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GI DRUGS & NUTRITIONAL DRUGS

By

Deidre N. Pickett

R.N., MSN

HOLMES COMMUNITY COLLEGE SCHOOL OF NURSING

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Drugs for Peptic Ulcer Disease (PUD)

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Pathogenesis of Peptic Ulcers

• Defensive factors– Mucus– Bicarbonate– Blood flow– Prostaglandins

• Aggressive factors– Helicobacter pylori – NSAIDs– Gastric acid– Pepsin – Smoking

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Figure 76-1 The relationship of mucosal defenses and aggressive factors to health and peptic ulcer disease.

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Figure 76-2 A model of the regulation of gastric acid secretion showing the actions of antisecretory drugs and antacids.

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Helicobacter pylori

• Test: breath test or serum

• Treatment (two antibiotics are prescribed)

– Bismuth compounds

– Clarithromycin

– Amoxicillin

– Tetracycline

– Metronidazole

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List of Available NSAIDs:List of Available NSAIDs:Prescription & OTC Prescription & OTC **

NON-SALICYLATESNON-SALICYLATES SALICYLATES COX-2 INHIBITORS SALICYLATES COX-2 INHIBITORS Diclofenac (Voltaren)Diclofenac (Voltaren) Aspirin Aspirin a,ca,c (Zorprin, Easprin) (Zorprin, Easprin) Celecoxib Celecoxib (Celebrex)(Celebrex)Diclofenac/Misoprostol (Arthrotec)Diclofenac/Misoprostol (Arthrotec) Diflunisal (Dolobid)Diflunisal (Dolobid) Rofecoxib Rofecoxib (Vioxx)(Vioxx)Etodolac (Lodine)Etodolac (Lodine) Salsalate (Disalcid, Salflex)Salsalate (Disalcid, Salflex) Valdecoxib Valdecoxib (Bextra)(Bextra)Fenoprofen (Nalfon)Fenoprofen (Nalfon) Choline salicylate (Trilisate)Choline salicylate (Trilisate)Flurbiprofen (Ansaid)Flurbiprofen (Ansaid) Magnesium salicylate (Magan)Magnesium salicylate (Magan) Ibuprofen Ibuprofen a,b,c a,b,c (Motrin, Advil) (Motrin, Advil) Indomethacin (Indocin)Indomethacin (Indocin)Ketoprofen Ketoprofen a,b,ca,b,c(Orudis) (Orudis)

Ketorolac (Toradol)Ketorolac (Toradol)cc

MeclofenamateMeclofenamateMefenamic acid (Ponstel)Mefenamic acid (Ponstel)Meloxicam (Mobic)Meloxicam (Mobic)Nabumetone (Relafen)Nabumetone (Relafen)Naproxen Naproxen a,b,ca,b,c(Naprosyn, Anaprox)(Naprosyn, Anaprox)Oxaprozin (Daypro)Oxaprozin (Daypro)Piroxicam (Feldene)Piroxicam (Feldene)Sulindac (Clinoril)Sulindac (Clinoril)Tolmetin (Tolectin)Tolmetin (Tolectin)

aa Also available as OTC preparations in U.S. Also available as OTC preparations in U.S.b b OTC dose is usually half of prescribed doseOTC dose is usually half of prescribed doseC C All OTC NSAIDs are All OTC NSAIDs are non-selectivenon-selective COX COX InhibitorsInhibitors

* * List of trade names is not List of trade names is not exhaustiveexhaustive

Comments on Over-the-Counter Comments on Over-the-Counter Preparations:Preparations:

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Endoscopic PhotographEndoscopic Photographof Gastric Ulcerof Gastric Ulcer

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Peptic Ulcer Disease

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Drugs for Peptic Ulcer Disease

• Peptic ulcer disease

– Upper GI disorders

– Degrees of erosion of the gut wall

• Cause

– Imbalance between mucosal and aggressive factors

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Classes of Antiulcer Drugs

• Antibiotics

• Antisecretory agents

• Mucosal protectants

• Antisecretory agents that enhance mucosal defenses

• Antacids

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Histamine2-Receptor Antagonists

• Cimetidine [Tagamet]

• Ranitidine [Zantac]

• Ranitidine bismuth citrate [Tritec]

• Famotidine [Pepcid]

• Nizatidine [Axid]

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Proton Pump Inhibitors

• Omeprazole [Prilosec]

– Inhibits gastric secretion

– Short half-life

– Used for short-term therapy

• Adverse effects

– Headache

– Gastrointestinal

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Sucralfate [Carafate]

• Protective barrier up to 6 hours

• Uses

– Acute ulcers

• Adverse effects

– Constipation

• Drug interactions

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CYTOTEC

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Laxatives

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Laxatives

• Used to ease or stimulate defecation

– Soften the stool

– Increase stool volume

– Hasten fecal passage through the intestine

– Facilitate evacuation from the rectum

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Indications for Laxative Use

• Constipation is determined by stool consistency and frequency of defecation

• Indications

– Diagnosis

– Treatment/procedure preparation

– Constipation

– Poisoning

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Classification of Laxatives

• Bulk-forming laxatives

– Psyllium [Metamucil]

• Surfactant laxatives

– Docusate sodium [Colace]

• Stimulant laxatives

– Bisacodyl [Dulcolax]

• Osmotic laxatives

– Milk of magnesia (MOM)

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Other Gastrointestinal Drugs

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ANTIACIDS

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Antiemetics

• Ondansetron [Zofran]

– Blocks type 3 serotonin receptors on afferent vagal nerve

– More effective when used with dexamethasone

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Figure 78-1 The emetic response: stimuli, pathways, and receptors. CTZ = chemoreceptor trigger zone.

