Self-Care Quiz 3

What is the MOA for stimulant laxatives?

*Locally irritates colonic mucosa --> increases motility* -Action on the intramural nerve plexus of intestinal smooth muscle -*Increases the secretion of water and electrolytes in the intestine*.

LES

*Lower Esophageal Sphincter* -Prevents backflow of stomach contents upward into esophagus

What would be the second-line of constipation treatment for a child 2-6 years old?

-*oral docusate sodium* -*magnesium hydroxide* -senna OR rectal glycerin -mineral oil or sodium phosphate

What are the DDIs for Saline laxatives?

-Oral anticoagulants (e.g. warfarin) -Digoxin -Chlorpromazine -Mg-containing can interfere with absorption of oral tetracyclines (e.g. doxycycline)

What are emollient agents good for?

-Preventing straining -Painful defecation Note: They are often used in combo with a stimulant -e.g. peri-colace is Docusate Sodium plus senna

What are the indications for Pepto-Bismol?

-Relief of heartburn, upset stomach, indigestion, nausea, diarrhea -Relief of upset stomach associated with belching -Relief of gas associated with overindulgence in food and drink Note: bismuth salicylate pepto comes in tablets and so does the pepto children's. No bueno.

Why is mineral oil generally not recommended for the treatment of constipation?

-Safer alternatives -Lipid pneumonia (aspiration) -Leakage -Interferes with fat-soluble vitamin absorption (A,D,E, and K)

Which laxatives should be avoided in the elderly?

-Saline laxatives -Mineral oil

What are some Hypomagnesemia symptoms?

-Seizures -Tremors -Cardiac arrhythmias • Torsades de Pointes (TdP) • QTc prolongation

What are the dosage forms for the stimulant laxatives?

-Tablets -liquid -suppository (bisacodyl comes both orally and rectally)

*Antacid-Drug Interactions* Which antibiotics can interact with antacids?

-Tetracyclines -azithromycin -fluoroquinolones Interactions: -Binding to divalent and trivalent cations -Potentially decreased antibiotic absorption

Antacids are indicated for:

-The treatment of mild, infrequent heartburn -sour stomach -and acid indigestion.

What are some common adverse reactions with saline laxatives?

-cramping -N/V -dehydration saline laxatives cause a lot of fluid loss if used often

What are side effects of PPIs?

-diarrhea -constipation -HA

Heartburn can occur alone or with...

-dyspepsia -GERD -PUD

Signs of upper GI bleeding include:

-hematemesis -melena -occult bleeding -anemia

Which OTC laxatives are ok to use in lactation?

-senna -bisacodyl -PEG 3350 -docusate

Odynophagia (painful swallowing) is one of the less common alarm symptoms and may indicate:

-severe ulcerative esophagitis -pill injury -infection

What is the dosing for PEG 3350?

1 capful (17 g) daily mixed in 4-8 ounces of fluid

The duration of action of an antacid is transient but increases when taken within ______ of a meal

1 hour

What is the dosing for glycerine suppositories?

1 suppository (adult, child, infant formulations) or as directed by PCP.

Complete relief with the use of PPIs is experienced in ______ days.

1 to 4

What are the Goals for the Self-Treatment of Heartburn and Dyspepsia?

1) Provide complete relief of symptoms 2) Reduce recurrence of symptoms 3) Prevent and manage unwanted effects of medications

What is the onset of effect for a PPI?

1-4 days

What are some "alarm symptoms" of Dyspepsia?

1. *Upper GI bleeding* -appears as either bright red or coffee grounds 2. *Dysphagia* (difficulty swallowing) 3. *Anemia* 4. *Unintended weight loss* Note: Any alarm symptoms should match up with exclusions.

The FDA warning associated with oral sodium phosphate products (e.g. Fleet ® PhosphoSoda), is due to....

Acute phosphate nephropathy and acute renal impairment

What side effect from Pepto-Bismol do you need to council on?

Black, tarry stools.....could mean lower GI bleed. also discoloration of tongue

PPIs are inhibitors of CYP______.

CYP2C19

True or False: Heartburn and GERD are interchangeable.

False Heartburn can occur without truly being GERD

What is the dosage form for di and monobasic sodium phosphate?

Only comes in an enema (fleet) -causes issues with renal dysfunction and electrolyte imbalance

High dose _______ use greater than 1 year associated with increased risk of hip, spine, and wrist fractures in older adults (> 50 y/o)

PPI

The onset of action for bulk-forming laxatives is ________ hours, but may take up to ____ hours

The onset of action for bulk-forming laxatives is *12-24* hours, but may take up to *72* hours

True or False: Avoiding the urge to stool can cause constipation

True

What class of drug would you recommend for a patient with episodic heartburn? a. H2 blocker b. ppi c. tums d. all of the above

a. H2 blocker

The only ingredient for children's antacid products is....

calcium carbonate

Which of the following products are *not* FDA approved for the treatment of constipation? a. Citrucel (Methylcellulose) b. Metamucil (psyllium) c. FiberCon (polycarbophil) d. FiberChoice (inulin) e. Benefiber (wheat dextrin) f. Unifiber (powdered cellulose) g. Sunfiber (Partially hydrolyzed guar gum)

d. FiberChoice (inulin) e. Benefiber (wheat dextrin) f. Unifiber (powdered cellulose) g. Sunfiber (Partially hydrolyzed guar gum)

Constipation is more common in _______ countries.

developed

What is your first line option for hyperosmotic agents?

polyethylene glycol 3350 -these are nice because they have few side effects, and there are no DDIs

The First step in Assessing a patient for constipation self-care is....

