Causes of GERD

Excessive acid contact with esophageal mucosa due to:

• ↑ acid production
• Defective lower esophageal sphincter
• Delayed gastric emptying
• Reduction in mucosal protective mechanisms

Medications that ↓ LES pressure

• Anticholinergics
• Barbituates & BZDs
• Methylxanthines
• Hormones (estrogen, progesterone)
• Nitrates
• Nicotine
• Ethanol
• CCBs
• Dopamine

Medications that directly irritate the GI

• NSAIDs/aspirin
• Bisphosphonates
• Iron
• Potassium chloride

Goals of Pharmacologic Therapy for GERD

• ↓ acid/ neutralize GI
• ↑ esophageal clearance or gastric emptying
• ↑ LES pressure & tone
• ↑ mucosal protective mechanisms (prostaglandins)

H2 blockers MOA & Effects

• Histamine-2 receptor antagonists inhibit gastric acid secretion
• ↓food-stimulated gastric acid secretion, nocturnal gastric acid secretion, & basal gastric acid secretion
• Admin prophylactically, most 30-60 min before meal, Cimetidine 0-30 min before meal.

• Used in treatment of PUD (promote ulcer healing), acute stress ulcer prophylaxis (ICU high risk patient with major physical trauma), & symptomatic GERD

Adverse Effects of H2 Blockers

• Headache, dizziness, diarrhea, myalgia
• Tagamet causes hormonal effects, including gynecomastia, galactorrhea, & oligospermia

H2 blocker drug interactions

Overall: ↓ absorption of drugs that have absorption dependent on acidic environment

Cimetidine:CYP 450 inhibition.  Don't take with Warfarin, phenytoin, carbamazepine, theophylline, etc.

H2 blocker DOC and dosage

Ranitidine (Zantac)

OTC: Zantac 75mg BID,

Zantac maximum strength 150mg BID

Rx: 150 mg BID or 300 mg QHS

Other H2 blockers

Cimetidine (Tagamet)

Famotidine (Pepcid)

Nizatidine (Axid)

PPI MOA & Uses

• H+/K+ ATPase Inhibitors
• Bind to proton pump of parietal cell causing suppression of secretion of H+ into the gastric lumen

• Superior for gastric acid secretion & ulcer healing (up to 90% decrease in stomach acid secretion)
• Pathologic hypersecretory syndromes (Zollinger-Ellison syndrome)
• Reduce risk of GI bleeds from aspirin or NSAIDs
• Part of combination regimens for H. pylori eradication

Adverse Effects & DIs of PPIs

• Possible decrease in B12 absorption
• Possible overgrowth of GI bacteria
• Prilosec may cause inhibition of metabolism of some CYP450 drugs (warfarin, phenytoin, cyclosporin).  This is not typically seen with other PPIs

Proton Pump Inhibitor DOC and dosages

Omeprazole (Prilosec)

OTC: 20 mg tablets (Qday)

Rx: 20 mg or 40 mg capsules (Qday)

Anticholinergics for GERD use

• Increase GI motility & secretions
• Used adjunctively for management of PUD and Zollinger-Ellison syndrome
• Metoclopramide (Reglan)

Antacids MOA & Uses

• Weak bases that help neutralize gastric acid by indirectly decreasing the activity of pepsin.
• Al & Mg: relieve symptoms associated with GERD & PUD
• Ca: relieve symptoms associated with GERD & PUD & also used as Ca supplementation

Calcium Carbonate Antacid Products

Tums

Rolaids softchews

Aluminum Hydroxide + Magnesium Hydroxide

Antacid Products

Maalox

Mylanta liquid

Magnesium Hydroxide + Calcium Carbonate

Antacid Products

Mylanta chewable tablets

Rolaids regular chewable tablets

Aluminum Hydroxide + Magnesium Carbonate

Antacid Products

Gaviscon: Alginate actions

(Alginic produces a foam barrier)

Actions & Uses of Sucralfate (Mucosal Protectant)

• Al hydroxide + sulfated sucrose binds to positively charged proteins of healthy & ulcerated gastric mucosal tissue
• Forms gel with epithelial cells to create a physical barrier to gastric acid & degradation of mucus by pepsin
• Also stimulates gastric prostaglandin release, mucus, & bicarbonate output
• Healing of duodenal ulcers & prevention of future duodenal ulcers

Actions of PeptoBismol (Mucosal Protectant)

