1. The Gastrointestinal & Urinary Systems
Jessica Tagerman
PharmD, RPh

2. Esophageal Disorders

3. What is an esophageal disorder
What is an esophageal disorder? What are examples of esophageal disorders?

4. Esophageal Disorders
An abnormality of the esophagus (tube that connects the back of the mouth to the stomach)
May be caused by complications of certain medications or infection

5. Esophageal Disorders Examples:
Heartburn: An incompletely closed LES allows acidic stomach contents to back up (reflux) into the esophagus. Reflux can cause heartburn, cough or hoarseness, or no symptoms at all.
Gastroesophageal reflux disease (GERD): When reflux occurs frequently or is bothersome, it's called gastroesophageal reflux disease (GERD).
Esophagitis: Inflammation of the esophagus. Esophagitis can be due to irritation (as from reflux or radiation treatment) or infection.
Esophageal ulcer: An erosion in an area of the lining of the esophagus. This is often caused by chronic reflux.

6. Treatment of Esophageal Disorders

7. Antacids Antacids Generic Name Brand Name Misc. Information
Baking Soda
May result in the product of carbon dioxide, leading to bloating and gas
Calcium Carbonate
Tums, Rolaid, etc.
Aluminum Hydroxide
May cause constipation
Magnesium Hydroxide
Diarrhea
Aluminum Hydroxide + Magnesium Hydroxide
Mylanta, Maalox
Used together to avoid constipation or diarrhea
The duration of action is approximately minutes
Caution:
Change acidity which can affect drug absorption (i.e. Tetracyclines)
Rebound effect

8. H-2 Receptor Antagonists
Histamine-2 Receptor Antagonist
Generic Name
Brand Name
Mechanism of Action
Cimetidine
Tagamet®
When histamine (a neurotransmitter) binds to H2 receptor on cells in the stomach, it causes secretion of acid. These drugs block the receptor to prevent the secretion of acid
Ranitidine
Zantac®
Famotidine
Pepcid®
Nizatidine
Axid®
Very well tolerated
Look for the –tidine ending!
Caution with cimetidine- causes many drug interactions!

9. Proton Pump Inhibitors
Generic Name
Brand Name
Mechanism of Action
Omeprazole
Prilosec®
Act within the stomach cells to prevent the production of acid
Pantoprazole
Protonix®
Lansoprazole
Prevacid®
Rabeprazole
Aciphex®
Esomeprazole
Nexium®
Look for the –prazole stem!
Lower stomach acid output more than H2 antagonists
Capsules may be opened and poured into applesauce, but DO NOT chew the pellets

10. H. Pylori Ulcer
When a bacterium (i.e. bacterium helicobacter pylori) weakens the lining of the stomach or duodenum.
Treatment includes combination of the following:
Antibiotics
PPI
+/- Bismuth Subsalicylate
Has an antibacterial effect and gastrointestinal effect
Commerically available combination products
Including “PrevPac”
Must treat with an antibiotic to kill the bacterium

11. Knowledge Check
Homer Simpson, on average, has 3 donuts a day. Unfortunately, they’ve been giving him terrible heartburn, so he’s been taking 2 tums after his dessert. What would the pharmacist say regarding his self-treatment?
“Stop taking the tums! Tums are bad!”
“Tums should only be used infrequently. If you’re having frequent heartburn, try taking a PPI, such as Prilosec.”
“Zantac is cheaper.”
“Try switching to Jelly Donuts. In my experience, they cause less heartburn”
Of course, first line therapy for Homer would be to cut out the donuts!
“Tums should only be used infrequently. If you’re having frequent heartburn, try taking a PPI, such as Prilosec.”

12. Knowledge Check Proton Pump Inhibitors end in ______________________
H2 Antagonists end in _________________________
PPIs: prazole
H2 blockers: tidine

13. Switching gears

14. “Stomach issues”

15. What is the pathophysiology of diarrhea?

16. Diarrhea
Muscle contractions move fecal material too quickly along the GI tract, so there isn’t enough time for water to be absorbed in the body.
Bowel movements are frequent and feces are loose and watery.

17. Antidiarrheal Medications
Anti-peristaltic agents
Generic Name
Brand Name
Mechanism of Action
Loperamide
Imodium® AD
Inhibit the propulsive movements of the intestine
Diphenoxylate/Atropine
Lomotil®
Misc.
Bismuth Subsalicylate
Pepto Bismol®, Kaopectate®
Anti-secretory action that fluid in diarrhea
Atropine alone causes dry mouth, blurred vision, slow heart rate
Salicylate poisoning: The earliest symptoms of acute aspirin poisoning may include ringing in the ears (tinnitus) and impaired hearing. More clinically significant signs and symptoms may include rapid breathing (hyperventilation), vomiting, dehydration, fever, double vision, and feeling faint.
Diphenoxylate/Atropine
High doses of diphenoxylate may cause narcotic like high, so given with atropine to discourage abuse.
Bismuth Subsalicylate
Caution: salicylate poisoning

18. What is the pathophysiology of constipation?

19. The body absorbs too much water out of the fecal material
Constipation
Fecal material doesn’t move fast enough through intestinal tract, leading to infrequent and painful emptying of the intestines.
The body absorbs too much water out of the fecal material

