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270 Cards in this Set
- Front
- Back
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syndrome =
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presence of various symptoms
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is IBS a disease
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no, there is no structural abnormalities so it is a syndrom
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IBS is considered a "______" disorder
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functional
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what does funtional disorder mean
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therr is an absence of any overt, organic strucutal disorders
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prevalence of IBS
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World wide: 7-10%
North America = 10-15% most prevalent GI disorder |
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epidemiology of IBS
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Incidence higher in:
Women Lower socioeconomic status Gulf war veterans Patients < 50 years of age more likely to be diagnosed |
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why are IBS drugs just FDA approved for women
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because the studies have only been done in women
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classifications of IBS
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Constipation predominant (IBS-C)
Diarrhea predominant (IBS-D) Mixed (IBS-M) |
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what is the key feature of IBS
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pain located in the abdominal area
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IBS pathophys
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psychococial factors (altered pain perception)
gas retention altered motility and secretions prior gastroenteritis or bacterial overgrowth altered sensation |
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Role of Serotonin in IBS
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95% of serotonin (5-HT) is found in the _GIT______
Also an important CNS neurotransmitter 7 subtypes of receptors: 5-HT1-7 1-4 most involved in GI processes Effects differ on subtype |
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95% of serotonin (5-HT) is found in the _______
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GIT
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Stimulation of serotonin leads to _______ motility and secretion & possibly pain modulation
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increased
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clinical features of IBS
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Gastrointestinal
Diarrhea and/or constipation Abdominal pain (can be absent, intermitent, or constant) Bloating, distention, spasm Urgency Psychiatric (up to 60%) Stress induced alterations in bowel function Depression Anxiety |
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consequences of IBS
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Significant reductions in patient quality of life
Increase absence from work Decreased productivity Significant healthcare/societal costs |
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Rome III Criteria (don't need to memorize just know concept)
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Abdominal pain or discomfort > 3 days per month in the last 3 months plus:
Presence of at least 2 of 3 features: Relief with defecation Onset associated with a change in frequency of stools Onset associated with change in stool form (appearance) Onset of symptoms > 6 months prior Absence of: rectal bleeding anemia weight loss fever family history of colon cancer onset after age 50 No Identifiable physical, radiologic, or laboratory evidence of organic disease long standing diagnosis |
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diagnosis of IBS (know!!!!)
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2009 ACG Guideline Definition
Abdominal pain or discomfort that occurs in association with altered bowel habits over a period of at least 3 months. Patients will often have an extensive work-up Lab tests Radiology Scopes Often a “diagnosis of exclusion” Check for celiac disease in IBS-D and IBS-M Food allergy testing or use of exclusion diets is not endorsed Lactose intolerance may be more prevalent (treat it) Role of small intestinal bacterial overgrowth (SIBO) (no good way to test for) ruling out other causes |
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Patients will often have an extensive work-up of IBS
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Lab tests: stool samples to check for infections
Radiology: MRI, motility, cat scan Scopes: determine that there are no structural abnormalities |
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Appropriate Referrals for IBS (know!!!)
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Age > 50
Unintentional weight loss Family history of GI malignancy, IBD, or Celiac Sprue (underlying strructural disorder) Severe unrelenting large volume diarrhea Fevers, chills (>102) Recent travel to an endemic area (over the last 1-2 months) Nocturnal symptoms (GIT should not be functioning at night) Hematochezia (blood in stool) |
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bright red blood indicates what knid of bleed
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lower GI
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what does dark red blood indicate in the stools
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upper GI bleed
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melena=
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upper GI bleed, black stools
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treatment of IBS and drug therapy targets
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Drug therapies may target:
Central pain perception Altered GI motility and secretion Altered GI sensation Gas/bloating |
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non-pharm for IBS
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Dietary: avoid aggravating foods
Psychosocial modification |
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Drug Treatment types for IBS
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Select based on predominant symptoms
Multiple types of agents utilized: Laxatives Motility ( or ) or change perception Antispasmodic agents Psychotropic agents Combinations |
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anticholinergis target symptoms of ______ in IBS
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diarrhea and pain
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anticholinergis and IBS
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Targets symptoms of: Pain and diarrhea
Avoid in: IBS-C Major adverse effects: could be long term but mainly PRN Hyoscyamine (Levsin®) 0.125-0.25 mg PO/SL q 4h prn (fast acting so good for prn) Dicyclomine (Bentyl®) 10-40 mg PO QID schedule or PRN |
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are anticholinergis scheduled or prn for IBS
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prn mainly because of SE
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TCA and IBS most common agents
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Amitriptyline
Doxepin Desipramine Nortriptyline |
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TCA effects in IBS
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reduce visceral sensitivity (altered sensation in the GI tract)
target symptoms of pain avoid in IBS-C |
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are TCAs scheduled or prn for IBS
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scheduled
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efficacy of TCAs for IBS
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Doses lower than depression (25-75mg/day)
May need to increase dose Pain reduction may only be minimal in some cases |
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adverse effects of TCAs
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anticholinergic effects
sedation ortho-static hypertension (may be less with TCAs such as nortriptyline because it is a secondary amine not tertiary |
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drug drug interactions with TCA
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are numerouse because of P450s
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do TCAs treat the aniety and depression asspect of IBS
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no
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what is the difference between SSRIs/SNRIs
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SSRI only increase the levels of 5HT whereas SNRIs increase the levels on 5HT and NE
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GI afffects of SSRIs/SNRIs
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decrease visceral sensitivity so targets pain
increawswe motility/secretions so targets motility |
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what is the additional benefit of using a SSRIs/SNRIs
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also may treat depression and anxiety
