MCP Gastrointesnal & Genitourinary Drugs

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MCPGastrointes.nal&GenitourinaryDrugs

SaraMcElroy2/19/10

[email protected]

LearningObjec.ves

•  Iden.fyOTC*vs.Rxtherapies•  DeterminewhentorecommendOTCtherapyvs.refer

•  Learncounselingpointsforlifestylemodifica.ons/medica.ons

•  Understandstepwiseapproachestopharmacologicaltreatment

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Outline•  UpperGIDisordersandDrugs•  LowerGIDisordersandDrugs•  UrinaryCondi.onsandDrugs

UpperGIDisordersandDrugsHeartburn&Dyspepsia

•  Whatarethey?– Heartburn

•  AcidReflux•  Loweresophagealsphincter(LES)incorrectlyallowsstomachacidtoentertheesophagus

•  Symptomofgastroesophagealrefluxdisease(GERD)

– Dyspepsia•  UpsetStomach

•  Indiges.on•  Canaccompanyheartburn

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•  CommonSymptoms– BurningSensa.on– Discomfortbehindbreastbone– Belching,bloa.ng– Nausea/vomi.ng

– Acidregurgita.on


•  Whentorefer– Severe,recurrent,persistentsymptoms

– Dysphagia– Painfulswallowing– Chestpain– Bleeding– Unexplainedweightloss– Elderly

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•  Nonpharmacologicalrecommenda8ons

–  Don’teatbeforebed.me/lyingdown–  Elevateheadofbed(~6inches)– Weightloss–  Reducepor.onsizes–  Smokingcessa.on–  Avoidtriggerfoods:

•  Faay•  Spicy•  Chocolate•  Citrus•  EtOH•  Caffeine

UpperGIDisordersandDrugsOverviewofPharmacologicalTreatment

ANTACIDS H2BLOCKERS PROTONPUMPINHIBITORS

LINEOFTHERAPY

1 2 3

INDICATIONSMild,infrequent

heartburn/dyspepsia

Mild‐moderateepisodicheartburn/

dyspepsia

Frequentheartburn/

dyspepsia2+daysperweek,GERD,pep.culcers

ONSET Instant 30‐45min2‐3hours,severaldaysforcomplete

relief

DURATION 20‐30min 4‐10hours 12‐24hours

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UpperGIDisordersandDrugsAntacids

CalciumCarbonate*,MagnesiumHydroxide*(Tums*,Rolaids*,Maalox*,Mylanta*)

•  MOA:Neutralizesstomachacid

byincreasinggastricpH

•  Indica8ons:Shorttermrelief

ofheartburn,dyspepsia

UpperGIDisordersandDrugsAntacids

•  Administra8on:– Swalloworchew1‐2tabletsor5‐10mLliquidwhensymptomsoccur

– Repeathourlyifsymptomsreturn

– Maximum:7000mgcalciumcarbonate/24hours,donotusemaxdosefor>2weeks

•  SideEffects:cons.pa.on,bloa.ng,gas,diarrheawithMg

•  Cau8ons/Contraindica8ons:hypercalcemia

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UpperGIDisordersandDrugsH2Blockers

famo.dine(Pepcid),rani.dine(Zantac),cime.dine(Tagamet)

(allOTCandRx)

•  MOA:Reversiblybindshistamine2

receptorsonparietalcells,

!acidsecre.on

•  Indica8ons:Short‐termtreatment

ofmildtomoderateheartburn/

dyspepsia

UpperGIDisordersandDrugsH2Blockers

•  Administra8on:–  Takewithorwithoutfood–  Longtermpreven&on:qhsordailyac–  Shorttermtreatment:take15min–1hourbeforeaheartburninducingevent

•  SideEffects:Pain,N/V/D,cons.pa.on,HA,dizziness•  Cau8ons/Contraindica8ons:

–  cime.dine–oldestinclass,manydruginterac.ons– ac.vityofdrugsthatrequireacidicpHforabsorp.on– doseinrenalorhepa.cimpairment–  Cau.oninpregnant/breasoeeding/elderlypa.ents

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UpperGIDisordersandDrugsProtonPumpInhibitors

rabeprazole(Aciphex),lansoprazole(Prevacid),omeprazole(Prilosec*),esomeprazole(Nexium),pantoprazole(Protonix)

•  MOA:Irreversiblyinhibitsprotonpumpsinparietalcells,!acidsecre.on

•  Indica8ons:–  Frequent(>2x/week)heartburn/dyspepsia,pep.culcerdisease,GERD

–  Incombowithan.bio.cstotreatulcers(H.pylori)–PrevPac(lansoprazole,amoxicillin,clarithromycin)


•  Administra8on:– Take30minutesbeforeea.ngfirstmealofday

– Mayopencapsulesandsprinkleonsopfoods/liquids•  Applesauce,Ensure,yogurt

– Dura.on:GERD4‐8wks,gastric/duodenalulcer8‐12wks•  Note:PrilosecOTCnotforlongtermuse,nottoexceed14daysevery4months

