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2013-03-23 11:59:50

GI meds. I skipped the anti-emetics except 5-HT3 receptor antagonist (only one on guide)
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  1. What are antacids used to treat?
    • Heartburn (GERD)
    • PUD
    • Hyperphoshatemia in CRF
    • Ca+ deficiency in post menopausal women/osteoporosis
  2. TRUE or FALSE
    Antacids neutralize acids in the GI tract and they all have the same ANC (Acid neurtralizing capacity).
    • FALSE.
    • Different combinations have different ANC
    • NaBicarb and CaCarbonate have HIGHEST ANC
  3. TRUE or FALSE
    Al & Mg based antacids are not absorbed with normal use.
    TRUE. Although chronic use will increase absorption.
  4. How are Al & Mg based antacids excreted?
    • According to our book:
    • Al based bind with phosphate ions in the intestine to form insoluble aluminum phosphate & are excreted in feces.
    • Mg based are excreted in urine. 
    • (Nancy says both are renally excreted)
  5. TRUE or FALSE
    Ca containing antacids require Vit D for absorption
    TRUE (and they're excreted mainly in the feces, 20% in urine)
  6. Should you place a hypercalcemic pt (or one who has renal calculi) on a calcium based antacids?
  7. TRUE or FALSE
    Mg based antacids are contraindicated in patients with renal failure or renal insufficiency.
  8. TRUE or FALSE
    It's ok to give an Al-based antacids to a patient with renal failure on dialysis.
  9. What patient population should you not prescribe Sodium bicarb to (or use caution)?
    It might affect pts with HTN, CHF, or renal failure. Could worsen illness...
  10. Mg based antacids can cause ____ and Al or Ca based antacids can cause ____ so ask the patient what their normal BM is like.....ackward!
    • Mg=diarrhea
    • Al or Ca = constipation
  11. Why do you need to do a drug to drug check when prescribing antacids?
    • They affect the absorption of a LOT of drugs!
    • Separate antacid administration with other drugs by at least 2 hrs.
  12. How are antacids used for GERD tx?
    • Usually pt takes them OTC prior to seeking help. Give Q30-60min until symptoms subside. Maintenance after meals and bedtime.
    • **H2 receptor antagonist and PPI are 1st line therapy
  13. How are antacids used for PUD tx?
    • Used as adjunct to triple therapy tx.
    • Used after meals and at bedtime.
  14. Antacids for Ca deficiency..
    CRF = ____mg /day
    osteoporosis prevention..
    Men & pre-menopausal women = __mg/day
    Post- menopausal women = ___mg/day
    • 1000mg in CRF
    • 1000mg men and pre-meno
    • 1500mg in post-meno

    Doses higher than 2000mg/day not recommended (can only absorb so much!)
  15. When an elderly patient needs an antacid, make sure you monitor they're ___level because they take a lot of ___ containing products chronically.
    Magnesium & Magnesium
  16. Which drugs do antacids effect absorption of? There are a million but just in case...
    (Hateful Nancy might ask, I suggest picking D. all of the above)
    • Dilantin (seizures)
    • Levodopa (Sinemet-Alzheimers)
    • ASA
    • Digoxin
    • Quinidine
    • Sulfoneureas (DM)
    • Ticlid (stroke prevention)
    • H2 receptors
    • TB drugs
    • Thyroid medications
    • ABX
    • Iron
  17. TRUE or FALSE
    Diarrhea usually requires medication
    FALSE! Kids and elderly especially need to get rid of diarrhea (infection) naturally
  18. What patient population can quickly get dehydrated quickly from diarrhea?
    Children! (& elderly)
  19. Name an absorbent preparation anti-diarrheal  and describe how it works.
    Bismuth subsalicylate (Pepto-Bismal & Kaopectate) which has antisecretory and antimicrobial effects. 

    • Kaolin & Pectin (Kapectolin & Kao-Spen) 
    • Kaolin: clay-powder that attracts & holds onto bacteria
    • Pectin: thickens stool
  20. How does Lomotil ( Diphenoxylate with atropine) work to treat diarrhea?
    • Diphenoxylate is an opioid. 
    • Atropine causes decreased bowel secretions and slows peristalsis.

