Gastrointestinal Disorders: GERD Overview

Gastrointestinal Disorders

• Heartburn is the most common symptom of gastroesophageal reflux disease (GERD), also known as acid reflux.
• GERD occurs when acid or other stomach contents back up into the esophagus.
• GERD can be controlled through behavior modification and over-the-counter medication.
• If symptoms persist or worsen, a gastroenterologist should be consulted for additional tests and to rule out more serious conditions.

Learning Objectives

• Classify the severity of a patient's GI complaints.
• Describe diet, pharmacologic agents, and other issues that can exacerbate heartburn & dyspepsia.
• Compare and contrast the mechanism of action, indications, onset, and duration of action, and adverse effects of OTC medications used to treat heartburn & dyspepsia.
• Assess the advantages and disadvantages of OTC medications used to treat heartburn & dyspepsia.
• Recommend an appropriate drug treatment selection for a patient with heartburn & dyspepsia.
• Formulate appropriate counseling information to be provided to a patient on a given treatment regimen for heartburn & dyspepsia.

SCHOLAR-MAC

• SCHOLAR-MAC is a mnemonic device used to help gather information about a patient's symptoms.
• The abbreviation stands for:
  • Symptoms
  • Characteristics
  • History
  • Onset
  • Location
  • Aggravating Factors
  • Remitting Factors
  • Medications
  • Allergies
  • Conditions

Causes of Heartburn

• Risk Factors: Food & beverages

  • Fried or fatty foods
  • Chocolate
  • Peppermint
  • Alcohol
  • Coffee (decaf too)
  • Carbonated beverages
  • Garlic, onions, peppers
  • Vinegar
  • Tomato sauce
  • Citrus fruits or juices

• Risk Factors: Lifestyle

  • Overeating
  • Smoking
  • Eating late at night
  • Bending over or lying down after eating
  • Wearing tight clothing
  • Pregnancy
  • Obesity
  • Stress
  • Certain medications (e.g., aspirin, ibuprofen, some antibiotics)

Key Learning Strategy

• Make it Stick!
  • Trying to solve a problem before being taught the solution leads to better learning, even when errors are made in the attempt.

