Nausea, Vomiting, and Diarrhea Treatment - PDF

Nausea, Vomiting and Diarrhea Hsin-Hui Chen, PharmD. PGY-2 Ambulatory Care Resident Albany College Of Pharmacy And Health Sciences 01/28/2025 Slides courtesy of Lavinia Salama...

Nausea, Vomiting and Diarrhea Hsin-Hui Chen, PharmD. PGY-2 Ambulatory Care Resident Albany College Of Pharmacy And Health Sciences 01/28/2025 Slides courtesy of Lavinia Salama & Kara Olstand & Shahad Almahmoud  Objectives Identify appropriate counseling points for pharmacologic and non-pharmacologic treatment of nausea, vomiting and diarrhea Given a patient case, determine if he/she is a candidate for self-care and select appropriate therapy for treatment Diarrhea  Objectives 1 2 3 4 5 Recall exclusions Distinguish Understand Evaluate a Select an for self care of patients that will indications and patient who appropriate drug diarrhea need referral to a dosing for presents with therapy for self medical provider commonly used symptoms of care treatment of vs. self care medications for diarrhea diarrhea treatment diarrhea  Diarrhea – A Global Burden Common cause of death worldwide Usually, 4 weight Chronic weeks  Clinical Classifications Type Mechanism Common Causes Osmotic Unabsorbed solutes  increased osmotic load Viruses Brush border damage (infection or lactase Bacteria deficiency)  decreased absorption Lactase deficiency Secretory Stimulation of crypt cells  flow of electrolytes Viruses and fluids into intestine Bacteria Tumors – secret GI hormones and peptides Ileal resection Thyroid cancer Inflammator Inflammation of intestinal mucosa – leaking of Ulcerative colitis y mucus, blood and pus Crohn’s disease Motor ↓ intestinal transit time reduces contact time Irritable bowel syndrome Diabetic neuropathy Diarrhea – Classification and Causes Acute Persistent Chronic (4 weeks) Type Examples Irritable bowel syndrome (IBS- Viral Norovirus, rotavirus D, idiopathic) Campylobacter, E. coli(most common), Inflammatory bowel diseases Bacterial Salmonella, Shigella (IBD) Cryptosporidium enteritis, Entamoeba Celiac disease Parasitic histolytica, Giardia lamblia Malabsorption Foodborne & Chronic infections Traced back to bacteria or viruses (E. Travelers’ coli, Salmonella) Tumors Diarrhea Medication side effects* Intolerance to foods: fatty, spicy, Food- lactose Induced High fiber diet *Medications can cause acute and chronic Medications* Side effects diarrhea and usually need referral to medical provider Select Medications that Can Cause Diarrhea Antacids containing magnesium Many antibiotics (especially broad-spectrum, as a side effect or diarrhea may be infectious C. difficile) Laxatives (mineral oil, docusate, senna) Metformin, GLP-1 agonists Prokinetic drugs (metoclopramide, cisapride) Antineoplastics(irinotecan, capecitabine, fluorouracil, methotrexate, TKIs) Acetylcholinesterase inhibitors(donepezil) Others: colchicine ,misoprostol, quinidine, roflumilast, nelfinavir)  Self-Treatment Goals fluid and electrolyte balances and Prevent or correct acid-base imbalance Control symptoms Identify and treat the cause Prevent acute morbidity and mortality  Dehydration Excessive Decreased Dry mouth Weight loss thirst urination Decreased Lack of Dark yellow Sunken eyes skin turgor tears/ sweat urine Confusion/ Falls/ High heart changes in Dizziness difficulty rate mental walking status  NOT Self- Self-Treatable Treatable Normal mental status, fatigued Apathetic, lethargic, unconscious Assessment Normal pulse and breathing Low BP, dizzy, tachycardia, weak of pulse Dehydratio Dry skin, slightly sunken eyes Dry skin, parched, >2 seconds for skin to recoil, sunken eyes n and Severity 6 stools/day Afebrile or fever 102.2 oF Thirsty, able to drink Unable to drink or drinks poorly 10% loss of body weight Exclusion to Self-Treatment Young age (< 6 months or < 8 kg) Frail patient >65 years Need to see Persistent fever (> 102.2 degrees F) a provider or emergency Blood, pus, or mucus in stool care High output and volumes of diarrhea Persistent vomiting Not responding well to oral rehydration Signs of severe dehydration (lethargy, no tears, hypotension, not urinating) Severe abdominal pain/ distress These patients may need IV Immunosuppressed (on chemo, AIDs, transplant recipient) rehydration, Pregnancy antibiotics or Chronic(>4 weeks) or persistent (2-4 weeks) other supportive care Self Care Treatment of Diarrhea Oral rehydration therapy (Oral Rehydration Solution/Salts = ORS) if dehydrated Symptomatic drug therapy Bismuth subsalicylate Digestive enzymes Loperamide Probiotics Zinc If diarrhea has not resolved (or greatly improved) 72 hours after initial treatment, see provider Pre-Oral Rehydration Solution Mild dehydration (< 3% weight loss), mild symptoms, healthy adult or