    I try to think lo (low) moti (motion)....helpful?!
  21. How does Loperamide (Imodium) work to tx diarrhea?
    It binds to opioid receptors and slows gastric motility.

    Similar action of Lomotil but you can get Loperamide OTC because it doesn't have opioids in it....
  22. Opioids decrease intestinal motility (useful for diarrhea) but it may cause _____.
  23. Are anti-diarrheals contraindicated in children with flu or viral illness?
    • YES! Diarrhea is getting rid of infection naturally....
    • Bismuth subsalicylate is contraindicated!
  24. A side effect of Bismuth (anti diarrheal) is
    black tongue and gray-black stools
  25. Diphenoxylate (lomotil) and Difenoxin (Motofen) are opioids and both have atropine. They are used to treat diarrhea but what are the side effects...
    • Dry, flushed, increased HR, urinary retention
    • CNS effects: dizziness, drowsiness, sedation, Headache
  26. Bismuth Subsalicylate (Pepto-Bismal or Kaopectate) may potentiate _____ ____.
    Salicylate toxicity (ASA toxicity)
  27. What anti-diarrheal is used to treat IBS?
    • Loperamide QID used as adjunct therapy...if it doesn't work, DC it!
    • (The main therapy for IBS is steroids and sulfasalazine)
  28. What anti-diarrheal is used to PREVENT traveler's diarrhea?
    Bismuth-subsaliclyate QAC and QHS.
  29. You're on vacation and you get diarrhea...what two drugs would you choose?
    • Bismuth subsalicylate q30min (max 8 doses) for up to 48hrs
    • Loperamide 4mg then 2mg qstool (max 8mg/day)
  30. How do you treat acute diarrhea?
    • 1st Kaopectate/peptobismol after each loose stool (1st line defense)
    • 2nd maintain hydration (kids-pedialyte, adults-flat soda)
    • 3rd opioids 3-4x/day or after each loose stool
    • (very strong, usually works in 1-2 doses)
  31. How do people get peptic ulcer disease?
    • They're old  (75yr +)
    • Addicted to NSAIDS
    • Took anti-coagulants
    • Prednisone use...
  32. TRUE or FALSE
    Sucralfate (Carafate) is used to treat PUD?
    TRUE, it selectively binds to ulcer tissue acting as a barrier
  33. Misoprostel (Cyotec) is a cytoprotective agent. How does it work?
    • It inhibits gastric secretion through inhibition of histamine stimulated AMP production.
    • Also has mucosal protective qualities
  34. What happens if you give Misoprostol to a pregnant patient
    • The Prostaglandin causes spontaneous abortion,  premature birth, or birth defects.
    • Category X (abortifacient)

  35. Cytoprotective agents still have side effects.
    Sulcralfate has SE of ___
    Misoprostol has SEs of ___ & ___ ___
    • Sucralfate = constipation
    • Misoprostol = diarrhea & menstrual problems
  36. TRUE or FALSE
    Sucralfate (cytoproctective agent) is safe for pregnant women of child bearing age
  37. Does sucralfate (cytoprotective agent) cause a decrease in absorption of other drugs?
    YES (to name a few, anticoagulants, ABX, and quinidines)
  38. TRUE or FALSE
    Misoprostol (cytoprotective agent) can cause diarrhea when taken with other Mg containing antacids
  39. How would you treat an ulcer?
    • 1st stop NSAID
    • Use misoprostol (QID) if pt requires NSAID therapy
    • *don't forget the pregnancy test!
  40. How would you treat a duodenal ulcer?
    • Sucralfate for us to 8 weeks to heal the ulcer.
    • Give QID 1 hr before meals
  41. Cytoprotective agents differ in when they should be adminstered. 
    Sucralfate is taken on an ____ _____.
    Misoprostol is taken with _____.
    Sucralfate is taken on an empty stomach.(remember it wants to bind and act as barrier)