• Forms a physical coating
• Inhibits pepsin activity
• Increased secretion of protective mucus
• Interact with damaged mucosal tissue (coat & protect for promotion of healing)
• Antimicrobial actions

Uses of PeptoBismol (Mucosal Protectant)

• In combination regimen for H. pylori
• Healing of ulcers
• Diarrhea (especially Traveler's)
• Heartburn/dyspepsia

Adverse Effects & Cautions for PeptoBismol

• Dark stools & black hairy tongue
• Salicylate allergies
• Use in pediatric patients with fever (Reye's syndrome)

First Line Treatment for H. Pylori

PPI (Omeprazole 20 mg BID) +

Clarithromycin (Biaxin) 500 mg BID +

Amoxicillin 1 g BID or Metronidazole (Flagyl) 500 mg BID

Duration: 14 days

Drug Induced Causes of N & V

Chemotherapy

Opiods

Antibiotics

Amphotericin B

Drug Toxicity Causes of N&V

Theophylline

Anticonvulsants

Digoxin

Drug Withdrawal Causes of N&V

Opiates

BZDs

Causes of N&V with Cancer Patients

• Chemotherapy-Induced (level 1-5 drugs, 5 highly emetogenic)
• Fluid & electrolyte abnormalities (hypercalcemia, volume depletion)
• Drug-induced (opiods, antibiotics)
• Metastases (brain, hepatic)
• Uremia
• Infectious causes
• Radiation therapy

Pharmacotherapeutics for N&V

Antacids

Antihistamines

Phenothiazines

Corticosteroids

Prokinetics

Substance P/Neurokinin Antagonists

Selective Serotonin Receptor Inhibitors

H1 Receptor Blockers for N&V

Diphenhydrinate (Dramamine)

• Treatment & prevention of nausea, vertigo, & vomiting associated with motion-sickness
• Unlabeled use for Meniere's disease
• Dosed 50-100 mg Q6 hours

H1 Receptor Blocker

Diphenhydramine (Benadryl)

• Prevention of motion sickness, antiemetic properties
• Other uses: allergies (allergic rhinitis, allergic dermatoses), sleep, topical anesthetic, treatment of antipsychotic-induced extrapyramidal symptoms

H2 receptor blockers for N&V

Ranitidine (Zantac)

Famotidine (Pepcid)

Antiemetic: Meclizine

Bonine, Antivert, Dramamine-Less Drowsy

• Prevention & treatment of motion sickness; vertigo
• Anticholinergic action by blocking Chemoreceptor Trigger Zone (CTZ) & decreased conduction of middle ear vestibular-cerebellar pathways

Adverse Effects & Drug Interactions of Antiemetics

• Drowsiness, thickened bronchial secretions, headache, fatigue, increased appetite, dry mouth, arthralgia
• Increased adverse effects with CNS depressants and anticholinergics
• Caution in use with BPH, GI obstruction, bladder obstruction

Dosing Antiemetic (meclizine) for Motion Sickness

25 mg 1 hour prior to travel, repeat every 12-24 hours

Anticholinergic for N&V prophylaxis

Scopolamine

• Transdermal use to prevent N/V associated with anesthesia, opiates, or motion sickness
• Blocks acetylcholine, dries secretions, antagonizes histamine & serotonin
• Apply at least 4 hours before travel (best if 12 hours before); replace every 3 days

Adverse effects of Scopalamine Patch

• CV: orthostatic hypotension, tachycardia
• CNS: drowsiness, confusion, fatigue
• Derm: photosensitivity
• GI: constipation, dry mouth, nausea
• GU: dysuria
• Ocular: increase intraocular pressure, blurred vision

Antiemetics: Phenothiazines

• Block dopamine receptors
• Used for N/V with low emetogenic chemotherapy, or other causes of N/V.
• Chlorpromazine (Compazine)

Adverse effects of Phenothiazines

Extrapyramidal side effects

Restlessness

Sedation

Actions and Uses of Phenergan

• Multiple antiemetic actions (antihistaminic, antidopaminergic effects)
• Used to treat allergic conditions, antiemetic, motion sickness, sedation (adjunctive in anesthesia regimens)
• 25 mg q 4-6 hours as rectal suppository, PO liquid or tablet, or injection

Black Box & Drug Interactions of Phenergan

• Respiratory fatalities have been reported in pediatrics < 2 years old; use lowest possible dose & avoid using with other drugs with respiratory depressant effects

• CYP450 substrate

Antiemetic: Metoclopramide (Reglan)

Uses & MOA

• Antiemetic & Prokinetic
• Gastroparesis, GERD, Chemo-induced nausea & vomiting, Post-op to aid gastric emptying
• Blocks 5HT3 (serotonin) receptors in chemoreceptor trigger zone, dopamine receptors; increased lower esophageal sphincter tone.
• Causes increased response to acetylcholine in upper GI tract, enhancing motility & gastric emptying without stimulating gastric acid.

