antacid

                                                               i.      Neutralize or reduce acidity of stomach and duodenal contents by combingin with HCL and increasing the pH.  Some may increases tone of esoph sphincter to prevent reflux

                                                               i.      Hyperacidity caused by

1.        heartburn, acide indigestion, sour stomach

2.        gastroesophageal reflux disease (GERD)

3.        peptic ulcer

                                                              ii.      Some are used for no GI conditions like aluminum carbonate a phosphate binding agent used for hyperphosphatemia in renal failure, etc

Adverse reactions of antacids

                                                               i.      Mag and Na containing may have laxative effect and produce diarrhea

                                                              ii.      Alum and calcium lead to constipation

                                                            iii.      Wide margin of safety, though are serious side effects (not common)

1.        Alinum containing – constipation, impaction, anorexia, weakness, tremors, bone pain

2.        Magnesium containing – severe diarrhea, dehydration, hypermagnesemia (N/V, hypotension and decreased respirations)

3.        Calcium containing – rebound hyperacisity, metabolic alkilosis, hypercalcemia, vomiting, confusion, headache, renal calculi, neuro impairement

4.        Sodium bicarbonate – systemic alkilosis and rebound hyperacidity

a.         

                                                               i.      Pts with severe ab pain of unknown cause

                                                              ii.      Lactation

                                                            iii.      Sodium containing – CV problems like HTN or HF and those on low Na diets

                                                            iv.      Calcium containing – pts with renal calculi or hypercalcemia

a.         

                                                               i.      Antacids reduce the absorption of the following

1.        digoxin

2.        isoniazid for infection

3.        phenytoin for seizures

4.        chlorpromazine

                                                              ii.      Antacids reduce the effectiveness of the following

1.        tetracycline

2.        corticosteroids (reduces anti-inflamm)

                                                            iii.      Antacids with salicylates makes salicylate excreted more rapidly in urine

                                                            iv.      Antacids with the following cause antacids and following to be excreted more slowly in urine

1.        quinidine

2.        amphetamines

 -DINE

cimetedine (Tagament)

 famotidine (Pepcid)

 nizatidine (Axid)

ranitidine (Zantac)

Proton pump inhibitors

LIST

a.         

a.        esomeprazole (Nexium)

b.        lansoprazole (Prevacid)

c.        omeprazole (Prilosec)

d.        pantoprazole (Protonix)

e.        rabeprazole

CIMETIDINE

FAMOTIDINE

NIZATIDINE

RANITIDINE

Histamine 2 receptor antagonists

Reduce stomach acid production

                                                                                    1.        prevent ulcers

2.        acute upper GI bleeding in critically ill

3.        heartburn/acid indigestion/sour stomach

4.        GERD

5.        Gastric/duodenal ulcer

6.        gastric hypersecretory conditions

1.        usually mild and transient; rare (less than 2%), includes

a.        dizziness, somnolence, headache

b.       confusion, hallucinations

c.        diarrhea

d.       reversible impotence

1.        renal/hepatic impairment

2.        severely ill

3.        elderly

4.        debilitated

5.        preg cats b and c so use with caution

Proton Pump Inhibitors (PPIs)

LIST

a.        esomeprazole (Nexium)

b.        lansoprazole (Prevacid)

c.        omeprazole (Prilosec)

d.        pantoprazole (Protonix)

e.        rabeprazole

ESMOEPRAZOLE

LANSOPRAZOLE

OMEPRAZOLE

PANTOPRAZOLE

RABEPRAZOLE

Proton pump inhibitors

Decrease stomach acid production

1.        suppress gastric acid secretion by inhibiting the hydrogen-potassium adenosine triphosphate (ATPase) enzyme system (or acid/proton pump system) of gastric parietal cells at the last step of gastric acid production by gastric mucosa.

1.        Gastric and duodenal ulcers, especially those assoc with h. pylori

a.        For H. pylori infection, are various triple drug regiments that include anti-infectives along with upper GI drugs like proton pump inhibitors, H2 antagonists, bismuth.

