Gastrointestinal Medications Chapter 16 Gastrointestinal Medications Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Digestive System Functions Structures Protective factors Performs the mechanical and chemical process of digestion, absorbs nutrients, and eliminates waste. Structures Mouth, esophagus, stomach, intestines, and accessory structures Protective factors The digestive tract must work without being destroyed by the strong acid it makes to digest food. Digestion variables Changes in GI blood flow, amount of surface available, and motility are found in very young and older adult patients. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Gastrointestinal Disorders Overview: nausea, vomiting, motion sickness, diarrhea, constipation, GERD Medications (treat or prevent) antiemetics, laxatives, antidiarrheals, prokinetic agents, medications for (IBS), chemotherapy-induced N+V Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Overview GI medications Three major types Restore/maintain lining GI tract; decrease acidity/motility exert laxative action- colon Miscellaneous medications: antiflatulents, digestive enzymes, emetics, and medications to treat gallstones and alcoholism Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Overview Peptic Ulcer Disease Therapeutic management outcomes Lessening of manifestations Encouragement of healing Decreased risk of complication Stopping reoccurrence Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Overview Peptic Ulcer Disease Groups of medications used in the management of peptic ulcer disease Antibiotics Antisecretory agents (H2 receptor antagonists and proton pump inhibitors) Mucosal protectants Antacids Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Peptic Ulcer Disease ANTIBIOTICS Amoxicillin (Amoxil) Clarithromycin (Biaxin) Metronidazole (Flagyl) Tetracycline eradication of H. pylori bacteria (combination of two or three antibiotics for 14 days) Nursing Administration Considerations nausea and diarrhea- common. Finish full course- prescribed medications. contraindications, and interactions.

Peptic Ulcer Disease HISTAMINE2-RECEPTOR ANTAGONISTS ranitidine (Zantac) cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid) –Purpose suppress secretion of gastric acid (block H2 receptors in parietal cells) Theraputic Uses: gastric/peptic ulcers, GERD, Zollinger- Ellison. H. pylori ulcers (with antibiotics)

Peptic Ulcer Disease HISTAMINE2-RECEPTOR ANTAGONISTS Complications Cimetidine (Tagamet) block androgen receptors (libido and impotence) Inform clients CNS effects (lethargy, depression, confusion) older adults kidney or liver dysfunction. should be avoided

HISTAMINE2-RECEPTOR ANTAGONISTS Nursing Administration advise good nutrition. avoid foods- promote gastric secretion, eat on a regular schedule, relaxed setting, do not overeat. adequate rest and reduction of stress, avoid smoking, avoid alcohol avoid aspirin and other NSAIDs ranitidine (Zantac) with or without food. monitor GI bleeding

PROTON PUMP INHIBITORS omeprazole (Prilosec) pantoprazole (Protonix) lansoprazole (Prevacid) esomeprazole (Nexium) Purpose reduce gastric acid secretion Therapeutic Use: gastric/duodenal ulcers, esophagitis, GERD, Zollinger-Ellison syndrome. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

PROTON PUMP INHIBITORS Nursing Administration do not crush, chew, break sustained-release capsules. sprinkle the contents omeprazole (Protonix) daily in AM avoid alcohol, irritating medications (NSAIDs) 4 to 6 weeks (active ulcers). monitor IV site (redness, swelling, pain). monitor GI bleeding Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

MUCOSAL PROTECTANT sucralfate (Carafate) Changes-thick substance-adheres to ulcer (6 hr) Therapeutic Uses acute duodenal ulcers Complications: constipation (1,500 mL/day) no systemic effects (caution chronic kidney disease) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

MUCOSAL PROTECTANT Nursing Administration sucralfate (Carafate) interferes with absorption (phenytoin, digoxin, warfarin, ciprofloxacin) Maintain a 2-hr intervals antacids should not be administered within 30 min medication regimen: four times daily, 1 hr before meals, HS Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

