J u s t t h e facte

In this chapter, you'll learn: II if • '

jjg classes of drugs used to improve Gl
functicjgl puses end varying actionsbf
these drugs || ■ :
♦ absorption, distribution, metabolization||
hd excretion of these drugs
♦ drug interactions and adverse
reactions to these drugs.

rugs and the Gl

system
The GI tract is basically a hollow, muscular tube
that begins at the mouth and ends at the anus; it
encompasses the pharynx, esophagus,
stomach, and the small and large intestines. Its
primary functions are to digest and absorb
foods and fluids and excrete metabolic waste.
Roll call
Classes of drugs used to improve GI function
include:
• antiulcer drugs
• adsorbent, antiflatulent, and digestive drugs
• antidiarrheal and laxative drugs
• antiemetic and emetic drugs. (See Where
drugs affect Gl secretions, page 300.)

iulcer drugs
A peptic ulcer is a circumscribed lesion in the
mucosal membrane, developing in the lower
esophagus, stomach, duodenum, or jejunum.
mm. ■
■

GASTROINTESTINAL DRUGS

§wp function
Where drugs affect Gl
secretions
Antiulcer drugs and digestive drugs that affect 61
secretions can decrease secretory activity, block the
action of secretions, form a protective coating on the
lining, or replace missing enzymes, the illustration
below depicts where these types of Gl drugs act
mm
Common culprits
The major causes of peptic ulcers include:
• bacterial infection with Helicobacter
pylori
• the use of nonsteroidal anti-
inflammatory drugs (NSAIDs)
• hypersecretory states such as Zollinger-
Ellison syndrome (a condition in which
excessive gastric acid secretion causes
peptic ulcers)
• cigarette smoking, which causes
hypersecretion and impairs ulcer healing
• a genetic predisposition, which accounts
for 20% to 50% of patients with peptic
ulcers.
Acting bacteria or bolstering
balance
Antiulcer drugs are formulated to eradicate
H. pylori or restore the balance between
acid and pepsin secretions and the Gl mu-
cosal defense. These drugs include:
• systemic antibiotics
• antacids
• histamine-2 (H2) receptor antagonists
• proton pump inhibitors
• other antiulcer drugs, such as
misoprostol and

Systemic antibiotics
H. pylori is a gram-negative
bacteria that's thought to be a
major causative factor in peptic
ulcer formation and gastritis
(inflammation of the stomach
lining). Eradicating the bacteria
promotes ulcer healing and
decreases recurrence.

It takes two
Successful treatment involves the use of
two or more antibiotics
in combination with other drugs. Systemic
antibiotics used to
treat H. pylori include: ^
• amoxicillin
• clarithromycin
• metronidazole
• tetracycline.

Pharmacokinetics
(how drugs circulate)
Systemic antibiotics are variably absorbed
from the Gl tract.
ood, especially dairy products, decreases the absorption of tetracycline but
doesn't significantly delay the absorption of the other antibiotics.
All of these antibiotics are distributed widely and are excreted primarily in
urine.

Pharmacodynamics (how drugs act)

Antibiotics act by treating the H. pylori infection. They're usually combined
with an H2-receptor antagonist or a proton pump inhibitor to decrease
stomach acid and further promote healing.

Pharmacotherapeutics
(how drugs are used)
Systemic antibiotics are indicated for H. pylori
eradication to reduce the risk of a duodenal ulcer.

Sounds like a plan

Treatment plans that use at least two antimicrobial
drugs and a proton pump inhibitor for 14 days and
then continue the proton pump inhibitor for 6 more
weeks, help reduce acid in the patient with peptic
ulcers.

Drug interactions
Tetracycline and metronidazole can interact with
many other drugs. For example, tetracycline
increases digoxin levels and, when combined with
methoxyflurane, increases the risk of nephrotoxicity.
Metronidazole and tetracycline increase the risk of
bleeding when taken with oral anticoagulants.

