1. Drugs Affecting the Gastrointestinal System and Nutrition Jan Bazner-Chandler MSN, CNS, RN, CPNP

2. Acid-related Pathophysiology Hydrochloric acid (HCL) aids in digestion and serves as a barrier to infection. Pepsinogen is an enzyme that digests dietary protein. Mucous protects the lining of the stomach from both HCL and digestive enzymes. Prostaglandins has an anti-inflammatory and protective function.

3. Antacids Are basic compounds used to neutralize stomach acid.

4. OTC Products Antacids were the most common products used for acid-indigestion until the 1970’s when histamine-2 (H2 antagonists) were developed.

5. Action Primary drug effect of antacids is the reduction of symptoms associated with acid- related disorders: pain and reflux (heartburn) Raises gastric pH from 1.3 to 1.6.

6. Indications Acute relief of symptoms associated with:  peptic ulcer disease (PUD)  Gastritis  gastric hyperacidity  Heartburn or gastro esophageal reflux (GEF)

7. GERD Most common disorder of esophagus Characterized by regurgitation of gastric contents into esophagus and exposure of esophageal mucous to gastric acid and pepsin. Main symptom is heart burn - occurs after eating Cause is thought to be incompetent lower esophageal sphincter

8. GERD

9. Peptic Ulcer Disease Ulcer formation in the esophagus, stomach or duodenum Mucous exposed to gastric acid and pepsin Imbalance between cell-destructive and cell- protective effects  Gastric acid and pepsin  H. pylori – infectious process

10. Peptic Ulcer Disease

11. Adverse Effects Magnesium preparations especially milk of magnesium or MOM can cause diarrhea. Calcium products can cause kidney stones. Sodium bicarbonate products can cause systemic alkalosis. Self-treatment can result in masking symptoms of a disease (bleeding ulcer or stomach cancer).

12. Keep away from small children Antacid ingestion can cause a state of alkalosis in children.  TUMS

13. Contraindications Allergy to the drug Severe renal failure Electrolyte disturbances Gastro intestinal obstruction

14. Interaction May effect absorption of other drugs. Chemically inactivates certain drugs Increased stomach pH decreasing absorption of acidic drugs

15. OTC Preparations Magnesium-containing antacids  Gaviscon Liquid, Milk of Magnesium Aluminum-containing antacids  Amphogel, Maalox Sodium-containing antacids  Alka-seltzer,Tums

16. Gelusil / Mylanta

17. Administration Chewable forms needs to be thoroughly chewed. Liquid forms need to be shaken well before taking. Take with 8 ounces of water to enhance absorption. Do not take within 1 to 2 hours of taking other medications – may effect absorption

18. H 2 Antagonists H2 receptor blockers  cimetadine (Tagamet),  ranitidine (Zantac)  famotidine (Pepcid)  nizatidine (Axid)

19. H2 antagonist or HAs Action:  blocks the H2 receptor of acid-producing parietal cells  Reduce hydrogen ion secretions to increase pH of stomach * Note: have become the most popular drugs for treatment of many of acid related disorders

20. Therapeutic Uses GERD or gastro-esophageal reflux disease PUD or peptic ulcer disease Zollinger-Ellison Syndrome (excessive gastric acidity)

21. Adverse Effects Overall very low incidence of adverse effects May cause some CNS effects in the geriatric patient. Smoking reduces effectiveness H2 antagonist should be taken 1 hours before taking any antacids

22. Proton Pump Inhibitors Newest drugs used in the treatment of acid- related disorders.  lansopraxole (Prevacid)  omeprazole (Prilosec)  rabeprzole (Acephex)  pantoprazole (Protonix)  exomepraxole (Nexium)

23. PPIs Action: Binds directly to the hydrogen- potassium - ATPase pump mechanism, inhibiting the action of the enzyme which results in a total blockage of hydrogen ion secretion from the parietal cells.

24. Adverse Effects Long term use might promote malignant gastric tumors. Concern about over prescribing resulting in reduction of normal acid-mediated antimicrobial protection. May need a probiotic when using PPI drug therapy.

