Ch 37: Drug Therapy for Peptic Ulcer Disease and Hyperacidity

Pathophysiology:

the study of how normal body functions change, break down, or become abnormal when a person has a disease or injury

Peptic Ulcer Disease (PUD):

the formation of ulcers in the esophagus, stomach, and duodenum in area exposed to gastric acid and pepsin

Pepsin:

a primarily digestive enzyme in the stomach that breaks down dietary proteins into smaller peptides and amino acids

can potentially digest the stomach wall if the body’s cell protective agents are overwhelmed

Primary Causes of Peptic Ulcer Disease (PUD):

infection with Helicobacter pylori (H. pylori)

use of Nonsteroidal Anti-Inflammatory Drugs (NASIDs)

Ulcer:

an open sore that forms on the lining of your stomach, small intestine, or skin

Types of Ulcers:

• gastric ulcers

• duodenal ulcers

Gastric Ulcers:

• occur more frequently in older adults

• generally take longer to heal than duodenal ulcers

Duodenal Ulcers:

• strongly associated with H. pylori infection, NASID use, and cigarette smoking

• can occur at any age

Gastroesophageal Reflux Disease (GERD):

a chronic disorder where stomach acid or bite refluxes, or backflows, into the esophagus, exposing the esophageal mucosa to gastric acid and pepsin

Primary Cause of Gastroesophageal Reflux Disease (GERD):

an incompetent lower esophageal sphincter (LES)

Common Triggers of Gastroesophageal Reflux Disease (GERD):

• fatty foods

• chocolate

• alcohol

• caffeinated drinks

• smoking

• certain medications

Gastroesophageal Reflux Disease (GERD) Demographics:

• occurs in men, women, and children

• particularly common during pregnancy

Common Symptoms of Gastric Ulcers:

• dull ache after eating (when the stomach is full)

• bloating

• indigestion

• heartburn

• nausea

• painless bleeding

Common Symptoms of Duodenal Ulcers:

• severe stomach pain

• burning sensation at the back of the throat

• bloating

• heartburn

• symptoms often worsen when the stomach is empty and may flare at night

Common Symptoms of GERD:

pyrosis (heartburn) which increases when in a recumbent or bending position; regurgitation of gastric fluid into the mouth

Medications for acid-peptic:

• promote healing of lesions and prevent recurrence of lesions

• some medication neutralize gastric acid and decrease pepsin production

Antacids

Prototype Mylanta:

• taken to offset effects of GI acids by neutralizing gastric acid

• usually given orally and have an onset of 20-60 minutes

Mylanta:

prototype of the aluminum hydroxide-magnesium hydroxide mixture

Simethicone:

isn’t an antacid; it’s an antiflatulent (treats gas)

Pharmacokinetics:

describes how the body affects a specific medication through absorption, distribution, metabolism, and excretion

Pharmacokinetics of Antacids

Prototype Mylanta:

• oral medication absorbed from the GI tract; excreted in the urine

• Mylanta reacts with hyrochloric acid in the stomach to neutralize acid; onset of 20-60 minutes

Use of Antacids

Prototype Mylanta:

used to prevent or treat:

• peptic ulcer disease

• GERD

• esophagitis

• heartburn

• gastritis

• GI bleeding

• stress ulcers

Use of Antacids: Children

Prototype Mylanta

ambulatory children may take Mylanta after meals and at bedtime

for prevention of GI bleed in critically ill children

Use of Antacids: Older Adults

Prototype Mylanta

smaller doses may be effective because there is less gastric acid than younger adults

Use of Antacids: Pts With Renal Impairment

Prototype Mylanta

shouldn’t take magnesium-based antacids like Mylanta because it may accumulate and lead to hypermagnesemia

Use of Antacids: Pts with critical illness

Prototype Mylanta

prevention of stress ulcers is a priority

pts with nasogastric tubes (NG) may be prescribed antacids to maintain neutral acid levels and prevent aspiration

Why shouldn’t pts with renal failure take aluminum based antacids?