Adverse reactions
Antibiotics used to improve GI tract function may lead to adverse reactions,
such as those listed here:
• Metronidazole, clarithromycin, and tetracycline commonly cause mild GI
disturbances.
• Clarithromycin and metronidazole may produce abnormal tastes.
• Metronidazole may cause a disulfiram-like reaction (nausea, vomiting,
headache, cramps, flushing) when combined with alcohol. Discourage
concomitant use.
• Amoxicillin may cause diarrhea.
Nursing process
These nursing process steps are appropriate for patients undergoing
treatment with systemic antibiotics.

Assessment
• Assess the patient's infection before therapy and regularly thereafter.
• Assess signs and symptoms of the patient's ulcer.
• Watch for edema, especially in the patient who's also receiving
corticosteroids; antibiotics, such as metronidazole, may cause sodium
retention.
• Assess for adverse reactions and drug interactions.
• Identify risk factors for peptic ulcer disease, such as cigarette smoking,
stress, and drug therapy with irritating medications (aspirin, other NSAIDs,
corticosteroids, or antineoplastics).
• Assess the patient's and family's understanding of drug therapy.

Key nursing diagnoses

• Ineffective health maintenance related to presence of susceptible organisms
• Risk for deficient fluid volume related to drug-induced adverse Gl reactions
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient's overall health status will improve.
• Stable vital signs and the patient's urine output will indicate improved fluid
volume status.
• The patient and his family will demonstrate an understanding of drug
therapy.

Implementation
• Administer drugs as appropriate for the patient's condition and diagnosis.
• Use measures to prevent or minimize peptic ulcer disease and gastric acid-
induced esophageal disorders.
• Observe the patient for improvement in symptoms.

Evaluation
• Patient is free from infection.
• Patient maintains adequate hydration throughout therapy.
• Patient and his family demonstrate an understanding of drug therapy. (See
Teaching about antiulcer drugs, page 304.)
GASTROINTESTINAL
DRUGS

Education edge

Teaching
about antiulcer
drugs
If l
antiulcer pressure.
drugs are •Take
prescribe medicatio
d, review ns with
these enough
points water to
with the avoid
patient irritating
and his the
caregiver esophagu
s: s.
•Elevate •Take
the heed antiulcer
of the drugs as
bed. directed;
•Avoid underuse
abdomina decrease
l s their
distention effectiven
by eating ess and
small overuse
meals. increases
•Don't lie adverse
down for effects.
1 to 2 •Swallow
hours capsules
after whole
eating. unless
•Decreas otherwise
e intake instructe
of fats, d; some
chocolate medicatio
, citric ns can be
juices, sprinkled
coffee, on
and applesau
alcohol.
ce if
•Avoid
they're
smoking.
difficult
•Avoid
to
obesity,
swallow.
constipati
•Take
on, and
medicatio
other
ns as
condition
prescribe
s that in-
d for
crease
maximu
intra-
m
abdomina
effectiven tory
ess. drugs.
•Take •Reduce
medicatio psycholo
ns with or gical
without stress;
food, as employ
prescribe stress
d, when manage
applicabl ment
e. technique
•Eat a s, as
well- needed.
balanced •Don't
diet take
•Get other
adequate medicatio
rest ns, over-
•Exercise the-
regularly. counter
•Avoid preparati
gastric ons, or
irritants herbal
as well as remedies
nonsteroi without
dal anti- first
inflamma consultin
* g with the
prescribe
r.

A
n Antacids are over-
t the-counter (OTC)
a medications used
c in combination
i with other drugs
d to treat peptic
s ulcers. Types of
antacids include:
• aluminum
carbonate gel
• calcium
carbonate
• magaldrate
(aluminum-
magnesium
complex)
•m
ag
ne
si
u
m
hy
dr
ox
id
e
an
d
a s work locally in
l the stomach by
u neutralizing
m gastric acid. They
i don't need to be
n absorbed to treat
u peptic ulcers.
m Antacids are
distributed
h throughout the GI
y tract and are elim-
d inated primarily in
r feces.
o
x Pharmac
i
d odynamic
e s
The acid-
a neutralizing action
of antacids
s reduces the total
i
amount of acid in
m
the GI tract,
e
allowing peptic
t
ulcers time to heal.
h
i
c
o
n
e
.

P
h
a
r
m
a
c
o
k
i
n
e
t
i
c
s
A
n
t
a
c
i
d
 Pepsin, a digestive enzyme, acts more effectively when the stomach is
highly acidic; therefore, as acidity drops, pepsin action is also reduced.

