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199 Cards in this Set
- Front
- Back
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What is ulcerative colitis?
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-mucosal inflammation confined to rectum and colon
-risk of colon cancer |
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What is Crohn's Disease?
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-transmural inflammation of mucosa may occur in any part of GI tract
-systemic disease associated with arthritis, uveitis, liver disease -has cobblestone appearance |
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What causes ulcerative colitis and Crohn's Disease?
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-infectious
-genetics -immunologic -stress, trauma -diet: milk, refined sugars, chemical food additives, dec fiber -smoking=neg risk for UC; positive risk for CD |
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What is the clinical presentation of ulcerative colitis?
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-abdominal pain/cramping, rectal bleeding, tenesmus, weight loss
-bloody diarrhea w/ or w/o anemia, tachycardia, wt loss or dec serum alb (<4=mild; >6 =severe; >10 = fulminent) |
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What is the clinical presentation of Crohn's disease?
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-abdominal pain/ cramping, diarrhea, fever, wt loss
-perirectal lesions -aphthous ulcers in mouth and perianal fissures, fistulae, and abscesses -can go into remission |
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What are the goals of therapy for ulcerative colitis and Crohn's disease?
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-resolve acute inflammatory processes
-resolve or prevent complications -alleviate systemic complications -tx complications -maintain QOL |
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What nutitional recommendations should you give a pt with ulcerative colitis and Crohn's disease?
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-avoid milk
-use parenteral nutrition to rest gut -take fish oil capsules |
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What drugs should be avoided in ulcerative colitis and Crohn's disease?
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-acarbose
-NSAIDs |
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What surgery is used for ulcerative colitis and Crohn's disease?
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-proctocolectomy cures UC; unsure in CD
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What pharmacologic treatment is used in ulcerative colitis and Crohn's disease?
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-sulfasalazine
-salicylates (Asacol, Rowasa, Pentasa, olsalazine, Lialda, Colazal) -corticosteroids -nicotine -immunomodulators (6-mercaptopurine, azathioprine, cyclosporine, MTX, fish oil) -antibiotic (metronidazole, ciprofloxacin, anti-TB) -immune enhancers (Levamisole, BCG vaccine) -mast cell stabilizer (Cromolyn) -Cholestyramine -Sucralfate -Anticholinergics (Tn belladonna, Tn opium, diphenoxylate, loperamide, codeine) -hydrophilic colloids (metamucil) -free radical scavengers (mesalamine) |
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How is mild to moderate ulcerative colitis treated?
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-sulfasalazine 4-8g/day
OR -mesalamine derivatives -rectal HC retention enemas or foam For ulcerative proctitis- rectal steroids or meslamine For left side colitis- po/topical aminosalicylates |
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How is moderate to severe ulcerative colitis treated?
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-steroids (prednisone 40-60mg/day; methylprednisone 35-40mg/day; or HC 200-300mg/day)
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How is severe ulcerative colitis treated?
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-NPO, hospitalize
-parenteral nutrition -steroids: prednisone 40mg/day -surgery -medical emergency for toxic megacolon |
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How should refractory ulcerative colitis be treated?
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-immunomodulators: azathioprine, 6-MP
-IV cyclosporine 4mg/kg/day |
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What type of surgery is used for ulcerative colitis?
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-ileostomy
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What maintenance treatment should be used in remissive ulcerative colitis?
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-mesalamine
-olsalazine, pentasa, mesalamine enema -no steroids |
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How is active Crohn's disease treated?
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-sulfasalazine--> steroids
-add metronidazole 250mg TID and/or azathioprine or 6-MP -use cyclosporine to dec. steroids For ileocolonic/ colonic: sulfasalazine or metronidazole 750-1500mg/day |
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How should moderate to severe active Crohn's disease be treated?
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-mesalamine (Pentasa or Asacol) for small intestine
-use I/D or metronidazole for perianal or fistulating |
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What maintenance treatment should be used in remissive Crohn's disease?
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-po mesalamine
-sulfasalazine? -steroids +/- effectiveness |
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What pt education is important about budesonide?
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-do not chew tablets
-do not drink grapefruit juice |
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What is irritable bowel syndrome?
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-abdominal pain/cramping
-changes in bowel function: bloating, gas, diarrhea, and constipation -mucus in stool -women>men -does not increase risk of colon cancer |
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What is the treatment for mild/moderate IBS?
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-manage stress
-diet -lifestyle modifications |
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What is the treatment for constipation in moderate/severe IBS?
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-metamucil or citrucel with fluids
-anticholinergics to relieve painful bowel spasms -SSRIs or tricyclics for pain and depression -tegaserod (Zelnorm): restricted distribution |
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What is the treatment for diarrhea in moderate/ severe IBS?
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-avoid caffeine, alcohol, and artificial sweeteners
-loperamide to control diarrhea -cholestyramine -anticholinergics to relieve painful bowel spasms -SSRIs or tricyclics for pain and depression -alosetron (Lotronox) |
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What is GERD?
