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193 Cards in this Set

  • Front
  • Back
what is nausea?
the inclination to vomit
what is vomiting?
expulsion of refluxed gastric contents from the mouth
define retching?
labored movement of abdominal and thoractic muscles before vomiting.
what are the GI mechanisms leading to NV?
-peptic ulcer disease
-gastric cancer
-pancreatic disease
what are the neurologic processess that cause NV?
-midline cerebellar hemorrhage
-increase ICP
-migraine headaches
-vestibular disorders
-head trauma
list the motility disorders to cause NV?
-gastroparesis
-IBS
-postgastric surgery
-anorexia
what are the 3 metabolic disorders to cause NV?
-Diabetes, DKA
-addison's disease
-renal disease
list the intra-abdominal emergencies that have caused NV
1. intestinal obstruction
2. acute pancreatitis
3. actue cholecystitis
4. acute viral hepatitis
5. acute pyelonephritis
Self induced and anticipatory NV are considered ___ causes of NV?
psychogenic
what are the pathogens for acute gastroenteritis?
-viral
-salmonellosis
-shigellosis
-enterotoxins
What are the therapies know to cause NV?
-chemo
-radiation
-theophylline tox
-anticonvulsants
-opiates
-dig tox
-antibiotics
-amphotericin
what are the cardiovascular disorders known to cause NV?
-AMI
-CHF
-shock and circulatory collapse
whta are the miscellaneous causes of NV?
-pregnancy
-noxious odor
-operative procedures
-any swallowed irritant
the vomiting center or ___ center is located int he nucleus __ __ of the __
emetic; tractus solitaries; medulla
what does the vomiting center contain?
-histamine
-acetylcholine
-serotonin receptors
how does the VC coordinate the act of vomiting?
Stimulates the

-salivary center
-vasomotor center
-respiratory center
-cranial nerves
the VC can be activated by what signals from the body?
1. Visceral afferents (GI tract)
2. Chemoreceptors trigger zone
3. vestibular system
4. limbic system
5. midbrain ICP reveptors
the chemoreceptor trigger zone is located in the area ___ of the ___
postrema; medulla
the CTZ contains dopamine, ___, acetylcholine and ___ receptors
histamine; serotonin
The CTZ is a major area of stimulation by ___
chemotherapy
What are the 4 types of chemo induced NV?
-actue
-delayed
-anticipatory
-breakthrough: despite prophylaxis
what is delayed CINV?
after 24 hours of chemotherapy
What are the risk factors of CINV?
-age (younger)
-sex (females)
-concomitant radiation therapy
-history of ethanol use or motion sickness
-emetogenicity
ToF: a person with a hx of ethanol use on chemo is at higher risk for CINV?
false: they are less likely to have chemo induced NV
What are level 1 emetogenic chemo agents?
the lowest level that has frequency of NV <10% of the patients
Level 2 emetogenics have what frequency of CINV?
10-30%
If an chemo agents causes NV in 30-60% of patients, what level emetogenic is it?
level 3
how many patients on level 5 emetogenics will have NV?
>90%
ToF: the route of administration of a chemo agent does not change its emetogenic potentia?
false! intrathecal admin of methotrexate(level 1) and cytarabine (level 2) increase them to level 3
What are the antihistaminc agents?
Anticholingeric agents (diphenhydramine (benadryl), Hydroxazine (atarax), scopolamine (transderm scop)
what is the MOA of the anticholinergic agents?
interrupt various visceral afferent pathways that stimulate nausea and vomiting
What place in chemotherapy do anticholingeric agents have?
simple nausea and vomiting; useful to prevent EPS
List the SE of anticholinergic agents.
-drowsiness
-constipation
-dry mouth
-confusion
-blurred vision
-urinary retention
what are the 2 therapeutic considerations for anticholinergic use in chemo?
-low potency
-pediatric considerations
List the dopamine antagonists.
Class: phenothiazines

-chlorpromazine (Thorazine)
-prochlorperazine (Compazine)
-promethazine (phenergan) black box warning

Class: butyrophenones
-Haloperidol (Haldol)
-droperidol (inapsine)