Adverse effects of Metoclopramide (Reglan)

• CNS: restlessness, drowsiness, Parkinson-like symptoms
• Endocrine/Metabolic: amenorrhea, galactorrhea, gynecomastia, impotence
• Hematologic abnormalities

Antiemetic: Serotonin Blocker Action & Uses

Ondansetron (Zofran)

• Blockade of serotonin receptors in the periphery & brain (vagal fibers & chemoreceptor trigger zone)
• Prevention of chemotherapy induced N&V, N/V associated with radiation therapy, and prevention/treatment of post-operative N&V
• Use on a scheduled basis -- NOT PRN

Adverse effects of serotonin blockers (Phenergan)

• CNS: headache, malaise, fatigue, drowsiness
• GI: changes in stool (constipation or diarrhea), increase liver function tests
• Local: injection site reactions
• Rare: paresthesias, arrrhythmias, anaphylaxis
• CYP450 Substrate

Antiemetics: substance P/Neurokinin Inhibitor

Aprepitant (Emend)

Actions & Uses

• Prevents acute & delayed vomiting at the substance P/Neurokinin 1 receptor; augments the antiemetic activity of serotonin antagonists & corticosteroids

• Prevention of acute & delayed N/V associated with moderately & highly emetogenic chemotherapy in combination with a corticosteroid & serotonin antagonist; Prevention of post operative nausea & vomiting

Antiemetics: Substance P/ Neurokinin Inhibitors

Aprepritant (Emend)

Adverse Effects & Drug interactions

• CNS: fatigue
• GI: stool changes (constipation or diarrhea), nausea, hiccups
• Musculoskeletal: muscle weakness
• Hematologic abnormalities
• CV: hypotension, bradycardia
• CYP450 3A4 inhibitor

Antiemetic properties of corticosteroids

• Chemotherapy induced N&V, post-operative N&V

• Blockade of cerebral innervation of the emetic center by inhibition of prostaglandin synthesis

Antiemetic properties of BZDs 

Lorazepam (Ativan)

• Mostly for anticipatory N/V associated with chemotherapy

Emetrol

Posphorolated carbohydrate solution used as antiemetic

all antibiotics, especially BROAD SPECTRUM (Clindamycin, Tetracycline, Sulfonamides)

Laxitives, Mg-containing antacids, chemotherapy, cholinergics, NSAIDS, colchicine, centrally-acting antihypertensives 

nonabsorbable salts, that hold water in the intestines by osmosis and distend the bowel causes an increase in activity. Used before colon procedure to prep the bowels. Bowels are evacuated within a few hours (1-6h).

AE: bloating, diarrhea, cramping

Magnesium Citrate, Magnesium Sulfate, Sodium Phosphate, Polytheyelene glycol (PEG), Lactulose 

Miralax

Polyethylene Glycol 3350 Powder

osmotic laxative

for occasional constipation (for a max of 7 days at a time) 

dosing: powder mixed with liquid qday dosing

AE: bloating, nausea, cramping, flatulence 

facilitates passage of hard stools by lubricating the bowels

AE: diarrhea, GI upset, aspiration, pneumonia

DrugsL mineral oil, glycerin suppositories 

Stool Softeners 

e.g. Docusate Sodium (Colace)

Bulk-forming laxatives

Psyllium, bran, methylcellulose

compound that body is unable to break down causes water to be drawn into the bowel. 

AE: constipation, bowel impaction, bloating, GI upset, no dependence, effects in 1-3 d 

for constipation predominant IBS, serotonin 5HT4 antagonist

AE: serious intestinal ischemic events

ST tx of women with severe, chronic, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy

*restricted due to severe GI events, including death 

-Sitz baths (rectal area in warm water for 15-20 min, 3-4 times per day)

-cleansing of rectal area with warm water after BMs

-avoid straining

-increase fluids, exercise, dietary fiber

-surgery (hemorrhoidectomy, incision, or removal or thrombosis

Local Anesthetics: benzocaine, dibucaine (Nupercainal), lidocaine (xylocaine), pramoxine (Anusol Proctoform), tetracaine (Pontocaine)