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-condition which develops when reflux of stomach contents into esophagus causes heartburn and/or complications 2x/week
-can result in esophagitis |
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What is GERD caused by?
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-episodes of retrograde movement of gastric contents from the stomach into the esophagus
-LES relaxed (not related to swallowing) AND pressure difference needed b/tw stomach and esophagus |
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Why is GERD increased in pregnancy?
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-hormonal effects on the esophagus and LES tone
-increased intra-abdominal pressure |
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What causes increased intragastric pressure in relation to GERD?
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-pressure: stomach>esophagus
-delayed gastric emptying d/t inc. gastric volume and dec. gastric emptying -obesity, pregnancy -bending over, lying in recumbent postition, wearing tight fitting clothes |
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How does mucus and refluxate play a role in GERD?
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-esophagus has limited protective mechanism (dec mucus)
-composition, pH, and volume factor in -greater amounts of gastric acid and pepsin |
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What foods decrease LES tonicity/ pressure?
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-fatty meals
-onions -caffeine -chili peppers -garlic -chocolate -ethanol -carminatives (peppermint, spearmint) |
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What foods directly irritate esophageal mucosa?
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-spicy foods
-tomato/orange juice -coffee -acidic foods |
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What foods increase LES pressure?
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-high protein meals
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What medications decrease LES tonicity/ pressure?
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-anticholinergics
-BZDs -phentolamine -estrogen -isoproterenol -nitrates -dopamine -theophylline -barbiturates -DHP CCBs -ethanol -progesterone |
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What medications directly irritate esophageal mucosa?
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-alendronate
-iron -quinidine -potassium chloride -aspirin/ NSAIDs |
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What are the typical and atypical symptoms of GERD?
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Typical:
-heartburn often after meals or w/ heavy lifting -water brash: inc. salivation -belching -regurgitation Atypical: -bronchospasm and/or aspiration of refluxate -chronic cough, hoarseness, pharyngitis, chest pain, dental erosions |
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What are the alarm symptoms of GERD?
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-dysphagia: difficulty swallowing
-odynophagia: pain on swallowing -bleeding, unexplained weight loss, choking, chest pain |
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How is a dx of GERD made?
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-sx
-endoscopy: screen for BE, adenocarcinoma, esophagitis -ambulatory reflux monitoring -esophageal manometry: determines esophagus fxn and peristalsis -PPI test: high dose PPI (2-3x nl BID x 1-2 wks) |
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What are the goals of therapy for GERD?
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-eliminate sx, decrease frequency and duration of reflux, promote healing of injured mucosa and prevent complications
-prevent reflux and/or decrease aggessive factors that worsen reflux or mucosal damage |
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What are the complications of GERD?
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-esophageal stricture: causes fricture, related to adenocarcinoma
-seophageal ulceration, perforation, bleeding -Barrett's esophagus and esophageal adenocarcinoma -Barrett's esophagus |
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What lifestyle modifications should be used in GERD treatment?
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-elevate head of bed by 6-8 inches or use foam wedge
-avoid lying down for several hours following a meal -weight loss -limit tight fitting clothes -avoid food and medications -eat smaller meals |
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What is the mechanism of action of antacids?
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-neutralize gastric acid
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Name some antacids?
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-Aluminum containing: Alternagel
-Calcium carbonate: Maalox, Rolaids, Tums -Magnesium containing: Milk of magnesia -Alginic acid: Gaviscon -Combination: Mylanta, Maalox Advanced |
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What are the adverse effects of antacids?
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-diarrhea (Mg products) and constipation (aluminum products)
-renal failure: avoid if CrCl<30ml/min -milk-alkali syndrome: HA, nausea, irritability, weakness caused by calcium products |
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What interactions are there between antacids and other drugs?
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-absorption of digoxin, iron salts, ketoconazole, isoniazid
-stagger dose by 2-4 hours |
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What is the mechanism of action of H2RAs?
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-competitively and selectively block H2 receptor on parietal cells to inhibit histamine-stimulated acid production
-inhibit basal and nocturnal acid secretion -decrease activity of pepsin |
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What is the OTC dose, nonerosive dose, and erosive dose for cimetidine in GERD?
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-OTC: 200mg BID
-NE: 400mg BID -E: 400mg q6h |
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What is the OTC dose, nonerosive dose, and erosive dose for famotidine in GERD?
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-OTC: 10mg BID
-NE: 20mg BID -E: 40mg q12 hr |
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What is the OTC dose, nonerosive dose, and erosive dose for nizatidine in GERD?
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-OTC: 75 mg BID
-NE: 150mg BID -E: 150mg q6h |
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What is the OTC dose, nonerosive dose, and erosive dose for ranitidine in GERD?
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-OTC: 75mg BID
-NE: 150mg BID -E: 150mg q6h |
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If a patient has moderate to severe renal insufficiency how should H2RA dosages be changed?