CLass: benzamides
-metoclopramide (reglan)
the MOA of the phenothiazines is...
to block dopamine receptors (CTZ)
what are the most widely prescribed antiemetics?
the phenothiazines (dopamine antagonists)
what type of NV is indicated for phenothiazines?
simple NV; mild emetogenic chemo
what are the SE of phenothiazines?
-sedation
-lethargy
-cardiovascular
-EPS
-hypersensitivity reactions
-liver dysfunction
what are the 3 therapeutic considerations with phenothiazines?
-adverse effects
-pediatric considerations
-inexpensive agents; useful for long term treatment
what is the MOA of the butyrophenones?
block dopamine stimulation (CTZ)
what types of emetogenics can be treated with butyrophenones?
Haldol and inapsine

the mild emetogenic chemotherapy agents
what are the SE of the butyrophenones?
Droperidol causes QT prolongation and/or torsades de points

general SE of the class:
-sedation
-hypotention
-tachycardia
-dystonic reaction
What are the indications for butyrophenones?
reserved for the patients that fail other treatment modalities for NV
what is the MOA of metoclopramide?
Reglan

-Blocks dopamine receptors
-blocks serotonin receptors at high doses
-increase LES tone, aides gastric emptying and transit time
what is the place in therapy for metoclopramide?
used for moderate emetogenic chemo agents
what are the Side effects fo metoclopramide?
Reglan

-EPS!
-sedations
-restlessness and agitation
-Diarrhea
-fatigue
what are the therapeutic considerations for reglan?
consider for breakthrough or patients allergic to serotonin antagonists
What are the serotonin antagonists?
-ondansetron (zofran)
-granisetron (Kytril)
-dolasetron (Anzemet)
what is the MOA for the serotonin antagonists?
-block serotonin receptors in the GI tract and CNS
the serotonin antags are used with ____ emetogenic chemo agents?
moderate to high
what are the SE of the serotonin antags?
-headache
-diarrhea
-Increased LFTs (zofran)
-somnolence (kytril)
-constipation (kytril)
-fatigue (anzemet)
-ekg changes (anzemet)
what are the therapeutic considerations with the serotonin antags?
-used in combo with corticosteroids (dexamethosone)
-these agents DO NOT CAUSE EPS or DYSTONIA
-dolestron (anzamet) associated with drug interactions (cimetidine and rifampin)
what class of drugs aid with delayed NV and typically used in combo with dopamine and or serotonin antags?
corticosteroids
what are the 2 corticosteroids often used for NV?
dexamethosone and methylprednisolone
what are the SE of the corticosteroids?
-GI upset
-anxiety/excitation
-increased appetite
-hyperglycemia
-euphoria
-headache
-insomnia
what are the therapeutic considerations for corticosteroids>
not indicated for patients with simple NV; may be associated with unacceptable risks
what drug falls under the calass of the cannabinioids?
dronabinol (marinol)
what are the SE of dronabinol?
-drowsiness
-euphoria
-somnolence
-vasodilation
-vision difficulties
-dysphoria
-hallucinations
-memory loss
-hunger
what are the therapeutic considerations for dronabinol?
cannabis:

