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These chapters cover medications involving GI disorders, including:

Medications for Peptic Ulcers (28)

1.  Antibiotics

2. Histamine-2 receptor antagonists

3. proton pump inhibitors

4. Mucousal protectants

5. Prostaglandin E. Analog

Medications for GI disorders (29)

1. Antiemetics

2. Laxatives

3. Antidiarrheals

4. Prokinetic Agents

5. Medications for IBS-D and C

6. 5- Aminosalicylates

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https://youtu.be/lcbH6e8_iCs

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Laxative, Bulk Forming Agent

Pregnancy Category: Unknown

Indications:

·        Indicated in management of simple or chronic constipation, particularly if associated in a low-fiber diet.

·        Useful in situations when straining should be avoided

·        used in the management of chronic watery diarrhea

Pharmacological action:
Helps to add water to stool, which promotes peristalsis and reduces transit time.

Therapeutic Effects
Relieves constipation.

Contraindicatons/precautions:

·        Hypersensitivity

·        abdominal pain

·        nausea or vomiting

·        serious adhesions

·        dysphagia

·        Use cautiously in diabetes (check if it has sugar first)

·        has been used safely in lactation

Adverse Reaction/Side Effects

·        bronchospasm

·        intestinal or esophageal obstruction

·        nausea, vomiting

Interactions:
Decreases absorption of

·        warfarin

·        salicylates

·        digoxin

Patient Teachings:

·        Encourage patient to use other forms of bowel regulation, such as increasing bulk in the diet, increasing fluid intake, and increasing mobility. Normal bowel habits are individualized and may vary from 3 times/day to 3 times/wk.

·        May be used for long-term management of chronic constipation.

·        Instruct patients with cardiac disease to avoid straining during bowel movements (Valsalva maneuver).

·        Advise patient not to use laxatives when abdominal pain, nausea, vomiting, or fever is present.

Nursing Administration (PO):
Taken PO as a powder, granules or wafer.

·        Administer with a full glass of water or juice, followed by an additional glass of liquid.

·        Solution should be taken immediately after mixing; it will congeal.

·        Do not administer without sufficient fluid and do not chew granules.

Other laxatives include
Docusate sodium
Bisacodyl
Magnesium Hydroxide

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Category B controlled substance

Expected pharmacological action:
Antidiarrheal drugs activate opioid receptors in the GI tract to decrease intestinal motility and to increase the absorption of fluid and sodium in the intestine

Therapeutic Effects/Indications:

·         Specific antidiarrheal agents can be used to treat the underlying cause of diarrhea. For example antibiotics can be used to treat diarrhea caused by a bacterial infection

·         Nonspecific antidiarrheal agents provide symptomatic treatment of diarrhea (decrease in frequency and fluid content of stool)

Contraindications/precautions:

·         There is an increased risk of megacolon in clients who have inflammatory bowel disorders. This could lead to serious complication, such as perforation of the bowel.

·         Diphenoxylate is contraindicated in clients who have severe electrolyte imbalance or dehydration. It is a controlled substance (category B)

·         Paregoric is contraindicated in clients who have COPD

·         Antidiarrheals are a pregnancy risk category C

·         Interacts with alcohol and other CNS depressants

Complications:

·         At recommended dose for diarrhea, diphenoxylate may not affect the CNS system.

·         At high doses, clients can experience typical opioid effects, such as euphoria or CNS depression. However, with the addition of atropines anticholinergic (drying) effects, it discourages doses that are higher that those prescribed.

Nursing Administration:

·         Administer initial dose of diphenoxylate plus atropine 5mg. Titrate to clients response. Max dose: 8 tabs/day

·         Loperamide is an analog of the opioid meperidine. This medication is not a controlled substance, and at high doses does not mimic morphine-like effects.

·         Advise clients who have diarrhea to drink small amounts of clear liquids or a commercial oral electrolyte solution to maintain electrolyte balance for the first 24 hr.

·         Advise clients to avoid drinking plain water because it does not contain necessary electrolytes that are being lost in the stool

·         Clients who have severe cases of diarrhea can be hospitalized for management of dehydration

·         Management of dehydration should include monitoring of weight, Is and Os, and vital signs. A hypotonic solution such as 0.45% sodium chloride may be prescribed.

Evaluation:
depending on therapeutic intent, effectiveness can be evidenced by return of normal bowel pattern AEB decrease in frequency and fluid volume of stool.

