Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
158 Cards in this Set
- Front
- Back
|
What is Gastroesophageal Reflux Disease (GERD)?
|
the movement of acid from the stomach into the esophagus
|
|
|
What causes GERD?
|
caused by a defective lower esophageal sphincter (LES) pressure
|
|
|
GERD might lead to what four conditions?
|
may lead to esophagitis, strictures, hemorrhage, and Barrett's esophagus.
Backwash of acid will affect cells --> precancerous states |
|
|
What are the typical s/s of GERD?
|
heartburn, regurgitation, acidic taste in mouth
|
|
|
What are the atypical s/s of GERD?
|
chronic cough, asthma-like symptoms, sore throat, laryngitis/hoarseness, non-cardiac chest pain
|
|
|
How do you diagnose GERD?
|
Review of symptoms, endoscopy, & pH testing
Diagnosis is confirmed by trial of medication |
|
|
How does endoscopy diagnose GERD?
|
visualization & grading of the esophageal mucosa
|
|
|
Why is pH testing used to diagnose GERD?
|
relationship between symptoms & abnormal acid exposure
Not as invasive as endoscopy |
|
|
What is Peptic Ulcer Disease (PUD)?
What are complications of PUD? |
Imbalance between aggressive factors & defensive factors
May lead to hemorrhage/GI bleed |
|
|
What three factors are significant in the development of PUD?
|
Bacterial GI infection
NSAID ingestion Cigarette smoking |
|
|
What are the three ways to diagnose PUD?
|
S/S epigastric pain
Endoscopy H. Pylori testing |
|
|
What are the two types of PUD & their distinctive symptoms?
What are the s/s they hold in common? |
Duodenal ulcer - epigastric pain that often occurs 1-3 hours following a meal & may be relieved by eating. Possibly worse at night.
Gastric ulcer - epigastric pain often made worse by eating Common s/s: heartburn, belching, bloated feeling, nausea, anorexia |
|
|
How does endoscopy diagnose PUD?
|
Visualization of duodenal/gastric mucosa
|
|
|
What are the six types of H. Pylori testing?
Which one is the test of choice & why? |
Histology, rapid urea test, culture, serological, urea breath test, stool antigen test.
Urea breath test - it is cheap & quick |
|
|
What are five non pharmacological therapies for PUD & GERD?
|
Dietary
Weight reduction Avoid tight fitting clothes Reduce/discontinue nicotine use Elevate the head of the bed (8-10") Avoid medications that affect LES |
|
|
What are dietary suggestions for the treatment of PUD & GERD?
|
Avoid aggravating foods/beverages (spicy, acidic)
Reduce fat intake & portion size (esp GERD) Remain upright following meals & avoid eating 3 hours prior to bedtime (esp GERD) |
|
|
What are the 7 types of PUD & GERD Drugs?
|
Antacids
Antacids + Alginic Acid Histamine2-Receptor Antagonists Proton-Pump Inhibitors Mucosal Protectants Prostaglandins Prokinetic Agents |
|
|
PUD & GERD Drugs: Antacids
Agents? |
Various OTC agents:
aluminum hydroxide (AlternaGEL, Amphojel) calcium carbonate (TUMS) magnesium hydroxide (Milk of Magnesia) magnesium hydroxide & aluminum hydroxide (Maalox) mag hydroxide & alum hydroxide w/simethicone (Mylanta, Maalox Plus) magaldrate (Riopan) sodium bicarbonate (Alka-Seltzer) |
|
|
PUD & GERD Drugs: Antacids
Indications? |
Short-term/intermittent relief of heartburn. Pts will often use OTCs & seek help if it doesn't work.