Myth buster
Contrary to popular belief, antacids don't work by coating peptic ulcers
or the lining of the Gl tract.

Pharmacotherapeutics
Antacids are primarily prescribed to relieve pain and are used ad-
junctively in peptic ulcer disease.
Churn, churn, churn
Antacids also relieve symptoms of acid indigestion, heartburn, dyspepsia
(burning or indigestion), or gastroesophageal reflux disease (GERD),
where the contents of the stomach and duodenum flow back into the
esophagus.
foiling phosphate absorption
Antacids may be used to control hyperphosphatemia (elevated blood
phosphate levels) in kidney failure. Because calcium binds with
phosphate in the Gl tract, calcium carbonate antacids prevent phosphate
absorption. (See Antacids: Aluminum hydroxide.)

Drug interactions
All antacids can interfere with the absorption of oral drugs if given at the same time.
Absorption of digoxin, phenytoin, ketoconazole, iron salts, isoniazid, quinolones, and
tetracycline may be reduced if taken within 2 hours of antacids. If a patient is taking an
antacid in addition to other drugs, separate the drugs' administration times.

Adverse reactions
All adverse reactions to antacids are dose related and include:
• diarrhea
• constipation
• electrolyte imbalances
• aluminum accumulation in serum.

Nursing process
These nursing process steps are appropriate for patients undergoing treatment with
antacids.
Assessment
• Assess the patient's condition before therapy and regularly thereafter.
• Record the number and consistency of stools.
• Assess the patient for adverse reactions.
• Monitor the patient receiving long-term, high-dose aluminum carbonate and
aluminum hydroxide for fluid and electrolyte imbalance, especially if he's on a
sodium-restricted diet.
• Monitor phosphate levels in the patient receiving aluminum carbonate or
aluminum hydroxide.
• Watch for signs of hypercalcemia in the patient receiving calcium carbonate.
• Monitor magnesium levels in the patient with mild renal impairment who
takes magaldrate.

Key nursing diagnoses

• Constipation related to adverse effects of antacids containing aluminum
• Ineffective protection related to drug-induced electrolyte imbalance
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient's underlying symptoms will improve.
• Laboratory studies will show normal electrolyte balance.
• The patient and his family will demonstrate an understanding of antacid
therapy.
Implementation
• Manage constipation with laxatives or stool softeners, or ask the prescriber
about switching the patient to a magnesium preparation.
• If the patient suffers from diarrhea, obtain an order for an an-tidiarrheal, as
needed, and ask the prescriber about switching the patient to an antacid
containing aluminum.
• Shake the container of a liquid form well.
• When giving the drug through a nasogastric (NG) tube, make sure that the
tube is patent and placed correctly. After instill- ^ ing the drug, flush the tube
with water to ensure passage to
the stomach and to clear the tube.

Evaluation
• Patient regains a normal bowel pattern.
• Patient maintains a normal electrolyte balance.
 ANTIULCER DRUGS
Ethk$tlon edge

Teaching about
antacids I Don't use sodium bicarbonate regularly as an
f antacids art prescribed, review these points antacid. Use a nonabsorbable antacid if antacids
with the patient and his caregivers: are needed often.
•Shake the suspension form well before taking it
• Don't take antacids indiscriminately or
switch antacids with-outthe prescribed consent
I Some antacids, such as aluminum hydroxide,
may color stools white or cause white streaks.
•Don't take calcium carbonate with milk or
* To prevent constipation, increase fluid and
other foods high in vitamin 0.
roughage intake and increase activity level.
• Don'ttake sodium bicarbonate with milk;
doing so could cause hypercalcemia.

• Patient and his family demonstrate an understanding of drug therapy. (See

Teaching about antacids.)
preceptor antagonists
H2-receptor antagonists are commonly prescribed antiulcer drugs in the United States. Drugs in this
category include:
• cimetidine
• famotidine
• nizatidine
• ranitidine.