Brand and Generic Medications with Indications, Adverse Effects, and Classes

• Aldactone (spironolactone): aldosterone antagonist indicated for heart failure and hypertension; potential adverse effects include eye irritation, gynecomastia, drowsiness, dry mouth, and hyperkalemia.
• Alphagan P (brimonidine ophthalmic): alpha-2 adrenergic agonist indicated for glaucoma; potential adverse effects include eye irritation.
• Catapres (clonidine): alpha-2 adrenergic agonist indicated for hypertension; potential adverse effects include drowsiness, dry mouth, and hyperkalemia.
• Lotensin (benazepril): angiotensin converting enzyme inhibitor (ACEI) indicated for hypertension and heart failure; potential adverse effects include dry cough and hyperkalemia.
• Vasotec (enalapril): angiotensin converting enzyme inhibitor (ACEI) indicated for hypertension and heart failure; potential adverse effects include dry cough and hyperkalemia.
• Zestril (lisinopril): angiotensin converting enzyme inhibitor (ACEI) indicated for hypertension and heart failure; potential adverse effects include dry cough and hyperkalemia.
• Altace (ramipril): angiotensin converting enzyme inhibitor (ACEI) indicated for hypertension and heart failure; potential adverse effects include dry mouth and hyperkalemia.
• Atrovent HFA (ipratropium inhaled): anticholinergic indicated for COPD; potential adverse effects include dry mouth and bitter taste.
• Spiriva Respimat (tiotropium inhaled): anticholinergic indicated for COPD and asthma; potential adverse effects include drowsiness and bitter taste.
• Tessalon Perles (benzonatate): antitussive indicated for cough; potential adverse effects include bradycardia and hallucination.
• Inderal (propranolol): beta-1 and beta-2 nonselective blocker indicated for migraine prophylaxis and essential tremor; potential adverse effects include eye irritation, fatigue, and eye sensitivity to light.
• Betimol (timolol ophthalmic): beta-1 and beta-2 nonselective blocker indicated for glaucoma; potential adverse effects include bradycardia and fatigue.
• Coreg (carvedilol): beta-1 and beta-2 nonselective blocker/alpha-1 blocker indicated for heart failure and hypertension; potential adverse effects include bradycardia and fatigue.
• Normodyne (labetalol): beta-1 and beta-2 nonselective blocker/alpha-1 blocker indicated for hypertension and heart failure; potential adverse effects include bradycardia and fatigue.
• Tenormin (atenolol): beta-1 selective blocker indicated for hypertension and angina; potential adverse effects include bradycardia and fatigue.
• Toprol XL (metoprolol succinate): beta-1 selective blocker indicated for hypertension and angina; potential adverse effects include bradycardia and fatigue.
• Lopressor (metoprolol tartrate): beta-1 selective blocker indicated for hypertension and angina; potential adverse effects include bradycardia and fatigue.
• Calan (verapamil): nondihydropyridine calcium channel blocker (CCB) indicated for hypertension, atrial fibrillation, and angina; potential adverse effects include hypotension, diarrhea, and hyperkalemia.
• Lumigan (bimatoprost ophthalmic): prostaglandin analog indicated for glaucoma; potential adverse effects include pruritus and eosinophilia.
• Xalatan (latanoprost ophthalmic): prostaglandin analog indicated for glaucoma; potential adverse effects include diarrhea.
• Travatan Z (travoprost ophthalmic): prostaglandin analog indicated for glaucoma; potential adverse effects include diarrhea.
• Dexilant (dexlansoprazole): proton pump inhibitor (PPI) indicated for GERD and GI ulcers; potential adverse effects include diarrhea.
• Protonix (pantoprazole): proton pump inhibitor (PPI) indicated for GERD and GI ulcers; potential adverse effects include diarrhea.
• Pristiq (desvenlafaxine): antidepressant; serotonin norepinephrine reuptake inhibitor (SNRI) indicated for depression; potential adverse effects include UV light sensitivity and nausea.
• Viibryd (vilazodone): antidepressant; selective serotonin reuptake inhibitor (SSRI) indicated for depression; potential adverse effects include nausea.
• Proventil HFA (albuterol inhaled): short-acting beta-2 agonist indicated for asthma and COPD; potential adverse effects include thrombocytopenia and peripheral edema.
• Xopenex (levalbuterol inhaled): short-acting beta-2 agonist indicated for asthma and COPD; potential adverse effects include nausea.
• Robaxin (methocarbamol): skeletal muscle relaxant indicated for muscle spasms; potential adverse effects include weight gain.
• Lioresal (baclofen): skeletal muscle relaxant indicated for muscle spasms; potential adverse effects include hypersensitivity to sulfa agents.
• Soma (carisoprodol): skeletal muscle relaxant indicated for muscle spasms; potential adverse effects include hypersensitivity to sulfa agents.
• Flexeril (cyclobenzaprine): skeletal muscle relaxant indicated for muscle spasms; potential adverse effects include xerostomia.
• Microzide (hydrochlorothiazide): thiazide diuretic indicated for hypertension and edema; potential adverse effects include nausea.
• Thalitone (chlorthalidone): thiazide-like diuretic indicated for hypertension and edema; potential adverse effects include nausea.

