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Roles of signals
1. Produce gastric acid
a. Parietal cell (H/K ATPase)
2. Help mucosa protect itself from acid
a. Superficial epithelial cell (HCO3- / mucous)
Drug strategies
Acid neutralizing (antacids)
Acid reduction (antisecretory)
↑ protection mucosal barrier (prostaglandin analogs)
Eradicate H. pylori
Antacids
Mechanism of action: Clinical indications: (distant 3rd to H2RA / PPI for these)
Basic compounds which neutralize HCl Duodenal ulcers
↑ gastric intraluminal pH GERD
Inactivate pepsin, bind bile salts Prophylaxis for stress ulcers
Pharmacokinetics
Require frequent administration – rapid clearance is bad (want it to stay there)
Caution in renal patients (cation absorption)
Indications: Duodenal / gastric ulcers (treatment, recurrence of duodenal), acute & chronic GERD treatment.
Inhibits basal acid secretion best (night / fasting), also physiologic acid secretion (feeding)
ranitidine
Administration: 1-2x/day
cimetidine
Pharmacokinetics: plasma peak 1-2h, mostly renal elimination, short half-life
famotidine
Toxicity:
CYP450 INHIBITION (warfarin, theophylline, phenytoin)
CNS confusion / somnolence
Anti-androgen effects (esp. cimetidine) - gynecomastia, impotence (males), alactorrhea (females)
Selective Toxicity: Only acts where activated by acid (also, not on inactive proton pumps)
Indications:
Peptic ulcers (esophagus, duodenum, stomach, esp. if H2RA unresponsive)
erosive esophagitis from GERD
Zollinger-Ellison syndrome
omeprazole Toxicity:
Potential bacterial overgrowth of small bowel
CYP450 inhibitor (watch out for phenytoin, diazepam, warfarin)
↑ risk of community acquired pneumonia (more bacteria; more chance of pneumonia on aspiration)
↑ risk of osteoporosis / fractures
Pharmacokinetics:
Covalent bonding; long effects - days after drug disappears from plasma
o de novo synthesis of proton pumps required to increase acid production.
Degraded by stomach acid (give enteric coating); metabolized by liver (need to adjust in liver failure)
Indications: stress ulcers (prophylaxis), peptic ulcers, bile reflux (chemical gastritis - from duodenum to stomach)
sucralfate
Administration: Technically: should take on empty stomach (avoid binding to dietary protein / aluminum; also pH
increases after meal - less activation). In practice: usually take when you eat & at bedtime.
Pharmacokinetics: most of dose excreted unchanged in stool (works locally), aluminum accumulates with renal failure
Toxicity:
Constipation, as an anion resin
Binds other drugs (phenytoin, digoxin, theophyllin bioavailability reduced if given at same time)
Toxicity:
Uterine contractions (abortifacent - DON'T USE in young women of reproductive age).
Diarrhea, abdominal cramping
Eradication of H. pylori
Gram-negative rod associated with gastritis, 60-95% of gastric ulcers / duodenal ulcers
o gastric adenocarcinoma & B-cell lymphoma too.
Mechanism: ↓ antral D-cells ↓ somatostatin ↑ gastrin ↑ acid production
50% of world’s population infected, 15% of those develop duodenal ulcer
Treatment
MULTIPLE ABX NEEDED: Single abx don’t work (lead to resistance!)
↑ effectiveness of pH-dependent abx (amoxicillin, clarithromycin) with PPI or H2-blocker
Regimens: OAC (omeprazole + amoxicillin + clarithromycin); OMC (omeprazole + metronidazole + clarithromycin)
10-14 days more effective than shorter courses
Gastrointestinal motility disorders
Primary motor neuron in wall of gut controls motility
Mechanism of Action: 5-HT4 receptor activation (also dopamine antagonist and cholinergic agonist)
Effects: enhances smooth muscle propulsive contractionsof upper gut, accelerates gastric emptying (dopamine
normally slows things down; blocking it speeds things up).
Also increases LES tone, has antiemetic effect (CNS dopamine antagonism)
Indications:
gastroparesis(diabetic / idiopathic)
GERD (increased LES tone, better gastric emptying)
metaclopramide
nausea / vomiting
Selective Toxicity: Acts at gut epithelium & works locally (fast metabolism; binds channels; doesn't get into blood)
Indications: Idiopathic chronic constipation, constipation-dominant IBS
lubiprostone
Pharmacokinetics: Negligible bioavailability; rapidly metabolized in gut epithelium
no hepatic or CYP450 involvement
Toxicity:
Nausea, diarrhea (too much of what you want)
Headache, abdominal distension (more fluid into gut lumen)
Flatulence
erythromycin Mechanism of action: Promotility agent; macrolide; stimulates GI motility by agonizing motilin receptor
Why vomit?