NOT appropriate for healing of established esophageal or gastric erosions |
|
|
PUD & GERD Drugs: Antacids
MOA? |
neutralizes acid & raises intragastric pH
Very rapid acting |
|
|
PUD & GERD Drugs: Antacids
Adverse Effects? |
constipation, diarrhea, acid-base disturbances
Renal impairment: avoid alum & mag products Prevents absorption of other drugs |
|
|
PUD & GERD Drugs: Antacid + Alginic Acid
Agents? |
Various OTC agents available
Gaviscon |
|
|
PUD & GERD Drugs: Antacid + Alginic Acid
Indications? |
Short-term/intermittent relief of heartburn
NOT appropriate for healing of established esophageal erosions |
|
|
PUD & GERD Drugs: Antacid + Alginic Acid
MOA? |
forms a highly viscous solution that floats on the surface of the gastric contents to act as a barrier to reflux
Very rapid acting, requires frequent dosing Does NOT enhance LES pressure NOT a potent neutralizing agent, less efficacious than antacid alone |
|
|
PUD & GERD Drugs: Antacid + Alginic Acid
Adverse Effects? |
nausea, constipation, diarrhea
Prevents absorption of other drugs |
|
|
PUD & GERD Drugs: Histamine2-receptor Antagonists
Agents? |
famotidine (Pepcid)
ranitidine (Zantac) cimetidine (Tagamet) nizatidine (Axid) - oral only All available OTC at half dosage |
|
|
PUD & GERD Drugs: Histamine2-receptor Antagonists
Indications? |
Heartburn, PUD, GERD, stress ulcer prophylaxis
Renal dysfunction requires dose adjustment |
|
|
PUD & GERD Drugs: Histamine2-receptor Antagonists
MOA? |
inhibition of gastric acid secretion
less effective than PPI therapy in healing erosive esophagitis |
|
|
PUD & GERD Drugs: Histamine2-receptor Antagonists
Adverse Effects? |
headache, dizziness, fatigue, somnolence and confusion, gynecomastia & thrombocytopenia (w/cimetidine)
May affect absorption of other drugs CNS SE can occur Several drug-drug interactions (w/cimetidine) |
|
|
PUD & GERD Drugs: Proton-Pump Inhibitors
Agents? |
omeprazole (Prilosec)
lansoprazole (Prevacid) rabeprazole (Aciphex) pantoprazole (Protonix) esomeprazole (Nexium) dexlansoprazole (Dexilant) |
|
|
PUD & GERD Drugs: Proton-Pump Inhibitors
Indications? |
PUD, GERD, Zollinger-Ellison syndrome
Superior to H2-receptor antagonists |
|
|
PUD & GERD Drugs: Proton-Pump Inhibitors
MOA? |
inhibition of gastric acid secretion
Slow onset (72 hours); but long duration of action Administer 30 minutes prior to meal |
|
|
PUD & GERD Drugs: Proton-Pump Inhibitors
Adverse Effects? |
headache, diarrhea, constipation, abdominal pain, nausea, but generally well tolerated
Rare: interstitial nephritis Potential increased risk of C. diff w/ prolonged use Several drug interactions Metabolized in liver, so no adjustment for renal dysfunction |
|
|
PUD & GERD Drugs: Mucosal Protectants
Agents? |
sucralfate (Carafate)
|
|
|
PUD & GERD Drugs: Mucosal Protectants
Indications? |
PUD, stress ulcer prophylaxis
NOT for acute symptoms, adjunct drug |
|
|
PUD & GERD Drugs: Mucosal Protectants
MOA? |
forms a viscous adhesive that promotes ulcer healing, needs acidic environment.
