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GI MEDS by Mind Map: GI MEDS

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