1. Week – 4 Pharmacology Drugs and Disorders of the Gastrointestinal Tract Nutritional Supplements chapters – 25 and 20

2. GI TRACT – A DEFINITION Long, hollow tube from the mouth to the anus primary purpose - to convert food into chemicals that can be used by the body Food’s pathway through GI tract … … Mouth  Esophagus  Stomach  Small Intestines  [gallbladder, liver, pancreas enzymes]  Large Intestine  Anus 2

3. HOW DRUGS WORK IN THE GI SYSTEM 3 1. they increase or decrease function by changing muscle tone, or changing the level of secretions (for example … decreasing the level of acid-production to prevent or cure ulcers) 2. Increase or decrease ‘emptying time’ (the time it takes food to pass through the stomach/GI tract) … this is accomplished by altering ‘peristalsis’ 3. Replacement of enzymes (in cases of deficiency)

4. LIFESTYLE MODIFICATIONS FOR GI PROBLEMS 15 Foods to avoid Tomato Orange/Grapefruit juice ETOH Caffeine Chocolate peppermint Don’t over eat, maintain ‘normal’ weight Avoid eating within 2 hours of bedtime Don’t smoke Elevate head of the bed 6-8 inches (gravity can help empty the stomach!)

5. GASTRIC CONDITIONS/ENVIRONMENT 5 Acidic environment is needed in the stomach for enzymes to work and inhibit or kill microorganisms found in food and other materials that are ingested Sometimes acid level is too high and can erode the stomach wall/lining Worry and Stress increase secretions in the stomach This can lead to ulcers Gastric ulcer = Peptic ulcer = stomach ulcer (all the same) ‘Deodenal ulcer’ is found at the junction of stomach and duodenum

6. ULCERS – GENERAL INFO 6 Goal of treatment: to alleviate symptoms, promote healing prevent complications, and prevent recurrence. Heliobacter pylori has been found in >75% of peptic ulcer disease! (the remaining 25% caused by NSAID & ASA use) Opportunistic infection at the site of the ulcer. Smoking slows the healing of ulcers … it increases acid production Eating multiple small meals decreases changing acid levels Drugs (ASA and NSAID’s) can cause irritation to the stomach

7. MEDICATIONS TO TREAT ULCER 7 All these work together to eradicate the microorganism Helicobacter pylori and reestablish an intact lining of the stomach by neutralizing excess hydrochloric acid. Antacids (neutralizes acid that is currently present) Mucosal protectants (forms a protective barrier on the surface of ulcerated tissue) Antibiotics Antisecretory Agents (reduce excess acid-production) Antispasmodics

8. ANTACIDS 8 Alkaline compounds used to neutralize HCl acid in the stomach Used as prophylaxis for stress-induced ulcers Relieves symptoms of Gastroesophageal Reflux Disease (GERD) Protect intestinal mucosa by neutralizing acid Poorly absorbed (this is good!), therefore they do not alter systemic pH when used properly

9. ANTACIDS CONTINUED 9 More effective when taken on a regular basis Can be dosed up to 7 times per day (before meals, after meals, and bedtime) Come in liquids, chew tabs, and a few swallow tabs or caps. Short duration of action … ~ 30 minutes on empty stomach Chronic use can produce acid rebound Classified by formulation (aluminum, magnesium, etc)

10. ANTACID FORMULATIONS 10 Aluminum (side-effect = Constipation) Calcium (side-effect = Constipation) Magnesium (side-effect = Diarrhea) Sodium (can change systemic pH – dangerous choice) Aluminum & Magnesium combo is common because these cancel out each other’s negative side-effects … very effective! Choose product with care, based on patient’s profile NOTE - sodium bicarbonate changes the pH (acid/base balance) in the body and can lead to other problems

11. PATIENT EDUCATION FOR ANTACIDS 11 Chewable antacids should be taken with a full glass of water or milk to help with absorption Shake liquids well and don’t follow with additional liquids … this dilutes the antacid, reducing its effect Antacids and H-2 blockers should be taken at least an hour apart, antacids first. careful when taking other medications, these can interfere with absorption of other drugs Examples of Antacids … Mylanta, Maalox Tums, Rolaids

12. ANTISECRETORY AGENTS 12 These Decrease the secretion of gastric fluids (acid) Two types H2-receptor antagonists (H2) Zantac (ranitidine) Pepcid (famotidine) Proton pump inhibitors (PPIs) Prilosec (omeprazole) Previcid (lansoprazole) Nexium (esomeprazole) * NOTE – see how the generic drug names within the same class tend to end with the same suffix? This is very helpful in learning drugs!

