1. Git - Misbah

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Nausea & vomiting in pregnancy

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Non prescription.. Dimenhydrinate use only for 2 to 3 days refer to physician if ineffective.

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Post chemotherapy nausea and vomiting (PCNV)

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Alter diet (emphasize on small & frequent meals. Avoid fatty or spicy foods).

The drug of choice for moderate emitogenic is dexamethasone

Drug of choice for acute emitogenic is 5HT3 antagonist ondansetron+ dexamethasone.

The drug of choice for high nausea and vomiting is dexamethasone + ondansetron + aprepitant

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Anticipatory nausea and vomiting:

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The drug of choice is benzodiazepine (lorazepam).

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Drug induced diarrhea could be caused by

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· Antibiotics· Chemotherapeutic agents· Anti-inflammatory agents (NSAIDs, Colchicine)· Anti-arrhythmic (Quinidine)· Anti-hypertensive (Beta-blockers, ACE inhibitors)· Antacids (Mg-containing antacids, ranitidine, omeprazole)· Miscellaneous;Misoprostol and theophylline

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TRAVELLERS DIARRHEA

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caused mainly by E. coli, Shigella sp and Campylobacter jejuni

Prevention.· Hot and cooked meals, cooked vegetables (no salad or no fresh salad).· Peeled fruits, boiled/bottled water, carbonated beverages without ice cubes, pasteurized milk (properly stored).· Bismuth sub salicylates as prophylactic agent.· Typhoid vaccine recommended for travelers.· Cholera vaccine for healthcare workers in endemic areas.Children and elderly should use oral rehydration solution. Adults maintain hydration with canned juices, purified boiled or bottle water, clear salty soup, carbonated water.Prevention: Dukoral vaccine can be recommended by pharmacist. Prior to departure, travelers should see physician for appropriate antibiotics.· Drug of choice is ciprofloxacin 500 mg BID X 3 days· Alternative azithromycin, and cefixime.· Cotrimoxazole of limited use due to widespread resistance

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Senna

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Stimulant laxative

It also causes water and electrolyte secretion into the bowel. In combination products with a decussate-containing stool softener, its useful in treating

opioid-induced constipation.

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Castor oil

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Pregnant patients should avoid castor oil because it may stimulate uterine contractions. Use of castor oil is generally not recommended due to poor palatability and potential for GI adverse effects.

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Bulk-laxative (psyllium, bran, and methylcellulose)

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· Adsorb water to soften the stool and increase the bulk, which stimulates peristalsis.· Should be taken with at least 250 mL water to prevent esophageal obstruction and/or fecal impaction.· Side effects include flatulence, bloating.

Safe to use in pregnancy.· Contraindication in patients with fluid restriction and mechanical obstruction of the GIT.· Not to be taken within 2 hours with other medications because it reduces drug absorption.

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Osmotic laxatives. (Lactulose, and glycerin)

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· Osmotic laxative preferable for constipation in infants and children.

· Lactulose not tolerated by most patients because of too much sweetness in taste. Can be used by diabetic patients.

· Lactulose is the drug of choice for hepatic encephalopathy, because it absorbs ammonia.

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Omeprazole

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Drug Interaction ; may decrease metabolism of warfarin, diazepam and phenytoin (require dosage adjustment), and clopidogrel

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Ranitidine

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decrease clearance of theophylline, phenytoin and warfarin Cimetidine; CYP450 inhibitors,

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PPI S/E

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1-Omeprazole and esomeprazole may decrease the effectiveness of clopidogrel because they inhibit CYP2C19 and prevent the conversion of clopidogrel to its active metabolite.

2- PPIs may increase the risk of fractures, particularly if the duration of use is 1 year or greater.

3-Prolonged acid suppression with PPIs (and H2 receptor antagonists) may result in low vitamin B12 because acid is required for its absorption in a complex with intrinsic factor.

4-Diarrhea and Clostridium difficile colitis may occur in patients receiving PPIs. Patients must be counseled to discontinue PPI therapy and contact their physician if they have diarrhea for several days.

5-Additional adverse effects may include hypomagnesaemia

6-an increased incidence of pneumonia.

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Crohn’s disease:

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Inflammation is present from the esophagus to the anus but predominantly in the small bowel or colon. Obstruction of the bowel abscess formation. Drug of choice to treat mild Crohn's disease 5ASA or oral budosenide. ¯ Drug of choice moderate oral budosenide and severe iv steroid

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Ulcerative colitis:

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Relapsing inflammatory condition in the colon with symptoms of bleeding, urgency, diarrhea and tenesmus. · Erosion and ulceration of the mucosa · Decrease in the number of goblet cells · Frequent infection secondary to fever and anemia · Drug of choice in mild to moderate is 5-ASA · Drug of choice in severe ulcers is oral prednisone

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prostaglandin

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Misoprostol, an analog of prostaglandin E1 , is approved for the prevention of NSAID-induced gastric ulcers .

.Prophylactic use of misoprostol should be considered in patients who take NSAIDs and are at moderate to high risk of NSAID-induced ulcers, such as elderly patients and those with previous ulcers.

