Drugs affecting the Gastrointestinal Tract Mary Jane Hopkins, ARNP, MSN

Key Structures of the Gastrointestinal Tract o Alimentary canal (digestive tract) o Biliary system Key Functions of the Gastrointestinal Tract o Digestion: process by which food substances enter digestive tract and undergo mechanical/chemical changes which allow nutrients to be absorbed and indigestible materials to be excreted o Peristalsis: movement of smooth muscle fibers surrounding the canal that (1) mixes the contents and (2) moves the mass through the tract Gastrointestinal TRACT Actions of Drugs Affecting the Gastrointestinal Tract o Act on muscular and glandular tissues (either directly on these cells or indirectly on autonomic nervous system) o Increase or decrease function, tone, emptying time, or peristaltic action of stomach/bowel o Relieve enzyme deficiency o Counteract excess acidity or gas formation o Produce or prevent vomiting o Aid with diagnosis Disorders Affecting the Mouth and Pharynx Mouth Irritation or inflammation of buccal structures Dental disorders Bacterial, viral, fungal infections Pharynx Irritation or inflammation caused by the common cold Infection strep throat Pathologic States Affecting the Esophagus and Stomach Gastroesophageal Reflux Disease = GERD Barretts Esophagus Pre-cancerous changes in the esophagus Esophageal Carcinoma Acute gastritis Chronic gastritis Peptic ulcer disease (PUD) Gastric ulcers Duodenal ulcers more common Disorders/Complications Affecting the Liver Viral hepatitis Lannecs cirrhosis Postnecrotic cirrhosis Carcinoma

 Chronic alcoholism
Complications of advanced liver disease Coagulopathies Portal hypertension Ascites Esophageal varices Hepatic encephalopathy Disorders Affecting the Gallbladder and Pancreas Gallbladder Cholecystitis Cholelithiasis Malignant tumors (uncommon) Pancreas Diabetes mellitus Pancreatitis Carcinoma Disorders Affecting the Intestines Both small and large intestines Diarrhea Constipation Small intestine Obstruction Malabsorption syndromes Large intestine Diverticular disease Ulcerative colitis Carcinoma Crohns disease Irritable bowel syndrome Hemorrhoids Drugs That Affect the Upper Gastrointestinal Tract Oral conditions Oral rinses Dental products Anti-infectives Saliva substitutes Conditions of the lower esophagus and stomach Drugs to treat acidity, ulcers, erosions, nausea, and vomiting Drugs That Affect the Stomach

Acid-Related Pathophysiology The stomach secretes:

Antacids Antiflatulents Digestants Antiemetics Emetics Drugs to treat peptic ulcer and gastroesophageal reflux disease

Acid-Related Diseases

Hydrochloric acid (HCl) Aids in digestion Barrier to infection Bicarbonate Natural mechanism to prevent hyperacidity Pepsinogen Precursor of the enzyme pepsin that aids in protein digestion Intrinsic factor Facilitates the gastric absorption of B12 Mucus Protects stomach lining Prostaglandins Antiinflammatory and protective functions Hydrochloric Acid Secreted by the parietal cells when stimulated by food Maintains stomach at pH of 1 to 4 Secretion also stimulated by: o Large fatty meals o Excessive amounts of alcohol o Emotional stress

Acid-Related Diseases

Caused by imbalance of the HCL, pepsinogen and mucous Most common: hyperacidity o Lay terms for overproduction of HCl by the parietal cells o Indigestion o Sour stomach o Heartburn o Acid stomach PUD: peptic ulcer disease GERD: gastroesophageal reflux disease o Helicobacter pylori (H. pylori) Bacterium found in GI tract of 90% of patients with duodenal ulcers, and 70% of those with gastric ulcers o Can be detected by serum antibody tests o Antibiotics are used to eradicate H. pylori
Types of Acid-Controlling Drugs Antacids H2 antagonists Proton pump inhibitors Antacids: Mechanism of Action Neutralize stomach acid Promote gastric mucosal defense mechanisms Secretion of: Mucus: protective barrier against HCl Bicarbonate: helps buffer acidic properties of HCl Prostaglandins: prevent activation of proton pump Antacids DO NOT prevent the overproduction of acid Antacids DO neutralize the acid once it is in the stomach Long term self-medication may be masking symptoms of a serious disease such as ulcers and cancer

If symptoms remain ongoing, patient should seek medical evaluation Antacids: Drug Effects Reduction of pain associated with acid-related disorders Raising gastric pH from 1.3 to 1.6 neutralizes 50% of the gastric acid Raising gastric pH 1 point (1.3 to 2.3) neutralizes 90% of the gastric acid Reducing acidity reduces pain Antacids OTC formulations available as:

Antacids: Aluminum Salts Have constipating effects Often used with magnesium to counteract constipation Often recommended for patients with renal disease (more easily excreted) Examples Aluminum carbonate: Basaljel Hydroxide salt: AlternaGEL Combination products (aluminum and magnesium): Gaviscon, Maalox, Mylanta, Di-Gel Antacids: Magnesium Salts Commonly cause diarrhea; usually used with other drugs to counteract this effect Dangerous when used with renal failure. the failing kidney cannot excrete extra magnesium, resulting in accumulation Examples Hydroxide salt: magnesium hydroxide (MOM) Carbonate salt: Gaviscon (also a combination product) Combination products such as Maalox, Mylanta (aluminum and magnesium) Antacids: Calcium Salts Forms: many, but carbonate is most common May cause constipation, kidney stones Monitor Calcium levels Used in Renal failure patients to help with excretion of phosphorus Long duration of acid action may cause increased gastric acid secretion (hyperacidity rebound) Often advertised as an extra source of dietary calcium Example: Tums (calcium carbonate) Antacids: Sodium Bicarbonate Highly soluble

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Capsules and tablets Powders Chewable tablets Suspensions Effervescent granules and tablets Used alone or in combination Aluminum salts Magnesium salts Calcium salts Sodium bicarbonate

Buffers the acidic properties of HCl Quick onset, but short duration May cause metabolic alkalosis Sodium content may cause problems in patients with HF, hypertension, or renal insufficiency Antacids: Drug Interactions Adsorption of other drugs to antacids Reduces the ability of the other drug to be absorbed into the body Chelation Chemical binding, or inactivation, of another drug Produces insoluble complexes Result: reduced drug absorption Increased stomach pH Increased absorption of basic drugs Decreased absorption of acidic drugs Increased urinary pH Increased excretion of acidic drugs Decreased excretion of basic drugs Antiflatulents Antiflatulents: used to relieve the painful symptoms associated with gas Several drugs are used to bind or alter intestinal gas and are often added to antacid combination products OTC antiflatulents Activated charcoal Simethicone Alters elasticity of mucus-coated bubbles, causing them to break Used often, but there is limited data to support effectiveness Antacids: Nursing Implications

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Use with caution with other medications due to the many drug interactions Most medications should be given 1 to 2 hours after giving an antacid Antacids may cause premature dissolving of enteric-coated medications, resulting in stomach upset Be sure that chewable tablets are chewed thoroughly, and liquid forms are shaken well before giving

Histamine Type 2 (H2) Antagonists Reduce acid secretion All available OTC in lower dosage forms Most popular drugs for treatment of acid-related disorders

H2 Antagonists Mechanism of Action: Block histamine at the (H2) receptors of acid-producing parietal cells

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cimetidine =Tagamet nizatidine =Axid famotidine =Pepcid ranitidine =Zantac

Production of hydrogen ions is reduced, resulting in decreased production of HCl Drug Effect: Suppressed acid secretion in the stomach H2 Antagonists: Indications

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GERD PUD Erosive esophagitis Adjunct therapy in control of upper GI bleeding Pathologic gastric hypersecretory conditions

H2 Antagonists: Adverse Effects

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Overall, very few adverse effects Cimetidine may induce impotence and gynecomastia Headaches, lethargy, confusion, diarrhea, urticaria, sweating, flushing, other effects

H2 Antagonists Drug Interactions:

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Cimetidine= Tagamet Binds with P-450 microsomal oxidase system in the liver, resulting in inhibited oxidation of many drugs and increased drug levels All H2 antagonists may inhibit the absorption of drugs that require an acidic GI environment for absorption SMOKING has been shown to decrease the effectiveness of H2 blockers Assess for allergies and impaired renal or liver function Use with caution in patients who are confused, disoriented, or elderly Take 1 hour before or after antacids For intravenous doses, follow administration guidelines The parietal cells release positive hydrogen ions (protons) during HCl production This process is called the proton pump Proton Pump Inhibitors irreversibly bind to H+/K+ ATPase enzyme This bond prevents the movement of hydrogen ions from the parietal cell into the stomach Result: achlorhydriaALL gastric acid secretion is temporarily blocked In order to return to normal acid secretion, the parietal cell must synthesize new H+/K+ ATPase GERD maintenance therapy Erosive esophagitis Short-term treatment of active duodenal and benign gastric ulcers Zollinger-Ellison syndrome Hypersecretion of HCL Treatment of H. pylori induced ulcers In addition to antibiotic therapy Proton Pump Inhibitors Total inhibition of gastric acid secretion