Pharmacokinetics
Cimetidine, nizatidine, and ranitidine are absorbed rapidly and completely from the Gl tract. Famotidine
isn't completely absorbed. Food and antacids may reduce the absorption of H2-receptor antagonists.
1
H2-receptor antagonists are distributed widely through-
out the body, metabolized by the liver, and excreted primari- QJfe&r"*
ly in urine. ^ - J|§"''' ^^il

Pharmacodynamics
H2-receptor antagonists block histamine from stimulating the acid-secreting parietal cells of the stomach.

•My in a bind
Acid secretion in the stomach depends on the binding of gastrin, acetylcholine, and histamine to
receptors on the parietal cells. If
GASTROINTESTINAL DRUGS

the binding of any one of these substances is blocked, acid secretion is

reduced The H2-receptor antagonists, by binding with H2 receptors,
block the action of histamine in the stomach and reduce acid secretion.
(See H^receptor antagonists: Famotidine.)

Pharmacotherapeutics
H^receptor antagonists are used therapeutically to:
• promote healing of duodenal and gastric ulcers
■ provide long-term treatment of pathologic GI hypersecretory
conditions such as Zollinger-Ellison syndrome
• reduce gastric acid production and prevent stress ulcers in severely
ill patients and in those with reflux esophagitis or upper GI bleeding.

Drug interactions
H^receptor antagonists may interact with antacids and other drugs:
• Antacids reduce the absorption of cimetidine, nizatidine, ranitidine,
and famotidine.
• Cimetidine may increase the blood levels of oral anticoagulants,
propranolol (and possibly other beta-adrenergic blockers), benzo-
diazepines, tricyclic antidepressants, theophylline, procainamide,
quinidine, lidocaine, phenytoin, calcium channel blockers, cyclo-
sporine, carbamazepine, and opioid analgesics by reducing their
metabolism in the Uver and their subsequent excretion.
• Cimetidine taken with carmustine increases the risk of bone marrow
toxicity.
• Cimetidine inhibits ethyl alcohol metabolism in the stomach, re-
sulting in higher blood alcohol levels.

Adverse reactions
Using H2-receptor antagonists may lead to adverse reactions, especially
in elderly patients or in patients with altered hepatic or renal function:
• Cimetidine and ranitidine may produce headache, dizziness, malaise,
muscle pain, nausea, diarrhea or constipation, rashes, itching, loss of
sexual desire, gynecomastia (cimetidine), and impotence.
• Famotidine and nizatidine produce few adverse reactions, with
headache being the most common, followed by constipation or di-
arrhea and rash.
 ANTIULCER DRUGS
Nursing process
These nursing process steps are appropriate for patients undergoing treatment
with H2-receptor antagonists.
9
Assessment
• Assess for adverse reactions, especially hypotension and arrhythmias.
• Periodically monitor laboratory tests, such as complete blood count and
renal and hepatic studies.

Key nursing diagnoses

• Impaired tissue integrity related to the patient's underlying condition
• Decreased cardiac output related to adverse cardiovascular effects
(cimetidine)
• Deficient knowledge related to drug therapy

Planning outcome goals

• The patient's tissue integrity will improve as evidenced by a reduction in
underlying symptoms.
• Stable vital signs and the patient's urine output will indicate adequate cardiac
output.
• The patient and his family will demonstrate an understanding of drug
therapy.

Implementation
• Administer a once-daily dose at bedtime to propote compliance. Twice-daily
doses should be administered in the morning and evening; multiple doses, with
meals and at bedtime.
• Don't exceed the recommended infusion rates when administering H2-
receptor antagonists I.V.; doing so increases the risk of adverse cardiovascular
effects. Continuous I.V. infusion may suppress acid secretion more effectively.„
• Administer antacids at least 1 hour before or after H2-receptor antagonists.
Antacids can decrease drug absorption.
• Anticipate dosage adjustments for the patient with renal disease. !f||
• Avoid stopping the drug abruptly.

Evaluation
• Patient experiences decrease in or relief from upper Gl symptoms with drug
therapy.
• Patient maintains a normal heart rhythm.
• Patient and his family demonstrate an understanding of drug therapy. (See
Teaching about H^receptor antagonists, page 310.)

era
 GASTROINTESTINAL DRUGS

Proton pump inhibitors

Proton pump inhibitors disrupt chemical binding in stomach cells to reduce acid production, lessening irritation
and allowing peptic ulcers to better heal. They include:
• esomeprazole
• lansoprazole
• omeprazole I pantoprazole
• rabeprazole.

