Week 9: Drugs Affecting the Digestive and Renal Systems

Oral Candidiasis (Thrush)

Definition:

• Fungal infection caused by Candida species

Symptoms:

• White patches on the tongue, inner cheeks, and throat

• Redness and soreness

• Difficulty swallowing

Risk Factors:

• Immunosuppression, antibiotic use, diabetes, dentures

Treatment:

• Anti-fungal medications (e.g., nystatin, fluconazole)

• Maintaining good oral hygiene

What are the symptoms of Oral Candidiasis (Thrush)?

• White patches on the tongue, inner cheeks, and throat

• Redness and soreness

• Difficulty swallowing

What is the treatment for Oral Candidiasis (Thrush)?

• Anti-fungal medications (e.g., nystatin, fluconazole)

• Maintaining good oral hygiene

Herpes Simplex Virus (HSV) Infections

Definition:

• Viral infection causing cold sores or fever blisters

  • “Oral Herpes”

Symptoms:

• Painful blisters or ulcers on the lips and inside the mouth

• Tingling or itching before blisters appear

Transmission:

• Direct contact with infected saliva or lesions

Treatment:

• Antiviral medications (e.g., acyclovir, valacyclovir)

• Pain relief measures

What are the symptoms of Herpes Simplex Virus (HSV)?

• Painful blisters or ulcers on the lips and inside the mouth

• Tingling or itching before blisters appear

What is the treatment for Herpes Simplex Virus (HSV)?

• Antiviral medications (e.g., acyclovir, valacyclovir)

• Pain relief measures

Mucositis

Definition:

• Inflammation and ulceration of the mucous membranes lining the digestive tract

Common Causes:

• Chemotherapy, radiation therapy

Impact:

• Significant pain, risk of infection, nutritional challenges

Symptoms:

• Painful sores in the mouth or throat

• Difficulty swallowing or eating

• Redness and swelling of the mucous membranes

• Increased risk of infection

What is the definition of Mucositis?

• Inflammation and ulceration of the mucous membranes lining the digestive tract

What are the symptoms of Mucositis?

• Painful sores in the mouth or throat

• Difficulty swallowing or eating

• Redness and swelling of the mucous membranes

• Increased risk of infection

Pharmacological Treatments for Mucositis

Topical Agents:

• Use of mouth rinses and gels to soothe and protect the mucous membranes (e.g., magic mouthwash, sucralfate)

Systemic Medications:

• Prescribed medications to manage pain and inflammation (e.g., opioids, anti-inflammatory drugs)

Gastritis

Definition:

• Inflammation of the stomach lining

Symptoms:

• N/v, abdominal pain, bloating

Causes:

• Infection (H. pylori)

• NSAIDs

• Alcohol

• Stress

  • “very common in ICU pts”

Treatment:

• Antacids

• H2 blockers

• Proton pump inhibitors (PPIs)

• Antibiotics

What are the causes of Gastritis?

• Infection (H. pylori)

• NSAIDs

• Alcohol

• Stress

  • “very common in ICU pts”

What are the treatments for Gastritis?

• Antacids

• H2 blockers

• Proton pump inhibitors (PPIs)

• Antibiotics

Peptic Ulcer Disease (PUD)

Definition:

• Sores that develop on the lining of the stomach, small intestine, or esophagus

Symptoms:

• Burning stomach pain, bloating, heartburn, nausea

Causes:

• H. pylori infection

• Long-term use of NSAIDs

Treatment:

• Antibiotics

• PPIs

• H2 blockers

• Antacids

What are the causes of Peptic Ulcer Disease?

• H. pylori infection

• Long-term use of NSAIDs

What are the treatments of Peptic Ulcer Disease?