use this agent should only be considered when other regimens do not provide desired efficacy (not first line)
what drug has been found useful for anticipatory NV?
benzodiazapines: lorazepam (ativan)
what are the SE for lorazepam?
-sedation
-amnesia
-lethargy
ToF: lorazepam is usually a monotherapy for CINV
false: mainly used in combo with others
what is the general approach to treatment of CINV?
-determine emetrogenic potential of chemo
-know potential ADRs
-understand pharmacologic and kinetic properties
-cost awareness
what is the best treatment for the prevention of acute CINV (levels 2-5)?
dexamethosone + serotonin receptor antag (30 mins prior to therapy
what are the guidelines for treatment of anticipatory CINV?
benzodiazapine +or- phenothiazine
what is the best treatment for delayed NV?
dopamine antag + dexamethosone
What are the drugs used for treatment of post-operative NV?
-dolasetron
-ondansetron
-lorazepam
-diphenhydramine
-promethazine
-proclorperazine
-metoclopramide
what is the best treatment for radiation induced emesis?
serotonin receptor antag prior to radiation
what are retrograde movement of gastric contents from the stomach to esophagus?
GER
what is GERD?
symptoms or damage that results from reflux
define reflux esophagitis.
inflammation of the esophagus due to repeated refluxed material
what is erosive esophagitis?
visible damage on endoscopy (redness, bleeding, superficial ulcerations, and exudates)
what is the passage of refluxed gastric contents into the oral pharynx?
regurgitation
what are the aggressive factors in the patho of GERD?
-gastric acid
-pepsin
-bile salts
-pancreatic enzymes
what is the body's defense mechs against GERD?
-lower esophageal sphincter
-esophageal mucus
-esophageal clearance
-acid neutralization by saliva
-gastric emptying
list the risk factors for having GERD?
-decreased/increased LES pressure
-delayed gastric emptying (motility)
-increased gastric acid secretion or is a direct irritant
-impaired gastroesophageal pressure gradient
what are the possible complications of GERD?
-esophageal stricture formation
-esophageal ulceration/hemorrhage
-erosive esophagitis
-barretts's esophagitis
-extra-esophageal complications
what is barrett's esophagitis?
esophagus ends up looking like the intestines. Increase risk of cancer
LIst the clinical presentation (symptoms) of GERD.
-Recurrent vomiting
-heartburn (pyrosis)
-early satiety
-acid regurg
-epigastric pain
-dysphagia or feeding refusal
-odynophagia
-irritability in infants
-sandifer syndrome
what are the atypical manifestations of reflux?
-respiratory complaints
-apnea or ALTE (acute life threatening event)
-noncardiac chest pain
-nausea
-hoarseness
-cough
what are the diagnosis methods for GERD?
-patient history
-endoscopy
-barium swallow
-ambulatory pH testing
-esophageal manometry (monitor pressure and pH)
List the goals of therapy of gERD?
-promote normal weight gain and growth
-heal inflammation
-prevent resp and other comps
what are the dietary modifications for infants and children to prevent gerd?
infant: alter formula to alimentum or hypoallergenic formula

children
-avoid foods that decrease LES pressure
-avoid foods that have a direct irritant effect (citric, spice)
-eat small meals
-avoid eating immediately prior to sleep
what are some medications that can cause GERD?
KCl, Fe, NSAIDs
infants with gerd should be placed in the __ position
supine
how should children and adolescentes with gerd be positioned?
-elevate head of bed
-avoid reclining after meals
what are some lifestyle modifications for adolescents to prevent gerd?
-stop smoking
-avoid alcohol
-avoid tight-fitting clothes
-reduce weight
-do not exercise immediate after eating
what are the antacids and the alginic acid?
-tums
-maalox
-mylanta

algininc (gaviscon)
list the MOAs of antacids.
-neutralize stomach acid
-deactivate pepsin
-decrease acidity of reflux
-form viscous solution, coast esophagus (alginic acid)
describe the place that antacids have in therapy.
-mild GERD; in conjunction with lifestyle modifications
-used in combo with other suppression therapies
when are antacids dosed?
-after meals and at bedtime
-as needed
what are the SE of antacids?
-diarrhea (Mg ones: mylanta)
-constipation (Al ones: maylox)
-alteration in mineral metab
-acid rebound
what are the therapeutic considerations of antacids?
-effective for mild or breakthrough symps
-avoid in patients with renal insufficiency
-drug interactions (tetracycline etc)
List the H2 receptor antagonists.
-Cimetidine (Tagamet)
-nizatidine (Axid)
-ranitidine (zantac)
-famotidine (pepcid)
what are the MOAs of H2s?
-block histamine-mediated gastric acid secretion
-decrease acidity of reflux
what place in therapy do H2's have?
-mild to mod GERD
-severe GERD (non-erosive disease)
LIst the SE of H2's
-Tachyphylaxis (stops working after a few weeks)
-headache!!
-mental confusion
-somnolence
-fatigue
-dizziness
-gastrointestinal complaints
-gynecomatia (cimetidine)
-impotence
-thrombocytopenia
which GERD medication can be used under age 1?
H2's: Zantac
what are the therapeutic considerations for H2s?
-ped consideration
-drug interactions (cimetidine)
-dose adjust for renal insuff
-approx 50% of patients have resolution of esophagitis
List the PPIs
-omperazole (prilosec)
-lansoprazole (prevacid)
-pantoprazole (protonix)
-rabeprazole (aciphex)
-esomperazole (nexium)
what is the MOA of the PPIs?
-block acid secretion by inhibiting (irreversibly the H+, K+-ATPase enzyme system in the parietal cells)
-cause profound, prolonged decrease in gastric acid secretion
-decrease acidity of reflu
which class of drugs are the of the ones of choice for GERD?
PPIs
what has been found to help with nocturnal rebound symptoms of GERD?
H2s in combo with PPIs
WHat are the SEs of the PPIs?
-diarrhea
-flatulence
-abd pain
-dizziness
-headache
what are the therapeutic consids for PPIs?
-superior to H2s in Tx of mod-to-severe esophagitis
-not many drug interactions
-cost considerations
-pediatric considerations
what are the prokinetic agents?
-cisapride (propulsid)
-metoclopramide (reglan)
what is the MOA of the prokinetic agents?
-increase gastric emptying
-increase LES pressure
What is the place in therapy for prokinetic agents?
-mild-to-moderate Gerd
-severe GERD; in combo with others
-useful in pts with belching, early satiety, nocturnal symps
what are the SE of prokinetic drugs?
-diarrhea, cramping
-somnolences
-fatigue
-dizziness
-weakness
-rash
-EPS
-anxiety, nervousness
-insomnia
what are the therapeutic considerations for prokinetic agents?
-side effect profile (EPS)
-tachyphylaxis
what are the maintenance therapy suggestions for FERD ?
-more likely necessary in patients with esophagitis or comlications
-PPI are highly effective
-H2s are less effective

