Drugs Used to Treat Gastroesophageal Reflux and Peptic Ulcer Diseases GI Meds Drugs Used to Treat Gastroesophageal Reflux and Peptic Ulcer Diseases Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Physiology of the Stomach Functions Store food Mix food Emptying Types of secretory cells Chief – secrete pepsinogen Parietal – secrete hydrochloric acid Mucus – secrete mucus Hydrochloric acid is needed for optimal pH of stomach. Parietal cells also secrete intrinsic factor needed for absorption of vitamin B12. Mucus protects the stomach wall from injury to stomach acids and enzymes. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Stomach Disorders Gastroesophageal reflux disease (GERD) Known as heartburn Symptoms: burning, bloating, belching, regurgitation Reflux of gastric secretions such as pepsin and hydrochloric acid into the esophagus Peptic ulcer disease (PUD) Several stomach disorders – commonly gastric and duodenal ulcers Symptoms: burning, gnawing, aching Helicobactor Pylori ( H. Pylori) GERD is referred to as acid indigestion; PUD is commonly referred to as heartburn or sour stomach. Always treat signs and symptoms of heartburn as cardiac disease until it is ruled out! Symptoms may resemble conditions such as ischemic heart disease, scleroderma, and gastric cancer. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

GERD vs. PUD GERD is referred to as acid indigestion; PUD is commonly referred to as heartburn or sour stomach. Always treat signs and symptoms of heartburn as cardiac disease until it is ruled out! Symptoms may resemble conditions such as ischemic heart disease, scleroderma, and gastric cancer. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education and Health Promotion Goals of Treatment of GERD and PUD Education – weight reduction, smoking cessation, consume smaller meals, avoid eating at bedtime, avoid tight clothing over abdomen, elevate HOB Drug therapy – used to relieve symptoms, promote healing, prevent recurrence IMPORTANT! Teach pts who use over the counter meds to use ONLY for up to two weeks and then seek medical attention. Limit use of NSAIDs – switch to acetaminophen if feasible Gathering Data: Nutrition, Esophagus & Stomach, Activity, Other disorders, Medication Hx, Stress level, Smoking

Drug Class: Antacids 1 billion in sales a year! Actions Buffer hydrochloric acid to a lower concentration so gastric contents less acidic Uses Treat heartburn from excessive eating and drinking and PUD Acute ulcer treatment requires large volumes Common adverse effect: chalky taste Serious adverse effects: constipation, diarrhea WATCH THOSE DRUG INTERACTIONS! Antacids DO NOT prevent the overproduction of acid-but act in the stomach to neutralize the acid For specific drugs, see Table 33-1. Therapeutic outcomes: relief of discomfort, reduced frequency of heartburn, healing of irritated tissues. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Antacids Aluminum Hydroxide Forms: Have constipating effects carbonate, hydroxide, phosphate Have constipating effects Often used with magnesium to counteract constipation Example: (Maalox, Mylanta) Also –see chart pg 514

Antacids Magnesium Hydroxide Forms: carbonate, hydroxide, oxide, trisilicate Commonly cause a laxative effect Usually used with other agents to counteract this effect Dangerous when used with renal failure—the failing kidney cannot excrete extra magnesium, resulting in accumulation Examples: magnesium hydroxide (MOM); combination products such as Maalox, Mylanta (aluminum and magnesium)

Antacids Calcium Carbonate Forms: many, but carbonate is most common May cause constipation Their use may result in kidney stones Long duration of acid action may cause increased gastric acid secretion (hyperacidity rebound) Often advertised as an extra source of dietary calcium Example: Tums (calcium carbonate)

Antacids Sodium Bicarbonate Highly soluble Quick onset, but short duration May cause metabolic alkalosis Sodium content may cause problems in patients with CHF, hypertension, or renal insufficiency

Antacids and Antiflatulents Antiflatulents: used to relieve the painful symptoms associated with gas Several agents are used to bind or alter intestinal gas, and are often added to antacid combination products. OTC Antiflatulents activated charcoal simethicone Alters elasticity of mucus-coated bubbles, causing them to break. Used often, but there are limited data to support effectiveness.

Antacids: Side Effects Minimal, and depend on the compound used Aluminum and calcium Constipation Magnesium Diarrhea Calcium carbonate Produces gas and belching; often combined with simethicone

Antacids: Drug Interactions Chelation Chemical binding, or inactivation, of another drug Chemical inactivation Produces insoluble complexes Result: reduced drug absorption

Antacids: Nursing Implications Assess for allergies and preexisting conditions that may restrict the use of antacids, such as: Fluid imbalances Renal disease CHF Pregnancy GI obstruction Patients with CHF or hypertension should use low-sodium antacids such as Riopan, Maalox, or Mylanta II.

Antacids: Nursing Implications Use with caution with other medications due to the many drug interactions. Most medications should be given 1 to 2 hours after giving an antacid. Antacids may cause premature dissolving of enteric-coated medications, resulting in stomach upset.