• Antibiotics

• PPIs

• H2 blockers

• Antacids

Gastroesophageal Reflux Disease (GERD)

Definition:

• Chronic condition where stomach acid flows back into the esophagus

Symptoms:

• Heartburn, regurgitation, chest pain, difficulty swallowing

Causes:

• Weak lower esophageal sphincter (LES)

• Obesity

• Smoking

Treatment:

• Lifestyle changes

• Antacids

• H2 blockers

• PPIs

What are the symptoms of GERD?

• Heartburn, regurgitation, chest pain, difficulty swallowing

What are the causes of GERD?

• Weak lower esophageal sphincter (LES)

• Obesity

• Smoking

What are the treatments for GERD?

• Lifestyle changes

• Antacids

• H2 blockers

• PPIs

Factors Preventing Breakdown of Defense Barriers

Mucus Production:

• Protects the stomach lining from acid

Bicarbonate Secretion:

• Neutralizes stomach acid

Blood Flow:

• Maintains healthy stomach lining

Prostaglandins:

• Promote mucus and bicarbonate production

Factors Leading to Ulcer Formation

H. pylori Infection:

• Damages the protective lining of the stomach

NSAIDs:

• Inhibit prostaglandin production, reducing mucus and bicarbonate

Excessive Acid Production:

• Overwhelms the protective mechanisms

Smoking and Alcohol:

• Irritate and damage the stomach lining

Drug Classifications for Stomach Disorders

Antacids:

• Neutralize stomach acid

H2 Blockers:

• Reduce acid production

Proton Pump Inhibitors (PPIs):

• Block acid production

Antibiotics:

• Treat H. pylori infection

Prokinetics:

• Enhance gastrointestinal motility

Antacids

Mechanism of Action:

• Neutralize stomach acid to provide quick relief from heartburn and indigestion

Nursing Considerations:

• Monitor for s/e such as constipation or diarrhea

• Educate patients on proper use

Examples:

• Calcium carbonate

  • “carbonate = basic, neutralizes acid”

• Magnesium hydroxide

• Aluminum hydroxide

What is the mechanism of action for Antacids?

• Neutralize stomach acid to provide quick relief from heartburn and indigestion

What are the examples of Antacids?

• Calcium carbonate

• Magnesium hydroxide

• Aluminum hydroxide

H2 Blockers

Mechanism of Action:

• Block histamine H2 receptors on parietal cells, reducing acid production

Nursing Considerations:

• Monitor for s/e such as headache, dizziness

• Educate patients on potential drug interactions

Examples:

• ranitidine

• famotidine (Pepcid)

• cimetidine

What is the mechanism of action for H2 Blockers?

• Block histamine H2 receptors on parietal cells, reducing acid production

What are the examples of H2 Blockers?

• ranitidine

• famotidine (Pepcid)

• cimetidine

Proton Pump Inhibitors (PPIs)

Mechanism of Action:

• Inhibit the proton pump in parietal cells, blocking acid production

Nursing Considerations:

• Monitor for s/e such as headache, GI issues

• Educate patients on long-term use risks

Examples:

• omeprazole (Prilosec)

• esomeprazole

• pantoprazole

What is the mechanism of action for Proton Pump Inhibitors (PPIs)?

• Inhibit the proton pump in parietal cells, blocking acid production

What are the examples of Proton Pump Inhibitors (PPIs)?

• omeprazole

• esomeprazole

• pantoprazole

Antibiotics for H. pylori

Mechanism of Action:

• Eradicate H. pylori infection to promote ulcer healing

Nursing Considerations:

• Monitor for s/e such as GI upset

• Ensure patient adherence to the full course of therapy

  • “have pt on probiotic, to not completely knock out gut flora”

Examples:

• Amoxicillin

• clarithromycin

• metronidazole

What are some examples of Antibiotics for H. pylori?

• Amoxicillin

• clarithromycin

• metronidazole

What does eradicating H. pylori do for the body?

It helps to promote ulcer healing

Prokinetics

Mechanism of Action:

• Enhance GI motility by increasing the movement of the stomach and intestines

Nursing Considerations:

• Monitor for s/e such as drowsiness, restlessness

• Educate patients on proper use

Examples:

• Metoclopramide

• domperidone

What are some examples of Prokinetics?