Antibiotic, Antifungal, and Antiviral Medications

• Zithromax (azithromycin): antibiotic; macrolide indicated for bacterial infections; potential adverse effects include diarrhea and nausea.
• Omnicef (cefdinir ): antibiotic; cephalosporin (3rd gen.) indicated for bacterial infections; potential adverse effects include diarrhea and nausea.
• Teflaro (ceftaroline IV): antibiotic; cephalosporin (5th gen.) indicated for bacterial infections; potential adverse effects include diarrhea and a positive direct Coomb's test.
• Keflex (cephalexin): antibiotic; cephalosporin (1st gen.) indicated for bacterial infections; potential adverse effects include nausea and vomiting.
• Lanoxin (digoxin): antiarrhythmic indicated for atrial fibrillation and anti-MRSA; potential adverse effects include atrial tachycardia and dizziness.
• Vibramycin (doxycycline): antibiotic; tetracycline indicated for bacterial infections and heart failure; potential adverse effects include photosensitivity and dermatologic effects.
• Plaquenil (hydroxychloroquine): antimalaria; aminoquinoline indicated for systemic lupus erythematosus (SLE) and malaria; potential adverse effects include CNS effects.
• Novolog (insulin aspart): antidiabetic; insulin, rapid-acting indicated for diabetes; potential adverse effects include hypoglycemia and weight gain.
• Levemir (insulin detemir): antidiabetic; insulin, long-acting indicated for diabetes; potential adverse effects include hypoglycemia.
• Lantus (insulin glargine): antidiabetic; insulin, long-acting indicated for diabetes; potential adverse effects include hypoglycemia and weight gain.
• Humalog (insulin lispro ): antidiabetic; insulin, rapid-acting indicated for diabetes; potential adverse effects include hypoglycemia and headache.
• Levaquin (levofloxacin): antibiotic; fluoroquinolone indicated for bacterial infections; potential adverse effects include diarrhea.
• Merrem (meropenem IV): antibiotic; carbapenem indicated for bacterial infections; potential adverse effects include hypersensitivity and UV light sensitivity.
• Minocin (minocycline): antibiotic; tetracycline derivative indicated for bacterial infections and acne; potential adverse effects include dizziness and headache.
• Macrodantin (nitrofurantoin): antibiotic indicated for bacterial infections (UTI); potential adverse effects include diarrhea and fatigue.
• Zofran (ondansetron): antiemetic; selective 5-HT3 receptor antagonist indicated for prevention of N/V; potential adverse effects include brown urine.
• Tamiflu (oseltamivir): influenza neuraminidase inhibitor indicated for prevention/treatment of flu; potential adverse effects include nausea and fatigue.
• PenVK (penicillin V potassium): antibiotic; penicillin indicated for bacterial infections; potential adverse effects include diarrhea and vomiting.
• Zosyn (piperacillin & tazobactam IV): antibiotic; penicillin-based indicated for bacterial infections; potential adverse effects include diarrhea and nausea.
• Phenergan (promethazine): phenothiazine; histamine-1 antagonist indicated for nausea; potential adverse effects include bradycardia and headache.
• Januvia (sitagliptin): antidiabetic; dipeptidyl peptidase-4 inhibitor (DPP-4) indicated for diabetes; potential adverse effects include hypoglycemia and CNS effects.
• Janumet (sitagliptin & metformin): dipeptidyl peptidase 4 (DPP-4) & biguanide indicated for diabetes; potential adverse effects include diarrhea and headache.
• Imitrex (sumatriptan): serotonin 5HT 1B/1D receptor agonist indicated for acute migraine and cluster headache; potential adverse effects include tingling sensation and chest tightness.
• Valtrex (valacyclovir): viral DNA polymerase inhibitor indicated for herpes simplex and herpes zoster; potential adverse effects include headache and nausea.
• Vancocin (vancomycin): antibiotic; glycopeptide indicated for bacterial infection; potential adverse effects include hypotension and red man syndrome.

