1. 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.

2. 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.

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. 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)

9. 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)

10. 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

11. 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.

12. 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

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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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)

20. 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

21. 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.

22. 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.

23. 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.

24. 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.

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

26. 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

27. 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

28. 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.

29. 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.

30. 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.

31. 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.