PH 13 Drugs for Gastrointestinal Problems PDF

13 Drugs for Gastrointestinal Problems LEARNING OUTCOMES 1. List the names, actions, possible side effects, and adverse effects of antiemetics and promotility drugs. 2. Explain what to teach patients and families about antiemetics and promotility drugs. 3. List the names, actions, possible side eff...

13 Drugs for Gastrointestinal Problems LEARNING OUTCOMES 1. List the names, actions, possible side effects, and adverse effects of antiemetics and promotility drugs. 2. Explain what to teach patients and families about antiemetics and promotility drugs. 3. List the names, actions, possible side effects, and adverse effects of antacids and histamine H2 receptor blockers. 4. Explain what to teach patients and families about antacids and histamine H2 receptor blockers. 5. List the names, actions, possible side effects, and adverse effects of proton pump inhibitors and cytoprotective drugs. 6. Explain what to teach patients and families about proton pump inhibitors and cytoprotective drugs. 7. List the names, actions, possible side effects, and adverse effects of laxatives and antidiarrheals. 8. Explain what to teach patients and families about laxatives and antidiarrheals. KEY TERMS antacids (ănt-Ă-sĕd, p. 251) A category of drugs used to help neutralize gastric acid and reduce symptoms of indigestion and heartburn. antidiarrheal (ĂN-tē-dī-ă-RĒ-ĕl, p. 259) Drug that reduces or stops loose, watery stools (diarrhea) and helps restore normal bowel movements. antiemetic drugs (ĂN-tē-ĭ-MĔ-tĭk, p. 242) A category of drugs used to prevent and treat nausea and vomiting. cannabinoids (kă-NĂ-bă-nōĭd, p. 247) Drugs that are either natural or synthetic forms of tetrahydrocannabinol (THC) that reduce nausea and vomiting by binding to both cannabinoid receptors in the chemoreceptor trigger zone (CTZ) and by preventing serotonin (5-HT3) from binding to its receptors in the CTZ. cytoprotective drugs (SĪ-tō-prō-TĔK-tiv, p. 253) A class of drugs that protects the lining of the stomach and prevents further damage to the lining from stomach acid. histamine H2-receptor antagonists (HĬ-stă-mēn, p. 252) A class of drugs that 443 inhibits the binding of histamine to H2 receptors on the parietal cells in the stomach, thereby decreasing gastric acid secretions. laxatives (LĂK-sĕ-tĭv, p. 254) A class of drugs that promotes bowel movements by stimulating peristalsis, increasing the bulk of the stool, or by softening the stool. They are typically used to relieve constipation. opioid agonists (Ō-pē-oid Ă-gă-nĭst, p. 260) A class of antidiarrheals that reduces GI motility and increases the ability of the intestine to absorb water. They do not have the analgesic or opioid-like effects of the drugs discussed in Chapter 11. phenothiazine (fē-nō-THĪ-ĕ-zēn, p. 246) A type of antiemetic drug that reduces nausea and vomiting by blocking dopamine receptors in the CTZ. These drugs are also called dopamine antagonists. promotility drugs (PRO-mō-tĭl-ĭ-tē, p. 248) A class of drugs that increases contraction of the upper GI tract, including the stomach and the small intestines, to move contents more quickly through the tract. They do this by blocking dopamine (D2) receptors in the CTZ and the intestinal tract. proton pump inhibitors (PRŌ-tŏn pŭmp ĭn-HĬ-bă-tĕrz, p. 248) A class of drugs that binds to the proton pump of the parietal cells in the stomach, which blocks acid secretion into the stomach. serotonin (5-HT3) receptor antagonists (sĕr-ă-TŌ-nĕn, p. 243) A class of antiemetic drugs that reduces or halts nausea and vomiting by blocking (5-HT3) receptors in the intestinal tract and the CTZ so serotonin cannot activate these receptors. substance P/neurokinin1 (NK1) receptor antagonists (NYŪR-ō-KĬ-nĕn, p. 245) A class of antiemetic drugs that blocks the substance P/neurokinin1 (NK1) receptors in the CTZ, preventing the substance P and neurokinin that are released from cells exposed to chemotherapy and from tissues that are traumatized during surgery from binding to and triggering the CTZ. The Digestive System The digestive system is composed of the mouth, esophagus, stomach, intestines, and accessory structures (Fig. 13.1). This system performs the mechanical and chemical processes of digestion, absorbs nutrients, and eliminates waste (Fig. 13.2). Although it is located inside the body, the digestive system is in constant contact with the external environment. After all, it is open at both ends and, unlike other internal body areas, substances placed in it do not need to be sterile. In addition to problems that arise within the digestive system itself, being open to the environment increases the number and type of problems that can occur anywhere along the GI tract. 444 FIG. 13.1 The digestive system. (Modified from Herlihy B: The human body in health and illness, ed 5, Philadelphia, 2014, Elsevier.) FIG. 13.2 Actions within the digestive system from ingestion of food and water, absorption of water and nutrients, secretion of aids to digestion, and removal of waste products. (From Vander AJ, Sherman JH, Luciano DS: Human physiology, ed 5, New York, 1990, McGraw-Hill. Used with permission.) Digestion begins in the mouth by chewing and mixing food with enzyme-rich 445 saliva secreted by salivary glands. The food passes from the mouth to the anus through the digestive tract. Here is where the complex compounds that enter the mouth as food are reduced to smaller dissolvable particles and their carriers (see Fig. 13.2). Usable food particles are absorbed while indigestible pieces and waste materials are eliminated. Accessory digestive glands (salivary glands, gallbladder, and pancreas) secrete enzymes and other chemicals that are required to break down food substances and promote absorption into the bloodstream. In the stomach, digestion requires a strong acid to break down protein or other substances. This acid is strong (has a low pH) and could erode the cells lining the stomach and form open sores (ulcers). Think of the burning sensation you feel in your mouth, throat, and nose when you vomit. Fortunately, several factors work together to protect the GI tract mucosa from injury. A protective substance secreted by stomach-lining cells is one type of prostaglandin. This substance triggers the production of a thick mucus that forms a gel-like layer in the stomach that helps prevent stomach acid and enzymes from coming into direct contact with and damaging the lining. Prostaglandins also maintain good blood flow to the stomach, which keeps these tissues well oxygenated and allows the immune system to help keep them healthy. As partially digested food and liquid leave the stomach and enter the duodenum (the first 12–18 inches of the small intestine), these stomach contents are still very acidic. The duodenum does not have the mucous protection that the stomach has. So the duodenum could easily develop ulcers from this exposure to acid and digestive enzymes. However, the pancreas produces a lot of bicarbonate and secretes it into the duodenum to neutralize the acid in the contents from the stomach. We have just mentioned two of the problems that the digestive system can have: vomiting and ulcer formation. Other problems include the movement of stomach contents back into the esophagus (gastric reflux), abnormally slow movement of contents through the intestinal tract (constipation), and abnormally fast movement of contents through the intestinal