*Obtain Medical History* -Remember QuEST SCHOLAR-MAC -Medication/CAM/OTC history -Do they have a history of constipation? -Do they have drug-induced or disease-induced constipation? -Are they pregnant? -What about their diet/exercise/lifestyle?

*Compare and contrast the onset of relief and the duration of relief between the pharmacologic treatments for self-care of heartburn and/or dyspepsia.* *PPIs plus antacids* Onset of relief: Duration of action:

*Onset of relief: 2-3 hours* *Duration of action: 12-24 hours*

*Compare and contrast the onset of relief and the duration of relief between the pharmacologic treatments for self-care of heartburn and/or dyspepsia.* *H2RAs* Onset of relief: Duration of action:

*Onset of relief: 30-45 minutes* *Duration of action: 4-10 hours* Note: H2RAs work by preventing acid production. -but the acid that is already in there needs to be neutralized in order to get relief.

*Compare and contrast the onset of relief and the duration of relief between the pharmacologic treatments for self-care of heartburn and/or dyspepsia.* *Antacids* Onset of relief: Duration of action:

*Onset of relief: <5 minutes* *Duration of action: 20-30 minutes* (BUT, food prolongs the duration of relief)

*Compare and contrast the onset of relief and the duration of relief between the pharmacologic treatments for self-care of heartburn and/or dyspepsia.* *H2RAs plus antacids* Onset of relief: Duration of action:

*Onset of relief: <5 minutes* *Duration of action: 8-10 hours* The nice thing about these are that they have the antacid in them that can neutralize the acid and provide some relief while the famotidine starts to work. -the antacid also helps to extend the duration of action.

______ or ______ may be used short-term in pregnant woman.

*Senna* or *bisacodyl* may be used short-term in pregnant woman. Note: PEG 3350 is recommended by some providers

What test should be performed in a patient suspected to have GERD?

*Upper Endoscopy* -Standard test to view type & extent of esophageal mucosal damage

If chest pain is accompanied by nausea, vomiting, sweating, and shortness of breath, then it is more likely related to ....

*cardiac issues* (i.e. ischemic pain and possible myocardial infarction)

Which oral agent has the fastest onset of action? a) Senna b) Bisacodyl c) Methylcellulose d) Mineral oil e) Docusate sodium f) Magnesium citrate

*f) Magnesium citrate* (30 min-3 hours) a) Senna (6-10 hrs) b) Bisacodyl (6-10 hrs) c) Methylcellulose (12-24 hrs) d) Mineral oil (6-8 hrs) e) Docusate sodium (12-72 hrs)

GERD related chest pain is usually ________.

*substernal* -May mimic ischemic cardiac pain by radiating to the back, neck, jaw or arms -Symptoms may worsen after meals or periods of emotional stress -Symptoms may awaken patient from sleep

Patients may also present with atypical or extraesophageal symptoms related to gastroesophageal reflux. These include:

-*non-cardiac chest pain* -asthma -laryngitis -hoarseness -globus sensation (sensation of a lump in the throat) -chronic cough -recurrent pneumonitis -dental erosion Note: Patients presenting with any alarm symptoms or atypical symptoms should be referred to their primary care provider for further evaluation. *Pagnucco says atypical symptoms--->refer to ER*

What is the MOA of Emollient Agents?

-Act in small and large intestines to increase the wetting efficiency of intestinal fluid -Literally softens the fecal mass

What is the MOA of lubricants (mineral oil)?

-Acts in colon to soften feces -Coats stool and prevents colonic absorption of H2O

Concomitant antacid administration may affect absorption of other medications mainly by .....

-Adsorbing -chelating -or by increasing intragastric pH

What are the pharmacologic options for the self-treatment of Heartburn and Dyspepsia?

-Antacids -Histamine 2-Receptor Antagonists (H2RAs) -Proton Pump Inhibitors (PPIs) -Bismuth Subsalicylate (BSS)

What medications does cimetidine interact with?

-Blood thinners such as warfarin or clopidogrel -Antifungals such as ketoconazole -Anticonvulsants such as phenytoin -antianxiety medications such as diazepam -theophylline -amiodarone

What are dyspepsia symptoms?

-Bothersome postprandial fullness -early satiation -epigastric pain -epigastric burning -anorexia -belching -nausea and vomiting -upper abdominal bloating Note: Dyspepsia is NOT necessarily acid related.

What is the MOA for hyperosmotic agents?

-Contains large, poorly absorbed ions/molecules -Pull water into the colon/rectum via osmosis

What are the etiologies for constipation in the elderly?

-Diet changes/decreased activity -Comorbid disorders -Polypharmacy Note: Should perform a medication review

What are the nonpharmacologic therapy options for the self-treatment of Heartburn and Dyspepsia?

-Dietary considerations -Lifestyle modifications

What is the MOA for bulk-forming laxatives?

-Dissolve or swell in the small and large intestines -Form emollient gels that stimulate peristalsis

Which drugs can produce pill-induced injury?

-Fosamax (bisphosphonates; need to be upright....etc.) -Tetracyclines -NSAIDs and aspirin -potassium chloride -vitamin C From the book: Medications, including iron, antibiotics, narcotics, digoxin, estrogens, theophylline, and nonsteroidal antiinflammatory drugs (NSAIDs), commonly cause dyspepsia through direct gastric mucosal injury, changes to GI function, exacerbation of reflux, or some other mechanism.

Why must patients adhere to the dosing limits of stimulant laxatives?