Relieves symptoms only, does NOT effectively heal ulcers |
|
|
PUD & GERD Drugs: Mucosal Protectants
Adverse Effects? |
constipation, nausea, dry mouth, metallic taste
Inhibits absorption of drugs Requires QID dosing (big pill or liquid) Accumulates in renal insufficiency |
|
|
PUD & GERD Drugs: Prostaglandins
Agents? |
Misoprostol (Cytotec)
|
|
|
PUD & GERD Drugs: Prostaglandins
Indications? |
Prophylaxis for NSAID induced gastric ulcer
Effectively prevents gastric ulcers in pts receiving NSAIDs |
|
|
PUD & GERD Drugs: Prostaglandins
MOA? |
Moderately inhibits acid secretion & enhances production of mucus & bicarbonate (mucosal defense)
|
|
|
PUD & GERD Drugs: Prostaglandins
Adverse Effects? |
Diarrhea, abdominal cramping, nausea, flatulence, headache
Abortifacient, confirm adequate contraception in women of childbearing age. Requires QID dosing |
|
|
PUD & GERD Drugs: Prokinetic Agents
Agents? |
metoclopramide (Reglan)
|
|
|
PUD & GERD Drugs: Prokinetic Agents
Indications? |
Adjunct therapy for GERD, refractory w/gastric paresis
Provides symptomatic improvement for some patients with GERD |
|
|
PUD & GERD Drugs: Prokinetic Agents
MOA? |
Increases LES pressure & accelerates gastric emptying
|
|
|
PUD & GERD Drugs: Prokinetic Agents
Adverse Effects? |
Dizziness, fatigue, somnolence, drowsiness, tardive dyskinesia, hyperprolactinemia, cardiac dysrhthmia, neuroleptic malignant syndrome
Adjust dose in renal impairment Multiple drug interactions |
|
|
What is the most common cause of Gastrointestinal bleeding?
What is the most frequent symptom? |
Primarily induced by NSAID use
Most frequent symptom is hematemesis or "coffee-ground" emesis |
|
|
What are the three ways to manage GI bleeding?
What is drug of choice? What drugs are NOT recommended |
Volume resuscitation & hemodynamic stabilization
Endoscopic intervention For confirmed ulcer: IV proton-pump inhibitors (continuous infusion vs IVPB) - severe bleed IV PPI is drug of choice. H2RA or somatostatin/octreotide NOT recommended |
|
|
In outpatient setting,
What would you diagnose & prescribe to a pt complaining of "gnawing epigastric pain?" If there is no known ulcer/bleeding, which drug would you NOT prescribe & why? |
Dx: Ulcer
Rx: H2RA PPIs, because they will become dependent d/t rebound reflux. |
|
|
What is a stress related injury?
|
Superficial diffuse upper GI ulceration
|
|
|
What a stress ulcer & possible complications?
|
deeper mucosal ulceration
may lead to bleeding & hemodynamic compromise |
|
|
What are three contributing factors for stress ulcers?
|
Hypoperfusion of the GI tract
Alterations in gastric motility Loss of defense mechanisms: mucosal/bicarbonate layer, prostaglandins |
|
|
What are the pharmacologic strategies for stress ulcer prophylaxis?
|
Antacids
Sucralfate Histamine2-receptor antagonists Proton-Pump inhibitors NOT routinely recommended in non-intensive care unit settings. |
|
|
H. pylori eradication therapy
Why do we have to use combination drug therapy? What are the types of drug in the combination? |
Combination drug therapy to achieve adequate rates of eradication & to decrease failures due to antibiotic resistance.
