1. ANTIEMETICS
1.1. CHOLINERGIC ANTAGONISTS
1.1.1. **SCOPOLAMINE (Trans-Scop)
1.1.1.1. 1.5mg patch q3 days PRN
1.1.1.1.1. start >4hrs before event
1.1.1.2. CI: glaucoma, BPH, arrhythmias, elderly, seizure hx, psychosis hx, POTASSIUM CHLORIDE/CITRATE/PHOSPHATE/ACID
1.1.1.3. AE: psychosis, seizures, heat stroke, glaucoma, IOP, withdrawal, dizziness, drowsiness, somnolence, agitaiton, blurred vision, mydriasis, rash
1.2. DOPAMINE ANTAGONIST
1.2.1. **METOCLOPRAMIDE (Metozolv, Reglan)
1.2.1.1. BLACK BOX: TARDIVE DYSKINESIA
1.2.1.2. Chemo N/V - 1-2mg IV q2-3hrs
1.2.1.2.1. give 30min before chemo then repeat q2hrs x 2 doses, q3h x 3 doses,
1.2.1.3. Post OP N/V - 10mg IM/IV x 1
1.2.1.3.1. or 20mg IM/IV x 1
1.2.1.3.2. repeat q6-8h pRN
1.2.1.4. CI: pheo, seizures, GI bleed, depression, parkinsons, HTN, CHF, DM, cirrhosis, -mine
1.2.1.5. AE: dystonia, suicidality, hallucinations, depression, seizures, drowsiness, fatigue, anxiety, confusion, gynocomastia, hypotension, bradycardia
1.2.1.6. prokinetic - stimulates gut motility
1.2.1.7. used for diabetic gastroparesis, short term GERD, post op
1.2.1.8. measure CR at baseline
1.3. SERATONIN ANTAGONIST
1.3.1. **ODANSETRON (Zofran)
1.3.1.1. CHEMO: .15mg/kg IV q4h x 3 doses
1.3.1.1.1. PO 24mg X1
1.3.1.1.2. PO 8mg Q8H X 2 doses
1.3.1.1.3. 30min before chemo
1.3.1.2. POST OP: 4mg IV/IM x 1
1.3.1.2.1. or 16mg PO 1h before anesthesia
1.3.1.3. GI: 2mg/8kg PO x 1
1.3.1.3.1. .15mg/kg IV x 1
1.3.1.4. CI: 1st trimester, long QT, lyte abnormalities, bradycardia, recent MI, CHF, hepatic impairment, dronedarone, pimozide
1.3.1.5. AE: anaphylaxis, bronchospasm, QT prolongation, headache, constipation, fatigue, diarrhea, hypoxia, fever, dizziness, urinary retention, agination pruritus
1.3.1.6. monitor ECG
1.4. CANNABINOIDS
1.4.1. DRONABINOL (Marinol)
1.4.1.1. 5mg/m2 PO 1-3 hours before chemo
1.4.1.1.1. increase dose by 2.5 mg/m2
1.4.1.1.2. MAX: 15mg/m2
1.4.1.1.3. taper dose
1.4.1.2. CI: hypersensitivity to sesame oil, psych disorder, seizure history, substance abuse, doxylamine
1.4.1.3. AE: seizures, depression hallucinations, dizziness, somnolence, euphoria, paranoia, N/V, tachycardia, anxiety, ataxia
1.4.1.4. only approved for cancer
1.5. HISTAMINE ANTAGONISTS
1.5.1. PROMETHAZINE (Phenergan)
1.5.1.1. 12.5-25mg PO/IM/IV/suppository q4-6h
1.5.1.1.1. MAX: 50mg/dose IM/PO
1.5.1.1.2. MAX: 25mg/dose IV
1.5.1.1.3. IM > IV
1.5.1.2. CI: SQ injection, coma, < 2 y/o, eldelry, asthma, COPD, glaucoma, BPH, hepatic impairment, seizure, dronedarone, pimozide, potassium, saquinavir, yohimbe