-Greater risk for adverse reactions --Vomiting, nausea, diarrhea, abdominal cramping -Colic, increased mucus secretion, excessive fluid loss can occur at high doses

What are the complications associated with constipation?

-Hemorrhoids -Anal Fissures -Rectal Prolapse -Fecal Impaction -Blood Pressure Surges -Cardiac Rhythm Disturbances

Histamine2-Receptor Antagonists (H2RAs) are Indicated for treatment of:

-Mild-to-moderate, infrequent, episodic heartburn -Prevention of heartburn associated with acid indigestion and sour stomach

What things can get in the way of fluid reabsorption in the intestines?

-Neurohormonal mechanisms -pathogens -drugs

What are the etiologies of constipation in pregnancy?

-Uterus suppresses the colon -Rising progesterone levels -Low fluid/fiber intake -Prenatal vitamins (high iron and calcium content)

What is the MOA for saline laxatives?

-Work in small and large intestine -Ions are not absorbed, draw water into intestines *↑ Red flag!*-- not for patients with renal dysfunction or ion imbalance! -Increase intraluminal pressure and intestinal motility

What are some "alarm symptoms" of Heartburn?

1. *Dysphagia* (difficulty swallowing) 2. *Odynophagia* (painful swallowing) -Consider other causes of esophagitis, such as: • Pill-induced injury • Infections 3. *Upper GI bleeding* 4. *Unintended weight loss* 5. *Atypical symptoms* Note: Any alarm symptoms should match up with exclusions.

HEartburn can be classified as either....

1. *Episodic* -mild, sporadic, and predictive (i.e. after the ingestion of spicy food/beverages) --may be helpful to recommend patient start keeping a diary in order to figure out their triggers. or 2. *Frequent* -occurs 2 or more days per week

Bulk-forming laxatives should be AVOIDED in: 1. ______-restricted patients 2. Intestinal ________, ________, __________ 3. Can lead to _______ if added too quickly or without enough fluid

1. *Fluid*-restricted patients (can choke if you don't drink enough fluid with the bulk-forming laxative, due to the emollient gel formation) 2. Intestinal *ulcerations*, *stenosis*, *adhesions* (these patients are at a higher risk for bowel obstructions) 3. Can lead to *obstruction* if added too quickly or without enough fluid

What are the 4 main symptoms of dyspepsia?

1. *Postprandial fullness*: -Unpleasant sensation perceived as prolonged persistence of food in the stomach 2. *Early satiation*: -Feeling of fullness soon after starting to eat --out of proportion to amount of food ingested 3. *Epigastric pain*: -Unpleasant sensation between the umbilicus and lower end of the sternum 4. *Epigastric burning*: -Unpleasant subjective sensation of heat Other, less specific symptoms: -Bloating -nausea, -vomiting -belching

What are the six types of Pharmacotherapy agents for constipation?

1. Bulk-Forming Laxatives 2. Hyperosmotic Agents 3. Emollient Agents 4. Lubricants 5. Saline Laxatives 6. Stimulant Laxatives

What are 4 types of foods that make you go poo?

1. Grains 2. cereals 3. fruits 4. veggies

Antacids contain at least one of the following salts:

1. Magnesium • Hydroxide, carbonate, trisilicate 2. Aluminum • Hydroxide, phosphate 3. Calcium carbonate 4. Sodium bicarbonate MOA: Cations react with chloride in HCl, and the anion reacts with hydrogen ions to form water. Note: Many times our drug reactions are related to divalent and trivalent cations.

Bulk-forming laxatives are GOOD for: 1. Patients on ______-residue diets 2. ________ and pregnancy 3. ________ patients 4. When _________ is an issue 5. _________ , _______, _________ disease

1. Patients on *low*-residue diets (low calorie/carb) 2. *Postpartum* and pregnancy 3. *Elderly* patients 4. When *straining* is an issue (bulk-forming laxatives make stool softer) 5. *IBS*, *colostomies*, *diverticular* disease

What are some things to consider when recommending bulk-forming laxatives to patients?

1. Patients should increase fiber slowly over 1-2 weeks -Flatulence and bloating are common adverse effects 2. Results are not always immediate 3. Add PLENTY OF fluid along with increased fiber -Choking hazards, obstruction 4. Pay attention to sugar content for patients who are diabetic 5. Balance tolerability, desirable dosage form, effectiveness and cost

What are the goals of Constipation Treatment:

1. Relieve constipation and reestablish normal bowel function 2. Establish dietary and exercise habits that aid in preventing recurrences 3. Promote safe and effective use of laxatives

The toxicity risk of saline laxatives is higher in which special populations?

1. Renal impairment 2. Newborns 3. Older adults Note: Dr. Smith tends to avoid recommending saline laxatives to older adults, even though a lot of them tend to like Phillips (MOM)

What are the 2 types of Fiber?

1. Soluble (dissolves in the GI tract) -e.g. fruits and grains 2. Insoluble (does not dissolve in the GI tract) -e.g. whole grains and veggies like broccoli and lettuce

What are the 2 types of contractions in the colon?

1. Stationary (non-propulsive) contractions 2. Giant migrating contractions (propulsive)

Which three drugs interact with antacids because they require low intragastric pH for disintegration, dissolution, or ionization?

1. itraconazole 2. ketoconazole 3. iron These have decreased absorption when taken with antacids.

In regards to polyethylene glycol 3350, a BM is produced in ____________ but may be up to 96 hours.

12-72 hours

In regards to glycerine suppositories, a BM is produced in ____________.

