IBD/IBS - Manautou

Medications that induce lower esophageal spinchter relaxation

anticholinergics tricyclic anti-depressants theophylline###non-medication causes of GERD

Medications that induce lower esophageal spinchter relaxation

anticholinergics tricyclic anti-depressants theophylline

non-medication causes of GERD

pregnancy obesity fatty meals, chocolate, carbonated beverages disorders of esophageal motility

medications that can irritate esophagus and cause GERD

tetracycline bisphosphonates iron NSAIDs, Aspirin dabigatran steroids potassium

GERD severe symptonms

dysphagia (difficulty swallowing) choking chest pain

extra esopageal GERD symtpoms

too advanced for OTC must see a doctor chronic cough asthma like symptoms recurrent sore throat laryngitis dental enamel loss

3 types of GERD

NERD (no complications) Erosive esophagitis Barrett's esophagus

recommended style of treatment for GERD

step-down treatment start maximum and go down

exclusion for self treatment

• symptoms > 3 months

• heartburn for 2 weeks

• nocturnal heartburn -alarm symptoms

• unexplained weight loss

• chronic cough

• vomitting

if had heartburn _____ times/week, drugs can use

2 weeks, OTC: antacids, H2RAs

life style modifications for GERD

• weight loss obese pts

• head of bed elevation -smoking cessation -avoid meals 2-3hrs before bed

• avoid caffeine, alcohol, chocolate, acidic, spicy -reduce portion size, reduce fat -pregnancy associated GERD resolve post partum

Antacids disadvantages

• short duration of action -drug interacitons by changing pH -chelate other medications (doxycyline, ciprofloxacin) -risk of electrolyte imabalance with renal insufficiency

antacids

preferred in pregnancy

ADEs of antacids

hypercalcemia, constipation

most effective antacid

magnesium hydroxide (milk of magnesium)

less effective antacid

aluminum hydroxide (mylanta)

risk of using milk of magnesia

most effective magnesium toxicity (muscle weakness) diarrhea

risk of using aluminum

neurotoxicity with renal dysfunction constipation

alkaseltzer

• high sodium 9.6g/day max

• bleching

• avoid if heart failure, hypertension, cirrhosis, chronic kidney disease -avoid aspirin allergy -avoid reyes disease in children -high GI risk bleeding (avoid NSAIDs)

Bismuth

-avoid if aspirin allergy -avoid if ulcer/bleeding disorder -avoid if kids with chicken pox/flu like symptoms

bismuth counseling points

black stool, black tongue

drug used for prophyaxis

H2RAs

H2RA counseling points

take without regard to meals

H2RAs side effects think benadryl

-side effects CNS, similar to benadryl (fatigue, dizzy, headache, tired) -use only for 2 weeks

H2RA drug interactions

protease inhibitors, calcium carbonate, iron

cimetidine inhibits

CYP450, 2D6, 1A2, 2C9 alot of drug-drug interactions

side effects of cimetidine

gynecomastia, impotence

cimetidine increase elevations of which drugs

dofetlide metformin

Cimetidine is not recommended in pts which a history of what?

heart failure, cirrhosis, chronic kidney disease

sucralfate

increase aluminum dysfunction

drugs safe for pregancy

Tums (first line) , sucralfate (2nd line)

sucralfate counseling points

• take on empty stomach

• 1g 2-4 times daily -constipation separate at least 2 hours with other drugs -usually used as a addition

PPI time before meals

30mins

PPI open and sprinkle

OLDER

PPI risk

osteoporosis avoid if risk for hip fracture

taper PPI

8-12 weeks H2RA/Tums PRN with taper

Dexlanprazole

dual delayed release without regard to meals

omeprazole sodium-bicarbonate

nocturnal symptoms before bed (IR release)

PPI chronic ADE

decrease B12, increase pneumonia risk, increase enteric infections

PPI drug interactions

iron, hep C, protease inhibitors, 2C19 (clopidogrel)

incomplete PPI

1. QD -> BID

2. switch PPI but switch only once

3. Add H2RA for nighttime

PUD treatment

1. serious bleeding

2. perforation

3. gastric outlet obstruction

1. supportive care + IV PPI

2. surgical intervention

3. surgical intervention

nonpharmacological PUD

• smoking cessation

• exacerbating foods

• stress

• avoid NSAIDs + aspirin in some pts

low GI, high CV risk which medications recommended

COX-2 celecoxib

high GI, low CV risk which medications recommended

COX-1 aspirin

nonselective NSAID

naproxen ibuprofen

risk factors for NSAID related PUD low risk medium risk high risk

low none medium 1-2 high >2 -aspirin is automatically high risk

if GI is low-medium risk can NSAID still be used?

yes

NSAID treatment

1. stop NSAID or lower dose if can't stop

2. screen for H. pylori

3. treat 4-8 weeks

4. QD -> BID

Stress ulcer prevention drugs

H2RA, PPI

H2RA side effects

CNS, thrombocytopenia

monitoring for H2RA

CHECK RENAL

PPI route in stress

NG or IV

IV drugs in PPI

esomeprazole and pantoprazole

UGIB

1. give blood

2. IV PPI (esomeprazole, pantoprazole)

endoscopy

visual bleeding -erythromycin 250mg

eythromycin side effect

QTc prolongation

Bleed treatment

1. IV PPI bolus/hr IV continuous x 72hrs OR

2. IV PPI BID for 3 days

3. fluids to restore BP

4. Switch IV BID -> PO if able to take PO and bleeding has stopped

Clarithromycin Triple Therapy ______ BID + ______ BID + _____ BID

PPI, clarithromycin, amoxicillin (use metronidazole if PCN allergy)

Bismuth Quadruple therapy ________ BID + _________ QID + _________ QID + _______ TID

PPI, bismuth salicyclate, metronidazole + tetracycline