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Drugs Affecting the Gastrointestinal System and Nutrition
Jan Bazner-Chandler MSN, CNS, RN, CPNP
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.
Antacids
Are basic compounds used to neutralize stomach acid.
OTC Products
Antacids were the most common products used for acid-indigestion until the 1970’s when histamine-2 (H2 antagonists) were developed.
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.
Indications
Acute relief of symptoms associated with: peptic ulcer disease (PUD) Gastritis gastric hyperacidity Heartburn or gastro esophageal reflux (GEF)
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
GERD
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
Peptic Ulcer Disease
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).
Keep away from small children Alkalosis
Contraindications
Allergy to the drug Severe renal failure Electrolyte disturbances Gastro intestinal obstruction
Interaction
May effect absorption of other drugs. Chemically inactivates certain drugs Increased stomach pH decreasing absorption
of acidic drugs
OTC Preparations
Magnesium-containing antacids Gaviscon Liquid, Milk of Magnesium
Aluminum-containing antacids Amphogel, Maalox
Sodium-containing antacids Alka-seltzer, Tums
Gelusil / Mylanta
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
H 2 Antagonists
H2 receptor blockers cimetadine (Tagamet), ranitidine (Zantac) famotidine (Pepcid) nizatidine (Axid)
H2 antagonist HAs
Action: blocks the H2 receptor of acid-producing parietal
cells Reduce hydrogen ion secretions to increase pH of
stomach
Therapeutic Uses
GERD or gastro-esophageal reflux PUD or peptic ulcer disease Zollinger-Ellison Syndrome (excessive gastric
acidity)
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
Proton Pump Inhibitors
Newest drugs used in the treatment of acid-related disorders. lansopraxole (Prevacid) omeprazole (Prilosec) rabeprzole (Acephex) pantoprazole (Protonix) exomepraxole (Nexium)
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.
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.
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.
Cytotec
Generic: misoprostol Action: acts on prostaglandin E analogue Indication: reduces the incidence of gastric
ulcers in patients taking NSAIDs.
Mylicon
Generic: simethicone Action: alters the elasticity of mucus-coated
gas bubbles, causing them to break down into smaller ones
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).
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.
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.
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.
Uses
Chronic Diarrhea Irritable Bowel Syndrome Digestive disorders Clients on oral or IV antibiotic therapy Status post abdominal surgery
Antidiarrheals and Laxatives
Chapter 42
Antidiarrheal Drugs
Used to treat diarrhea. Adsorbents Antimotility (anticholenergic and opiates) Intestinal flora modifiers or bacterial replacement
drugs
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.
Pepto-Bismul and Kaoectate
Generic: bismuth subsalicylate Same chemical structure as salicylate
use with caution in children. May cause Reyes Syndrome
Use with caution in clients who are on anti-coagulation therapy.
Pepto-bismol
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.
Label advises not to give to children under age 12 years.
Anticholinergics
Used either alone or in combination with other antidiarrheal drugs.
Acts by slowing GI tract motility Atropine hyoscyamine hyoscine
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
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)
Laxatives
Laxative act by: Affecting the consistency of the stool Increasing fecal movement through the colon Facilitating movement through the colon
Constipation
Definition: abnormally infrequent and difficult passage of feces.
Constipation is a symptom not a disease.
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.
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.
Citrucel (methylcellulose)
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.
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.
Emollients
Uses: post partum postoperative patients Clients on long-term pain control
Outcomes: soft stool with easier defecation
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
Hyperosmotic Laxatives
Glycerine Action: promotes bowel movement by
increasing the osmotic pressure in the intestine.
Note: given in the form of a suppository
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.
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.
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.
Antiemetic and Antinausea Drugs
Chapter 52
Chemoreceptor Trigger Zone (CTZ) The area of the brain that is involved in the
sensation of nausea and the action of vomiting.
Vomiting Center (VT)
The area of the brain that is involved in stimulating the physiologic events that lead to nausea and vomiting.
Antiemetic Drugs
Drugs used to relieve nausea and vomiting. All emetic drugs work at some site in the
vomiting pathways.
Syrup of Ipecac
AAP recommendations in 2003 issued an alert to stop the use of this drug to induce vomiting after drug overdose.
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.
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
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.
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
Prokinetics
Metoclopramide Trade name: Reglan Action: promote the movement of substances
through the GI tract and increases motility. Often given in patients getting tube feeding to
promote gastric emptying time.
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
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.
Side effects from all antiemetics May cause dizziness Caution with use while driving. CNS depression Hypotension
Herbal Therapies
Ginger Root May increase absorption of all oral
mediations, may increase bleeding in clients taking Coumadin and Plavix.