1.5.1.3. AE: Apnea, seizures, hallucinations, jaundice, angioedema, bradycardia, tachycardia, drowsiness, sedation, blurred vision, confusion, disorientation, dermatitis, rhinitis,
1.5.1.3.1. BLACK BOX: Respiratory depression, gangrene
1.5.1.4. works really well for migraines
1.5.2. MECLIZINE (Antivert)
1.5.2.1. 25-50mg PO q24h
1.5.2.1.1. start 1h before travel
1.5.2.2. CI: elderly, renal/hepatic impairment, glaucoma, hyperthyroidism, HTN, ashtma, COPD, PUD, BPH, potassium
1.5.2.3. AE: anemia, leukopenia, arrhythmias, seizures, psychosis, drowsiness, dizziness, constipation, dysuria, hypotension, diplopia, palpitaitons, tachycardia
1.5.3. DIMENHYDRINATE (Dramamine)
1.5.3.1. 50-100 mg PO/IM/IV q4-6h
1.5.3.1.1. MAX: 8 tabs/day
1.5.3.1.2. give .5-1h before activity
1.5.3.2. CI: <2y/o, ashtma, IOP, glaucoma, hyperthyroidism, asthma, HTN, BPH, PKU, potassium
1.5.3.3. AE: anemia, leukopenia, arrhythmias, seizures, psychosis, drowsiness, dizziness, HA, constipation, dysuria, hypotension, blurred vision, photosensitivity
2. ANTIDIARRHEAL
2.1. OPIOID
2.1.1. **LOPERAMIDE (Imodium)
2.1.1.1. stops perastolsis - limits fluids in gut
2.1.1.2. OTC - 2mg tabs
2.1.1.2.1. take one after every watery stool
2.1.1.2.2. MAX: 16mg/day
2.1.1.3. for travelers diarrhea and IBS
2.1.1.4. CI: abd p with diarrhea, bloody or infectious diarrhea, c. diff, UC, pt <2, hepatic impairment, HIV, diarrhea >48hr, potassium
2.1.1.5. AE: Toxic megacolon, ileus, angioedema, SJS, EM, heat stroke, syncope, constipation, nausea, cramps, dizziness, drowsiness
2.1.2. DIPHENOXYLATE/ATROPINE (Lomotil)
2.1.2.1. 2 tabs PO QID
2.1.2.1.1. MAX: 8 tabs
2.1.2.1.2. D/C after 48h if no improvement
2.1.2.2. CI: c.diff, diarrhea, volume depletion, electrolyte imbalance, jaundice, potassium
2.1.2.3. AE: respiratory depression, ileus, pancreatitis, toxic megacolon, angioedema, N/V, anorexia, abd pain, paresthesia, euphoria, depression, confusion, dizziness, sedation, lethargy
3. IBS TX
3.1. SEROTONIN MODULATORS
3.1.1. ALOSETRON
3.1.1.1. .5-1mg PO BID
3.1.1.1.1. START .5mg PO BID X 4wk
3.1.1.1.2. MAX: 2mg/day
3.1.1.2. CI: constipation, GI obstruction, toxic megacolon, GI perf, ischemic colitis, hypercoaguable state, Chrons, diverticulitis, fluvoxamine
3.1.1.3. AE: constipation, ischemic colitis, mesenteric ischemia, ileus, GI obstruction/perf, diverticulitis, UC, constipation, N/V, dyspepsia, abdominal distention, hemorrhoids, flatulence, URI
3.1.1.4. BLACK BOX: appropriate use, GI adverse events, appropriate indication
3.1.1.4.1. diarrhea-predominant IBS without adequate response to conventional treatment