• Metoclopramide

• domperidone

Nonpharmacologic Interventions for Stomach Disorders

Dietary Modifications:

• Avoiding spicy, acidic, or fatty foods

• Eating smaller, more frequent meals

Lifestyle Changes:

• Weight management

• Smoking cessation

• Reducing alcohol intake

Stress Management:

• Techniques such as relaxation exercises, counseling

Integrating Pharmacologic and Nonpharmacologic Treatments

Comprehensive Care Plan:

• Combining medications with lifestyle and dietary changes for optimal management of stomach disorders

Patient Education:

• Importance of adherence to treatment plans and making sustainable lifestyle changes

Common Causes of Nausea and Vomiting

GI Disorders:

• Gastroenteritis, gastritis, peptic ulcers

CNS Disorders:

• Migraine, motion sickness

• Increased ICP

  • “vomiting w/o nausea indicates brain issue”

Medications:

• Chemotherapy, opioids, antibiotics

Pregnancy:

• Morning sickness

Other Causes:

• Food poisoning, infections, anxiety

Interventions for Nausea and Vomiting

Nonpharmacologic Interventions:

• Dietary changes, hydration, relaxation techniques

Pharmacologic Interventions:

• Antiemetics (e.g., ondansetron, metoclopramide)

• Antihistamines (e.g., diphenhydramine)

• Anticholinergics (eg., scopolamine)

Types of Chemotherapy-Induced Nausea and Vomiting

Acute CINV:

• Occurs within 24 hours of chemotherapy

Delayed CINV:

• Occurs more than 24 hours after chemotherapy

Anticipatory CINV:

• Triggered by sights, smells, or thoughts associated with chemotherapy

Acute CINV

Assessment:

• Monitor for onset of symptoms within 24 hours of chemotherapy

Interventions:

• Administer prescribed antiemetics

• Provide patient education on managing symptoms

Delayed CINV

Assessment:

• Monitor for symptoms occurring more than 24 hours after chemotherapy

Interventions:

• Administer long-acting antiemetics

• Educate patients on symptom management and adherence to medication schedules

Anticipatory CINV

Assessment:

• Identify triggers and assess patient anxiety levels

Interventions:

• Use behavioral therapies (e.g., relaxation techniques)

• Administer antiemetics before chemotherapy sessions

Therapeutic Classes of Antiemetics

• Serotonin (5-HT3) Receptor Antagonists

• Dopamine Antagonists

• Antihistamines

• Anticholinergics

• Neurokinin-1 (NK1) Receptor Antagonists

• Cannabinoids

Antiemetic: Serotonin (5-HT3) Receptor Antagonists

Mechanism of Action:

• Block serotonin receptors in the gut and CNS

Uses:

• Effective for CINV, postoperative nausea and vomiting (PONV)

Nursing Considerations:

• Monitor for s/e such as headache, constipation, and QT prolongation

• Educate patients on proper use and adherence

Examples:

• ondansetron (Zofran)

• granisetron

What are examples of Serotonin (5-HT3) Receptor Antagonists?

• ondansetron (Zofran)

• granisetron

Antiemetic: Dopamine Antagonists

Mechanism of Action:

• Block dopamine receptors in the brain

Uses:

• Effective for CINV, PONV, and nausea related to GI disorders

  • “great for delayed CINV”

Nursing Considerations:

• Monitor for s/e such as drowsiness, extrapyramidal symptoms, and hypotension

• Educate patients on potential drug interactions

Examples:

• metoclopramide

• prochlorperazine

What are examples of Dopamine Antagonists?

