CHAPTER 40 ANTIULCER DRUGS

Peptic Ulceration Mucosal lining erosion Esophageal Gastric Duodenal Hypersecretion HCl (hydrochloric acid; from the parietal cells of the stomach, is influenced by 1. Histamine 2. Gastrin 3. Acetylcholine Pepsin (is a digestive enzyme, activated at a pH of 2; if the pH of gastric secretions increases to pH 5, the pepsin declines) pH of 2-5 (gastric secretion in the stomach is normal at this pH) GERD PREDISPOSING FACTORS NONPHARMACOLOGIC MEASURES a. b. c. d. e. helicobacter pylori (H. Pylori) genetic (zollinger-ellison syndrome) smoking diet (spice, caffeine) drugs (NSAID)aspirin, ibuprofen (Motrin, Advil, nuprin), Indocin, corticosteroids (cortisone, prednisone), potassium salts, antineooplastic drugs f. Mechanical disturbances (Hypersecretion acid and pepsin, Gastric mucosal barrier
ANTIULCER TREATMENTS a. b. c. d. e. f. g. Tranquilizers Anticholinergic drugs Antacids Histamine 2 blockers Proton pump inhibitors Pepsin inhibitors Prostaglandin E 1 analog a. b. c. d. e. Avoid tobacco Avoid alcohol Loss weight Avoid hot spicy, greasy foods Take any NSAIDs (aspirin, oral glucocorticoids with food, or decrease your dosage f. Sit upright g. Do not eat before bedtime h. Wear loose fitting clothes

of mucous secretion, Impaired GMB resistance, incomplete cardiac or pyloric sphincter.) SYMPTOMS: aching pain in the stomach

ANTIULCER DRUGS CHAPTER 40

ANTACIDS: do not promote healing of ulcer or help to get rid of H. Pylori. Excessive use may affect electrolyte levels. aluminum (Al) Hydroxide (AlternaGel) WATCH RENAL INSUFFICENCY (Anti-heartburn agent) o Combining aluminum compounds with magnesium (Gaviscon, Maalox, and Mylanta) increases their effectiveness and reduces the potential for constipation. o They are minimally absorbed ADMIN: Primary action is to neutralize stomach acid by raising the pH of stomach contents Encourage pt to drink 2 o Do not reduce the volume of acid secretion. ounces of water after Most effectively used in combo with other antiulcer drugs for antacid to ensure it symptomatic relief of heartburn due to PUD or GERD. nd reaches the stomach. A 2 aluminum salt (aluminum carbonate (BASALIJEL) is also used to treat heartburn. Give aluminum antacids o A/E: constipation, nausea, stomach cramps at least 2 hours before or S/S/E: FECAL IMPACTION after other drugs because HYPOPHOSPHATEMIA (low level of phosphate in the blood) a.

absorption could be affected.

A/E: when taken reg. or in ^ doses, causes constipation.

When taken @ ^ doses, it binds w/ phosphate in the GI tract and can cause phosphate depletion.

^ Risk Pt: malnourished, alcoholics, pt. w/ renal disease ACTIONS OF ANTACIDS MONITOR: ELECTROLYTES, URINARY Neutralize gastric acid, reduce pepsin activity pH, calcium, and Systemic side effects phosphate levels Sodium excess, water retention, metabolic alkalosis, acid rebound Nonsystemic side effects Mg: diarrhea; Al: constipation Combination: none

Drug- Drug: Aluminum compounds should not be taken at the same time as other meds. They can interfere with absorption Used w/sodium polystyrene sulfonate may cause systemic alkalosis. Values for serum gastrin and urinary pH may ^. Serum phosphate values may decrease May inhibit the absorption of dietary iron. Do not admin with other oral drugs; take 1 2 hours after admin of other drugs Do not give with tetracycline, digoxin or quinidine (it binds with and inactivated most of the drug.