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names of SSRIs
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Sertraline, fluoxetine, citalopram, escitalopram
Paroxetine: |
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names of SNRIs
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venlafaxine, duloxetine
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what is the first line agent for IBS-C
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SSRI
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roles for SSRI/SNRI
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increase motility in IBS-C
treat depression |
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is a SSRI/SNRI contraindicated in a patient with IBS-D
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no
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are SSRI/SNRI scheduled or prn
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scheduled
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Diarrhea Predominant IBS options
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Antimotility agents
Loperamide: Does not treat Pain Diphenoxylate/atropine ( can cause a little bit if cramping) PPIs and H2RAs Role? only in people with reflux or heartburn |
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what is the max dose of loperamide RX strength
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16 mg/day
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what is the max dose of loperamide OTC strength
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8 mg/day
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Alosetron (Lotronex®)
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Serotonin (5 HT3) antagonist
Diarrhea predominant IBS Modifies pain response Slows transit and secretion Indication: severe IBS-D in women failing other therapies >18 years of age Symptoms > 6 months Pregnancy category B |
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what is the only approved 5HT antagonit for IBS-D
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alosetron/lotronex
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what is the major SE of Alosetron (Lotronex®)
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constipation (10-29%)
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why was Alosetron (Lotronex®) from the market
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ischemic colitis: like a infarct of the GIT
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incidence of the ischemic colitis
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Incidence: 1.1/1000 patient-years
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syptoms of ischemic colitis
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Symptoms: worsening abdominal pain, bloody stool
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contraindications for Alosetron (Lotronex®)
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Constipation
Obstruction, stricture, perforation Impaired intestinal circulation Hypercoaguable states IBD Diverticulitis Strong CYP 1A2 or 3A4 inhibitors Fluvoxamine (SSRI) |
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prescribing Alosetron (Lotronex®)
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Physician must register in prescribing program
Appropriate indication for drug Sign attestation form (signed consent that is kept on record) Receive prescribing kit Read educational materials Discuss risk/benefits with patient Give patient copy of medication guide Signed inform consent (MR) |
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prescritptions for alosetron
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Place sticker on prescription
May write refills Report any adverse events The sticker indicates that this prescription is in compliance with the prescribing program for lotronex |
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dispensing alosetron
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Cannot accept prescriptions via:
Phone, Fax, or computer Dispense retail pack Medication guide, medication, survey, package insert Counsel on appropriate use Encourage patient to fill out follow-up survey (so the manufacture can determine if it is working and SE) |
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Alosetron Efficacy for IBS-D
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What can patients expect?
10-50% greater ↓ in pain/discomfort Increase in number of formed stools 13-60% greater reduction in urgency May reduce to ~ 1 day per week Greater reduction in stool frequency to 1 or 2 BM per day (clinically significant) |
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what asspects of IBS-D do antisasmodics, TCAs and SSRI treat
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Pain
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when does a patient turn to alosetron
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as a last resort when every thing else has failed
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Constipation Predominant IBS and bulk forming agents
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Bulk forming agents
Generally considered first line Targeted symptom(s) constipaiton Most evidence with psyllium May worsen symptoms of gas and bloating Alternative fibercon and methylcellulose (the synthetic products) May increase number of stools Role of dietary fiber? contraversial |
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what is the first line therapy for IBS-C
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bulf forming agents
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osmatic laxatives and IBS-C
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May increase number of stools
No effects on other symptoms only treats constipation Preferred agents miralax, PEG |
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what is the major SE of MOM
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cramping
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what is the major draw back of saline laxitives
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short term use
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stimulants and IBS-C
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second line may worsen syptoms of cramping
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Lubiprostone (AMITIZA®)
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Chloride channel activator (CIC-2) (whihc is the epithelium of the gut)
Increases fluid secretion in intestinal tract Targeted symptom(s) constipation and bloating FDA approved for IBS-C in women > 18 years old Dose: 1 capsule (8 mcg) twice daily with meals Prescription only |
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Lubiprostone (AMITIZA®) SE
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Nausea
Diarrhea Abdominal pain |
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Lubiprostone (AMITIZA®) pregnancy category
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c
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what is the efficacy of Lubiprostone (AMITIZA®)
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a 17% decrease in syptoms
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Tegaserod (Zelnorm®) class
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5HT partial agonist
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what is the role of Tegaserod (Zelnorm®)
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Constipation predominant IBS
Stimulates peristalsis and secretion Reduces visceral sensitivity |
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efficaciy of Tegaserod (Zelnorm®)
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39%-67% response rate
Increase to average of 6 stools/week ~10% better than placebo for: abdominal pain, discomfort, bloating, straining |
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why was Tegaserod (Zelnorm®) pulled from the market
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Cardiovascular ischemic events (18,600 patients)
(0.11%) Tegaserod (1 per 7,031) (causes platelet aggregation) (0.01%) placebo (p = 0.024) Withdrawn from market: 3/07 2007: Reintroduced with restricted Access 2008: Available only for emergent situations “immediately life-threatening or serious enough to qualify for hospitalization.” |
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Probiotics in IBS MOA (don't really need to know, just thought I would include it)
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Possible Mechanisms
Immunomodulatory effects Enhanced barrier function Inhibit bacterial adhesion Alteration in nutrient fermentation Alterations in mucosal response to stress Inhibition of visceral hypersensitivity |
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probiotic products
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Products
Lactobacillus Bifidobacteria infantis Streptococcus Combinations |
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what probiotic plays the biggest role in IBS
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Bifidobacteria infantis
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Probiotics compared to placebo1
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RR of IBS not improving = 0.71; 95% CI = 0.57 to 0.88 with an NNT = 4 (95% CI = 3 to 12.5).