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-decrease dose by 50% when CrCl<50ml/min
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What are possible drug interactions with H2RAs?
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-cimetidine inhibits CYP 1A2, 2D6, 3A
-all H2RAs affect absorption of pH sensitive drugs |
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What are the adverse effects of H2RAs?
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-HA, somnolence, fatigue, constipation and/or diarrhea
-rare cases of thrombocytopenia -transient elevation in serum transaminases (LFTs), but hepatotoxicity is rare -cimetidine cause antiandrogenic effects -confusion, restlessness, somnolence, agitation, HA, dizziness |
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What is the mechanism of action of PPIs?
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-irreversible inhibit the H+/K+ ATPase of the parietal cell (inhibits active pumps)
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What are some important pharmacokinetics of PPIs?
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-short t1/2: 0.5-2hours, but inhibition d/t PP regeneration
-no dose adjustment in renal/hepatic failure -met by CYP2C19 and 3A -acid liable: release in duodenum |
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What is the OTC dose, nonerosive dose/erosive and maintenance dose for dexlansoprazole in GERD?
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-OTC: none
-NE: 60mg daily -Maintenance: 30mg daily |
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What is the OTC dose, nonerosive dose/erosive and maintenance dose for esomeprazole in GERD?
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-OTC: none
-NE/E: 20-40mg daily -M: 20mg daily |
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What is the OTC dose, nonerosive dose/erosive and maintenance dose for lansoprazole in GERD?
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-OTC: 15 mg daily x 14 days q4month
-NE/E: 15-30mg daily/BID -M:15-30mg daily |
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What is the OTC dose, nonerosive dose/erosive and maintenance dose for omeprazole in GERD?
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-OTC: 20mg daily x 14 days q4months
-NE/E: 20mg daily-BID -M: 20mg daily |
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What is the OTC dose, nonerosive dose/erosive and maintenance dose for pantoprazole in GERD?
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-OTC: none
-NE/E: 40mg daily-BID -M: 40mg daily |
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What is the OTC dose, nonerosive dose/erosive and maintenance dose for rabeprazole in GERD?
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-OTC: none
-NE/E: 20mg daily-BID -M: 20mg daily |
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What are the adverse effects of PPIs?
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-HA, dizziness, somnolence, diarrhea, constipation, nausea, vitB deficiency
-rebound acid secretion -C. diff colitis -increased hip fractures |
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What drug interactions are possible with PPIs?
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-dec stomach pH- affect absorption of pH dependent meds
-omeprazole and esomeprazole inhibit 2C19 (diazepam, phenytoin, warfarin) -lansoprazole slightly induces 1A2 (met theophylline) -Clopidogrel |
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What is the mechanism of action of metoclopramide?
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-dopamine antagonist
-central antidopaminergic -peripheral dopaminergic -indirect and direct stimulation of cholinergic receptors -inc. LES tonicity/pressure |
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What is the dose of metoclopramide in GERD treatment?
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-10-15mg up to QID
-take 30min prior to meals and at bedtime -elderly: 5mg QID |
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What are the adverse effects of metoclopramide? What are the CI of metoclopramide?
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-drowsiness, GI disturbances, increased lactation
-extrapyramidal SE in 1% CI: GI hemorrhage, obstruction or perforation, pheochromocytoma, seizure disorders, Parkinson's |
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What are possible drug interactions with metoclopramide?
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-MAOIs, tricyclics, or sympathomimetics are CI
-do not use w/ phenothiazines d/t inc. EPS |
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When should medications be used in GERD tx?
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-H2RAs and antacids=quick relief
-PPIs only for long-term; best for healing esophagus; more potent -antacids PRN w/ PPI or H2RA |
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What medications should be used in intermittent/ mild heartburn?
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-antacids: PRN or after meals/ at bedtime
AND/OR -OTC dose of H2RA or PPI |
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What medications should be used in mild sx of GERD?
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-H2RA for 6-12 weeks or PPI for 4-8 weeks
- if recurrence, consider maintenance dose |
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What medications should be used in mod-severe sx of GERD?
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-PPI for 4-16 weeks
-may consider maintenace dose if recurrence |
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What medications should be used for warning signs or known erosive esophagitis w/ GERD?
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-refer to endoscopy
-w/o complications: PPI for 4-16 weeks -w/ complications: refer, may use PPI |
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What is peptic ulcer disease?
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-acid-related lesion of upper GI tract that penetrates at least 3 mucosal layers (epithelium, lamina propria, and muscularis mucosa)
-either gastic ulcer (GU) or duodenal ulcer (DU) |
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What are the three common forms of peptic ulcers?
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-H. pylori associated
-NSAID associated -stress-related mucosal damage/disease |
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What is the pathophysiology of peptic ulcers? What are the aggressive factors? What are the protective factors?
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-presence of acid and pepsin + HP, NSAIDs, critical illness, or predisposing factor
-Aggressive: gastric acid, pepsin -Protective:mucus, bicarbonate, cell kinetics/ regeneration, mucosal blood flow |
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What is the pH gradient between the gastric lumen and the mucus?