20. Laxatives 7 classes of laxatives: Bulk-Forming Emollient Lubricant
Saline
Hyperosmotic
Stimulant
Combination

21. Laxatives Class1: Bulk-Forming Class 2: Emollient Laxatives
Generic Name
Brand Name
Mechanism of Action
Psyllium
Metamucil®
Dissolve or swell in the intestine, which stimulates the movement of the intestine.
Methylcellulose
Citrucel®
Class 2: Emollient Laxatives
Docusate Sodium
Colace®
“Stool Softeners”- mix fatty and watery substances in the intestine to soften fecal content.
Time to Relief:
Bulk-Forming Laxatives: hours
Emollient Laxatives: up to 5 days

22. Laxatives Class 3: Lubricant Laxatives Class 4: Saline Laxatives
Generic Name
Brand Name
Mechanism of Action
Mineral Oil
Coats the stool to allow passage with no straining
Class 4: Saline Laxatives
Magnesium Citrate
Citroma®
Contain salts that are not absorbed, and these salts draw water into the intestines. The increased pressure from the water stimulates movement in the intestine
Magnesium Hydroxide
Milk of Magnesia
Time to Relief:
Saline Laxatives: 30 minutes

23. Laxatives Class 5: Hyperosmotic Class 6: Stimulant Laxatives
Generic Name
Brand Name
Mechanism of Action
Glycerin
Draw water into the intestine
Polyethylene Glycol
Miralax®
Class 6: Stimulant Laxatives
Senna
Senokot®
Irritate the lining of the intestine which causes the intestines to excrete their contents.
Bisacodyl
Dulcolax®
Time to Relief:
Hyperosmotic Agents: 30 minutes
Stimulant Agents: up to 12 hours orally, 15 minutes rectally

24. Laxatives Combination Generic Name Brand Name Mechanism of Action
Senna/Docusate
Senokot®-S, Peri-Colace®

25. Gastrointestinal infections

26. Gastrointestinal Infections
Caused by viruses, bacteria, parasites, or protozoan organism
↑ peristaltic activity of GI tract leading to nausea, vomiting, or diarrhea
Protective response to rid body of bacteria
Take caution when giving anti-diarrheal or anti-nausea medications: the body is trying to rid itself of the organism!

27. Knowledge Check
Grandma left the potato salad in the sun for 5 hours at the family picnic yesterday. When she got home, she put it back into the refrigerator, and then served it for lunch the next day. Everybody got sick. What treatment would the pharmacist most likely recommend?
Senna/Docusate q2h
No treatment- just replenish fluids with sports drinks/pedialyte
Pepto Bismol q8h
Lomotil q12h
B) Most likely it’s from an organism, “food poisoning”- let your body rid yourself of the organism

28. Switching gears

29. Inflammatory bowel disease

30. What is Inflammatory Bowel Disease?

31. Inflammatory Bowel Disease
Chronic condition where bowels are sensitive to foods and stress
Primary symptom may be diarrhea, constipation, or a mix of both
Includes Crohn’s disease and ulcerative colitis
Goals of treatment: resolution of abdominal pain, diarrhea, inflammation, and other symptoms
Multiple medications may be used concurrently
Treatment also includes diet modification
May be triggered by anxiety.

32. Medications to treat IBD
Aminosalicylates
Generic Name
Brand Name
Mechanism of Action
Mesalamine
Asacol®, Lialda®, Pentasa®
Block production of some inflammatory mediators.
Sulfasalazine
Azulfidine®
NEVER use in patients with aspirin allergies

33. Medications to treat IBD
Oral Corticosteroids
Generic
Brand
Mechanism/Notes
Budesonide
Entocort® EC
Delivers medication straight to the illeum
Immunosuppressive Agents
Generic
Brand
Mechanism/Notes
Azathioprine
Imuran®
Suppress the immune system to decrease inflammation
Reserved for patients who don’t respond to steroid agents.
Cause myelosuppression, liver toxicity, infections, and pancreatitis
Mercaptopurine
Other agents may include: anti-diarrheals, anti-bacterials, antidepressants

34. Medications to treat IBD
Monoclonal antibodies
Generic Name
Brand Name
Mechanism of Action
Infliximab
Remicade®
Bind to tumor necrosis factor (a cell signaling protein) to reduce inflammation
Adalimumab
Humira®
Look for –mab suffix!
IV or SQ routes of administration
May reactivate TB- must be given TB skin test before starting therapy

35. Knowledge Check
Suzy Q suffers from IBD but also has an aspirin allergy. Which product should not be prescribed?
Humira®
Mesalamine
Imuran®
Budesonide
Mesalamine- do not use in patietns with allergies to aspirin

36. Switching gears

37. The Urinary System

38. What causes overactive bladder?

39. Overactive Bladder
Caused by involuntary muscle contractions creating an urgent need to urinate.
Muscle contractions can be blocked if you block a certain type of receptor, muscarinic receptors.
Caution: Side effect profile! Muscarinic receptors also located in:
Brain
Heart
Eyes
Salivary Glands
GI tract
SE include dry mouth, constipation, urinary retention, dry eyes, blurry vision, increased heart rate, confusion

40. Overactive Bladder Lubricant Laxatives Generic Name Brand Name
Darifenacine
Enablex®
Oxybutynin
Ditropan®
Solifenacin
Vesicare®
Tolterodine
Detrol®