Drugs Recommended for Adults with GI Issues PDF

GI • What are indications for the drugs listed in the above section with the exemplar list? Adverse Effects? -see above section • What are important principles of use for PPIs and H2RAs? -see above sections • What impact do antacids have on absorption of other drugs? -they can inhibit or decrease th...

GI • What are indications for the drugs listed in the above section with the exemplar list? Adverse Effects? -see above section • What are important principles of use for PPIs and H2RAs? -see above sections • What impact do antacids have on absorption of other drugs? -they can inhibit or decrease the absorption of certain drugs such as antibiotics and oral iron GU • Which are indications for each of the drugs in the above section with the exemplar list? Adverse Effects? -see above section • Which drug(s) discussed in this lecture have potential anticholinergic side effects? -oxybutynin, solifenacin • What are some important components of patient education for a patient starting an alpha-adrenergic antagonist for BPH? -avoid use with other alpha blockers; change positions slowly to avoid orthostatic hypotension • Why are phosphodiesterase-5 inhibitors contraindicated with use of nitrates (Rosenthal & Burchum, Ch. 53)? -can cause significant hypotension GI Omeprazole, pantoprazole, esomeprazole • Class: Proton Pump Inhibitors • Indications: o 1st line tx for mod to severe GERD & hypersecretory conditions o Erosive esophagitis o PUD o Stress ulcer prophylaxis • MOA: blocks the final common pathway in acid secretion—> the proton pump o H+/K+ ATPase pumps o Take 3-4 days to achieve max acid suppression • Considerations: o Dose start daily then titrate to BID if unresponsive o Give 30-60 min prior to meal o Drug interactions—> CYP2C9 (clopidogrel) o Give the lowest effective dose for the shortest amount of time • Adverse Effects: o GI: abdominal pain, diarrhea o Headache o Interstitial nephritis o B12, Calcium, magnesium deficiency o o o o Risk of fractures (hip, spine, wrist) Pneumonia C. Diff Rebound acid after discontinuing Cimetidine, Famotidine • Class: H-2 antagonists • Indications: o Mild to mod GERD & dyspepsia o Maintenance therapy in erosive esophagitis following a PPI trial o Stress ulcer prophylaxis • MOA: competitively inhibit parietal cells (H2) receptors to inhibit basal & meal stimulated acid secretion • Famotidine = most potent with fewer drug reactions o Adjust if CrCl < 50 o Onset = 30 min o Adverse Effects: ▪ HA, dizziness, fatigue ▪ Diarrhea or constipation ▪ Confusion, hallucinations, agitation in elderly or critically ill Antacids • Weak acid bases that react w/ gastric HCL to form salt & water—> increase intragastric pH—> immediate symptomatic relief • Neutralizes acid up to 3 hrs (after a meal) o Doesn’t work as long if taken on an empty stomach • If a patient needs to use chronically, they just need to go ahead and be on a PPI or H2A • Indications: mild GERD Calcium Carbonate (TUMS) • Drug to drug interactions: o Tetracyclines, fluoroquinolones, ferrous sulfate o Do not take tums 2 hrs within taking these other meds • Adverse Effects: o Belching o Constipation o Metabolic alkalosis o Hypercalcemia, Hypophosphatemia Aluminum Hydroxide/Mag Hydroxide • Available as liquid and can be combined with simethicone • Has many drug-to-drug interactions • Adverse Effects: o Diarrhea (mag) constipation (aluminum) • o Hypermagnesemia, hypophosphatemia Contraindications: Renal patients Ondansetron • Class: 5HT3 Receptor Antagonist • MOA: central serotonin 5HT3 antagonist in the vomiting center and trigger zone o Intestinal vagaries and spinal afferent nerves • Indications: o Chemo nausea, radiation nausea, post op nausea • Adverse Effects: o Constipation, HA, dizziness, fatigue, QT prolong Dimenhydrinate • Class: First gen antihistamine & anticholinergic • MOA: prevent activation of Muscarinic M1 and histaminic H1 receptors in the vomiting center; inhibits the stimulation of these receptors in the vestibular system in the middle ear • Indications: o Motion sickness and vertigo o Nausea o Not useful against nausea r/t chemo • Adverse Effects: o Blurry vision, dry mouth, urinary