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-lumen: pH 1-2
-mucus: pH 6-7 |
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What is H. pylori? How is it transmitted? How does it cause PUD?
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-spiral-shaped, pH-sensitive, microaerophilic bacterium in stomach
-transmitted oral-oral and fecal-oral -causes chronic gastritis w/ direct mucosal damage via virulence factors, enzymes, and adherence |
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How do NSAIDs cause PUD?
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-nonselective NSAIDs, ASA cause gastric mucosal damage through irritation of gastric epithelium and inh. COX
-GI toxicity |
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What are the risk factors for NSAID induced PUD?
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-prior hx of PUD
-age>65 -concomittant corticosteroid use -concomittant ASA use -high dose NSAID -NSAID + anti-plt, anticoag, bisphosphonates, SSRIs |
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What meds/habits other than NSAIDs can lead to PUD?
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-antiplt therapy (clopidogrel)
-smoking -stress |
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What are the complications of PUD?
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-GI bleeding : NSAIDs=risk factor
-perforation -gastric outlet obstruction |
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What are the s/sx of PUD?
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-may be asymptomatic
-abdominal pain: burning, discomfort, fullness, cramping or dyspepsia -may have heartburn, belching, bloating as well -N/V, anorexia w/ GU -endoscopy |
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What are the differences in s/sx of GU vs DU?
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-GU: pain relieved by food, occurs at night, asymptomatic
-DU: pain less frequent; pain precipitated by eating |
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What dx tests are done for PUD?
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-Hgb/ Hct, occult blood test, HP test
-esophagogastroduodenoscopy (EGD) -single barium contrast -endoscopic test for HP: gold std -biopsy (rapid) urease: active infection -Culture -Antibody test: AB elevated for 6-12 months after HP infection -Urea breath test: active HP infection -stool antigen: active HP infection |
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For the urea breath test and stool antigen test, what must be done prior?
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-d/c antibiotis, bismuth, or PPIs
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What are the goals of therapy for PUD?
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-eliminate sx, heal ulcer, prevent recurrence and complications
-eradicate HP - |
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What are the lifestyle modifications for PUD?
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-avoid irritants (spicy foods, alcohol, caffeine)
-eliminate/reduce stress -smoking cessation -avoid ASA/ NSAIDs |
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What is the dosing for cimetidine in active ulcer and maintenance of PUD?
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-AU: 800mg at bedtime; 400mg BID; 300mg QID
-M: 400-800mg at bedtime |
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What is the dosing for famotidine in active ulceration and maintenance in PUD?
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-AU: 40mg at bedtime; 20 mg BID
-M: 20-40mg at bedtime |
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What is the dosing for nizatidine and ranitidine in active ulceration and maintenance in PUD?
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-AU: 300mg QHS; 150mg BID
-M: 150-300mg QHS |
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What is the dosing for esomeprazole in active ulceration and maintenance in PUD?
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-AU: 20-40mg daily
-M: 20-40mg daily |
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What is the dosing for lansoprazole in active ulceration and maintenance in PUD?
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-AU: 15-30mg daily
-M: 15-30mg daily |
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What is the dosing for omeprazole in active ulceration and maintenance in PUD?
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-AU:20-40mg daily
-M:20-40mg daily |
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What is the dosing for pantoprazole in active ulceration and maintenance in PUD?
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-AU:40mg daily
-M: 40mg daily |
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What is the dosing for rabeprazole in active ulceration and maintenance in PUD?
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-AU: 20mg daily
-M: 20mg daily |
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What is the mechanism of action of sucralfate?
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-mucosal protective barrier
-may enhance mucosal defensive mechanisms by stimulating endogenous prostaglandin release, gastric bicarb secretion, mucous production, and epithelial cell renewal |
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What is the dosing of sucralfate in active ulceration and maintenance of PUD?
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-AU: 1g QID or 2g BID
-M: 1g QID or 1-2g BID |
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What drug interactions are present with sucralfate use?
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-binds to cimetidine, digoxin, flouroquinolones, ketoconazole, phenytoin, ranitidine, tetracycline, theophylline
-avoid admin of other meds w/in 2 hrs |
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What is misoprostal used for in treatment of PUD?
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-prevention of NSAID-induced GU in high risk pts
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What is the mechanism of action of misoprostal?
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-inc mucous and bicarb secretion
-stimulates surface-active phospholipids -inc gastric mucosal blood flow -moderately inh acid secretion (dose-related) |
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What is the dose of misoprostal in tx of PUD?
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-200mg QID
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What are the adverse effects of misoprostal?
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-diarrhea and abdominal pain
-N/V, flatulence, HA, dyspepsia, constipation -abortifacient |
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How should HP-associated PUD be treated?
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acid-supressor + 1-2 antibiotics
-antibiotics: clarithromycin, + amoxicillin, metronidazole, tetracycline, and/or bismuth salts -tx 7days, prefer 14 days of PPI |
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What is in a Helidac pack?