Improvement in global IBS symptoms compared to placebo2 RR 0.77 (95% CI 0.62-0.94) Abdominal pain compared to placebo2 RR 0.78 (95% CI 0.69-0.88) 22% decreaase in abdominal pain overall it is shown that probiotics imporve syptoms these results were all significant |
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Rifaximin (Xifaxan®) in IBS
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Nonabsorbable antibiotic
Use based on potential contribution of small intestinal bacterial overgrowth (SIBO) Most studies in patients with IBS-D can reduce certain symptoms FDA approved for travelers diarrhea |
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effacay of Rifaximin (Xifaxan®)
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8-23 % more likely to experience global improvement in IBS symptoms compared with placebo
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effacacy of Rifaximin (Xifaxan®)
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8-23 % more likely to experience global improvement in IBS symptoms compared with placebo
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most improvement of syptoms with Rifaximin (Xifaxan®) is seen in
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bloating and gas
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cons of Rifaximin (Xifaxan®)
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Cost
No FDA approved indication for IBS Effects may not last |
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IBS-M
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Get a good idea of patient’s baseline
Evaluate adherence to treatment (bulk forming agents do not have good adherance rates) Avoid medications that may exacerbate diarrhea or constipation May try PRN options for each episode first Avoid over treating diarrhea treat the symptom at that time |
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Alternative Therapies for IBS
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Peppermint oil
Artichoke extract Teas Agrimony, blackberry or raspberry leaf Tannins: antisecretory properties Acupuncture Psychological therapies Cognitive behavioral therapy (CBT) Dynamic psychotherapy Hypnotherapy |
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natural stimulants
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Cascara
Aloe Senna European buckthorn |
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natural sources of fiber
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Apple pectin, flaxseed, fenugreek
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BMI classifications
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BMI 25-29.9 kg/m2 = overweight
BMI ≥ 30 kg/m2 = obese BMI ≥ 40 kg/m2 = “extremely” |
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waist cicumference (wc)
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Estimates central adiposity
Strong marker for health risks (visercial adipose tissue is mor metabolically acitve therefore poses more of a health risk) |
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_____ and _____ are better assessments than weight
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BMI
WC |
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Obesity and Comorbidities
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Cardiovascular
* Hypertension * Left ventricular hypertrophy * Congestive heart failure * Coronary artery disease * Stroke Pulmonary * Obstructive airway disease * Sleep apnea * Pulmonary hypertension Metabolic * Hypercholesterolemia * Hypertriglyceridemia * Low serum HDL * Diabetes mellitus * Hyperinsulinemia * Polycyctic ovarian syndrome Musculoskeletal * Degenerative joint disease Dermatologic * Acanthosis nigricans * Stretch marks * Hirsutism * Skin tags Gastrointestinal * Cholelithiasis * Esophageal reflux * Hiatus hernia Psychological * Eating disorders * Depression * Affective disorders * Social stigma Neoplasm * Breast cancer * Colon cancer |
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Obesity and Comorbidities associated with metabolic x syndrome
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HTN
Hypercholesterolemia Hypertriglyceridemia Low serum HDL Diabetes mellitus Hyperinsulinemia |
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central fat distribution
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apple
Mostly visceral fat Intra-abdominal best estimated by CT or MRI Increased cardiovascular risk (lipids, DM) deadly fat because it is more metabolically active and it is the deep fat that surrounds the organs |
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gynecoid/gluteofemoral fat distribution
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pear shaped
Mainly subcutaneous fat Lower risk of mortality |
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Adipose Endocrine Functions
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Release of free fatty acids (FFAs)
Production of adipokines (fat produces and secretes) Leptin, adiponectin, resistin Pro-coagulation Plasminogen activator inhibitor (PAI-1) (stops the breakddown of fibrin clots) Promotion of insulin resistance TNFα IL-6 (these cause insulin resistance and inflammation) |
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what is leptins role
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a saitiety hormone it has been shown that obese can be leptin resistant
determines energy balance |
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Adipose Types
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White Fat
Dominant form of adipose in adults Storage of fat for energy the main type of fat found in adults Brown Fat Abundant in newborns and hibernating animals (newborns cannot shiver therefore the brown fat generates heat) Generates body heat Present in adults in upper chest and neck\burns white fat |
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etiology of obesity
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Multi-factorial
Environmental, genetic, physiologic Increased calorie intake (portion distortion) From 1970 to 1990 ↑kcal by 200/day This translates to 1 extra lb every 17-18 days Sedentary behavior Less physical work required with jobs Less emphasis in schools, play at home “Thrifty gene” theory * use to be a survival strategy to be able to store body fat (now it is a survival disadvantage) |
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can resting metabolic rate be changed
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yes, when a person exercise they burn more calories throughout the day
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Other Weight Gain Causes
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Medical causes
Hypothyroidism Cushing’s syndrome (increase cortisol) Binge eating disorders Genetic syndromes Medication causes Diabetes medications (insulin is a growth factor) Atypical antipsychotic agents (decreased CNS effects but weight gain is substantial) Anticonvulsants |
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other wieght gain causes
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Medical causes
Hypothyroidism Cushing’s syndrome (increased cortisol) Binge eating disorders Genetic syndromes Medication causes Diabetes medications Atypical antipsychotic agents Anticonvulsants |
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what are the main organs/tissues controlling appetite
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sotmach
pancreas brain adipose tisse GIT |
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appetite
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Complex behavioral process influenced by multiple factors
Involves hypothalamus, limbic system, brainstem, hippocampus, cortex Influenced by hormones released by adipose and by GI tract (encretins are hormones secreted whe food is tasted and released by the small intestine) Influenced by large number of neurotransmitters and neuropeptides |
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appetite Controlled beyond basic hunger/satiety
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Humans eat in response to much broader stimuli
Reward, pleasure, learning, memory all involved |
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weight loss
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Losing only 5% of total body weight beneficial
Evidence of improved blood pressure Improved lipid profile Improved insulin sensitivity, glucose tolerance ~$30-$50 billion spent annually in the United States on weight loss attempt At any given time, 50% of women and 25% of men in the US are trying to lose weight |
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the best wieght loss programs incorpoarte multiple approaches being
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Dietary adjustments
Physical activity +/- Pharmacologic therapy |
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what are the 5 As of weight loss
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ask
advise assess assist arramge |
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what is the first question you should ask an obese patient in regards to weight loss
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are you comfortable with you weight?
If yes: the conversation ends there |
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what sould you advise a patient about in regards to obesity
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the risks and how it can negatively impact there health
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what is to be assessed in regards to obesity
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readiness to change
BMI diet physical ativity health risks cultural asspects enviromental/psschological eating barriers |
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assist a patinet with weight loss by
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setting realistic goals for wieght loss and how to maintain the weight loss
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when arranging asspects of weight loss
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referral and or follow up to acheive weight loss and maintain it
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at what category should an obese patient consider medications
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BMI>/= 30
or BMI >/= 27 with comorbidities |
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at what category should an obese patient consider surgery
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BMI>/= 40
or BMI >/= 35 with comorbidities |
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at what category should an obese patient consider liestyle modifications onle
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BMI>/= 25
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at which BMI should a patient avoid weight gain
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all except <18
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Nutritional Considerations
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Calorie restriction vs macronutrients
Overall restriction most important Debate as to “optimal” macronutrient balance “Portion distortion” Calorie restriction is much easier than focusing on particular nutrients in order to loose weight (because the more focused diets are harder to maintain) Ingestion of fat Both animals and humans prefer high-fat foods Fat has a desirable texture and sensory characteristics in mouth Fat enhances the flavor of other foods |
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Barriers to weight loss
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Financial
Surgery extremely expensive, limited coverage Weight loss medications rarely covered Successful programs (ie Weight Watchers) have monthly membership fees (loss with less money have a harder time lossing weight) Losing weight vs maintaining weight loss Dieters describe relative ease in losing weight Relapse to original weight occurs at very high rates (the body has a particular set point it wants to be at) |
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Motivational Interviewing
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Are you currently comfortable with the weight you are at?”