retention, constipation Scopolamine • Anticholinergic patch • Indication: post op nausea and motion sickness • Behind the ear Q 3days—place 4 hrs pre-op Dronabinol (Marinol) • THC derivative • Schedule III drug • Appetite stimulator • May be used in chemo nausea Promethazine • Class: First gen antipsychotic • MOA: inhibit dopamine in the trigger zone and histamine and muscarinic receptor activation in the brain • Indications: o Simple nausea, esp. in the setting of gastroenteritis • Adverse Effects: o Drowsiness/sedation, dizziness, dry mouth, constipation, blurry vision, hypotension, urinary retention • Contraindications: o Elderly & pts w/ glaucoma Others: o Prochlorperazine (comparing)—good for chemo nausea o Haloperidol—good for post op nausea at low doses • Sucralfate • Mucosal protection o In H2O or acidic solutions, forms a paste that bind to the upper GI tract to ulcers for up tp 6 hrs • Indications—symptomatic relief of GERD s/s for short term • Decreases absorption of other meds (Coumadin, fluoroquinolones)—must take these drugs 2 hrs prior to carafate • Adverse Effects: Constipation PUD Treatment Approach NSAID related • • • stop NSAID or decrease dose 4 wk PPI (alter. H2A or sucralfate) If keeping NSAID, extend PPI to 8-12 wks H. Pylori Related • • • • • • • PPI based regimen for 10-14 days If s/s persist, consider the pt being nonadherent, resistance to certain abx or a different diagnosis Clarithromycin therapy Clarithro 500 mg BID Amox 1000 mg BID or Metronidazole 500 BID with a PPI (high dose) BID Can also use all 4 together Duration 14 days for triple tax and 10-14 days if using all 4 Adverse Effects of Clarithromycin -many drug interactions -changes in taste, diarrhea, vomiting, QT prolong If resistant to Clarithromycin Bismuth based quadruple therapy • PPI standard BID • Bismuth subsalicylate 524 mg QID (pepto bismol) • Tetracycline 500 mg QID • Metronidazole 250 mg QID • 10-14 days • • PPIs interfere w/ detection of H. Pylori so stop 2 wks before testing (test should be done 1 month after treatment regimen is done) Can also use levofloxacin triple therapy Metoclopramide • Dopamine receptor antagonist—> stimulates gut motor function; increased lower esophageal sphincter pressure and increases gastric emptying • Indications: GERD, nausea r/t delayed gastric emptying, gastroparesis, some ileus • Adverse Effects: o Extrapyramidal symptoms, diarrhea, restlessness, drowsiness, confusion • Consideration: o Caution with elderly and do not use long term **Infectious diarrhea needs antibiotics NOT anti-diarrheals / viral gastroenteritis may use antidiarrheal -instruct patient that anti-diarrheals don’t treat the cause—seek treatment if having to use anti diarrhea meds > 48 hrs Bismuth subsalicylate • Anti secretory, anti-inflammatory, and anti-microbial • Indication: indigestion, abd cramps, diarrhea (prevention of traveler's diarrhea) • Adverse Effects: o Darkening of tongue and stool o Excess use—> salicylate toxicity (tinnitus, N/V, confusion) • Contraindications: o children recovering from chicken pox or flu-like illness—> reye syndrome o Salicylate allergy Loperamide • Opioid derivative—-acts peripherally with no central opioid activity—overdoses can still happen though • Antisecretory properties through regulation of chloride secretion • Adverse Effects: o Dizziness, constipation • Contraindications: o Patients < 2 yrs old • Caution: o Risk of torsades de pointes & sudden death if used higher than recommended doses o Must stop when diarrhea resolves Diphenoxylate/atropine (Lomotil) • Opioid derivative & anticholinergic to deter abuse o Schedule V controlled • Adverse Effects: o Drowsiness, dizziness, euphoria o Dry mouth, constipation o Pruritis o Urinary retention • Caution: o Atropinism (hyperthermia, tachy, urinary retention, flushing, dryness of skin and mucus membranes) o Elderly Bulk forming Laxatives • Psyllium o Plant derivative —> more bloating/gas o MOA: increase the water content of stool to increase bulk, weight, and stimulate peristalsis o Produces stool in 3 days o Must take a lot of water with it to avoid obstruction Docusate sodium • Stool softener • MOA: mixes aqueous & fatty substances within the GI tract