Combination therapy consists of two antibiotics plus either a proton pump inhibitor or bismuth. |
|
|
H. pylori eradication therapy
What types of proton pump inhibitors are used & how ofhen are they given? |
Omeprazole 20, rabeprazole 20, lansoprazole 30, pantoprazole 40 & esmoprazole 40
All PPIs are given BID, except for esmeprazole, which is given once daily. |
|
|
H. pylori eradication therapy
What are the three types of PPI combination therapies? |
MOC (Metronidazole + Omeprazole + Clarithromycin)
AOC (Amoxicillin + Omeprazole + Clarithromycin) MOA (Metronidazole + Omeprazole + Clarithromycin) |
|
|
H. pylori eradication therapy
MOC? |
Metronidazole (Flagyl) (if allergic to PCN) 500mg BID WITH meals,
Omeprazole 20mg (or PPI of choice) BID BEFORE meals, & Clarithromycin (Biaxin) 500mg BID WITH meals for 7 days Instruct patient that Flagyl should not be taken with alcohol or vinegar. |
|
|
H. pylori eradication therapy
AOC? |
Amoxicillin (Amoxil) 1g BID WITH meals, Omeprazole 20mg (or PPI of choice) BID BEFORE meals
Clarithromycin (Biaxin) 500mg BID WITH meals for 7 days Preferred for those whose disease is resistant to metronidazole. |
|
|
H. pylori eradication therapy
MOA? |
Metronidazole 500mg BID WITH meals,
Omeprazole 20mg (or PPI of choice) BID BEFORE meals Amoxicillin 1mg BID WITH meals, For 7 to 14 days |
|
|
H. pylori eradication therapy
Why are PPI combination therapies preferable to Bismuth regimens? |
Regimens that use bismuth compounds require 4 times a day dosing and have a greater number of adverse effects than the PPI regimens.
|
|
|
H. pylori eradication therapy
BMT & BMT+O |
BMT: Bismuth subsalicylate 2 tabs QID + metronidazole 250mg QID + tetracycline (Tetracyn) 500mg QID.
All pills are taken with meals & at bedtime. BMT+O: Same as above, plus omeprazole 20mg BID before meals for 7 days |
|
|
H. pylori eradication therapy
What is the 5-day treatment? What are the benefits & who can use it? |
Three antibiotics (amoxicillin 1g BID, clarithromycin 250mg BID & metronidazole 400mg BID), plus either lansoprazole 30mg BID or ranitidine 300mg BID.
This is an effective, cost-saving option for patients older than 55 years who have no history of PUD. |
|
|
H. pylori eradication therapy
For how long is antiulcer therapy recommended after treatment regimens & why? What drugs are given & for how long after treatment? |
Antiulcer therapy is recommended 3 to 7 weeks after treatment regimens described previously; to ensure symptom release and ulcer healing.
Duodenal ulcers: Omeprazole 40mg daily or lansoprazole 30mg daily should be continued for 7 additional weeks. H2 blockers or sucralfate can be given for 6 to 8 weeks. |
|
|
H. pylori eradication therapy
What is the suggested follow up for duodenal ulcers? |
No further evaluation is necessary if the patient is symptom free after 8 weeks of therapy.
|
|
|
H. pylori eradication therapy
What is the suggested follow up for gastric ulcers? |
Repeat endoscopy should be performed 4 to 6 weeks after therapy is completed.
Completely healed ulcers require no follow up? |
|
|
H. pylori eradication therapy
What is the suggested follow-up for partially healed gastric ulcers? |
If greater than 50% healing occurs & findings are negative for carcinoma, 6 weeks of additional therapy is required, followed by reevaluation.
If healing is greater than 59% but findings are positive for carcinoma, surgical intervention is required. Less than 50% healing requires surgery. |
|
|
H. pylori eradication therapy
What about surgery for duodenal ulcers or gastric ulcers? |
Surgery for refractory ulcers is rarely performed today.
Selective vagotomy for duodenal ulcer or ulcer removal with antrectomy or Hemigastrectomy without vagotomy for gastric ulcers. |
|
|
Constipation
What are the four major causes of constipation? |
Lack of exercise
Insufficient fluid intake Medications that decrease motility Foods |
|
|
Constipation
What are the medications that decrease motility? |
Opioids
Anticholinergics Antihistamines Others |
|
|
Constipation
Foods that may cause constipation? |
Alcoholic beverages
Refined white flour products Dairy products Chocolates Others - some foods will affect people in different ways |
|
|
Constipation
What is the difference between laxatives & cathartics? |
Laxatives promote defecation.
