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GI Pharmacology
Dr. Alia Shatanawi
5/4/2018
• Drugs used in Peptic Ulcer Diseases.
• Drugs Stimulating Gastrointestinal Motility &Laxatives.
• Antidiarrheal Agents.
• Drugs used in Irritable Bowel Syndrome.
• Antiemetic Agents.
• Drugs used in Inflammatory Bowel Disease.
• Pancreatic Enzyme Supplements.
• Bile Acid Therapy for Gall stones.
• Drugs used in Variceal Hemorrhage.
Drugs Used in Gastrointestinal Diseases
Upper GI Drugs
Peptic ulcer is a defect in the lining of the stomach or
the duodenum
• The most common cause is infection of the
stomach by bacteria called Helicobacter pylori
(H.pylori).
• Ulcers can also be caused or worsened by drugs
such as aspirin, ibuprofen, and other NSAIDs
• Other factors: Smoking, Stress, Spices (diet) and
alcohol….
• Gastrinomas (Zollinger Ellison syndrome), rare
gastrin-secreting tumors
Causes of Peptic Ulcer
Treatment Approach
Peptic ulcer
1. Reduce acid secretion
from parietal cells
2. Neutralize acid in the
lumen
3. Protect the mucosa from
acid destruction
4. Antibiotics to eradicate
Helicobacter pylori
Physiology of gastric secretion
Gastrin
Histamine
Pepsin
HCl
Three pathways control parietal cell acid secretion
Acetylcholine receptor pathway
• Sight, smell, taste of food cause stimulation of vagal nerve to release acetylcholine.
• Ach binds to M3 receptor and Cai rises activating phosphokinases
• H+K+ATPase translocates to the secretory canaliculus.
• K+ in extracellular space exchanged for H+.
• Cl- diffuse across cell membrane to form HCl in canaliculus.
• Ach increases gastrin and histamine release.
Gastrin receptor pathway
• Digested food in stomach stimulates release of gastrin from G cells in antrum of stomach; distention releases Ach increasing gastrin levels.
• Gastrin binds to CCK-B receptor and Cai rises activating phosphokinases.
• H+K+ATPase translocates to the secretory canaliculus.
• K+ in extracellular space exchanged for H+.
• Cl- diffuse across cell membrane to form HCl in canaliculus.
• Gastrin increases histamine release.
Histamine receptor pathway
• Ach and gastrin release stimulates
ECL cells to release histamine.
• Histamine binds to H2 receptor and
Cai and cAMP rises activating
phosphokinases.
• H+K+ATPase translocates to the
secretory canaliculus.
• K+ in extracellular space
exchanged for H+.
• Cl- diffuse across cell membrane to
form HCl in canaliculus.
Were used long time ago, and were mainstay of treatment.
Nonprescription remedies.
Are weak bases that react with gastric HCl to form salt and water.
Also stimulate mucosal prostaglandin production, therefore may promote mucosal defense mechanisms.
Antacids
Given after a meal, can neutralize acidity for up to
2 hours.
Efficacy varies according to rate of dissolution,
water solubility, rate of reaction with acid and the
rate of gastric emptying.
May affect the absorption of other medications by
binding to drugs or by changing ph, therefore,
dissolution.
Antacids
Sodium Bicarbonate (Baking Soda):
– Reacts rapidly with acid to produce NaCl
and CO2.
– CO2 leads to gastric distension and
belching.
– NaCl may exacerbate fluid retention.
– Systemic absorption leads to metabolic
alkalosis.
Antacids
Magnesium Hydroxide.
Aluminum Hydroxide.
– React slowly and without gas formation.
– Metabolic alkalosis is also uncommon.
– Mg salts cause diarrhea.
– Aluminum salts cause constipation.
– Usually given in combination.
– Contraindicated in renal insufficiency.
Antacids
Neutrolization of acid
Antacids
• Aluminum antacids absorb or chelate many drugs; most common used.
• Magnesium antacids have laxative action; diarrhea.
