Peptic Ulcer Disease (PUD)

Key Concepts

• Peptic ulcer disease, gastrointestinal disorders, and the use of vitamins, minerals, and supplements are key concepts
• Gastrointestinal disorders include nausea, vomiting, diarrhea, constipation, and IBS

Peptic Ulcer Disease (PUD) Management

• Antibiotics like amoxicillin, bismuth, clarithromycin, metronidazole, tetracycline, and tinidazole are used
• Histamine2-receptor antagonists like ranitidine are used
• Proton pump inhibitors like omeprazole are administered
• Mucosal protectants like sucralfate are given
• Antacids such as aluminum hydroxide and calcium carbonate are used
• Prostaglandin E analogs like misoprostol are used

PUD Pharmacological Management

• Aims to restore GI mucosal defenses using mucus and bicarbonate
• Reduces offending agents like H. pylori, gastric acid, pepsin, smoking, and NSAID use
• Medications like antibiotics heal the GI tract
• Key therapeutic outcomes include reduction of symptoms, promotion of healing, prevention of complications, and prevention of recurrence
• Patients should avoid alcohol, smoking, and NSAID use during treatment
• Antibiotics are generally taken for 2 weeks, while total therapy lasts 4-6 weeks

Antibiotics for H. pylori

• Used to eradicate infections
• Therapy includes a combination of 2-3 antibiotics for 14 days
• These measures increase effectiveness and reduce medication resistance
• Amoxicillin, clarithromycin, and metronidazole can be taken with food to decrease GI symptoms
• Nausea and diarrhea are common side effects
• Completing the full course of antibiotics is imperative

Histamine2-Receptor Antagonists

• Includes cimetidine, ranitidine, famotidine, and nizatidine
• Blocks histamine action at H2 receptors, reducing gastric acid volume and hydrogen ion concentration
• Commonly prescribed for gastric and duodenal ulcers, GERD, hypersecretory conditions, aspiration pneumonitis, heartburn, and acid indigestion
• Used with antibiotics to treat H. pylori
• They decrease gastric acidity, increasing bacterial colonization risk Use cautiously in high-risk pneumonia patients, including those with COPD
• Cimetidine has numerous side effects like blocked androgen receptors, gynecomastia, decreased libido, impotence, CNS depression, lethargy, confusion, and depression
• Ranitidine can cause constipation, diarrhea, and nausea
• Famotidine may cause drowsiness, dizziness, and constipation, advise taking at bedtime
• Cimetidine can cause toxic levels of warfarin, phenytoin, theophylline, and lidocaine
• Antacids and H2 blockers should not be taken together, as it decreases effectiveness

Proton Pump Inhibitors (PPIs)

• Includes omeprazole, pantoprazole, lansoprazole, dexlansoprazole, rabeprazole, esomeprazole
• Blocks basal and stimulated acid production, reducing gastric acid secretion
• Prescribed for gastric and duodenal ulcers, erosive esophagitis, GERD, and hypersecretory conditions
• Short-term side effects include headache, diarrhea, nausea, and vomiting
• Long-term therapy impacts GI defense mechanisms and nutritional absorption
• This can lead to pneumonia, osteoporosis, fractures, rebound acid hypersecretion, and hypomagnesemia
• Monitor for infection signs/symptoms, increase calcium and vitamin D intake, taper off medication slowly, and report tremors, muscle cramps, or seizures
• Use cautiously in clients with COPD
• Omeprazole raises digoxin and phenytoin levels, potentially causing toxicity
• PPIs decrease absorption of antifungal medications and the effectiveness of clopidogrel (Plavix)

Mucosal Protectants

• Sucralfate adheres to the ulcer surface for up to 6 hours, protecting it from acid and pepsin
• Mostly used for acute duodenal ulcers and maintenance therapy, less so for gastric ulcers and GERD
• Can be split or dissolved (slurry), but not crushed or chewed; taken four times a day
• Administer 1 hour before meals/AC and at bedtime (HS)
• Not absorbed, resulting in no systemic effects
• Drink at least 1500 ml fluids daily and increase fiber to prevent constipation
• Use cautiously in patients with impaired renal function
• Impairs absorption of phenytoin, digoxin, warfarin, and ciprofloxacin to subtherapeutic levels
• Take medications at least 2 hours apart and do not take with antacids

Antacids

• Aluminum hydroxide, magnesium hydroxide, and calcium carbonate neutralize gastric acid
• Creates neutral salts and inactivates pepsin
• Stimulates prostaglandin production to protect the gastric mucosa
• Treats peptic ulcer disease and GERD, promoting healing and pain relief
• Administer seven times a day
• Chew and swallow tabs with 8 ounces of milk or water or shake liquids well
• Take on an empty stomach 1 hour before or 3 hours after meals, and at bedtime
• Separate from other medications by 1 hour
• Baking soda (sodium bicarbonate) mixed in water can be an effective antacid
• This can also cause metabolic alkalosis in large quantities
• Aluminum and calcium cause constipation
• Magnesium causes diarrhea

