GI MEDS

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ssilvis
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202047
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GI MEDS
Updated:
2013-02-20 12:38:32
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GI MEDS
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MEDS
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  1. NAUSEA AND VOMITTING-
    • 1. Phenothiazines
    • 2.  Antihistamines-Anticholinergics
    • 3.  Benzodiazepines
    • 4.  Serotonin Antagonists
    • 5.  Metoclopramide (Reglan)
    • 6.  Cannabinoids
    • 7.  Antacids
  2. PHENOTHIAZINES-
    • 1st line treatment for N/V- commonly used
    • Indications: monotherapy for mild to moderate N/V
    • MOA- involves dopamine receptro blockade in CTZ (chemoreceptor trigger zone)
    • Contraindications: caution with other CNS depressants, sedatives, hypnotics
    • Adverse Reactions: sedation and drowsiness, EPS effects (masklike face, drooling, trmorem cogwheel rigidity)
  3. ANTIHISTAMINES-ANTICHOLINERGICS-
    • Indications: mild nausea and motion sickness
    • MOA: interuption of visceral afferent pathways
    • Prototypes: Visteral/Atarax, Antivert, Dramamine, Scopolamine patch
    • Contraindications: during pregnancy
    • Adverse Reactions: may potentiate CNS depression with ETOH, tranquilizers and sedatives. CNS: sedation, drowsiness, confusion.  Anticholinergic: blurred vision, dry mouth, urinary retention, tachycardia THESE S/E MAY CAUSE NEED FOR D/C
  4. BENZODIAZEPINES-
    • Indications- prevent emesis, decrease anxiety, may cause amnesia (useful for anticipatory n/v associated with chemotherapy)
    • MOA- not fully understood, may inhibit vomiting center, used in combo with other agents
    • Prototypes- Ativan
    • Contraindications- not with renal or hepatic failure.
    • Adverse Reactions- CNS depression: drowsiness, fatigue, memory impairment, impaired coordination, paradoximal stimulation
  5. SEROTONIN ANTAGONISTS-
    • Indications: prevent chemo-induced N/V
    • MOA: antagonizing type 3 serotonin (5HT3) receptors in the CTZ
    • Prototypes: COSTLY- zofran, kytril
    • Contraindications: pregancy risk B (no harm in animal studies), caution in breast feeding mothers
    • Adverse reactions: h/a 25%, diarrhea 16%, EKG changes (monitor electrolyte imbalances (hypo K and hypo Mg).
  6. METOCLOPRAMIDE (REGLAN)-
    • Indications: treat N.V, diabetic gastroparesis, GERD
    • MOA: enhances motility and gastric emptying, dopamine receptor inhibition in  the CTZ
    • Prototypes: Reglan
    • Contraindications: caution in renal failure/ Creat clear < 50%, excreted by kidneys, sedation, potentiate CNS depression
    • Adverse Reactions: EPS effects (dystonia, involuntary movements, motor restlessness- TREAT THESE WITH BENADRYL PO OR IV
  7. ANTACIDS-
    • Indications: mild n/v
    • MOA: coating the stomach and neutralizing gastric acid
    • Prototypes:
    • 1.  Calcium carbonate
    • 2. Magnesium Hydroxide
    • 3.  Aluminum Hydroxide
    • 4.  Aluminum Carbonate
    • Contraindications: extended use requires GI workup, monitor electrolytes (alum and Mg may accumulate)
    • Adverse Reactions: may interfere with other medication absorption/requires timing of doses.
  8. NAUSEA AND VOMITING CONCLUSIONS-
    • Etiologies:
    • Multiple stimuli/causes
    • Mechanism/treatment
    • Algorithm for N/V:
    • Special considerations (post-op, pediatric, chemo induced)
    • Recommended order of treatement
    • 1st line, 2nd line, 3rd line- look up!
  9. GERD-
    • Definition-
    • Reflux of stomach contents into esophagus, abnormal exposure of esophageal mucosa to retrograde gastric contents.
    • Causes: Transient relaxation of the lower esophogeal sphinchter (LES)
    • Risk factors- see handout
    • S/S- see handout
    • Clinical stages: see handout
  10. GERD TREATMENT-
    • 1.  H2 receptor Antagonists
    • Indications: initial treatment of presenting problematic symptoms(heartburn, indigestion, belching, epigastric pain)
    • MOA- decrease acid secretion by inhibition of H2 receptors
    • Prototypes:
    • 1. Tagamet- 1ST LINE
    • 2.  Zantac
    • 3.  Pepcid
    • 4.  Axid
    • Contraindications: Tagement may d/d interactions, Zantac had no d/d interactions
    • Adverse Reactions: h/a, confusion, dizziness, gynocomastia withTagament.
  11. GERD TREATMENT-
    • 2. Proton pump inhibitors-
    • Indications: initial treatment of presenting problematic symptoms (heartburn, indigestion, belching, epigastric pain) expensive agents.
