Chapter 47

ANTIULCER DRUGS

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Physiology of the Stomach

Primary Functions
Storing food Mixing food with gastric secretions Slowly emptying the stomach

Types of Secretory cells

Chief cells pepsinogen, inactive enzyme Parietal cells hydrochloric acid by stimulation

of acetylcholine from cholinergic fibers, gastrin and histamine Mucus cells mucus that coats stomach wall
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Peptic Ulcers

Peptic Ulceration
Mucosal

lining erosion
Esophageal Gastric Duodenal

Hypersecretion HCl Pepsin pH of 2-5

GERD
Common sites of peptic ulcers.

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Peptic Ulcers

Predisposing factors
Helicobacter pylori Mechanical Genetic Environmental Drugs

(H. pylori)

Symptoms
Aching

pain

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Nonpharmacologic Measures

Avoid tobacco Avoid alcohol Weight loss Avoid hot, spicy, and greasy foods Take any NSAIDs, including aspirin and oral glucocorticoids, with food or in decreased dosage Sit upright Do not eat before bedtime Wear loose-fitting clothing
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Antiulcer Drugs

Tranquilizers Anticholinergic drugs Antacids Histamine2 blockers Proton pump inhibitors Pepsin inhibitor Prostaglandin E1 analog Prokinetic drugs Antispasmodic drugs

Actions of the seven antiulcer drug groups.

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Antiulcer Drugs

Tranquilizers decrease stimulation of vagus nerve Anticholinergic drugs decrease acetylcholine Antacids neutralize gastric acid, thereby causing gastric contents to be less acidic Histamine2 blockers decrease the volume of HCl produced, increasing gastric pH and thereby resulting in decreased irritation of gastric mucosa Proton pump inhibitors block the formation of HCL, reducing irritation of gastric mucosa

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Antiulcer Drugs

Pepsin inhibitor (Coating agents) provide a protective covering over the ulcer crater Prostaglandin E1 analog inhibit gastric acid and pepsin secretion to protect ulceration in the stomach & duodenum

Prokinetic agents increase the lower esophageal sphincter muscle pressure and peristalsis
Antispasmodic agents reduce the secretion of saliva, HCl, pepsin, bile and other enzymes; decrease GI motility

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Antiulcer Drugs (contd)

Tranquilizers

Chlordiazepoxide and clidinium (Librax) is combination of anxiolytic/anticholinergic Glycopyrrolate (Robinul) Reduces vagal stimulation, decreases anxiety Propantheline (Pro-Banthine) Inhibits release of HCl by blocking acetylcholine and
histamine Take with meals to decrease acid secretion

Anticholinergics

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Antiulcer Drugs (contd)

Antacids

Aluminum (Al) hydroxide (Amphojel) Magnesium (Mg) hydroxide/aluminum hydroxide (Maalox) Calcium carbonate (Tums) Sodium bicarbonate (Alka-Seltzer) (systemic)

Action

Neutralize gastric acid, reduce pepsin activity

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Antiulcer Drugs (contd)

Systemic side effects

Sodium excess, water retention, metabolic alkalosis, acid rebound

Nonsystemic side effects

Mg: diarrhea; Al: constipation Chalky taste

Drug Interactions

Inhibits tetracycline, ciprofloxacin, ketoconazole, digoxin, iron compounds Increases Levodopa absorption Increases urinary pH that inhibits excretion of quinidine and amphetamines
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Antiulcer Drugs (contd)

Histamine2 blockers

Cimetidine (Tagamet), Ranitidine (Zantac) Famotidine (Pepcid), Nizatidine (Axid) 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, hepatotoxicity Drug Interactions Inhibits metabolism or excretion of benzodiazepines, theophylline, B-blockers, phenytoin, lidocaine, quinidine Enhances warfarin anticoagulating effects
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Antiulcer Drugs (contd)

Proton pump inhibitors

Esomeprazole (Nexium), Pantoprazole (Protonix) Omeprazole (Prilosec), Lansoprazole (Prevacid) Action Reduce gastric acid by inhibiting gastric acid

(hydrogen/potassium ATPase) pump of stomachs parietal cells

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

abdominal pain, rashes Drug Interactions Inhibits metabolism or excretion of diazepams, phenytoin, warfarin, Enhances theophylline metabolism
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Antiulcer Drugs (contd)

Pepsin inhibitors

Sucralfate (Carafate) Action Combines with protein to form thick paste covering
ulcer, protects from acid and pepsin

Side effects Constipation, dry mouth, dizziness Nursing Interventions Given 30 min before meals and bedtime