15-30 minutes

PPIs treat frequent heartburn that lasts for ___ more days per week.

2

Patients taking tetracyclines, fluoroquinolones, azithromycin, digoxin, ketoconazole, itraconzole, and iron supplements should not take antacids within ___ hours of taking any of these medications.

2

In children > ______ old; symptoms of mild, transient and infrequent heartburn, acid indigestion, or sour stomach may be treated with children's products containing calcium carbonate if used according to package directions.

2 years

Stool infrequency = fewer than _____ bowel movements (BMs) per week

3 Note: "Normal" can range from 3 BMs a day to 3 a week!

Frequent and persistent heartburn lasts for ________ or longer and is typical for GERD.

3 months

The onset of action for MOM (magnesium hydroxide) is within...

30 minutes to 6 hours

Patients should NEVER use laxatives for more than __________ unless they are directed to by their provider (or are on chronic, constipating medications)

7 days

___ Liters of fluid passes through the small intestine on a daily basis.

9

What is Zollinger-Ellison syndrome?

A condition in which a gastrin-secreting tumor or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers.

What are the exclusions for heartburn self-care?

Add: Adults > 45 y/o with new onset dyspepsia Stuff pagnucco stressed: -frequent heartburn for more than 3 months -Heartburn while taking the recommended dosages of nonprescription H2RA or PPI -Heartburn that continues after 2 weeks of treatment with an H2RA or PPI -*Nocturnal heartburn* -Difficulty or pain on swallowing solid foods -vomiting up blood ar black material -hoarseness, wheezing, coughing, choking. (sometimes the acid can get aspirated and cause irritation in the lungs) -Nursing mothers -*children under 2 (for antacids)* -*children under 12 (for H2RAs)* -*children under 18 (for PPIs)*

What are the DDIs with stimulant laxatives?

Antacid, H2-receptor blockers, PPIs and milk can erode bisacodyl's enteric coating -Separate by at least 1 hour

Antacids are usually taken ________; relief of symptoms typically begins within ___ minutes.

Antacids are usually taken *at the onset of symptoms*; relief of symptoms typically begins within *5* minutes.

What are some lifestyle modifications that can be recommended to patients with heartburn and/or dyspepsia (non-nocturnal)?

Avoid food, beverages, and activities that may precipitate or increase the frequency and severity of symptoms. If possible, avoid the use of medications that may aggravate heartburn or dyspepsia. Avoid eating large meals; eat smaller meals. Stop or reduce smoking. Lose weight if overweight and not pregnant. Wear loose-fitting clothing.

Why is it not necessarily a good thing that bulk-forming laxatives are not systemically absorbed?

Because when they are sitting in the GI tract and a patient is taking other medications on top of it, it is very common for those medications to bind to the fiber, which will reduce the absorption of the other medications.

First pharmacological treatments for constipation in the elderly are:

Bulk-forming -BUT: avoid in bedridden, very frail, fluid-restricted patients PEG 3350 -Safe and very tolerable (Dr. Smith's laxative of choice for the elderly) Docusate -Good choice for patients with hemorrhoids/fissures or those who shouldn't strain Note: use caution with Stimulant laxatives

What is recommended for constipation in pregnant women after lifestyle modifications have been unsuccessful?

Bulk-forming laxatives

What are the first line OTC treatments for constipation (Note: this is after lifestyle changes have been recommended)?

Bulk-forming or Hyperosmotic agents

How do patients describe heartburn?

Burning sensation in stomach or lower chest that rises up toward neck and occasionally to the back -Can occur with dyspepsia

Which medications can cause constipation?

CCBs = Calcium Channel Blockers -e.g. amlodipine and diltiazem GI antispasmodic example is Loperamide (imodium) Anticholinergic examples are benztropine and glycopyrrolate Antimuscarinic examples are oxybutynin and tolterodine Anticonvulsant examples are carbamazepine and divalproate

cimetidine is a CYP_____ inhibitor

CYP2C19

*Ages for children and exclusions for heartburn self-care:* Children under _____ for antacids Children under _____ for H2RAs Children under _____ for PPIs

Children under *2* for antacids Children under *12* for H2RAs Children under *18* for PPIs

*Name That Active Ingredient!!!* Tagamet

Cimetidine

Which infectious disease is associated with the importance of the OTC duration limit for PPIs?

Clostridium difficile associated diarrhea (CDAD)

Constipation is more commonly seen in _______ (women or men?) and _________ (elderly or children).

Constipation is more commonly seen in *women* and the *elderly*. -3 times more likely in women than men -5 times more likely once you hit 65

PPI drug interactions

Consult a health care provider if you are also taking other medications including a blood thinner such as warfarin or clopidogrel, an antifungal such as ketoconazole, an anticonvulsant such as phenytoin, an antianxiety medication such as diazepam, antiretroviral medications, theophylline, tacrolimus, digoxin, or cilostazol.

What is the MOA of H2RAs?

Decrease fasting and food-stimulated gastric acid secretion and gastric volume by inhibiting histamine on H2 receptor of the parietal cell.

What is the definition for constipation in children?

Delay or difficulty in defecation for 2+ weeks Note: Many times the child has fecal impaction before it's found out. -there is just too much poo and they can't get it out; they have to be decompacted

What is the first recommendation for children with constipation?