13. H2-RECEPTOR ANTAGONISTS 13 Inhibits interaction of histamine (H2) at the H2-receptors Histamine receptors in gastric mucosa mediate the secretion of gastric acid and pepsin Work to directly inhibit the acid secretions Not affected by food (ok with or w/o meals) best to take at bedtime (acid production peaks during the overnight hours!) Well tolerated, low incidence of side-effects Very effective for GERD Available as OTC and RX

14. PROTON PUMP INHIBITORS (PPIS) 14 Inhibits chemicals essential to Gastric-acid production (H+ and K+ ions, which generate gastric acid) For SHORT TERM treatment of benign gastric ulcers and GERD! often used in combo with antibiotics for H. pylori to promote healing and prevent reoccurrence Should only be used for confirmed active ulcers and erosive esophagitis. Side effects are relatively rare (headache, abdominal pain, diarrhea, nausea, constipation are possible)

16. PROTECTANTS 16 Carafate (sucralfate) Adheres to ulcerated tissue, forming a barrier Soothing effect like Antacids Does not alter pH Take on empty stomach Cytotec (misoprostol) Protects from irritation of certain medications, like NSAIDS Used to prevent ulcers in patients who must take medications that can cause gastric irritation Take on a empty stomach

17. ANTIBIOTICS 17 Commonly used to treat Heliobacter pylori Treatment with two antibiotics decreases resistance Used in combo with bismuth-salts to prevent bacteria from attaching stomach wall. Antibiotics that are commonly used … Amoxicillin Tetracycline Metronidazole (Flagyl) Clarithromycin (Biaxin) antisecretory agents often used in combo (PrevPak) See table 25-6 in text on page 503

18. ANTISPASMOTICS 18 These relax GI smooth-muscle tissue, reducing cramping and spasms (IBS) Not as commonly used as the previously mentioned medications due to more frequent Side-Effects Cause problems in glaucoma & urinary retention patients more Side Effects … Visual disturbances Confusion in demented patients Changes in heart rhythm Headache Insomnia

19. VITAMINS, MINERALS, AND GENERAL NUTRITION CHAPTER - 20

20. “YOU ARE WHAT YOU EAT” o Your body needs a balance of nutrients for optimum health … Water Minerals/Vitamins Proteins/Carbohydrates Fiber Essential fatty acids

21. FOOD & NUTRITION BOARD OF THE NATIONAL ACADEMY OF SCIENCE o a DRI is a ‘Dietary Reference Intake’ for vitamins and minerals: EAR (E STIMATED A VERAGE R EQUIREMENT ) RDA (R ECOMMENDED D AILY A LLOWANCE ) AI (A DEQUATE I NTAKE ) UL (U PPER I NTAKE L EVEL )

22. o Vitamins- ( origin of names - see pg. 46) Organic materials required in minute amounts/ we can’t manufacture. o Minerals- non-organic material, found in the “earth”. o Essential fatty acids- found in fats, not produced by the body made up of carbon and hydrogen. o Antioxidants - inhibit oxidation, reducing tissue damage/aging: Vitamin C Vitamin E Lutien o Fiber - (see table 15-1 for sources) A food substance, found only in plants… not digested “roughage”

23. VITAMINS: CHARACTERISTICS Organic in nature Very small amounts needed daily Preformed in the diet or synthesized by intestine NECESSARY for body’s normal growth & function Store in dark containers in a cool place NECESSARY for enzymatic reactions Common vitamin-deficiency symptoms include … - aches/pains - general, overall ‘poor’ feeling - tiredness/low energy

24. ‘FAT SOLUBLE’ VITAMINS o be careful … these can accumulate! Vitamin A Vitamin D Vitamin E Vitamin K

25. ‘WATER SOLUBLE’ VITAMINS (2) General Groups 1) Those that release energy from food (thiamine, riboflavin) 2) Aides to red blood cell formation (folic acid, Vitamin B 12 )

26. FOLIC ACID IN PREGNANCY o extremely important supplement for women! o Reduces the incidence of neural tube birth defects such as … * Spina Bifida * anenchephaly * encephalocele o … essential for DNA formation o Women of childbearing age should consume 0.4-mg/day of Folic acid o Also known as ‘Folate’

27. MINERALS o Iron – (oral, injectable) o Calcium - (lactate/glucomate/chloride/carb onate) o Phosphorous o Potassium – (chloride/gluconate) o Freely found in soil, plants used for food, and sea food. o Only required in trace amounts o Role in transmission of nerve impulses o Control of cardiac rhythm

28. 1)The disease that develops due to a vitamin overdose is…? 2)A non-organic material found in the Earth’s crust is a…? QUESTIONS!

29. ANSWERS! 1)Hypervitaminosis 2)Mineral

30. HAVE A GREAT WEEK, THANKS FOR YOUR INPUT! Remember, you are welcome to submit any and all questions to me as they arise … I check my email daily, as well as the ‘VIRTUAL OFFICE’. Thanks again, -Dr. C