Anticonvulsants, Antiemetics, and Antipsychotics

• Neurontin (gabapentin): anticonvulsant indicated for postherpetic neuralgia and adjunct for seizures; potential adverse effects include dizziness and drowsiness.
• Lyrica (pregabalin): anticonvulsant indicated for fibromyalgia and neuropathic pain; potential adverse effects include dizziness and peripheral edema.
• Topomax (topiramate): anticonvulsant indicated for epilepsy and migraine; potential adverse effects include dizziness and drowsiness.
• Reglan (metoclopramide): antiemetic; gastrointestinal prokinetic agent indicated for diabetic gastroparesis and prevention post-op & chemo n/v; potential adverse effects include drowsiness and dystonia.
• Tegretol (carbamazepine): antiepileptic indicated for seizures and neuralgia; potential adverse effects include nausea and low WBC count.
• Trileptal (oxcarbazepine): antiepileptic indicated for epilepsy and neuralgia; potential adverse effects include nausea and low WBC count.
• Zestoretic (lisinopril & hydrochlorothiazide): antihypertensive; angiotensin converting enzyme inhibitor (ACEi) & thiazide diuretic indicated for hypertension; potential adverse effects include dizziness and hypotension.
• Trexall (methotrexate): antineoplastic; antirheumatic indicated for cancer and rheumatoid arthritis; potential adverse effects include thrombocytopenia and diarrhea.
• Requip (ropinirole): antiparkinson; dopamine agonist indicated for Parkinson's disease and restless leg syndrome; potential adverse effects include hypotension and syncope.
• Mirapex (pramipexole): anti-parkinson; dopamine agonist indicated for Parkinson's disease and restless leg syndrome; potential adverse effects include orthostatic hypotension and drowsiness.
• Plavix (clopidogrel): antiplatelet; thienopyridine indicated for acute coronary syndrome; potential adverse effects include bleeding.
• Vyvanse (lisdexamfetamine): CNS stimulant indicated for ADHD and binge eating disorder; potential adverse effects include hypertension and palpitations.
• Medrol (methylprednisolone): corticosteroid indicated for allergic conditions and skin conditions; potential adverse effects include cardiovascular symptoms and CNS effects.
• Trulicity (dulaglutide): glucagon-like peptide-1 receptor agonist (GLP-1) indicated for Type 2 diabetes; potential adverse effects include hypoglycemia and diarrhea.
• Victoza (liraglutide): glucagon-like peptide-1 receptor agonist (GLP-1) indicated for Type 2 diabetes; potential adverse effects include hypoglycemia and diarrhea.
• Vytorin (ezetimibe & simvastatin): HMG-CoA reductase inhibitor indicated for hyperlipidemia; potential adverse effects include myalgia, nausea, and diarrhea.
• Namenda (memantine): N-Methyl-D-Aspartate (NMDA) receptor antagonist indicated for Alzheimer's dementia; potential adverse effects include dizziness and headache.
• MS Contin (morphine LA): opioid analgesic indicated for pain; potential adverse effects include sedation and constipation.
• Percocet (oxycodone & acetaminophen): opioid analgesic indicated for pain; potential adverse effects include sedation and constipation.
• OxyContin (oxycodone LA): opioid analgesic indicated for pain; potential adverse effects include sedation and constipation.
• Ultram (tramadol): opioid analgesic & selective norepinephrine reuptake inhibitor (SNRI) indicated for pain; potential adverse effects include sedation and constipation.
• Strattera (atomoxetine): selective norepinephrine reuptake inhibitor (SNRI) indicated for ADHD; potential adverse effects include nausea.
• Jardiance (empagliflozin): sodium-glucose cotransporter 2 (SGLT2) inhibitor indicated for Type 2 diabetes; potential adverse effects include nausea and fatigue.
• Synthroid (levothyroxine): thyroid indicated for hypothyroidism; potential adverse effects include UTI and dyslipidemia.
• Zyloprim (allopurinol): xanthine oxidase inhibitor indicated for gout; potential adverse effects include angina and cardiac arrhythmia.
• Lithobid (lithium): antimanic indicated for bipolar disorder; potential adverse effects include arrhythmia and ataxia.
• Haldol (haloperidol): antipsychotic; butyrophenone indicated for schizophrenia and bipolar disorder; potential adverse effects include extrapyramidal reaction, arrhythmias, dizziness, xerostomia, akathisia, insomnia, and sedation.