Drug Interactions Interferes with absorption of tetracyclines, omeprazole and lansoprazole

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Antiulcer Drugs (contd)

Prostaglandin E1 analog

Misoprostol (Cytotec) Action Inhibits gastric acid and pepsin secretion and
protects mucosa Induce uterine contractions

Side effects GI distress, diarrhea Contraindications Pregnancy and lactation

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Antiulcer Drugs (contd)

Prokinetic Agents

Cisapride (Propulsid) Action Stimulates GI motility by stimulating cholinergic nerve

fibers Increases lower esophageal sphincter pressure and esophageal motility, accelerates gastric emptying an intestinal transit

Side effects Headache, diarrhea, nausea Dizziness, rapid or irregular heartbeat

Drug Interactions Anticholinergics and narcotics decrease therapeutic effects of cisapride Antifungals, phenothiazines, H2 antagonists, diuretics and antiviral agents and grapefruit inhibits metabolism of cisapride
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Antiulcer Drugs (contd)

Antispasmodic Agents

Atropine, Scopolamine Action Acts by preventing acetylcholine from attaching tot the
cholinergic receptors in the GI tract

Side effects Blurred vision, constipation, urinary retention, dry mouth Orthostatic hypotension, palpitations, arrhythmias,

hallucinations Drug Interactions Amantadine, tricyclic antidepressants and phenothiazines potentiates therapeutic effects of antispasmodics

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Case Study
A client has peptic ulcer disease due to H. pylori. An antibiotic and proton pump inhibitor have been ordered.

Critical Thinking Explain the importance and use of a dual, triple, or quadruple drug therapy program in the eradication of this bacterial infection.

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Quiz for Finals

1. Which of the following drug classification of antiulcer drugs provide a protective covering over the ulcer crater? a. Proton pump inhibitors b. Histamine2 blockers c. Pepsin inhibitor d. Prostaglandin E1 analog 2. Which of the following nursing actions is appropriate when administering Diazepam with Omeprazole knowing the latter drug inhibits the metabolism or excretion of Diazepam? a. Suggest to the MD to decrease the dosage of diazepam b. Administer the dosage of diazepam as ordered c. Increase the dosage of diazepam d. Suggest to the MD to decrease dosage of omeprazole
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Quiz for Finals

3. Which of the following drug classification of antiulcer drugs neutralize gastric acid, thereby causing gastric contents to be less acidic? a. Proton pump inhibitors b. Histamine2 blockers c. Pepsin inhibitor d. Antacids 4. Which of the following assessment findings should the nurse watch out for when administering Warfarin with Cimitedine knowing the latter drug enhances the effects of Warfarin ? a. respiratory distress b. hypertension and tachycardia c. black tarry stools and hematuria d. allergic reactions
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Quiz for Finals

5. Which of the following diet should the nurse restrict the client when taking aluminum hydroxide (Amphojel)? a. pineapple b. green leafy vegetables c. banana d. all of the above 6. The client is diagnosed with peptic ulcer disease. Which of the following drug acts on the parietal cells in the stomach that reduces the production of HCL acids to prevent further ulcerations? a. Maalox b. Omeprazole c. Sucralfate d. Cisapride
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Quiz for Finals

7. Which of the following clients will the nurse advise to restrict from taking misoprostol, a prostaglandin analog? a. non-nursing mother b. hypertensive mother c. pregnant woman d. woman taking oral contraceptives 8. The client diagnosed with peptic ulcer disease is taking Sucralfate. Which of the following health teachings in taking the medication should the nurse give? a. take the drug 30mins or 1 hour before meals b. take the drug 1 hour after meals c. take the drug with meals d. take the drug with other medications
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Quiz for Finals

9. When taking digoxin with antacids, which of the following should the nurse monitor closely knowing that antacids can interfere with digoxin? a. respiratory distress b. hypersensitivity reactions c. dysrhythmias d. urinary retention 10. The client diagnosed with peptic ulcer disease is taking anticholinergics. Which of the following assessment findings will the nurse NOT likely to observe in this client? a. pupil constriction b. bronchial dilation c. tachycardia d. constipation
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Practice Question #1
Which of the following are most likely to be included in a dual drug therapy program for peptic ulcer disease due to H. pylori?
A. B. C. D.

Omeprazole and clarithromycin Tetracycline and metronidazole Ranitidine and amoxicillin Ciprofloxacin and sucralfate

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Practice Question #1 (contd)

Answer: A. Rationale: Omeprazole and clarithromycin are commonly included in a dual drug therapy program for peptic ulcer disease due to H. pylori.

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