Cathartics are stronger agents than laxatives. |
|
|
Constipation
Six types of Laxatives & Cathartics? |
Bulk-Forming
Saline & Osmotic Diuretics Stimulants Stool Softeners / Surfactants Herbal Agents Miscellaneous Agents |
|
|
Constipation: Bulk-Forming L&C
Agents? |
Calcium Polycarbophil (FiberCon, Fiberall, Mitrolan)
Methylcellulose (Citrucel) Psyllium Mucilloid (Metamucil, Naturacil, others) |
|
|
Constipation: Bulk-Forming L&C
MOA? |
Absorbs H2O, thus adding size to the fecal mass; may be taken on a regular basis without ill effects.
|
|
|
Contipation: Saline & Osmotic diuretics
Agents? |
Magnesium Hydroxide (Milk of Magnesia)
Polyethylene Glycol Sodium (Miralax) |
|
|
Contipation: Saline & Osmotic diuretics
MOA? |
Not absorbed in the intestines; pull H2O into the fecal mass to create a more watery stool.
|
|
|
Contipation: Saline & Osmotic diuretics
How quickly do they work? Can they be used regularly? |
Produce results in 1-6 hours
Should not be used regularly for fluid & electrolyte danger. |
|
|
Constipation: Stimulants
Agents? |
Bisacodyl (Dulcolax)
Castor Oil (Emulsoil, Neoloid, Purge) |
|
|
Contipation: Stimulants
MOA? |
Irritate the bowel to increase peristalsis
|
|
|
Constipation: Stimulants
Adverse Effects? Can they be used routinely? |
May cause laxative dependence, abdominal cramping, and fluid & electrolyte depletion.
Not for routine use |
|
|
Constipation: Stool Softeners / Surfactants
Agents? |
Docusate (Surfak, Dialose, Colace, others)
|
|
|
Constipation: Stool Softeners / Surfactants
MOA? |
Cause more H2O & fat to be absorbed into stools
|
|
|
Constipation: Stool Softeners / Surfactants
Indications? Contraindications w/ herbal preps? |
Ineffective at treating constipation, but are most ofetn used to prevent it, especially in patients who have undergone surgery.
Should not be given to patients taking herbal preps = increased absorption --> increase risk of liver toxicity |
|
|
Constipation: Herbal Agents
Agents? MOA? |
Senna (Senokot, Ex-Lax)
OTC natural products Senna is most commonly used - a potent herb that irritates the bowel & increases peristalsis |
|
|
Constipation
Miscellaneous Agents? |
Mineral Oil
Lubiprostone (Amitza) - approved for chronic idiopathic constipation |
|
|
Constipation: Miscellaneous Agents
MOA & Adverse Effects for Mineral Oil |
Lubricates the stool & colon mucosa
May interfere with the absorption of fat-soluble vitamins |
|
|
Diarrhea
Pathophysiology Review |
When the large intestine does not reabsorb enough water from fecal --> watery stools
|
|
|
Diarrhea
Causes? |
Medications, infections, viruses & substances (e.g. lactulose)
Antibiotics kill the normal flora of the gut --> diarrhea (overgrowth of pathologic organisms) |
|
|
Diarrhea
Primary goal of treatment? |
Assess & treat the underlying cause of diarrhea
|
|
|
Antidiarrheals: Opioids
Agents? |
Difenoxin with Atropine (Motofen)
Diphenoxylate with Atropine (Lomotil) Loperamide (Imodium) Camphorated Opium Tincture (Paregoric) - not been found to be safe & effective, product labeling not approved by the FDA |
|
|
Antidiarrheals: Opioids
MOA? |
Slows peristalsis in the colon
|
|
|
Antidiarrheals: Opioids
Most common opioid antidiarrheal? |
Lomotil = codeine + diphenoxylate with atropine
|
|
|
Antidiarrheals: Opioids
What is Loperamide (Imodium)? |
An analog of meperidine with no narcotic effects
|
|
|
Antidiarrheals: Opioids
Issues with infectious diseases cause? |
If there is an infectious disease cause, antibiotics or antiparasitics are warranted.