• Ditropan (oxybutynin): antispasmodic indicated for overactive bladder; potential adverse effects include dizziness and xerostomia.
• Abilify (aripiprazole): atypical antipsychotic indicated for schizophrenia and bipolar disorder; potential adverse effects include akathisia, insomnia, weight gain, sedation, and xerostomia.
• Seroquel (quetiapine): atypical antipsychotic indicated for schizophrenia and bipolar disorder; potential adverse effects include sedation, xerostomia, weight gain, and dizziness.
• Risperdal (risperidone): atypical antipsychotic indicated for schizophrenia and bipolar disorder; potential adverse effects include sedation, dizziness, weight gain, decreased BMD, thrush, nausea, and insomnia.
• Xanax (alprazolam): benzodiazepine indicated for anxiety and panic disorder; potential adverse effects include drowsiness, ataxia, sedation, and lethargy.
• Klonopin (clonazepam): benzodiazepine indicated for anxiety and seizure disorder; potential adverse effects include drowsiness, ataxia, sedation, and lethargy.
• Valium (diazepam): benzodiazepine indicated for anxiety; potential adverse effects include hypotension, sedation, and drowsiness.
• Restoril (temazepam): benzodiazepine indicated for insomnia; potential adverse effects include hypotension, sedation, and drowsiness.
• Ativan (lorazepam): benzodiazepine indicated for anxiety and status epilepticus; potential adverse effects include hypertension, urinary retention, tachycardia, insomnia, and oral candidiasis (thrush).
• Myrbetriq (mirabegron): beta-3 agonist indicated for overactive bladder (OAB); potential adverse effects include tachycardia, insomnia, and oral candidiasis (thrush).
• Wellbutrin (bupropion): dopamine/norepinephrine-reuptake inhibitor indicated for depression and smoking cessation aid; potential adverse effects include decreased BMD, thrush, nausea, insomnia, and cardiac problems.
• Advair (fluticasone & salmeterol): inhaled corticosteroid & long acting beta-2 agonist indicated for asthma and COPD; potential adverse effects include headache and flushing.
• Symbicort (budesonide & formoterol): inhaled corticosteroid & long-acting beta-2 agonist indicated for asthma and COPD; potential adverse effects include nausea, insomnia, or sedation, and ejaculatory disorders.
• Chantix (varenicline): nicotine receptor partial agonist indicated for smoking cessation; potential adverse effects include tachycardia, palpitations, and GI problems.
• Voltaren (diclofenac): non-steroidal anti-inflammatory drug (NSAID); acetic acid indicated for inflammation and pain; potential adverse effects include tachycardia, palpitations, and GI problems.
• Cialis (tadalafil): phosphosdiesterase-5 inhibitor indicated for erectile dysfunction and benign prostatic hyperplasia; potential adverse effects include headache, flushing, and nausea.
• Lexapro (escitalopram): selective serotonin reuptake inhibitor (SSRI) indicated for depression and anxiety; potential adverse effects include insomnia, or sedation, and ejaculatory disorders.
• Zoloft (sertraline): selective serotonin reuptake inhibitor (SSRI) indicated for depression and anxiety; potential adverse effects include insomnia, or sedation, and ejaculatory disorders.
• Combivent (Respimat) (albuterol & ipratropium): short-acting beta-2 agonist & anticholinergic indicated for COPD and asthma; potential adverse effects include cardiac arrhythmia and ataxia.
• DuoNeb (solution) (albuterol & ipratropium): short-acting beta-2 agonist & anticholinergic indicated for COPD and asthma; potential adverse effects include cardiac arrhythmia and ataxia.
• Elavil (amitriptyline): tricyclic antidepressant indicated for depression; potential adverse effects include angina and orthostatic hypotension.
• Apresoline (hydralazine): vasodilator indicated for hypertension; potential adverse effects include hypotension and dizziness.
• Isordil (isosorbide dinitrate): vasodilator indicated for angina; potential adverse effects include hypotension and dizziness.
• Aricept (donepezil): acetylcholinesterase inhibitor indicated for Alzheimer's dementia; potential adverse effects include gastrointestinal (NVD), insomnia, dizziness, and rash.
• Lamictal (lamotrigine): anticonvulsant indicated for seizures; potential adverse effects include increased diastolic BP, drowsiness, and thrombocytopenia.
• Keppra (levetiracetam): anticonvulsant indicated for seizures; potential adverse effects include nausea, tremor, sedation, and nystagmus.