3.1.2. TEGASEROD
3.1.2.1. withdrawn from US market
3.1.2.2. CI: renal, hepatic, GI obstruction, abdominal adhesions, diarrhea, HTN, ischemic heart disease, HTN, hyperlipidemia, DM, obesity, smokers, pt >55, anxiety, depression
3.1.2.3. AE: diarrhea, ischemic colitis, cholecystitis, MI, stroke, angina, HA, abdominal Pain, N/D, faltulence, dizziness
3.2. ANTI SPASMODIC
3.2.1. **HYOSCYAMINE
3.2.1.1. .125-.25 mg PO/SL q4h PRN
3.2.1.1.1. MAX: 1.5mg/day
3.2.1.1.2. ER - .375mg PO q8-12h
3.2.1.2. CI: glaucoma, ileus, UC, BPH, MI, toxic megacolon, MG, fever, hyperthyroidism, elderly, renal/hepatic, CAD/CHF/HTN
3.2.1.3. AE: anaphylaxis, heat stroke, IOP, psychosis, hallucinations, dry eyes, urinary retention, constipation, confusion, impaired memory, excitement, nervousness ,flushing, dizziness, fever, hives, insomnia, N/V
4. PEPTIC ULCER AND GERD TX
4.1. ANTACIDS
4.1.1. ALUMINUM HYDROXIDE
4.1.1.1. 320 - 1280 mg/day
4.1.1.1.1. 1-3 hours after meals and at bedtime
4.1.1.2. CI: GI obstruction, renal impairment, volume depletion, sodium citrate
4.1.1.3. AE: aluminum intox, osteomalacia, encephalopathy, constipation, hypophosphatemia, abdominal pain
4.1.2. CALCIUM CARBONATE
4.1.2.1. 1-3mg PO QID PRN
4.1.2.2. CI: hypercalcemia, nephrolithiasis, dehyrdation, Vit D tox, GI bleed, -stine, potassium
4.1.2.3. AE: hypercalcemia, nephrolithiasis, hypomagnesemia, constipation, nausea
4.1.3. AL HYDROXIDE/MG HYDROXIDE
4.1.3.1. 15-30 mL PO QID PRN
4.1.3.1.1. 1-3h after meals and bedtime
4.1.3.2. CI: GI obstruction, renal failure, volume depletion, sodium citrate,
4.1.3.3. AE: AL toxicity, hypermagnesemia, osteomalacia, diarrhea, constipation, dehydration N/V
4.1.4. BISMUTH SUBSALICYLATE (Pepto bismol)
4.1.4.1. antisecretory, antimicrobial, anti inflammatory
4.1.4.2. aspirin metabolite
4.1.4.3. turns tongue and stool black
4.1.4.4. 2 tabs or 30mL PO q30-60min PRN
4.1.4.4.1. MAX: 16 tabs or 240mL/24 hr
4.1.4.5. CI: PREGNANCY, G6PD, GI bleed, coag disorder, flu/Varicella/febrile viral infx, renal impairment, hepatic impairment, gout, dichlorphenamide
4.1.4.6. AE: Reye's, black stool, black tongue, constipation, tinnitus
4.2. MUCOSAL PROTECTANTS
4.2.1. MISOPROSTOL
4.2.1.1. 100-200 mcg PO QID
4.2.1.2. CI: pregnancy, CV dx, IBS,
4.2.1.3. AE: miscarriage, uterine rupture, bronchospasm, hTN, hypotension, MI, arrhythmias, dehydration, diarrhea, abdominal pain, nausea, HA, dyspepsia
4.2.2. **SUCRALFATE
4.2.2.1. 1g PO QID-BID
4.2.2.2. CI: GI obstruction, DM, renal failure, aspiration, dysphagia, potassium,
