1. Pharmacology

2. Peptic Ulcer Disease Imbalance between mucosal defensive factors and aggressive factors Major defensive – mucus and bicarbonate Major aggressive – gastric acid, H. pylori, nonsteroidal anti-inflammatory drugs, pepsin

3. Defensive factors Prevent the stomach and duodenum from being harmed (self-digestion). Mucus – continually secreted, protective effect Bicarb – secreted from endothelial cells, neutralized hydrogen ions Blood flow – good blood flow helps to maintain mucosal integrity Prostaglandins – stimulate secretion of bicarb and mucus and help promote blood flow, suppress secretion of gastric acid

4. Aggressive factors Helicobacter pylori – gram negative bacteria, can live in stomach and duodenum May breakdown mucus layer, inflammatory response to presence of the bacteria may breakdown defenses, also produces urease – forms CO2 and ammonia which are toxic to mucosa

5. NSAIDS – inhibit the production of prostaglandins Decrease blood flow, decrease mucus production and bicarb synthesis, promote gastric acid secretion Gastric Acid – also needs to be present for ulcer to form – activates pepsin and injures mucosa

6. Pepsin Smoking

7. Classes of drugs Antibiotics Antisecretory agents Mucosal protectants Antisecretory agents that enhance mucosal defenses Antacids

8. Nondrug therapy Diet – change in eating pattern, 5-6 small meals a day Smoking cessation, NSAID and ASA should be avoided whenever possible, avoid alcohol

9. Antibacterial drugs Combinations must be used Bismuth – disrupts cell wall of H. pylori, pepto-bismol Clarithromycin – inhibits protein synthesis Amoxicillin – disrupts cell wall, good when given with omeprazole Tetracyclin – inhibits protein synthesis Metronidazole – resistance,

10. Histamine 2-receptor antagonists Suppress secretion of gastric acid (activation of H2 receptors promotes secretion of gastric acid) Cimetidine - first available, oral, IV, IM May take up to twelve weeks for ulcer to be healed Therapeutic uses – ulcers, GERD, Zollinger- ellison syndrome, aspiration pneumonitis, heartburn, indigestion

11. Ranitidine (Zantac) More potent – than cimetidine Fewer side effects Fewer drug interactions PO, IM, IV Famotidine, Nizatidine

12. Proton Pump Inhibitors Suppress secretion of gastric acid Omeprazole – prilosec – prodrug that converts to active form in parietal cells of stomach – inhibits enzyme that generates gastric acid Ulcers, GERD, Zollinger-Ellison syndrome May contribute to development of gastric tumors?

13. Other PPIs Lansoprazole Rabeprazole Pantoprazole – protonix – usually given 40 mg per day

14. Sucralfate Creates a protective barrier against acid and pepsin Form sticky gel that coats ulcer portion Given every 6 hours Very few side effects – minimal systemic absorption

15. misoprostol Cytotec – prevention of gastric ulcers caused by long-term NSAID therapy Replacement for endogenous prostaglandins

16. Antacids Peptic ulcers and GERD Neutralize acid Dosing – 7 times per day

17. Schemes of combined treatment of gastric ulcer De-nol + amoxycillin De-nol + metronidazole Omeprazole + amoxycillin + clarythromycin De-nol + clarythromycin + metronidazole De-nol + controlok + amoxycilin + clarythromycin

18. Laxatives Laxative effect – production of a soft formed stool over a period of 1 or more days Catharsis – prompt, fluid evacuation of the bowel, more intense

19. Function of the colon – water and electrolyte absorption Bowel evacuation – individual Dietary fiber

20. Constipation Consistency vs. frequency Causes – diet and fluid, medications, activity

21. Indications for laxative use Pain associated with bowel movements To decrease amount of strain under certain conditions Evacuate bowel prior to procedures or examinations Remove poisons To relieve constipation caused by pregnancy or drugs