Vasoconstrictor: phenylephrine

Skin Protectants: aluminum hydroxide, cocoa butter, glycerin, kaolin, lanolin, petrolatum, shark liver oil 

Astringents:

Witch Hazel (Tucks), Calamine

Preperation H Cream-glycerin, phenylephrine, pramoxine, white petrolatum

Preperation H suppositories-cocoa butter, phenylephrine, shark liver oil

Preperation H gel-phenylephrine, witch hazel 

Class 5-ASA derivative

MoA-modulates local inflammatory mediators, scavenges free radicals, and inhibits TNF, sulfa antimicrobial activity

-used for UC and RA

DI-hypoglycemics and anticoagulants (increases effect); azathioprine, mercaptopurine (myelosupression)

more AE's than mesalamine b/c of sulfa moiety

HA, photosensitivity, SJS, hematologic abnl, fever, oligospermia, abdominal pain, worsening of IBD with start of therapy

CAUTION in sulfa and salicylate allergy

-Class 5 derivative

-for IBD

-AE-neuromuscular pain, hematologic abnl, abdominal pain with initial therapy

CI-salicyclate allergy

DI-azathioprine, mercaptopurine (increase myelosupression)

Pentasa-rectum, colon, small bowel; enema (1-4 g/d), capsule (2-4 g/d)

Rowasa-rectum, terminal colon, enema, 1-4g/d

asacol-distal ileum, colon, tab, 2.4-4.8g/d

prednisone (PO) or prednisolone (IV)

methylprednisolone (PO-Medrol and IV SoluMedrol)

budesonide (entocort EC, PO capsules)

hydrocortisone IV PR (Cortifoam, Anucort, Protocort)

AE: local effects on rectum; typical steroid use AE, increase blood glucose, decrease bone density, cataracts, glaucoma, truncal obesity, insomnia, psychosis, HTN 

Biologic Response Modulators

Infliximab (Remicade)

Etancercept (Enbrel)

immunomodulators, used for unresponsive IBD, better for Crohn's (stronger autoimmune) than for UC 

AE: myelosuppression, opportunistic infections, lymphoma

IV or injection

PO aminosalicylates:

Sulfasalazine 4-8 g/d for active inflammation; start with 500 mg and titrate up 

topical for distal dz: mesalamine PR, steroid PR

sulfasalazine/mesalamine, steroids (prednisone)

if unresponsive to sulfasalazine/mesalamine add steroid (dose up to 1 mg/kg/d)

-if unresponsive to these things, add an immunosuppressant  (Azathioprine or Mercaptopurine)

IV hydration and IV steroid (hydrocortisone)

-If adequate response to this, change to prednisone PO, add sulfasalzine/mesalamine then taper steroid in 1-2 months

-if no response to hydrocortisone in 5 d, use IV cyclosporin

-can tx procititis or colitis with rectal/topical administrations

-transdermal nicotine can improve active UC dz

reduce dosages of suldasalazine, mesoalamine

taper off steroids 

Sulfasalazine-good for colon involvement

mesalamine (Pentasa or Asacol)-better for small bowel 

Immunosuppressants for Crohn's

Azathioprine

Mercaptopurine

Cyclosporine (rarely used)

limited for unresponsive pts with other therapies or for steroid-sparing therapy

6 mo of therapy required for response

monoclonal Ab

for refractory or fistulizing Crohn's 

5 mg/kg/d infusion for 8 weeks

more difficult than UC

aminosalicylates are good in prevention

steroids not good for LT control

Immunosuppressants (Azathioprine and Mercaptopurine) good for remission maintenance

tx Crohn's and lowers cholestorol

used in IBD if diarrhea is b/c of inability to absorb bile acids (in multiple intestinal resections) 

NSAIDS-can cause flairs (esp. UC)

-causes decreased integrity of GI mucosa

Opioids-can cause decrease in GI motility

Anitdiarrheals-don't use in active dz can acutely precipitate colonic dilation; may consider in controlled dz 

NPO-tom minimize stimulation

Parenteral or enteral nutrition support greater than 1 week

NG aspiration-if bad pain, severe dz, paralytic ileus, intractable vomiting

aggressive fluid resuscitation-to correct intravascular volume depletion and maintain bp

IV colloids if loss of protein rich fluids

analgesics-Meperidine (Demerol)-less spasm of spincter of Oddi, Morphine

Broad Spectrum Antibiotics-Imipenem/Cilastatin

if PCN allergy-ciprofloxacin + metronidazole (Flagyl)