2.        GERD and erosive esophagitis

3.        hypersecretory conditions

1.        headache

2.        nausea

3.        diarrhea

4.        abdominal pain

5.        prolonged tx may decrease ability of b12 absorption resulting in anemia

1.        hypersensitivities

2.        omerprazole, lansoprazole, rabeprazole, pantoprazole contraindicated in pregnancy and lactation

1.        older adults

2.        hepatic impairment

1.        sucralfate for GI distress – decreases absorb of ppi

2.        ketocozanole – decreased absorb of ketocozanole

3.        ampicillin – decreased absorb of ampicillin

4.        oral anticoags – increases risk of bleeding

5.        digoxin – increases absorb of digoxin

6.        benzos – risk for toxic levels of benzo

7.        phenytoin for seizures – risk for toxic level of phenytoin

a miscellaneous (uncategorized) acid reducer that is used to reduce the risk of NSAID induced ulcers

•  inhibits gastric acid production and mucosal protedction
• can cause abortion and birth defects – contraindicated for pregnant or those who may become pregnant, or lactating.
• Adv rxns are headache, nausea, diarrhea, ab pain
• It’s effects are decreased when given with antacids.

• a misc. acid reducer   
• a pepsin inhibitor and mucosal protectant
• binds with proteins to form visous substance to buffer acid and protect mucosa; used for short-term treatment of duod. ulcers.
• Most common ad rx is constipation
• Interactions are similar to the PPIs

less used

 reduce gastric motility and decrease acid secretion; largely replaced by h2 antagonists bc more effective and less adv rxs. 

Both is ch 27:

a.        propantheline

b.       glycopyrrolate

GASTROINTESTINAL STIMULANTS

LIST

a.        metoclopramide (Reglan)

b.        dexpanthenol (Ilopan)

                                                               i.      Treat delayed gastric emptying and emesis; increase motility of upper GI w/out increasing secretions

                                                              ii.      Sensitizes tissue to acetylcholine to increase tone and amplitude of gastric contractions to hasten gastric emptying into small intestine

                                                            iii.      Inhibition of stimulation of the CHEMORECEPTOR TRIGGER ZONE (CTZ) which is a group of nerve fibers on surface of 4^th ventricle of brain that sends signals to vomiting center of medulla

                                                               i.      GERD

                                                              ii.      GASTRIC STASIS in diabetics, those with N/V assoc with cancer chemo and those in the immediate post-op period.

                                                            iii.      dexpanthenol may be given IV immediately after abdom surgery to reduce risk of PARALYTIC ILEUM (no peristalsis)

                                                               i.      GI obstruction

                                                              ii.      Gastric perforation or hemorrhage

                                                            iii.      Pheochromocytoma (an adrenal tumor)

                                                            iv.      Parkinson’s or seizure disorder who when taking these drugs are likely to have extrapyramidal effects

                                                             v.      Dexpanthenol should not be used by hemophiliacs

                                                               i.      Diabetes

                                                              ii.      Cv disease

                                                            iii.      Use with caution in pregnancy and lactation (b and c categories)

                                                                                    1.        antidopaminergics

2.        cholinergic blocking

3.        5-HT3 receptor antagonists

4.        Miscellaneous

ANTIDOPAMINERGIC ANTIEMETICS

LIST

a.        chlorpromazine (Thorazine)

b.        perphenazine

c.        prochlorperazine (Compazine)

d.        promethazine

e.        thiethylperazine

f.         triflupromazine

CHLORPROMAZINE

PERPHENAZINE

PROCHLOPERAZINE

PROMETHAZINE

THIETHYLPERAZINE

TRIFLUPROMAZINE

DOLASETRON

GRANISETRON

ONDANSETRON

PALONSETRON

is Marinol

The only medically available cannabinoud for antiemesis

One side effect is euphoria

Synthetic cannibinoid used to treat nausea (anti-emetic)

One side effect is euphoria

                                                               i.      Treat of prevent severe N/V, often prophylactically before/after surgery; anticancer drugs and radioation

                                                              ii.      Also used in infections and adverse drug reactions causing severe N/V. 