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4 x metronidazole 250mg (1QID)
4 x tetracycline 500mg (1QID) 8 x bismuth subsalicylate 262.4mg (2QID) Need PPI or H2RA |
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What is in a Prevpac?
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2x lansoprazole 30mg (1BID)
4 x amoxicillin 500mg (2BID) 2 x clarithromycin 500mg (1BID) |
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What is in Pylera pack?
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3-in-1 capsule w/ bismuth, metronidazole, tetracycline
take 3 capsules QID Need PPI or H2RA |
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How should a conventional ulcer be treated and maintained?
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-H2RA, PPI, or sucralfate for 4-6 weeks
-continued long-term therapy |
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How should NSAID induced ulcers be treated and prevented?
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-PPI/misoprostal
-use COX-2 selective NSAIDs -H2RA w/ NSAIDs for DU -PPI + clopidogrel in high-risk pts -d/c NSAID if possible |
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How should treatment failure PUD be treated?
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-use an alternate regimen with different antibiotics
-add bismuth -treat for 10-14 days -consider maintenance therapy with PPI/ H2RA |
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What are the risk factors of NSAID-induced ulceration?
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-prior hx of PUD
-presence of HP -use of multiple NSAIDs -anticoagulation or coagulopathy -use of antiplt agents -serious underlying disease -age>65yo -high dose NSAIDs |
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What are the doses of PPIs for the prevention of NSAID ulcers?
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-omeprazole 20mg daily
-lansoprazole 15-30mg daily -pantoprazole 40mg daily -rabeprazole 20mg daily -esomeprazole 20-40mg daily |
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When should H2RA co-therapy with NSAIDs be used?
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-duodenal ulcers
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What therapy should be used in high risk NSAID-associated ulcer patients?
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-PPI + clopidogrel
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What therapy should be used for low/no NSAID GI risk and no/low CV risk?
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-lowest dose NSAID
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What therapy should be used for moderate NSAID GI risk (1-2 risk factors) and no/low CV risk?
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-NSAID
-PPI/misoprostal |
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What therapy should be used for high NSAID GI risk (complicated ulcer hx, >2 risk factors) and no/low CV risk?
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-alternative therapy or COX-2 selective NSAID
-PPI/ misoprostal |
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What therapy should be used for no/low NSAID GI risk and high CV risk (using ASA prophylaxis)?
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-naproxen
-PPI/misoprostal |
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What therapy should be used for moderate NSAID GI risk (1-2 risk factors) and high CV risk (using ASA prophylaxis)?
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-naproxen
-PPI/misoprostal |
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What therapy should be used for high NSAID GI risk (complicated ulcer hx, >2 risk factors) and high CV risk (ASA prophylaxis)?
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-avoid NSAIDs or COX-2 selective
-use alternative therapy |
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What is the recommended prophylaxis for therapy of prevention of antiplatelet associated ulcers?
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-combo therapy w/ ASA and NSAID/COX-2 inhibitor
-ASA or clopidogrel used in pts at high risk of adverse effects (dual antiplt tx, hx GERD/PUD, age>60yo, corticosteroid use) -ASA or clopidogrel in combo with anticoagulant |
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What medication may be effective in preventing complications related to ASA?
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-famotidine 20 mg BID
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How should NSAID-induced ulcers be treated?
|
-if HP positive, use PPI-based HP eradication
-d/c NSAID and tx w/ PPI, H2RA, or sucralfate for 6-8 weeks -if cannot d/c NSAID, tx w/ PPI for 8-12 weeks (best to use COX-2 selective or diclofenac) |
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What laboratory tests are looked at in LFTs?
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-albumin
-bilirubin -cholesterol -BUN -INR |
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What laboratory tests are looked at in Liver Injury Tests (LIT)?
|
-Aspartate aminotransferase (AST)
-Alanine aminotransferase (ALT) -Alkaline phosphatase (Alk Phos) -Gamma glutamyl transferase (GGT) |
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Which laboratory tests are specific to the liver?
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-LDH
-Alb -INR, PT, aPTT – elevated in cirrhosis |
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What is the normal value for AST and ALT? When will these numbers be elevated?
|
-AST: 0-50 IU/L
-any disease that injures liver, heart, skeletal muscle, kidney, brain, spleen, pancreas, and lungs -ALT:5-60 IU/L -cirrhosis, obstructive jaundice, and hepatitis |
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What is the normal value for Alk Phos and GGT? When will these numbers be elevated?
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-Alk Phos: 35-130 IU/L
-obstructive jaundice, liver lesions, cirrhosis, Paget's disease, metastatic bone disease -GGT:0-85 IU/L -cirrhosis, cholelithiasis, biliary obstruction |
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What is the normal value for total bilirubin and direct/conjugated bilirubin? When will these numbers be elevated?
|
-Total bili: 0-1.4mg/dl
-Conjugated bili: 0-0.3mg/dl -hepatitis, cirrhosis |
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What are the normal levels of lactate dehydrogenase (LDH) and serum albumin? How will these numbers change in liver dysfunction?