    • MOA: inhibits parietal cell proton pump (H+, K+), inhibits gastric acid secretion
    • Prototypes: Prilosec and Prevacid
    • Contraindications: do not crush or open capsule
    • Adverse Reactions: diarrhea, h/a, flatulence
  12. TREATMENT ALGORITHM FOR GERD-
    • *see handout
    • RECOMMENDED ORDER FOR TREATMENT-
    • 1st line: H2 Antagonist
    • 2nd line: PPI
    • 3rd line: Referral for GI workup (endoscopy)
  13. PEPTIC ULCER DISEASE-
    • Definition: chronic Helibactor pylori  infection of the gastric mucosal lining
    • Incidence: 1 in 10 Americans (10% of pop), 6500 deaths per year
    • Causes-
    • 1.  H-pylori
    • 2. NSAID induced
    • 3.  Zollinger-Ellison syndrome (hypersecretory disorder/less common)
  14. PEPTIC ULCER DISEASE TREATMENT OPTIONS/COMBO THERAPY (P. 377)-
    • 1.  Triple therapy:
    • Metronidazole/ Omeprazole/Clarithromycin (MOC): 88% eradication rate, bid dosing X 10-14 days
    • 2.  Quadruple Therapy:
    • Bismuth/Metronidazole/Tetracycline/PPI, qid X 14 days
  15. COMBO TREATMENT-
    • *see handout
    • 1.  Antibiotic
    • Metronidazole: active against various anarobic bacteria and protozoa.
    • Amoxicillin: interfers with cell wall synthesis/higher eradication rates if used in  combo with 2nd abt and PPI.
    • Tetracycline: inhibits protein synthesis/gram + and gram - infections/ give 2 hours before or after food for improved absorption used with bismuth to facilitate binding.
    • 2.  H2 receptor antagonis/ or PPI-
    • Improves the action  of abt. by increasing gastric pH- Ranitidine is used most often.
    • 3.  Antacids-
    • Neutralize HCL, DO NOT heal ucers but provide rapid relief of pain and dyspepsia.
    • Can cause diarrhea or constipation
    • Potential d/d interaction: affect absorption
    • consider co-morbities: renal impairment- electrolyte disturbances
    • 4.  Bismuth Subsalicylate-
    • Complex MOA: inhibits protein/cell wall and ADT synthesis thus prevents H-pylori from adhering to gastric epithelium.  Use in combo with at least 2 antibiotics.
    • 5.  Sucrafate-
    • Provides a barrier to prevent penetration of acid/pepsin and bile into gastric mucosa.
    • 6.  Misoprostol-
    • Inhibits secretion of gastric acid, especially useful in NSAID induced ulcer disease, use with caution in child bearing females.
  16. CONSTIPATION-
    • Definition: infrequent or inadequate evacuation of stool
    • Causes- Medication(see handout), Diet: inadequate fiber and fluids, overuse/dependency on laxatives
    • Risk factors: see handout
    • S&S- see handout
    • Clinical Stages: see handout
  17. CONSTIPATION TREATMENT ALGORITHIM-
    • 1st line: Bulk forming agents
    • 1.  Methhycellulose
    • 2.  Psyllium
    • 3.  Docusate
    • 4.  Glycerin
    • 2nd line:
    • 1.  MOM
    • 2.  Lactulose
    • 3.  Sorbitol
    • 3rd line:
    • 1.  Stimulant laxatives: Senna, cascara, biscodyl
    • 2.  Sodium Biphosphates
    • 3.  Mag. Citrate
    • 4.  Castor oil
  18. DIARRHEA-
    • Definition: increase in frequency of loose watery stools (3 or more daily)
    • Causes: see handout
    • 1.  Medications- antibiotics, antacids, metformin, colchicine.
    • 2.  Organisms- see hanout for appropriate treatment based upon culture
    • 3. Comorbidities
    • C-diff- see handout
    • Clinical stages: see  handout
  19. DIARRHEA ALGORITHIM-
    • 1st line: Immodium
    • 2nd line: Pepto-Bismol, Kaopectate
    • 3rd line: Lomotil
  20. IBS-
    • Definition: functional bowl disorder involving motility and sensory abnormalities.  Leads to dysregulaiton of the bowel as normally modulated by CNS.
    • Hallmak sign: abdominal pain/change in consistancy of stool/relieved with defecation.
    • ROME II criteria for IBS (see handout)
    • Recommended order for treatment: see handout
    • Overview of selected treatments for IBS- see handout.
  21. MEDS FOR IBS-
    • *depends on presenting s/s
    • 1.  Bulk forming agents
    • 2.  Hyperosmotic laxatives
    • 3.  Surfactant laxatives
    • 4.  Anti-diarrheal agents
    • 5.  Anti-spasmodic/Anti-cholinergic agents
    • 6.  Newer agents: brain-gut-neurotransmitter connection.
    • -Serotonin-3 receptor: Lotronox
    • -Serotonin-4 Agonist: Tegaserod (Zelnorm)
    • Can get Gallbladder disease, and do not give in renal or hepatic failure.

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