• metoclopramide

• prochlorperazine

Antiemetic: Antihistamines

Mechanism of Action:

• Block histamine receptors in the brain

Uses:

• Effective for motion sickness, vertigo, and nausea related to inner ear disorders

Nursing Considerations:

• Monitor for s/e such as drowsiness, dry mouth, and blurred vision

• Advise patients to avoid activities requiring alertness

  • “better if used w/other nausea meds”

Examples:

• diphenhydramine (Benadryl)

• meclizine

What are some examples of Antihistamines?

• diphenhydramine (Benadryl)

• meclizine

What are Antihistamines used for?

• Effective for motion sickness, vertigo, and nausea related to inner ear disorders

Antiemetics: Anticholinergics

Mechanism of Action:

• Block acetylcholine receptors in the brain

Uses:

• Effective for motion sickness and PONV

Nursing Considerations:

• Monitor for s/e such as dry mouth, urinary retention, and blurred vision

• Educate patients on proper application of transdermal patches

Examples:

• Scopolamine (Transdermal Patch)

What is an example of an Anticholinergic used as an antiemetic?

• Scopolamine (Transdermal Patch)

Antiemetic: Neurokinin-1 (NK1) Receptor Antagonists

Mechanism of Action:

• Block NK1 receptors in the brain

Uses:

• Effective for CINV, especially when used in combination w/other antiemetics (Zofran+Benadryl)

Nursing Considerations:

• Monitor for s/e such as fatigue, hiccups, and liver enzyme changes

• Educate patients on the importance of adherence to the prescribed regimen

Examples:

• Aprepitant

• fosaprepitant

What are some examples of NK1 Receptor Antagonists?

• Aprepitant

• fosaprepitant

Cannabinoids

Mechanism of Action:

• Activate cannabinoid receptors in the brain

Uses:

• Effective for CINV, especially in patients who do not respond to other antiemetics

Nursing Considerations:

• Monitor for s/e such as dizziness, euphoria, and dry mouth

• Educate patients on the potential for psychoactive effects and safe use

  • “helps put on weight, increases appetite”

Examples:

• dronabinol

• nabilone

What are some examples of Cannabinoids?

• dronabinol

• nabilone

Introduction to Constipation

Definition:

• Infrequent or difficult bowel movements

Common Causes:

• Low fiber diet, dehydration, lack of physical activity, medications

Bulk-Forming Laxatives

Mechanism:

• Absorb water to form a gel-like mass, adding bulk to stool and promoting peristalsis

Nursing Considerations:

• Ensure adequate fluid intake to prevent intestinal obstruction

Examples:

• psyllium

• methylcellulose

What are some examples of Bulk-Forming Laxatives?

• psyllium

• methylcellulose

Osmotic Laxatives

Mechanism:

• Draw water into the bowel, softening stool and promoting bowel movements

Nursing Considerations:

• Monitor for electrolyte imbalances and dehydration

Examples:

• Lactulose

• polyethylene glycol

What are some examples of Osmotic Laxatives?

• Lactulose

• polyethylene glycol

Stimulant Laxatives

Mechanism:

• Stimulate intestinal motility and increase water and electrolyte secretion into the bowel

Nursing Considerations:

• Use short-term to prevent dependency and bowel dysfunction

Examples:

• Bisacodyl

• senna

What are some examples of Stimulant Laxatives?

• Bisacodyl

• senna

Stool Softeners

Mechanism:

• Lower surface tension of stool, allowing water and fats to penetrate and soften it

Nursing Considerations:

• Encourage fluid intake to enhance effectiveness

Examples:

• Docusate sodium (Colace)

Lubricant Laxatives

Mechanism:

• Coat the stool and intestinal lining with a waterproof film, keeping moisture in the stool

Nursing Considerations:

• Use with caution to avoid aspiration and lipid pneumonia

Examples:

• Mineral oil

Introduction to Diarrhea

Definition:

• Frequent, loose, or watery bowel movements

Common Causes:

• Infections (bacterial, viral, parasitic)

• Food intolerances

• Medications

• Digestive disorders (e.g., IBS)

Locally Acting Antidiarrheal Agents

Mechanism:

• Act directly on the intestines to absorb toxins and reduce inflammation

Nursing Considerations:

• Monitor for s/e such as constipation and black stools

Examples:

• Bismuth subsalicylate (Pepto-Bismol)

• kaolin-pectin

What are some examples of Locally Acting Antidiarrheal Agents?