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-LDH: 90-200 IU/L
-serum alb: 3.6-5g/dL -low in liver disease |
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What are the normal levels of ammonia and BUN? How will these numbers change in liver dysfunction?
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-ammonia: 15-50micromole/L
-BUN: 10-20mg/dL -low in cirrhosis |
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How are cholesterol and coagulation (INR, aPTT, and PT) levels changed in liver dysfunction?
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-cholesterol: low
-coagulation: elevated in cirrhosis |
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What causes liver disease?
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-viral infections
-drugs -Wilson's disease -biliary cirrhosis -hemochromatosis -non-alcoholic fatty liver -alpha-1 antitrypsin deficiency |
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How is Hepatitis A transmitted?
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-fecal-oral
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What vaccines are available for Hep A prevention? How many doses are needed?
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-Havrix: 2
-Vaqta:2 |
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How is Hepatitis B transmitted?
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-sexually
-parenterally -perinatally |
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What are the complications of Hep B?
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-cirrhosis
-hepatocellular carcinoma |
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What vaccines are available for Hep B prevention?
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-Engerix-B (Single Antigen)
-Recombivax HB (single antigen) -Comvax (Combination) -Pediarix (combo) -TwinRix (combo w/ HepA) |
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How is Hep A treated?
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-supportive care
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What is the MOA of interferon and peginterferon-alpha? What are the doses of interferon and peginterferon-alpha in the treatment of Hep B?
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-MOA: suppress HBV replication
-interferon: 5MU daily or 10MU 3x/wk x 16-24 weeks -peginterferon-alpha:180mcg weekly x 48 weeks (12 months) |
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What are the SE of interferon and peginterferon-alpha?
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-flu-like sx
-inc ALT -fatigue -anorexia + weight loss -hair loss -anxiety, depression, suicidal tendency |
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What is the MOA and dosage for lamuvidine in the treatment of Hep B?
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-MOA: premature DNA chain termination-> inh HBV replication
-use monotherapy or w/ interferon -dose: 100mg daily (req renal adjustment) |
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What is the MOA and dosage for adefovir in the treatment of HepB? What is the SE?
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-MOA: HBV DNA chain termination
-dose: 10mg daily (renal adjustment) -SE: nephrotoxicity |
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What is the MOA and dosage for entecavir in the treatment of HepB?
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-MOA: inh HBV replication by 3 mechanisms
-dose: 0.5mg daily (1mg daily in lamivudine resistance) |
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How is Hepatitis C transmitted?
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-parenterally
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What are the complications/ sequelae of HepC?
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-chronic hepatitis
-cirrhosis -hepatocellular cancer |
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What is important for HepC treatment with adherence?
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-80% of meds at least 80% of time
-treatment based on genotype |
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What is the treatment regimen with dosages for HepC?
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-Peg-INF 180 mcg weekly for 24 weeks
-Ribavirin 800 – 1200 mg QD for 24 weeks |
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What is the MOA and SE of ribavirin?
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-MOA: unknown
-SE: hemolytic anemia -must dec dose once Hgb drops <10g/dL |
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Allergies to which meds may cause drug-induced hepatitis?
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-minocycline
-nitrofuratoin -phenytoin |
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Toxic levels of which meds may cause drug-induced hepatitis?
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-APAP
-ASA in children (Reye's syndrome) |
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Autoimmune rxns to which medications may cause drug-induced hepatitis?
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-carbamazepine
-sulfamethoxazole -isoniazid -phenytoin |
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What herbal remedies may cause drug-induced hepatitis?
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-kava
-St. John's wort |
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What are the 3 main histological phases of alcoholic liver disease (ALD)? Are these reversible?
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-steatosis/ fatty liver: reversible
-acute alcoholic hepatitis -cirrhosis: non-reversible |
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What is acute alcohol hepatitis? What are the s/sx of Acute Alcohol Hepatitis?
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-clinical syndrome of jaundice and liver failure occuring after decades of heavy drinking (>100g/day)
-s/sx: rapid onset of jaundice, RUQ pain, encephalopathy (altered mental status) |
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Other than s/sx, how is acute alcohol hepatitis dx?
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-CAGE questionnaire
-laboratory assessments -Maddrey's score |
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What is maddrey's score?
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(4.6 x prothrombin time-control prothrombin time) + serum bilirubin in mg/dl
-score>32: poor prognosis, threshold for starting corticosteroids, pentoxifylline |
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What laboratory test changes are expected with acute alcohol hepatitis?
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-AST: 2-3x higher than ALT
-ALT: inc, but not much higher than 100 -INR/PT: inc -Total bili: inc -Alb: dec |
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What is the treatment for alcoholic liver disease?
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-ETOH abstinence
-nutrition therapy -steroids -pentoxifylline |
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What is the MOA and dose of pentoxifylline?