child Likely don’t need official ORS products Tx: water, soups, sports drinks Try complex carb rich foods Consider ORS if symptoms progress and fluid loss not being replaced by usual dietary fluids  Oral Rehydration Solution Provides electrolytes and fluids lost during acute diarrhea phase and minimal dietary intake Mild-moderate dehydration in children 6 months to 5 years and no exclusions to self care, 3-9% weight loss Drink ORS 50-100 mL/kg over 3-4 hours Continue until Add 10 mL/kg for each Vomiting is NOT a rehydrated (usually loose stool thereafter contraindication** takes 4-6 hours) For patients 6 years, weight still best, but can do 2-4 L over 3-4 hours if weight unknown Use judgement (i.e. less fluid for a small 6-year-old vs a large 50-year-old person) **Small volumes (1-2 tsp every 1-2 minutes) maybe tolerated by vomiting child and can be enough to maintain proper hydration  Oral rehydration solution (ORS) MOA Fluid and electrolyte replacement Dosing Based on patient’s fluid status Rehydration Phase Over 3-4 hours to quickly replace water and electrolyte deficits and restore normal body composition Maintenance Phase Maintain normal body composition until adequate dietary intake is established Inappropriate For children 102.2 oF) care Blood in vomit Yellow skin, eye discoloration, dark urine Stiff neck, headache – meningitis? Head injury – concussion? These patients Pregnancy (Can self treat if mild or morning sickness) Not may need IV responding well to oral rehydration rehydration, Psychogenic induced/self harm antibiotics or other supportive Chronic disease induced care (like Caused by drugs such as chemo, overdose, antipsychotics antibiotics or RX Additional exclusions for children (< 6 mo, lower threshold for symptoms products) Ch 19, P. 340 Determining Appropriate Treatment If patient has NOT met exclusions for self treatment, may be able to treat at home Many times, nausea and vomiting is self limiting The following can sometimes be treated with self care: Overeating/disagreeable foods Food poisoning or viral Motion sickness Mild nausea with pregnancy Medication related May be able to change medication timing, take with food, etc Contact PCP to notify of medication changes/recommendations Seek medical care if condition remains the same or worsens after 48 hours of onset or after 72 hours of initial treatment  Oral Rehydration Solutions/ Salts Bismuth Subsalicylate Self- Treatment Antihistamines Dimenhydrinate(Dramamine) Options Diphenhydramine(Benadryl) Doxylamine for Nausea Meclizine(Bonine, Dramamine All Day Less Drowsy) & Phosphorated Carbohydrate Solution Vomiting Pyridoxine (Vitamin B6) Ginger Motion Sickness: Non-pharmacologic Measures Avoid reading Focus the line Avoid excess Stay where Avoid strong Drive the during travel of vision fairly food or motion is least odors, vehicle if straight ahead alcohol before experienced particularly possible (e.g., sit in a and during (e.g., from of from food or position that extended the car, near tobacco allows vision travel the wings of smoke out of the car an airplane) Pharmacological: antihistamines window) and meclizine (FDA approved)  NVP = nausea and vomiting of pregnancy = “morning sickness” 50-90% Pregnanc After 10 weeks of pregnancy y NVP – HCP referral Severe = hyperemesis gravidarum Exclusion to self-care Pharmacologic al OTC: doxylamine, pyridoxine, ginger Pregnancy NVP - Non-Pharmacologic Measures Make sure to have fresh air in the room where you sleep Get out of bed very slowly Before getting out of bed, eat several dry crackers and relax in bed for 10-15 minutes Make sure there is plenty of fresh air in the areas where meals are prepared and eaten Do not overeat at meals. Eat 4 or 5 meals per day instead of large meals Do not drink fluids or eat soups at mealtime. Instead, drink small sips of liquid between meals When nauseated, try small of carbonated beverages or fruit juices Avoid greasy or fatty foods such as fried foods, gravy, mayonnaise, spicy, acidic food Eat dry, bland and high-protein food If necessary, Eat food that is chilled rather than warm or hot (cold foods tend to be less nauseating) Motion sickness band (acupressure) Non-Pharm: Oral Rehydration Solutions (ORS) Indicated for: - Overeating/disagreeable foods - Food poisoning or viral - Self-limiting N&V of unknown cause - Important for maintaining electrolyte status and preventing dehydration - Even small sips are helpful if that is all they can tolerate! Typical dose of ORS varies depending on hydration status: (1) Minimal dehydration (2) Mild-moderate dehydration Notes: - Children 10 kg: 120- 30%-50% of fluid loss in the first increments 240 mL per episode 24 hours is preferred Generally: - 5 mL every 5 minutes for children (3) Severe dehydration: - 15 mL every 5 min for older children and exclusion to self care adults - Avoid aggravating foods and drinks (Ex. spicy, milk) - BRAT (banana, rice, applesauce and toast) diet  Oral Rehydration Solutions/ Salts Bismuth Subsalicylate Antihistamines Dimenhydrinate Diphenhydramine Doxylamine Meclizine Phosphorated Carbohydrate Solution Pyridoxine (Vitamin B6) Ginger Pharmacological Interventions Bismuth Subsalicylate(Pepto Bismol) Mechanism Exhibits antisecretory, antimicrobial action and may provide some anti-inflammatory action Reacts with HCl in stomach to form bismuth oxychloride (antimicrobial) and salicylic acid (antisecretory, so less fluid loss) Indications Acute nausea and vomiting age 12 and older Dose 525 mg every 30-60 minutes PRN MAX: 4,200 mg/day for up to 2 days Contraindications Salicylate allergy, use with other salicylates, ulceration, coagulopathy, black/ bloody stools, pregnancy Bismuth Subsalicylate(Pepto Bismol) Side effects Black tongue/ stool Salicylate toxicity if used excessively (early s/s include tinnitus, N/V, increased respiratory rate, diaphoresis) Interactions Many!! Aspirin, anticoagulants (warfarin, apixaban, heparin, rivaroxaban) = bleeding risk a trivalent cation, binds medications like tetracycline antibiotics Notes Caution in renal insufficiency Children and teenagers who are recovering from the flu, chickenpox, or other viral infections should not use due to risk of Reye’s syndrome  MOA Antihistamines Histamine1 receptor antagonists Blocks effect of acetylcholine, which transmits nerve signals between the ear's vestibular, or balance, center and the part of the brain involved with nausea and vomiting Meclizine blocks vasodepressor response to histamine, slightly inhibits acetylcholine Cross blood brain barrier (BBB) Indication Motion sickness, nausea Dosing Important to know! The higher the dose the more the side effects (see next slide) Interactions Sedating medication Avoid in elderly (due to strong anticholinergic effects; Beers criteria) and children < 2 years Caution in patients with glaucoma, CV disease, dementia Adverse events Somnolence, drowsiness, cognitive impairments, strong anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation) Antihistamine Antihistamine for Example Dosing Antiemetic Use Brand Dimenhydrinate Dramamin 50-100 mg every 4-6 hours (adult) e 25-50 mg every 6-8 hours (age 6-12) 12.5-25 mg every 6-8 hours ( age 6 months to 2 y/o) Diphenhydramine Benadryl 25-50 mg every 6-8 hours (adult) Unisom 12.5-25 mg every 6-8 hours (age 6-12) Meclizine (MEK li zeen) Dramamin 25-50 mg 1 hour before travel (adult), can e repeat Q24 hrs prn Bonine Doxylamine (dox IL a meen) Unisom 10-12.5 mg every 8 hours (adult) – SAFE FOR USE IN PREGNANCY (can be used with Dimenhydrinate Meclizine Diphenhydramine OTC = Draminate, Rx = Antivert Doxylamine OTC = Unisom, Dramamine, or OTC = Bonine or OTC = Unisom Sominex, Benadryl, Gravol Dramamine Genahist ◦ Use brand and generics!! ◦ These are first generation antihistamines ◦ More sedating ◦ On American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults ◦ Medications more likely to cause cognitive impairment, confusion, dry mouth, constipation, bladder obstruction or falls in the elderly ◦ Avoid or start at lower doses in the elderly  Phosphorated What is it? A mixture of dextrose (glucose), levulose (fructose), and Carbohydrate phosphoric acid Solution (Emetrol) How it works Decreases smooth muscle contraction and slows gastric emptying as a hyperosmolar solution Indication Nausea and vomiting with food or beverage for age 2 and older Dose 15-30 mL every 15 minutes for adults; 5-10 mL every 15 minutes for children ages 2-12 y/o Risks Stomach pain, diarrhea Warnings/ precautions Diabetes (consult provider), fructose intolerance Complementa ry Therapies Ginger Pyridoxine Acupuncture Aromatherapy Ginger Nausea related to pregnancy and Primary Use motion sickness NOTE: NOT ginger ale 250 mg of root given PO QID Total daily dose of 1 gram has been given Dose in 2-3 divided doses Caution in formulations that exceed 1 gram daily Contraindications/ Remember the 5 G’s (bleeding, garlic, Interactions gingko, ginseng, ginger, and gotu kola) GI effects including heartburn, diarrhea, Side effects mouth irritation Pyridoxine (Vitamin B6) Chief function Water-soluble B vitamin that is important in various metabolic functions, including protein metabolism, hemoglobin synthesis and neurotransmitter function Dose Recommended RDA in adults: 1.3-2 mg/day NVP: 10-25 mg TID with/ without doxylamine 10-12.5 mg TID Deficiency Anemia, depression, confusion, fatigue scaly dermatitis, paresthesia Sources Chicken breast, beef liver, turkey breast, banana, baked potato, avocado Questions?