Dietary and/or behavioral modifications -Insure the child knows to go when they have to -Increase fluids, fruit juices containing sorbitol, add small amounts of corn syrup/barley malt extract to juice or milk

*Emollient Agents Dosing* Docusate Sodium: ______mg daily in single or divided doses Docusate Calcium: ______mg daily or until BMs are normal

Docusate Sodium: *50-200mg* daily in single or divided doses Docusate Calcium: *240mg* daily or until BMs are normal

_________ is described as consistent or recurrent discomfort in upper abdomen (epigastrium).

Dyspepsia

Emollient agents will have action in approximately __________ but may take as long as __________.

Emollient agents will have action in approximately *12-72 hours* but may take as long as *3-5 days*. -Recall that the mechanism of action is simply softening the stool, but not adding bulk. --you get the mush but no push

What is the effect of antacids on concomitant use of enteric coated tablets?

Enteric-coated products may break down early due to increased gastric pH

The Second step in Assessing a patient for constipation self-care is....

Exclusions

What does exercise have to do with constipation?

Exercise promotes intestinal/bowel motility

True or False: PPIs are intended for the relief of mild, occasional heartburn.

False

True or False: alginic acid is a type of antacid that is used for neutralizing stomach acid.

False

True or False: Involuntary relaxation of the anal sphincter allows defecation.

False (I suppose you would defecate if the relaxation was involuntary, but the normal physiological process is voluntary relaxation.)

True or False: Dietary and Lifestyle modifications are a part of self-care for mild episodic and moderate episodic but not for frequent heartburn.

False Dietary and Lifestyle modifications are a part of all 3

True or False: Glycerine suppositories may cause rectal irritation and hyperkalemia if overused.

False Glycerine suppositories may cause rectal irritation and *HYPOkalemia* if overused.

True or False: Dyspepsia is highly specific for a GERD diagnosis.

False Heartburn is highly specific for a GERD diagnosis.

True or False: Women have a higher incidence of Barrett's esophagus than men.

False M>F

True or False: H2RA use may increase the risk of Clostridium difficile associated diarrhea (CDAD).

False PPIs will but not H2RAs

True or False: The results seen with bulk-forming laxative use is generally pretty rapid.

False Results are not always immediate

True or False: The Bioavailability of H2RAs is affected by food

False The Bioavailability of H2RAs is *unaffected* by food Note: May be slightly decreased by antacids

True or False: The active ingredient in Gaviscon is alginic acid.

False alginic acid is NOT an active ingredient, it's an inactive ingredient. MOA: -Forms a viscous layer (reacts with sodium bicarbonate in saliva) that floats on the surface of gastric contents -Theoretically, forms protective barrier against esophageal irritation -Alginic acid does not neutralize acid

True or False: Histamine2-Receptor Antagonists (H2RAs) are effective at relieving fasting, but not nocturnal symptoms.

False effective at both

*Name That Active Ingredient!!!* Pepcid AC

Famotidine

*Name That Active Ingredient!!!* Pepcid complete

Famotidine Calcium carbonate Magnesium hydroxide

Fiber: ____ gm for adult women, _____ gm for adult men

Fiber: *25* gm for adult women, *38* gm for adult men

Food spends approximately ____ hours in the stomach and ____ hours in the small intestine.

Food spends approximately *3* hours in the stomach and *3* hours in the small intestine.

Heartburn is a common ______ symptom

GERD (Gastroesophageal Reflux Disease)

GERD

Gastroesophageal Reflux Disease

Which OTC product contains alginic acid?

Gaviscon

What are some general characteristics of constipation?

Generally defined as: -not frequently passing stool -difficulty passing stool -incompletely passing stool -passing small or hard stools

Generally, antacids should not be used more than ___ times a day, or regularly for more than ____ weeks.

Generally, antacids should not be used more than *4* times a day, or regularly for more than *2* weeks.

Glycerine suppositories may cause __________ and _________ if overused.

Glycerine suppositories may cause *rectal irritation* and *hypokalemia* if overused.

If antacids are used more often than ____ times per week or, regularly for longer than _____ weeks, refer to provider.

If antacids are used more often than *two* times per week or, regularly for longer than *two* weeks, refer to provider. Note: Frequent antacid users may need to switch to a longer-acting product, e.g. H2RA, H2RA plus antacid or PPI

What are some lifestyle modifications that can be recommended to patients with *nocturnal* heartburn and/or dyspepsia?

If nocturnal symptoms are present: -Avoid lying down within 3 hours of a meal. -Elevate the head of the bed placing 6-8 inch blocks under legs at head of bed -Use a foam wedge pillow (GERD pillow) under patient's upper torso and head

In regards to lubricants (mineral oil), the onset of action is ________ (oral) and ________ (rectal)

In regards to lubricants (mineral oil), the onset of action is *6-8 hours* (oral) and *5-15 minutes (rectal)*

In regards to polyethylene glycol 3350, you should ask the PCP before using in ___________ or _______.

In regards to polyethylene glycol 3350, you should ask the PCP before using in *renal insufficiency* or *IBS*.

In regards to the stimulant laxatives, the onset of action is ________ (oral) and ________ (rectal)

In regards to the stimulant laxatives, the onset of action is *6-10 hours* (oral) and *15-60 minutes* (rectal)

Why should PPIs not be taken with methotrexate?

Increased risk of methotrexate toxicity Delayed elimination of methotrexate and metabolite, hydroxymethotrexate

What is dyspepsia?

Indigestion

What is bowel retraining?

It's a nonpharmacological approach to treating constipation. It includes: -Go when the urge occurs -Spend an adequate amount of time -Reflexes are highest in the morning and 20-30 minutes after a meal

What is Barrett's esophagus?

