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pharm exam 4
GI disorders
| Question | Answer |
|---|---|
| Fluid in the GI Tract | 2 L oral intake 7 L intestinal secretions |
| ileum | 1 L can be reabsorbed in the 3rd part of the SI (ileum) |
| colon | excretes 100mL |
| things that disrupt the GIT | Change in active ion transport Change in motility Increase in osmolarity Increase in hydrostatic pressure Surgical alterations |
| anything disrupting the ileum or colon cause | a disrupt in fluid balance in body and the ability to reabsorb/secrete |
| causes of diarrhea | viruses, bacteria, food (poisoning), medications |
| diarrhea mechanisms | Secretory Osmotic Exudative Altered Intestinal Transit |
| diarrhea mechanisms: secretory | cells of intestines secrete fluids more rapidly into intestine which means reabsorption can't happen as effectively |
| diarrhea mechanisms: osmotic | solutions with more molecules want to make area isotonic - sugars will want to bring water into the intestines unknowingly |
| diarrhea mechanisms: exudative | damage to tissues |
| diarrhea mechanisms: Altered Intestinal Transit | changing hormones, acting on receptors, shortening GIT |
| evaluating diarrhea | assess for the cause!! because not all diarrhea is the same |
| what to assess for in diarrhea | Assess for contraindication to treatment; e.g. fever, hypotension, blood Assess for dehydration – skin turgor, mucous membranes Assess history of substance abuse Assess beliefs about bowel habits |
| what to educate pt on with diarrhea | rapid reduction of anti-diarrheal when diarrhea dissipates |
| if you overuse anti diarrhea meds, | you can cause constipation |
| non pharm management of diarrhea aka | HYDRATE |
| non pharm management of diarrhea | oral rehydration solutions (carbohydrate, Na, K, CL, Citrate or Bicarbonate) |
| examples of oral rehydration solutions | Pedialyte and Enfalyte |
| pharm management of d: anti motility | loperamide (imodium) diphenoxylate (lomotil) paregoric tincture of opium |
| anti motility agents are | have opioid component |
| anti motility agents work by | slowing down the GIT which allows GIT for more time to absorb |
| loperamide (imodium) | give dose according to most recent stool, given OTC also anti secretory abuse potential - euphoria with high doses - lead to cardio probs |
| diphenoxylate (lomotil) | step up from imodium, need prescription |
| loperamide (imodium) and paregoric are not good for | pediatrics |
| if anti motility agents are overused | can cause CNS toxicity |
| Opiate derivative anti-diarrheals: mechanism of action | Prolong intestinal transit Increase gut capacity, prolonging contact and absorption Stimulate water absorption |
| diphenoxylate/atropine (lomotil) adverse effects | blurred vision, dry mouth, and urinary hesitancy dry mouth and dizziness (anticholinergic) |
| pharm management of d: adsorbent aka | bulking agents |
| pharm management of d: adsorbent are available in | outpatient |
| pharm management of d: adsorbent examples | Kaolin-Pectin (Kapectolin®) Polycarbophil (e.g. FiberCon) Attapulgite (Di-Gon II, Diarrest) |
| Polycarbophil (e.g. FiberCon) | calcium based so will interact with medications that interact with cations since they bind things up |
| pediatric indicated bulking agents | Kaolin-Pectin (Kapectolin®) Attapulgite (Di-Gon II, Diarrest) |
| pharm management of d: anti secretory | Bismuth Subsalicylate (Kaopectate®) |
| pharm management of d: anti secretory is available in | chewable tablets/oral suspension |
| warning with Bismuth Subsalicylate | salicylate content – aspirin allergy; ulcers; anticoagulant use or kids |
| side effect of Bismuth Subsalicylate | black tongue, black stools |
| KIDs list stands for | Key potentially Inappropriate Drugs in pediatrics |
| pharm management of d: miscellaneous | lactase lactobacillus acidophilus, bulgaricus octreotide |
| lactase is an | enzyme replacement |
| lactase works by | breaking down lactose into the 2 sugars that can be absorbed |
| lactase is available in | chewable tablet/oral suspension |
| lactase is safe in kids | 1yr or older |
| lactobacillus acidophilus, bulgaricus is a | bacterial replacement |
| constipation is characterized by | Difficult or infrequent passage of stool Straining, Incomplete defecation |
| quantification of constipation | less than 3 BM per week |
| causes of constipation | Diet Hypothyroidism Medications with Ca, Aluminum or opioids Obstruction |
| higher risk of constipation in hospital because | decreased immobility which means decreased motility |
