1. John 1:14 And the Word was made flesh, and dwelt among us. (and we beheld his glory, the glory as of the only begotten of the Father.) full of grace and truth.

2. Drugs for PUD

3. Figure 76-1 The relationship of mucosal defenses and aggressive factors to health and peptic ulcer disease.

4. Helicobacter pylori Test: breath test or serum Treatment (2 Antibiotics are prescribed) –Proton Pump Inhibitor –Bismuth compounds –Clarithromycin –Amoxicillin –Tetracycline –Metronidazole

6. Antacids Ancient Greeks crushed coral Principle antiulcer treatment until 1970’s Alkaline compounds used to neutralize stomach acid May enhance mucosal protection by stimulating production of prostaglandins Several interactions affect absorption, may dissolve EC tablets Teach patients to avoid caffeine, harsh spices, and black pepper

7. Classification of Antacids Aluminum Compounds (AlternalGEL) –Aluminum hydroxide-treats hyperphospatemia –Constipation Calcium Compounds (Tums) –May cause kidney stones –May increase gastric acid secretion, constipation

8. Classification of Antacids Magnesium Compounds (Milk of Magnesia) –Can cause Mg toxicity with renal impairment –Diarrhea Sodium Compounds –Sodium Bicarbonate-maintain pH balance/ESRD –Avoid with HTN/CHF

9. Memory Booster Magnesium Diarrhea Renal MD DR

11. Figure 76-2 A model of the regulation of gastric acid secretion showing the actions of antisecretory drugs and antacids.

12. Histamine 2 -Receptor Antagonists Binds to H2 receptor sites on the parietal cells of stomach which reduces hydrogen ion concentration Side Effects –Antiandrogenic –CNS especially elderly Cimetidine [Tagamet] Ranitidine [Zantac] Ranitidine bismuth citrate [Tritec] Famotidine [Pepcid]- dose with elderly/renal Nizatidine [Axid]

13. Sucralfate [Carafate] MOA: Creates a protective barrier against acid and pepsin Must have an acidic environment to work Uses –Acute ulcers Adverse effects –Constipation Drug interactions-impedes absorption of phenytoin, theophylline, digoxin, warfarin and fluoroquinolones antibiotics. Take 1 hour before meals

14. Proton Pump Inhibitors Most effective. Irreversibly inhibits H/K/ATPase Lansoprazole (Prevacid) Rabeprazole (AchipHex) Pantoprazole (Protonix) Esomeprazole (Nexium) Omeprazole [Prilosec] –Short half-life –Used for short-term therapy Adverse effects –Headache –Gastrointestinal

15. Misoprostol (Cytotec) Analogue of prostaglandin E1 Used with RU-486 for abortion Used to replace the prostaglandin lost with LT aspirin use NOT for use during pregnancy

16. Antiflatulent Simethicone (Mylicon) Doesn’t eliminate gas but relieves discomfort by causing big gas bubbles to break up into smaller ones.

17. Antidiarrheals Abnormal passage of loose stools, increased frequency and fluid Results in Fluid and Electrolyte imbalance Especially affects pediatrics and elderly Acute lasts 3 days to 2 weeks Chronic > 3 weeks Contraindications: Pseudomembranous colitis….Toxic megacolon which can lead to perforation and then septicemia, death –Intestinal obstruction –colitis

18. Antidiarrheal Agents Adsorbents –Coat the wall of the GI and bind to causative bacteria or toxin –Activated Charcoal, bismuth subsalicylate (Pepto-Bismol), attapulite (Kaopectate) Anticholinergic –Decrease peristalsis and muscular tone of intestine –Atropine

19. Antidiarrheal Agents Opioids –Most effective –Diphenoxylate with atropine [Lomotil] –Loperamide (Imodium) –Activate opioid receptors in the GI tract, decrease intestinal motility, slow intestinal transmit, more time for fluids and electrolytes to be absorbed

20. Antidiarrheal Agents Intestinal Flora Modifiers –Supply normal intestinal flora to suppress diarrhea causing bacteria –Lactobacillus acidophilus

21. Laxatives

22. GI Tract

23. Laxatives Laxative-production of soft, formed stool over a period of 1 or more days Catharsis-prompt, fluid evacuation of the bowel Used to ease or stimulate defecation –Soften the stool –Increase stool volume –Hasten fecal passage through the intestine –Facilitate evacuation from the rectum

24. Contraindications to Laxative Use Abdominal pain Nausea Cramps Acute surgical abdomen Symptoms of appendicitis Enteritis Diverticulitis Ulcerative Colitis

25. Classification of Laxatives Bulk-forming laxatives Surfactant (Emollient) laxatives Stimulant laxatives Osmotic laxatives (Hyperosmotic- Saline)

26. Bulk-forming laxatives Most natural and safest Acts like fiber Psyllium [Metamucil] Methylcellulose [Citrucel] Take with liberal amount of water to prevent fecal impaction, esophageal obstruction

27. Surfactant laxatives Allow more fat and water to be absorbed into stool, softens and expands the stool. Lubricates fecal matter. Mineral oil- decreases absorption of fat soluble vitamins Docusate sodium [Colace] Docusate calcium [Surfak]

28. Osmotic laxatives Osmotic action retains water and softens stool, fecal swelling promotes peristalsis Milk of magnesia (MOM) Magnesium citrate Polyethylene glycol (GoLytely, Miralax) Lactulose (Chronulac) –Ammonia Level 15-56 mcg/dl

29. Stimulant laxatives Acts directly on the intestinal mucosa to stimulate peristalsis along GI tract Bisacodyl (Dulcolax) –Oral 6-12 hours –Suppository 15-60 minutes Cascara sagrada Senna Casanthrol Can cause cramps, dependence

30. Laxative Abuse Break laxative habit Increase fiber consumption Exercise daily, especially after meals Avoid cathartics If laxative needed- must use smallest effective dose

31. Antiemetic Agents

33. Figure 78-1 The emetic response: stimuli, pathways, and receptors. CTZ = chemoreceptor trigger zone.

34. Anticholinergics Bind to and block acetylcholine in the vestibular nuclei and reticular formation Scopolamine (Transderm-Scop) Side effects –Dry mouth –Blurred vision –Drowsiness

35. Antihistamines Histamine 1 Receptor Blockers Prevent cholinergic stimulation in the vestibular and reticular formation of the brain Meclizine (Antivert) Dimenhydrinate (Dramamine) Diphenhydramine (Benadryl)

36. Neuroleptic Agents Block dopamine receptors in the CTZ and also block ACh Also used to treat psychotic disorders Prochlorperzine (Compazine) Promethazine (Phenergan) Droperidol (Inapsine) post op, chemo, radiation

37. Prokinetic:Metoclopramide (Reglan) MOA: Blocks dopamine, Increases GI motility TX: Delayed gastric emptying, GERD, Antiemetic Side Effects: GI: Dry mouth Endo: Gynecomastia CNS: Drowsiness, Depression, EPS, Restlessness, TD CV: Dysrhythmias, HTN, Tachycardia

38. Serotonin Blockers Ondansetron [Zofran] Granisetron [Kytril] Blocks type 3 serotonin receptors 5-HT on afferent vagal nerve Prevents N/V associated with chemotherapy and post op ( GI tract cells rapidly dividing and chemo stimulates VC) More effective when used with dexamethasone

39. Tetrahydrocannabinoids Dronabinol (Marinol) Cannabinoids- active component in marijuana that produce psychological and physical effects. Approved for cancer chemotherapy, stimulate appetite with AIDs Controlled Substance Schedule III (was II) Contraindicated with psychiatric disorders