tract (diarrhea). This chapter focuses on drug therapy to prevent or manage these problems. In addition, the digestive tract can become infected with bacteria, viruses, fungus, and parasites. Drug therapy for conditions related to infectious agents is presented in Chapters 5 and 6. Antiemetic Drugs Nausea and vomiting are common GI problems that occur as a result of infection, fever, motion, certain foods, anesthesia, and exposure to many drugs, including cancer chemotherapy. Very often, nausea and vomiting occur together or vomiting follows nausea. However, nausea can occur without vomiting and is still an unpleasant sensation. Vomiting also can occur without the sensation of nausea. Although we tend to think of nausea and vomiting as just problems of the digestive tract, they result from a complex set of interactions that involve the brain, nervous system, inner ear, and the stomach and intestines (Fig. 13.3). Messages from the cerebral cortex (e.g., fear or anxiety), the sensory organs (e.g., sights, odors, or pain), or the vestibular apparatus in the inner ear (e.g., motion sickness) can be sent to the vomiting center in the brain. These are called direct-acting stimuli because the message goes directly to the vomiting center. Indirect-acting stimuli involve the chemoreceptor trigger zone (CTZ). For example, opioids, alcohol, certain antibiotics, 446 and types of anesthesia can stimulate the CTZ. The CTZ then sends messages to the vomiting center. Signals from the stomach or small intestine can send messages to the CTZ (such as after a big meal or a food that “does not agree” with you). Think of the last time you felt nauseated and had vomiting. Was it a direct or indirect stimuli that caused your nausea and vomiting? FIG. 13.3 Vomiting is a complex reflex. It involves stimuli to the vomiting center (VC) directly or indirectly through the chemoreceptor trigger zone (CTZ). You can see that many types of receptors are involved in vomiting. By understanding that there are different types of receptors, you can understand different types of antiemetics and how they work. For example, some affect dopamine, some serotonin, some histamine, and some acetylcholine. Top Tip for Safety Patients with nausea and vomiting are at risk for dehydration, weight loss, and electrolyte imbalance. Monitor and report any changes in fluid balance, food intake, and laboratory abnormalities. Antiemetic drugs are used to prevent and treat nausea and vomiting that occur 447 with any problem. There are many classes of antiemetic drugs, including serotonin receptor antagonists, substance P antagonists, phenothiazines, cannabinoids, promotility drugs, butyrophenones, and anticholinergics. Most of these drugs work in the brain, stomach, and intestinal tract, to change the sensation of nausea and to reduce the stomach contractions that make vomiting occur. Which class of drug is used depends on the severity of the problem and the patient's individual response. Some patients may require a combination of two or more types of antiemetic drugs for effective management of nausea and vomiting. We will discuss the first five categories of drugs. The butyrophenones and anticholinergic drugs are discussed in Chapter 9. Memory Jogger The major categories of antiemetic drugs are: • serotonin (5-HT3) receptor antagonists • substance P antagonists • phenothiazines (dopamine antagonists) • cannabinoids • promotility drugs • butyrophenones • anticholinergics Serotonin (5-HT3) Receptor Antagonists Action and Uses A major neurotransmitter (chemical that transmits signals from one nerve to the next nerve in the pathway or to the brain) that causes nausea and vomiting when it binds to its receptors in either the CTZ or to its receptors in the GI system is one particular form of serotonin. This specific form of serotonin is serotonin 5-hydroxytryptamine type 3 (5-HT3). The serotonin (5-HT3) receptor antagonists are a class of antiemetic drugs that reduces or halts nausea and vomiting by blocking serotonin (5-HT3) receptors in the intestinal tract and the CTZ so serotonin cannot activate these receptors. The major uses of this class of antiemetics are to reduce or prevent the nausea and vomiting resulting from cancer chemotherapy, radiation therapy, and anesthesia-induced nausea and vomiting after surgery. They may be called setrons for short because they typically end in “setron.” Table 13.1 lists the names, dosages, and nursing implications for common serotonin (5-HT3) receptor antagonists. Be sure to consult a drug reference book for more information about specific drugs. Table 13.1 Examples of Common Antiemetics Serotonin (5-HT3) receptor antagonists: reduce or halt nausea and vomiting by blocking (5-HT3) receptors in the intestinal tract and the CTZ so serotonin cannot activate these receptors DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS 448 dolasetron (Anzemet) 100 mg orally given 1 hour before chemotherapy ondansetron (Zofran, Zuplenz) 8 mg orally 30 min before chemotherapy, then every 8 and 16 hours after the initial dose. May give doses every 12 hours 1–2 days after chemotherapy completed palonosetron (Aloxi) 0.5 mg orally as a single dose 1 hour before chemotherapy • Make sure the patient has a call light available because these drugs can cause dizziness. • Give the drug before the patient has an episode of vomiting because they can prevent or relieve nausea before the patient vomits. • Contact the healthcare provider if the patient is also taking any drugs that affect serotonin levels because the interaction can cause serious adverse effects. • These drugs may be given for postoperative nausea and vomiting but are typically given intravenously rather than orally. Substance P/neurokinin1 receptor antagonists: reduce or prevent immediate and delayed nausea and vomiting by blocking the substance P/neurokinin1 receptors in the CTZ, preventing both of these substances from binding to and triggering the CTZ DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS aprepitant (Emend-oral): on day 1, give 125 mg orally 1 hour before • Always double-check doses of substance P/neurokinin1 receptor agonists chemotherapy; on days 2 and 3, give 80 mg orally 1 hour before because protocols vary according to the potential of the chemotherapy chemotherapy, or if no chemotherapy is scheduled on days 2 and 3, give drugs to cause nausea and vomiting. More “emetogenic” chemotherapy in the morning. Available as capsule or as oral suspension. drugs may require more frequent dosing. rolapitant (Varubi) 180 mg orally on day 1, given 1–2 hours before • In some cases this drug may be combined with a corticosteroid agent to chemotherapy reduce symptoms of nausea and vomiting even further. Phenothiazines: reduce nausea and vomiting by blocking dopamine (D2) receptors in the CTZ DRUG/ADULT DOSAGE RANGE prochlorperazine (Compazine, Compro) 5–10 mg orally three to four times daily; IM 5–10 mg every 3–4 hours PRN; rectal 25 mg twice daily; sustained release 10–15 mg every 12 hours promethazine (Phenadoz, Phenergan, Promethegan) 12.5–25 mg orally every 4–6 hours as needed; 12–25 mg IM every 4–6 hours as needed; rectal 12.5–25 mg by rectum every 4–6 hours as needed NURSING IMPLICATIONS • Teach patients to change position slowly because these drugs can cause orthostatic hypotension. • Remind patients that alcohol may increase drowsiness and increase risk for injury. • Watch carefully for