Need to be careful with antimotility drugs --> may lead to toxic megacolon |
|
|
Antidiarrheals: Miscellaneous agents
Two Misc Agents? |
Bismuth Salts & Lactobacillus
|
|
|
Antidiarrheals: Miscellaneous agents
MOA of Bismuth Salts? |
Pepto-Bismol binds & absorbs toxins
|
|
|
Antidiarrheals: Miscellaneous agents
MOA of Lactobacillus? |
Normal inhabitant of gut & vagina, may correct GI flora following diarrhea (yogurt)
|
|
|
In Outpatient Setting,
Most common cause of diarrhea? Suggested treatment < 72 hours? What test should be done > 72 hours? Inpatient setting, what test should be done? |
Most likely viral cause
"Puke or Poop it out" - drink fluids > 72hrs - stool sample to test for ova & parasites Inpatient - test for C. diff. |
|
|
Inflammatory Bowel Disease (IBD)
What are the two major disorders of IBD? Who does it affect? |
Ulcerative colitis (UC) & Crohn's Disease (CD)
There has been an increase of crossover patients > 1 million Americans have IBD Both men & women are affected equally |
|
|
IBD: Etiology
Infection factors theory |
Microflora of GI tract may activate inflammatory process
|
|
|
IBD: Etiology
Immunologic mechanisms |
Abnormal regulation fo the immune response --> the body is attacking it's own mucosa
Most popular cause of IBD |
|
|
IBD: Etiology
Genetic factors |
1st degree relatives have a 13-fold increase in risk
|
|
|
IBD: Etiology
Psychological factors |
Mental health changes correlate with remissions & exacerbations
|
|
|
IBD: Etiology
Diet & smoking |
Dietary habits do not appear to play a role in the development of IBD
Smoking plans an important but contrasting role in UC (+) & CD (-) |
|
|
CD vs UC
Common s/s? |
Fever
Abdominal pain Diarrhea Rectal bleeding Weight loss |
|
|
CD vs UC
S/S typical of CD only? |
Occurs anywhere mouth to anus
Ulcerations extend to submucosa or deeper Patchy inflammation Fistula/performation/strictures |
|
|
CD vs UC
S/S typical of UC only? |
Primarily confined to rectum & colon
Crypt abscesses Superficial ulcerations Continuous inflammation Toxic megacolon |
|
|
CD vs UC
Diagnosis of Crohn's Disease? |
No one conclusive diagnostic test.
Pt's medical history & physical exam Certain blood & stool tests are performed. Visualization of the small intestine, colon & the lining of rectum & lower bowel |
|
|
CD vs UC
Diagnosis of Ulcerative Colitis? |
Symptoms
Certain blood & stool tests are performed to r/o infection Visual examination of the lining of the rectum & lower color or the entire colon Small, painless biopsies Barium enema X-ray of the colon |
|
|
IBD: Nonpharmacologic Therapy
Nutritional Support |
Eliminate foods that exacerbate symptoms
Maintain adequate hydration Vitamin & mineral supplementation Fish oil supplementation (?) Parenteral nutrition / complete bowel rest |
|
|
IBD: Nonpharmacologic Therapy
Surgery |
Curative for UC, but not for CD
Resection of segments of the affected intestine Correction of complications (fistulas) or drainage of abscesses |
|
|
IBD: Pharmacologic Therapy
Types of Medications? |
Aminosalicylates (DOC - acute & maintenance)