Patient needs to be committed to weight loss Provider should identify person’s motivations, outline health risks Discussions of benefits of losing weight Recognize difficulty of sustained weight loss Multifactorial approach acknowledge the amount of work the patient is undertaking figure out what is important to the patient and use ti to help them they need encouragement |
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lifestyle modifications
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Calorie Restriction
Total calories > any “type” of calorie Fat is the most calorie-dense food type skip the second portion Physical Activity Energy balance between energy in and energy out Data shows exercise key component in maintaining weight loss Behavioral Therapy (use different apporaches to change habits) |
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What are some ideas for consuming less food???
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cut the portion in half a t a resturant before eating
drink a glass of water before you eat don't go to the grocery store hungry don't getr too hungry |
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weight loss goals
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Small, gradual weight loss
Avoid the “30 lbs in 30 days” Target 5% of total body weight for goal 1-2 lbs/week (1 lb = ~3500 calories) decreasin daily calories by 500/day it is not healthy to loose weight quickly, looking for lifestyle changes that can be maintained |
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Weight loss followed by maintenance
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Lifestyle changes
Program must be something that can be followed long-term |
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bariatric surgery
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Indicated for patients with BMI ≥ 40 kg/m2
Indicated for BMI ≥ 35 kg/m2 with co-morbidity Numbers of U.S. procedures climbing rapidly 47,000 in 2001 68,000 in 2003 220,000 in 2008 Gastric Banding and Roux-en-Y most common |
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gastric banding
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Restrictive procedure
No “bypassing” of stomach or intestines Sustained weight loss not as pronounced as with malabsorptive procedures ~66 lbs at 1 year, 77 lbs at 3 years creates an artificial stomach so it restricts how much food can be eaten so the patient feels full more quickly |
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chronic disease remission and gastric banding
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~70% T2DM remission, ~80% HTN, ~80% dyslipidemia
Chronic disease remission increases as more weight is loss |
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gastric banding risks
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0.4% mortality with procedure
Risk of band slipping, eroding, failing |
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Price of gastric banding
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Expensive procedure
Not always covered by insurance $12,000-$36,000 for surgery |
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main SE of gastric banding
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N/V (the patient has to re-learn how to eat)
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Roux-en-Y Gastric Bypass
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Bypasses most of stomach and some of duodenum
Small “pouch” created as stomach Unidirectional intestine prevents bile from spilling back into pouch produces big metabolic changes it works by limiting intake by passing the stomach |
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price of Roux-en-Y Gastric Bypass
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~$25,000 for Roux-en-Y procedure
Does not include complications/extended hospital stay Cosmetic surgery sometimes done to remove “unsightly” skin this doesn't include any complications |
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T2DM remission occurs before weight loss in the Roux-en-Y Gastric Bypass
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30-35% of patients are in remission before hospital discharge, ~83% remission overall
Greatest success in younger, shorter disease duration ( so do sooner rather than later) |
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Mechanisms for Remission and gastric bypass surgery?
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Duodenum bypass theory
Suggests changes in gut hormone behavior Animal models demonstrate diabetes remission “Sleeve” procedures reinforce this theory Lower intestinal theory Nutrient-sensing L cells are hyperstimulated Increased secretion of GLP-1 (a good regulator of blood glucose) and PYY |
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Unresolved Issues- Bar. Surgery
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Gallstone formation and cholecystitis
Related to surgery and weight loss Present in ~30% of patients at 6 months Prevented with ursodiol, but poorly tolerated Food intolerance Both banding and bypass causes Significant meat and protein intolerance Vomiting can occur on weekly or even daily basis malabsorption is common because maybe only taking in 1000 calories a day |
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problems with urosdiol and gastric bypass surgery
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SE are GI and these patients are already having GI problems
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why is ursodiol givern to patients that have undergone gastric bypass surgery
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to prevent gallstone formation and cholecystitis
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Hyperinsulinemic Hypoglycemia in regards to gastric bypass surgery
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Severe hypoglycemia, usually post-prandial
Overfunction of β-cells New β-cells or overstimulated β-cells? Late onset: 1-9 years after procedure (typically 2-4) Cause debated- could be increased GLP-1 levels 145 cases as of 2008 1/3 required partial pancreatectomy (in order to get rid of some of the beta cells and reduce insulin production) Mayo clinic reports 2 new patients/month |
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Unresolved Issues- Nutrients in regards to gastric bypass surgery
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Nutrient deficiency
Iron, B12, folate, riboflavin, niacin, thiamin Calcium, vitamin D, zinc Vitamin A, vitamin C Nutrients’ absorption enhanced by gastric acid Duodenum essential for nutrient absorption Proteins, fats, carbohydrates Calcium, magnesium, trace vitamins & elements |
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what nutrients can patients be deficient in after gastric bypass surgery
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Iron, B12, folate, riboflavin, niacin, thiamin
Calcium, vitamin D, zinc Vitamin A, vitamin C Nutrients’ absorption enhanced by gastric acid can become anemic deficiencies in B1 can cause neurological problems |
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Bariatric Surgery Considerations
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Surgical professional societies want to extend coverage to all T2DM with BMI > 30 kg/m2
~18 million T2DM patients in the U.S. ~50% have a BMI > 30 kg/m2 Nutrient replacement suboptimal 36% non-compliance rate Those who comply may still be deficient 13% deficient in folate 30% deficient in B12 and iron |
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nutrient replacement maybe suboptimal after gastric bypass
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36% non-compliance rate
Those who comply may still be deficient 13% deficient in folate 30% deficient in B12 and iron these patients have to be closely monitored |
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Gastric Sleeve (Endo-Barrier)
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Gastric sleeve that lines upper duodenum
13.3 kg weight loss at 12 weeks (n=24) vs 5.5 kg weight loss in diet control (n=11) A1C reduction of >2.4% at 24 weeks (better reduction than meds provide) creates an impermeable barrier |
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Indications for Treatment of obesity with meds
