-idines

MoA: inhibit His at H2-receptors of gastric parietal cells

Indications: symptomatic GERD, PUD, stress ulcer prophylaxis

-30-69 min prior to meals (except Cimetidine)

AE-mild, HA, diarrhea (except Cimetidine)

-Medications: Ranitidine (Zantac), Famotidine (Pepcid)

-Cimedtine (Tagament)

-H2RA

-can be taken immediately prior to meal and maintains efficacy

-AE-hormonal effects including gynecomastia, galactorrhea

DI-CYP 450 inhibitor 

-prazole

MoA: suppress acid secretion by inhibiting parietal cell

-H+/K+ ATP (proton pump)

-uses: PUD, symptomatic GERD, hypersecretory syndromes 

-better than H2RA's for healing of ulcers

-effects begin in 1-2 h, maximal effects may take days to weeks 

-Meds: Omeprazole (Prilosec) -more DI than others

-Lansoprazole (Prevacid) 

MoA-weak bases to neutralize gastric acid

common ingredients: Al (constipation), Mg (diarrhea), Ca, Na Bicarbonate 

-combo of Al and MG to balance bowel effects

-Na-use caution in edematous states

-Al, Mg, Ca can accumulate in renal  dysfunction 

Sulcralfate (Carafate)

-forms gel with epithelium and makes a physical barrier

Bismuth Salicyclate (PeptoBismol)

-coating of epithelium and damaged tissue, decreases pepsin, increases protective mucus, antimicrobial actions

Use-dydpepsia, traveler's diarrhea, part of H. Pylori regiimen

AE-dark stools, black hairy tongue

Caution: salicylate allergy, febrile PED patient 

1st line: 3 drug tx

-PPI + OMeprazole 20 mg BID

-Clarithromycin (Biaxin) 500 mg BID

-Amoxicillin 1 g BID or Metronidazole (Flagyl) 500 mg BID

-therapy usually lasts 14 days

-other approved regimens also 

-Diphenhydrinate (Dramamine)-tx and prevention of N/V assoc. with motion-sickness or vertigo

-Anticholinergics:

-Scopolamine (Transderm Scop)-blocks Ach, dries secretions, antagonizes His and serotonin,for motion sickness (1 patch behind ears 4-12 hr before travel; replace q3d), opioids, and anesthesia; AE: anticholinergic and photosensitivity 

-tx N/V

-MoA-block dopamine receptors

AE-extrapyramidal effects, sedation

drugs: chlorpromazine (Compazine), Promethazine (Phenergan)--also has anti-His activity (in PO and PR forms) 

-Setron

-tx N/V

-block 5HT3 receptors in CNS and periphery (vagal fibers and CTZ)

-prevention of chemo-induced N/V, radiation induced N/V, post-op N/V

Meds: Ondansetron (Zofran), Ganisetron (Kytril), Dolasetron (Anzamet), Palonsetron (Aloxi)

-tx N/V

-Aprepitant (Emend)-prevents acute and delayed N/V, augments serotonin blockers and corticosteroids

-tx N/V too assoc. with gastric acid 

-H2RA

-tx N/V with gastroparesis, alternative tx for PUD

-multiple MoA-blocks dopamine and serotonin receptors in CTZ, increases response to Ach in upper GI to cause enhanced motility and gastric emptying w/o stimulating secretions, increases LES tone

AE-movement d/o, diarrhea, drowsiness, CV effects 

-tx of diarrhea

-bulk-forming: polycarbophil (Fibercon)

-clay: kaolin pectin, Attapulgite

-binds certain bacteria and toxins, decreases water loss 

tx of diarrhea

-opioid derivatives:

-Loperamide (Imodium)-inhibit peristalsis and prolong transit time, decrease fecal volume with increased viscosity, increase tone of anal sphincter

-Diphenoxylate.Atropine (Lomotil)

-tx of diarrhea

-Bismuth Subsalicylate (PeptoBismol)