25. Miscellaneous Acid-Controlling Drugs sucralfate (Carafate) Uses: long-term therapy for PUD Action: acts locally binding directly to the surface of the ulcer. Note: not used as often due to short-term action and multiple daily dosing.

26. Cytotec Generic: misoprostol Action: acts on prostaglandin E analogue Indication: reduces the incidence of gastric ulcers in patients taking NSAIDs.

27. Mylicon Generic: simethicone Action: alters the elasticity of mucus-coated gas bubbles, causing them to break down into smaller ones

28. Mylicon Used to reduce the discomfort of gastric or intestinal gas (flatulence) Used post-operatively and in post-partum patients to relieve gas pain. Often used in combination with activated charcoal in oral poisoning (overdose).

29. Probiotics Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called "friendly bacteria" or "good bacteria." Probiotics are available to consumers mainly in the form of dietary supplements and foods. They can be used as complementary and alternative medicine.

30. Probiotics Probiotics are available in foods and dietary supplements. Examples of foods containing probiotics are yogurt, fermented and unfermented milk, miso, and some juices and soy beverages. In probiotic foods and supplements, the bacteria may have been present originally or added during preparation.

31. Probiotics Most probiotics are bacteria similar to those naturally found in people's guts, especially in those of breastfed infants (who have natural protection against many diseases). Most often, the bacteria come from two groups, Lactobacillus or Bifidobacterium. A few common probiotics, such as Saccharomyces boulardii, are yeasts, which are different from bacteria.

32. Uses Chronic Diarrhea Irritable Bowel Syndrome Digestive disorders Clients on oral or IV antibiotic therapy Status post abdominal surgery

33. Antidiarrheals and Laxatives Chapter 42

34. Antidiarrheal Drugs Used to treat diarrhea.  Adsorbents  Antimotility (anticholenergic and opiates)  Intestinal flora modifiers or bacterial replacement drugs

35. Adsorbents Act by coating the walls of the GI tract. Bind with the causative bacteria or toxin to their adsorbent surface for elimination through the stool.

36. Pepto-Bismul and Kaoectate Generic: bismuth subsalicylate Same chemical structure as salicylates  use with caution in children. May cause Reyes Syndrome  Use with caution in clients who are on anti- coagulation therapy. # Note: Aspirin is a part of the salicylate classification of drugs.

37. Pepto-bismol

38. FDA Warning The main ingredient, bismuth subsalicylate, has been linked with Reye Syndrome, a potentially life-threatening disorder that has been associated with kids that have viral illnesses, especially the flu and chicken pox, and who take aspirin and other salicylate containing medications, like Pepto-Bismol.fluchicken pox Label advises not to give to children under age 12 years.

39. Anticholinergics Used either alone or in combination with other antidiarrheal drugs. Acts by slowing GI tract motility  Atropine  hyoscyamine  hyoscine

40. Opiates Products containing Codeine Nursing consideration: clients on opioids for post-operative pain control may suffer from constipation Atropine: often used to control secretions during surgical procedure – may contribute to post-operative constipation

41. Nursing Alert In a postoperative patient you need to know what medications received pre-operative. Atropine is often used to dry up oral secretions during surgery. Codeine in the form of Tylenol #1, #2 or # 3 all can cause constipation when used to control post-operative pain.

42. Imodium A D Generic name: loperamide Classification: Opiate antidiarrheal Action: inhibits both peristalsis in the intestine and intestinal secretions, decreasing the number of stools and their water content. Contraindications: ulcerative colitis, acute diarrhea due to E-coli (Escherichia coli)

43. Imodium A-D OTC drug to control diarrhea Contraindicated in children under 6 years of age.

44. Laxatives Laxative act by:  Affecting the consistency of the stool  Increasing fecal movement through the colon  Facilitating defecation through the rectum

45. Constipation Definition: abnormally infrequent and difficult passage of feces. Constipation is a symptom not a disease.

46. Bulk-forming Laxatives Composed of water-retaining natural and synthetic cellulose derivates.  Psylium is an example of natural bulk-forming laxative.  Methylcellulose is an example of a synthetic cellulose derivative.

47. Bulk-forming Laxative Action: increases water absorption, which results in greater bulk of the intestinal contents. Tend to produce normal, formed stools. Action limited to GI tract so adverse effects are minimal.