1.        buclinzine

2.        cyclizine

3.        dimenhydrinate (Dramamine)

4.        duphendydramine (Benadryl)

5.        meclizine

6.        scopolamine 

                                                               i.      Mostly varying degrees of drowsiness

                                                               i.      Severe CNS depression

                                                              ii.      5-HT3 not used by those with heart block or prolonged QT intercals

                                                            iii.      not recommended furing lactation and pregnancy

                                                            iv.      uncomplicated vomiting in young children

                                                             v.      prochlorperazine contro in bone marrow depression, blood dyscrasia, Parkinson’s, severe liver or CV disease

                                                            vi.      Thiethylperazine is preg cat X

                                                               i.      Do not treat severe N/V with antiemetic alone, must understand cause; antiemetics can hamper dx of causes like brain tumors, appecdiciting, drug tox, etc.

                                                              ii.      Cholinergic blocking antiemetics used with caution in glaucoma, obstructive GI or genitourinary disease, reanal/hep dysfunction, older men with possible prostate hypertrophy

                                                            iii.      Promethazine used cautiously with HTN, sleep apnea, epilepsy

                                                            iv.      Trimethobenzamide in children with viral illness bc can increase risk of Reye’s

                                                             v.      50HT3 receptor antagonists caution in pts with cardiac conduction problems or electrolyte imbalances

                                                            vi.      Are classes B and C (except for thiethylperazine is X)

  Causes local irritation of stomach and stimulation of medullary vomit center

                                                               i.      Not altered mental status and risk of aspiration is high

                                                              ii.      Pt in convulsions

                                                            iii.      Substance injected can cause altered mental state or convusions

                                                            iv.      Sunstance is caustic or corrosive

                                                             v.      Substance injested is low-viscosity petroleum distillate with potential for pulm aspiration and dvlp of chemical pneumonitis

                                                            vi.      Pt has medical condition that may be exacerbaeted by vomiting like severe ht, bradycardia, hemorrhagic diathesis

                                                               i.      Type and intensity of symptoms like pain, discomfort, nausea, vomiting, etc. for baseline

                                                              ii.      Document # and times pt has vomited and approx amount of fluid lost

                                                            iii.      Assess for signs of fluid and electrolyte imbalance

                                                            iv.      Take vitals

                                                             v.      For preventative antiemetic, explain why.

                                                               i.      Monitor continually for continued complaints of pain, sour taste, production of bloody coffe ground emesis. 

                                                              ii.      Keep suction equip available is case a NG tube must be inserted to prevent aspiration

                                                            iii.      If severe vomiting, observe for signs of electrolye imbalance and monitor BP, pulse, RR q 2-4 hours or as ordered

                                                            iv.      Carefully monitor I and O includine emesis until vomiting ceases and pt can drink sufficiently

                                                             v.      Document q time pt vomits\

                                                            vi.      Notify PCP if blood in emesis or suddenly more severe

                                                          vii.      May also need to take weight daily if prolonged vomiting

                                                         viii.      Assess frequently for effectiveness of drug and notify PCP if fails to relieve or diminish symptoms.

                                                                        1.        can be given hourly for first 2 weeks for acute peptic ulcer

2.        After this, give 1-2 hours after meals and at bedtime

3.        PCP may order for self-admin at bedside

a.        Ensure enough water and cups for measuing the dose

4.        NURSING ALERT – no oral drug should be admin within 1 to 2 hours of an antacid bc of the potential for interactions

1.        maybe bc are unconscious (surgery eg)

2.        many acid-reducing come in IM and IV.  IV preferred if has existing line bc these drugs are irritating and IM must be given deep to minimize tissue harmd

3.        NURSING ALERT – when “one of these drugs” (acid reducing or all upper GI?) given IV, nurse must monitor rate of infusion at frequent intervals.  Too rapid may induce cardiac arrythmias

4.        Debilitated pts with NG at risk for gastric ulcer so may be given acid-reducers. 

a.        Always check med label to see if can be crushed or capsule opened

b.       If so, mix with 40mL apple juice, inject and fluch

c.        Many come in liquid form; request this if given fvia tub to prevent clogging

1.        Drugs used when for chemotherapy N/V

a.       granisetron

b.      ondansetron (Zofran)

c.       dolasetron

2.      given before chemo admin, at first IV

3.      always by nurse trained in admin of cancer chemo

 1.    antacids can cause diarrhea or constipation, so keep BM log (ha)

a.       if diarrhea, must keep I&O

b.      change in antacide usually fixes problem

2.      Dehydraton big problem for vomiting pt so observe for sign of dehydration

a.       poor skin turgor, dry mucous membranes, low/concentrated urine, restlessness, irritability, up RR and confusion

b.      monitor I&O q 8 hrs

c.       Offer fluids

d.      observe for electrolyte imbalances

e.       If elec imb or dehydration, contact PCP bc may need IV fluid/elec.