| risk factors for constipation | Low activity Female Non-white Advanced Age Low level education/income |
| medications that cause constipation | Anticholinergic Opiates Calcium Channel Blockers Aluminum Iron Phenothiazines 5-HT3 receptor antagonists |
| medical causes of constipation | IBS Tumors Diabetes Mellitus Hypothyroidism Heart Failure Pregnancy Spinal Cord Injury Parkinson’s Disease |
| primary function of the colon | reabsorption of water from intestinal content |
| the longer the fecal matter in the colon, | the "drier" and more formed it is |
| normal defecation physiology | controlled by cerebral cortex voluntary contol Extended contraction of external sphincter - “holding it” |
| defecation controlled by cerebral cortex | “training” to release in acceptable times/places |
| voluntary control of defecation | Contracts sphincter to prevent defecation Inhibits external anal sphincter to allow defection |
| Extended contraction of external sphincter - “holding it” | Defecation reflex dissipates “Urge” does not recur until additional feces enter rectum – several hours later |
| non pharm approaches to constipation | activity/exercise - could be even just walking dietary fiber - fruits or veggies fluid intake!!! if not contraindicated establish bowel routine - avoid delays, help get to BR |
| how much fluid intake should a person get during constipation | 48-80 oz/day, approximately 1.5 – 2.4L/day |
| last resort to treating constipation | laxatives |
| types of laxatives | bulk forming emollients osmotic (slow) stimulants/cathartics osmotic (fast) intestinal secretagogues opioid antagonists |
| bulk forming laxatives | psyllium bring bulk into stool to create more pressure on baroreceptors |
| emollient laxatives | docusate oily components, make feces more slippery and slide out easier so less strain |
| osmotic (slow) laxatives | Lactulose, Sorbitol, Polyethylene glycol 3350 (Miralax®) bring fluid into bowel |
| stimulants/cathartics laxatives | Senna, Bisacodyl (oral) create irritation and stimulate bowels to say "get moving" |
| stimulants/cathartics laxatives cause | cramping while others are more gentle |
| osmotic (fast) laxatives are | electrolyte based |
| osmotic (fast) laxatives examples | Magnesium citrate Magnesium hydroxide (Milk of Magnesia) Bisacodyl (rectal) (Dulcolax) |
| intestinal secretagogues laxatives | Lubiprostone, Linaclotide (linzess), Plecanatide used for IBS |
| opioid antagonists laxatives | Methylnaltrexone, Naloxegol used to treat constipation due to opioid use |
| key laxative examples from slide!! | bisacodyl magnesium citrate psyllium docusate |
| bisacodyl MoA | Irritate mucosa > H20 into colon > peristalsis |
| bisacodyl causes | Watery stool, fluid/electrolyte, acid-base imbalance |
| bisacodyl SE | abd cramping, pain |
| magnesium citrate MoA | Osmotic effect > H20 into colon > distension > peristalsis |
| magnesium citrate: important to remember!! | Fluid/electrolyte imbalance; avoid in renal failure because pt will be unable to excrete Mg which will lead to hypermagnesemia |
| psyllium MoA | Add mass > peristalsis > defecation |
| psyllium must be taken with | water!! |
| docusate MoA | decrease surface tension of feces > water/fats penetrate > softer, easier to expel |
| irritable bowel syndrome (IBS) background | 10% adults Chronic abdominal pain w/altered bowel habits and no other cause Either Constipation or Diarrhea- Predominant |
| IBS dx based on what criteria | ROME IV criteria |
| IBS dx by | Recurrent abd pain/discomfort>3days/mo in last 3 mo and 2 of the following: Relieved with defecation, onset associated with change in stool frequency, onset associated with change in stool appearance |
| IBS constipation treatment path | 1. Dietary Fiber/Fluid 2. Osmotic laxatives 3. Linaclotide,plecanitide, tenapanor, lubiprostone 4. Serotonin-4 agonist (tegaserod) |
| IBS diarrhea treatment path | 1. Limit lactose, caffeine, alcohol food/drug triggers 2. Loperamide 3. Rifaximin/eluxadine/TCA 4. Serotonin-3 antagonists (alosetron) |
| stool scale to measure stool patterns | bristol stool form scalen |
| nausea | inclination to vomit or feeling that emesis in imminent |
| vomiting | ejection or expulsion of gastric contents – often forceful and out of our control |
| who is at risk for n/v | Post-Op Mechanical/Obstructive MI DKA Migraine Vestibular Disorders Uremia Pancreatitis Noxious Odors Pregnancy Drug Withdrawal |
| most common SE of drug therapy | n and ha |
| patho of n/v: n is mostly in | CNS not GIT!! |
| two important areas in patho of n/v | chemoreceptor trigger zone (CTZ) vomiting center (VC) |