Contraindications:

·         Hypersensitivity;

Severe liver disease;

Infectious diarrhea (due to Escherichia coli, Salmonella, or Shigella);

Diarrhea associated with Clostridium difficile-associated diarrhea (CDAD);

Dehydrated patients;

Angle-closure glaucoma;

Children <2 yr;

Known alcohol intolerance (some liquid diphenoxylate/atropine products only).

Adverse Effects:

·         dizziness, confusion, drowsiness, headache, insomnia, nervousness

·         blurred vision, dry eyes

·         tachycardia

·         constipation, dry mouth, epigastric distress, ileus, nausea, vomiting

·         urinary retention

·         flushing

Patient Teaching:

Instruct patient to take medication as directed. Do not take more than the prescribed amount because of the habit-forming potential and risk of overdose in children. If on a scheduled dosing regimen, missed doses should be taken as soon as possible unless almost time for next dose. Do not double doses.

Medication may cause drowsiness. Advise patient to avoid driving or other activities requiring alertness until response to drug is known.

Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may relieve dry mouth.

Caution patient to avoid alcohol and other CNS depressants concurrently with this medication.

Advise patient to inform health care professional of medication regimen prior to treatment or surgery.

Instruct patient to notify health care professional if diarrhea persists or if fever, abdominal pain, or palpitations occur.

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Expected Pharmacological Action:

·         If CTZ is activated (by chemo) the CTZ in turn activates the vomiting center to expel gastric contents. Metoclopramide controls nausea and vomiting by blocking dopamine and serotonin receptors in the CTZ

·         Metoclopramide augments action of acetylcholine, which causes an increase in upper GI motility, increasing peristalsis.

Therapeutic uses

·         Control of postoperative and chemotherapy-induced nausea and vomiting, as well as facilitation of intubation and examination of the GI tract.

·         The oral form is used for diabetic gastroparesis (delayed stomach emptying with gas and bloating) and management of GERD through its ability to increase gastric motility.

Complications/Adverse Effects:

·         Extrapyramidal symptoms

·         Sedation

·         Diarrhea

Nursing Considerations:

·         Inform clients of the possible adverse effects of extrapyramidal symptoms, such as restlessness, anxiety, and spasms of the face and neck.

·         Administer and antihistamine, such as diphenhydramine, to minimize these effects.

·         Monitor bowel function and indications of dehydration related to the patients diarrhea

·         Advise clients to avoid alcohol and other CNS depressants

·         Advise clients to avoid using opioids and medications with anticholinergic effects

Client Education:

·         Inform clients of the potential for sedation

·         Advise clients to avoid activities that require alertness, such as driving.

Contraindications/Precautions

·         Contraindicated in GI perforation, bleeding or bowel obstruction, and hemorrhage.

·         Contraindicated in seizure disorder due to an increased risk of seizures

·         Use cautiously in children and older adults due to the increased risk for extrapyramidal symptoms

Interactions:

·         Concurrent use of alcohol and other CNS depressants increases the risk of seizures and sedation.

·         Opioids and anticholinergics decrease the effects of metoclopramide.

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Indications:
Treatment of IBS with no other GI symptoms or diseases.

Expected Pharmacological Action:
Selective blockade of 5-HT3 receptors which innervate the viscera and result in increased firmness in stool and decrease in urgency and frequency of defecation

Therapeutic Uses:
Approved only for female clients who have sever IBS-D that has lasted more than six months and has been resistant to conventional management.

Complications/Adverse Effects:
Can result in GI toxicity such as ischemic colitis, toxic megacolon, bowel obstruction, impaction or perforation. Some of these symptoms are life-threatening (ischemic colitis and toxic megacolon)

Nursing Considerations:

·         Because of the potentially fatal outcome of GI toxicity, only clients who meet specific criteria and are willing to sign a treatment agreement may receive prescriptions for medications

·         Instruct clients to watch for rectal bleeding, bloody diarrhea or abdominal pain and report to the provider.

·         Instruct clients that manifestations should resolve within one to four weeks but will return one week after medication is discontinued

·         Dosage will start as once a day and may be increased to BID

Contraindications/Precautions:

·         Chronic constipation

·         History of bowel obstruction

·         Crohn’s disease/ulcerative colitis

·         Impaired intestinal circulation

·         Diverticulitis and thrombophlebitis

Patient Teaching:

·         Instruct patient to take alosetron exactly as directed. If a dose is missed, skip the dose and return to regular schedule; do not double doses. Counsel patients about the risks and benefits of alosetron and the impact of IBS symptoms on their life. Patients should read the Medication Guide before starting alosetron and each time they refill their prescription.