side/adverse effects relating to these drugs and their effects on dopamine. Contact the healthcare provider for any Parkinson's disease–like tremors or gait changes, any muscle spasms, or any changes in motor movement such as tongue rolling or lip smacking because these are serious adverse effects. • Monitor the patient carefully for any sudden increase in temperature because this can be an indication of neuroleptic malignant syndrome, a rare but life-threatening adverse effect. Cannabinoids: are either natural or synthetic forms of THC that reduce nausea and vomiting by binding to both cannabinoid receptors in the CTZ and by interfering with serotonin 5-HT3 from binding to its receptors in the CTZ DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS dronabinol (Marinol, Syndros) as liquid-filled capsules 5 mg/m2 orally • Cannabinoids are typically reserved for patients who continue to have given 1–3 hours before chemotherapy and then every 2–4 hours afterward nausea and vomiting who do not respond to other categories of for a total of four to six doses per day; 4.2 mg/m2 as oral solution (rounded antiemetics. to the nearest 0.1 mg), given 1–3 hours before chemotherapy and then • These drugs are typically given as solution or in liquid-filled capsules every 2–4 hours after chemotherapy, for a total of four to six doses per day with the dosage individualized according to body surface area. For nabilone (Cesamet) 1–2 mg orally twice daily; the initial dose is given 1–3 example, a person who is 6 feet tall and weighs 225 pounds would receive hours before chemotherapy; a dose of 1–2 mg the night before 11.2 mg of the drug. The dosage will be determined using body surface chemotherapy may be useful area calculations by the healthcare provider in conjunction with the pharmacist. • For liquid drugs, always make sure to use the proper measuring device (such as an oral syringe) to ensure accuracy. • The first dose should be taken on an empty stomach 30 minutes before meals. After the first dose, these drugs can be taken with food. • Advise patients to avoid alcohol, sedatives, or other CNS depressants because they may increase the risk for sedation. • Monitor the patient carefully for changes in mental status. Cannabinoids can cause confusion, sedation, and at times feelings of euphoria or a “high.” These typically decrease after a few days of use. Promotility drugs: a class of drugs that increases contraction of the upper GI tract including the stomach and the small intestines; they do this by blocking dopamine (D2) receptors in the CTZ and the intestinal tract DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS metoclopramide (Reglan) 10–15 mg orally four times daily 30 minutes • Monitor the patient carefully for any mood changes or restlessness before meals and at bedtime because these are common side effects. trimethobenzamide (Tigan) 300 mg orally three to four times daily PRN; IM • Check vital signs regularly to assess for changes in blood pressure 200 mg three to four times daily PRN (decrease) because there is a risk for orthostatic hypotension. • Give these drugs at least 30 minutes before meals and at bedtime because these are times of increased potential for nausea. CTZ, Chemoreceptor trigger zone. Memory Jogger All of the serotonin (5-HT3) receptor antagonists have the suffix -setron in their generic names. Expected Side Effects Common central nervous system (CNS) side effects for serotonin (5HT3) receptor antagonists include dizziness, headache, and drowsiness. Some patients experience changes in taste, heartburn, constipation, or diarrhea. Rarely, a patient may 449 experience chills with shivering. Adverse Reactions Adverse reactions include allergic reactions, dysrhythmias, and renal or liver damage. Serotonin syndrome can occur if the patient is taking other drugs that increase serotonin (e.g., certain antidepressants, St. John's wort). For more information about serotonin syndrome, see Chapter 10. Drug Interactions As mentioned earlier, these drugs can interact with a variety of drugs that contain the neurotransmitter serotonin or drugs that are like serotonin. Examples include monoamine oxidase inhibitors, morphine, and serotonin reuptake inhibitors. When combined with phenothiazine drugs, the patient may experience cardiac dysrhythmias. Nursing Implications and Patient Teaching Planning and implementation. In addition to the general nursing considerations related to care of the patient with antiemetic drugs described in Box 13.1, the following issues and actions are important. Follow protocols very carefully to ensure adequate timing before the patient receives chemotherapy. Monitor vital signs before and after giving the drug. In addition, ask your patient about any abdominal pain. Severe pain may indicate infection, bleeding, or other severe problems in the GI tract. Follow up with your patient to make sure they are getting relief from their nausea. Box 13.1 General Nursing Considerations for Antiemetic Drug Therapy • Assess heart rate, blood pressure, respiratory rate, and level of consciousness before giving any antiemetic agent. • Remove any foods, smells, or images that may make nausea worse. • Ask the patient to describe his or her nausea, and if the patient vomits, record the color, consistency, and amount. • Give the antiemetic drug for nausea rather than waiting until the patient vomits. • Vomiting can result in dehydration and electrolyte imbalance, so make sure to monitor weight, skin turgor, and intake and output. Review serum electrolytes and report abnormal results to the healthcare provider. • If the patient is taking an antiemetic for chemotherapy, carefully review the prescribed protocol to ensure good timing of drug administration. • Determine the effectiveness of the antiemetic by monitoring the patient's report of relief from nausea and no further vomiting. 450 • Tell the patient to ask for help when getting out of bed or out of the chair because these drugs can cause dizziness and drowsiness. Be sure to have the call light within the reach of the patient. • Report any symptoms of severe abdominal pain or signs of abdominal distention to the healthcare provider immediately because these may be signs of complications. • Report emesis that looks like coffee grounds or is red-tinged to the healthcare provider immediately because this may indicate bleeding in the GI tract. • Tell the patient to avoid driving or use of heavy machinery while taking antiemetics because they can cause dizziness and drowsiness. • Teach the patient to contact the healthcare provider before adding any over-thecounter drugs or herbal drugs because they can increase risk for drug interactions. • Remind the patient to avoid alcohol, sedatives, or tranquilizers unless specifically advised by the healthcare provider. • Many of these drugs cause increase in sun sensitivity, so patients must avoid direct sunlight without sunscreen and/or protective clothing. • Teach the patient to rinse his or her mouth carefully with clear liquids after vomiting. Ice chips or mild-flavored popsicles may be soothing to the patient. • Teach the patient to contact his or her healthcare provider if nausea and/or vomiting lasts more than 2 days or if the patient is unable to take any fluids or has fever. Patient and family teaching. Tell the patient and family the following: • Do not take any herbal agents without checking with a pharmacist or other