3.      Fluid/electrolyte monitoring esp important in elderly or chronically ill

1.      Provide emesis basin and check; maesure amount

2.      can give oral rinse

3.      Decraesed appetite from nausea so make environment pleasant without strong odors

watch for CNS adverse reactions and report to PCP before next dose bc may be discontinued.  Also report before next dose tardive dyskinesia.  These effets (TD and extrapyr.) may be irreversible if continued.        

                                                               i.      difficulty speaking or swallowing, masklike face, shuffling gate, rigidity, tremors, uncontrolled movements of mouth, face, or extremities, uncontrolled chewing or unusual movements of tongue

1.      behind ear

2.      after apply, wash hands well with soap and water to prevent contact of drug with eyes

3.      disk will last 3 days, can apply another after

4.      after discarding disk, again thorough washing of hands

5.      only one disk a time!

6.      Adverse reactions are dizziness, dry mouth, and blurred vision

7.      stress caution with hazerdous tasks

·         for digestive upset, ulcers, etc.  Generally safe.  Antispasmodic effect on  GI smooth muscle and protects against ulcers.  Can produce mild to severe allergies though.

o        Anticholinergics

o        Antihistamines

o        Phenothiazines

o        Tricyclics

o        Opioids

o        Non-K-sparing diuretics

o        Iron preparations

o        Barium

o        Clonidine

o        Antacids containing calcium or aluminum

·          

o        about 1.4 million is US

o        is both Chron's and ulcerative colitis

o        cause inflammation of intestines

o        cause unknown, though though is bacteria or virus

o        Crohn's

§         ab pain and distension

§         as progresses anorexia, diarrhea, weight loss, dehydraion and nutritional deficiencies

o        Ulcerative colitis

§         more abrupt onset

§         sudden need to defecate with severe blood/mucus filled diarrhea or no stool at all.

§         Pain and fatigu

o        No evidence that IBD caused by psychological factor

o        Drugs for IBD are antibiotics, corticosteroids, biologic agents and aminosalicylates

                  i.    aspirin like with anti-inflamm

                                                              ii.      mechanism unknown

                                                            iii.      topical anti-inflamm in bowel

                                                            iv.      used for Crohn's and UC and other inflamm disorders (Infammatory Bowel Diseases or IBD)

                                                         ab pain, nausea, diarrhea, fever and weakness

                                                               i.      hypersensitivity to all salicylates

                                                              ii.      hypersensitivities to sulfanomides and sulfites

                                                            iii.      intestinal obstruction

                                                            iv.      children under 2

                                                               i.      cats b and c

                                                              ii.      pregnency and lactation

Immodium

Kaopectate

antidiarrheal

NOT rt opioids

acts on muscles of bowel directly to slow motility

difenoxin (Motofen) anddiphenoxylate (Lomitil)

no analgesia

have sedative and euphoric effects

combined with atropine for negative side effects of sry mouth etc (anticholinergic)

                                                               i.      GI - anorexia, N/V, constipation, ab discomfot, pain and distension

                                                              ii.      CNS- dizziness, drowsiness, headache, sedation, euphoria

                                                            iii.      Other - rash

                                                               i.      diarrhea cuased by organisms like e.coli and shigella that must be evacuated

                                                              ii.      psudomembranous colitis

                                                            iii.      ab pain of unknown urigin

                                                            iv.      obstructive jaundice

                                                             v.      children under 2

                                                            vi.      loperamide prg cat B but not recommended for use during pregnancy and lactation

                                                               i.      NURSING ALERT - if diarrhea persists more than 2 days when OTCs used, pt dc use and seek treatment

                                                              ii.      severe hepatic impairment

                                                            iii.      IBD

                                                            iv.      preg cat C use with caution pregnancy and lactation

                                                               i.      antihistamines, opiods or hypnotics - increases risk of CNS depression

                                                              ii.      antihistamines and general antidepressants - increases risk of anti-cholinergic effects

                                                            iii.      MAOIs - increased risk of hypertensive crisis

1.        charcoal

2.        simethicone (Gas-X)