Further Antacid Considerations

• Aluminum can cause hypophosphatemia and hypomagnesemia
• Magnesium toxicity is possible for patients with renal impairment
• Sodium-containing antacids can result in fluid retention
• Avoid in patients with heart failure and hypertension
• Use cautiously with abdominal pain; do not use if perforation is suspected
• Aluminum compounds bind to phenytoin, separate by 4-6 hours

Simethicone

• Used to treat sharp gassy pains, often in babies

Prostaglandin E Analogs

• Misoprostol is an endogenous prostaglandin
• Decreases acid secretion, increases bicarbonate and protective mucus secretion, and promotes vasodilation
• Maintains submucosal blood flow, preventing gastric ulcers
• Used for long-term NSAID use and with medications like diclofenac
• Common side effects include diarrhea, dysmenorrhea, and spotting
• Pregnancy Risk Category X drug and can cause spontaneous abortion
• Take with meals and at bedtime

Peptic Ulcer Disease Management Review

• Signs of effective therapy for peptic ulcer disease include reduced abdominal pain and absence of GI bleeding
• When educating a patient with H. pylori on taking amoxicillin and clarithromycin, advise them to take these medications with food
• When teaching about omeprazole for heartburn, inform the client that this medication decreases the production of gastric acid
• When teaching a client taking sucralfate and phenytoin, instruct them to allow a 2-hour interval between the medications
• Misoprostol is contraindicated for a pregnant client

Gastrointestinal Disorders

• Includes nausea, vomiting, diarrhea, constipation, motion sickness, hiatal hernias, GERD, and irritable bowel syndrome
• Medications aim to control symptoms
• Antiemetics include glucocorticoids, substance P/neurokinin antagonists, serotonin antagonists, dopamine antagonists, cannabinoids, anticholinergics, antihistamines, and benzodiazepines

Anti-Emetic Applications

• Used for nausea and vomiting, motion sickness, and preoperatively
• Chemotherapy-induced nausea and vomiting (CINV) best responds to premedication with multiple agents, such as dexamethasone, ondansetron, and aprepitant
• Antiemetics can increase orthostatic hypotension, CNS depression, and anticholinergic effects, advise against alcohol or other CNS depressants

Serotonin Antagonists

• Ondansetron prevents emesis by acting on serotonin receptors in the brain and GI tract
• Used for chemo, radiation, and postoperative nausea
• Can be given PO, IM, IV
• Causes headache, diarrhea, and dizziness
• Prolonged QT interval can cause Torsades de Pointes

Dopamine Antagonists

• Prochlorperazine blocks the effects of dopamine in the brain
• Used for chemo, opioid-related nausea, and postoperative nausea
• Can be given PO, IM, IV (slowly)
• Causes Extrapyramidal symptoms (EPS)
• Monitor for restlessness, anxiety, spasms of face and neck
• Treat with anticholinergics like diphenhydramine and benztropine
• Can cause hypotension
• Causes sedation, avoid combining with other CNS depressants
• Anticholinergic effects include dry mouth, urinary retention, and constipation
• Increase PO fluids, ambulate, and use hard candy or chew gum
• Stimulant laxatives will improve bowel motility and need to ensure client has voided
• Use cautiously in young children and the elderly, contraindicated for those under 2

Further Considerations on Anti-Emetics

• Use cautiously if history of urinary retention, obstruction, asthma, or narrow-angle glaucoma

Benzodiazepines

• Lorazepam which is very effective at controlling nausea
• They depress nerve function in the CNS and can be used with other medications to suppress CINV
• Administer PO, IM, or IV (slowly)
• Side effects include sedation, drowsiness, and CNS depression, which increases the risk of falls, aspiration, injury, and respiratory issues
• Monitor vital signs and provide a safe environment

Laxatives

• Used to promote stool evacuation, with various mechanisms
• Classifications include bulk-forming, surfactant, stimulant, and osmotic laxatives
• Bulk-forming laxatives are safe for long-term use
• Chronic use can lead to fluid and electrolyte imbalances
• Increase high-fiber foods, fluids (2-3 liters a day), fresh fruits, and vegetables
• Ambulation is key for normal bowel habits
• Can cause GI irritation, rectal burning, or proctitis
• Do not use in patients with fecal impaction, bowel obstruction, or acute surgical abdomen, perforation can occur

Bulk-Forming Laxatives

• Psyllium acts as dietary fiber. Softens fecal mass and increases bulk
• Decreases diarrhea in patients with IBS and diverticulosis
• Controls stool for clients with ileostomy
• Promotes defecation in elderly clients with decreased peristalsis due to age

Surfactant Laxatives

• Docusate sodium lowers the surface tension of the stool to allow more water in
• Effective at relieving constipation related to pregnancy and opioid use
• Prevents painful stools, straining, and decreases impaction risk in immobile clients

Stimulant Laxatives

• Bisacodyl increases peristalsis
• Used to prepare for GI procedures
• Also effective for short-term management of opioid-induced constipation (OIC)