Get rid of toxins (smell, sense, etc)
Protective: Less delicious to lions if you vomit all over yourself
Triggers:
Motion (inner ear) Local irritants
Sensory input Memory, fear
(via higher centers) Gagging
Blood-borne emetics
By knowing where these things work, you can figure out what medicine will be useful for which condition
Note: don’t use serotonin antagonist for motion sickness – not involved in that pathway!
Indications:
Chemotherapy-induced nausea, nausea from upper GI irradiation
odansetron hyperemesis of pregnancy
(zofran) postoperative nausea
NOT MOTION SICKNESS (no serotonin in that pathway)
Others
Type Examples Blocks Special Indications
Phenothiazines Dopamine @ CTZ Motion sickness
prochlorperazine
Histamine, ACh too (better than ondansetron: anti-histamine / antiAch)
metaclopramide Dopamine @ CTZ
Prokinetics
domperidone (prokinetics)
promethazine Post-op emesis
Antihistamines Histamine
diphenhydramine Motion sickness
Anticholinergics scopolamine Muscarinic Ach receptor Motion sickness
activates cannabinoid Stimulates appetite too (AIDS pts)
Cannabinoids dronabinol
receptors in vomiting center? Expensive!
Diarrhea / Constipation: Overview
Key concepts:
Fluid content = principal determinant of stool volume, consistency (usually 75-80% stool wt is H2O)
Extent of fluid absorption by gut parallels transit time
o Faster transit less fluid absorption (less time to absorb fluid) diarrhea
o Slower transit more fluid absorption (more time to absorb fluid) constipation
Numbers
9L presented to small intestine each day (2 from diet, 7 from secretions)
Making solid stool: conserves water & better bowel control
Colon: can absorb 4-5 L /day (so it can pick up some slack if ↓ small bowel absorption)
Diarrhea:
Intraluminal agents
Put things into payload delivered to colon that absorb water (hygroscopic agents)
Hydroscopic agents Absorb excess water (↓ water content of stool) psyllium (Metamucil)
Bile salt binders Bind excess bile salts to avoid colon secretion cholestyramine (Questran)
Unknown mechanism, but bismuth has antisecretory,
Bismuth compounds bismuth subsalicylate (Pepto-Bismol)
anti-inflammatory, antimicrobial effects
Opiods
Mechanism of Action: opiod antimotility/antisecretory agent
Effects:
↑ fluid absorption, ↓ fluid secretion, ↓ motility (↑ transit time)
↓ longitudinal muscle activity (propulsion), ↑ segmentation activity (non-propulsive)
Indications: diarrhea (but not treating underlying cause)
loperamide
Pharmacokinetics: doesn't penetrate CNS in normal doses. loperamide is 40-50x more potent as anti-diarrheal than
morphine; quick onset affter oral dosing, peak 3-5h, half life 11h, hepatic metabolism
Constipation
General mechanisms of action
Retain intraluminal fluid (osmotic / hydrophilic mechanisms)
↓ net absorption of fluid
Motility effects:
o Inhibit segmenting (nonpropulsive) contractions
o Stimulate propulsive contractions
Indications: used more for irritable bowel syndrome than for constipation
Mg salts
Most commonly used agents; hypertonic > isotonic for efficacy
Mechanism of action:
Mg poorly absorbed ↑ intraluminal osmolarity ↑ water retention by stool
Maybe ↑ CCK secretion (↑ bowel motility, secretion)
Stimulant cathartics
Direct effects on enterocytes, enteric neurons, muscle.
Mechanism of action: induce low grade inflammation in small bowel & colon!
Inflammation ↑ fluid, electrolytes ↑ intestinal motility
Examples
Bisacodyl
Anthraquinones (senna)
Mechanism of action: Anthraquinone laxatives; "stimulant" cathartic (laxative)
Effects: induce low grade inflammation in small bowel & colon!
Inflammation ↑ fluid, electrolytes ↑ intestinal motility
Administration: not for daily use (see below)
senna Toxicity:
melanosis coli (dark colon - reversible)
"CATHARTIC COLON" (years of laxative abuse; becomes dilated & ahaustral; neurons lost & muscularis propria
atrophies - bowel function lost!)