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American College of Physicians (ACP) recommendations
Pharmacologic tx for BMI ≥ 30 kg/m2 BMI ≥ 27 kg/m2 with co-morbidities Diabetes, CV disease, obstructive sleep apnea |
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Ephedra / ephedrine
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CNS stimulant, appetite suppressant, thermogenic agent
FDA removed from market due to safety concerns in 2004 |
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Caffeine sources
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Listed as guarana (SR formulation), cola nut, tea extract, or mate
Decreased food intake- appetite suppressant |
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what effects does caffenine as a CAm product for obesity
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stimulant
thermogenic |
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Appetite suppressants
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5-HTP, Hoodia, St Johns Wort (like an SSRI in a sense)
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Thermogenic agents
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Bitter orange (works just like ephedran and still has CV risks), ephedra
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Digestion inhibitors
|
Barley, bean pod, blond psyllium, chitosan, glucomannan, guar gum, guggul, inulin
binds fat so does not absorb |
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Miscellaneous Cam agents for weight loss
|
7-keto-DHEA, aristolochia, calcium, cha de bugre, chromium, conjugated linoleic acid, garcinia, pyruvate, irvingia gabonensis, usnea
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|
Possibly Effective Agents for weight loss
|
Calcium
Adults/children with lower calcium intake more likely to gain weight Increasing dairy consumption seems to increase weight reduction/fat loss (~1000mg/day) Benefits not observed with supplements Conjugated linoleic acid (CLA) Fatty acid found primarily in dairy, beef Theorized efficacy by shrinking adipose tissue by inducing apoptosis of fat cells Some evidence shows decrease of body fat mass but not overall BMI reduction May cause insulin resistance- more data needed |
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Cautions with OTC Diet Aids
|
No FDA regulation
Content/purity not guaranteed No labeling regulation Increased risk of overuse “If 1 is good, 2 is better!” Dexatrim example High chance for CV risks, arrhythmias |
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Pharmacologic Agents for weight loss
|
Noradrenergic Agents (NE)
Phentermine (Fastin, Ionamin, Adipex) Diethylpropion (Tenuate) Noradrenergic/Serotonergic Agents Sibutramine (Meridia) Gastrointestinal Lipase Inhibitors Orlistat (Xenical, Alli) |
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|
what are the 2 products that are FDA approved for long term weight loss
|
sibutraime
orlistat |
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Phentermine
|
Stimulates release of NE in CNS
Differ from amphetamine due to no DA release from synapse Reduction of appetite with NE binding ~3.6kg weight loss in 6 months Phentermine shown to produce greater weight loss vs. diethylpropion FDA Approval limited to short-term use (<12 weeks) Dosed 18.75-37.5 mg/day $34.99/30 30mg capsules |
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SE phentermine
|
Headache, insomnia, irritability, palpatations, nervousness
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SE diethylpropion
|
Headache, insomnia, irritability, palpatations, nervousness
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SE fluoxetine
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Agitation, nervousness
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SE sibutramine
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Headache, insomnia, dry mouth, constipation
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SE Orlistat
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Diarrhea, flatulence, bloating, abdominal pain, dyspepsia
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what agent is more effective for weight loss phentermine or diethylpropion
|
phentermine
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when the patient stops taking phentermine what happens to their appetite
|
it increses
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|
phentermine contraindications
|
hyperthyroidism, glaucoma, advanced arteriosclerosis, moderate HTN, pulmonary HTN
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what needs to be monitored when taking phentermine
|
Monitor blood pressure, weight
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Phentermine previously combined with fenfluramine (Phen-Fen)
|
Resulted in primary pulmonary HTN and heart valve damage
Both fenfluramine and dexfenfluramine are withdrawn it was the fenfluamine that was BAD |
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Sibutramine
|
Activity primarily through 2 active metabolites on both NE and 5-HT reuptake
N-desmethyl, N-bisdesmethyl sibutramine Supresses appetite, increases satiety, increases thermogenesis ~4.45 kg weight loss at 12 months FDA approved for long-term (>12 months) management of obesity Data show weight regained once treatment is stopped |
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what biochemical risk factors are reduced while taking sibutramine
|
Reduction in TGs, TC, LDL-C, ↑HDL-C
Slight improvement in glucose control BP increases were observed (~2 mm Hg) provides the patient with better glucose control |
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contraindications of sibutramine
|
MAO-I tx or centrally-active appetite suppressants
Anorexia or bulimia nervosa History of CHF, arrhythmia, stroke |
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dose of sibutramine
|
Dosed 10-15mg qd up to 2 years
30 10mg capsules: $109.99 |
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scout trial
|
Sibutramine Cardiovascular OUTcomes
Phase 3 trial started in 2002 Almost 10,000 patients enrolled Investigating long-term use of sibutramine Increased cardiovascular risk in patients Rate of CV events 11.4% vs 10% placebo Removed from European market (1/21/10) FDA- Now contraindicated in patients with cardiovascular disease increases BPand dyslipidemia |
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orlistat
|
Reversible gastrointestinal lipase inhibitor
Inactivates hydrolyzation of dietary fat Prevents absorption of dietary fat by ~30% 2.59 kg loss at 6 mo, 2.89 kg at 12 mo Approved for long-term (>12 mo) obesity management Some evidence of LDL-C, BP and glucose improvements for long-term use blocks the breakdown of fat so it cannot be absorbed |
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SE of orlistat
|
Pronounced GI side effects
Diarrhea, flatulence, bloating, abdominal pain, dyspepsia, oily “leaky” stools Decreased fat soluble vitamin absorption (A,D,E,K) |
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Changes in eating patterns due to orlistat
|
Fat intake results in bad GI side effects
Ideally people make lower fat food choices the patients learn to make better, healthier decisions because the med makes them feel like poo the colon does adjust but is does take time take it with high fat containing meals could use fiber to decrease the SE |
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Orlistat availiability
|
Available by prescription and OTC
Rx: 120mg TID with fat-containing meals OTC: 60mg TID with fat-containing meals 90 120mg: $325.30, 90 60mg: $54.95 |
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FDA safety review of orlistat
|
Possibly implicated in liver injury
32 case reports including 6 liver failure cases, mostly (30) outside of U.S. |
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investigational drugs for weight loss
|
CB1 (cannobiod receptor)selective antagonists
Rimonabant approved 4/06 in Europe trying to block the urdge to eat, but blocking may cause nerve damage 4.8 kg weight loss at 12 months Improvements in HDL-C and TG Removed 10/08 due to psychiatric SE Currently over 30 drugs in development GLP-1 agonists Leptin agonists |
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LOSS study
|
390 volunteers, 2-year randomized controlled “pragmatic clinical trial”
