Pregnancy Category: Unknown

·        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. 

·        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

·        bronchospasm

·        intestinal or esophageal obstruction

·        nausea, vomiting

Interactions:
Decreases absorption of 

·        warfarin

·        salicylates

·        digoxin

·        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 

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

·         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.

·         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 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

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.

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

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

·         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)

·         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

·         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.

·         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.

·         Hypersensitivity;

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

·         blurred vision, dry eyes

·         tachycardia

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

·         urinary retention

·         flushing

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

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

·         Administer PO, IM, or IV

·         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

·         Congenital long QT syndrome

·         Use of apomorphine (can cause sever hypotension)

·         Use cautiously after abdominal surgery (may cause ileus)

·         Serotonin syndrome/ drowsiness

·         ECG abnormalities

·         Extrapyramidal reactions

·         Stevens-Johnsons Syndrome (toxic epidermal necrolysis)

·         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.

·         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.

·         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.

·         Extrapyramidal symptoms

·         Sedation

·         Diarrhea

·         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

·         Inform clients of the potential for sedation

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

·         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

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

·         Opioids and anticholinergics decrease the effects of metoclopramide.

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)

·         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

·         Chronic constipation

·         History of bowel obstruction

·         Crohn’s disease/ulcerative colitis

·         Impaired intestinal circulation

·         Diverticulitis and thrombophlebitis

·         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.

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

·         IBS with constipation in women

·         Chronic Constipation

·         Diarrhea

·         Nausea

·         Pregnancy risk C

·         Contraindicated in bowel obstruction

·         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

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

·         IBS, Crohn’s disease, ulcerative colitis

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

·         Often used in combination therapy

·         Blood disorders including agranulocytosis, hemolytic and macrocytic anemia

·         Nausea

·         Cramps

·         Rash

·         Arthralgia

·         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

·         Monitor complete blood count

·         Notify the provider if adverse effects persist

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

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.