1. PYRAMID POINTS CHAPTER 56: GASTROINTESTINAL MEDICATIONS

2. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-2 PYRAMID POINTS I. Antacids  Description Should be taken on regular schedule; some as prescribed taken 1 and 3 hours after each meal or at bedtime Should be taken on regular schedule; some as prescribed taken 1 and 3 hours after each meal or at bedtime For maximum benefit treatment with antacid, elevate gastric pH above 5 For maximum benefit treatment with antacid, elevate gastric pH above 5 Tablets should be chewed thoroughly, followed with glass of water or milk Tablets should be chewed thoroughly, followed with glass of water or milk Allow 1 hour between antacid administration, administration of other medications Allow 1 hour between antacid administration, administration of other medications  Aluminum hydroxide preparations Contain significant amounts of sodium; use with caution in clients with hypertension, heart failure Contain significant amounts of sodium; use with caution in clients with hypertension, heart failure Constipation most common side effect Constipation most common side effect Can reduce effects of tetracyclines, warfarin sodium (Coumadin), digoxin (Lanoxin); reduce phosphate absorption; can cause hypophosphatemia Can reduce effects of tetracyclines, warfarin sodium (Coumadin), digoxin (Lanoxin); reduce phosphate absorption; can cause hypophosphatemia

3. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-3 PYRAMID POINTS I. Antacids (continued)  Calcium carbonate preparations rapid acting, can cause constipation  Magnesium hydroxide preparations Also saline laxative; most common side effect diarrhea Also saline laxative; most common side effect diarrhea Contraindicated in clients with intestinal obstruction, appendicitis, undiagnosed abdominal pain Contraindicated in clients with intestinal obstruction, appendicitis, undiagnosed abdominal pain In clients with renal impairment, magnesium can accumulate, leading to toxicity In clients with renal impairment, magnesium can accumulate, leading to toxicity  Sodium bicarbonate Can cause systemic alkalosis in clients with renal impairment Can cause systemic alkalosis in clients with renal impairment Use with caution in clients with hypertension, heart failure Use with caution in clients with hypertension, heart failure

4. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-4 PYRAMID POINTS II. Gastric Protectants  Misoprostol (Cytotec) Administer with meals Administer with meals Causes diarrhea, abdominal pain Causes diarrhea, abdominal pain  Sucralfate (Carafate) Administered orally on empty stomach Administered orally on empty stomach May cause constipation May cause constipation May impede absorption of warfarin sodium, phenytoin (Dilantin), theophylline, digoxin, some antibiotics May impede absorption of warfarin sodium, phenytoin (Dilantin), theophylline, digoxin, some antibiotics  Administer 2 hours apart from these medications

5. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-5 PYRAMID POINTS III. Histamine 2 Receptor Antagonists  Description Suppress secretion of gastric acid Suppress secretion of gastric acid  Should be used with caution in clients with impaired renal or hepatic failure  Cimetidine (Tagamet) Food reduces rate of absorption Food reduces rate of absorption If administered IV, 300-mg dose can be diluted in total volume of 20 mL normal saline or 5% dextrose, injected slowly over not less than 2 minutes; also may be diluted in 100 mL, infused over 15 to 20 minutes If administered IV, 300-mg dose can be diluted in total volume of 20 mL normal saline or 5% dextrose, injected slowly over not less than 2 minutes; also may be diluted in 100 mL, infused over 15 to 20 minutes Administer 1 hour apart from antacids Administer 1 hour apart from antacids Passes blood-brain barrier; central nervous system side effects may occur Passes blood-brain barrier; central nervous system side effects may occur

6. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-6 PYRAMID POINTS III. Histamine 2 Receptor Antagonists (continued)  Cimetidine (Tagamet) (continued) Reduced dosage in clients with renal impairment necessary Reduced dosage in clients with renal impairment necessary IV administration can lead to hypotension, dysrhythmias IV administration can lead to hypotension, dysrhythmias  Ranitidine (Zantac) Side effects uncommon Side effects uncommon Does not penetrate blood-brain barrier Does not penetrate blood-brain barrier For IV administration, dilute with 20 mL normal saline or 5% dextrose; administer slowly over 5 minutes; may be diluted in 100 mL, administered over 15 to 20 minutes For IV administration, dilute with 20 mL normal saline or 5% dextrose; administer slowly over 5 minutes; may be diluted in 100 mL, administered over 15 to 20 minutes  Famotidine (Pepcid), nizatidine (Axid) Do not need to be administered with food Do not need to be administered with food

7. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-7 PYRAMID POINTS IV. Proton Pump Inhibitors  Suppress gastric acid secretion  Used to treat active ulcer disease, erosive esophagitis, pathological hypersecretory conditions  Contraindicated in hypersensitivity  Common side effects include headache, diarrhea, abdominal pain, nausea

8. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-8 PYRAMID POINTS V. Medication Regimens to Treat Helicobacter pylori Infections  Antibacterial agent alone not effective in eradicating bacterium  Dual, triple, quadruple therapy with variety of combinations used  Combinations include antibacterial agents, proton pump inhibitors, histamine 2 receptor antagonists, antacids  Common treatment protocol is triple therapy with two antibacterial agents, one proton pump inhibitor  If triple therapy fails, quadruple therapy recommended, with two antibiotics, one proton pump inhibitor, one bismuth or histamine 2 receptor antagonist

9. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-9 PYRAMID POINTS VI. Gastrointestinal Stimulants  Stimulate motility of upper gastrointestinal tract, increase rate of gastric emptying  Used to treat gastroesophageal reflux, paralytic ileus  May cause restlessness, drowsiness, extrapyramidal reactions, insomnia, headache  Usually administered 30 minutes before meals or at bedtime  Contraindicated in clients with sensitivity, mechanical obstruction, perforation, gastrointestinal hemorrhage

10. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-10 PYRAMID POINTS VI. Gastrointestinal Stimulants (continued)  Can precipitate hypertensive crisis in clients with pheochromocytoma  Safety in pregnancy not established  Metoclopramide (Reglan) can cause parkinsonian symptoms  Anticholinergics, opioid analgesics antagonize effects of metoclopramide  Alcohol, sedatives, cyclosporine (Sandimmune), tranquilizers produce additive effect

11. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-11 PYRAMID POINTS VII. Bile Acid Sequestrants  Description  Act by absorbing, combining with intestinal bile salts, which are then secreted in feces, preventing intestinal reabsorption  Used to treat hypercholesterolemia, biliary obstruction, pruritus associated with biliary disease  Taste, palatability causes for noncompliance  Should be used cautiously in clients with bowel obstruction, severe constipation  Side effects include nausea, bloating, constipation  Stool softeners, other sources of fiber can be used to relieve side effects

12. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-12 PYRAMID POINTS VIII. Medications to Treat Hepatic Encephalopathy  Lactulose (Cholac, Chronulac, Duphalac) Reduces ammonia levels Reduces ammonia levels Administered orally or rectally Administered orally or rectally  Neomycin Administer orally or via nasogastric tube Administer orally or via nasogastric tube Used with caution in clients with renal impairment Used with caution in clients with renal impairment

13. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-13 PYRAMID POINTS IX. Pancreatic Enzyme Replacements  Used to supplement, replace pancreatic enzymes  Should be taken with meals or snack  High-fiber diet may increase efficacy of medication  Side effects include abdominal cramps, pain, nausea, diarrhea  Products that contain calcium carbonate or magnesium hydroxide interfere with action of enzyme replacement

14. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-14 PYRAMID POINTS X. Treatment of Inflammatory Bowel Disease  Antimicrobials Prevent or treat secondary infections Prevent or treat secondary infections  5-Aminosalicylates (5-ASA) Decrease inflammation Decrease inflammation  Corticosteroids Decrease inflammation Decrease inflammation  Immunosuppressants Suppress immune system Suppress immune system  Immunomodulators Reduce inflammation Reduce inflammation

15. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-15 PYRAMID POINTS XI. Antiemetics  Control vomiting and motion sickness  Monitor for drowsiness  Protect the client from injury  Monitor intake and output

16. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-16 PYRAMID POINTS XII. Laxatives  Bulk-forming laxatives Increase bulk Increase bulk Contraindicated in bowel obstruction Contraindicated in bowel obstruction  Stimulant cathartics Stimulate GI motility Stimulate GI motility  Saline (osmotic) cathartics Produce bulk; stimulate peristalsis Produce bulk; stimulate peristalsis  Stool softeners Soften feces Soften feces  Lubricants Mineral oil interferes with absorption of fat-soluble vitamins Mineral oil interferes with absorption of fat-soluble vitamins

17. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-17 PYRAMID POINTS XIII. Medications to Control Diarrhea  Opioids Decrease intestinal motility, peristalsis Decrease intestinal motility, peristalsis When poisons, infections, bacterial toxins are cause of diarrhea, opioids worsen condition When poisons, infections, bacterial toxins are cause of diarrhea, opioids worsen condition  Other antidiarrheals Monitor bowel movements Monitor bowel movements Monitor fluid and electrolyte balance Monitor fluid and electrolyte balance

18. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-18 PYRAMID POINTS XIV. Antispasmodics  Description Relax smooth muscle of GI tract Relax smooth muscle of GI tract  Side effects Constipation or diarrhea Constipation or diarrhea Rash Rash Euphoria Euphoria Dizziness Dizziness Nausea and vomiting Nausea and vomiting Weakness Weakness

19. ADULT HEALTH: Gastrointestinal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.56-19 The client has been given a prescription for metoclopramide (Reglan) four times a day. The nurse determines that the client is taking the medication at optimal times if the client reports using the medication: 1. One hour after each meal and at bedtime 2. Every 6 hours, spaced evenly around the clock 3. 30 minutes before meals and at bedtime 4. With each meal and at bedtime