• Bismuth subsalicylate (Pepto-Bismol)

• kaolin-pectin

Systemically Acting Antidiarrheal Agents

Mechanism:

• Slow intestinal motility and increase water absorption

Nursing Considerations:

• Monitor for signs of ileus and toxic megacolon, especially in infectious diarrhea

Examples:

• Loperamide (Imodium)

• diphenoxylate with atropine

What are some examples of Systemically Acting Antidiarrheal Agents?

• Loperamide (Imodium)

• diphenoxylate with atropine

Nursing Assessments for Hydration: Constipation

Assessment:

• Monitor fluid intake and output, skin turgor, mucous membranes

Interventions:

• Encourage adequate fluid intake, dietary fiber, and physical activity

Nursing Assessments for Hydration: Diarrhea

Assessment:

• Monitor fluid intake and output, skin turgor, mucous membranes, weight changes

Interventions:

• Encourage oral rehydration solutions, monitor for signs of dehydration

Electrolytes to Monitor in Diarrhea

Key Electrolytes:

• Sodium

• Potassium

• Chloride

• Bicarbonate

Monitoring:

• Regular blood tests to check electrolyte levels, especially in prolonged or severe diarrhea

Pharmacologic Therapy Overview (Renal)

Goal:

• Prevent or delay complications by treating underlying kidney disease

Common Drug Categories:

• Phosphate-binding agents

• Calcium supplements

• Antihypertensive and cardiac medications

• Statins

• Anticonvulsants

• Erythropoietin-stimulating agents (ESAs)

  • “kidneys responsible for releasing erythropoietin (RBCs)”

Intensive blood glucose control helps prevent microalbuminuria and progression of diabetic nephropathy

Calcium and Phosphorus Binders

• Hyperphosphatemia → stimulates hyperparathyroidism → hypercalcemia → ↑cardiovascular calcification risk

• Management:

  • Dietary phosphate restriction

  • Hemodialysis

    • “3x/week for 2-3 hours”

  • Phosphate-binding medications reduce intestinal phosphate absorption

• Common Agents:

  • Sevelamer carbonate (preferred over hydrochloride)

  • Lanthanum carbonate

• Goal: Serum phosphorus ≤ 5.5 mg/dL or near normal

Parathyroid Agents

Cinacalcet (calcimimetic):

• Binds calcium-sensing receptors in the parathyroid gland

• Suppresses PTH secretion → ↓bone resorption → mitigates bone loss

Used for secondary hyperparathyroidism in kidney failure

• “secondary hyperparathyroidism almost exclusively bc CKD”

Pearls for Practice - Pill Burden

• Patients may take 1-4 phosphate binders per meal/snack (3-5 times/day)

  • Approximately 11 pills/day just for phosphate binders

• Nurses should:

  • Assess patient knowledge and willingness to adhere

  • Acknowledge complexity and support autonomy

  • Build trust to improve decision-making and adherence

Pathophysiology Pearls

In Kidney Failure:

• Collecting tubules cannot reabsorb calcium

• Vitamin D activation impaired → ↓intestinal calcium absorption

Results in:

• Hypocalcemia

• Secondary hyperparathyroidism

• Hyperphosphatemia

Antihypertensive and Cardiovascular Agents

• HTN common in CKD; BP ≥ 140/90 mmHg inversely related to GFR

  • “kidneys trying to get perfusion”

• Aggressive treatment slows CKD progression

• Common Agents:

  • Thiazide diuretics (chlorthalidone preferred)

  • ACE inhibitors (ACEIs)

  • ARBs

  • Calcium channel blockers (CCBs)