healthcare provider while taking the serotonin (5-HT3) receptor antagonists, to avoid possible interactions. • Tell your healthcare provider if you are taking serotonin (5-HT3) receptor antagonists because these drugs interact with a variety of other drugs. • Avoid driving, operating any machinery, or participating in critical decision making while taking this drug because it may impair your judgment and reflexes. • It is best to take the drug before you have vomited rather than waiting until after you have had an episode of vomiting. • Do not use any alcohol or drugs with sedating effects 451 while taking this drug. Substance P/Neurokinin1 Receptor Antagonists Action and Uses Another receptor in the CTZ that can cause nausea and vomiting when activated is the substance P/neurokinin1 (NK1) receptor. Substance P is produced by many normal cells all over the body when they have been traumatized with inflammation and pain or exposed to noxious stimuli. Substance P enters the bloodstream and crosses into the brain, where it can bind to the substance P/NK1 receptors that are present in many areas of the brain, including the CTZ and areas that perceive pain. Activating these receptors in the CTZ stimulates immediate and delayed nausea and vomiting. Substance P/neurokinin1 (NK1) receptor antagonists are drugs that block the substance P/NK1 receptors in the CTZ. This prevents both substance P and neurokinin that are released from cells exposed to chemotherapy and from tissues injured during surgery from binding to and triggering the CTZ. The most common uses for drugs in this class are to reduce or prevent the nausea and vomiting that result from cancer chemotherapy and after surgery. These drugs are especially effective at managing the delayed nausea and vomiting that often starts 24 to 72 hours after chemotherapy. The first drug in this class is aprepitant (Emend). These drugs are most effective when used in combination with the serotonin (5-HT3) receptor antagonists. Table 13.1 lists the names, dosages, and nursing implications for the substance P/NK1 receptor antagonists. Be sure to consult a drug reference book for more information about specific drugs. Expected Side Effects Fatigue, diarrhea, headache, and dizziness are side effects of the substance P/NK1 receptor antagonists. In addition, the patient may experience mild hiccups, flatulence, and sweating. Adverse Reactions Neutropenia is one of the most common adverse reactions associated with substance P/NK1 receptor antagonists. Angioedema, severe allergic reactions, and respiratory depression may occur. Other blood abnormalities include anemia and thrombocytopenia, so monitor laboratory values carefully. Drug Interactions Substance P/NK1 receptor antagonists interact with a variety of drugs. In particular, these drugs interact with opioid drugs, causing increased dizziness, drowsiness, and sedation. Use of these drugs with certain benzodiazepines can increase the effect of the benzodiazepines so should be used together with caution. Nursing Implications and Patient Teaching Planning and implementation. 452 In addition to the general nursing considerations related to care of the patient with nausea and vomiting listed in Box 13.1, the following issues and actions are important. Carefully review the drug instructions to make sure it is prepared properly. For example, the oral form of aprepitant should not be opened until ready to prepare. At that time, the mixing cup provided in the drug kit should be filled with room temperature drinking water. Once you have added the precise amount of water to the mixing cup as directed, pour the contents of the drug into the cup and then snap the lid shut. Gently swirl the solution 20 times to mix it, then invert the cup. Do not shake the cup or foaming may occur. Be sure there are no clumps or foam in the solution. At that time, you can measure the solution to give to the patient. Discard any remaining solution. Just as for the oral liquid aprepitant, injectable fosaprepitant must be carefully prepared. Do not shake the drug. You may gently swirl the drug or invert the solution to gently mix. Follow directions specifically for proper mixing and rate of administration. Patient and family teaching. Tell the patient and family the following: • If you are taking the oral solution, avoid shaking the mixture. You can gently swirl and turn over the measuring cup or syringe. • After the drug is mixed, it can be stored in the refrigerator for up to 30 days. • Avoid alcohol and any sedating drugs while you are taking these drugs, to prevent side effects. • Do not take any over-the-counter or herbal drugs without checking with your healthcare provider or pharmacist because drugs from this category can interact with other drugs. Phenothiazines Action and Uses Phenothiazines are a type of antiemetic drug that reduces nausea and vomiting by blocking dopamine (D2) receptors in the CTZ of the brain. For this reason drugs in this class are also called dopamine antagonists. Dopamine receptors are present in many other areas of the brain and the body. As a result, these drugs have many other effects in the body in addition to the antiemetic effects. Dopamine antagonists are approved to reduce nausea and vomiting from many problems except for the morning sickness associated with pregnancy. Table 13.1 lists the names, dosages, and nursing implications for the phenothiazines. Be sure to consult a drug reference book for more information about specific drugs. 453 Expected Side Effects Common side effects include drowsiness, blurred vision, dry mouth, and dizziness. Some phenothiazines can cause urine to change to a pinkish red color. Sensitivity to sun exposure is common. Adverse Reactions Adverse reactions to phenothiazine drugs are most common at higher doses. As a result of blocking dopamine, the patient can experience extrapyramidal symptoms (EPS) as discussed in Chapter 10. These effects include tardive dyskinesia, acute dystonia, and even neuroleptic malignant syndrome. Blood abnormalities are also possible while the patient is taking phenothiazines. These drugs should be avoided in patients with cardiovascular disease because they can cause patients to experience angina, tachycardia, and/or orthostatic hypotension. Drug Interactions Phenothiazines interact with a wide variety of drugs. They should not be given with metoclopramide (Reglan), which also affects dopamine levels. Phenothiazines can increase the effects of any other drug that affects dopamine, including monoamine oxidase inhibitors and several other antidepressants. Benzodiazepines can cause increased drowsiness. Phenothiazines should be avoided in patients who are taking levodopa/carbidopa for Parkinson's disease. Nursing Implications and Patient Teaching Planning and implementation. In addition to the general nursing considerations related to antiemetic drug therapy listed in Box 13.1, the following issues and actions are important. Make sure to carefully assess the vital signs in patients who are taking phenothiazines because they can cause a decrease in blood pressure and an increase in heart rate in some patients. Avoid giving the phenothiazine antiemetic to any patient who has low blood pressure or is dehydrated. Make sure the patient has the call light available to ask for help when getting out of bed after receiving this drug because it can cause orthostatic hypotension. Assess for any occurrence of EPS as discussed in detail in Chapter 10. If the patient demonstrates any unusual muscle movements or has any abrupt changes in temperature, heart rate, or blood pressure, notify the healthcare provider immediately. Patient and family teaching. Tell the patient and family the following: • You may experience dizziness, drowsiness, or blurred vision while taking this drug. Avoid driving or using any heavy equipment or participating in any dangerous activity. 