Pharmacokinetics
Proton pump inhibitors are given orally in enteric-coated formulas to bypass the stomach because they're highly
unstable in acidM They dissolve in the small intestine and are rapidly absorbed.

Highly protein bound

These drugs are highly protein bound and extensively metab-
olized by the liver to inactive compounds and then eliminated ::':W
in urine. j^

Ml
armacodynamics
Proton pump inhibitors block the last step in gastric acid secretion by combining with hydrogen, potassium, and adenosine triphosphate in
the parietal cells of the stomach. (See Proton pump inhibitors: Omeprazole.)

Pharmacotherapeutics
Proton pump inhibitors are indicated for:
• short-term treatment of active gastric ulcers
• active duodenal ulcers
• erosive esophagitis
• symptomatic GERD that isn't responsive to other therapies
• active peptic ulcers associated with H. pylori infection (in combination with antibiotics)
• long-term treatment of hypersecretory states such as Zollinger-Ellison syndrome.

Drug interactions
Proton pump inhibitors may interfere with the metabolism of diazepam, phenytoin, and warfarin, causing increased half-lives and elevated
plasma concentrations of these drugs. Proton pump inhibitors may also interfere with the absorption of drugs that depend on gastric pH for
absorption, such as ketoconazole, digoxin, ampicillin, and iron salts.

Adverse reactions!
Adverse reactions to proton pump inhibitors include:
• abdominal pain
• diarrhea
• nausea and vomiting.

Nursing process
These nursing process steps are appropriate for patients undergo ing treatment with proton pump inhibitors.

Assessment
• Assess the patient's condition before therapy and regularly thereafter.
• Assess the patient for adverse reactions and drug interactions.
• Monitor the patient's hydration status if adverse GI reactions occur.
• Assess the patient's and family's knowledge of drug therapy.
 ■HBHB
Key nursing diagnoses
• Impaired tissue integrity related to upper gastric disorder Risk for
deficient fluid volume related to drug-induced adverse
61 reactions
I Deficient knowledge related to drug therapy

Planning outcome goals

I The patient's tissue integrity will improve as evidenced by a re-
duction in presenting symptoms.
I Adequate fluid volume, as evidenced by the patient's vital signs and
urine output, will be maintained
• The patient and his family will demonstrate an understanding of
drug therapy.

Implementation
• Administer the drug 30 minutes before meals.
• Dosage adjustments aren't needed for patients with renal or hepatic
impairment
• Tell the patient to swallow capsules whole and not to open or crush
them.

Evaluation
• Patient responds well to therapy.
• Patient maintains adequate hydration throughout therapy.
• Patient and his family demonstrate an understanding of drug
therapy. (See Teaching about proton pump inhibitors.}

Education e d g e

Teaching about proton pump

inhibitors
If proton pump inhibitors are tomato juice. Capsule
prescribed, review these contents can also be sprinkled
points with the patient and his on 1 tablespoon of
caregivers: I Take the drug applesauce, pudding, cottage
before eating; however, oral cheese, or yogurt SwaHow the
pantoprazole may be taken mixture immediately without
with or without food. chewing the granules.
I Swallow the tablets or I Observe for the drug's
capsules whole; don't crush or effects; if symptoms persist or
chew them. These advent reactions (such as
formulations are delayed- headache, diarrhea,
release and long-acting; abdominal pain, and nausea
opening, crushing, or chewing or vomiting) occur, notify the
them destroys the drug's prescriber. I Don't take over-
effects. | If swallowing the-counter preparations,
capsules is difficult other prescription drugs, or
lansoprazole capsules can be herbal remedies without first
opened and mixed with 60 ml consulting with the prescriber.
of apple, orange, vegetable, or
 ANTIULCER DRUGS
Other antiulcer drugs
Research on the usefulness of other drugs in
treating peptic ulcer disease continues. Two
other antiulcer drugs currently in use are:
• misoprostol (a synthetic prostaglandin E { )
• sucralfate.

