Causes of constipation - ANSWER-Low fiber
Low fluid intake
Inactive lifestyle
Aging
Diseases (IBS, Diabetes, Endocrine, neurological,
... [Show More] cancer)
Medications
Name some medications that can cause constipation - ANSWER-CCBs
Diuretics
Iron supplements
Calcium supplements
Opioids
Anticholinergics
1st line treatment for constipation - ANSWER-OTC laxatives
What are indications for prescription constipation medications targeted to a specific diagnosis? - ANSWER-Chronic idiopathic constipation
IBS w/ constipation
Opiod induced constipation
Docusate - ANSWER-stool softener
Mineral oil - ANSWER-lubricants
Psyllium - ANSWER-Fiber/bulk agent
Glycerin, lactulose, sorbitol, polyethylene glycol, saline laxatives - ANSWER-Osmotic agents
Bisacodyl, senna - ANSWER-Stimulant laxatives
Docusate (colace) MOA - ANSWER-Surfactant laxative, increases water, fat penetration of the stool, allows for easier passage of stool
Contraindications to docusate (colace) - ANSWER-Mineral oil (will increase absorption of mineral oil)
Is mineral oil for long term use? - ANSWER-No, occasional constipation
Precautions for mineral oil - ANSWER-Avoid long term
Avoid in bedridden patients - aspiration
Avoid in children, elderly, pregnancy
Can decrease absorption of fat soluble vitamins
Contraindications for mineral oil - ANSWER-Docusate (increase absorption of mineral oil)
Fiber/bulk agents MOA - ANSWER-Adds bulk, holds water in stool, promotes peristalsis
Precautions for fiber/bulk agents - ANSWER-Need to drink lots of water and move around, don't use in bedridden patients or with fluid limitations
Special populations for fiber/bulk agents - ANSWER-Older adults need to continue to drink and move around
Pregnancy ok with plenty of water
Glycerin MOA - ANSWER-Osmotic agent that induces evacuation by local rectal stimulation
Special populations for glycerin - ANSWER-Suppositiories (sizes for infants, kids, adults)
Commonly used in children
Can be used in pregnancy
Lactulose, sorbitol MOA - ANSWER-Osmotic agents, non-absorbable sugars pull water into lumen of colon, promote peristalsis
Long term use for lactulose, sorbitol - ANSWER-Prevention and treatment of chronic constipation; daily use not recommended
Precautions for lactulose, sorbitol - ANSWER-Electrolyte imbalance; patients with DM (high amount of lactose)
Special populations for lactulose, sorbitol - ANSWER-Daily use not recommended due to electrolyte imbalance
Polyethylene glycol MOA - ANSWER-Non absorbable osmotic sugar, draws water into lumen of Colon but also contains electrolytes to prevent electrolyte shifts into colon
1st line constipation agent in hospitals , very common, safe for daily use - ANSWER-Polyethylene glycol
Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) MOA - ANSWER-Non-absorbable salts pull fluid into intestines and colon; promote peristalsis
Long term use for saline laxatives (Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) - ANSWER-Not for long term use (occasional)
Precautions for Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) - ANSWER-Cramping, dehydration, diarrhea, electrolyte imbalance
Special populations for Saline laxatives (Magnesium hydroxide, citrate; sodium phosphate) - ANSWER-Caution dehydration
Renal
Cardiac
Bisacodyl, Senna MOA - ANSWER-Stimulant agents, directly stimulate GI tract through local mucosal irritation
Special populations for bisacodyl, senna - ANSWER-For patients on chronic constipating meds, safe in older adults
Are stimulant laxatives ok for long term use? - ANSWER-Yes
pathophysiology of OIC - ANSWER-Options act on mu receptors in gut
- Decrease motility
- Increase absorption
- Decrease secretion
- Decrease defecation reflux
Naloxegol (Movantik) MOA - ANSWER-Peripherally u-opioid receptor antagonist, does not cross BBB
Place in therapy for Movantik - ANSWER-2nd line for OIC with chronic non cancer pain
Dose adjustments for Movantik - ANSWER-Renal impairment
Avoid in severe hepatic impairment
Naldemedine (Symproic) MOA - ANSWER-Inhibit u-opiod receptors in GI tract, does not cross BBB
Dose adjustments for Naldemedine (Symproic) - ANSWER-No renal dose adjustments; avoid in severe hepatic impairment
Treatment for community acquired acute diarrhea - ANSWER-Oral rehydration
No probiotics
Loperamide
Bismuth salicylate
Treatment for Traveler's diarrhea - ANSWER-Rehydrate, bismuth, loperamide, ABx
Prophylaxis: Bismuth, ABx, probiotics
Medications that can cause diarrhea - ANSWER-ACEi
Digoxin
Colchicine
Antacids
PPIs