| how does n/v occur | Impulses from Chemoreceptor Trigger Zone (CTZ), cerebral cortex and visceral afferents from pharynx and GI tract to Vomiting Center (VC) |
| VC coordination results in | Salivation Pharynx closure (brief) Respiratory stop Abdominal muscles contract ^^all of the above then results in vomiting |
| why do we salivate during vomiting | to protect oral cavity from acidic stomach contents coming up |
| CTZ stimulation | pregnancy, chemotherapy, other meds |
| when you block the stimulation of CTZ, then | decrease in n/v |
| neurotransmitters involved in n/v | Cholinergic Histaminic Dopaminergic Opiate Serotonergic Neurokinin Benzodiazepine |
| vestibular system controls | balance/movement |
| vestibular system: meds | histamine-1 - dimenhydrinate (dramamine) muscarinic-1 |
| CTZ meds | D2 – Prochlorperazine , Metoclopramide, Olanzapine (Zyprexa®), Haloperidol (Haldol®) NK1 – Aprepitant (Emend®), fosaprepitant 5HT3 – ondansetron (Zofran®) |
| VC meds | Histamine, Muscarinic, NK1, 5HT3 |
| very big deal causes of n/v | post op (PONV) chemo (CINV) |
| other causes of n/v | Mechanical obstruction Gastroparesis or GERD Pancreatitis Gastroenteritis Myocardial Infarction Migraine Vestibular Disorders DKA Uremia (renal disease) Medications Drug withdrawal Pregnancy Noxious odors |
| meds used for n/v | Phenothiazines Antihistamines 5-HT3 Receptor Antagonist Substance P/Neurokinin Antagonist |
| Phenothiazines examples | Promethazine, Prochlorperazine (Compazine) |
| Phenothiazines SE | blurred vision!, urinary retention, dry mouth!, photosensitivity, drowsiness, confusion |
| Phenothiazines components | anticholinergic, antihistaminic, dopamine |
| Phenothiazines are | on the BEERS list and are dose limiting |
| antihistamines examples | Hydroxyzine, Dimenhydrinate, Diphenhydramine |
| antihistamines SE | drowsiness, dizziness, confusion, dry mouth, blurred vision, urinary retention, tachycardia |
| 5-HT3 Receptor Antagonist examples | ondansetron (zofran) |
| 5-HT3 Receptor Antagonist SE | Diarrhea, headache, dizziness, constipation, fatigue, pain at injection site |
| 5-HT3 Receptor Antagonist are most useful in | PONV pts |
| Substance P/Neurokinin Antagonist examples | aprepitant |
| Substance P/Neurokinin Antagonist SE | fatigue, weakness, dizziness, headache, hiccups, arrhythmia |
| important to remember when using meds to treat N/V | using multimodal drugs and not multiple drugs of same class |
| treating n/v in children | Promethazine contraindicated children < 2years so not seen in pediatrics |
| treating n/v in elderly | Hydroxyzine, dimenhydrinate, diphenhydramine, promethazine – BEERS list because issue with sedation with the antihistamines |
| treating post on nausea | drugs like ondansetron – drugs of choice |
| identify risk factors for n/v | disorders or medications |
| specifics info to gather when assessing for n/v | Frequency, duration, precipitating factors Accompanying signs/symptoms - ex: pain Amount, color, odor, presence of blood Measures that relieved nausea |
| interventions for n/v | Identify triggers Avoid stimuli Premedication before painful procedures Administer anti-emetic medication 30-60 minutes prior to inciting events (radiation, chemotherapy, travel) Can oral medications be taken with food? |
| stimuli to avoid with n/v | odors, sights; excessive ingestion of food, alcohol, NSAIDs |
| more interventions for n/v | Pregnancy: Small frequent meals; Crackers/toast before rising in morning Supportive care; mouth rinsing; cool, wet washcloth to face/neck Replacement fluids/electrolytes Decrease environmental stimuli; motion |
| gastroparesis causes | Diabetes - more common in T1 Gastric Surgery (e.g vagotomy, gastric resection) |
| Metoclopramide (Reglan®) | Dopamine blockade in CTZ increase LES tone, increase gastric emptying, increase small bowel transit |
| SE/cautions with Metoclopramide | Extrapyramidal symptoms, Tardive Dyskinesia Beers list; KIDs List; renally dosed |
| ulcerative disease | Gastroesophageal Reflux Disease (GERD) Peptic Ulcer Disease (PUD) Stress-Related Mucosal Damage (SRMD) |
| disease modifying targets | Acid Reduction Cytoprotection - protecting the GIT Risk Mitigation |
| GERD is characterized by | regurgitation of gastric contents into esophagus |
| symptoms of GERD | heartburn!, dysphagia, belching, hypersalivation, odynophagia; also chest pain, hoarseness, chronic cough |
| GERD may result in | tissue damage due to gastric acid and pepsin |
| examples of tissue damage caused by GERD | esophagitis, Barrett’s esophagus, strictures, adenocarcinoma |