• Depakote, Depakene (valproic acid and derivatives): anticonvulsant; antimanic indicated for epilepsy and bipolar disorder (mania); potential adverse effects include fatigue, hypotension, hot flashes, and fatigue.
• Dilantin (phenytoin): antiepileptic; hydantoin indicated for epilepsy; potential adverse effects include bleeding, hypotension, headache, abdominal pain, and increased BP.
• Hyzaar (losartan & hydrochlorothiazide): antihypertensive; angiotensin II receptor blocker (ARB); thiazide diuretic indicated for hypertension and edema; potential adverse effects include tachycardia, insomnia, and decreased serum calcium.
• Arimidex (anastrozole): antineoplastic; aromatase inhibitor indicated for breast cancer; potential adverse effects include abdominal pain/regurgitation, anorexia, insomnia, and increased BP.
• Integrilin (IV) (eptifibatide): antiplatelet; glycoprotein IIb/Illa Inhibitor indicated for acute coronary syndrome; potential adverse effects include immunosuppression, increased blood sugar, edema, venous thromboembolism, and malaise.
• Aggrenox (aspirin & dipyridamole): antiplatelet; salicylate & phosphodiesterase inhibitor indicated for stroke prevention; potential adverse effects include nausea, vomiting, hypertension, peripheral edema, headache, xerostomia, and confusion.
• Adipex-P (phentermine): appetite suppressant indicated for obesity; potential adverse effects include sedation, dizziness, and constipation.
• Fosamax (alendronate): bisphosphonate indicated for osteoporosis and Paget's disease; potential adverse effects include sedation and constipation.
• Focalin XR (dexmethylphenidate): CNS stimulant indicated for ADHD and narcolepsy; potential adverse effects include sedation and constipation.
• Adderall XR (dextroamphetamine & amphetamine): CNS Stimulant indicated for ADHD; potential adverse effects include hyper or hypokalemia, hyperuricemia, hypotension, and local irritation.
• Deltasone (prednisone): corticosteroid indicated for inflammation and pain; potential adverse effects include skin atrophy.
• Estrace (estradiol): estrogen derivative indicated for breast cancer and osteoporosis prevention; potential adverse effects include flu-like injection reactions, upper respiratory tract infections.
• Imuran (azathioprine): immunosuppressant indicated for prevent kidney transplant rejection; potential adverse effects include dizziness, drowsiness, nausea, low WBC count, and hypotension.
• Cellcept (mycophenolate): immunosuppressant indicated for prophylaxis of organ rejection and rheumatoid arthritis; potential adverse effects include hypotension, syncope, orthostatic hypotension, drowsiness, bleeding, and hypertension.
• Lunesta (eszopiclone): nonbenzodiazepine hypnotic indicated for insomnia; potential adverse effects include headache, abdominal pain, increased BP, tachycardia, and insomnia.
• Ambien (zolpidem): nonbenzodiazepine hypnotic indicated for insomnia; potential adverse effects include sedation, constipation, and constipation.
• Lortab (acetaminophen & hydrocodone): opioid analgesic indicated for pain; potential adverse effects include sedation, constipation, and constipation.
• Duragesic (fentanyl): opioid analgesic indicated for pain; potential adverse effects include sedation, constipation, and constipation.
• Dilaudid (hydromorphone): opioid analgesic indicated for pain; potential adverse effects include sedation, constipation, and constipation.
• Dyazide (triamterene & hydrochlorothiazide): potassium-sparing diuretic & thiazide diuretic indicated for hypertension and edema; potential adverse effects include hyper or hypokalemia, hyperuricemia, hypotension, and local irritation.
• Kenalog (triamcinolone): topical corticosteroid indicated for pruritis and inflammation; potential adverse effects include skin atrophy.
• Humira (adalimumab): tumor necrosis factor (TNF) alpha blocker indicated for Crohn's disease and ulcerative colitis; potential adverse effects include flu-like injection reactions, upper respiratory tract infections, and rash.### Common Diseases and Conditions
• GERD
• Gastric ulcer
• Depression
• Anxiety
• Asthma
• COPD
• Muscle spasm
• Spasticity
• Hypertension
• Edema
• Bradycardia
• Increased pigmentation of the iris and eyelashes, as well as eyelash growth
• Diarrhea
• Nausea
• Headache
• Tachycardia
• Drowsiness
• Hypokalemia