• Avoid ACEI + ARB combination (↑hyperkalemia risk)

• Monitor for:

  • Cough, angioedema, hyperkalemia (ACEIs)

  • Labs for potassium and renal function

Cardiovascular Risk and Statins

• CVD is leading cause of mortality in CKD

• Risk Factors:

  • DM, anemia, high LDL, vascular calcification

• Statins:

  • Reduce CV risk in stage 2 or early stage 3 CKD

  • Lower mortality and major CV events by ~20%

• Lifestyle changes:

  • DASH diet, sodium restriction, weight management, physical activity

Anticonvulsants and Neuromuscular Agents

• Seizures may occur as uremia worsens:

  • IV diazepam, lorazepam, or phenytoin used for control

• Safety:

  • Raise side rails, bed in lowest position, protect head during seizure

• Restless Leg Syndrome (RLS):

  • Common in dialysis patients

  • Avoid caffeine, alcohol, nicotine

  • Medications:

    • Anticonvulsants

    • Benzodiazepines

    • Dopamine agonists

    • Iron

    • Opioids if refractory

Erythropoietin-Stimulating Agents (ESAs)

• Treat anemia in CKD:

  • Epoetin alfa or darbepoetin alfa

• Effects:

  • Initial improvement in 1-2 weeks

  • Target hemoglobin: 10-11 g/dL (avoid >11 g/dL)

• Iron supplementation based on ferritin levels

• Administration:

  • IV at end of dialysis or subcutaneous

ESA Adverse Effects and Nursing Role

Side Effects:

• HTN

• HF

• Thrombotic events (stroke, MI)

• Headache, arthralgia, nausea

  • “arthralgia = joint pain, describing discomfort, aching, or soreness in one or more joints”

Nursing Considerations:

• Use lowest effective dose

• Monitor BP, hemoglobin, iron stores

• Expected outcomes: ↑ energy, improved well-being, better dialysis tolerance

Thiazide Diuretics

Primary Use:

• First-line for HTN and mild edema

Mechanism of Action:

• Inhibit sodium reabsorption in the distal convoluted tubule

• Leads to increased excretion of sodium and water

Examples:

• Hydrochlorothiazide

• Chlorthalidone

Key Points:

• Monitor electrolytes (especially potassium)

• Risk of dehydration and orthostatic hypotension

• Educate on maintaining hydration

Loop Diuretics

Primary Use:

• Potent diuretics for HF, pulmonary edema, and severe fluid overload

Mechanism of Action:

• Act on the ascending loop of Henle to inhibit sodium and chloride reabsorption

Examples:

• Furosemide (Lasix)

• Bumetanide

Key Points:

• Monitor for hypokalemia, dehydration, and ototoxicity

• Assess BP and renal function regularly

Potassium-Sparing Diuretics

Primary Use:

• Prevent potassium loss when used with other diuretics

Mechanism of Action:

• Interfere with sodium-potassium exchange in the distal tubule

Examples:

• Spironolactone

• Amiloride

Key Points:

• Monitor for hyperkalemia

• Avoid potassium supplements unless prescribed

• Useful in HF for aldosterone blockade

Carbonic Anhydrase Inhibitors

Primary Use:

• Less common for fluid removal

• Used for glaucoma and altitude sickness

Mechanism of Action:

• Inhibit carbonic anhydrase in the proximal tubule, reducing sodium and bicarbonate reabsorption

Example: Acetazolamide

Key Points:

• Monitor for metabolic acidosis

• Assess for electrolyte imbalances

Osmotic Diuretics

Primary Use:

• Acute settings: reduce ICP or treat acute kidney failure

Mechanism of Action:

• Increase blood osmolarity, drawing water out of tissues into urine

Example: Mannitol

Key Points:

• Monitor for signs of fluid overload and electrolyte imbalance

• Use with caution in HF patients

  • “will turn brain into raisin, good for cerebral edema”