MEDICATIONS FOR GASTROINTESTINAL TRACT DISORDERS I.

Antiemetics - antivomiting drugs See book for physiology of vomiting Addresses the chemoreceptor trigger zone (CTZ) and vomiting center. There are basically 7 groups of antiemetics: 1. antihistamines Atarax, Vistaril, phenergan 2. anticholinergics - scopolamine 3. dopamine antagonists block dopamine2 receptors at the CTZ thorazine, compazine, vesprin 4. benzodiazepines valium, ativan 5. serotonin receptor antagonists- block serotonin in the CTZ and vagal nerve terminals in the upper GI tract Zofran, 6. cannabinoids active ingredients in marijuana (Marinol in chemotherapy) 7. miscellaneous work different ways - Tigan, vontrol, reglan, II. Emetics meds used to induce vomiting When vomiting should not be induced if caustic substances have been ingested (additional injury to the esophagus). Ammonia, chlorine bleach, lye, toilet cleaners, battery acid. if petroleum distillates have been ingested (risk of aspiration). Gasoline, kerosene, paint thinners, lighter fluid. Ipecac?? III. Antidiarrheals used to stop diarrhea and decrease GI motility. There are basically 4 types of antidiarrheal meds: 1. Opiates and opiate related meds Decrease GI motility, and therefore peristalsis CNS depression and constipation are SE Paragoric, tincture of opium Lomotil (diphenoxylate with atropine) Atropine decreases cramping, hypersecretion, and intestinal motility. Needs script. SE of atropine (constipation, dry mouth, blurred vision, urinary retention). CNS SE of dizziness, drowsiness, from diphenoxylate. Loperamide (Imodium) Lacks CNS SE. OTC 2. Somatostatin analogs Sandostatin is a somatostatin analog that inhibits gastric acid secretion, gastrin, pepsinogin, cholecystikinin, serotonin, and intestinal fluids. Diarrhea for metastatic CA, or with diarrhea in folks with ileostomies. 3. Adsorbents Stick to the toxins or bacteria that are causing the diarrhea. Coat the walls of the GI tract Kaolin and Pectin Kaopectate Bismuth salts Pepto-bismol adsorbs bacterial toxins 4. Miscellaneous antidiarrheals lactobacillus, etc. (replenish normal GI flora

IV. Laxatives used to eliminate fecal matter There are basically 4 types of laxatives: 1. Osmotic laxatives Hyperosmolar salts pull water into the colon and increase water in the feces to increase bulk, which puts pressure on the colon walls and stimulates peristalsis. Salts, salines, lactulose, glycerine Must monitor electrolytes (Mg and Na are absorbed!!) Need good renal function Saline laxatives are contraindicated in patients with CHF 3 types of electrolyte salts 1. sodium salts -Na Phosphate, Na bisphosphate (Fleet) 2. magnesium salts - Mg hydroxide (Milk of Mag); Mg citrate; Mg sulfate (Epsom salts) GoLYTELY polyethylene glycol (PEG) is isotonic, has electrolytes, not absorbed. Used for bowel preps for surg or diagnostic tests Drink 3-4 liters of it over 3 hours 240 ml q 15 minutes Can put in NG tube Lactulose Has big sugar molecules that draw water into the bowel Also decreases ammonia levels in liver patients Avoid with diabetes Glycerine Suppository that pulls water into the colon 2. Stimulant laxatives also called contact or irritant laxatives Increase peristalsis by irritating the sensory nerve endings in the intestinal mucosa Phenolphthalein (Ex-lax; Feen-A-Mint; Correctol) Bisacoldyl (Dulcolax, cascara sagrada, senna Senokot) Both abused- develop dependency upon the laxatives electrolyte imbalances - OTC Castor oil Acts on small bowel and produces a watery stool Harsh purgative Avoid with pregnancy stimulates uterine contractions 3. Bulk-Forming laxatives Natural fibrous substances that promote large, soft stools by absorbing water into the intestine to increase bulk and promote peristalsis. Not absorbed mimic real fiber in the gut Must be mixed in a glass of water or juice, stirred and drank right away Must follow with plenty of water or can develop an obstruction Do not cause dependence Metamucil, Perdiem, Citrucel, FiberCon 4. Emollients stool softeners Surface wetting drugs that decrease straining during defecation. Lower surface tension and promote water accumulation in the intestine and the stool to make stools soft. Soft stools will move easier and prevent constipation later.

Docusate sodium (Colace), Docusate sodium with casanthranol (Peri-Colace) ANTIULCER MEDICATIONS See textbook for pathophysiology of PUD and GERD There are currently 7 types of antiulcer meds. 1. Tranquilizers Librax (not used much any more) 2. Anticholinergics decrease GI motility and secretions (not used much any more) 3. Antacids (710) Promote ulcer healing by neutralizing HCl and reducing pepsin activity Do not coat ulcer or change the amount of acid produced Avoid giving with other meds; decreases absorption Give 1-3 hours after meals; 1-2 hours after other meds Those with a systemic effect: Sodium bicarbonate hypernatremia, water retention (Alka-Seltzer) Calcium carbonate Hypercalcemia, alkalosis, crystalluria, renal failure Those without systemic effects: Aluminum salts Aluminum hydroxide Causes constipation Need good renal function Magnesium salts Magnesium hydroxide, magnesium phosphate Causes diarrhea Need good renal function Aluminum hydroxide and magnesium hydroxide (Maalox) Combination of the two to counteract side effects Simethicone An antigas agent- Mylanta II, Maalox plus Riopan Low sodium Gaviscon Foamy stuff on top that will go up into the esophagus in case the patient has reflux, therefore preventing the stomach acid from damaging the esphagus. 4. Histamine 2 Blockers (713) Histamine 2 blockers, or H2 blockers, or histamine 2 receptor antagonists Block the H2 receptors of the parietal cells in the stomach, therefore reducing gastric acid secretion and concentration Came out about 1975, and revolutionized how we treat ulcers and GERD Not the same as the allergic antihistamines

Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid) Ranitidine (Zantac)

Note how they end in tidine Tagamet the earliest; lots of bad SE. As they are making newer ones, they have less SE Also, gone from every 8 hours to only every 12 hour dosages for compliance. Axid is the latest and can be given at bedtime only, so it is easy to remember. Can be used to prevent ulcers and aspiration pneumonia from reflux SE include vertigo/dizziness, headache, nausea, diarrhea, or constipation, depression (elderly), confusion, rash, blurred vision 5. Proton Pump Inhibitors or PPIs Suppress gastric acid secretion by inhibiting the hydrogen/potassium ATPase enzyme system located in the gastric parietal cells. Block the final step of HCl production Inhibit gastric acid secretion up to 90% better than the H2 blockers
Esomeprazole magnesium (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Rabeprazole (Aciphex)

Note how they end in prazole Have gone from dosages several times a day to once a day Pretty much wipe out HCl, allowing ulcers to heal, preventing GERD Take before meals SE headache, dizziness, diarrhea, abdominal pain, rash, gastric CA in mice

6. Mucosal Protective Drug Sucralfate (Carafate) A complex of sulfated sucrose and aluminum hydroxide . Non absorbable. Can cause constipation. Pooped out. Combines with protein to form a viscous substance that covers the ulcer and protects it from HCl and Pepsin. Does not neutralize acid or decrease acid secretion Fours times a day (before meals) and at bedtime 7. Prostaglandin Analogs Misoprostol (Cytotec) A synthetic prostaglandin analog. Prevents and treats peptic ulcers Increases cytoprotective mucus in the GI tract Often added to NSAIDS to prevent gastric irritation Pregnancy category X stimulates uterine contractions.