Nonabsorbable sugars
If not absorbed by small intestine, can reach colon (metabolized to osmotically active organic FAs)
Osmotic effect of FAs fluid secretion, ↑ motility
Examples: lactulose, glycerin, sorbitol, mannitol, lactose (if lactase deficient)
Drugs and the Liver
Hepatic Drug Metabolism
Phase I metabolism:
Oxidation rxns catalyzed by CYP450 enzymes
(membrane-bound, have substrate specificity)
Electrons transferred: substrate ferric iron O2
NADPH serves as co-substrate (NADPH NADP+)
Some products are highly electrophilic; react with cellular metabolites
Phase II metabolism:
Conjugation with UDP-glucuronic acid, glutathione, sulfate, amino-acids
Catalyzed by several different transferases
Substrate-specific (both endogenous & exogenous substrates: drugs)
Almost all products are non-toxic, water-soluble
IMPORTANT Definitions
Systemic clearance = hepatic clearance for drugs metabolized ONLY in the liver
Instrinsic clearance (Clint): clearance that depends on enzymatic metabolism (hepatic)
Extraction ratio (E): fraction of drug that is metabolized by “first pass” through the stomach / liver after oral ingestion
For low extraction drugs, Clhepatic = Clint (hepatic clearance is ≈ the intrinsic clearance)
The rate of clearance depends mostly on how the enzymes are working (increasing flow won’t really help)
Drugs with E close to 1 (high extraction) Drugs with low E (low extraction)
LOW oral bioavailability HIGH oral bioavailability
IV drug levels will be higher than PO if same dose
IV drug levels will be the same as PO
(IV skips 1st pass metabolism)
Variables that affect hepatic drug clearance
Intrinsic clearance
Hepatic blood flow Drug binding to plasma
(activity of drug-metabolizing enzymes)
Interactions with other drugs and alcohol Drugs with high E are flow limited
(inhibition, induction) 1st pass effect! Only free drug is active
Liver disease, Nutrition, Gender, Genetics Heart failure, shunts (e.g. TIPS) affect flow
Pharmacokinetics
Polymorphisms exist for CYP450 isozymes
May account for toxicity of certain drugs (e.g. isoniazide) – why do some get idiosyncratic drug rxns?
Influence rates of elimination
Drugs & Cirrhosis
Low-extraction drugs
(e.g. antipyrine)
For drugs that are oxidized by CYP450, the activity of enzymes decreases in advanced cirrhosis
o No drop-off until severe cirrhosis: flow doesn’t play a big role
Hepatic clearance and intrinsic clearance decrease in parallel! (ClHep ≈ Clint)
o Enzyme activity is the key player!
High-extraction drugs
(e.g. lidocaine)
For high E drugs, systemic clearance is normally dependent on flow (Q), not on Clint
In cirrhosis, blood isn’t all flowing through liver (portal hypertension, porto-hepatic shunting, etc)
Intrinsic clearance becomes driving factor (how much can your enzymes work?)
↑ oral bioavailability: can now give lidocaine orally
o Need to lower oral doses (or would wind up with higher levels of drug)
o E.g. Propranolol: high extraction in liver; need to give less in cirrhosis
st
(normally a lot gets cleared on 1 pass; not anymore!)
Basically: in cirrhosis, there’s “no such thing as a high extraction drug” anymore!
↓ flow through liver, so intrinsic clearance becomes more important
Cirrhosis: summary
↑ oral biovailability of drugs with high extraction ratio
↓ elimination of drugs metabolized by CYP450 in advanced cirrhosis
↓ binding (↓ serum protein) so ↑ “free drug” too!
Classification of DILD
Intrinsic hepatotoxins Idiosyncratic hepatotoxins
Usually dose-related Not always dose-related
Short interval between ingestion / evidence of toxicity Host factors play important role in risk
Same type of injury across spectrum of individuals Different reactions in different individuals
Reproducible in animal models Not reproducible in animal models
Features: hypersensitivity!
Fever, rash, oral ulcers, lymphadenopathy, arthritis
Cytopenias, eosinophilia
Genetic susceptibility, family history
↑ risk in immunosuppressed (counterintuitive)
o HIV/AIDs, SLE, corticosteroids (e.g. TMP-SMX in AIDS)
Pathogenesis: Reactive Metabolite Hypothesis
Case examples:
Acetaminophen toxicity
Histology: damage is mostly around terminal hepatic venule
Pathogenesis:
Note: APAP = n-acetyl-p-aminophenol = “acet-amino-phen”!
In acetaminophen overdose
↑ APAP ↑ NAPQI produced deplete GSH can’t get rid of
NAPQI more bad stuff happens (↑ *NAPQI+)
Treatment: give N-acetyl cystine (restore GSH levels depleted by acetaminophen toxicity)
Summary
• Most drugs are metabolized in liver
• Advanced liver disease affects hepatic drug elimination, particularly for those drugs that are oxidized by P450
• Drug induced liver damage most often related to metabolism of drugs to reactive metabolites that cause liver injury
• Host factors are important determinants of both metabolism and toxicity (idiosyncratic)