454 • Change position slowly to avoid dizziness. • Do not drink alcohol while taking this drug. Alcohol may increase the side effects. • You may notice a slight change in the color of your urine to a pinkish red. This is an expected side effect. • If you have any muscle spasms (particularly of the neck muscles); involuntary movements of the face, tongue, or upper or lower extremities; or any unusual restlessness, notify your healthcare provider immediately. • The drug may decrease your ability to sweat, so make sure to avoid becoming overheated during physical activity or very hot weather. • For relief of dry mouth, try sugarless gum or candy, or use ice chips to moisten your mouth. • These drugs can cause your skin to be more sensitive to light, so avoid direct sunlight and, if needed, wear protective eyewear and clothing. Wear sunblock while outside to avoid sunburn. Cannabinoids Action and Uses Marijuana, a common street drug recently approved in some states for use in the medical treatment of certain health problems, has been used to help control the nausea and vomiting associated with cancer chemotherapy. Although many chemicals are present in marijuana, the ingredient that has antiemetic actions is tetrahydrocannabinol (THC). All humans have THC receptors in many areas of the brain, including in the CTZ and in pleasure centers. Cannabinoids are drugs that are either natural or synthetic forms of THC that reduce nausea and vomiting by binding to both cannabinoid receptors in the CTZ and by preventing serotonin 5-HT3 from binding to its receptors in the CTZ. Use of cannabinoids as antiemetics is typically reserved for patients with severe nausea and vomiting that has not been relieved by other antiemetics because of the potential for addiction (rare but possible) and other side effects. Table 13.1 lists the names, dosages, and nursing implications for the cannabinoids. Be sure to consult a drug reference book for more information about specific drugs. Expected Side Effects The most common side effects are related to the effect of cannabinoids on the CNS. 455 Some patients experience a dose-related “high” (easy laughing, elation, and increased awareness). Other CNS effects are dizziness, anxiety, insomnia, difficulty concentrating, and mood changes. Some patients may experience emotional lability (wide swings in emotion). These side effects may decrease after 2 weeks of treatment. Some patients have GI side effects such as nausea, vomiting, and abdominal pain. Orthostatic hypotension is more common in older adults. Adverse Reactions Acute confusion, hypersensitivity, and seizure-like activity have occurred in some patients. Rarely, hallucinations, excessive sweating, or fainting can happen, so it is important to carefully monitor the patient. Cannabinoids should be used with caution in patients who have a history of substance abuse (including alcohol) because of the increased risk for abuse of the drug. Drug Interactions Cannabinoids can interact with a variety of drugs. Examples include warfarin, calcium channel blockers, opioid agonists, and a variety of antiretroviral drugs used to treat HIV. Patients who take dronabinol should avoid grapefruit juice because it can increase adverse effects. Nursing Implications and Patient Teaching Planning and implementation. In addition to the general nursing considerations related to antiemetic drug therapy listed in Box 13.1, the following issues and actions are important. These drugs can be given using standard tablets and capsules or can be given as a liquid or in liquidfilled capsules with the dosage individualized according to body surface area (measure of the total external surface area of the body). The dosage is determined using body surface area calculations by the healthcare provider in conjunction with the pharmacist. If you are giving a dose of the liquid drug, use the proper measuring device (such as an oral syringe) to ensure accuracy. Give the first dose on an empty stomach 30 minutes before meals. After the first dose, these drugs can be given with food. Carefully monitor the patient for changes in mental status. Cannabinoids can cause confusion, sedation, and at times feelings of euphoria or a “high.” These typically decrease after a few days to weeks of use. Advise patients to avoid alcohol, sedatives, or other CNS depressants because they may increase the risk of sedation Patient and family teaching. Tell the patient and family the following: • Avoid using alcohol, sedatives, or any antianxiety drugs with these drugs without talking to your healthcare provider. • Take the dose as prescribed; do not increase without 456 talking to your healthcare provider. • This drug may cause you to feel slightly “high,” with feelings of easy laughing, mood changes, elation, and increased awareness. These feelings decrease in a few days to a few weeks. • Do not drive, operate any machinery, or participate in important decision making while taking this drug. • Ask family members to stay with you when you first start taking the drugs in case you have some confusion or dizziness. Promotility Drugs Action and Uses Promotility drugs (also called prokinetic drugs) are used to increase contraction of the upper GI tract including the stomach and the small intestines, which move contents more quickly through the tract. These drugs do this by blocking dopamine (D2) receptors in the CTZ. They work similarly to the phenothiazines but do not have the sedating side effect. The promotility drugs may be used in patients with postoperative nausea and vomiting, chemotherapy-induced nausea and vomiting, and gastroesophageal reflux disease (GERD). They may also be used in patients who have difficulty emptying their stomach, such as a patient with diabetic gastroparesis. Table 13.1 lists the names, dosages, and nursing implications of common drugs from the promotility class. Be sure to consult a drug reference book for more information about specific drugs. Expected Side Effects The most common side effects are drowsiness, fatigue, and restlessness. Others are visual impairment, urinary incontinence, and insomnia. Adverse Reactions These drugs should be used with caution in patients with a history of depression because they can cause depression and even suicidal ideation, as well as seizures, blood disorders, cardiac dysrhythmias, and heart failure. Other adverse effects are related to the decrease in the neurotransmitter dopamine. This can result in symptoms similar to Parkinson's disease including tremor, bradykinesia (slow movement), and masklike facies. These symptoms decline in 2 to 3 months after stopping the drug. More severe adverse effects include tardive dyskinesia, akathisia, and acute dystonia. Neuroleptic malignant syndrome is a rare, life-threatening reaction to drugs that decrease dopamine. For more discussion about these problems, see Chapter 10. Drug Interactions 457 Promotility drugs are contraindicated in patients who are taking