.Misoprostol is contraindicated in pregnancy, since it can stimulate uterine contractions and cause miscarriage

. Thus, PPIs are preferred agents for the prevention of NSAID-induced ulcers.

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Small intestine

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Consist of duodenum, jejunum, and ileum.

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Carbohydrates digestion

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The most common site of carbohydrate absorption is small intestine. Only monosaccharides such as glucose, fructose, and galactose are absorbed.Amylase: Hydrolyse starch and glycogen into maltose. There is amylase in saliva and stomach.· Maltase: Converts maltose into glucose + glucose· Sucrase: Converts sucrose into glucose + fructose.· Trehalase: degrades carbohydrate to glucose.· Glucosidase: breakdown sucrose and starch to glucose (Acarbose inhibits alpha glucosidase).· Lipase is released mainly from the pancreases into the GI track to help breakdown fat. (Orlistat, Xenical inhibit lipase)· Lactase: Converts lactose (milk) into glucose + galactose.Pancreatic Secretions (High HCO3 isotonic, pancreatic lipase, amylase, proteases).

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Lipid Absorption

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Bile acids emulsify lipids in the small intestine, increase surface for digestion. Pancreatic lipases, hydrolyse, lipids to fatty acids, monoglycerides, cholesterol and lysolecithin.Lipid absorption disorders. Malabsorption of lipids thus causing fatty stools, this also referred as stethorrhea.

Stethorrhea can cause by· Pancreatic diseases such as pancreatitis, and cystic fibrosis.· Hyper secretion of gastrin· Ileal resection· Bacterial overgrowth

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Absorption of Proteins (small intestine)

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Trypsin and chymotrypsin are secreted by pancreas, which helps in digestion of proteins.· Trypsin is secreted in the inactive form as trypsinogen and is converted to trypsin by enzyme enterokinase.· Chymotrypsin is secreted in the inactive form as chymotrypsinogen and converted to chymotrypsin by trypsin.

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Absorption of nucleic acid

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· Nuclease --> Nucleic acid into nucleotide. · Ribonuclease --> Hydrolyses RNA · Deoxyribonuclease --> Hydrolyses DNA

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Absorption of water (H2O)

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It is isosmotic in the small intestine and gallbladder.

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Absorption of Vitamins and Nutrients:

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Fat soluble vitamins (ADEK) are absorbed in small intestine along with other lipids. Vitamin B12 is absorbed in the ileum and that requires intrinsic factor.

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Absorption of calcium:

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Mainly occurs in small intestine, which assisted by active form of vitamin D3, 1, 25-dihydroxycholecalciferol, which is produced in kidney. Chronic renal failure or vitamin D deficiency results in inadequate intestinal Ca2+ absorption, causing rickets in children and osteomalacia in adults.The mechanism of calcium absorption is passive absorption.

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Absorption of Iron

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It is absorbed as heme iron (iron bound to hemoglobin or myoglobin) or as free Fe2+. In intestinal cells, heme iron is degraded to Fe2+ and released. The free Fe2+ binds to apoferritin and is transported into the blood. The iron absorbed from small intestine in the form of ferrous Fe2+ Transferrin: Free Fe2+ circulates binds transferring and transports it from small intestine to its storage sites in the liver and from the liver to the bone marrow for the synthesis of hemoglobin.

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Sjogren syndrome

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(dry mouth, dry eyes) is autoimmune disease, it is associated with rheumatoid arthritis.

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Sialorrhea

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is an excessive secretion of saliva in infants, children, Parkinson’s disease. Can cause by mucosal irritation.

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Dyspepsia

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: Defined as pain or discomfort in the upper abdomen. Symptoms are nausea, fullness, early satiety, bloating or regurgitation. The dyspepsia could be due to esophagitis, GERD, peptic ulcer (GU or DU) 15-25%, Reflux esophagitis, 5-15%, gastric or esophageal cancer (<2%).

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Zollinger Ellison syndrome

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(ZES) is a rare condition that is characterized by the presence of one or more benign tumors, called gastronomes, in the pancreas and/or the small intestine. These tumors secrete large amounts of the hormone gastrin, which stimulates the production of stomach acid. As a result, people with ZES have high levels of stomach acid,

- Omeprazole is the drug of choice

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Treatment of H. Pylori

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bismuth subsalicylate, metronidazole, and tetracycline plus a PPI is a recommended first-line option.

triple therapy consisting for 14 days.

a PPI combined with amoxicillin (metronidazole may be used in penicillin-allergic patients) plus clarithromycin is a preferred treatment when rates of clarithromycin resistance are low and the patient has no prior exposure to macrolide antibiotics.

a PPI combined with metronidazole , levofloxacin ( salvage therapy) for 10 days.

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Prostaglandins

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c. Misoprostol, an analog of prostaglandin E1 , is approved for the prevention of NSAID-induced gastric ulcers .

d. Prophylactic use of misoprostol should be considered in patients who take NSAIDs and are at moderate to high risk of NSAID-induced ulcers, such as elderly patients and those with previous ulcers.

e.nMisoprostol is contraindicated in pregnancy, since it can stimulate uterine contractions and cause miscarriage.

