Esomeprazole
Rapid Review
- Mechanism of Action: Proton pump inhibitor; suppresses secretion of gastric acid
- Indications: Upper GI bleed (given prior to endoscopy), GERD, peptic ulcer disease
- Contraindications:
- Dosage: 80 mg IV bolus for acute GI bleed; 20-40 mg PO daily for GERD/PUD
- Onset: Less than 1 hour
- Duration: Peak concentrations within 1-4 hours
- Adverse Reactions: Headache, diarrhea, nausea, constipation
- Special Considerations: None
Pearls
- Esomeprazole may be slightly more efficacious than omeprazole for the treatment of GERD and esophagitis, however the American College of Gastroenterology does not recommend one PPI over the other.
- Long term esomeprazole usage (> 3 months), may cause hypomagnesemia.
Deep Dive
Famotidine
Rapid Review
- Mechanism of Action: Histamine-2 antagonist;
- Indications: GERD, PUD
- Contraindications: Allergy to drug/class; Use caution in renal impairment
- Dosage: Generally 20 mg BID x 2-4 weeks (depending on disease/severity)
- Onset: Less than 1 hour
- Duration: Peaked effect at 1-3 hours; duration is 10-12 hours
- Adverse Reactions:
- Special Considerations: May sometimes be given for allergic reactions to provide additional relief of hives.
Pearls
- Famotidine can be used as an adjunct for allergic reactions to treat urticaria and/or pruritus but should not be prioritized over life-saving interventions (ex. epinephrine) for cases of anaphylaxis.
- Avoid using famotidine long-term, as tachyphylaxis can occur within 3 days of use.
Deep Dive
Glucagon
Rapid Review
- Mechanism of Action: Anti-hypoglycemic agent; increases plasma glucose levels by initiating degradation of hepatic stores of glycogen into glucose.
- Indications: Severe hypoglycemia, beta-blocker/calcium-channel blocker overdose.
- Contraindications: Allergy to drug/class, pheochromocytoma, insulinoma
- Dosage: For hypoglycemia: 1 mg IV/SQ/IM. For beta-blocker/Ca channel blocker toxicity: 3-10 mg IV loading dose followed by 1-10mg/hour IV continuous infusion.
- Onset: Immediate
- Duration: 60-90 minutes (IV); unknown for IM/SQ
- Adverse Reactions: Hypotension, nausea/vomiting, hypokalemia
- Special Considerations: Requires glycogen stores in the liver in order to work for hypoglycemia.
Pearls
- In non-emergent scenarios (ex. food impaction), consider pretreating with antiemetics prior to glucagon administration, as nausea/vomiting is a very common side effect.
- Glucagon requires that glycogen stores in the liver be available in order to work for hypoglycemia. Replenishing glycogen stores typically takes at least 24-48 hours under ideal circumstances.
Deep Dive
Metoclopramide
Rapid Review
- Mechanism of Action: Antiemetic; dopamine antagonist. Also stimulates upper GI tract motility.
- Indications: Vomiting prevention/treatment, treatment of chronic GI motility disorders (diabetic gastroparesis)
- Contraindications: Allergy to drug/class, pheochromocytoma, seizure disorder, GI bleeding/obstruction
- Dosage: 10 mg IV q 6 hours prn
- Onset: 1-3 minutes (IV)
- Duration: 1-2 hours
- Adverse Reactions: Extrapyramidal symptoms, dystonia, parkinsonism, drowsiness, fatigue
- Special Considerations: None
Pearls
- Metoclopramide has gastric prokinetic features, making it especially ideal as antiemetic for patients with gastroparesis or constipation.
- Although still a dopamine antagonist, metoclopramide tends to carry fewer side effects than phenothiazines (promethazine, prochlorperazine)
Octreotide
Rapid Review
- Mechanism of Action: Octapeptide; mimics endogenous somatostatin to promote vascular smooth muscle contraction. Decreases splanchnic blood flow and inhibits gastrin, growth hormone, serotonin, and vasoactive intestinal peptide.
- Indications: Bleeding esophageal varices, sulfonylurea overdose
- Contraindications: Hypersensitivity, insulinoma
- Dosage:
- Variceal bleeding: 50 mcg IV bolus, followed by 50 mcg/hr infusion
- Sulfonylurea toxicity: 50 mcg SQ q 6 hours prn
- Half-life: 1.7 hours (IV)
- Adverse Reactions: Bradycardia, arrhythmias, pancreatitis, nausea/vomiting
Pearls
- Octreotide for GI bleeding and sulfonylurea toxicity are both “off-label” uses in the ED. It is typically used for chronic treatment of carcinoid tumors, VIPomas, and acromegaly.
- For upper GI bleeding, octreotide may have a modest benefit in reducing bleeding and the need for surgery, but has not yet been shown to have a mortality benefit.
Deep Dive
Ondansetron
Rapid Review
- Mechanism of Action: Antiemetic; antagonizes serotonin 5-HTC receptors to reduce nausea
- Indications: Nausea/vomiting
- Contraindications: Allergy to drug, sertontine syndrome, long QT syndrome
- Dosage: 4-8 mg q4-6 hours. Max 24 mg/day
- Onset: 30 minutes
- Duration: Half life of approximately 3-7 hours
- Adverse Reactions: QT prolongation, bronchospasm, headache, fatigue
- Special Considerations: Tends to be more effective if given prior to vomiting
Pearls
- Ondansetron is an effective antiemetic for most etiologies of nausea, but it is not effective for motion sickness-induced nausea.
- Return visits within 72 hours for pediatric patients with gastroenteritis are substantially reduced when they are sent home initially with PO ondansetron.