H2 Antagonists: Nursing Implications

Proton Pump Inhibitors (PPIs)

Proton Pump Inhibitors Indications:

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lansoprazole = Prevacid omeprazole = Prilosec rabeprazole = Aciphex pantoprazole = Protonix IV form available esomeprazole =Nexium

Proton Pump Inhibitors Adverse Effects:

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Safe for short-term therapy Some approved for long-term therapy Adverse effects uncommon

Proton Pump Inhibitors Nursing Implications:

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Assess for allergies and history of liver disease Pantoprazole is the only proton pump inhibitor available for parenteral administration, and can be used for patients who are unable to take oral medications May increase serum levels of diazepam, phenytoin, and cause increased chance for bleeding with warfarin PPIs often work best when taken 30 to 50 minutes before meals

Cytoprotective drug

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sucralfate = Carafate Used to promote healing of stress ulcers, PUD Attracted to and binds to the base of ulcers and erosions, forming a protective barrier over these areas Protects these areas from pepsin, which normally breaks down proteins making ulcers worse Little absorption from the gut May cause constipation, nausea, and dry mouth Do not administer with other medications May impair absorption of other drugs give other drugs at least 2 hours before or after sucralfate Administer on an empty stomach

Synthetic prostaglandin analog misoprostol = Cytotec Prostaglandins have cytoprotective activity

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Protect gastric mucosa from injury by enhancing local production of mucus or bicarbonate Promote local cell regeneration Help to maintain mucosal blood flow Used for prevention of NSAID-induced gastric ulcers Doses that are therapeutic enough to treat duodenal ulcers often produce abdominal cramps, diarrhea This drug is chemically related to mifepristone= RU486. The abortion pill It is a prostaglandin analog and can induce uterine contractions It is contraindicated during pregnancy and should be used cautiously in women of child bearing age. (Pregnancy Category X) Misoprostol is used off label for the induction of labor at full term

Antiflatulent drug Simethicone

Digestants

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Used to reduce the discomforts of gastric or intestinal gas (flatulence) Alters elasticity of mucus-coated gas bubbles, breaking them into smaller ones Result is decreased gas pain and increased expulsion via mouth or rectum Promote the process of digestion when a deficiency exists of some substance essential to that process Besides deficiency, other causes of digestive problems include organic disease states and reactions to emotional situations and stress Pancreatic enzymes are the digestants most commonly used clinically

Antiemetics Given to relieve nausea and vomiting These drugs vary widely in: Chemical class Receptor site affinity Sites of action Determining the cause of gastric distress is essential because these drugs mask symptoms of more serious illnesses Primary Pathways for the Vomiting Reflex Higher central nervous system or cerebral cortex stimulation

Emotional or anticipatory
Peripheral or central nerve transmission secondary to body tissue or organ alterations Irritation of the gastrointestinal tract Increased intracranial pressure Vestibular stimulation Stimulation from the chemoreceptor trigger zone (CTZ) Toxins circulating in blood Activation of the CTZ and Emetic Center ( Vomiting Center- VC)

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Neurotransmitters Used to Control or Prevent Nausea and Vomiting Dopamine receptors located in the gastrointestinal tract and chemoreceptor trigger zone Acetylcholine receptors in the vestibular and vomiting center Histamine receptors in the vestibular and vomiting centers Serotonin receptors in the gastrointestinal tract, chemoreceptor trigger zone, and emetic centers

Antiemetics Mechanism of Action Many different mechanisms of action Most work by blocking one of the vomiting pathways, thus blocking the stimulus that induces vomiting Mechanism of Action and Other Indications Anticholinergic drugs =ACh blockers

Bind to and block acetylcholine receptors in the inner ear labyrinth

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Block transmission of nauseating stimuli to CTZ Also block transmission of nauseating stimuli from the reticular formation to the VC o Scopolamine= Transderm Scop o Also used for motion sickness

Antihistamine drugs (H1 receptor blockers)

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Inhibit ACh by binding to H1 receptors Prevent cholinergic stimulation in vestibular and reticular areas, thus preventing nausea and vomiting o dimenhydrinate= Dramamine o diphenhydramine= Benadryl o meclizine = Antivrert, Bonine o promethazine= Phenergan o Also used for motion sickness, nonproductive cough, allergy symptoms, sedation

Neuroleptic drugs

Block dopamine receptors on the CTZ o chlorpromazine= Thorazine o prochlorperazine= Compazine o promethazine= Phenergan o Also used for psychotic disorders, intractable hiccups