Corticosteroids (acute only) Immunomodulatores (acute & maintenance) Anti-tumor Necrosis Factor Agents (acute & maintenance) Antibiotics (CD second line) Nicotine (UC second line) |
|
|
IBD: Aminosalicylates
Agents? |
sulfasalazine (Azulfadine)
mesalamine (Asacol, Pentasa) balsalazide (Colazal) olsalazine (Dipentum) |
|
|
IBD: Aminosalicylates
Indications? |
Induction & maintenance of remission
Adjust dose in renal impairment |
|
|
IBD: Aminosalicylates
MOA? Administration? |
Topical anti-inflammatory effect
Oral, rectal (enema, suppository) |
|
|
IBD: Aminosalicylates
Adverse Effects? |
nausea, vomiting, headache, hypersensitivity (sulfasalazine)
Assess for aspirin allergy |
|
|
IBD: Corticosteroids
Agents? |
prednisone (Deltasone)
methylprednisolone (Solu-Medrol) budesonide (Entoort) hydrocortisone |
|
|
IBD: Corticosteroids
Indications? |
Induction of remission
No role for maintenance therapy |
|
|
IBD: Corticosteroids
MOA? Administration? |
Systemic anti-inflammatory
Works quickly to suppress flares oral, IV & rectal (enema, suppository) |
|
|
IBD: Corticosteroids
Adverse Effects? |
nausea, vomiting, weight gain, water retention, osteoporosis, hyperglycemia
Need to taper dose (over 6-12 mod) after remission is achieved |
|
|
IBD: Immunomodulators
Agents? |
6-mercaptopurine (Purinethol)
azathioprine (Imuran) cyclosporine (Neoral) methotrexate (Trexall) - worst SE |
|
|
IBD: Immunomodulators
Indications? |
maintenance of remission; acute flares unresponsive to steroids
"Steroid sparing agents |
|
|
IBD: Immunomodulators
MOA? Administration? |
Inhibits immune response
Oral, IV |
|
|
IBD: Immunomodulators
Adverse effects? |
nausea, pancreatitis, bone marrow suppression, hepatotoxicity
Several drug interactions Need to monitor drug levels (cyclosporine) |
|
|
IBD: Anti-Tumor Necrosis Factor Agents
Agents? |
infliximab (Remicade)
adalimumab (Humira) certolizumab (Cimzia) |
|
|
IBD: Anti-Tumor Necrosis Factor Agents
Indications? |
induction & maintenance of remission patients with Crohn's Disease
Very costly $$$ |
|
|
IBD: Anti-Tumor Necrosis Factor Agents
MOA? Administration? |
neutralizes tumor necrosis factor (TNF) & alters immune response
IV infusion or SQ |
|
|
IBD: Anti-Tumor Necrosis Factor Agents
Adverse Effects? |
fever, chills, pruritis, urticaria, chest pain, hypotension, infection, hypersensitivity
PPD prior to therapy to rule out TB |
|
|
IBD: Antibiotics
Agents? |
metronidazole (Flagyl)
ciprofloxacin (Cipro) |
|
|
IBD: Antibiotics
Indications? |
Crohn's disease (generally second line)
No benefit for UC patients |
|
|
IBD: Antibiotics
MOA? |
Bacterial flora may contribute to the pathogenesis of inflammatory bowel disease
|
|
|
IBD: Antibiotics
Adverse Effects? |
diarrhea, photosensitivity, disulfiram reaction (metronidazole)
Many drug-drug & drug-food interactions Resistance? |
|
|
IBD: Nicotine
Agents? |
Nicotine transdermal patch
|
|
|
IBD: Nicotine
Indications? |
Ulcerative colitis (generally second line)
May be beneficial for the treatment of active UC, but ineffective as maintenance therapy No role in CD patients, worsens CD |
|
|
IBD: Nicotine
MOA? |
unknown; affect smooth muscle in colon (?)