48. Citrucel (methylcellulose)

49. Nursing Alert Have client take with 8 ounces of water. If powdered form needs to be mixed with 8 ounces of water. Fluid must be taken immediately to avoid swelling of the product in the throat or esophagus or fecal impaction. Best for clients with chronic constipation.

50. Emollient laxative Generic classification: docusate salts Trade names: Colace, Surfak Action: work by lowering the surface tension of GI fluids; more water and fat are absorbed into the stool and intestine.

51. Emollients Uses:  post partum  postoperative patients  Clients on long-term pain control Outcomes: soft stool with easier defecation Slow acting: often takes 4 to 5 days to see results

52. Mineral Oil Action: eases the passage of stool by lubricating the intestines and preventing water from escaping the stool. Contraindications  Abdominal pain  Nausea and vomiting  Intestinal obstruction

53. Mineral Oil

54. Hyperosmotic Laxatives Glycerine Action: promotes bowel movement by increasing the osmotic pressure in the intestine. Note: given in the form of a suppository

55. Stimulant Laxatives Through the use of natural plant products and synthetic chemical drugs induces intestinal peristalsis. Note: the stimulant class is the most likely to cause dependence.

56. Stimulant Laxatives Generic: senna Trade: Senokot Action: stimulates the GI tract Adverse effects: may cause abdominal pain. Onset of action: complete bowel evacuation in 6 to 12 hours.

57. Irritable Bowel Syndrome IBS A condition of chronic intestinal discomfort, including cramps, diarrhea / or constipation. Two drugs to manage symptoms:  Lotronex (alostron) – approved for women only  Zelnorm (tegaserod) – approved for men and women Action: works on serotonin receptors in the intestinal tissue.

58. Antiemetic and Antinausea Drugs Chapter 52

59. Chemoreceptor Trigger Zone (CTZ) The area of the brain that is involved in the sensation of nausea and the action of vomiting.

60. Vomiting Center (VT) The area of the brain that is involved in stimulating the physiologic events that lead to nausea and vomiting.

61. Antiemetic Drugs Drugs used to relieve nausea and vomiting. All emetic drugs work at some site in the vomiting pathways.

62. Syrup of Ipecac AAP recommendations in 2003 issued an alert to stop the use of this drug to induce vomiting after drug overdose.

63. Anticholinergic Drugs Act by binding to and blocking acetylcholine receptors (ACh) in the vestibular nuclei, located deep in the brain. One drug scopolamine Most commonly used drug for treatment and prevention of nausea and vomiting associated with motion sickness and postoperatively.

64. Antihistamines Action: binds to H1 receptors, potentiate anticholinergic activity. Most popular OTC medications Generic name: dimenhydrinate Trade name: Dramamine and Benadryl OTC drugs used for motion sickness

65. Neuroleptics Action: antidopaminergic, antihistamine and anticholinergic properties. Trade names: Compazine, Thorazine, Phenergan Often given as preoperative medication. Used to treat psychotic disorders due to effect on dopamine.

66. Compazine: Nursing Alert Adverse reaction: extrapyramidal reaction--a muscle spasm of the tongue. Other typical adverse extrapyramidal reactions include tremors, drooling, and muscle spasms that usually involve muscles in the shoulders, neck, or eyes. Antidote: Benadryl

67. Prokinetics Metoclopramide Trade name: Reglan Action: promote the movement of substances through the GI tract and increases motility. Uses in delayed gastric emptying time and gastroesophageal reflux.

68. Serotonin Blockers Called 5-HT3 receptor blockers because they block the 5-HT3 receptors in the GI tract, CTZ and vomiting centers VC. Four drugs in this category

69. ondansetron  Trade name: Zofran is the prototype drug. Approved in 1992. Major break through in treating chemotherapy induced nausea and vomiting and postoperative nausea and vomiting. Approved for use in pregnancy.

70. Side effects from all antiemetics May cause dizziness Caution with use while driving. CNS depression Hypotension

71. Herbal Therapies Ginger Root May increase absorption of all oral mediations, may increase bleeding in clients taking Coumadin and Plavix.