• Calcium antacids stimulates acid rebound by promoting gastrin release.
• Sodium antacids should be avoided; aggravate CHF and counteracts diuretic therapy for HBP, short duration of action, followed by acid rebound, highly absorbed.
Cimetidine, prototype, many problems.
Ranitidine.
Famotidine.
Nizatidine.
– Were the most commonly prescribed
drugs in the world.
H2- Receptor Antagonists(1970s-1990s)
Selective competitive inhibitors of the parietal
cell H2 receptors and suppress basal and
meal-stimulated acid secretion in a dose-
dependent manner.
Also decrease volume of secretion and pepsin
concentration.
Decrease secretion stimulated by:
– Histamine.
– Gastrin.
– Acetylcholine.
H2- Receptor Antagonists(1970s-1990s)
• Duration of action: 12 hours.
Inhibit 60-70% of total 24-h acid secretion.
– 90% of nocturnal acid.
– 60% of day-time and meal- stimulated acid..
H2- Receptor Antagonists(1970s-1990s)
H2 Receptor Antagonists
• Competitively inhibit the interaction of histamine with H2 receptors.
• Selective for H2 over H1 receptors; appear to only interfere with H2 physiological functions on gastric acid secretion.
• Well-absorbed orally and reach peak serum concentration in 1-3 hours.
• Found in cerebrospinal fluid, cross placental barrier, and excreted in breast milk.
H2 Receptor Antagonists
• Developed in 1970’s.
• Inhibit basal (fasting) and nocturnal acid secretion.
• Decreases volume of gastric “juice” and [H+].
• Decreases acid secretion stimulation by food, distention, and pharmacological agents.
• Used for Zollinger-Ellison syndrome, ulcers, GERD.
• OTC preparations advertised for “heartburn”.
Histamine
Cimetidine
(many side-effects)
Ranitidine
Famotidine
(Most potent)
Nizatidine
Cimetidine (Tagamet)
• Inhibits cytochrome P450 activity; will slow down metabolism of other drugs.
• Anti-androgen activity; loss of libido, impotence
• Increases plasma estradiol in men; increases secretion of prolactin.
• CNS effects in elderly with systemic illnesses; confusion, agitation, lethargy.
H2- Receptor Antagonists
Duration of action: 12 hours.
Inhibit 60-70% of total 24-h acid secretion.
– 90% of nocturnal acid.
– 60% of day-time and meal- stimulated acid.
H2- Receptor Antagonists
Clinical Uses:
Gastroesophageal Reflux:
– Prophylactically, before meals.
– Afford healing for erosive esophgitis in less
than 50% of patients.
– Proton pump inhibitors are preferred.
Non Ulcer Dyspepsia.
Stress- Related Gastritis:
– Can prevent bleeding, usually given IV.
H2- Receptor Antagonists
Peptic Ulcer Disease:
– Replaced by PPI.
– Healing rate greater than 80-90% after 6-8
weeks.
– Not effective in the presence of H. pylori
infection.
– Not effective if NSAID is continued.
H2- Receptor Antagonists
Adverse Effects:
Extremely safe drugs, but can (in 3%
of patients) cause diarrhea, headache,
fatigue, myalgia and constipation.
CNS:
– Confusion, hallucinations and agitation
occur only with IV cimetidine to elderly
patients in ICU.
H2- Receptor Antagonists
Adverse Effects:
Endocrine Effects:
– Again only with cimetidine, can inhibit DHT
binding to its receptor, estradiole metabolism,
and can increase prolactin serum levels.
Pregnancy and Nursing Mothers:
– Can cross placental barrier and appear in breast
milk.
Other Effects:
– Rarely can cause blood dyscrasias, bradycardia
and hypotension.
H2- Receptor Antagonists
Drug Interactions:
Cimetidine can inhibit
cytochrome P450
enzymes(CYP1A2, CYP2C9,
CYP2D6, and CYP3A4), so can
increase half life of many drugs.
Ranitidine binds 4-10 times less.
Nizatidine and famotidine binding
is negligible.