-surgery is last line
What is IBD?
term used to describe a family of closely related intestinal disorders including UC and crohns
what is UC?
a mucosal inflammatory condition confined to the recum and colon
what is Crohns?
a transmural inflammation of the GI tract that can affect any part, from the mouth to the anus
what groups have the highest rates of IBD?
ashkenazi Jews>>whites>blacks and asians
ToF: males have higher incidence of IBD than females
false: they are =
what are the proposed etiologies of IBD?
-infectious agent
-genetics
-environmental
-immune defects
-psychologic factors (stress increases flare up)
which disorder, (UC or CD), is common to have fistulas/abcesses/strictures?
Crohns
what is the location of the sores of UC? of crohns?
UC: mucosal (superficial)
Crohns: transmural
which disorder has crypt abscess, cryptitis?
UC
which disorder has tissue granuloma and cobble stone appearance?
Crohns
what are the minor complications of UC?
-hemorrhoids
-anal fissures
-perirectal abscesses
what are the major complications of UC?
-toxic megacolon (rapid dilation: severe)
-colonic carcinoma
what are the systemic issues of UC?
-hepatobiliary complications
-joint complications
-ocular complications
-dermatologic complications
-mucosal complications
what are the local complicatios of Crohns?
-small bowel stricture/obstruction
-fistula formation
-hypochromic anemia (due to bleeding)
-colonic carcinoma
what are the systemic issues of crohns?
-similar to UC
-renal stones more common in CD than UC
-NUTRITIONAL DEFICIENCIES
what are the SxS of UC?
-abd cramping
-increase BMs with rectal bleeding
-weight loss
-systemic involvement (fever, tachy, joint, ocular and dermatologic complications)
what are the PE findings for UC?
-local complications (hemorrhoids, anal fissures, perirectal abscesses)
-ocular complications (iritis, uveitis, and conjucntivitis)
-dermatologic findings
what are the lab findings for UC?
-decreased Hgb/Hct
-increased ESR
-leukocytosis and hypoalbuminemia
what is mild UC?
fewer than four BMs per day containing minimal or no blood; no systemic symptoms such as fever; and an ESR wtihin nml limits
what is moderate UC?
> 4 BMs/day but with minimal systemic compliations
what is the definition of severe UC?
> 6 BMs a day with blood; evidence of systemic complications (fever, tachy, anemia, and or ESR > 30
what are the SxS of crohns?
-abd pain
-increased BM
-hemotachezia
-systemic involvement
-weight loss
-fistula
what are some of the PE findings for crohns?
-adb mass and tenderness
-local complications
what are the lab findings of Crohns?
Increased WBC and ESR
what IBD commonly has an abdominal mass?
Crohns
what is the distribution of UC and CD?
UC: continuous
CD: dicontiuous (skip lesions)
what are the diagnostic procedures for IBD?
-patient hx
-PE
-lab tests
-biopsy
-stools studies
-sigmoidoscopy/colonoscopy
-histologic exam
-barium studies
what ist he goal of IBD therapy?
-develop a regimen of medical, surgical and nutritional interventions that reverese the mucosal inflammatory response, maintain disease remission, prevent malignancy, optimize nutrition, and max QOL.
what are the 4 general approaches to treatment of IBD?
-pharmacologic
-surgical
-nutritional
-disease complications considered
what are the aminosalicylates?
-sulfasalazine
-Mesalamine
-Olsalazine
-Balsalzide
what is the MOA of the aminosalicylates?
UNKNOWN: data suggests that they work topically to inhibit the generation of potent pro-inflammatory cytokines; other daya say they inhibit inflammatory trasncription factor NF-kB, block of prostaglandin and leukotriene production
what are the place in therapy of aminosalicylates?
-mild to moderate disease (both)
-maintenance of remission (both)
what are the SE of the aminosalicylates?
-headache
-N
-photosensitivity
-diarrhea,
-colitis
-pancreatitis
-hepatitis
-anemia
-interstitial nephritis
-proteinuria
WHat are the therapeutic considerations for aminosalicylates?
-patients treated with sulfasalazine should receive daily folate to prevent deficiency complications (anemia, neural tube defects)
-patients treated with sulfasalazine or mesalamine should undergo annual urinalysis, bi-annual CBC, and periodic LFT and pancreatic tests
-site of activity
___ patients on steroids go into remission
3/4
what are the commonly used corticosteroids of IBD?
prednisone
prenisolone
hydrocortisone
methyprednisone
what is the place in therapy of IBD for corticosteroids?
-Moderate to severe disease (UC and CD)
--remission (induction) rates are 60-80% in moderates UC and CD and 55% in severe cases)