It's a serious complication of GERD and a precancerous condition. -when there is constant irritation of the cells lining the esophagus they constantly have to turn over and repair which can lead to cancer.

Laxative overuse is rampant in the elderly population. These patients are more prone to _____________,____________________ and ________

Laxative overuse is rampant in the elderly population. These patients are more prone to *dehydration*, *electrolyte imbalances* and *DDIs*

Levothyroxine administration should be separated from antacids by ________ in order to avoid decreased _________.

Levothyroxine administration should be separated from antacids by *4 hours* in order to avoid decreased *absorption*.

Which recommendations for constipation in the elderly come first?

Lifestyle modifications first -Caution with fluid restricted patients and arthritic and disabled patients -Add fiber slowly if appropriate

What are the dosage forms for saline laxatives?

Liquids for oral administration and rectal administration (enemas)

PPI use > 1 year may be associated with a decrease in which nutrient?

Magnesium

Which saline laxatives are generally only used for acute evacuation, poisonings, or colonoscopies?

Magnesium citrate and sodium phosphate -this is because they work quickly and harshly (yikes) -Magnesium citrate works in about 30 minutes after you drink the whole bottle

What are the medications Risk factors that may contribute to heartburn?

Meds that Pagnucco stressed: 1. *aspirin and NSAIDs* -can have a direct irritant effect in the stomach from swallowing them as well as when they get absorbed systemically through the prostaglandin inhibition. 2. *Bisphosphonates* (e.g. alendronate) -people who take these have to stay upright for 30-60 minutes after taking them because if they lie back down, there can be serious erosion. 3. clindamycin 4. doxycycline 5. progesterone 6. anticholinergics 7. TCAs (tricyclic antidepressants)

What are the active ingredients in the bulk-forming laxatives?

Methylcellulose, polycarbophil, and psyllium are all FDA approved bulk-forming laxatives.

What are the etiologies for constipation in children?

Most common: "Withholding" or "Functional" -GI disturbances or other serious diseases (rare) -Changes in diet/environment -Febrile illness -Family conflict

When should PPIs be taken?

Most effective when taken 30-60 minutes BEFORE a meal, preferably before breakfast

If a patient took a PPI for 14 days 3 months ago, should you recommend another course?

No

*Name That Active Ingredient!!!* Alka-Seltzer Original

Note the directions: -8 tabs of 325mg Aspirin is enough to do some stomach damage (i.e. GI bleeds). People may not even realize they're taking aspirin when they're taking Alka-Seltzer.

*Side effects of antacid ingredients* Calcium carbonate

Note: calcium carb sometimes comes up for constipation as well

Compare and contrast the onset of relief and the duration of relief between the pharmacologic treatments for self-care of heartburn and/or dyspepsia.

Note: when acid has been produced, the only thing you can do is neutralize it. -therefore, the fastest working are the antacids.

*Name That Active Ingredient!!!* Mylanta

OH MY LANTA!

What would be the second-line of constipation treatment for a child 6-12 years old?

Oral: -methylcellulose -calcium polycarbophil -psyllium powder -docusate sodium -magnesium hydroxide Note: PEG 3350 is not labeled for kids, but is frequently used because of safety, efficacy and tolerability

Patients should increase fiber _______ (slowly or rapidly?) over _________.

Patients should increase fiber slowly over *1-2 weeks*. -This is because flatulence and bloating are common adverse effects

How is reflux cleared?

Peristaltic contractions -Swallowing, neutralization by bicarbonate in saliva, gravity (upright) -Transient episodes in healthy person - unnoticed, no damage Gastric acid with pepsin, bile salts; combined more damage than acid exposure alone

PPIs and Plavix

Plavix (clopidogrel): **PRODRUG** -Metabolism to its active component PPIs inhibit CYP 2C19 -Primary conversion of clopidogrel to its ACTIVE form - CYP 2C19 -decreased concentration -Omeprazole and esomeprazole have the greatest potential to inhibit the conversion to active form

___________ heartburn occurs within two hours after eating, especially after large or fatty meals.

Postprandial

Which special populations have a higher incidence of heartburn?

Pregnant women -Most pregnant women experience heartburn -30-80% complain of heartburn, especially in 1st trimester. If a pregnant woman comes in with heartburn symptoms find out if they have a provider. Many times they just need to get through the 1st trimester.

*Name That Active Ingredient!!!* Zantac

Ranitidine

The Third step in Assessing a patient for constipation self-care is....

Recommend and Re-Evaluate Note: Do not recommend any self-care to a pregnant woman unless she has had the ok from her OBGYN. -RE in 7 days for th dietary and exercise adjustments and if she hasn't had any bowel changes then she has to go to th doc.

Self-care with PPIs is limited to ____ days; no more often than every ____ months.

Self-care with PPIs is limited to *14* days; no more often than every *4* months.

_______ is the strongest risk factor for development of esophageal adenocarcinoma.

Symptomatic GERD

Laxative overuse is rampant in which population?

The Elderly -Traditional thoughts of "Needing to go every day"

What are secondary constipation disorders?

These patients may have constipation due to certain etiologies (figure) DM = Diabetes Mellitus IBS = Irritable Bowel Syndrome CVA = Cerebrovascular Accident

Name one rare but serious side-effect for H2RAs.

Thrombocytopenia (low platelets)

How often during the year can a patient use a PPI?