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Drugs for Motion Sickness

• Scopolamine• Side effects

– Dry mouth– Blurred vision– Drowsiness

• Antihistamines

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Antidiarrheal Agents

• Opioids

– Diphenoxylate [Lomotil]

– Activate opioid receptors in the GI tract, decrease intestinal motility, slow intestinal transmit, more time for fluids and electrolytes to be absorbed

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Drugs for Inflammatory Bowel Disease (IBD)

• Tricyclic antidepressants

• Antibiotics

• Acid suppressants

• Alosetron [Lotronex]

• Tegaserod [Zelnorm]

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More Drugs for IBD

• Aminosalicylates

• Glucocorticoids

• Immunomodulators

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Vitamins

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Intake of Vitamins

• Recommended Dietary Allowances (RDAs) for vitamins are set by the Food and Nutrition Board of the Nation Academy of Sciences and represent the average daily dietary intake sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy individuals in a particular life stage or gender.

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Intake of Vitamins (cont’d)• The Tolerable Upper Intake Limit (UL) for a

vitamin is the highest average daily intake that can be consumed by nearly everyone without a significant risk of adverse effects.

• The UL is an index of safety—not a recommendation to exceed the RDA.

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Vitamins

• Classification of vitamins

• Fat soluble

– Vitamins A, D, E, K

• Water soluble

– Vitamin C

– Vitamin B complex—thiamin, riboflavin, niacin, pyridoxine, panthothenic acid, biotin, folic acid, cyanocobalamin

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Vitamin A (Retinol)

• Deficiency causes

– Night blindness

– Xerophthalmia

– Keratomalacia

– Blindness

– Therapeutic uses

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Vitamins D and E

• Vitamin D

– Regulates calcium and phosphorus

– Deficiency causes rickets or osteomalacia

• Vitamin E

– Antioxidant properties

– Dietary sources—fresh greens, seeds, oils

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Vitamin K

• Action required for synthesis of prothrombin and other clotting factors

• Deficiency produces bleeding• Adverse effects

– Hypersensitivity reaction– Hyperbilirubinemia

• Therapeutic use– Warfarin overdose

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Vitamin C

• Action required for production of collagen and other compounds that bind cells together.

• Has antioxidant properties

• Facilitates iron absorption

• Deficiency can lead to scurvy

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Vitamin B Complex

• Niacin (nicotinic acid)

• Riboflavin (vitamin B2)

• Thiamin (vitamin B1)

• Pyridoxine (vitamin B6)

• Cyanocobalamin (vitamin B12)

• Folic acid

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Enteral and

Parenteral Nutrition

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Enteral and Parenteral Nutrition

• Enteral nutrition is defined as provision of nutrients by way of the GI tract

• Criteria

– Patients with a healthy digestive tract but are unable or unwilling to eat sufficient food

– Patients who have a digestive or absorptive disorder that cannot be overcome by diet modification

• Contraindications

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Enteral Modes of Delivery

• Tube placement– Nasogastric– Nasoduodenal– Nasojejunal– PEG tube

• Schedule of administration– Continuous– Cyclic– Intermittent– Bolus

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Enteral Modes of Delivery (cont’d)

• Method of administration

– Syringe

– Gravity

– Enteral pump

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Components of Enteral Nutrition

• Amino acids

• Carbohydrates

• Fats

• Electrolytes

• Vitamins

• Trace elements

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Complications of Enteral Nutrition

• Aspiration

• Pneumonitis

• Diarrhea

• Vomiting

• Insufficient gastric emptying

• GI bleeding

• Hyperglycemia

• Electrolyte imbalances

• Fatty acid deficiency

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Parenteral Nutritional Therapy

• Routes – Peripheral vein– Central venous catheter

• Components– Amino acids, dextrose, fats, carbohydrates,

vitamins, electrolytes, and trace elements• Complications

– Increased blood urea nitrogen (BUN)– Glucose intolerance– Hyperlipidemia– Allergy

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Complications of Parenteral Therapy

• Infection

• Metabolic disturbances

• Catheter-related complications

• Pneumothorax

• Venous thrombosis

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Complications of Parenteral Therapy

• Infection

• Metabolic disturbances

• Catheter-related complications

• Pneumothorax

• Venous thrombosis

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Drugs for Obesity

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Drugs for Obesity

• Assessment—obesity

– Degree of obesity

• Body mass index (BMI)

– Pattern of fat distribution

• Waist circumference

– Presence of risk factors

• Coronary heart disease, diabetes, hypertension

• Other atherosclerotic diseases, sleep apnea

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Figure 81-1 Weight classification based on body mass index (BMI).

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Weight Loss Therapy Guidelines

• Who should be treated?

– BMI of 30 or more

– BMI of 25 to 25.9 with two risk factors

– Waist circumference with two risk factors

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Treatment Modalities

• Diet therapy

• Exercise

• Behavior modification

• Drug therapy

• Bariatric therapy

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Sibutramine [Meridia]• Suppresses appetite and decreases

absorption of fat• Drug interactions• Adverse effects

– Headache

– Dry mouth– Constipation

– Elevated heart rate– Insomnia

– Elevated blood pressure

– Nervousness

– Anxiety

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Orlistat [Xenical]

• Acts in the GI tract to reduce absorption of fat

• Adverse effects

– GI effects

– Reduced absorption of fat-soluble vitamins

• Caution

– Warfarin

– Wardrobe Malfunctions are highly likely.