T/F: Especially in Cdiff, the treatment goal of diarrhea should be to stop it as quickly as possible - ANSWER-False, need to get rid of pathogen or toxin
Name two anti motility agents - ANSWER-Loperamide
Diphenoxylate with atropine
Loperamide
Diphenoxylate with atropine MOA - ANSWER-Stimulate u-opiod receptors in gut, does not cross BBB
Precautions for anti motility agents - ANSWER-Discouraged in bloody or infectious diarrhea; addiction potential (60 mg will cross BBB)
Special populations for anti motility agents - ANSWER-Not recommended age <2
Weight based dosing for children up to 12
Black box warning for anti motility agents - ANSWER-QT prolongation
Name an antispasmodic agent - ANSWER-Dicyclomine
Dicyclomine MOA - ANSWER-Blocks ACh receptors in smooth muscle
Name an anti secretory/adsorbent agent - ANSWER-Bismuth salicylate (pepto-bismol)
Bismuth MOA - ANSWER-Decreases decreases, adsorbs bacteria, toxins, fluids, decreasing stool liquidity and frequency
Precautions for bismuth - ANSWER-Can blacken tongue and/or stool
May reduce absorption of some medications
Name some probiotics - ANSWER-Bifidobacterium
Lactobacillus
Saccharomyces boulardi
The smell of food, ingested food stimulates what 3 receptors on parietal cell - ANSWER-Histamine, gastrin, ACh
Stimulation of histamine/gastrin/ACh receptors on parietal cells results in activation of - ANSWER-Proton pump
(H+ combines with Cl to form HCL or stomach acid)
Antacids MOA - ANSWER-neutralize acid and raise pH
Drug interactions for antacids - ANSWER-Chelation (binding) - fluoroquinolones
Increases pH and reduces absorption of some drugs - itraconzaole, iron
Zantac 360 is brand name - ANSWER-Famotidine
T/F: Ranitidine is not currently on market - ANSWER-True
Drug interactions for H2RA - ANSWER-Cimetidine (most)
increases levels of warfarin, phenytoin, diazepam, propranolol
Special populations for H2RA - ANSWER-Require dose adjustment in moderate to severe renal impairment
Avoid in elderly at high risk of delirium
Precautions for proton pump inhibitors - ANSWER-May increase fracture risk
May decrease oral absorption of magnesium and B12 with chronic use
May increase risk of infection (C. diff)
Respiratory - CAP
Drug interactions for PPIs - ANSWER-Inhibitor of CYP2C19
- increase levels of clopidogrel (bleeding risk)
Which PPI Is better to use with clopidogrel? - ANSWER-Pantoprazole
Which neurotransmitters are associated with CINV? - ANSWER-Serotonin - 5HT3
Substance P Neurokinin NK1 receptor
Dopamine - D2
Which neurotransmitters are associated with vertigo, motion sickness - ANSWER-ACh
Histamine 1
Role of corticosteroids and olanzapine in CINV - ANSWER-Aid in helping antagonists
Acute CINV - ANSWER-0-24 hrs after chemo
Delayed CINV - ANSWER->24 hrs after chemo
Patients with high (>90%) chance of N/V should be treated with what agents - ANSWER-NK1 antagonist + 5HT3 antagonists + corticosteroid +/- olanzapine
Patients with moderate (30-90%) chance of N/V should be treated with what agents - ANSWER-5HT3 antagonists + corticosteroid +/- olanzapine
Patients with a low (10-30%) chance of N/V should be treated with what agents - ANSWER-Dopamine antagonists +/- corticosteroid
Name the serotonin (5HT3) antagonists - ANSWER-Ondansetron
Alosetron
Granisetron
Dolasetron
Palonosetron
Precautions for 5HT3 antagonists - ANSWER-QT prolongation, serotonin syndrome
Drug interactions for 5HT3 antagonists - ANSWER-Substrate of CYP3A4 (major)
Special populations for 5HT3 antagonists - ANSWER-Caution with patients at risk of arrythmia
Name the NK-1 antagonists - ANSWER-Aprepitant
Fosaprepitant
Precautions for NK-1 antagonists - ANSWER-hypersensitivity during IV infusions
Drugs interactions for NK-1 antagonists - ANSWER-Many; substrate of CYP3A4 (major); induces CYP2CP (warfarin)
Use of corticosteroids in N/V - ANSWER-Improves antiemetic activity 5HT3 antagonists and NK-1 antagonists
Olanzapine MOA - ANSWER-Second generation anti-psychotic with moderate antagonism of 5HT3, dopamine, histamine
Use for olanzapine - ANSWER-off label acute and delayed; break through N/V
Name the dopamine antagonists - ANSWER-Prochlorperazine
Promethazine
Use for dopamine antagonists - ANSWER-breakthrough
Name two benzo's - ANSWER-Lorazepam (Ativan)
Alprazolam (Xanax)
Uses for benzo's in N/V - ANSWER-to prevent anticipatory N/V
Special populations for scopolamine - ANSWER-Pregnancy - avoid
Avoid in older adults
Name the antihistamines - ANSWER-Dimenhydrinate
Meclizine
Uses for antihistamines - ANSWER- [Show Less]