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-MOA: PDE inhibitor that modulates TNF-alpha
-Dose: 400mg TID -dec risk of hepato-renal syndrome and mortality of hospitalized pts |
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What are the s/sx of ETOH withdrawal?
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-HA, tremors, sweating, N/V, irritability, anorexia
-appear w/in a few hours, worsen b/tw 24-48hrs, continue 48hrs |
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What is the treatment of ETOH withdrawal?
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-fluid resuscitation
-thiamine 100mg daily during withdrawal period -MVI daily -folic acid 1mg daily x few weeks -BZDs |
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What are the s/sx of delirium tremens?
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-severe agitation, tremor, disorientation, persistent hallucinations, elevated HR and RR
-appears 72-96hrs post ETOH cessation, continue 3-5days |
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What is the treatment of delirium tremens?
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-BZDs
-Haldol (not typically used) -Clonidine 0.1-0.2mg po q8h during withdrawal period |
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When will ETOH withdrawal seizures present? How should they be treated?
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-w/in 24 hours
-BZDs; chronic tx NOT indicated |
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What is Wilson's disease? What is the treatment for Wilson's disease?
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-recessive inherited disease of copper overload
-inc serum copper, dec serum ceruloplasmin, inc 24-hr urinary copper levels -treatment: penicillamine, trientine, liver transplant |
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What is hemochromatosis? What is the treatment for hemochromatosis?
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-inherited disorder of iron overload
-slate-colored skin, diabetes, cardiomyopathy, arthritis, or hepatic dysfxn -tx: phlebotomy |
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What alpha1-antitrypsin deficiency? What is the treatment for alpha1-antitrypsin deficiency?
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-dec. serum alpha1-antitrypsin conc
-tx: transplantation |
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What are the complications of cirrhosis?
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-portal HTN
-varices -ascites -hepatic encephalopathy -coagulation defects -hepato-renal syndrome |
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What is the clinical presentation of cirrhosis?
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-jaundice
-bruising -anorexia -fatigue -bleeding -hepatomegaly -splenomegaly -scleral icterus (yellow eyes), -spider angiomata (red spot w/veins diffusing out from it) -caput medusae (engorged blood vessels-looks like bubbly raised skin) -gynecomastia -dec libido -testicular atrophy -pruritis -dupuytren's contracture |
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How will the laboratory values change in cirrhosis?
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-AST/ ALT: inc
-Alk Phos: inc -GGT: inc -LDH: inc -PT: inc -bilirubin: inc -albumin: dec -total protein: dec -plts: dec |
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What are the treatment goals for cirrhosis?
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-decrease disease progression
-pt education -alcohol cessation -sodium restriction -prevent further insult to liver -minimize complications |
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What is portal HTN caused by? What is the treatment for portal HTN?
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-↑ resistance in portal vein + ↑ blood volume in splachnic bed
-precipitation factor for: variceal bleeds, ascites, SBP, HE, coagulopathies, hepato-renal syndrome -Treatment o propranolol 10 mg BID, titrate to HR and BP tolerance o nadolol 20 mg QD o isosorbide mononitrate used in combo with BB |
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What are the s/sx of varices?
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N/V, hematemesis, melena, pallor, fatigue, weakness, hypoTN, tachycardia, mental status Δs, ↓ Hgb&Hct
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What is the MOA and dosages for octreotide?
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-MOA: selective vasoconstriction of splanchnic arteries (dec splanchic/portal blood flow and dec portal pressure)
-Dose: o Loading: 50-100mcg IV o Maintenance: 25-50mcg/ hr IV infusion continue tx for 24-72 hrs after bleeding has stopped |
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What is the MOA and dosages of Terlipressin in the treatment of variceal bleeding?
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-MOA: vasoconstriction of the splanchnic bed
-Dosing o initial dose: 2mg q4h x 24 hrs o maintenance: 1mg q4h x 24hrs |
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What is the MOA and dosage of PPIs in the treatment of variceal bleeding?
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-MOA: dec stomach acid helps control GI bleeding
-dose: o initial: 80mg IV load o maintenance 8mg/hr continuous infusion for 72-96 hrs and high dose po PPI x 4weeks post bleed |
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What prophylaxis is needed for variceal bleeding?
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MUST have prophylaxis antibiotics
-3rd generation cephalosporin -flouroquinolone |
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What non-PCOL tx is used for variceal bleeding?
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-transjugular intrahepatic portosystemic shunts (TIPS): inc risk of hepatic encephalopathy
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What tx is used for variceal/ portal prevention?
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To dec portal pressure:
-non-selective beta-blockers: propanolol 10mg BID-TID or nadolol 20mg daily + iso mono |
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What are the s/sx of ascites?
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-abdominal pain and fullness
-nausea -SOB -inc abdominal pressure |
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What tests are used for the dx of ascites?
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-cell count with differential
-albumin -total protein -gram stain -bacterial culture |
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How is ascites graded?