Treatment course: 14 days Frequency: Every 4 months (3 times per year) Before you make a recommendation to someone who qualifies for PPI self-care, you need to ask when the last time they took a treatment course was AND HOW they took the course. -some people will take it for 3 or 4 days and then stop because they think it isn't working. (note: the time for onset of a ppi is between 1 and 4 days). -"have you worked with another pharmacist on this? what did you try? when did you try it?" --good questions to ask!

True or False: Bisacodyl is frequently used for colonoscopy evacuation.

True

True or False: Bulk-forming laxatives are NOT systemically absorbed.

True

True or False: Dyspepsia may be associated with underlying conditions such as GERD, PUD, and irritable bowel syndrome.

True

True or False: Emollient agents act in both the small and large intestines.

True

True or False: Glycerine, for the treatment of constipation, only comes in a suppository.

True

True or False: H2RAs may be used to relieve symptoms of, or prevent heartburn and indigestion associated with meals.

True

True or False: H2RAs work by decreasing acid production in the stomach.

True

True or False: Irregular contractions occur in the small intestine when food is present for mixing and absorption.

True

True or False: LES is contracted at rest.

True

True or False: Low carb/low calorie diets can induce constipation.

True

True or False: PPIs are NOT indicated for the immediate relief of occasional or acute episodes of heartburn or dyspepsia.

True

True or False: PPIs are associated with bacterial gastroenteritis.

True

True or False: PPIs have a more potent, prolonged antisecretory effect than H2RAs.

True

True or False: Pregnant women with mild and infrequent heartburn may use calcium- or magnesium-containing antacids safely if recommended daily dosages are not exceeded.

True

True or False: Saline laxatives should not be use in patients who cannot tolerate fluid loss.

True

True or False: The small intestine is motile in fasting and non-fasting states.

True

True or False: You should generally avoid recommending mineral oil, castor oil, aloe extract, and cascara segrada.

True

True or False: You want to be weary of laxative "overuse" associated with stimulant laxatives.

True -also watch out for elderly patients who think they need to have a bowel movement every day

True or False: There is a higher prevalence of Heartburn in the Western World.

True -could be associated to higher levels of obesity. --obesity effects pressure changes in the esophagus and in the stomach.

True or False: Senna tea is safe for short-term use.

True -however standardized products are preferred

Your body is automatically wired to go to the bathroom in the __________ and ______ minutes after a meal.

Your body is automatically wired to go to the bathroom in the *morning* and *20-30* minutes after a meal. -Reflexes are highest in the morning and 20-30 minutes after a meal

Which of the following constipating medications can be purchased OTC? a) Calcium carbonate b) Oxycodone c) Ferrous sulfate d) Diphenhydramine e) Verapamil f) Aluminum hydroxide g) Bismuth

a) Calcium carbonate c) Ferrous sulfate d) Diphenhydramine f) Aluminum hydroxide g) Bismuth

Which of the following are non-pharmacological lifestyle changes you can suggest to a patient with complaints of constipation? a) Drink at least 8 glasses of water per day b) Don't go to the bathroom right away, hold it to strengthen your pelvic floor muscles c) Incorporate fruits, veggies, and grains into your diet d) Perform moderate aerobic exercise for at least 30 minutes on most days of the week e) Eat more dairy, cheese, meat, and processed foods f) Start using more fiber in the form of supplements 2-3 times per day immediately

a) Drink at least 8 glasses of water per day c) Incorporate fruits, veggies, and grains into your diet d) Perform moderate aerobic exercise for at least 30 minutes on most days of the week

A weary mom comes into the pharmacy with a 4-yearold boy. She explains that he hasn't been going to the bathroom regularly and has already been to the pediatrician and they put him on a special diet and he's been getting a lot of fiber and fluids. That was two weeks ago. He is still not stooling often and his stools have been hard. What do you suggest? a) Oral docusate sodium b) Magnesium hydroxide c) Glycerin suppositories d) Mineral oil enema

a) Oral docusate sodium: -*GOOD* because it will soften the stool and is gentle. -*BAD* because it works slow. b) Magnesium hydroxide: -*GOOD* because it will work fast. -*BAD* because it may cause some cramping. c) Glycerin suppositories: -*GOOD* because it will work fast and has few side effects. -*BAD* because administration is difficult and can be traumatic d) Mineral oil enema: -*GOOD* because it will work fast. -*BAD* because administration is difficult and can be traumatic So what do you suggest? -Ask the mom her comfort level with administering a suppository -Probably either oral docusate or glycerin suppository -Or even both. The suppository will work quickly and the docusate could be given at bedtime thereafter to help prevent the hard stools -Would re-evaluate in 7 days and suggest the child see the doctor if not better -PEG 3350 is another option

Which of the following products should NOT be used in patients who are fluid-restricted? a) Psyllium (oral) b) Glycerin suppository c) Bisacodyl suppository d) PEG 3350

a) Psyllium (oral)

An elderly man comes in looking for something to "make him go." After questioning him, you determine that he is a candidate for an OTC product. He tells you he takes FiberCon® daily. He wants something that is not going to give him cramps and will help him pass his recently very hard stools. What do you suggest and why? a) Psyllium powder b) Colace® c) Peri-Colace® d) Phillips® Milk of Magnesia

a) Psyllium powder: -*GOOD* because it doesn't cause cramping. Good for elderly, not absorbed. -*BAD* because it requires a lot of fluid to work well; patient already is having very hard stools. Has many DDIs. Works slow. Already taking FiberCon. b) Colace®: -*GOOD* because it will soften the stool and doesn't cause cramping. -*BAD* because it works slow. c) Peri-Colace®: -*GOOD* because it will soften the stool, and help push the stool. Works relatively fast. -*BAD* because it has a stimulant which may cause cramping. d) Phillips® Milk of Magnesia: -*GOOD* because it works fast and will increase intestinal pressure and motility. -*BAD* because it may cause cramping and dehydration. So what do you suggest? -Probably Colace® or Peri-Colace® if the latter doesn't do the trick -Fluid, prune juice -Exercise as tolerated -Ask about diet -Other options? PEG 3350, suppositories