-antisecretory and antimicrobial

-used for diarrhea-mild/nonspecific, Traveler's diarrhea (E.coli), part of H. pylori regimen 

-assoc with antibiotic use (within 5-10 d)

2 hr up to 3 mo after antibiotics

tx: Metronidazole (Flagyl)

assoc. with foreign travel and lake/pond water

tx: Metronidazole (Flagyl)

-tx constipation

-MoA-secrete water/electrolytes into bowel; stimulate peristalsis in about 8-10 hr

AE: diarrhea, abdominal cramping, fluid/electrolyte abnl, dependence

-Senna (Senekot), Biscodyl (Dulcolax)

Saline/Osmotic Laxatives

Cathartics

-tx constipation

-MoA-nonabsorbable salts hold water in bowel causing distention and increased bowel activity

-used for bowel-prep before procedures (effective in 1-6 h)

AE: bloating, diarrhea, cramping

-Mg Citrate, Na Phosphate, Polyethylene glycol (PEG), Lactulose 

-osmotic laxative 

-tx occasional constipation (different formula than bowel prep)

tx constipation

-MoA-facilitate passage of stools by lube

-AE-diarrhea, GI upset (mineral oil aspiration pneumon)

-drugs-mineral oil, glycerin suppositories 

-tx constipation

-emulsify with stool producing softer stools (effects in 1-3 days)

-safe for regular or LT use--NO DEPENDENCE

-often used in conjunction with opioids to prevent constipation

-can take several days to show results

-Docusate Sodium (Colace)

-tx constipation

-MoA-indigestible compounds that accumulate in the bowel and draw water into the bowel

AE-constipation, bowel impaction, bloating, GI upset

-NOT assoc with dependence

-Psyllium, bran, methylcellulose

-effects in about 1-3 days 

-tx IBD

-MoA-modulation of local inflammatory mediators, scavenges free radicals and inhibits TNF 

-meds:

-Sulfasalzine-sulfa antimicrobial activity; high AE; caution in sulfa allergy

-Mesalamine-site of action depends on product (rectum, colon, distal small bowel)

-AE-abdominal pain and possible worsening of symptomatic IBD with the initiation of therapy  

-tx topically if possible with 5-ASA (colon, rectum, perianal)

-tx systemically with 5-ASA if topical tx is not possible or unsuccessful

-if systemic 5-ASA is ineffective, try systemic PO corticosteroids

-if PO ineffective, IV hydrocortisone

-if that uneffectice, then immunosuppresants and immunomodulators 

-if pt has severe dz and continuous symptoms, put on IV fluids and hydrocortisone

-rectal corticosteroids available topically too 

-non-selective BB (NSBB

-1st line tx to reduce portal HTN

-decrease bleeding and mortality in pts with varices

-start dose low and titrate to decrease HR by 25% or 55 bpm

-if HR goal isn't reached, think about adding a Nitrate 

-Propanolol (Inderal), Nadolol (Corgard)

-diuretics:

-Spironolactone (Aldactone)-aldosterone antagonist counteracts the effects of RAAS

-Furosemide (Lasix)-combo therapy req (Furosemide + Spironolactone)-ratio of 40 mg of Furosemide to 100 mg of Spironolactone to maintain a serum K in the nl range; wait at least 3 days in between dosages (ascites takes longer to equilibrate with vascular fluid than peripheral edema)

-target of ascites tx is 0.5L/qday

-maintain adequate excretion of Na

spot urine Na/K ratio greater than 1.0 

-tx variceal bleeding-control bleeding, prevent rebleeding, avoid acute complications, mortality of 1st episode is 55%

-octreotide-somatostain analog, decrease portal venous pressure by selective vasoconstriction of splanchnic bed, loading dose then hr infusions for 2-3 d, greatest risk of re-bleed within 1st 5 days, so therapy can cont that long

-antibiotic prophylaxis-recomended in acute variceal bleeding to decrease hospital-acquired infections (and mortality)

-use FQ or 3G Ceph