200 in IMI vs 190 in UCC 187 of 390 patients completed 2 years (~50%) Protocols followed at 8 study sites 14 hours of training given to providers Monthly monitoring of sites throughout study 2 sites withdrawn Intensive group given diet, medications, and behavior treatments |
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LOss study intensive group
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Intensive intervention group- 3 phases
Phase 1= low calorie liquid diet + 10g fat (12 weeks preferred) Phase 2= Highly structured diet + behavior therapy + medication (4 months) Sibutramine preferred, orlistat & diethylpropion also dispensed Phase 3= Medications + 1 meal replacement + monthly group sessions (7-24 months) |
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LOSS study results
|
in a primary care setting patients had sustainable weight loss
there was a mulifactorial intervention * diet * drugs * behavioral changes it was found that the above can induce wieght loss in those he do nto want surgery |
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obesity summary
|
Obesity epidemic continues to increase in numbers
Modest weight loss can greatly reduce serious health risks Multifactorial causes require multifactorial treatment approach Person needs to be committed to losing weight Bariatric surgery shows strong, sustained weight loss & risk reduction but has its own risks and limitations Some OTC/herbal therapies may have efficacy but many have too high of risks for use |
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What are the major clinical issues with using or recommending CAAM?
|
drug interactions
efficacy (placebo effect) no FDA regulated no safety data |
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Where can you look to find accurate information about CAM products
|
natural medicine database
german monographs |
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traditional CAM
|
accupuncture
traditional chinese medicine homeopathy herbal medicine ayrvedic medicine osteopathy and chiropratice hypnotherapy faith healing |
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complementary CAM
|
aromatherapy
biofeedback detoxification reflexology arts therapies nutritioal medicine probiotics |
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GI conditions treated with CAAM
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Constipation/Diarrhea
IBS IBD N/V PUD |
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Hepatic conditions treated with CAAM
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Cirrhosis
Alcoholic liver disease (ALD) Viral hepatitis (hepatitis C) Ingestion of hepatotoxic substances |
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plantago
|
AKA: Psyllium seed or plantain
Up to 80% insoluble fiber Main uses = __constipation______ Dose = 7-40 g per day Take with adequate_____water___ Don’t chew or crush seeds Avoid co-administration with other drugs Some chance of allergic reaction Avoid “black” psyllium in non-commercial products (this is a pigment released if chewed or crushed and it is nephrotoxic) like a bulk forming laxitive |
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main use of plantago
|
constipation
|
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|
what is the difference between soluble and insoluble fiber
|
solube absorbs water and breaksdown and swells
insoluble doesn't breakdown in water |
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buckthorn
|
like senna
AKA: cascara, buckthorn root or bark MOA: __stimulant_________ Main Use:___constipation_____ Bacterial conversion of anthroglycosides Works on large intestine Dose = 20-30mg (Caps, Teas) Chronic use can lead to __potassium__ depletion Can increase toxicity of digoxin Avoid in pregnancy and lactation (don't want abdominal cramping) |
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chamomile
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MOA: anti-inflammatory
0.3-2% essential oils ? Inhibition of COX and lipoxygenase May have “calming” properties Uses = diarrhea, IBD, PUD, dyspepsia, “colic” Roman, German, or common Teas, capsules, tablets, flowers Dose = 1 ml 3 times per day of extract ADRs: Allergic reactions 1-2% Contraindicated in pregnancy and lactation |
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aloe vera
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Main components: gel + latex
Main Pharmacologic effects Laxative: 30% anathraquinones Antioxidant and inhibition of PGs Products Juice, capsules, softgels 100-200 mg aloe or 50 mg aloe extract taken in the evening Adverse effects Abdominal pain, cramping, potassium depletion Hypoglycemia Avoid on pregnancy and lactation |
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what componenet of aloe vera provides the GI effect
|
the latex it is a stimulant
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|
is it ok to use aloe vera in patients with a latex allergy
|
yes
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Ginger main uses
|
anti-emetic
|
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|
MOA of ginger
|
antiemetic
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|
|
evidence suggests that ginger has similar efficacy to
|
metoclopramide
it does not block D2 |
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|
can ginger be used in pregnancy
|
yes
similar to pyridoxine (B6) |
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|
what drug does ginger interact with
|
warfarin has anti-platelet effects
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|
licorice
|
Active constituents
Triterpene glycoside Glycyrrhizin (DL)→ metabolized to glycyrrhetinic (GA) DGL = De-Glycyrrhizinated Licorice May inhibit PG breakdown and decrease gastric acid secretion Similar results to cimetidine Main uses =stomach upset Dose = 200-600mg daily x 4-6 weeks May use grated roots to make tea |
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|
DGL licorice
|
does not have Glycyrrhizin (DL)→ metabolized to glycyrrhetinic (GA) which can be harmful to some patients
|
|
|
adverse effects of licorice
|
Sodium, water retention
hypokalemia BP: Avoid in CV and renal disease |
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|
drug interactions with licorice
|
May reduce antihypertensive effects: __promote Na and water retention to increase BP
DGL__may avoid this effect May inhibit CYP450 3A4 Potential for increased digoxin toxicity due to ↓ K May decrease effectiveness of warfarin |
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|
should licorice be used in pregnancy
|
avoid
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|
|
what form of licorice can be used inHTN patients
|
DGL because it prevents the increase in BP
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|
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peppermint MOA
|
relax smooth muscle
|
|
|
main use of peppermint
|
anit-spasmotic, colic and IBS
|
|
|
adverse effects of peppermint
|
heartburn
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|
|
constiuents of peppermint
|
essential oils (potent)
menthol |
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|
what enzymes may peppermint inhibit
|
May inhibit CYP 3A4 and 2C9
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|
|
MOA artichoke
|
several different components
Antiemetic Antispasmodic Cholerectic (stimulates bile to flow through the bilary system) |
|
|
uses of artichoke
|
IBS
N/V |
|
|
adverse effects of artichoke
|
Well tolerated
Avoid in pregnancy and lactation |
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|
probiotic definition
|
live microorganisms which when administered in adequate amounts confer a health benefit to the host”
400 species of bacteria in the human intestine |
|
|
how are probiotics administered
|
May be adminsitered via extracts or through food
|
|
|
common strains of probiotics
|
Lactobacillus
Bifidobacterium Streptococci Saccharomyces |
|
|
what is a prebiotic
|
the food that probiotics eat (insulin, lactolose)
take the prebiotics to stimulate the growth of our own flora |
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|
how do probitics work
|
the normal microflora and probiotics interact with the host metabolic activites and immune function and prevent colonization of opportunistic and pathogenic microorganisms
stimulate good immune health and get rid of the bad guys |
|
|
Uses for Probiotics (KNOW!!!!)