ANTACIDS aluminum hydroxide (Amphojel) aluminum carbonate (Basaljel) magnesium hydroxide (Milk of Magnesia) calcium carbonate (Tums) neutralize gastric acid Therapeutic Uses: peptic ulcer disease (PUD) + GERD. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

ANTACIDS Complications Aluminum/calcium: constipation. Magnesium: diarrhea, toxicity –impaired kidney function. Sodium: fluid retention. Bicarbonate: alkalosis (impaired kidney function) Aluminum: hypophosphatemia and hypomagnesemia. (Monitor electrolytes) yright © 2016 by Mosby, an imprint of Elsevier Inc.

ANTACIDS Nursing Administration chew tablets-drink at least 8 oz water or milk. shake liquid to disperse compliance difficult (seven times a day): 1 hr before and 3 hr after meals, and again at bedtime. other medications at least 1 hr before or after taking an antacid. yright © 2016 by Mosby, an imprint of Elsevier Inc.

ANTIEMETICS ondansetron (Zofran) metoclopramide (Reglan) dronabinol (Marinol) scopolamine (Transderm Scop) hydroxyzine (Vistaril) lorazepam (Ativan) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Antiemetic Nursing Administration Prevent or treat N+V Nursing assessment can identify factors. Chemotherapy agents cause severe N+V Administering antiemetics prior to chemo more effective Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

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Anticholinergics Antispasmodics preparations reduce GI tract spasm, intestinal motility, acid production, gastric motility (reduces pain) Theraputic Uses: peptic ulcer, pylorospasm, biliary colic, hypermotility, irritable colon, and acute pancreatitis What contributes to the GI discomfort patients often feel? The anticholinergic-antispasmodic agents act with antacids in prolonging or continuing the therapeutic benefits of both drug categories. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

ANTIDIARRHEALS diphenoxylate plus atropine (Lomotil) loperamide (Imodium) paregoric (Camphorated Tincture of Opium) Action: decrease intestinal motility, increase absorption fluid and sodium- intestine. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

ANTIDIARRHEALS Complications ●● At recommended doses for diarrhea, diphenoxylate does not affect the CNS system. ●● At high doses, clients can experience typical opioid effects, such as euphoria or CNS depression. atropine, which has unpleasant adverse effects (blurred vision, dry mouth, urinary retention, constipation, tachycardia) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

LAXATIVES Psyllium (Metamucil) Docusate sodium (Colace) Bisacodyl (Dulcolax) Magnesium hydroxide (Milk of Magnesia) senna (Senokot), lactulose (Cephulac) How does the use of laxatives relate to a patient’s age? When is regular use of laxatives indicated? What problems may arise with regular laxative use? Can you identify a procedure in which laxatives may be indicated as patient preparation? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

LAXATIVES Bulk-forming laxatives: psyllium (Metamucil) soften fecal mass decrease diarrhea IBS control stool (ileostomy/colostomy) promote defecation (older adults) How does the use of laxatives relate to a patient’s age? When is regular use of laxatives indicated? What problems may arise with regular laxative use? Can you identify a procedure in which laxatives may be indicated as patient preparation? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

LAXATIVES Surfactant laxatives: docusate sodium (Colace) lower surface tension of stool allow penetration water. pregnancy or opioid constipation prevent painful elimination (hemorrhoids or episiotomy) prevent straining (aneurysm or post-MI) promote defecation (older adults) How does the use of laxatives relate to a patient’s age? When is regular use of laxatives indicated? What problems may arise with regular laxative use? Can you identify a procedure in which laxatives may be indicated as patient preparation? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

LAXATIVES Stimulant laxatives: bisacodyl stimulation peristalsis, increase water in intestine prepare client prior to surgery or diagnostic tests such as a colonoscopy constipation (opioid use) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

LAXATIVES Osmotic laxatives: magnesium hydroxide (MOM) draw water to intestine increases peristalsis. painful elimination (episiotomy or hemorrhoids) client preparation (colonoscopy) rapid evacuation of bowel (poisons/parasites) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

