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NAUSEA AND VOMITTING-
- 1. Phenothiazines
- 2. Antihistamines-Anticholinergics
- 3. Benzodiazepines
- 4. Serotonin Antagonists
- 5. Metoclopramide (Reglan)
- 6. Cannabinoids
- 7. Antacids
- 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)
- 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
- 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
- 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).
- 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
- Indications: mild n/v
- MOA: coating the stomach and neutralizing gastric acid
- 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.
NAUSEA AND VOMITING CONCLUSIONS-
- Multiple stimuli/causes
- Algorithm for N/V:
- Special considerations (post-op, pediatric, chemo induced)
- Recommended order of treatement
- 1st line, 2nd line, 3rd line- look up!
- 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
- 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
- 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.
- 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
TREATMENT ALGORITHM FOR GERD-
- *see handout
- RECOMMENDED ORDER FOR TREATMENT-
- 1st line: H2 Antagonist
- 2nd line: PPI
- 3rd line: Referral for GI workup (endoscopy)
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
- 1. H-pylori
- 2. NSAID induced
- 3. Zollinger-Ellison syndrome (hypersecretory disorder/less common)
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
- *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.
- 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
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
- 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
- 1st line: Immodium
- 2nd line: Pepto-Bismol, Kaopectate
- 3rd line: Lomotil
- 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.
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.