide (Milk of Magnesia) 2.4-4.8 g PO once daily
•Lactulose (Enulose®) 10-20 g PO daily
MOA:
•Causes water retention in the stool to increase stool frequency
Considerations/ Precautions with Osmotic laxatives
Adverse effects:
•Diarrhea
•Flatulence
•Nausea
Precautions:
•Electrolyte imbalance
•Avoid use in patients with bowel obstruction
Constipation Prostaglandins
•Lubiprostone (Amitiza®) 24 mcg PO BID
MOA:
•Activates chloride channels in gut to increase fluid and peristalsis
Place in therapy:
•Chronic idiopathic constipation
•Irritable bowel syndrome
•Opioid-induced constipation
Considerations/ Precautions with Constipation Prostaglandins
Adverse effects:
•Headache
•Nausea
•Diarrhea
Contraindications:
•GI obstruction
Precautions:
•Dyspnea
•Hypotension
•Reserved for experts in GI
Considerations/ Precautions with Constipation Prostaglandins
Adverse effects:
•Headache
•Nausea
•Diarrhea
Contraindications:
•GI obstruction
Precautions:
•Dyspnea
•Hypotension
•Reserved for experts in GI
Opioid Antagonists
•Naloxegol (Movantik®) 25 mg PO once daily
MOA: peripherally acting opioid antagonist
•Blocks opioid-induced GI effects, but does not affect analgesic activity (does not cross the BBB)
Considerations/ Precautions with Opioid Antagonists
- Adverse effects:
- Abdominal pain
- Diarrhea
- Headache
Precautions:
•Contraindicated in patients with risk of GI obstruction
•Reserved for specialist prescribing
IBS PAIN: Antispasmodics
Antispasmodics:
•Dicyclomine 10-20 mg PO q4-6 hours prn
•Hyoscyamine 0.125 – 0.25 mg PO or sublingual q4 hours prn
MOA: blocks action of acetylcholine at parasympathetic sites in smooth muscle
Place in therapy:
•As needed and/or in anticipation of stressors
Considerations/ Precautions with Antispasmodics
Adverse effects:
•Dizziness, dry mouth, blurred vision, drowsiness
Precautions:
•CNS effects
•Delirium in elderly
Contraindications: obstruction of GI tract, severe ulcerative colitis, glaucoma, infants <6 months of age
IBS PAIN: Antidepressants
Antidepressants:
•Amitriptyline: 10-75 mg PO once daily at bedtime
MOA: analgesic properties in addition to anticholinergic properties, which may slow the intestinal tract
Place in therapy:
•Use cautiously in patients with constipation (anticholinergic effects)
Considerations/Precautions with Antidepressants for IBS Pain
Adverse effects:
•Sedation
•Dry mouth
Precautions:
•Contraindications: coadministration with MAOIs
•BBW for suicidal thinking/behavior
IBS PAIN: Antibiotics
Antibiotics:
•Rifaximin(Xifaxan®) 550 mg PO TID x 14 days, may retreat up to 2 times
MOA: semisynthetic antibiotic with low systemic absorption
Place in therapy:
•Not routinely recommended
•Moderate to severe IBS without constipation
•Failed other therapies
Considerations/Precautions with Antibiotics for IBS PAIN.
Adverse effects:
•Peripheral edema, dizziness, fatigue, nausea, headache
Precautions:
•C. difficile infection
IBS Diarrhea: Antidiarrheal
Alosetron (Lotronex®) 0.5 mg PO BID for 4 weeks (max 2 mg/day)
MOA: selective 5-HT3 receptor antagonist – decreases colonic motility and secretion
Place in therapy:
•Severe IBS-D, female patients; symptoms >6 months; failed to respond to all other conventional treatment
Adverse effects:
•Constipation, fatigue, headache, nausea, GI pain, UTI
Precautions:
•Contraindications: constipation, intestinal obstruction, Crohn disease
•BBW: risk of ischemic colitis and serious complications of constipation•Reserved for specialist prescribing
IBS CONSTIPATION
•Linaclotide (Linzess®) 290 mcg daily
MOA: agonist of guanylate cyclase C, which increases chloride and bicarbonate secretion into the intestinal lumen, increasing intestinal fluid and GI transit.
Adverse effects: diarrhea, headache, abdominal pain, upper respiratory tract infections
Precautions:
- -Contraindications: <6 years (BBW); mechanical GI obstruction
- -Severe diarrhea