Prototype Mylanta

aluminum-based antacids may accumulate in pts with renal failure leading to encephalopathy

Adverse Effects of Antacids

Prototype Mylanta

• aluminum containing antacids can cause constipation

• hypophosphatemia and osteomalacia may develop in people who take large amounts over a long period of time

• antacids with magnesium can cause diarrhea and hypermagnesemia

• older adults can experience neuromuscular effects

Contraindications of Antacids

Prototype Mylanta

• patients with renal failure should not take Mylanta

  • magnesium is eliminated by the kidney; serum magnesium is increased in patients with renal impairment

• people with signs of appendicitis or inflamed bowel should not take Mylanta

Nursing Implications of Antacids: Preventing Interactions

Prototype Mylanta

few drugs alter their effects

• Anticholinergic drugs increase effects by delaying gastric emptying and decreasing acid secretion

• can prevent absorption of most drugs

increased absorption of drugs like levodopa and valproic acid

• separate administration by 1-2 hours

Nursing Implications of Antacids: Administration

Prototype Mylanta

taken 1-3 hours after meals and at bedtime

Nursing Implications of Antacids: Therapeutic effects

Prototype Mylanta

• decreased epigastric pain in patients with ulcers

• pain relief

• assess for decreased GI bleeding

• test pH of gastric contents

Histamine 2 Receptor Antagonists

Prototype Cimetidine (Tagamet):

inhibits both basal secretion of gastric acid and the secretion stimulated by histamine, acetylcholine, and gastrin

Cimetidine (Tagamet):

prototype of histamine 2 receptor antagonist

Pharmacokinetics of Histamine 2 Receptor Antagonists

Prototype Cimetidine (Tagamet):

• well absorbed when taken orally

• IV and IM administration ave rapid absorption

• peak levels occur in 1-1.5 hours with a duration of approximately 6 hours

Actions of Histamine 2 Receptor Antagonists

Prototype Cimetidine (Tagamet):

inhibits the action of histamine at the h2 receptors of the stomach, decreasing the amount, acidity, and pepsin content of gastric juices

Indications of Histamine 2 Receptor Antagonists

Prototype Cimetidine (Tagamet):

• prevention and treatment of peptic ulcer disease

• GERD

• esophagitis

• GI bleeding due to acute stress ulcers

• Zollinger-Ellison syndrome

  • rare condition characterized by excessive secretion of gastric acid and a high incidence of ulcers

Use of Histamine 2 Receptor Antagonists: Older Adults

Prototype Cimetidine (Tagamet):

more likely to experience adverse effects, like confusion, agitation, and disorientation

Use of Histamine 2 Receptor Antagonists: pts with renal impairment

Prototype Cimetidine (Tagamet):

• cautioned, may be necessary to reduce the dosage in pts with impaired renal failure

• cimetidine may cause mental confusion in pts with renal impairment

Use of Histamine 2 Receptor Antagonists: Pts with hepatic impairment

Prototype Cimetidine (Tagamet):

partial metabolism occurs in the liver; caution is warranted

Use of Histamine 2 Receptor Antagonists: Pts with Critical Illness

Prototype Cimetidine (Tagamet):

used to prevent stress-induced gastric ulceration, usually intermittent IV administration

Adverse Effects of Histamine 2 Receptor Antagonists:

Prototype Cimetidine (Tagamet):

• diarrhea

• dizziness

• drowsiness

• headache

• confusion

• gynecomastia

more likely with prolonged use of high doses, increasing age, and impaired renal or hepatic function

Contraindications of Histamine 2 Receptor Antagonists:

Prototype Cimetidine (Tagamet):

known hypersensitivity of cimetidine

caution is warranted in people with renal and hepatic impairment and in women who are lactating or pregnant

Nursing Implications of H2 Receptor Antagonist: Preventing Interactions

Prototype Cimetidine (Tagamet):

• antacids decrease absorption of cimetidine, do not give at the same time

• may increase serum levels/pharmacologic effects of other drugs

Nursing Implications of H2 Receptor Antagonist: Administration

Prototype Cimetidine (Tagamet):

• oral

• IV and IM administration

Nursing Implications of H2 Receptor Antagonist: Therapeutic Effects

Prototype Cimetidine (Tagamet):