b. Calcium carbonate (titralac, Tums; these should not be taken with milk or any items that have Vitamin D= milk alkali syndrome=permanent renal damage if drug is continued at high dosages. Calcium carbonate with magnesium hydroxide (Mylanta (contains simethicone, aluminum hydroxide and magnesium hydroxide and is classified as a anti-flatulent) Rolaids) o A/E: constipation, flatulence o S/S/E fecal impaction, metabolic alkalosis, Hypercalcemia, renal

calculi (kidney stones)

c. Magaldrate (riopan) Magnesium hydroxide (milk of magnesia) Magnesium trisilicate with aluminum hydroxide (Gaviscon) Magnesium hydroxide with aluminum hydroxide and simethicone (Mylanta, Maalox plus) o A/E: diarrhea, nausea, vomiting, abdominal cramping

o S/S/E: hypermagnesaemia, dysrhythmias (IV admin) d. Sodium bicarbonate (Alka-Seltzer, baking soda) o A/E: stomach distention, belching, flatulence o S/S/E metabolic alkalosis, fluid retention, edema hypernatremia ^ (Na+)

TRANQULIZERS: often used with anitcholinergics. Have little effect in preventing or treating ulcers. Reduce vagal stimulation, and decrease anxiety. Chlordiazepoxide and clidinium (Librax): a combo of anxiolytic/anticholinergic a. Take a.c. (before meals) h.s. (bedtime) b. Contains Benzodiazepine Glycopyrrolate (Robinul): For peptic ulcers and gastric disorder caused by hyper acidity (too much acid). Used as a pre-anesthetic drug. reduces vagal stimulation, decreases anxiety ANTICHOLINERGICS: (antimuscarinics, parasympatholytics), relieve pain by decreasing GI motility and decrease GI secretion. They work by inhibiting acetylcholine and blocking histamine and hydrochloric acid. They delay gastric emptying time, so usually used for

duodenal ulcers. Should be used as an adjunctive therapy and NOT as the only antiulcer drug. o Propantheline (Pro-Banthine) inhibits gastric secretions and is used to treat peptic ulcers, decreases gastric secretions, IBS, pancreatitis and urinary bladder spasm. a. Inhibits release of HCI (hydrochloric acid) b. Take with meals to decrease acid secretion
SIDE EFFECTS OF ANTICHOLINERGICS:

a. b. c. d. e. f. g. h. i. j. k.

Dry mouth Decrease secretions H/A Blurred vision Drowsiness Dizziness Lethargy Palpitations Bradycardia/tachycardia Urinary retention Constipation

****Because anticholinergic decrease GI motility, gastric emptying is delayed and can stimulate gastric secretions and aggravate the ulceration.

HISTAMINE 2 BLOCKERS H2 receptors are responsible for increasing acid secretion in the stomach. These drugs block H2 receptors in the stomach to decrease acid production. Suppress the volume and suppress the acidity of the parietal cell secretions. All are available OTC for short-term (2 wks.) treatment of GERD. Long term use can result in decrease of RBC and WBC and platelets. Ensure pt. safety esp. older adults because this drug can cause drowsiness.

a. Cimetidine (Tagamet),take with food/ bedtime b. Ranitidine (Zantac), Take after meal and can be taken @ bedtime MONITOR LIVER/RENAL FUNTION!!! Does not cross the blood brain barrier so there is no confusion or CNS depression. Periodic blood counts are performed. High does can cause impotence or loss of limbido in men. Antacids should not be given within 1 hour of H2 receptor antagonist because the effectiveness may be decreased due to reduced absorption. Smoking decreases the effect of ranitidine. May cause decrease in B12 and Iron c. Famotidine (Pepcid) take 2 xs daily/bedtime, Nizatidine (Axid) ,take at bedtime Action: Reduce gastric acid by blocking H2 receptors of parietal cells in stomach Promote healing of ulcer by eliminating cause Side effects: Headaches, dizziness, diarrhea, constipation, reversible impotence, gynecomastia (enlargement of the gland tissue of the male breast), hepatotoxic (Damaging or destructive to the liver.)