For which of the following laxatives should you counsel patients to drink plenty of water? (select all that apply) a. Bulk-forming agents b. Emollient agents "stool softeners" c. Stimulant laxatives d. Saline laxatives e. Hyperosmotic agents

a. Bulk-forming agents b. Emollient agents "stool softeners" d. Saline laxatives

Which of the following constipation etiologies would result in the recommendation of Bulk-forming or Hyperosmotic agents for self-care (select all that apply)? a. Diet b. Pregnant c. Episodic d. Situational

a. Diet c. Episodic d. Situational

What is the equation for figuring out how much fiber a child over 2 should get?

age + 5g/day

what is pyrosis?

another term for heartburn

Should H2RAs be taken on an as needed or on a daily basis?

as needed This is because tolerance may develop with daily use, leading to decreased efficacy

At what time of day should the saline laxatives be used?

at bedtime

When are H2RAs usually taken?

at the onset of symptoms or 30 minutes-1 hour before symptoms are expected.

*Name That Active Ingredient!!!* Dulcolax

bisacodyl (diphenyl methanes)

Flaxseed is generally regarded as safe, and acts like a ________ laxative.

bulk-forming

Which of the following is not a dosage form of bulk-forming laxatives? a. powders b. fiber chews c. suppositories d. wafers e. gummies f. tablets

c. suppositories

Constipated patients should reduce their intake of foods with little fiber and/or high ______ content

calcium

What are the dosage forms of emollient agents?

capsules and syrup

Which of the H2RAs may interact with a number of medications?`

cimetidine

Which of the Histamine2-Receptor Antagonists (H2RAs) has the shortest duration of action?

cimetidine

The ______ does most of the fluid reabsorption in the GI tract (90% of fluid presented initially)

colon

Dyspepsia is described as...

consistent or recurrent discomfort in upper abdomen (epigastrium).

What are the adverse effects of emollient agents?

diarrhea and mild cramping

Over-the-counter laxatives should only be used in kids <2 years when....

directed by a health care provider Note: Can't recommend any OTC laxatives to children under 2

__________ is appropriate for dry or hard stool in pregnant woman.

docusate

Chronic opioid-induced constipation should be PREVENTED with...

docusate/stimulant combo OR PEG 3350

Saline laxatives can cause __________ if used long term or at higher than recommended doses

electrolyte imbalances

Histamine2-Receptor Antagonists (H2RAs) are used for ________ (frequent or episodic?) heartburn?

episodic

Bulk-forming laxatives are a type of _______.

fiber

The classification of type of heartburn is based on the _________.

frequency

The FDA has approved antacid combination products with aspirin or acetaminophen for overindulgence in food and drink and for ________.

hangovers

The relative bioavailability of PPIs _________ (increases or decreases?) with continued daily dosing.

increases

Aluminum hydroxide may decrease ______ absorption.

isoniazid

Episodic heartburn occurs _____ (more or less?) than 2 days per week.

less

Dysphagia (difficulty swallowing) is slowly progressive for solid food and is usually associated with...

longstanding heartburn

*Name That Active Ingredient!!!* Phillips

magnesium hydroxide (aka milk of magnesia)

Slower-than-normal transit time or defecatory disorders are classified as _________ (primary or secondary?) constipation.

primary These patients are otherwise healthy and just happen to have some constipation

The urge to defecate occurs when fecal matter drops to the _____.

rectum

Magnesium and Aluminum are both ______ excreted.

renally Thus, accumulation may occur in renal insufficiency. -if patient has a kidney issue, do not recommend magnesium or aluminum

*Name That Active Ingredient!!!* Senokot

senna (anthraquinone)

*Name That Active Ingredient!!!* ex-lax

sennosides

What does alginic acid react with to produce its protective function?

sodium bicarbonate in saliva

________ are the second-line therapy after bulk-forming and PEG.

stimulant laxatives

The variability in onset of action between antacids depends on ......

the cation

Where is fecal matter stored?

the sigmoid colon

H2RAs can be taken when needed up to ____ daily for 2 weeks

twice

The rule of thumb for taking bulk-forming laxatives is to separate all medications from bulk-forming laxatives by at least ____ hours!!

two

Postprandial heartburn occurs within ______ after eating, especially after large or fatty meals.

two hours -Most have 'simple'; mild, infrequent, episodic, and associated with diet/lifestyle --Aggravated - bending over/lying down

What are some Exclusions for Self-Treatment of Constipation?

• Abdominal Pain • Nausea/Vomiting • *A sudden change in bowel habits that persists for 2 weeks* • Use of a laxative product *> 7 days* unless directed by PCP • *Occurrence of rectal bleeding or lack of bowel movement after laxative use at any time during treatment* (patient should stop use and contact PCP) Other ones from the book: -Marked and unexplained flatulence -Fever -Presence of chronic medical condition that may preclude self-care laxative treatment -Daily laxative use -Unexplained changes in bowel habits especially accompanied by weight loss -Any bowel symptom that persists for > 2 weeks or recur over a period of at least 3 months. -Anorexia -Age < 2 years