-infection prophylaxis started in 1st 48 hours and continued for 2-3 weeks 

-avoid ethanol and fatty meals

-analgesics

-pancreatic enzyme supplementation (antisecretory drugs can increase effectiveness of enzyme supplementation, e.g. H2 blockers, PPIs)

-increase dosing until symptoms are controlled or is limited by AE's

-most enzymes are enteric coated-requires lower dosing for effectiveness; take immediately prior to meals; req. multiple tabs before meals and at bedtime

Amylase, lipase, and protease

-Creon, Lipram, Pancrease, Ultrase, Viokase 

Medications that may cause hepatitis

• Aspirin
• Isoniazid
• Methyldopa (Aldomet)
• Minocycline (Minocin)
• Nitrofurantoin (Macrobid)
• NSAIDs
• PTU (for thyroid treatment)

Treatment of Alcoholic Hepatitis

• Abstain from alcohol
• Nutritional support including vitamins (folic acid, thiamine)
• Corticosteroids used in cases with encephalopathy or greatly increased bilirubin and PT changes (Methylprednisolone 32 mg/day) x 1 month

Immune Globulin

Solution containing antibodies from sterilized human plasma that provides passive immunity

Used for post-exposure prophylaxis (PEP) for some types of viral hepatitis

Vaccine prevention of Acute Hep A

• Efficacy within 1 month after primary vaccination (94-100% with a booster 6-12 months later.
• Recommended for all children at age 1, others at high risk who weren't vaccinated at 1 year of age.
• Can use as post-exposure prophylaxis -- single dose within 2 weeks of exposure.

Treatment of Acute Hep A

Supportive/Symptomatic

Treatment of Acute Hep B

• Supportive/Symptomatic
• Antivirals are controversial
• Repeat testing for HBsAg & aminotransferase in 3-6 months

Prevention of Acute Hep B

• vaccine -- 3 IM doses over several months (active immunity)
• Immunoglobulin -- post exposure prophylaxis (temporary passive immunity).  Recent sexual contacts should be provided with immunoglobulin.
• Routine screening of pregnant women & prophylaxis of newborns.  All infants should receive vaccine within 12 hours of birth.  If born to infected mother should receive first dose of vaccine and immunoglobulin within the first 12 hours of life.

Acute Hep C Treatment

• Treat only if RNA remains detectable for 2-3 months after onset of infection
• Peginterferona alfa 2a or alfa 2b once weekly for 24 weeks
• Ribavirin daily

Acute Hep C Prevention

• No vaccine available
• Universal precautions & screening for blood or organ donors
• Monitor aminotransferase levels, RNA, & antibody at baseline, 1, & 6 months after possible exposure

Dosages of Hep Vaccines

• Only available for A & B
• Increased dosage based on age group (0.5 mL peds, 1 mL adults)
• Increased dosage of B vaccine for patients on dialysis (1-2 mL)

Determining Treatment of Chronic Hep B

• NOT recommended with patients with normal ALT
• Positive antigen: ALT > 2x ULN or moderate hepatitis on biopsy
• Negative antigen: ALT> 2x ULN, elevated HBV DNA or moderate hepatitis on biopsy

Treatment Goals for chronic Hep B

• Eradication or permanent suppression of virus; limit hepatic inflammation & decrease fibrosis, prevention of complications
• Avoid alcohol & immunosuppressive medications

Drugs for Chronic Hep B

• Interferon alpha 2B -- generally 1st line treatment
• Nucleosides or Nucleotide Analogs: Lamivudine (may be 1st line if interferon is ineffective or in patients with decompensated cirrhosis who can't take interferon)
• Adefovir dipivoxil

Treatment of Chronic Hep C

Combination therapy with peginterferon & ribavirin

Treatment of Chronic Hep D

Prolonged course high dose interferon alfa, most relapse when therapy is stopped

Use & Dosing of Interferon

• Chronic Hep B with HBsAg, HBeAg, & HBV DNA with increased serum aminotransferase 
• Ineffective in patients with normal or near normal serum aminotransferase
• SQ injections 3 times per week for 24-48 weeks

Side effects & contraindications of Interferon

• AEs: Fatigue, muscle aches, fever, depression, irritability, suicide, psychosis, renal failure, cardiac failure, infections, autoimmune disorders, hematologic disorders
• Contraindicated in: advanced cirrhosis, organ transplant, immunocompromised patient