Thus, PPIs are preferred agents for the prevention of NSAID-induced ulcers.

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Crohn’s disease:

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Inflammation is present from the esophagus to the anus but predominantly in the small bowel or colon. Obstruction of the bowel abscess formation.

Drug of choice to treat mild Crohn's disease 5ASA or oral budosenide.

¯ Drug of choice moderate oral budosenide and severe iv steroid

¯ Drug of choice to treat fistula? Azathioprine or 6-MP, infliximab

Drug of choice to treat NO remission (not cured) from initial therapy? AZA, 6MP, or MTX and in severe biologics (infliximab, adalimumab, cetrolizumab).

Drug of choice for maintenance therapy? 5ASA, Infliximab, adalimumab, Azathioprine, 6MP.

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Ulcerative colitis:

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- Relapsing inflammatory condition in the colon with symptoms of bleeding, urgency, diarrhea and tenesmus.

· Drug of choice in mild to moderate is 5-ASA

· Drug of choice in severe ulcers is oral prednisone

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Irritable Bowel Syndrome (IBS): القولون العصبي

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(IBS) is characterized by chronic abdominal pain and altered bowel habits in the absence of an organic cause.

Pharmacological treatment

· Dicyclomine. It has anticholinergic side effects

· Loperamide: Used for diarrhea

· Magnesium hydroxide: Used for heartburn · Lactulose: Used for constipation

· Psyllium.Bulk laxative

· Cholestyramine: For patients with bile salts malabsorption

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Inflammatory Bowel Disease

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(IBD) is a group of idiopathic chronic intestinal conditions characterized by immune mediated GI tract inflammation in response to bacterial antigens in the intestinal lumen. The most common subtypes of IBD are Crohn’s disease (CD) and ulcerative colitis (UC).

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Opioid induced nausea and vomiting (OINV)

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· Use other anti-emetic. Metoclopramide (drug of choice), and prochlorperazine, diphenhydramine, dimenhydrinate, ondansetron, haloperidol.

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Post chemotherapy nausea and vomiting (PCNV)

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The drug of choice for moderate emetogenic is dexamethasone

Drug of choice for acute emetogenic is 5HT3 antagonist ondansetron+ dexamethasone.

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Motion sickness

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For short duration of exposure, dimenhydrinate is effective for most patients. Diphenhydramine is an alternative. Take oral medication at least 60 min in advance. Because motion induces gut stasis. The second dose can be used after 6 hrs.

Scopolamine Trans dermal patch: Placed behind ears. 1 patch every 72 h, can be removed and reused within 72 h but should rotate site of application.

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Q Drug induced diarrhea could be caused by:

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· Antibiotics

· Chemotherapeutic agents

· Anti-inflammatory agents (NSAIDs, Colchicine)

· Anti-arrhythmic (Quinidine)

· Anti-hypertensive (Beta-blockers, ACE inhibitors)

· Antacids (Mg-containing antacids, ranitidine, omeprazole)

· Miscellaneous;Misoprostol and theophylline

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TRAVELLERS DIARRHEA

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Prevention. · Hot and cooked meals, cooked vegetables (no salad or no fresh salad). · Peeled fruits, boiled/bottled water, carbonated beverages without ice cubes, pasteurized milk (properly stored).

· Bismuth sub salicylates as prophylactic agent.

· Typhoid vaccine recommended for travelers.

· Cholera vaccine for healthcare workers in endemic areas.

· Drug of choice is ciprofloxacin 500 mg BID X 3 days

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Magnesium hydroxide

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is an antacid that is commonly used to neutralize stomach acid.

Magnesium hydroxide is also a mild laxative, meaning it can have a cathartic effect

it can stimulate bowel movements and relieve constipation. This is due to the fact that magnesium ions in the gut stimulate water movement into the colon and increase the bulk of feces.

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treatment PINWORM

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Drug of choice pyrantel pamoate Q

Avoid in pregnant and with liver disease

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· Senna

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· May discolor the urine from red to pink or brown to black, excreted into breast milk.

· The drug of choice for opioids induced constipation Q

· Faster onset of action than bulk laxatives.

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· Bisacodyl

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· Preferred stimulant laxative for long term use in patients on H2 antagonist and should not be taken within 1 h of antacids. Q

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Ascites الاستسقاء

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is an effusion and accumulation of serous fluid in the abdominal cavity;

- Accumulation of fluids in the peritoneal cavity

- called also abdominal or peritoneal dropsy.

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Antacid

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Diarrhea is the most common side effect seen with the administration of magnesium hydroxide antacid.

-Aluminum and calcium carbonate cause constipation.

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Sucralfate

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- Effective in the healing of stress induced duodenal ulcers.

- Reduces the number of H. pylori

- Causes constipation.

- · Requires acid pH to be activated should not be administered with antacids, H2 antagonists or proton blockers.