| patho of GERD | Reflux of gastric contents into esophagus/mouth Caused by incompetent lower esophageal sphincter (at the junction of esophagus and stomach) |
| risk factors for GERD | Obesity Age >40-50 years Pregnancy Smoking Alcohol consumption Medications Foods |
| other contributing factors to GERD | Gastric distention Recumbent position |
| non pharm treatment strategies for GERD | Dietary changes, meal size Weight loss Smoking cessation Remaining upright after eating Elevating head of bed |
| pharm treatment strategies for GERD | Proton-pump Inhibitors (PPIs) Histamine-2 receptor antagonists (H2RAs) Antacids |
| peptic ulcer disease (PUD) is distinct from gastritis in that | ulcers are larger (>5mm) and deeper (into muscularis mucosa) |
| PUD usually occurs in | the stomach (gastric ulcer) or intestine (duodenal ulcer), but can occur in esophagus, jejunum, ileum or colon |
| causes of PUD | Helicobacter pylori + NSAID-induced Stress-related mucosal damage (SRMD) |
| risk factors for PUD | smoking, alcohol use, hypersecretory conditions, medication non-adherence, chemotherapy, radiation, shock, psychological stress |
| presentation of PUD | Pain usually 1-4 hrs after eating and usually relieved by food because food is neutralizing of the stomach acid |
| diagnosis of PUD | Pain is not necessary for diagnosis Diagnosis dependent on endoscopic visualization of ulcer Helicobacter pylori testing – endoscopic, urea breath test, fecal antigen, blood antibody |
| meds for GERD and PUD | different doses for various indications |
| meds for GERD and PUD options | decrease gastric acidity, cytoprotection |
| decrease gastric acidity | antacids, proton pump inhibitors, Histamine-2 Receptor Antagonists |
| antacids | Aluminum Hydroxide, Magnesium Hydroxide, Calcium Carbonate) Tums®, Maalox®, Rolaids®, Mylanta® |
| proton pump inhibitors (PPIs) | Omeprazole, Prilosec® |
| Histamine-2 Receptor Antagonists | Famotidine, Pepcid® |
| cytoprotection med examples | Misoprostol, Sucralfate |
| antacids work by | Neutralizing of Stomach Acid ( HCl) |
| antacids SE | Al – constipation, Mg- diarrhea, electrolyte disturbance |
| antacids major interactions | cation: chelation; Inc pH - solubility |
| are antacids safe in pregnancy | yes! |
| Histamine-2 Receptor Antagonists work by | decreasing HCl production by blocking histamine-2 |
| adverse effects of Histamine-2 Receptor Antagonists | diarrhea, dizziness, drowsiness, headache, confusion |
| major interactions of Histamine-2 Receptor Antagonists | cimetidine CYP inhibitor, medications that require acidic environment |
| clinical pearls for geri/peds/pre/lactating | renally eliminated and require dose adjustment |
| Famotidine used cautiously because | Beers list, renally eliminated, excreted in breastmilk, crosses placenta |
| are Histamine-2 Receptor Antagonists safe in pregnancy | yes, benefits outweigh the risks |
| Proton Pump Inhibitors (omeprazole, pantoprazole) work by | decreasing HCl production by parietal cells in stomach |
| PPIs SE | Diarrhea, bone fracture, hypomagnesemia, headache, acute interstitial nephritis, C. Diff risk |
| PPIs major interactions | omeprazole CYP inhibitor |
| why are PPIs on beers list? | yes for risk of CDI so use in caution |
| can PPIs be used with Histamine-2 Receptor Antagonists | yes, additively because they work differently than each other |
| misc medications examples | Misoprostol (Cytotec®) Sucralfate |
| Misoprostol (Cytotec®) | prostaglandin analog that is cytoprotective in the setting of NSAID use (which reduces naturally occurring protective prostaglandin E) |
| Misoprostol not used in | pregnancy or children |
| Misoprostol is used for | diarrhea |
| Sucralfate | sulfated sucrose/aluminum compound that provides a protective coating in stomach |
| Sucralfate may cause | hypophosphatemia |
| Helicobacter pylori Therapy | Acid reduction – Proton pump inhibitor twice daily antimicrobial combinations |
| antimicrobial combinations for Helicobacter pylori Therapy | Clarithromycin + Amoxicillin Bismuth subsalicylate + Metronidazole + Tetracycline |
| Bismuth subsalicylate can cause | tongue discoloration, black stools!!! |
| review of GERD | allows stomach acid to back up into the esophagus four major symptoms are heartburn, regurgitation, dysphagia, and waterbrash |
| review of PUD | general term that refers to ulcer formation in the esophagus, stomach, or duodenum |
| review of H pylori infection | a gram-negative, spiral bacterium that weakens the protective mucous lining of the stomach and duodenum |
| review of n/v | caused by stimulation of the chemoreceptors in the brain and GI tract |
Created by:
leh195