Benefit of Peginterferon

Increased half life allowing for once weekly dosing instead of three times weekly

Effects of Nitric Oxide released in Cirrhosis

• Blood pressure & renal perfusion decrease
• Renin-Angiotensinogen-Aldosterone System is activated to increase sodium & water retention
• The sympathetic nervous system works to increase blood pressure
• Antidiuretic hormone is released to retain sodium

Hormone & Platelet effects of Cirrhosis

• Steroid hormone alterations lead to decreased libido, gynecomastia, testicular atrophy
• Decreased platelet production leads to splenomegaly due to increased splenic sequestration of platelets
• End stage liver disease may result in decreased production of clotting factors

Effects of hepatic encephalopathy

Decreased cognition, confusion, and behavior changes with physical signs due to toxin buildup, including ammonia

Lifestyle Modifications of Cirrhosis

• Immediate cessation of alcohol
• No more than 2 grams/day of tylenol (half normal max dose)
• With ascites, less than 2 grams NaCl per da

Procedural Modifications to Manage Cirrhosis

• Nasogastric suction in patients with variceal bleeding to prevent aspiration
• Vaccinations/immunizations: hep A, B, influenza, +/- pneumococcal
• Endoscopic band ligation, sclerotherapy, balloon tamponade to treat variceal bleeding
• Shunts for portal HTN
• Therapeutic paracentesis for ascites

Treatment for volumes over 5 L removed from ascites

Volume resuscitation with albumin

Non-selective Beta Blockers (use for portal HTN)

Propranolol (Inderal), Nadolol (Corgard)

1st line treatment to reduce portal HTN

Start dosage low & titrate to decrease heart rate by 25% or to 55 bpm

May need to add a nitrate if HR goal isn't reached

Diuretics for Cirrhosis & Portal HTN

Spironolactone (Aldactone)

Aldosterone antagonist, counteracts the effects of the renin-aldosterone-angiotensinogen system

Diuretics for Cirrhosis & Portal HTN

Combination therapy

• Ratio of 40 mg Furosemide (Lasix) to 100 mg of Spironolactone to maintain serum K in normal range
• Wait at least 3 days between increase in dosage (ascites takes longer to equilibrate with vascular fluid than peripheral edema)
• Target ascites treatment 0.5 L per day
• Take spot urine to maintain adequate excretion of Na, want Na/K ratio > 1.0

Treatment of Variceal Bleeding

Octreotide

• Decreases portal venous pressure by selective vasoconstriction of sphlanchnic bed
• Loading dose of 50-100 mcg, then 25-50 mcg/hour infusion
• Continue for at least 24-72 hours after bleeding has stopped, continue for 5 days since increased risk for bleeding is greatest for 1st 5 days.

Antibiotic prophylaxis for Variceal bleeding

Fluroquinolone or 3rd generation cephalosporin

Used to decrease risk for hospital-acquired infections & associated mortality

Treatment for suspected SBP in Cirrhosis patient

• Begin empiric antimicrobial while awaiting C&S
• 1st line treatment: IV 3rd Generation Cephalosporine -- Ceftriazone (Rocephin) or Cefotaxime (Claforan)
• Alternative: IV Zosyn or PO Levaquin or Cipro

Use of Prophylactic Antibiotics with Cirrhosis

• Indicated with previous SBP and low protein-ascites or previous variceal bleeding
• Use Sulfamethoxazole/Trimethoprim (Bactrim) DS 5 days per week or Cipro 750 mg once weekly

Treatment and prevention of encephalopathy

• Lactulose -- undigestible synthetic disaccharide laxative
• Causes water to enter colon & stimulates bowel movements
• Lowers pH in the colon, favoring conversion of ammonia to ammonium (which can be eliminated in the feces)
• Initiated at 15-30 mL PO BID-TID & titrated to results of 2-4 soft BM daily

Management of Coagulation abnormalities associated with cirrhosis

• Prolonged clotting times may be due to vitamin K deficiency through malnutrition or malabsorption
• Trial of Phytonadione (vit K) 10 mg SQ daily x 3 days helps to distinguish if caused by vit K deficiency

Cirrhosis Monitoring Summary

• Non-selective BB for portal HTN
• Evaluate diuretic therapy/assess Na intake
• Assess for anemia, thrombocytopenia,or coagulopathy
• Monitor transaminases & ammonia blood levels
• Mental status evaluation for encephalopathy
• Titrate Lactulose