phenothiazine drugs, typical and atypical antipsychotics (see Chapter 10), and levodopa/carbidopa (see Chapter 9). In addition, use of these drugs along with certain antidepressants can increase the risk for serotonin syndrome, which is discussed in greater detail in Chapter 10. Nursing Implications and Patient Teaching Planning and implementation. In addition to the general nursing considerations related to antiemetic drug therapy listed in Box 13.1, the following issues and actions are important. Carefully monitor the patient for symptoms of restlessness, dizziness, and fatigue. This is especially important for the older adult who may be at greater risk for confusion or falls. Also monitor the patient for any Parkinson's disease–like symptoms such as tremor, slower gait, or masklike facial appearance. If the patient experiences these side effects, notify the healthcare provider because the drug may need to be discontinued. Patient and family teaching. Tell the patient and family the following: • Avoid driving, using any heavy machinery, or making important decisions while using this drug until you are aware of the effects. • Do not drink alcohol while taking this drug, to avoid severe side effects. • If you have any depression or thoughts of suicide, notify your healthcare provider immediately. • Inform your healthcare provider immediately if you have any sudden increase in fever, muscle spasms, or difficulty with movement because these may be signs of a more serious health issue. • Some men may experience erectile dysfunction or gynecomastia (enlargement of the breasts); some women may experience menstrual irregularities. These are generally reversible within a few weeks to a few months. Drugs for Peptic Ulcer Disease and Gastroesophageal Reflux Disease The lining of the stomach is usually strong enough to resist the powerful digestive 458 juices and acids that aid normal digestion. Gastric distress may be caused when stress or disease produces excess secretion of gastric acids, or when alcohol, chemicals, drugs, or disease produces destruction of the protective mucosal lining. If the protective lining is not repaired or the gastric acid level reduced, duodenal and gastric ulcers are produced. This is known as peptic ulcer disease (PUD), as shown in Fig. 13.4. PUD is associated with inflammation, pain, bleeding, reduced nutrition, and reduced quality of life. FIG. 13.4 (A) Peptic ulcer pathophysiology: The mucosa breaks down and an open sore develops. (B) A peptic ulcer may lead to bleeding, perforation, or other emergencies. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) Memory Jogger Prostaglandins maintain good blood flow to the stomach, which keeps these tissues well oxygenated and allows the immune system to help keep them healthy. This is why drugs that decrease prostaglandins, such as corticosteroids and NSAIDs, can be harmful to the stomach. For many people, another problem is GERD, which is when the highly acidic stomach contents move backward (reflux) into the esophagus (Fig. 13.5). The esophagus has no protection for this acidity and thus can be damaged very easily. Drug therapies for PUD and GERD are essentially the same. Commonly used drug therapies include antacids, histamine H2 receptor antagonists, proton pump inhibitors (PPIs), and cytoprotective drugs. Table 13.2 lists the names, dosages, and nursing implications of common drugs for PUD and GERD. More than one drug type may be used at the same time to help in healing the initial problem. 459 FIG. 13.5 Pathophysiology of gastroesophageal reflux disease (GERD). Acid reflux into the esophagus through the lower esophageal sphincter. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) Table 13.2 Common Drugs for Peptic Ulcer Disease and Gastroesophageal Reflux Disease Antacids: These drugs neutralize stomach acids to help relieve heartburn and indigestion. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS aluminum hydroxide (Alternagel, Alu-cap) dosages vary • Antacids are often available as combination drugs, so make sure to review drug depending on the formulation; make sure to check your drug information carefully before giving. handbook • Timing of antacids relating to meals and other drugs is very important. Many calcium carbonate (Rolaids Extra Strength, Tums, Caltrate, Maalox) drugs bind with antacids and thus lose effectiveness. In general, antacids should be dosages vary depending on the formulation; make sure to check given 1 hour before any other drugs and 2 hours after any other drugs. your drug handbook • Patients with heart failure or any other cardiac diseases should avoid antacids magnesium hydroxide (Milk of Magnesia) regular suspension: 5– high in sodium. 15 mL orally up to four times per day; concentrated suspension: 2.5–7.5 mL orally up to four times per day; chewable tablets: two to four tablets orally up to four times per day Histamine H2 receptor antagonists: These drugs bind to the H2 receptor in the stomach cells leading to a decrease in production of basal and nighttime gastric acid. They also decrease the amount of gastric acid that is released with meals and with substances such as caffeine. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS famotidine (Pepcid AC) OTC 10 mg orally may repeat 1 time to • Over-the-counter doses are typically about half the prescription drug doses. maximum of 20 mg/day Patients who are taking over-the-counter histamine H2 receptor antagonists should famotidine (Pepcid) 20 mg orally twice daily for up to 6 weeks not take them for more than 2 weeks without seeing a healthcare provide because nizatidine (Axid) 150 mg orally twice daily for up to 12 weeks they may be experiencing a more significant health issue. ranitidine (Zantac) 150 mg orally twice daily • Monitor the patient for signs of restlessness or confusion because these side effects may increase the risk for falls. Proton pump inhibitors: These drugs help heal gastric ulcers and reduce symptoms of GERD by stopping the acid secretory pump that is located within the gastric parietal cell membrane. This helps reduce the amount of acid secreted into the stomach. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS esomeprazole (Nexium) 20 mg orally once daily given 60 minutes • Give with a full glass of water 30–60 minutes before meals for maximum benefit before first meal of the day for up to 8 weeks (read drug information carefully). lansoprazole (Prevacid) 15–30 mg orally once daily 30–60 minutes • Over-the-counter proton pump inhibitors should not be taken for more than 2 before first meal of the day weeks because failure to relieve symptoms may indicate a more severe health omeprazole (Prilosec) 20–40 mg orally once daily before first meal problem. of the day for 2–8 weeks • Prescriptions of proton pump inhibitors may vary in length from 2 to 8 weeks pantoprazole (Protonix) 20–40 mg orally once daily for 2–8 weeks depending on the patient's presenting condition. • Teach patients it may take several days to experience relief once beginning proton pump inhibitors • If the patient has H.pylori bacteria in the stomach, the proton pump inhibitor will be combined with specific antibiotics to treat the infection so remind them to take the full prescription. Cytoprotective drugs: These drugs protect the lining of the stomach and protect from further damage. When taken properly, some of these drugs can “stick” to the ulcerated areas in the