Common Adverse Effects (AEs)

• Constipation
• Blurred vision or stinging
• Sexual dysfunction
• Nervousness
• Dizziness
• Transient increased urination

Medications

• Generic Name:
  • Nebivolol (Bystolic)
  • Beclomethasone (inhaled) (Qvar inhaler)
  • Budesonide (inhaled) (Pulmicort Flexhaler)
  • Fluticasone (nasal) (Flonase)
  • Fluticasone (inhaled) (Flovent HFA)
  • Amlodipine (Norvasc)
  • Nifedipine (Procardia)
  • Fenofibrate (Tricor)
  • Meclizine (Antivert)
  • Atorvastatin (Lipitor)
  • Pravastatin (Pravachol)
  • Rosuvastatin (Crestor)
  • Simvastatin (Zocor)
  • Ezetimibe (Zetia)
  • Montelukast (Singulair)
  • Furosemide (Lasix)
  • Diltiazem (Cardizem)
  • Finasteride (Proscar)
  • Tamsulosin (Flomax)
  • Doxazosin (Cardura)
  • Tizanidine (Zanaflex)
  • Guanfacine (Intuniv)
  • Celecoxib (Celebrex)
  • Meloxicam (Mobic)
  • Buspirone (BuSpar)
  • Solifenacin (Vesicare)
  • Dicyclomine (Bentyl)
  • Enoxaparin (Lovenox)
  • Rivaroxaban (Eliquis)
  • Apixaban (Xarelto)
  • Mirtazapine (Remeron)
  • Citalopram (Celexa)
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Trazodone (Desyrel)
  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor XR)
  • Nortriptyline (Pamelor)
  • Irbesartan (Avapro)
  • Losartan (Cozaar)
  • Olmesartan (Benicar)
  • Valsartan (Diovan)

Medication Classes

• Beta-1 selective blockers
• Corticosteroids
• Dihydropyridine calcium channel blockers (CCB)
• Fibric acid derivatives (fibrate)
• Histamine H-1 antagonists
• HMG-CoA reductase inhibitors
• Intestinal cholesterol absorption inhibitors
• Leukotriene receptor antagonists
• Loop diuretics
• Nondihydropyridine calcium channel blockers (CCB)
• 5-alpha reductase inhibitor
• Alpha-1 adrenergic antagonist
• Alpha-2 adrenergic agonists
• Analgesics
• Antianxiety agents
• Anticholinergics
• Anticoagulants
• Antidepressants
• Antihypertensives
• Angiotensin II receptor blockers (ARB)

Common Drug Indications

• Beta-1 selective blockers: hypertension
• Corticosteroids: asthma, allergic rhinitis
• Dihydropyridine CCBs: hypertension
• Fibric acid derivatives: hypertriglyceridemia
• Histamine H-1 antagonists: vertigo
• HMG-CoA reductase inhibitors: hyperlipidemia
• Intestinal cholesterol absorption inhibitors: hyperlipidemia
• Leukotriene receptor antagonists: asthma
• Loop diuretics: edema
• Nondihydropyridine CCBs: hypertension
• 5-alpha reductase inhibitor: benign prostatic hyperplasia (BPH)
• Alpha-1 adrenergic antagonists: BPH
• Alpha-2 adrenergic agonists: spasticity, hypertension
• Analgesics: pain
• Antianxiety agents: anxiety
• Anticholinergics: overactive bladder, irritable bowel syndrome
• Anticoagulants: venous thromboembolism, prevent/treat blood clots
• Antidepressants: depression, anxiety
• Antihypertensives: hypertension
• Angiotensin II receptor blockers: hypertension, diabetic nephropathy, heart failure