22. Laxative contraindications Inflammatory bowel diseases Acute surgical abdomen Chronic use and abuse

23. Classifications I – osmotic (high doses) II – osmotic (low doses), stimulant except castor oil – most frequently abused III – bulk-forming, surfactant

24. Bulk-forming Identical to fiber – soften fecal mass, increasing bulk Temporary treatment of constipation, preferred for patients with inflammatory bowel diseases May help with diarrhea

25. Adverse reactions Not absorbed – no systemic effects Must take with sufficient water Intestinal, esophageal obstruction Metamucil, citrucel

26. Surfactant laxatives Bisacodyl, castor oil Stimulate intestinal motility Increase water and electrolytes in intestinal lumen Produce stool within 6-12 hours

27. types Bisacodyl – dulcolax – suppository, orally Anthraquinones – cascara and senna Castor oil – works in small intestine

28. Bisakodil

29. Osmotic laxatives Draws water into intestinal lumen Time of action is dose-dependent Magnesium, sodium and potassium salts Can cause dehydration Electrolyte imbalances

30. Guttalax

31. Miscellaneous laxatives Mineral oil Lactulose Glycerin suppository Polyethylene glycol-electrolyte solutions

32. Laxative abuse Most common cause of constipation Teaching

33. Prokinetic agents Reglan – suppresses emesis and increases upper GI motility Given for nausea related to chemotherapy GERD Diabetic gastroparesis Adverse effects – diarrhea, sedation, EPS, (dopamine antagonist)

34. propulsid GERD and nocturnal heartburn Taken off the market Causes potentially lethal dysrhythmias

35. Antiemetic drugs Serotonin receptor antagonists – Ondansetron (Zofran) – most effective with chemo-type drugs, very effective – works well with dexamethasone

36. Phenothiazines Blocks dopamine2 receptors in the chemoreceptor trigger zone Side effects include EPS, anticholinergic effects, hypotension and sedation Prochlorperzine, phenergan,

37. butyrophenones Haloperidol and droperidol (Inapsine) Block dopamine 2 receptors in chemoreceptor trigger zone

38. Additional drugs Glucocorticoids Cannaboids Benzodiazepines Antihistamines

39. Antidiarrheals Symptom – excessive volume and fluidity of stools Infection, digestion problems, bowel disorder, inflammation

40. Complication and goal of treatment Electrolyte imbalances and dehydration Goal of treatment – treat underlying cause, replace water and salts (electrolytes), relief of pain, cramping and reducing passage of unformed stools

41. Nonspecific – treat symptoms Opioids – slow intestinal motility, decrease fluid in small intestine – stool goes into large intestine with less fluid Lomotil and imodium Bulk-forming agents Anticholinergics antispasmodics - atropine

42. Infectious diarrhea Infections – bacteria and virus Salmonella, shigella, campylobacter, clostridium Traveler’s diarrhea – e coli

43. Crohn’s disease and ulcerative colitis Aminosalicylates – sulfasalazine – metabolized producing component which reduces inflammation Mild to moderate ulcerative colitis

44. Glucocorticoids – suppress inflammation Primarily used for an exacerbation

45. immunomodulators Azathioprine and mercaptopurine Cyclosporine Infliximab methotrexate

46. Tocopherole acetate (Tocopheroli acetas) Vitamin E is produced in many forms: 5 %, 10 % and 30 % oil solution in 10, 20 and 50 ml bottles; elastic capsules with 0,1 and 0,2 ml of 50 % solution in oil; ampoules with 1 ml of 5 %, 10 % and 30 % oil solutions.

47. CarsilLegalon

48. Mechanism of action of legalon

49. Essentiale Is produced in 5 ml ampoules and in capsules

50. Lipostabil

51. Pancreatin (Panсreatinum) Is produced in 0,25 g and 0,5 g dragee (tablets).

52. Panzynorm forte

53. Festal, Enzistal, Mezym-forte

54. No-spa, nicospan

55. Baralgin

56. Bil-berries St. John’s wort

57. Pepper mint Chamomile

58. END