·         Caution patient to stop taking alosetron and report constipation or signs of ischemic colitis to health care professional immediately. Immediately contact health care professional again if constipation does not resolve after discontinuation of alosetron. Alosetron should be resumed only after constipation has resolved and on the advice of their health care professional. Treatment with alosetron should not be resumed in patients who develop ischemic colitis.

·         Advise female patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding.

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https://www.viberzi.com/?guid=sem_goo_43700009261226463

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Funny commercial about Irritable Bowel Syndrome (IBS). Start: Alison Becker (brunette), Ilana Becker (red).

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Expected Pharmacological action:
increases fluid secretion in the intestine to promote intestinal motility

Therapeutic Uses:

·         IBS with constipation in women

·         Chronic Constipation

Complications/Adverse Effects:

·         Diarrhea

·         Nausea

Contraindications/Precautions:

·         Pregnancy risk C

·         Contraindicated in bowel obstruction

Nursing Considerations:

·         Monitor frequency of stools, notify provider if severe diarrhea occurs

·         Instruct clients to take the medication with food to decrease nausea

·         Oral dosage should be taken BID

Patient Education:
Instruct clients to take the medication with food

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5 aminosalicylates (sulfasalazine)

Expected Pharmacological Action:
Decrease inflammation by inhibiting prostaglandin synthesis, which dilates blood vessels and relaxes smooth muscles.

Therapeutic Uses:

·         IBS, Crohn’s disease, ulcerative colitis

·         IBD is controlled, rather than cured, by these medications

·         Often used in combination therapy

Complications/Adverse Effects:

·         Blood disorders including agranulocytosis, hemolytic and macrocytic anemia

·         Nausea

·         Cramps

·         Rash

·         Arthralgia

Contraindications/Precautions

·         Women who are pregnant, plan to become pregnant, or who are breastfeeding should consult the provider about continued use of sulfasalazine

·         5-aminosalicylates are contraindicated in clients who have sensitivity to sulfonamides, salicylates, or thiazide diuretics.

·         Use cautiously in older adults

·         Use cautiously in clients with liver disease or kidney disease

·         Caution in clients with blood dyscrasias

Nursing Administration:

·         Monitor complete blood count

·         Notify the provider if adverse effects persist

·         Ensure that controlled release and EC medications are not crushed or chewed

Patient Teaching:

Instruct patient on the correct method of administration. Advise patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered unless almost time for next dose.

May cause dizziness. Caution patient to avoid driving or other activities that require alertness until response to medication is known.

Advise patient to notify health care professional if skin rash, sore throat, fever, mouth sores, unusual bleeding or bruising, wheezing, fever, or hives occur.

Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.

Inform patient that this medication may cause orange-yellow discoloration of urine and skin, which is not significant. May permanently stain contact lenses yellow.

Instruct patient to notify health care professional if symptoms worsen or do not improve. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, discontinue therapy and notify health care professional immediately.

Inform male patient that sulfasalazine may cause infertility.

Instruct patient to notify health care professional if symptoms do not improve after 1–2 months of therapy.

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Pregnancy category C

Steroidal anti-inflamatory, used as an ant-emetic (with other drugs) in chemotherapy

Indications and Therapeutic Effects:

·         Used in combination with other anti-emetics to treat chemotherapy induced nausea and vomiting

·         Administered PO or IV

Pharmacological action:
The anti-emetic mechanism is unknown.

Contraindications/precautions:

·         Active untreated infections (may be used in patients being treated for tuberculous meningitis)

·         Known alcohol or bisulfite hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients)

·         Epidural use (may result in serious neurological injury or death)

·         Lactation: Avoid chronic use.

Adverse Effects:

Adverse reactions/side effects are much more common with high-dose/long-term therapy

·         depression, euphoria, hallucinations, headache, increased intracranial pressure in children, insomnia, personality changes, psychoses, restlessness

·         cataracts, increased intraocular pressure

·         hypertension, edema

·         peptic ulceration, anorexia, nausea, increased appetite, vomiting

·         acne, decreased wound healing, ecchymoses, hirsutism, petechiae

·         adrenal suppression, hyperglycemia

·         amenorrhea, hypokalemia, alkalosis

·         thromboembolism, thrombophlebitis

·         weight gain

·         muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain

·         cushingoid appearance (moon face, buffalo hump), increased susceptibility to infection

Patient Teaching:

Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately; may be life-threatening.

·         Corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately.

·         Caution patient to avoid vaccinations without first consulting health care professional.

·         Review side effects with patient. Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur. Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes.

·         Advise patient to notify health care professional of medication regimen before treatment or surgery.