LAXATIVES Complications Laxatives should be used briefly- smallest effective dose GI irritation Do not crush or chew enteric-coated tablets. Rectal burning Discourage suppositories- regular basis. magnesium hydroxide-toxic levels of magnesium. (renal dysfunction) (sodium salts- risk fluid retention) Cardiac disorders Monitor for dehydration (skin turgor, I&O, increase water intake (2000mL) Chronic use-diminish defecatory reflexes

PROKINETIC AGENTS metoclopramide (Reglan) controls N+V Therapeutic Uses postoperative and chemotherapy-induced N+V management of GERD. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

PROKINETIC AGENTS Complications Extrapyramidal symptoms (EPS): restlessness, anxiety, spasms of face and neck.(diphenhydramine to minimize) Sedation: avoid driving. Diarrhea: Monitor bowel function/dehydration. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Miscellaneous GI Medications Antiflatulents Gallstone-Solubilizing Agents Pancreatic digestive enzymes Emetics Disulfiram How does simethicone work as an antiflatulent? When would the use of an emetic be contraindicated? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Antiflatulents Break up and prevent mucus-surrounded pockets of gas from forming in the intestine; reduce gastric pain Intended for short-term use When is the use of activated charcoal indicated? What physical assessments would the nurse observe in the patient who has excessive gas? Antiflatulents are often used in combination with what other GI drug? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Gallstone-Solubilizing Agents Act on the liver to suppress cholesterol and cholic acid synthesis; biliary cholesterol desaturation is enhanced, and breakup occurs Used in selected patients with radiolucent stones in gallbladder Adverse reactions: dose-related; diarrhea, anorexia, constipation, cramps, dyspepsia, epigastric distress, flatulence, heartburn, nausea, nonspecific abdominal pain, and vomiting What patient characteristics and/or history warrant the use of these agents? If the patient complains of epigastric pain, where would the pain be located? Which other drug may reduce the absorption of these medications? What type of diet education would the patient with a history of gallstones benefit from? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Digestive Enzymes Promote digestion by acting as replacement therapy when the body’s natural pancreatic enzymes are lacking, not secreted, or not properly absorbed For which clinical conditions would these enzymes be indicated? Why is proper dietary balance of fat, protein, and starch indicated for the patient who is receiving these enzymes? If the patient is receiving supplemental iron while on these enzymes, what side effect can occur? When are digestive enzymes usually scheduled to be given? What other patient education should be offered to patients taking these preparations? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Alcoholism Treatment Diazepam (valium) Lorazepam (Ativan) Theraputic Use: benzodiazepines alcohol detoxification- decrease anxiety, decrease risk seizures. Disulfiram (ANTABUSE) Theraputic Use: aversion (behavioral) therapy. Management-alcoholism What symptoms would the patient experience if this drug were taken with alcohol? What physiologic condition within the body produces the disulfiram reaction? What other medication, when taken with alcohol, produces a reaction similar to the disulfiram-alcohol reaction? Why is it important for the patient to carefully read label ingredients (food, personal care items, over-the-counter medications) while on this drug? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Disulfiram (ANTABUSE) acetaldehyde syndrome alcohol ingestion: N+V, weakness, sweating, palpitations, hypotension. (can progress- respiratory depression, cardiovascular suppression, seizures, death) medication effects) persist for 2 weeks- discontinuation What symptoms would the patient experience if this drug were taken with alcohol? What physiologic condition within the body produces the disulfiram reaction? What other medication, when taken with alcohol, produces a reaction similar to the disulfiram-alcohol reaction? Why is it important for the patient to carefully read label ingredients (food, personal care items, over-the-counter medications) while on this drug? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Disulfiram (ANTABUSE) potential dangers of drinking any alcohol (avoid cough syrups, mouthwash,aftershave lotion). monitor LFT (hepatotoxicity) medical alert bracelet participate in a 12-step self-help program. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.