PROTON PUMP INHIBITORS: reduce acid secretion in the stomach by binding irreversibly to H+, K+-ATPase, the enzyme that acts as a pump to release acid on the surface of the GI mucosa. Longer duration of action and reduce acid secretion better than H2 antagonists. Heal more than 90% of duodenal ulcers w/in 4 wks. Heal 90% of gastric ulcers in 68 wks. Beneficial effects continue for 3 -5 days after drugs have been stopped. Used only for short term in GERD and peptic ulcers (usually 4 wks.) Omeprazole/Lansoprazole used with antibiotics to eradicate Pylori. Esomerprazole (Nexium) and pantoprazole (Protonix) offer convenience of a 1 time a day dosing. Omeprazole (Prilosec) is used for longer periods in pt. who suffer from ZOLLINGER-ELLISON SYNDROME (a chronic Hypersecretion of gastric acid). Should be taken on an empty stomach 20-30 min before breakfast, in the morning. S/E headache, stomach pain, diarrhea, nausea, rash, dizziness and vomiting. Long term therapy increase the risk of osteoporosis related fractures of the hip, wrist, or spine,

because they interfere with calcium absorption. A calcium supplement should be given with these drugs. May be admin. with an antacid Esomeprazole (Nexium), Pantoprazole (Protonix) Omeprazole (Prilosec) used with WARFARIN may increase bleeding, Lansoprazole (Prevacid) Action Reduce gastric acid by inhibiting hydrogen/potassium ATPase

Side effects Headache, insomnia, dizziness, dry mouth, flatulence, abdominal pain

PEPSIN INHIBITORS:

Sucralfate (Carafate): consists of sucrose (a sugar) plus aluminum hydroxide (an antacid). Produces a thick gel-like substance that coasts the ulcer, protecting it from further erosion and promoting health. Does not affect the secretion of gastric acid. S/E constipation. The disadvantage is it Must be taken 4Xs daily. Action Combines with protein to form thick paste covering ulcer, protects from acid and pepsin

Side effects Constipation

Nursing Interventions Given 30 min before meals and bedtime Space medications from Carafate

PROSTAGLANDIN E1 ANALOG: inhibits gastric acid secretion and stimulates the production of protective mucus. Used primarily for the prevention of peptic ulcers in pt. who are taking high doses of NSAIDs or corticosteroids. S/E diarrhea, abdominal cramping. Classified as a Preg. X drug!!! (Sometimes used to terminate preg.) Misoprostol (Cytotec) Action Inhibits gastric acid secretion and protects mucosa

Side effects GI distress, constipation Do not use with child-bearing women unless 2 forms of birth control; can induce abortion/miscarriage

METOCLOPRAMIDE (REGLAN): used for short-term therapy of symptomatic PUD in pt. who fail to respond to first line drugs. Prescribed to treat nausea and vomiting associated with surgery or cancer chemotherapy. Causes muscle in the upper intestine to contract, resulting in faster emptying of the stomach, and blocks food from re-entering the esophagus from the stomach which is a benefit for pt with GERD. S/E CNS effects (drowsiness, fatigue, confusion, insomnia. BLACK

BOX WARN: (can cause tardive dyskinesia; involuntary jerky movements of the face, tongue, jaws, trunk, and limbs with long term use)

NURSING CARE FOR PEPTIC ULCERS: a. Drugs used for to treat hyper acidic conditions raise the gastric Ph and impact the bodys normal defense mechanisms against respiratory pathogens. Antibiotics may need to be admin. of infections develop. b. Monitor for severe diarrhea, esp. if mucus, blood, or pus is present (drugs used to treat hyperacidic conditions raise the gastric pH and increase the risk of Clostridium difficile associated diarrhea (CDAD) or pseudomembranous colitis (PMC) c. Monitor for the effectiveness of other drugs taken w/ H2 receptor antagonists or antacids because they impair the absorption or effects of other drugs. d. Teach pt to increase intake of dairy products containing live active cultures (youurt or kefir, to help restore normal flora) e. H2 receptor blockers: 1. may be taken without regard to mealtime 2. do not take with antacids unless drug is available in a combo product like Pepcidcomplete Proton pump inhibitors: 1. 2. 3. 4. ON AN EMPTY STOMACH!!!take 30 min before meals if once a day dose is ordered take drug in the morning before breakfast Antacids may be taken with it. Do not take drug beyond 3 to 4 months unless directed by health care provider

Antacids: 1. Take 2 hrs. before or after meals with a full glass of water 2. Do not take this med at the same time as others f. Helicobacter pylori: a. Is linked with the development of peptic ulcer b. Is known to cause, gastritis, gastric ulcer, duodenal ulcers. c. When a peptic ulcer recurs after antiulcer therapy and the ulcer is not caused by nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen, the pt. should be tested for the presence of H. pylori.