                                                               i.      do not absorb or remove gag, they only help body release the gas

1.        charcoal binds gas for expulsion

2.        simethicone has defoaming agent that prevents small gas pockets

                                                               i.      preg cat of simethicone not determined, but may be safe bc it is not actually absorbed into body (still consult dr)

                                                              ii.      Charcoal is preg cat C

                                                               i.      charcoal may absorp other drugs, decreasing their effectiveness

                                                              ii.      No known interactions with simethicone

are bowel evacuants

polyethylene glycol is Miralax

polyethylene glycol-electrolyte solution if GoLYTELY

1.        lubricate and soften stool

2.     Promote water retention in stool

                                                               i.      To evacuate colon for exams - stimulants, emolliants, saline

                                                              ii.      prevention of strain after surgery or MI - stool softeners or mineral oil

                                                            iii.      IBS and diverticular disease - psyllium and polycarbophil

                                                            iv.      Reduction of blood ammonia levels in hepatic encephalopathy - the hyperosmotic agent lactulose

                                                               i.      Water and electrolyte loss

                                                              ii.      ab pain discomfort, N/V, perianal irritation, bloating, flatulance, cramps

                                                            iii.      weakenss, fainting

                                                            iv.      prolonged use can cause serious electrolyte imblanaces and a lax habit (dependency to have BM)

                                                             v.      Some contain tartrazine which may cause allergic reactions including bronchial asthma

                                                            vi.      Can cause abstructions of esophagus, stomach, small intestine, colon if bulk-forming not given with enough water or with pts with intestinal stenosis

                                                          vii.      Very young or old, or debilitated greatest risk for aspiration of mineral oil into lungs when taken orally.  Can lead to lipid pneumonitis.

                                                               i.      persistnat ab pain, N/V of unknown cause

                                                              ii.      signs of appendicitis

                                                            iii.      Only used when benefit outweigh risks (preg cat C): cascara, docusate, glycerin, phemolphthalein, magnesium, senna

                                                               i.      Magnesium admin with caution in any degree of renal impairment

                                                              ii.      Pts with recatl bleeding

                                                            iii.      pregnancy and lactation

                                                               i.      Mineral oil impairs absorption of fat-souble DAKE vitamins

                                                              ii.      Laxtives reduce absorptin of other drugs by wither combining with them of hastening their removal

                                                            iii.      Surfactants wit h mineral oil, may increase mineral oil absorption

                                                            iv.      Milk, antacids, histamine H2 antagonists, and PPIs should not be administered 1 to 2 hours before bisacodyl bc enteric coating may dissolve early resulting in gastric lining irritation or dyspepsia and deccrease the lax effect of the drug

                                                               i.      what is med diagnosis and reason for admin

                                                              ii.      review symptoms for baseline

                                                            iii.      listen to BS and palpate lokoing for guarding/discomfort

                                                            iv.      May hear hypoactive sounds but have liquidy BM, this could be OBSTIPATION, which mean liquid stool is moving aroung fecal mass

                                                               i.      dx relief? notify PCP if not or if adv rxns

                                                              ii.      VS more freq if diarrhea severe

1.        notify PCP if temp high, severe ab pain, ab rigidity/distension, indicates infection orintestinal performation

2.        severe diarrhea may req IV fluids, electrolyte replacement, etc

3.        Chronic diarrha, encourage to drink extra fluid

4.        close I&O

5.        Antidiarrheals may cause drowsiness, advise re hazardous tasks and may need assistance

6.        For perianal irritation, edu clean w mild soap , dry and apply emolliant like petroleum

7.        If diarrhea occurs bc over admin of a laxative, notify PCP

1.        simethicone is taken after each meal and at bedtime

2.        thoroughly chew bc particle dispersion enhances antiflat action

3.        notify PCP if sx not better in several days

1.        avoid long-term use, dependency, unless oked by PCP

2.        Constipation can occur as rebound

3.        do not use when ab pain, N/V

4.        notify PCP if not better or if rectal bleeding and other sxs occur

5.        with casara sagrada or senna, pink to red to violet to brown or even black discoloration can occur

use cemetidine (Tagamnet) cautiously with diabetes (higher risk of pneumonia, greater succeptibility to certain virus, which one?)