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-Grade 1: detected only on ultrasound; req only salt restriction
-Grade 2: moderate abdominal distention -Grade 3: marked ascitic fluid and abdominal distention -Tense/refractory: intolerant to diuretics |
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What is SAAG?
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serum ascites albumin gradient (SAAG)= alb(serum)- alb(ascites)
>1.1g/dL = portal HTN <1.1g/dL = peritoneal carcinoma, peritoneal infection (TB, fungal, CMV), nephrotic syndrome |
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What are the treatment goals for ascites?
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-minimize acute discomfort of tense ascites: use therapeutic paracentesis
-re-equilibrate ascitic fluid -prevent spontaneous bacterial peritonitis -fluid loss -sodium restriction: <2g/day with urinary sodium excretion > 78mmol/day |
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What is the dosage and SE of furosemide in the tx of ascites?
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- dose: 40mg daily-> max: 160mg daily
-SE: hypokalemia, acute renal failure |
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What is the dosage and SE of spironolactone in the tx of ascites?
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-dose: 25-100mg daily -> max: 400mg daily
-SE: hyperkalemia, gynecomastia |
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What is the spironolactone: furosemide ratio for the tx of ascites?
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100:40 spironolactone: furosemide
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What is the dosage and SE of amiloride in the treatment of ascites? When should amiloride be used?
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dose: 10 mg QD, max of 40 mg QD
-SE: hyperkalemia, hypotension -use IF experienced painful gynecomastia with spironolactone |
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What is paracentisis and what are some of its complications?
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-TAP, removal of fluid
-Complications: hypotension, hyponatremia, azotemia |
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What should be used with paracentisis?
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-volume expanders: albumin 10g/L over 5L removal
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What is spontaneous bacterial peritonitis? What are the s/sx?
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-infection of the peritoneal fluid
-sx: fever, chills, abdominal pain, changes in mental status -s: ascitic fluid analysis o PMN> 250cells/mm3 (WBC x %polys) o dec total protein o inc neutrophil count o (+) bacterial culture: E.coli, Klebsiella pneumoniae, or Strep. pneumoniae |
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What is the treatment with dosages of spontaneous bacterial peritonitis?
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Empiric coverage antibiotic (just 1)
-ceftriaxone 1 – 2 g IV QD -cefotaxime 2 g Q 8 – 12H -piperacillin/tazobactam 3.375 g Q 6H -ticarcillin/clavulanate 3.1 g Q 6H IV -ofloxacin 400 mg BID -levfloxacin 500 mg QD -ciprofloxacin 500 mg BID |
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What is the prophylaxis treatment of spontaneous bacterial peritonitis?
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-req previous SBP or low protein (<1g) in ascitic fluid
- TMP/SMX 1 DS tab QD - norfloxacin 400 mg QD - ciprofloxacin 250 mg QD or 750 mg QW (old school dosing) |
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What is hepatic encephalopathy caused by? What are the s/sx of hepatic encephalopathy?
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- ↑ NH3 generated by gut bacteria
- caused from: infection, varicies, renal insufficiency, electrolyte abnormalities, ↑ dietary protein, TIPs, hepato-renal syndrome - s/s: neurological Δs, asterixis |
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What is the treatment regimen for hepatic encephalopathy?
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- protein 10 – 20 g/day restriction until HE improves
- lactulose 45 mL/hr until catharsis, MD 15 – 45 mL Q 8 – 12H o MOA = lowers colonic pH & binds NH3 - antibiotics = ↓ gut flora → ↓ NH3 production -metronidazole 250 mg Q 6H for ≤ 2 weeks o SE: peripheral neuropathy, alcohol-upset -neomycin 4 – 12 g daily in divided doses, don’t use > 2 weeks o SE: malabsorption, nephrotox, ototox -rifaximin 400 mg Q 8H x 5 – 10 D oSE: HA, gas |
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What is the MOA and treatment of thrombocytopenia?
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thrombocytopenia ( plt < 100,000/mm3)
-MOA = ↓ platelet production & splenic sequestration - vit. K ( ↑ INR, PT, aPTT, bruising/bleeding) o 10 mg SQ x 3D |
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What is the mortality for type 1 and type 2 hepatorenal syndrome pts?
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-type 1: w/in 10 days
-type 2: 3-5 months after presentation |
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What causes hepato-renal syndrome? What are the s/sx?
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- ↑ renal vasoconstriction → decreased renal function
-s/s: asterixis, scleral icterus, caput medusae, ascites |
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What is the treatment for hepato-renal syndrome?
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1st line: Alb + octreotide + midodrine
- Alb 1 g/kg x 1D, then 20 – 40 g/day - octreotide 100 mcg SQ TID or IVF - midodrine 5 – 7.5 mg po TID 2nd line: liver transplant |
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What are the two disease staging scores?
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-Child-Pugh
o used for dose reductions -MELD score o based on SCr, bili, INR, etiology of liver disease o determines if Pt. gets transplant or not |