    Misoprostol is taken with food.
  42. TRUE or FALSE
    Once you are sick, ant-emetics will not help.
  43. How does Ondansetron (Zofran) work?
    It is an 5-HT3 receptor antagonist. It blocks serotonin on vagal nerve terminals & in the chemoreceptor trigger zone.
  44. 5-HT3 receptor antagonist like Zofran (Ondansetron) may mask progressive ____
  45. What are some side effects of Zofran (Ondansetron)?
    • Constipation, HA, fatigue, dizziness, & diarrhea
    • Rare cases of Tachycardia, bradycardia, hypotension, & prolonged QT
  46. 5-HT3 receptor antagonist  are used to treat ___ & ___ due to drugs or ____.
    • Nausea and Vomiting
    • Gastroenteritis
  47. What kind of ant-emetics are used to treat motion sickness?
    • Anti-histamines 
    • Dimenhydrinate (Benadryl) and meclizine (Anti-Vert)
  48. TRUE or FALSE
    5-HT3 receptor antagonist (Zofran aka Ondansetron) are the drug of choice for gastroenteritis and have the fewest side effects.
  49. What is the ONLY prokinetic drug?
    REGLAN (metoclopramide)
  50. When do you use a prokinetic (Reglan)
    • Gastroparesis (10mg 30min before meals)
    • GERD (rare for this)
    • Emesis w/CA chemo 
    • Diabetic Gastroparesis (10mg 30min before meals and at bedtime for 2-8 weeks)
  51. How does a prokinetic (Reglan) work?
    • Stimulates the motility of the upper GI tract w/out stimulating gastric, biliary, or pancreatic secretions.
    • Results in increased tone/amplitude of gastric contractions, relaxes pyloric sphincter & duodenum bulb, increases peristalsis of duodenum & jejunum, accelerates gastric emptying & increases speed of gastric transit.
  52. TRUE or FALSE
    Prokinetic (Reglan) has some anti-nausea properties
    TRUE not sure of exact mechanism but thinks it sensitizes tissues to actions of ACh
  53. Reglan (Metoclopramide) has black box warning d/t risk of developing _____ _____.
    • Tardive dyskinesia
    • Especially w/chronic use (not meant to be used for more than 12 weeks...but DM use it for gastroparesis so tend to be longer users)
  54. When is using a prokinetic (Reglan) contraindicated?
    GI hemorrhage, mechanical obstruction, new surgery on the GI tract, or perforation