Common Adverse Effects

• Beta-1 selective blockers: bradycardia, throat irritation
• Corticosteroids: oral candidiasis (thrush), throat irritation, unpleasant taste, nosebleeds, reflex tachycardia
• Dihydropyridine CCBs: angina, peripheral edema, reflex tachycardia, increased LFTs
• Fibric acid derivatives: dyspepsia, dry mouth
• Histamine H-1 antagonists: drowsiness, headache
• Statins: myalgia, headache, diarrhea
• Intestinal cholesterol absorption inhibitors: headache, dizziness
• Leukotriene receptor antagonists: headache, dizziness
• Loop diuretics: hypokalemia, increased urination
• Nondihydropyridine CCBs: bradycardia
• 5-alpha reductase inhibitor: decrease libido, ejaculation failure
• Alpha-1 adrenergic antagonists: orthostatic hypotension, dizziness
• Alpha-2 adrenergic agonists: hypotension, xerostomia, drowsiness
• Analgesics: peripheral edema, hypertension
• Antianxiety agents: dizziness, nausea
• Anticholinergics: xerostomia, sedation
• Anticoagulants: bleeding, thrombocytopenia
• Antidepressants: sedation, increased appetite, insomnia or sedation, ejaculatory disorders, serotonin syndrome
• Antihypertensives: orthostatic hypotension, malaise

Solution Dosage Forms

• A solution is one or more chemical substances dissolved in a suitable solvent or mix of solvents.
• Oral solutions are sweetened and/or flavored to improve palatability and mask drug taste.
• Injectable and ophthalmic solutions must be sterile.
• The vehicle (solvent) should be selected based on the route of administration and drug solubility.
• "Like dissolves like" - polar solvents dissolve polar solutes and vice versa.
• Water is the most common solvent, but others include alcohol, USP, glycerin, propylene glycol, oils, acetone, isopropanol, polyethylene glycol, collodion, polymers.

Labeling of Solution Preparations

• If a preparation is for oral administration, the instruction should use "Give/Take…orally…"
• If a preparation is for topical administration, the instruction should use "Apply… (indicate area)"
• If a preparation is for a specific use (e.g., shampoo or soak) use an appropriate verb like "Use..."
• If a preparation is administered nasally or otically, use "Place/Instill... (indicate route)"
• For oral solutions, express the active ingredient concentration as a metric weight or volume per volume to be administered (e.g., 50 mg/5 mL)
• For electrolyte solutions, include both milliequivalent and metric weight (e.g., 8 mEq (50 mg)/5 mL)
• For topical, nasal, or otic solutions, express as a percentage concentration (e.g., 10%)
• If Alcohol, USP is used as an excipient, its %(v/v) concentration within the final product must be expressed on the prescription label.

Auxiliary Labeling

• If a solution is not dispensed in a tight container with a safety closure, an appropriate label is required.
• Oral solutions, even if preserved, should be refrigerated, unless contraindicated.
• Possible contraindications for refrigeration include solutions near saturation point, high viscosity, or medications unstable at low temperatures.
• If the prescription is for non-oral administration, it should contain a label indicating the appropriate route of elimination (e.g., "For external use only" or "Not for oral use").
• Solutions should be dispensed in an appropriately sized amber bottle or other packaging device suitable for the application (e.g., unit dose oral syringes, nasal or topical sprays).

Phenobarbital Example (Case #1)

• Phenobarbital 40 mg/5 mL solution is prepared with glycerin (13.5 mL) and made up to 3 fl.oz.
• The phenobarbital concentration is 1.5% (w/v).
• Glycerin concentration is 15% (v/v).
• To ensure solubility, the formulation will likely contain co-solvents (e.g., Alcohol, USP) which are not explicitly stated in the text.
• Dilution of the solution with water or juice is not advised.
• Phenobarbital is a weak acid and therefore sensitive to pH changes.
• Diluting with juice may make phenobarbital less soluble and alter the equilibrium of the drug.
• If the patient is concerned about taste, the product can be reformulated with flavors and/or sweeteners.