to create softer stool • Not great for treating—great for prevention • Adverse Effects: diarrhea, abdominal cramps Polyethylene glycol (Miralax) • Osmotic laxative • MOA: increases stool due to osmotic effect and stimulate peristalsis • 1st line tx for chronic constipation (may be used up to 6 months) o GoLYTLEY = bowel prep for colonoscopy • Adverse Effects: o Fluid & electrolyte imbalance, cramps, flatulence, N/V • Glycerin (pedia-lax)—> suppository for intermittent constipation in kids Bisacodyl • MOA: stimulates peristalsis by irritating the mucosal nerve plexus in the colon & alter fluid & electrolyte transport o Reserved for cases of failing osmotic agents o Do not use > 1 wk with acute constipation o May use long term in pts with non-modifiable risk factors for constipation (ie. neuro injury) —safer than senna to use long term and can be combined with miralax in bowel prep • Adverse Effects: o Severe abdominal cramps, N/V, rectal burning, weakness, F&E imbalance Senna • Anthraquinone plant derivative that acts as a stimulant on the colon -same as above Sulfasalazine • Prototype ASA o Dual molecule consisting of sulfapyridine & mesalamine (active form) o Works locally in GI tract by scavenging free radicals, inhibits leukocytes, interferes with TNF-a and NFkB, suppresses IL-1, and inhibits leukotriene and prostaglandin production • Indication: inflammatory bowel disease (IBD) GU Tamsulosin • 3rd gen uroselective alpha 1A receptor antagonist • Causes less hypotension • MOA: relax smooth muscle in the prostate • Adverse Effects: o Tiredness, anejaculation, hypotension, tachy, nasal congestion priapism • Consideration: o Patient must notify provider prior to cataract surgery to prevent intraoperative floppy iris syndrome Finasteride • 5 alpha reductive inhibitor • Indications: mod to severe BPH; male pattern baldness at a lower dose • MOA: suppress DHT production; slows disease progression and reduces risks of BPH related complications • Adverse Effects: o Ejaculation probs o Decreased libido o Nause, abdominal pain o Gynecomastia Sildenafil • PDE 5 inhibitor • MOA: relax smooth muscle of prostate and bladder neck • Indications: BPH w/ ED symptoms • As irritative s/s develop that mimic overactive bladder syndrome, anticholinergic agents or mirabegron may be used to reduce urgency & frequency Terazosin • 2nd gen alpha 1 antagonist—peripherally acting in addition to the prostate • Adverse Effects: first dose hypotension, orthostatic hypo, dizziness Treatment steps for BPH: • • • obstructive symptoms: uroselective alpha 1 antagonist (ie. Flomax) obstructive s/s AND enlarged prostate: add on a 5-alpha reductase inhibitor (ie. Finasteride) obstructive s/s with irritative s/s: add anticholinergic or mirabegron Oxybutynin (ditropan/oxytrol) • Anticholinergic/antimuscarinic • Mainstay tx for overactive bladder and incontinence after doing non pharm mgmt (bladder training) • MOA: suppress premature detrusor contractions—> enhance bladder storage and decrease number of micturitions per day • Adverse Effects: o Anticholinergic effects (“can’t see, can’t pee, can’t shit, can’t spit”) o Cognitive effects = most concerning • Contraindications: o Avoid in elderly o Avoid with narrow angle glaucoma Solifenacin (vesicare) • 2nd Gen anticholinergic with less SEs • Adverse Effects: some antichol. SEs & QT prolong in high doses • CYP 3A4 interactions Mirabegron (myrbetriq)/Vibegron • Beta 3 agonists • MOA: relaxes bladder detrusor muscle during filling phase to increase capacity • Adverse Effects: o Hypertension (contraindicated in pts with uncontrolled hypertension) o Nasopharyngitis o UTI o Headache o Interacts with digoxin, metoprolol, antipsychotics, and amphetamines Phenazopyridine • Urinary analgesic in combo with antibiotics to reduce bladder irritation with lower UTIs, interstitial cystitis, or bladder pain syndrome • Limit to 2 days of use due to risk of side effects and for antibiotics to take effect • • • • Contains Azo dye that produces an anesthetic effect Given with or after meals TID Adverse Effects: o Reddish orange urine o Abdominal pain, HA, dizziness o Rare hemolytic anemia o Renal or liver dysfunction Contraindications: o CrCl < 50