·         Discuss possible effects on body image. Explore coping mechanisms.

·         Instruct patient to inform health care professional if symptoms of underlying disease return or worsen.

·         Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history.

·         Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed.

Nursing Administration:

If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol. Periods of stress, such as surgery, may require supplemental systemic corticosteroids.

·         PO: Administer with meals to minimize GI irritation.

·         Tablets may be crushed and administered with soft food, chocolate syrup, or fluids for patients with difficulty swallowing.

·         Use calibrated measuring device to ensure accurate dosage of liquid forms.

·         IM: IM doses should not be administered when rapid effect is desirable. Do not dilute with other solution or admix.

·         Rate: Administer over 1–4 min if dose is <10 mg.

·         Intermittent Infusion: Diluent: High-dose therapy should be added to D5W or 0.9% NaCl solution. Solution should be clear and colorless to light yellow; use diluted solution within 24 hr. Concentration: Up to 10 mg/mL.

·         Rate: Administer infusions over 15–30 min

Other antiemetics include
Aprepitant
Odanseton
Prochlorperazine
Dronabinol
Scopolamine
Dimenhydrinate
Lorazepam

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Pregnancy category B, antiemetics

Pharmacological Action: Prevents emesis by blocking the serotonin receptors in the chemoreceptor trigger zone and antagonizing the serotonin receptors on the afferent vagal neurons that travel from the upper GI tract to the chemoreceptor trigger zone

Therapeutic Effects:

·         Prevents emesis related to chemotherapy, radiation therapy, and postoperative recovery

·         Administer PO, IM, or IV

Nursing Considerations:

·         Treat headache with nonopoid analgesics

·         Monitor stool pattern

·         Prolonged QT interval can can lead to a serious dysrhythmia (should not be given to clients with long QT syndrome)

·         Monitor ECG in clients with cardiac disorders

Contraindications/Cautions:

·         Congenital long QT syndrome

·         Use of apomorphine (can cause sever hypotension)

·         Use cautiously after abdominal surgery (may cause ileus)

Adverse Effects:

·         Serotonin syndrome/ drowsiness

·         ECG abnormalities

·         Extrapyramidal reactions

·         Stevens-Johnsons Syndrome (toxic epidermal necrolysis)

Indications:

·         Prevention of nausea and vomiting associated with highly or moderately emetogenic chemotherapy.

·         PO: Prevention of nausea and vomiting associated with radiation therapy.

·         Prevention and treatment of postoperative nausea and vomiting.

Patient Teaching:

Instruct patient to take ondansetron as directed.

Advise patient to notify health care professional immediately if symptoms of irregular heart beat, serotonin syndrome, or involuntary movement of eyes, face, or limbs occur.

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A nurse is preparing to administer ondansetron IV for an older adult client with a history of diabetes mellitus and cardiac myopathy and is receiving chemotherapy for cancer. For which of the following adverse effects should the nurse monitor? (select all that apply)
A) Headache
B) Diarrhea
C) Hyperglycemia
D) Shortened PR interval
E) Prolonged QT interval

(A, D, E)

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A) correct: headache is a common adverse effect of ondansetron
B) correct: diarrhea or constipation are adverse effects of ondansetron
C) Ondansetron does not effect blood glucose
D) A shortened PR interval is not an adverse effect of ondansetron
E) Correct: A prolonged QT interval is a possible adverse effect of ondansetron that can lead to torsades de pointes (a serious dysrhythmia)

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Chepsy, P.C and Biju, G. (2014) An Evidence Practice Gap in Antiemetic Prescription with Chemotherapy 22-26

Henry, Norma Jean E. RN Pharmacology for Nursing: Review Module. Assessment Technologies Institute, 2016.

Hines, T. [Thomas Hines] (June 20, 2016) Viberzi—The Big Meeting Retrieved from: ttps://www.youtube.com/watch?time_continue=4&v=mpLOM3LdFNk

“How Stomach Ulcers Form Animation - Peptic Ulcer Disease: Causes, Symptoms and Treatments Video .” Manipal Hospitals, 2016.

Vallerand, Sanosky with Deglin (2017) Mansell Ed. Davis Drug Guide retrieved from  https://www.drugguide.com/ddo/

Mason, M. (2014) Eluxadoline for use in IBS-D retrieved from https://pharmpractice.ku.edu/journal-club-digest/eluxadoline-use-ibs-d

“Living with Recurring Abdominal Pain and Diarrhea?” Viberzi (Eluxadoline), www.viberzi.com/?guid=sem_goo_43700009261226463.