Osmotic Laxatives

• Magnesium hydroxide draws water into the intestine
• Increases stool mass, stretches intestinal musculature, and promotes peristalsis
• Low doses prevent painful elimination
• High doses prepare for GI procedures or rapid bowel evacuation after poison ingestion or treatment for parasites

Anti-Diarrheals

• Diphenoxylate with atropine, loperamide, and paregoric activate opioid receptors in the GI tract
• Decreases intestinal motility and increases fluid and sodium absorption
• Specific causes of diarrhea can be treated with antibiotics or antiparasitics
• Non-specific agents treat symptoms, decreasing stool frequency and fluid content
• Patients should drink small amounts of electrolyte-containing solutions frequently and avoid caffeine
• Diphenoxylate does not impact the CNS at prescribed doses
• At high doses, can cause euphoria, CNS depression, respiratory depression, and altered mental status
• Atropine causes anticholinergic effects at higher doses and discourages misuse
• Do not use on patients with fevers or acute infectious processes
• Monitor for cessation of stool, left lower quadrant pain, and signs of megacolon or perforation

Prokinetic Agents

• Metoclopramide controls nausea and vomiting and stimulates cholinergic receptors in the GI tract to promote motility
• Controls postoperative nausea, CINV, and for endoscopy examinations
• Oral form helps promote peristalsis in diabetic gastroparesis
• Can cause EPS, monitor for signs/symptoms and treat with anticholinergics
• Can be administered PO or IV (slow)
• Contraindicated in bowel obstructions, perforations, and bleeding
• Do not use if the patient has a seizure disorder
• Effects are decreased by opioids and anticholinergics

Irritable Bowel Syndrome (IBS)

• Has both diarrhea and constipation manifestations

IBS-D

• Alosetron slows down peristalsis
• Results in firmer stool and decreased urgency and frequency of defecation
• Approved for women with IBS-D for more than 6 months
• Can cause constipation and lead to ischemic colitis, bowel obstruction, fecal impaction, and perforation
• Patients must sign an agreement to understand potential GI toxicity side effects
• Contraindicated in Crohn’s, ulcerative colitis, impaired intestinal circulation, diverticulitis, or thrombophlebitis
• Onset is within 1-4 weeks, and effects return within 1 week of stopping medication

IBS-C

• Lubiprostone increases fluid secretion in the intestine to promote GI motility
• Used for IBS-C in women and chronic constipation
• Contraindicated in bowel obstructions
• Take with food twice daily to decrease nausea

Other IBS Medications

• Sulfasalazine (5-aminosalicylate) inhibits prostaglandin synthesis, decreasing inflammation
• Used in IBS, Crohn’s, and UC
• IBS is controlled, not cured
• Contraindicated in patients with allergies to sulfonamides, salicylates, or thiazide diuretics
• Use cautiously in older adults, liver or kidney disease, and blood dyscrasias

Review of Gastrointestinal Medications

• A nurse caring for a client who received prochlorperazine four hours ago and reports twitching of the face should request an order for diphenhydramine
• When administering ondansetron IV to an older adult with diabetes mellitus II, cardiomyopathy, and CINV, monitor for headache, diarrhea, and prolonged QT interval
• A nurse instructing a patient with heart failure about laxatives should advise them to avoid sodium phosphate
• For a patient with diabetes experiencing nausea related to gastroparesis, the nurse should check for a PRN order for metoclopramide

Other GI Tract Related Medications:

• Stomatitis management includes keeping the oral mucosa clean, moist, and treating infections
• Oral pain can hinder adequate nutrition
• Oral rinses like sodium chloride and/or sodium bicarbonate can be dissolved in water
• Patients can swish, expectorate, or gargle the solution
• Topical analgesics/anesthetics such as benzocaine come in gels or lozenges and are applied topically or used as a swish and expectorate solution
• Prescription mouthwashes like BMX may contain benadryl, maalox, and xylocaine to numb oral cavity and neutralize acids
• Antimicrobials can be antibiotics, antifungals, and antivirals that treat infections in the mouth or throat
• Swish and swallow, systemic effect occurs when swallowed

Poisoning and Ingestion Management

• People who ingest medications, cosmetics, plants, or cleaning solutions should contact poison control at 1-800-222-1222 immediately
• Do not induce vomiting unless poison control specifies
• Syrup of ipecac is rarely used due to aspiration risk
• Do not give ipecac or neutralizing agents, place an NG tube, or use activated charcoal if the person ingested a caustic substance
• Activated charcoal binds substances in the GI tract, preventing systemic absorption
• Sorbitol acts as a laxative, speeding up transit through the GI tract to further decrease absorption

Obesity Management

• Many over-the-counter weight management medications exist
• Mechanisms of action include increasing metabolism, blocking fat or glucose absorption, acting as a laxative, or adding bulk fiber

Anorexiants

• Anorexiants stimulate the sympathetic nervous system and decrease hunger
• Cause adrenergic responses and are dangerous for people with hypertension and heart disease
• Anyone with cardiovascular risk factors should consult a physician prior to use
• Consult https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity for prescription weight loss medications