-ineffective for maintenance therapy, dose taper after remission is induced
what are the SE of the corticosteroids?
-excessive bone loss
-weight gain
-cataracts
-glucose intolerance
-HTN
-neuropsyhiatric complaints
-facial swelling, acne, striae
-decreased linear growth
what are the therapeutic considerations of corticosteroids for IBD?
-minimize incidence and severity of steroid induced adverse effects
-consider calcium and vit D supplement
-budesonide associated with less adverse effects (adrenal suppression, acne); remission rates slightly lower than prednisolone group
what are the Abx that are often used in IBD?
metronidazole and cipro
what is the place in therapy of Abx for IBD?
-treat both mucosal inflammation as well as complications (abscesses)
-metronidazole used in treatment of active CD of the colon and rectum; ineffective for inducing remission in patients with active UC but may play a role in UC maintenance
-cipro used in treatment of CD and UC
What are the side effects of metronidazole?
-Reversible peripheral neuropathy
-abdominal pain
-nausea and vomiting
-pancreatitis
-neutropenia
-disulfiram-like reaction (teenagers and adults)
What are the SE of cipro?
-tendonitis
-NVD
-skin and urogenital complaints
list the therapeutic considerations for abx in IBD treatment.
-used in combo with a mesalamine product or steroid therapy when those agents alone are not effective
What are the immunomodulatory drugs used for IBD?
-azathioprine
-mercaptopurine
-methotrexate
what is the MOA of azathrioprine?
inhibits inflammatory response such as interfering with protein synthesis, nucleic acid metabolism,and the clonal expansion of lymphocytes
what is the MOA of methotrexate in IBD?
inhibition of proinflammatory cytokines as well as down-regulation of activated T cells and neutrophils
describe the instances when immunomodulatory agents help prevent clinical relapse of IBD?
-where aminosalicylate therapy failed
-who failed weaning of corticosteroids
-who required mercaptopurine/azathioprine as part of induction regimen
-that are weaned from cyclosporine and tacrolimus therapy
ToF: azathiprine/mercaptopurine demonstrated induction of mucosal and clinical remission of IBD
true
when is methotrexate used for IBD?
reserved for patients that failed azath/mercapto therapy due to administration concerns and hepatotoxicity
what are the SE of immunomodulatory therapy for IBD?
-BONE MARROW SUPPRESSION
-HEPATOTOXICITY
-INFECTION
-pancreatitis
-malaise, ND
-rahs
-hypersensitivity
-risk of malignancy
what are the SE for methotrexate?
-BONE MARROW TOX
-Pulmonary disease
-hepatitis
-ND
-anorexia
-fatigue
What should patients receiving methotrexate also be taking?
folate supplementation to decrease incidence and severity of adverse effects
ToF: methotrexate has shown to effectively treat CD
false; not as effective
What are the immunosuppresants used for IBD?
cyclosporine and tacrolimus
what are the MOA of the immunosuppresants for iBD?
inhibit production of IL2 and other cytokines that encourage proliferation of Tcells
What place in therapy do immunosuppresants have for IBD?
-severe disease refractory to intravenous corticosteroids
-if discontinued, most patients require colectomy
-concomitant azathio/mercapto therapy results in decrease need for surgery
what are the SE of cyclosporine?
-ACNE, HIRSUTISM, Gingival hyperplasia
-Hyperlipidemia, HTN
-nephrotoxic
-seizures, confusions, tremor
-ND
-diabetes
what are the SE of tacro>?
-TREMOR, seizures, confusion
-ALOPECIA
-ND
-nephrotoxic
-HTN
-diabetes
what are the therapeutic considerations for the immunosuppresants?
-therapuetic drug monitoring needed
-don't switch between formulations
-adverse reaction decrease compliance
-patients with low serum cholesterol levels may be better for tacro
what are the biologic agents used in IBD?
MoAbs