4.2.2.3. AE: anaphylaxis, hyperglycemia
4.3. H2 BLOCKERS
4.3.1. CIMETIDINE (Tagamet)
4.3.1.1. GERD: 1600 mg/day PO BID/QID x 12 weeks
4.3.1.2. PUD: 800mg PO qhS 4-8 weeks
4.3.1.2.1. maintenance = 400mg PO qHS
4.3.1.3. CI: renal/hepatic impairment, elderly, DM, cisapride, dofetilide, thioridazine
4.3.1.4. AE: anemia, hallucinations, psychosis, pancreatitis, bradycardia, tachycardia, HA, diarrhea, dizziness, gyneocomastia, N/V, confusion, rash
4.3.2. FAMOTIDINE (Pepcid)
4.3.2.1. GERD: 20-40mg PO BID x 12 weeks
4.3.2.1.1. 20mg IV q12h
4.3.2.2. PUD: 40mg PO qHS x 4-6weeks
4.3.2.2.1. maintenance: 20mg PO qHS
4.3.2.3. CI: renal impairment, -navir, -pril, -nib, naproxen,
4.3.2.4. AE: angioedema, SJS, seizures, arrhythmias, hepatitis, HA, dizziness, constipation, diarrhea, taste changes, B12 deficiency
4.3.3. **RANITIDINE (Zantac)
4.3.3.1. 150mg PO daily or BID
4.3.3.2. GERD: 150mg PO BID
4.3.3.3. PUD: 150mg PO BID
4.3.3.3.1. Maintenance: 150mg PO qHS
4.3.3.4. CI: porphyria, hepatic/renal impairment, elderly, DM, -navir, -pril, -nib, iron, -azole, naproxen
4.3.3.5. AE: HA, diarrhea, constipation, vertigo, malaise, dizziness, N/V, rash confusion, fatigue, B12 deficiency
4.3.4. best for long term use - last 24 hours
4.4. PPI
4.4.1. AE: SJS, erythema multiforme, renal impairment, fracture, hypomagnesium, C.Dif, HA, abdominal pain, N/V/D, URI, fever, B12 deficiency
4.4.2. CI: long term use, hepatic impairment, hypomagnesemia, nelfinavir, rilpivirine
4.4.3. **OMEPRAZOLE (Prilosec)
4.4.3.1. GERD: 30mg PO qd x 4-8 WEEKS
4.4.3.2. PUD: 40mg PO qd x 4-8 weeks
4.4.4. ESOMEPRAXOLE (Nexium)
4.4.4.1. GERD: 20mg PO/NG qd x 4-8wks
4.4.4.2. PUD: 40mg PO qd x 4-8 wks
4.4.5. LANSOPRAZOLE (Prevacid)
4.4.5.1. GERD: 15-30mg PO qd x 8 weeks
4.4.5.2. PUD: 15-30mg PO qd-BID x 4-8 wks
4.4.6. PANTOPRAZOLE (Protonix)
4.4.6.1. GERD: 20mg qd x 4-8wks
4.4.7. RABEPRAZOLE (Aciphex)
4.4.7.1. GERD: 20-40mg PO qd x 4-8weeks
4.4.7.2. PUD: 20mg PO qd x 4weeks
4.5. ABX THERAPY (H.PYLORI)
4.5.1. TRIPLE THERAPY (Prev Pac)
4.5.1.1. PPI, amoxacillin, clarithromycin x 14 days
4.5.2. QUADRUPLE THERAPY
4.5.2.1. PPI, amoxacillin, clarythromycin, pepto mismol, bismuth sulfate
5. CONSTIPATION
5.1. STOOL SOFTENER
5.1.1. **DOCUSATE
5.1.1.1. prevents hard stool does not treat
5.1.1.2. 50-300mg/day PO divided into QD-BID PRN
5.1.1.3. CI: fecal impaction, mineral oil, appendicitis, GI obstruction,
5.1.1.4. AE: diarrhea, cramps, throat irritation, electrolyte disorder, bitter taste
5.2. BULK LAXATIVES
5.2.1. METHYLCELLULOSE
5.2.1.1. caplets or powder
5.2.1.1.1. 2 tabs PO PRN