•  SideEffects:HA,nausea,diarrhea,dizziness

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•  Cau8ons/Contraindica8ons:– LongtermusemayresultinVitaminB‐12deficiency

•  Symptoms:weakness,.redness,increasedHR

– ac.vityofdrugsthatrequireacidicpHforabsorp.on

– Renalorhepa.cimpairment– Cau.oninpregnant/breasoeeding/elderlypa.ents– Poten.aldruginterac.onsduetoCYP450enzymemetabolism

UpperGIDisordersandDrugsOverviewofPharmacologicalTreatment

ANTACIDS H2BLOCKERS PROTONPUMPINHIBITORS

LINEOFTHERAPY

1 2 3

INDICATIONSMild,infrequent

heartburn/dyspepsia

Mild‐moderateepisodicheartburn/

dyspepsia

Frequentheartburn/

dyspepsia2+daysperweek,GERD,pep.culcers

ONSET Instant 30‐45min2‐3hours,severaldaysforcomplete

relief

DURATION 20‐30min 4‐10hours 12‐24hours

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Outline•  UpperGIDisordersandDrugs✔•  LowerGIDisordersandDrugs•  UrinaryCondi.onsandDrugs

LowerGIDisordersandDrugsCommonCondi.ons

•  Cons.pa.on

•  Diarrhea

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LowerGIDisordersandDrugsCons.pa.on&Diarrhea

•  Whentorefer:– Bloodinfeces– Nausea/vomi.ng– Acuteabdominalpain/cramps– Temperature>101F

– Dehydra.on– Las.nglongerthan3‐5days– Children,elderly,pregnant

LowerGIDisordersandDrugsCons.pa.on&Diarrhea

Non‐pharmacologicalrecommenda8ons:•  Cons.pa.on

•  Addfiber,wholegrainstodiet

•  Drinkmoreliquids

•  Exerciseregularly•  Avoidstress

•  Diarrhea•  Drinkcaffeinefree,clear

liquids

•  Avoiddairy•  Replaceelectrolytes‐

Pedialyte,Gatorade

•  BRATDiet•  Bananas•  Rice•  Applesauce•  Toast

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LowerGIDisordersandDrugsOverviewofPharmacologicalTreatment

CONSTIPATION DIARRHEA

STOOLSOFTENERSOPIOIDRECEPTOR

INHIBITORS

LAXATIVES

LowerGIDisordersandDrugsStoolSopeners

docusatesodium(Colace,DOSS‐Relief)(RxandOTC)

•  MOA:Drawswaterintothestooltomixwithandsopenstool

•  Indica8ons:– Cons.pa.on– Topreventstraininginptswithanorectalcondi.ons

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LowerGIDisordersandDrugsStoolSopeners

•  Administra8on:–  Take1‐4.mesdailyasneeded–  Takewithafullglassofwater– Useforupto1weekunlessotherwiseadvisedbyPCP–  Timetoeffect1‐3days

•  SideEffects:Diarrhea,cramps,biaertasteinmouth•  Cau8ons/Contraindica8ons:

– GIobstruc.on,nauseaorvomi.ng–  Contraindicatedininflammatoryboweldisorders

•  Crohn’sdisease,ulcera.vecoli.s–  Cau.oninpregnant/breasoeeding/children

LowerGIDisordersandDrugsLaxa.ves

polyethyleneglycolelectrolytes(Miralax,Golytely),lactulose(Enulose),senna(Senokot,Exlax)

•  MOA:–  PEG/lactulose:drawswaterintostoolviaelectrolyteandosmo.ceffects,causingperistalsisandbowelmovement

–  Senna:s.mulatesperistal.cac.vitybydirectac.ononintes.nalmucosaornerveplexus

•  Indica8ons:–  Treatmentofoccasionalcons.pa.on–  Bowelprep/cleansingbeforeintes.nalprocedures(ex:colonoscopy)

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•  Administra8on:–  PEGlaxa.ve:dissolve1capfulinliquidanddrink1‐2.mesdaily,useupto2weeks

–  PEGbowelprep:filljugwithwater,drinkevery10minutesun.l4Lisconsumed,orrectaleffluentisclear.Chillingdrinkhelpstaste.

–  Lactulose:takemax60mlliquid/day

–  Senna:recommended15mgdaily,oncedailydosesshouldbetakenatnight.


•  Timetoeffect:–  PEGlaxa.ve:24‐72hours

–  PEGbowelprep:30‐60minutes

–  Lactulose:24‐48hours

–  Senna:6‐10hours

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•  SideEffects:Diarrhea,bloa.ng,cramps,flatulence,nausea

•  Cau8ons/Contraindica8ons:– GIobstruc.on,nauseaorvomi.ng–  Inflammatoryboweldisorders

•  Crohn’sdisease,ulcera.vecoli.s– Cau.oninpregnant/elderly– Overuseorexcessiveusemayresultinlaxa.vedependence

– Lactulose:cau.oninpa.entswithdiabeteswhorequirealowgalactosediet

LowerGIDisordersandDrugsAn.diarrheal

loperamide(Immodium*),diphenoxylate/atropine(Lomo.l)