-infliximab
-adalimumab
what is the mechanism of the biologic agents?
-neutralize proinflammatory cytokine TNK; activbates complement-mediated cytolysis of TNF-producing monocytes
what are biologic agents used for with IBD?
treatment of moderate to severe crohns
What are the SE of the biologic agents ?
-infusion-related reactions
-hypersensitivity
whta are the therapeutic considerations for the biologic agents>
-may develop antibodies to infliximab: use steroids to reduce this
-smoking reduces the response of infliximab
-discontinue with hypersensitivity
-limited data for use in pediatric UC
what are the additional agents for IBD?
-thalidomide
-mycophenolate
what is the MOA of thalidomide?
inhibition of TNF production and angiogenesis
what is the MOA of mycophenolate?
suppresses lymphocyte prolif through an inhibition of DNA synthesis
what place does thalidomide have in therapy of IBD?
-restricted to corticosteroid dependent patients with CD
-results in improvements in clinical symptoms, biochemical papremeters, endoscopic/histo appearance, reduction in corticosteroid dose, and QOL
what is the place in therapy for mychophenalate?
-Alternative to mercapto/azathio therapy
-conflicting data in regards to efficicay
what are the SE of thalidomide>
-sedation
-peripheral neurop
-constipation, rash, fatigue, and dizziness
what are the SE for mycophenolate?
-DV, abd pain
-HTN
-Headache
-fever
-infection
What does thalidomide cause that limits its use?
congenital defects
-controlled studies have found use in CD is warranted
What alternative treatment has been found to help with UC, but not crohns>?
nicotine therapy
-results based on onset of symptoms after smoking cessations in some individuals
what has enetral nutrition been found to do in IBD>?
-induced disease remission in children with small bowel CD
-role in maintenance therapy in peds patients with CD
-compliance concerns
what has been found with parenteral nutrition with IBD?
-assists in treatment of severe disease
-allows bowel rest and remission
-required in long-term therapy patients (short gut)
what have probiotics been found to do?
-reestablish normal bacterial flora within the gut
-mixed success with IBD remission
-potentially effective in preventing pouchitis
what is a curative approach for UC?
surgery
what is pouchitis?
inflammation of the ileal pouch made during surgical intervention for UC.

need abx, probiotic therapy and removal and revert to ileostomy
what is a proctolectomy?
permanent ileostomy
describe surgery for crohns?
needed for patients with strictures, fistulizing disease, abscesses formation, and extraintestinal complications
-resection of major intestinal area
-colostomy placement
-multiple surgical intervential usually required within 15years