5.2.1.1.2. 1 TBSP PO QD-TID PRN
5.2.1.2. CI: acute abdomen, appendicitis, fecal impaction, sodium phosphate
5.2.1.3. AE: cramps, N/D
5.2.2. **PSYLLIUM
5.2.2.1. 3.4g PO QD
5.2.2.1.1. increase slowly
5.2.2.2. CI: suspected appendicitis, GI obstruction, sodium phosphate
5.2.2.3. AE: esophageal obstruction, GI obstruction, diarrhea, constipation, cramps, bronchospasm, rhinoconjunctivitis
5.3. OSMOTIC LAXATIVES
5.3.1. **POLYETHYLENE GLYCOL (GoLitely, miralax)
5.3.1.1. pull water into colon
5.3.1.2. 17g "heaping teaspoon"
5.3.1.2.1. or cap dissolved in 8oz clear liquid
5.3.1.3. CI: GI obstruction, elderly, sodium phosphate
5.3.1.4. AE: electrolyte disorders, laxative dependence, nausea, abdominal distention, cramping, flatulence, diarrhea, urticaria
5.3.2. LACTULOSE
5.3.2.1. 10-20g daily
5.3.2.1.1. MAX: 40g daily
5.3.2.2. 15-30mL PO QD-BID
5.3.2.2.1. MAX: 60mL/day
5.3.2.3. CI: galactosemia, DM, sodium phosphate
5.3.2.4. AE: diarrhea, electrolyte disorders, flatulence, cramps, abdominal distention, N/V
5.3.3. GLYCERIN SUPPOSITORY
5.3.3.1. 1 adult supp PR QD PRN
5.3.3.1.1. retain in rectum for 15-60min
5.3.3.2. for peds
5.3.3.3. CI: anuria, volume depletion, pulmonary edema, heptic/renal impairment, sodium phosphate
5.3.3.4. AE: N/D, HA, rectal irritation
6. IBD TX
6.1. SALICYLATES
6.1.1. **SULFASALAZINE (Azulfidine)
6.1.1.1. 500mg PO q6h
6.1.1.1.1. start 1g PO q6-8
6.1.1.1.2. MAX: 6g/day
6.1.1.2. CI: porphyria, GI obstruction, renal/hepatic, G6PD, asthma, ICH, dehydration, methenamine
6.1.1.3. AE: anaphylaxis, EM, SJS, exfoliative dermatitis, pulmonary toxicity, hepatotoxicity, nephrotoxicity, seizures, meningitis, aplastic anemia, infertility, anorexia, HA, N/V, dyspepsia, rash, ab p, dizziness, itching, hives, cyanosis, photosensitivity
6.1.2. MESALAMINE (APRISO)
6.1.2.1. step 1 drug
6.1.2.2. ASACOL
6.1.2.2.1. coating that dissolves at pH 7
6.1.2.2.2. terminal ilium
6.1.2.2.3. D/C in US
6.1.2.3. PENTASA
6.1.2.3.1. starts at pyloris
6.1.2.3.2. 100mg PO QID x 8wk
6.1.2.3.3. CI: flu/vzv/viral infx, renal/hepatic, pyloric stenosis, hypersensitivity, streptozocin,
6.1.2.3.4. AE: acute UC, nephropathy, interstitial nephritis, renal failure, hepatotoxicity, pericarditis, myocarditis, aplastic anemia, reyes, N/V/D, HA, rash, dyspepsia, ALT/AST elevation
6.1.3. 5-AMINO SALICYLIC ACID
6.1.4. SULFAPYRIDINE
6.2. STEROIDS
6.2.1. HYRDOCORTISONE
6.2.2. METHYLPREDNISOLONE
6.2.3. **PREDNISONE
6.2.4. BUDESONIDE
6.2.5. step 2
6.3. IMMUNOMODULATORS
6.3.1. METHOTREXATE
6.3.2. INFLIXIMB (Remicade)
6.3.2.1. first line for IBS
6.3.3. step 3