Gastrointestinal Medications Chapter 19 Gastrointestinal Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 1

Learning Objectives Identify common uses for antacids and histamine H2-receptor antagonists Compare and contrast the actions of anticholinergic and antispasmodic medications on the gastrointestinal (GI) tract Compare the actions and adverse reactions of the five major classifications of laxatives Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antacids, H2-Receptor Antagonists, Proton Pump Inhibitors Action and Uses Antacids neutralize hydrochloric acid which decreases gastric pH; inhibit pepsin Histamine H2-receptor antagonists displace histamine from the receptor site and prevent stimulation of the secretory cells (neutralize acid and promote healing of ulcers) Proton pump inhibitors irreversibly stop the acid secretory pump embedded in the parietal cells for the length of time they are taken Of the three drugs, which classification is considered first-line therapy in the treatment of peptic ulcer disease over 6 to 8 weeks? What conditions would antacids be used to treat? How are ulcers caused by Helicobacter pylori treated? When would proton pump inhibitors be used for long-term therapy? How do misoprostol and sucralfate differ in their action? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antacids, H2-Receptor Antagonists, Proton Pump Inhibitors (cont.) Nursing Implications and Patient Teaching Assessment: interaction possibilities Diagnosis: smoking/alcohol intake, stress Planning: increase fluid intake Implementation: forms and routes of administration vary Evaluation: continued symptoms of GI distress Patient and Family Teaching: administration times and drug specificity, adverse reactions, drug storage and efficacy, medical follow-up, drug interactions What administration considerations will the nurse note if the patient is receiving an antacid and an enteric-coated drug scheduled for the same time each day? If the patient is receiving an aluminum-containing antacid, the diet should contain adequate amounts of phosphorus. What foods are naturally high in phosphorus? If the patient is unable to swallow a proton pump inhibitor whole, what might be considered? When is the best time to administer an oral proton pump inhibitor? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antacids Tums Riospan Milk of Magnesia Mag Ox Generics: calcium carbonate Riospan magaldrate Milk of Magnesia magnesium hydroxide Mag Ox magnesium oxide Generics: aluminum carbonate sodium bicarbonate Antacid combinations Maalox magnesium hydroxide & aluminum hydroxide Gelusil aluminum hydroxide, magnesium hydroxide & simethicone **Aluminum tends to constipate a person.

H2 Receptor antagonists (-tidines) Tagamet cimetidine Pepcid famotidine Axid nizatidine Zantac ranitidine

Gastric medications Helidac/ Pylera Cytotec Carafate Treatment for H pylori Miscellaneous Helidac/ Pylera Bismuth subsalicylate, metronidazole & tetracycline Get 4 pills with each dose QID Chew the bismuth and swallow the Metro. & tetra. Cytotec misprostol acts to increase gastric mucus layer/ protects Carafate sucralfate coats stomach wall/ protects ulcers so they can heal

Proton Pump Inhibitors (PPIs) -prazoles Nexium esomeprazole Prevacid lansoprazole Prilosec omeprazole Protonix pantoprazole Aciphex rabeprazole

Anticholinergics and Antispasmodics Action and Uses Anticholinergic-antispasmodic preparations reduce GI tract spasm and intestinal motility, acid production, and gastric motility, thus reducing pain Use: peptic ulcer, pylorospasm, biliary colic, hypermotility, irritable colon, and acute pancreatitis Antidiarrheals reduce the fluid content of the stool and decrease peristalsis and motility of the intestinal tract; increase smooth-muscle tone and diminish secretions Use: treatment of nonspecific diarrhea or diarrhea caused by antibiotics Why would a GI motility agent be prescribed for an elderly patient with gastroesophageal reflux disease? When would it be inadvisable to use an antidiarrheal agent for a patient who has diarrhea? What is the action of bismuth salts on the intestines? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Anticholinergics Sal-Tropine Scopace Librax Robinul Pro-Banthine Belladonna Alkaloids Anticholinergics Sal-Tropine atropine sulfate Scopace scopolamine Librax clidinium Robinul glycopyrrolate Pro-Banthine propantheline Anticholinergic combo drug Donnatol hyoscyamine, atropine, scopolamine & phenobarbital

Gastrointestinal medications antispasmodic GI Stimulant Bentyl dicyclomine Reglan metaclopramide Increase speed at which the stomach empties

Antidiarrheals Pepto-Bismol Lomotil – ‘Lo motility’ Kaopectate Bismuth subsalicylate (think ASA) Lomotil – ‘Lo motility’ diphenoxylate and atropine sulfate Kaopectate kaolin & pectin Bacid / Lactinex lactobacillus Immodium loperamide Asacol – for ulcerative colitis mesalamine Azulfidine – for ulcerative colitis sulfasalazine

Question 1 Antidiarrheals act by: increasing the fluid content of the stool. decreasing peristalsis in the intestinal tract. increasing digestive secretions. decreasing smooth muscle tone. Correct Answer: 2 Rationale: Antidiarrheals reduce the fluid content of the stool and decrease peristalsis and motility of the intestinal tract. They increase smooth muscle tone and diminish digestive secretions. The bismuth salts absorb toxins and provide a protective coating for the intestinal mucosa. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives Action and Uses Bulk-forming laxatives absorb water and expand, increasing the bulk and moisture content of the stool; peristalsis increases, and absorbed water softens the stool Fecal softeners lower the surface tension, which allows the fecal mass to be softened by intestinal fluids Hyperosmolar laxatives produce an osmotic effect by drawing water into the bowel, thereby promoting peristalsis and bowel movement Fecal softeners may inhibit the reabsortion of what two products by the intestine? What conditions other than constipation are bulk-forming laxatives used to treat? Why would a stool softener be indicated for the patient after rectal or cardiac surgery? Saline laxatives may be used as a bowel prep before diagnostic and surgical procedures. A patient on prolonged bedrest may be prescribed which type of laxative? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives (cont.) Action and Uses (cont.) Lubricant laxatives create a barrier between feces and the colon, preventing colon reabsorption and causing softening of the stool Stimulant or irritant laxatives work according to the agent Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives Citrucel Metamucil / Fiberall Colace Bulk forming Fecal softener Citrucel methylcellulose Metamucil / Fiberall psyllium seed Colace docusate

Laxatives cont. Philips Milk of Magnesia Fleet’s enema Emulsoil Saline / hyperosmolar Lubricants Philips Milk of Magnesia magnesium Fleet’s enema sodium salts Emulsoil castor oil Stimulant / Irritant Dulcolax / Correctol bisacodyl Cascara cascara sagrada Senekot / Ex-Lax senna

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 © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Miscellaneous GI Medications Antiflatulents activated charcoal (think liquid briquettes from the grill) Mylanta Gas Relief / Mylicon Simethicone – makes the bubbles smaller so they are easier to pass Emetics Syrup of Ipecac – ipecac (will clean out entire GI tract!!)

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 Gallstone Dissolvers – Actigall - ursodiol 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 © 2013, 2010, 2006, 2003, 2000, 1995, 1991 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 Digestive enzymes Creon pancreatin Pancrease pancrelipase 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 © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disulfiram Used in the management of alcoholism Unpleasant reaction when combined with alcohol Anti-alcoholic product: Antabuse - disulfiram 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 © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Questions?