Apparently, cimetidine also has antiviral activity....

• anti-infectives
• bismuth
• PPIs lansoprazole (Prevacid) and omerprazole (Prilosec)

has very high sugar content, so pulls water into colon

those with renal damage often get this, reduces blood ammonia levels by pulling ammonia into the stool from the blood

• A GI stimulant
• Increases gastric emptying (no extra acid production)
• Sensitizes tissue to acetylcholine, inkcreasing gastric tone and contractions
• Also inhibits stimulation of the CTZ, preventing nausea
• Used to treat GERD, gastric stasis in diabetes, cancer N/V and pts after surgery
• Adverse reactions normally mild, but higher or prolonged admin can produce CNS symptoms like drowsiness, restlessness, dizziness, extrapyramidal effects, tremor, invol movements of limbs, rigidity), facial grimacing and depression

• a gi stimulant and anti-emetic
• enhances gastric emptying and inhibits CTZ, reducing N/V
• Treats GERD and gastric stasis
• May be adminned IV
• Adv rxns are itching, difficulty breathing, and urticaria

• Give bulk producing with water at admin, and another after
• Mineral oil preferred empty stomach
• Mask flavor somehwo
• Record BMs
• Watch for diarrhea, notify if severe
• Watch for ineffectiveness and notify
• encourage liberal fluid and fiber intake; exercise
• avoid long term use of stimulants; habit forming and rebound constipation
• DO NOT USE IF N/V or ABDOMINAL PAIN
• Edu pt to notify if constipation not releived, rectal bleeding
• Cascara sagrada and senna can cuase urine discoloration

• Do not use if alterred mental status, risk aspiration
• so not use if convuslions
• Do not use if substance injested can cuase alterred mental states
• Do not use if substance is caustic or corrosive
• Do not use with petroleum products bc aspiration can cause chemical pneumonitis
• Do not use in pt w/ another condition that can be exacerbated by vomiting, like bradycardia, severe HTN, hemorrhagic diathesis
• MUST KNOW WHAT WAS INJESTED!!!!!  ALSO THE TIME and SYMPTOMS. TALKS TO POISON CONTROL IF NECESSARY.
• Assesss fluid lost
• VS frequently, esp bc of fluid and electrolyte imbalances
• Watch for signs of dehydration 

• May admin hourly for first 2 weeks for acute peptic ulcer, then 1-2 hours after meals and at bedtime
• Can possibly left at bedside for self-admin with order
• Make sure enough water and cups
• No oral drug should be administered within 1 to 2 hours of an antacid
• Antacids may cuase diarrhea or constipationn, so monitor BMs
• If diarrhea, monitor I&O; con be controlled by combining mag with calc or alum antacids, or changing
• Instruct to chew thoroughly and then drink water
• Can order liquid if needed, and flavored; must shake liquid thoroughly
• MAKE SURE PT UNDERSTANDS THAT ANTACIDS, ESP NA CONTAINING, RAISE BP; can interact with other conditionn, so see dr first
• ANTACIDS IMPAIR ABSORPTIONF OF OTHER DRUGS, SO DO NOT TAKE OTHER DRUGS WITHIN 2 HRS OF ANTACIDS
• White streaks in stool fine
• Too many antacidscan cause incraesed acid productin
• Advise of constipation and diarrhea causing antacids

• GI stimulants
• PPIs
• H2 antagonists
• Antacids

• H2 antagonists reduce acid production (Tagament, Zantac, Pepcid)
• PPIs can block acid production and allow time for espophagus to heal (Prevacid and Prilosec)

Pts with cardiac conduction problems

Pts with electrolyte imbalances

Use cautiously

Except for thiethylperazine is category X

obstruction

upper GI bleed

decreased kidney function

respiratory insufficiency

renal impairment

cardiac disease

tetracycline and corticosteroids

makes salicylates excreted more rapidly in urine

What class of drugs are the following:

balsalazide

mesalamine

olsaazine

sulfasalaze

Extrapyramidal effects:

Difficulty speaking or swallowing, masklike face, shuffling gate, rigidity, tremors, uncontrolled movements of mouth, face or extremities, uncontrolled chewing or unusual movements of tongue

glaucoma, obstructive GI or genitourinary disease, renal/hep dysfunction, older men with possible prostate hypertrophy