|
Helicobacter pylori eradication
Appears to possibly augment antibiotic therapy Lactobacillus Saccharomyces Antibiotic Associated Diarrhea (biggest use) Lactobacillus GG Saccharomyces boulardii (giving back what is killed off) Recurrent Clostridium difficile infection Saccharomyces boulardii Adjunctive to antibiotic therapy (metronidazole) Prevention of radiation induced diarrhea Post-op adjunctive therapy VSL #3 IBD Questionable benefit May lead to higher remission rates when used adjunctively Ulcerative colitis for patients with “pouchitis” Saccharomyces, Bifidobacterium VSL #3 IBS Possible improvement Large placebo effect Bifidobacterium, VSL #3, or Lactobacillus GG |
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|
safety of probiotics
|
Generally considered safe
Rare reports of systemic infections Mostly with Lactobacillus GG Some studies in immunocompromised that show products are safe HIV Risk may outweigh benefit if use prevents infection with more serious organisms |
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|
milk thistle
|
Uses = viral hepatitis, “hepatoprotection”, hepatotoxin ingestion
AKA: Silybum marianum Active constituent Silymarin Undergoes enterohepatic recirculation MOA: Alters the hepatocyte membrane to prevent entry of hepatotoxic substances Stimulates ribosomal synthesis via polymerase “A” Inhibits leukotriene production Inhibits TNF-α Antioxidant properties |
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|
efficacy of milk thistle
|
Lowers LFTS, but questionable for ALD and chronic hepatitis
High study dropout rates because of diarrhea |
|
|
SE of milk thistle
|
Diarrhea, allergic reactions
|
|
|
what may milk thislt inhibit
|
May inhibit CPY 2C9
|
|
|
does milk thistle decrease LFTs
|
yes it does, but is does not necessarily mean in is providing clinical benefits
|
|
|
Potentially Hepatotoxic Agents
|
Kava
Used for anxiety, ADHD, insomnia, chronic fatigue Skullcap Used for anxiety, insomnia Mistletoe Abortifacient properties Valerian Used for anxiety, insomnia |
|
|
Colonic Cleansing
|
AKA: “Colonic” or colonic irrigation
Based on “autointoxication” by undigested by products Imbalance of “bodily humors” Cleanses the bowel Benefits? Risks Water intoxication Electrolyte disturbances Perforation |
|
|
everything from the liver and pancreas drain into which duct
|
common bile duct
|
|
|
what kind of digestive organ is the pancreas primary or secondary
|
secondary
(excessory) |
|
|
are enzymes stored in active or inactive forms
|
inactive so they do not digest the organ they are stored in (if enzymes were sotred in the active form in the pancreas they would cause pancreatitis)
|
|
|
zymogen granules
|
inactive enzymes
|
|
|
aciner cells
|
secrete enzymes from the pancreas
|
|
|
pancreatic functions exocirne
|
Exocrine (Digestive)
Major Enzyme Groups release of enzymes |
|
|
major enzymes released form the pancreas
|
Proteolytic: Proteases
trypsinogen chymotrypsinogen Procarboxypeptidase Amylolytic: Amylase Also found in:_saliva__________ Lipolytic: Lipase/prophospholipase A2 |
|
|
what do the ductal cells of the pancreas release
|
bicarb and Na
|
|
|
what is the purpose of bicarb released from the pancreas
|
to neutralize the acidic chyme coming form the stomach in order to protect the enzymes so they are not degraded
|
|
|
what pH do enzymes function at
|
physiological pH
|
|
|
what is the most important enzyme released from the pancreas
|
lipases
|
|
|
when the gallstone goes into the duct what happens
|
it obstructs the flow causing an increase in pressure which leads to enzyme activation and inflammation
|
|
|
why is ursodiol prescribeb for
|
not effective for acute gallstone dissolution (6-12 mo)
it is used as a preventative after gastric by-pass surgery |
|
|
etiologies of chronic pancreatitis
|
Alcohol (70-90 % of Cases)
Usually > 10 years of heavy use Idiopathic (~20%) Various Others: genetic, autoimmune, infections, chronic duct obstruction |
|
|
funtional and srtuctural damgae in chronic pancreatitis
|
Progression to irreversible state
Pancreatic insufficiency |
|
|
alcohol and pancreatitis
|
there is a genetic component that possibly can cause alterarions in the metabolism causing oxidative stress which leads to activation of the stellate cells which then produce fibrotic molecules
|
|
|
Chronic Pancreatitis Features
|
Chronic Abdominal Pain (because of continual stimulation)
May be related to CCK Maldigestion Malabsorption Fat malabsorption leads to steatorrhea >90% loss of exocrine function Diabetes: because beta cells are dysfunctioning so give insulin weight loss: cachexia Jaundice (10%) |
|
|
maldigestion
|
cannot digest food because the enzymes are not present
|
|
|
what comes first maldigestion of malabsorption
|
maldigestion
|
|
|
fat malabsorption leads to
|
steatorrhea
|
|
|
chronic pancreatitis
|
Acute exacerbations
Complications Pseudocysts Pleural Effusions Ascites or peripheral edema Bile duct stricture Calcification Mortality 50% within 20-25 years of diagnosis |
|
|
general management of chronic pancretitis
|
Abstinence from alcohol
Nutritional support Low fat diet Small frequent meals Possibly TPN/Enteral for severe cases Pain Management Treat Malabsorption Surgery: refractory cases Management of endocrine dysfunction |
|
|
chroninc pain managment for pancreatitis