stomach or duodenum to protect them from further damage and allow them to heal. 460 DRUG/ADULT DOSAGE RANGE sucralfate (Carafate, Sulcrate) 1 g orally two to four times daily 1 hour before meals and at bedtime bismuth subsalicylate (Pepto-Bismol) For relief of gastric distress: Chewable or caplets: 2 tablets orally every 30–60 minutes PRN; do not exceed eight doses per day Liquid regular strength: 30 mL orally every 30–60 minutes PRN; do not exceed eight doses per day misoprostol (Cytotec) 50–200 mcg orally four times per day, with meals and at bedtime NURSING IMPLICATIONS • Do not give antacids within 30 minutes before or 1 hour after sucralfate because they decrease the effectiveness. • Do not crush or chew the tablets. The tablets are scored, so they may be cut in half for easier swallowing. For patients who are unable to swallow the half or whole tablet, dissolve the tablet in 10 mL of water and allow to stand for 10–20 minutes (called a “slurry”). • Shake the oral suspension well before giving to achieve a consistent dose of drug in solution. • Carefully review dosages for bismuth subsalicylate before giving because this drug can be given for several conditions besides gastric distress (e.g., treatment of diarrhea or prevention of traveler's diarrhea). It can also be used for antibiotic properties. • If patients do not receive relief from the recommended doses, make sure to contact the patient's healthcare provider in case there is a significant underlying condition that needs treatment. • Teach patients that bismuth subsalicylate can turn stools dark brown or even black while taking this drug. • Taking too much bismuth subsalicylate can result in symptoms of aspirin toxicity (because of the salicylate components of the drug). • Encourage the patient to drink at least 2–3 L of liquid unless contraindicated because this drug can cause constipation. • Remember that misoprostol must never be given to pregnant women because it can cause uterine contractions. GERD, Gastroesophageal reflux disease. Memory Jogger Common drugs used to manage peptic ulcers and GERD are: • antacids • histamine H2 receptor antagonists • PPIs • cytoprotective drugs Some peptic ulcers may be caused by Helicobacter pylori (H. pylori). H. pylori infections are typically treated by a combination of antimicrobial drugs and PPIs. Currently, patients with H. pylori–associated ulcers are treated for about 10 to 14 days with a standard triple therapy (consisting of a combination of a PPI and two selected antimicrobials). Alternatively, a standard quadruple therapy might be considered with a PPI and three antimicrobials. The H. pylori bacteria must be eradicated for successful treatment of the peptic ulcer. Chapter 5 discusses the patient teaching issues and nursing implications for antimicrobial therapy. Antacids Action and Uses Antacids are drugs that neutralize hydrochloric acid (HCl) and increase gastric pH (making the stomach's pH less acidic), which in turn reduces gastric irritation. Antacids are typically formulated with at least one of the following ingredients: calcium, magnesium, and aluminum. They are most often used in combination with other drugs to treat a number of GI conditions including PUD, gastritis, gastric ulcer, peptic esophagitis, hiatal hernia, gastric hyperacidity, and GERD. In most cases antacids are not used as the primary treatment for these disorders because they provide only temporary relief and do not prevent any future attacks. Table 13.2 lists the names, dosages, and nursing implications of common antacids. Be sure to 461 consult a drug reference book for more information about specific drugs. Expected Side Effects Using antacids as directed rarely results in significant side effects. In general, brands with magnesium can cause diarrhea; brands with calcium or aluminum can cause constipation. Other side effects include loss of appetite, frequent burping, nausea and vomiting, fatigue, and weight loss. Adverse Reactions Adverse reactions are usually specific to the type of antacid. For example, if the patient is taking a magnesium-based antacid, adverse effects are usually related to hypermagnesemia, such as muscle weakness, low blood pressure, and low heart rate. Adverse effects of calcium-containing antacids include bone pain, kidney stones, and in severe cases, cardiac dysrhythmias. Aluminum-containing antacids can cause mood changes, confusion, osteoporosis, and hypercalcemia. Drug Interactions A major concern for all antacids is the impact on absorption of other drugs. For this reason, timing of administration of the antacids related to meals and other drugs is very important. Always consult your drug reference before you give an antacid. Nursing Implications and Patient Teaching Planning and implementation. In addition to the general nursing considerations related to care of the patient with PUD or GERD listed in Box 13.2, the following issues and actions are important. Antacids are available over the counter and in a variety of flavors and forms to help make them more palatable to the patient. Depending on the brand, antacids can come as liquids, chewable tablets or gummies, or as tablets that dissolve in water. The neutralizing abilities of antacids vary, so one type of antacid does not necessarily result in the same results as another. The sodium content of various antacids must be carefully assessed before giving any antacid to patients who are on restricted sodium intake. These patients include pregnant women and patients with congestive heart failure (CHF) or other cardiac conditions, hypertension (high blood pressure), edema (fluid buildup in the body tissues), or renal failure. Box 13.2 General Nursing Considerations for the Patient With Peptic Ulcer Disease or Gastroesophageal Reflux Disease • Teach patients to avoid eating within 3 hours of bedtime to reduce the risk of reflux while lying flat in bed. 462 • Recommend that the patient stop smoking because nicotine increases stomach acid. • Recommend that the patient eat smaller portions at mealtimes. • Tell patients to notify their healthcare provider if they have taken H2 receptor blockers for longer than 2 weeks because these drugs can lose their effectiveness over time and the patient may need different drugs. • GERD and peptic ulcer have similar symptoms to cancer of the stomach, and overuse of the over-the-counter drugs can mask symptoms of other health problems. • For patients with peptic ulcer disease, make sure to monitor vital signs regularly. Make sure to notify the healthcare provider of increase in heart rate or decrease in blood pressure that may indicate internal bleeding. • Monitor level of consciousness while patient is taking drugs for GERD and PUD because they often cause confusion or restlessness, particularly in older adult patients. • Teach patients to avoid driving, using heavy machinery, or making important decisions while taking these drugs because they can cause drowsiness or confusion in some cases. • Tell the patient to report any severe dizziness or changes in stool color (black) because these may be an indication of bleeding. Patient and family teaching. Tell the patient and family the following: • Antacids neutralize gastric acids and are typically most beneficial if given between meals and at bedtime. • Take the drug exactly as prescribed. Antacids are generally taken 1 hour after meals and before bedtime. • If you are taking other drugs, it