Pharmacokinetics
Each of these drugs has slightly different
pharmacokinetic properties.
After an oral dose, misoprostol is absorbed
extensively and rapidly. It's metabolized to
misoprostol acid, which is clinically active,
meaning it can produce a pharmacologic
effect. Misoprostol acid is highly protein bound
and is excreted primarily in urine.
Sucralfate is minimally absorbed from
the GI tract. It's excreted in feces.

Pharmacodynamics
The actions of these drugs vary.

Reduce and boost

Misoprostol protects against peptic ulcers
caused by NSAIDs by reducing the secretion of
gastric acid and by boosting the production of
gastric mucus, a natural defense against peptic
ulcers.

A sticky situation
Sucralfate works locally in the stomach, rapidly reacting
with hydrochloric acid to form a thick, pastelike substance
that adheres to the gastric mucosa and, especially, to ulcers.
By binding to the ulcer site, sucralfate actually protects the
ulcer from the damaging effects of acid and pepsin to
promote healing. This binding usually lasts for 6 hours.

Pharmacotherapeutics
Each of these drugs has its own therapeutic use.

Attention to prevention
Misoprostol prevents peptic ulcers caused by NSAIDs in
patients at high risk for complications resulting from
gastric ulcers.
^taatand prevent
Sucralfate is used for short-term treatment (up to 8 weeks)
of duodenal or gastric ulcers and prevention of recurrent
ulcers or stress ulcers.
GASTROINTESTINAL DRUGS

Drug interactions
Misoprostol and sucralfate may interact with other drugs:
• Antacids may bind with misoprostol or decrease its absorption. However,
this effect doesn't appear to be clinically significant.
• Cimetidine, digoxin, norfloxacin, phenytoin, fluoroquinolones, ranitidine,
tetracycline, and theophylline decrease the absorption of sucralfate.
• Antacids may reduce the binding of sucralfate to the gastric and duodenal
mucosa, reducing its effectiveness.

Adverse reactions
Adverse reactions to misoprostol include:
• diarrhea (common and usually dose-related)
• abdominal pain
• gas • • W:
• indigestion
• nausea and vomiting
• spontaneous abortion (women of childbearing age shouldn't become
pregnant while taking misoprostol).
Adverse reactions to sucralfate include:
• constipation
• nausea and vomiting
• metallic taste.

Nursing process
These nursing process steps are appropriate for patients undergoing treatment
with the antiulcer drugs misoprostol and sucralfate.

Assessment
• Assess the patient's condition before therapy and regularly thereafter.
• Assess for adverse reactions and drug interactions.
• If the patient is taking misoprostol and is female, the drug can cause danger to
the fetus if pregnancy occurs; discuss contraceptive methods or alternative
treatment.
• Monitor the patient's hydration status if adverse Gl reactions occur.
• Assess the patient's and family's understanding of drug therapy.

Key nursing diagnoses

• Impaired tissue integrity related to upper gastric disorder
• Risk for deficient fluid volume related to drug-induced adverse Gl reactions
• Deficient knowledge related to drug therapy
ADSORBENT, ANTIFLATULENT, AND DIGESTIVE
DRUGS

Planning outcome goals

• The patient's tissue integrity will improve as evidenced
by a reduction in presenting symptoms.
• Adequate fluid volume will be maintained as evidenced
by stable vital signs and urine output.
• The patient and his family will demonstrate an
understanding of drug therapy.

Implementation
• Administer sucralfate 1 hour before meals and at
bedtime.
• Administer misoprostol with food.
• Tell the patient to continue the prescribed regimen at
home to ensure complete healing. Pain and ulcerative
symptoms may subside within the first few weeks of
therapy.
• Urge the patient to avoid cigarette smoking because it
may increase gastric acid secretion and worsen disease.
• Tell the patient to avoid alcohol, chocolate, spicy foods,
or anything that irritates his stomach. I Elevate the head
of the bed for comfort.
• Tell the patient to avoid large meals within 2 hours
before bedtime.
• In women, start misoprostol therapy on the second or
third day of the next normal menses to ensure that the
patient isn't pregnant.

Evaluation
• Patient responds well to therapy.
• Patient maintains adequate hydration throughout
therapy.
• Patient and his family demonstrate an understanding of
drug therapy.