more controlled trials are needed |
|
|
IBD: Nicotine
Adverse Effects? |
skin irritation (erythema, pruritus, edema, rash), tachycardia, HA, insomnia, nervousness
|
|
|
IBD: Adjunct Therapy
Management of Symptoms of IBD |
Very important to pt's quality of life
Antidiarrheals Antispasmodics |
|
|
IBD: Adjunct Therapy
Antidiarrheal Agents |
loperamide (Imodium)
diphenoxylate-atropine (Lomotil) Use with caution in severe disease; may precipitate toxic megacolon |
|
|
IBD: Adjunct Therapy
Antispasmodics |
dicyclomine (Bentyl)
propantheline (Pro-Banthine) hyoscyamine (Levsin) cholestyramine (Questran) |
|
|
Irritable Bowel Syndrome (IBS)
What % of adults have IBS? Malignant or benign? What exacerbates IBS? More common in men or women? |
One of the most common GI disorders encountered in clinical practice
Affects as many as 20% of adults worldwide Benign, but is chronic & recurring in nature Exacerbated by psychological stress More common in women |
|
|
What are the three classifications of IBS?
|
Constipation predominant disease (IBS-C)
Diarrhea predominant disease (IBS-D) Mixed pattern disease (IBS-M) |
|
|
Treatment of IBS-C?
|
Dietary modification
Laxatives (MOM, MiraLAX, bisacodyl, lactulose) |
|
|
Treatment of IBS-D?
|
Avoidance of certain food products (caffeine, alcohol), r/o lactose intolerance
Antidiarrheals (loperamide, cholestyramine) |
|
|
Treatment of Abdominal pain related to IBS?
|
Antispasmodics (dicyclomine, hyoscyamine)
Antidepressants |
|
|
IBS Drugs: Lubiprostone (Amitiza)
Indication? |
IBS-C
Approved for use in women; efficacy in men not confirmed/established. Reserved for patients who have failed other therapy |
|
|
IBS Drugs: Lubiprostone (Amitiza)
MOA? |
Enhances intestinal fluid secretion & acts as a laxative
|
|
|
IBS Drugs: Lubiprostone (Amitiza)
Adverse Effects? |
abdominal distention, HA, abdominal pain, diarrhea, flatulence, nausea
GI SE are a main deterrent |
|
|
IBS Drugs: Alosetron (Lotronex)
Indication? |
IBS-D
Only for women with severe diarrhea predominant IBS failing more conventional therapy |
|
|
IBS Drugs: Alosetron (Lotronex)
MOA? |
Serotonin receptor antagonist, blunts/reduces the hyperactivity of the GI tract
|
|
|
IBS Drugs: Alosetron (Lotronex)
Adverse effects? |
constipation, nausea & GI discomfort, abdominal pain, ischemic colitis
|
|
|
IBS Drugs: Alosetron (Lotronex)
Special concerns? |
D/t risk of ischemic colitis, was pulled from market.
In June 2002, US FDA approved supplemental NDA that allows marketing with restrictions REMS program |
|
|
IBS Drugs: Antidepressants
Agents? |
SSRIs & TCAs
amitriptyline (Elavil) desipramine (Norpramin) citalopram (Celexa) escitalopram (Lexapro) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) |
|
|
IBS Drugs: Antidepressants
Indications? |
Improve abdominal pain & global symptoms of IBS
SSRI use is more controversial d/t lacks evidence Best used when pain is the predominant symptom |
|
|
IBS Drugs: Antidepressants
MOA? Onset of action? |
analgesic properties (all)
slow GI transit time (TCAs) increase GI transit time (SSRIs) 4 weeks |
|
|
IBS Drugs: Antidepressants
Adverse Effects? |
anticholinergic effects, sedation, insomnia, orthostasis, HA, sexual dysfunction, somnolence
|
|
|
IBS Drugs: Antispasmodics
Agents? |
dicyclomine (Bentyl)
hyoscyamine (Levsin) |
|
|
IBS Drugs: Antispasmodics
Indications? |
Improve abdominal pain or bloating of IBS
Can be used for IBS-C, IBS-D, IBS-M Experts advocate use on PRN basis rather than continuous dosing |
|
|
IBS Drugs: Antispasmodics
MOA? |
smooth muscle relaxation
|
|
|
IBS Drugs: Antispasmodics
Adverse Effects? |
dry mouth, flushing, nausea, vomiting, tachycardia, urinary retention, dizziness, sedation, blurred vision
|
