LITERATURE REVIEW: IMPAIRED DRUG ABSORPTION IN PATIENTS WITH SHORTENED BOWEL Atalie Ferring, Lindsay Snodgrass, Dr. Nita Pandit (Mentor) Drake University College of Pharmacy and Health Sciences, Department of Pharmaceutical Sciences Background Drug absorption may be a problem in patients with shortened bowel due to:  Less surface area  Less residence time  pH dependent drugs  Loss of bile salt reabsorption [small intestine] Clinicians are often unaware of this when creating dosing regimens. There is insufficient literature on this topic. Normal Small Intestine (Small Bowel) 1,2 Total length: feet Duodenum: <1.0 foot Jejunum: feet Ileum: feet Normal Large Intestine 3,4 (Large Bowel/Colon) Total length: feet Shortened Intestines Small intestine: short bowel syndrome (SBS) Large intestine: no medical diagnosis Reasons for shortening 5  Inflammatory bowel disease  Intestinal cancer  Intestinal obstruction Ostomy  Drug easily identified in stool [bag]  Use as resource Objectives 1.Review published evidence of impaired drug absorption in patients with shortened small intestine or large intestine 2.Make recommendations to clinicians for appropriate drug therapy in these patients 3.Use ostomy patients as a resource for identifying drug absorption problems Hypothesis: Drugs that will be a problem Shortened small intestine  Poorly dissolving/poorly absorbing  Poor bioavailability Shortened small intestine or large intestine  Sustained-release or extended-release  Drugs given in large doses Methods Studies obtained through literature searches of MEDLINE, SCOPUS, SciFinder Scholar, and SuperSearch databases Keywords: drug malabsorption, absorption, bioavailability, ostomy, ileostomy, short bowel, drug monitoring. Results 15 papers found; discuss drug malabsorption  Problems reported with 14 drug products Reliability of papers  Sample size, variability, peer-reviewed  Difficult to assess Lack of published literature  Drug malabsorption in patients with shortened bowel  Drug products in ostomy bags  Clinicians unaware of problem Options for patients with shortened bowel  Individual dose-adjustment  Selection of a different route  Therapeutic monitoring of blood levels  Crushing NameProblem in SBS/SC PatientsProposed Reason cimetidine 6,7 ↓ absorption, ↓ efficacyAbsorption in ileum digoxin 8,9.10 ↓ dissolution/absorption, ↓ FPoorly dissolved hydrochlorothiazide 11 ↓ absorption, ↓ Fduodenum/ jejunum isosorbide dinitrate 12 ↓ absorptionAbsorption in colon nifedipine 12 ↓ absorptionAbsorption in colon diclofenac sodium 12 ↓ absorptionAbsorption in colon cefaclor 13,10 ↓ absorption, ↓ efficacy? Rapidly absorbed erythromycin stearate 14 ↓ absorption? Rapidly absorbed cyclosporin 15,10 ↓ absorption, ↓ FPoorly absorbed acetaminophen 16,10 ↓ absorption, ↓ FAbsorption in jejunum amoxicillin 17 ↓ absorption, ↓ FRapidly absorbed oral contraceptives 18 ↓ absorptionRapidly absorbed phenytoin 19 ↓ absorptionAbsorption in entire intestine morphine sulfate 20 ↓ absorptionAbsorbed in entire intestine, poor F Conclusions