• decreased epigastric pain in patients with ulcers

• decreased heartburn with GERD

Nursing Implications of H2 Receptor Antagonist: Adverse Effects

Prototype Cimetidine (Tagamet):

• diarrhea

• constipation

• headaches

• dizziness

• muscle aches

• fatigue

• skin rashes

• mental confusion

• delirium

• coma

• depression

• fever

• can decrease sperm count and cause gynecomastia in men and galactorrhea in women

Proton Pump Inhibitors (PPI)

Prototype Omeprazole (Prilosec):

• most potent inhibitor of gastric acid secretion

• similar to H2RAs but act differently

• suppresses more gastric acid for a longer period of time, faster relief and faster healing of acid related diseases

Omeprazole (Prilosec):

prototype for Proton Pump Inhibitors (PPI)

Proton Pump Inhibitors (PPI): Pharmacokinetics

Prototype Omeprazole (Prilosec):

• oral administration, absorbed well

• onset of effects in 2 hours and lasts 72 hours or longer

• half-life 1-1.5 hours

• metabolized in the liver and excreted in the urine

Proton Pump Inhibitors (PPI): Action

Prototype Omeprazole (Prilosec):

binds to the gastric proton pump to prevent “pumping” or release of gastric acid from parietal cells in the stomach lumen

Proton Pump Inhibitors (PPI) are the treatment choice for:

Prototype Omeprazole (Prilosec):

• peptic ulcer disease (duodenal and gastric)

  • begins to heal ulcers within 2 weeks

• GERD with erosive esophagitis

  • eliminates symptoms of GERD and erosive gastritis within 1-2 weeks

  • heals esophagitis in 8 weeks

• Zollinger-Ellison syndrome

Use of Proton Pump Inhibitors (PPI): Children

Prototype Omeprazole (Prilosec):

• used for GERD, peptic ulcers, and treatment of H. pylori

• formulated in various form for pediatric consumption

Use of Proton Pump Inhibitors (PPI): Older Adults

Prototype Omeprazole (Prilosec):

• tolerate well

• drug choice for symptomatic GERD

• long-term use can lead to increased risk of hip fractures

Use of Proton Pump Inhibitors (PPI): pts with hepatic impairment

Prototype Omeprazole (Prilosec):

• bioavailability is increased because of decreased first pass metabolism

• metabolism occurs in the liver, can elevate liver function tests

Use of Proton Pump Inhibitors (PPI): Pts with critical illness

Prototype Omeprazole (Prilosec):

usually tolerated well, IV administration is an option if needed

Proton Pump Inhibitors (PPI): Adverse Effects

Prototype Omeprazole (Prilosec):

• nausea

• diarrhea

• headache

• long-term use can lead to risk for bone fractures

Proton Pump Inhibitors (PPI): Contraindications

Prototype Omeprazole (Prilosec):

known hypersensitivity to omeprazole

Nursing Implications for Proton Pump Inhibitors (PPI): Preventing Interactions

Prototype Omeprazole (Prilosec):

• increases blood levels of some benzodiazepines and warfarin

• coadministration of clopidogrel (Plavix) may reduce cardio protective effects from Plavix

Nursing Implications for Proton Pump Inhibitors (PPI): Administration

Prototype Omeprazole (Prilosec):

• administered before food intake

• should shallow pills whole, no crushing or chewing

Nursing Implications for Proton Pump Inhibitors (PPI): Therapeutic Effects

Prototype Omeprazole (Prilosec):

• decreased epigastric pain in patients with gastric and duodenal ulcers

• decreased heartburn with GERD

Nursing Implications for Proton Pump Inhibitors (PPI): Adverse Effects

Prototype Omeprazole (Prilosec):

• diarrhea

• headaches

• nausea

• vomiting

• abdominal pain

Prevention and treatment of Peptic Ulcer Disease:

• a preparation of sulfated sucrose and aluminum that binds to normal and ulcerated mucosa

• relieves irritation of mucosa, especially in esophagus

Medication for H.pylori

2 antibiotics, and an acid reducer known as triple therapy

Bismuth Subsalicylate (aka Pepto-Bismol)

• coats ulcers, protecting them from stomach acid and to treat Pylori

• used for diarrhea and nausea

• contraindicated in patients who can not take aspirin