    • Use cautiously for pt w/hx of depression
    • *can cause depression including suicidal ideation
  55. About 20-30% of pt's taking Prokinetic drugs (Reglan aka metoclopramide)will have SE so you need to know them!!
    • Tardive dyskinesia
    • Depression or dizziness
    • Diarrhea
    • Hypoglycemia (DM)
    • Rare: galactorrhea, amenorrhea, gynecomastia, impotence secondary to hyperprolactinemia
  56. Can additive CNS depression when taking Reglan with other CNS depressants?
    Yes. There is also an risk of EPS with other drugs that have potential for EPS
  57. TRUE or FALSE
    Drugs with anticholinergic effects reverse the action of metoclopramide (Reglan) making it ineffective.
  58. You need to give Joe a dose Reglan (Metoclopramide) but he has a Creatinine clearance below 40ml/min. How should you initiate his therapy?
    Start at approximately half the recommended dose.
  59. How does H2 receptor antagonist (Rantidine aka Zantac) work?
    • H2RA's are reversible competitive blockers of histamine at histamine 2 receptors.
    • It's HIGHLY selective.
    • Reduces gastric acid secretion by 35-50%
  60. TRUE or FALSE
    H2 Receptor antagonist have different potencies in controlling gastric acid secretion.
    • TRUE
    • Zantac is 5-12x more potent than Cimetidine
    • Famotidine is 30-60x more potent than Cimetidine
    • ***Potency does not equal effectiveness, just dosing...
  61. TRUE or FALSE
    Occasional reversible hepatitis or hepatocellular disorders have occurred with Zantac (Rantidine)
    • TRUE.
    • Also be cautious of renal impairment
  62. Is Zantac ok to give a child?
  63. How would you treat GERD with Zantac (a H2 receptor antagonist)
    • Twice daily dosing
    • Success with children however, no empiric tx of infants with GERD so don't initiate treatment without FIRM diagnosis
  64. TRUE or FALSE
    You should never give a Rx for Zantac because the patient can easily get it OTC
    FALSE! OTC is less expensive than Rx but dose is lower and cost difference is lost in the increased number of pills so just write the Rx
  65. Do you take H2 Receptor antagonist (Zantac aka Rantidine) with or without meals?
    • Take Zantac WITH meals
    • Seperate from antacids by 30min to 1hr
  66. How does a Proton Pump Inhibitor (Omeprazole aka Prilosec) work?
    • Reduces the H+ secretion by inhibition of the H+/K+/ATPase enzyme system at the secretory surface of the parietal cell. 
    • Decreases in acid secretion (lasts up to 72hrs after each dose....VERY effective!)
  67. What PPIs are approved in children as young as 1 yr?
    • Esomeprazole
    • Omeprazole (Prilosec)
    • Lansoprazole
  68. Is Pantoprazole or Rabeprazole approved for children less than 12yr old?
  69. TRUE or FALSE
    PPI (Omeprazole) is metabolized extensively in the liver and needs to be used cautiously in those w/hepatic dysfunction or the elderly
  70. Can you give a pregnant patient a PPI (Omeprazole aka Prilosec)?
    • It's category B or C
    • Congential anomalies have been reported so use w/caution!
  71. PPIs (Omeprazole aka Prilosec) put patients at risk for significant nutrient deficiencies. What kind?
    • Iron
    • Vitamin B
    • Calcium 
    • So check LABS!
  72. Can long term use of PPI (omeprazole or Prilosec) increase risk of osteoporosis and increased hip fractures?
    YES! (I have a friend who broke her arm falling at a Bruins game, she was young but on a PPI for a long time...)
  73. TRUE or FALSE
    Long term PPI (Omeprazole or Prilosec) can decrease risk of C. Diff, Salmonella, and Camphylobacteria infections.
    FALSE! It increases this risk!
  74. PPI (omeprazole or Prilosec) can decrease effectiveness of ___ drugs.
    HIV drugs (atazanavir, indinavir, & nelfinavir)

    Also decrease absorption of drugs that depend on acidic gastric pH to be effective
  75. ____ has a black box warning regarding interactions with Omeprazole (Prilosec)
    • Clopidrogrel (Plavix)
    • It inhibits Plavix absorption by 46%!

    *Also increased monitoring of INR w/Warfarin
  76. Do you take a PPI (omeprazole or Prilosec) before or after meals?
    BEFORE meals
  77. What types of problems do you treat with a PPI (prilosec or omprazole)
    • Duodenal & Gastric Ulcers (comination w/abx for H. Pylori)
    • GERD (8weeks-may need to double dose for 1st four weeks)
    • Zolliger-Ellison Syndrome (need higher dose and longer use)
  78. PPI may mask the symptoms of ____ cancers
  79. Explain the step up approach for GERD
    • Step 1: Lifestyle modifications
    • not working then Step 2: H2RA for 4-8weeks
    • if that works, H2RA for 8-12weeks
    • if it doesn't work, step 3: PPI for 4-8 weeks
    • if it works, try going back to H2RA & if needed go back onto PPI...

    If PPI doesn't work, consult a gastroenterologist
  80. Explain the step down approach for GERD
    • Step 1: Lifestyle modifications & PPI for 8 weeks
    • If it works, go down to H2RA
    • If not, increase PPI to 2s/day for 4-8 weeks
    • If that works in 4 weeks, go back to PPI 1x/day & reassess in 6-12 M
    • If doesn't work, after 8 weeks of PPI refer to gastroenterologist