•  MOA:Directlybindsintes.nal

opioidreceptorstoinhibit

peristalsis

•  Indica8ons:Diarrhea(acuteandchronic)

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LowerGIDisordersandDrugsAn.diarrheal

•  Administra8on:–  Immodium:Max16mg/day–  Lomo.l:5mgdiphenoxylate/0.05mgatropineperday–  Drinklotsof:caffeine‐freeclearliquidsduringfirst24hours–  Timetoeffect:45minto1hour,lasts3‐4hours

•  SideEffects:Abdominaldiscomfort,N/V,cons.pa.on,dizziness,drowsiness

•  Cau8ons/Contraindica8ons:–  Notforuse>10days–  Notforuseinchildren<2yo–  Cau.onwithpregnant/children–  An.bio.crelateddiarrhea–riskofpseudomembranouscoli.s–  Severeliverdisease

LowerGIDisordersandDrugsOverviewofPharmacologicalTreatment

CONSTIPATION DIARRHEA

STOOLSOFTENERSOPIOIDRECEPTOR

INHIBITORS

LAXATIVES

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Outline•  UpperGIDisordersandDrugs✔•  LowerGIDisordersandDrugs✔

•  UrinaryCondi.onsandDrugs

UrinaryCondi.onsandDrugsCommonCondi.ons

•  BenignProsta.cHyperplasia(BPH)

•  UrinaryIncon.nence/FrequentUrina.on

•  UrinaryPain

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UrinaryCondi.onsandDrugsBPH

In untreated BPH, pressure at the bladder neck and on the urethra as it passes through the prostate

causes urinary symptoms

UrinaryCondi.onsandDrugsOverviewofPharmacologicalTreatment

BPHURINARY

INCONTINENCEDYSURIA

ALPHA‐1BLOCKER

ANTICHOLINERGICAGENTS

TOPICALANALGESIC

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tamsulosin(Flomax)

•  MOA:blocksalpha‐1adrenergicprostatereceptors,relaxingsmoothmuscle,urineflow

•  Indica8ons:BPH


•  Administra8on:–  Daily–  30minutesapersamemeal

–  Longtermeffectswithin2weeks

•  SideEffects:HA,dizziness,libido,nausea,blurredvision,priapism(contactprescriber)

•  Cau8ons/Contraindica8ons:–  Pa.entswithcataractsurgery,prostatecancer,historyoffain.ng–  Pa.entstakingotheralphablockersorsildenafil(Viagra)

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UrinaryCondi.onsandDrugsIncon.nence/FrequentUrina.on

tolterodine(Detrol,DetrolLA),oxybutynin(Ditropan),solifenacin(Vesicare)

•  MOA:an.cholinergicagentsthatblockacetylcholinereceptors,smoothmuscleandbladdercontrac.on,urineflow

•  Indica8ons:Urinaryincon.nenceorfrequenturina.on


•  Administra8on:–  tolterodine–max4mg/day–  oxybutynin–max15mg/day–  solifenacin–Max10mg/day–  Timetoeffect:acute1‐2days,longterm1‐2weeks

•  SideEffects:an.cholinergiceffects,tachycardia,hallucina.ons,demen.aexacerba.on– Note:managementofan.cholinergiceffects

•  Takesmallesteffec.vedose•  Increasewaterintake•  Usesalineeyedrops•  Hardcandy•  Changetoanotherdrug

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•  Cau8ons/Contraindica8ons:– Pa.entsaggravatedbyan.cholinergiceffects

•  Takingpotassiumsalts•  Pregnant/breastfeeding• WithahistoryofQTprolonga.on•  Impairedrenal/hepa.cfunc.on

•  PoorCYP2D6metabolizers

UrinaryCondi.onsandDrugsDysuria

phenazopyridine(Pyridium,Urogesic,Uristat,Azo)

•  MOA:Producestopicalanalgesiaonbladdersmoothmuscle

•  Indica8ons:ReliefofUTIsymptoms

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UrinaryCondi.onsandDrugsDysuria

•  Administra8on:–  Take100‐200mgTIDX2days–  Takeapermeals–  Timetoeffect:1‐2days– Opentakenwithanan.bio.ctotreatbothsymptomsandinfec.on

•  SideEffects:dizziness,anemia,rash,nausea,dyspepsia*Changesurinecolorreddish‐orange.*Willstaincontactlenses

•  Cau8ons/Contraindica8ons:–  Pa.entswithrenalorhepa.cimpairmentorcondi.ons(ex:hepa..sC)

–  Pa.entswithdiabetesorG6PDdeficiency

UrinaryCondi.onsandDrugsOverviewofPharmacologicalTreatment

BPHURINARY

INCONTINENCEDYSURIA

ALPHA‐1BLOCKER

ANTICHOLINERGICAGENTS

TOPICALANALGESIC

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Outline•  UpperGIDisordersandDrugs✔•  LowerGIDisordersandDrugs✔

•  UrinaryCondi.onsandDrugs✔

•  Iappreciateyourfeedback!•  Ques.ons?

– [email protected]

MCP Gastrointesnal & Genitourinary Drugs

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