is usually best to take them 1 hour before or 2 hours after taking the antacid. Consult your pharmacist or healthcare provider if you have any questions. • Diarrhea or constipation are common side effects of different antacids. Contact your healthcare provider if they are severe. • Never take more than the recommended amount, to avoid adverse effects. • Antacids are used for short-term treatment only; they do not prevent future attacks. • If you are taking a chewable antacid, chew it 463 thoroughly before swallowing and with a full glass of water. • Shake any liquid antacid well before taking to ensure the dosage is correct. Histamine H2 Receptor Antagonists Action and Uses Histamine H2 receptor antagonists bind to the H2 receptor in the stomach cells, leading to a decrease in production of basal (the minimum amount of acid your body needs throughout the day) and nighttime gastric acid. It also decreases the amount of gastric acid released with meals and with substances such as caffeine. They may be used intravenously before and during long, major surgical procedures to prevent ulcer formation resulting from the physiologic stress of surgery. Table 13.2 lists the names, dosages, and nursing implications of common histamine H2 receptor antagonists. Be sure to consult a drug reference book for more information about specific drugs. Memory Jogger All the histamine H2 receptor antagonists have the suffix -tidine in their generic names. Expected Side Effects Expected side effects include headache, nausea, diarrhea or constipation, and mild abdominal pain. Some patients may have mental status changes, including confusion, anxiety, or depression. These usually resolve when the drug is stopped. Adverse Reactions Severe adverse reactions to H2 receptor blockers are rare and include severe allergic reactions, a variety of blood disorders, and cardiac dysrhythmias. Although the reason is not fully known, patients may also be at risk for pneumonia. Drug Interactions H2 blockers can affect certain enzymes in the liver that metabolize drugs. This can result in changes in how certain drugs are metabolized in the body, including warfarin, beta blockers, benzodiazepines, calcium channel blockers, and alcohol. Contact the healthcare provider or pharmacist if there is any concern about interactions. Nursing Implications and Patient Teaching Planning and implementation. 464 In addition to the general nursing considerations related to care of the patient with PUD or GERD listed in Box 13.2, the following issues and actions are important. Make sure to assess the complete blood count and check for unusual bleeding or signs of infection. Make sure to monitor patients for any changes in mental status, such as confusion or anxiety, after beginning H2 receptor blockers. For best effects, these drugs should be given with meals and at bedtime. Patient and family teaching. Tell the patient and family the following: • Once-a-day dosing of H2 receptor blockers is best taken at bedtime to reduce symptoms of acid reflux at night. • Avoid cigarette smoking because it increases gastric acid production and can decrease the effectiveness of H2 blockers. • Take H2 blockers only for occasional episodes of heartburn because they can lose their effectiveness. If symptoms continue, contact your healthcare provider for diagnosis and treatment. • Do not drive or operate heavy machinery until you see how the drug affects you. These drugs may cause dizziness in some people. • Use handrails when you are using stairs in case you have any dizziness. • Ask your family members to observe you for any changes in mental status, such as confusion or anxiety and depression. Lifespan Considerations Older Adults Older adults are more likely than younger adults to experience confusion and dizziness as side effects of H2 blockers. Proton Pump Inhibitors Action and Uses 465 PPIs help heal gastric ulcers and reduce symptoms of GERD by stopping the acid secretory pump that is located within the gastric parietal cell membrane. This helps reduce the amount of acid secreted into the stomach. PPIs are used to reduce gastric acid in a variety of conditions including GERD or peptic ulcer, or in combination with other drugs to treat H. pylori infection. They also may be used in acute care settings to decrease the risk for stress ulcers in critically ill patients. Length of treatment varies according to the type of illness the patient is experiencing but typically is about 4 to 8 weeks. In some cases longer-term treatment may be indicated in patients who produce excessive amounts of gastric acid (e.g., Zollinger-Ellison syndrome). In fact, some patients may need the drug for as long as 5 years. Table 13.2 lists the names, dosages, and nursing implications of common PPIs. Be sure to consult a drug reference book for more information about specific drugs. Memory Jogger All the PPIs have the suffix -prazole in their generic names. Expected Side Effects Common side effects include headache, mild abdominal pain, nausea and vomiting, flatulence (“passing gas”), and diarrhea or constipation. Many patients experience increased sensitivity to light (photosensitivity). Less common side effects include dizziness, anxiety, or mild rash. Low vitamin B12 levels leading to anemia may develop in patients who have taken PPIs for more than 1 year. Adverse Reactions Possible adverse reactions include severe allergic reactions, pancreatitis, and blood abnormalities including thrombocytopenia and hemolytic anemia. There is some concern that decreased calcium absorption in the stomach may place the patient at risk for osteoporosis and bone fractures with long-term use. Drug Interactions PPIs also inhibit certain enzymes in the liver that are involved in metabolizing other drugs. This is important because PPIs can increase or decrease the effectiveness of other drugs. Examples include warfarin, alprazolam, drugs given to treat tuberculosis, and certain drugs used to decrease blood cholesterol. Nursing Implications and Patient Teaching Planning and implementation. In addition to the general nursing considerations related to care of the patient with PUD or GERD listed in Box 13.2, the following issues and actions are important. Give PPIs about 30 to 60 minutes before the first meal of the day (usually breakfast). This will help to decrease the amount of acid secreted while eating. It may take 1 to 3 days for the patient to experience any relief from symptoms. In patients at risk for or 466 with osteoporosis, manage their bone status according to the healthcare providers' recommendations from current clinical practice, and ensure adequate vitamin D and calcium supplementation. Patient and family teaching. Tell the patient and family the following: • Avoid driving or using heavy machinery while using this drug because it may cause dizziness. • Contact your healthcare provider for recommendations about calcium and vitamin D because this drug may increase your risk for osteoporosis. • Do not use over-the-counter PPIs for longer than 2 weeks. If symptoms continue, contact your healthcare provider. • If you are taking prescription PPIs, make sure to take the full prescription even if you feel better. • These drugs do not cure ulcers, but they do reduce acid in your stomach so that the ulcer can heal. • Wear sunscreen and protective clothing because your skin may be more sensitive to light. Cytoprotective Drugs Action and Uses Cyto