|
Analgesics
Multidisciplinary stepped approach Use same drug for as needed and scheduled narcotic analgesics if possible Recommend non-narcotic drugs to reduce narcotic utilization Pancreatic Enzymes Negative feedback inhibition of pancreas related to CCK release (want to shut off pancreas secreations) |
|
|
should a patient that has alcohol induced pancreatitis be put on APAP
|
no
|
|
|
chronic pain mangement products for chronic pancreatitis
|
Long-acting oral narcotics
Every 8-12 hour dosing Morphine (Oramorph®, MS Contin®) Oxycodone (Oxycontin®) Transdermal fentanyl patches every 3 days (Duragesic®) Short acting Acetaminophen Tramadol (Ultram®) or Ultracet® NSAIDs (ibuprofen, celecoxib, etc) Oxycodone, morphine try to keep the same drug on board so as morphine IR + morphine ER |
|
|
what is the problem with non-narcotic analgesics and chronic pancreatitis pain management
|
there are a lot of limitations
with nsaids you don't want Na and H2O retention tramadol use with caution with ETOH APAP is bad if alcoholic |
|
|
treating malabsorption and pancreatitis
|
Goals of therapy
Reduce Steatorrhea Weight gain Pain reduction Prevention/treatment of nausea Improve QOL Alcohol abstinence Non-adherence or failure of medical therapy may result in long term parenteral nutrition |
|
|
enzyme supplementation and chronic pancreatitis
|
Theory: simulate pancreatic enzyme release in relation to meals
lipase is most important determinant, so dosing is based on this component Requires mixture with food and delivery to duodenum Enzymes inactivated at pH < 4 5% of maximal pancreatic enzyme output required |
|
|
should pancreatic supplemental enzymes be given with or without food
|
with to stimulate the endogenous process
especially with high fat meals so the fat can be digested and therefore prevent steatorrhea |
|
|
pancreatic enzyme preperations
|
All are porcine based products
Also referred to as pancrelipase (includes 3 enzyems) Enteric coated (preferred), because it protects it from gastric acid) (Mini) Microspheres or microtablets Each sphere or tablet is enteric coated Designed to release at pH of 5.5-6 Do NOT crush, some products may be opened Superior weight gain seen clinically Need for less enzymes overall |
|
|
can a person with pork allergies take pancreas enzyme supplements
|
no
|
|
|
what pH are the pancreas enzyme supplement active
|
5.5-6
|
|
|
past regualtion of pancreatic enzymes
|
1968 FDA-DRUG EFFICACY STUDY IMPLEMENTATION (DESI)
implemented recommendations of the National Academy of Sciences Of 3443 products tested only 68% were found to be effective Pre-DESI Drugs Generally recognized as safe due to many years of public use Have not undergone efficacy studies |
|
|
are all pancreatic enzymes equal
|
prior to 2010 no
Differences existed in: Enzyme content Formulation Dissolution Enzyme products were not traditionally FDA approved Products were not considered interchangeable |
|
|
decoding the pancreatic enzyme label
|
MS or MT = microsphere or microtablet
Number (6-20): refers to the lipase content of each tablet/capsule in increments of 1000 units Need to look at label for: Amylase and Protease |
|
|
prior to 2010 were pancreatic enzymes AB rated
|
no, so there were problems with switching between products
|
|
|
what are the regulations on pancreatic enzymes now
|
Bethesda, Md; April 27, 2004
Today the FDA initiated a requirement that all manufacturers of pancreatic enzyme replacements obtain FDA approval for their products within the next 4 years. Manufacturers need to file an NDA now have to be FDA approved |
|
|
common pancreatic enzyme preperation
|
FDA Approved Products as of today
Creon® 6,000, 12,000, 24,000 Enteric coated minimicrospheres ZENPEP® 5,000/10,000/15,000/20,000 Enteric coated beads Uncoated Products (Viokase®) Enteric coated microspheres (Ultrase ®) Enteric coated microtablet (Ultrase MT® , Pancrease MT®) Enteric coated microspheres with sodium bicarbonate buffer (Pancrecarb MS ®) |
|
|
decoding the label of pancreatic enzymes 2010
|
MS or MT = may or may not specify
Number (6,000-20,000): refers to the lipase content of each tablet/capsule Need to look at label for: Amylase and Protease Both are ~ 3-5 times lipase content No more generic products |
|
|
pancreatic enzyme supplementation dosing
|
Empiric: ~30,000 units lipase per meal
Weight based: 500-1000 U lipase/kg/meal Max = 2500 u/kg/meal or 10,000 u/kg/day ~ ½ dose for snacks Give enzymes immediately before or during meals Consider lipase content to reduce number of tabs/caps per meal |
|
|
pancreatic enzyme SE
|
GI: nausea/cramping
Hyperuricosuria, hyperuricemia Kidney stones Impaired folate absorption Possible drug interactions with bicarbonate Fibrosing colonopathy Due to enzyme overdosing Results in scarring and strictures Reason for 10,000 u/kg/day max and no products with > 20,000 units lipase |
|
|
guidelines for titrating the dose of pancreatic enzymes
|
No set guidelines for titration of doses
Titrate by capsule/tablet strength Use steatorrhea and weight gain as clinical markers of efficacy |
|
|
if pancreatic enzymes seem to be ineffective what can be done
|
Consider adding antisecretory drug if enzymes ineffective
Check adherence and proper dosing first Start with H2RA Advance to PPI if necessary pH may not be high enough in duodenum |