LANSOPRAZOLE: A.GERD stands for gastroesophageal reflux disease, also called reflux esophagitis. It is an inflammation of the esophageal mucosa caused by the reflux of gastric acids into the esophagus. Its main cause is an incompetent lower esophageal sphincter. B.Approximately 40% to 44% of the adult U.S. population suffers from heartburn, which in many cases is GERD A. Drugs that neutralize gastric contents and drugs that reduce gastric acid secretion are used for GERD treatment. I. Drugs that neutralize gastric contents include nonsystemic antacids such as aluminum hydroxide, magnesium hydroxide, magaldrate, sodium bicarbonate, and combinations of these products. Drugs that reduce the production of gastric acid include histamine blockers such as cimetidine, ranitidine, famotidine, and nizatidine; and proton pump inhibitors (PPIs) such as lansoprazole, omeprazole, pantoprazole, and rabeprazole

II.

A. Proton pump inhibitors work by inhibiting the hydrogen/potassium adenosine triphosphatase (ATPase) enzyme system located in gastric parietal cells. These agents are much more effective than histamine blockers by blocking the final step of acid production B. Lansoprazole (Prevacid) is available in an orally disintegrating and liquid dosage form for patients who have difficulty or are unable to swallow capsules. This dosage form is similar to a breath mint that dissolves quickly in the mouth, and it should then be followed by a glass of water to make sure that the drug reaches the stomach. The client can also be instructed to open the capsule and sprinkle the contents into applesauce, pudding, or other palatable food to ease administration. The client should be instructed not to chew the contents of the capsule. The client should be advised to ask the prescribing health care provider about obtaining these dosage forms. C. ALUMINUM HYDROXIDE (AMPHOJEL, ALTERNAGEL, ALUTAB); peptic ulcer pain.
A client has just been prescribed aluminum hydroxide (Amphojel, ALternaGEL, Alu-Tab) for peptic ulcer pain. The nurse has provided instructions to the client. Which statement by the client indicates to the nurse that the client understands the instructions? The client should drink 2 ounces of water after taking aluminum hydroxide to ensure the drug reaches the stomach. Aluminum hydroxide should not be taken at mealtime as it slows gastric emptying time. Aluminum hydroxide should not be taken within 1 to 2 hours of other oral medications. The client should contact the

health care provider if constipation develops as the antacid may need to be changed; self-treatment should be avoided.

1.

What is a priority nursing intervention when administering ranitidine (Zantac)? Should be given just before meals to decrease food-induced acid secretion, or at bedtime

2.

The health care provider prescribes lansoprazole (Prevacid) to a client. Which assessment indicates to the nurse that the medication has had a therapeutic effect?

Lansoprazole (Prevacid) is a proton pump inhibitor that is effective in suppressing gastric acid secretions. An absence of throat pain would be an indication that the client does not have reflux esophagitis 3. The nurse is caring for a client who is taking sucralfate (Carafate, Sulcrate) for treatment of a duodenal ulcer. Which assessment requires action by the nurse? As sucralfate (Carafate, Sulcrate) is not systemically absorbed, there are few adverse effects. Constipation is an adverse effect of Sucralfate

1.

When administering sucralfate (Carafate) to a client with a nasogastric tube, what is an essential intervention?

It is important to give sucralfate (Carafate) on an empty stomach so that it may dissolve and form a protective barrier over the gastric mucosa. The tablet form will not dissolve in water when crushed; it must be left whole and allowed to dissolve. Crushing the medication so that it will not dissolve could lead to clogging of the nasogastric tube and decreased effectiveness of the drug. 2. What information should the nurse include in a teaching plan for the client who is prescribed sucralfate (Carafate)? Sucralfate (Carafate) affects the gastric mucosa. It forms a pastelike substance in the stomach, which adheres to the gastric lining, protecting against adverse effects related to gastric acid. It also stimulates healing of any ulcerated areas of the gastric mucosa 3. The nurse is caring for a client who is experiencing gastric distress from the long-term use of aspirin for treatment of arthritis. What is the best intervention for this client? (Select all that apply.) Misoprostol and omeprazole are each indicated for the prevention of NSAID-induced ulcer. They may be taken during NSAID therapy, including with aspirin