Antacids: Nursing Implications Be sure that chewable tablets are chewed thoroughly, and liquid forms are shaken well before giving. Administer with at least 8 ounces of water to enhance absorption (except for the “rapid dissolve” forms). Caffeine, alcohol, harsh spices, and black pepper may aggravate the underlying GI condition.

Antacids: Nursing Implications Monitor for side effects: Nausea, vomiting, abdominal pain, diarrhea With calcium-containing products: constipation, acid rebound Monitor for therapeutic response: Notify heath care provider if symptoms are not relieved.

Drug Class: Histamine-2 Receptor Antagonists Actions Block H2 receptors resulting in decreased volume of acid secreted, pH of stomach increases as a result Uses Treat GERD, duodenal ulcers, stress ulcers, Zollinger-Ellison syndrome, prevention of stress ulcers in critically ill and post-op patients (also allergic reactions) Common adverse effects Dizziness, headache, somnolence, diarrhea, constipation Serious adverse effects Confusion, disorientation, hallucinations, gynecomastia, hepatotoxicity For specific drugs, see Table 33-2.

Histamine Type 2 (H2) Antagonists Reduce acid secretion All available OTC Most popular drugs for treatment of acid-related disorders Drugs: cimetidine (Tagamet) famotidine (Pepcid) nizatidine (Axid) ranitidine (Zantac)

H2 Antagonists: Drug Interactions Cimetidine Causes oxidation of many drugs and increased drug levels. (Warfarin, beta-blockers) All H2 antagonists may inhibit the absorption of drugs that require an acidic GI environment for absorption. AND THINK!...we can buy these OTC!  SMOKING has been shown to decrease the effectiveness of H2 blockers

H2 Antagonists: Nursing Implications Assess for allergies and impaired renal or liver function. Use with caution in patients who are confused, disoriented, or elderly. Take 1 hour before or after antacids. Ranitidine may be given intravenously; follow administration guidelines.

Drug Class: Gastrointestinal Prostaglandins Drug: misoprostol (Cytotec) Actions Inhibit gastric acid and pepsin secretion Uses Prevent and treat gastric ulcers caused by NSAIDs (including aspirin) Common adverse effect Diarrhea Contraindicated for use in pregnancy because of the effect of inducing uterine contractions. Contraindicated for use in pregnancy because of the effect of inducing uterine contractions. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Proton Pump Inhibitors Actions Inhibit gastric secretion by inhibiting gastric acid pump of the parietal cells Uses Treat severe esophagitis, GERD, gastric and duodenal ulcers Common adverse effects Diarrhea, headache, fatigue, muscle pain Serious adverse effects Rash For specific drugs, see Table 33-3. Be alert to drug interactions. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Proton Pump Inhibitors The parietal cells release positive hydrogen ions (protons) during HCl production. This process is called the “proton pump.” H2 blockers and antihistamines do not stop the action of this pump.

Proton Pump Inhibitors: Drug Effect Total inhibition of gastric acid secretion lansoprazole (Prevacid) omeprazole (Prilosec) rabeprazole (Aciphex) pantoprazole (Protonix) esomeprazole (Nexium)

Proton Pump Inhibitors: Therapeutic Uses GERD maintenance therapy Erosive esophagitis Short-term treatment of active duodenal and benign gastric ulcers Zollinger-Ellison syndrome Treatment of H. pylori-induced ulcers

Proton Pump Inhibitors: Nursing Implications Assess for allergies and history of liver disease Pantoprazole is the only proton pump inhibitor available for parenteral administration, and can be used for patients who are unable to take oral medications May increase serum levels of diazepam, phenytoin, and cause increased chance for bleeding with warfarin

Proton Pump Inhibitors: Nursing Implications Instruct the patient taking omeprazole: It should be taken before meals. The capsule should be swallowed whole, not crushed, opened or chewed. A good time to take is in the middle of the night or late before bedtime usually 2-3 hours after food.

Drug Class: Coating Agents Drug: sucralfate (Carafate) Actions Adhere to craters of an ulcer, protecting it from acids, pepsin, and bile salts Uses Treat duodenal ulcers; for patients who cannot tolerate other therapies Common adverse effects Constipation, dry mouth, dizziness This medication should be administered on an empty stomach. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Prokinetic Agents Drug: metoclopramide (Reglan) Actions Reduce reflux, increase stomach contractions, relax pyloric valve, increase peristalsis Uses Treat gastric reflux esophagitis, diabetic gastroparesis; antiemetic Common adverse effects Drowsiness, fatigue, lethargy, dizziness, nausea Serious adverse effects Extrapyramidal symptoms WHAT ARE THE PREMEDICATION ASSESSMENTS? Be alert for drug interactions.

Drug Class: Antispasmodic Agents Actions: anticholinergic Uses Treat irritable bowel syndrome, biliary spasm, mild ulcerative colitis, pancreatitis, infant colic, PUD Common adverse effects Blurred vision; constipation; urinary retention, dry mouth, nose, throat Serious adverse effects Confusion, depression, nightmares, hallucinations, orthostatic hypotension, palpitations, dysrhythmias HOW DOES THIS RELATE TO ANTICHOLINERGIC? For specific drugs, see Table 33-4.