Prokinetic drugs

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Block dopamine in the CTZ Cause CTZ to be desensitized to impulses it receives from the GI tract Also stimulate peristalsis in GI tract, enhancing emptying of stomach contents o metoclopramide =Reglan o Also used for GERD, delayed gastric emptying o Note cisapride=Propulsid was in this class, but was removed from the market by the FDA because it caused fatal cardiac arrhythmias

Serotonin ( 5-HT3) Antagonists

Block serotonin receptors in the GI tract, CTZ, and VC o dolasetron= Anzemet o granisetron = Kytril o ondansetron = Zofran o Used for nausea and vomiting in patients receiving chemotherapy and for postoperative nausea and vomiting

Substance P/NK1 Receptor Antagonists

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For Chemotherapy induced nausea and vomiting A selective antagonist at substance P/ neurokinin 1 (NK1) receptors in the brain Used in combination with dexamethasone and 5-HT3 antagonists Taken 1 hour prior to chemotherapy and the for 2 days after chemo o aprepitant= Emend o Very expensive- approximately $300.00 for 3 day supply

Tetrahydrocannabinoids (THC)

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Major psychoactive substance in marijuana Inhibitory effects on reticular formation, thalamus, cerebral cortex

Alter mood and bodys perception of its surroundings o dronabinol = Marinol o Used for nausea and vomiting associated with chemotherapy, and anorexia associated with weight loss in AIDS patients

Nursing Implications

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Assess complete nausea and vomiting history, including precipitating factors Assess current medications Assess for contraindications and potential drug interactions Many of these drugs cause severe drowsiness; warn patients about driving or performing any hazardous tasks Taking antiemetics with alcohol may cause severe CNS depression Teach patients to change position slowly to avoid hypotensive effects Nursing Implications (contd) For chemotherapy, antiemetics are often given 1 to 3 hours before a chemotherapy drug Monitor for therapeutic effects Monitor for adverse effects

Emetics

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Administered to induce vomiting Include ipecac syrup Rarely used today to treat drug overdoses or poisonings Common Inflammatory Bowel Diseases

Bowel Disorders Crohns disease Lesions penetrate through entire gut wall Ulcerative colitis More common than Crohns disease Presents with abdominal pain, cramping, and frequent diarrhea Inflammation restricted to rectum and colon Common Uses of Laxatives

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Relieve or prevent constipation Expel parasites or poisonous substances Obtain specimen Cleanse bowel for diagnostic exam Absorb water to increase bulk Distend bowel to initiate reflex bowel activity Examples: psyllium =Metamucil methylcellulose =Citrucel Calcium polycarbophil= Mitrolan

Laxatives: Mechanism of Action Bulk forming- High fiber

Emollient Stool softeners and lubricants

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Promote more water and fat in the stools Lubricate the fecal material and intestinal walls

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Examples: Stool softeners: docusate salts =Colace, Surfak Lubricants: mineral oil

Hyperosmotic

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Saline

Increase fecal water content Result: bowel distention, increased peristalsis, and evacuation o Examples: o polyethylene glycol =GoLYTELY o sorbitol, glycerin o lactulose = Chronulac o also used to reduce elevated serum ammonia levels but at higher doses Increase osmotic pressure within the intestinal tract, causing more water to enter the intestines Result: bowel distention, increased peristalsis, and evacuation o Saline laxative examples: o magnesium sulfate (Epsom salts) o magnesium hydroxide (MOM) o magnesium citrate o sodium phosphate (Fleet Phospho-Soda, Fleet enema)

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Stimulant

Increases peristalsis via intestinal nerve stimulation o Examples: o castor oil o senna o Cascara sagrada o Bisacodyl =Dulcolax

Bulk forming

Acute and chronic constipation Irritable bowel syndrome Diverticulosis

Emollient Acute and chronic constipation Softening of fecal impaction Facilitation of BMs in anorectal conditions Hyperosmotic Chronic constipation Diagnostic and surgical preps Saline Constipation Diagnostic and surgical preps Removal of helminths and parasites Stimulant Acute constipation Diagnostic and surgical bowel preps

Laxatives: Adverse Effects Bulk forming

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Impaction Fluid overload Skin rashes Decreased absorption of vitamins Lipid pneumonia Abdominal bloating Rectal irritation Magnesium toxicity (with renal insufficiency) Cramping Nutrient malabsorption Skin rashes Rectal Irritation

Emollient

Hyperosmotic

Saline

Stimulant

Laxatives: Nursing Implications

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Obtain a thorough history of presenting symptoms, elimination patterns, and allergies Assess fluid and electrolytes before initiating therapy Patients should not take a laxative or cathartic if they are experiencing nausea, vomiting, and/or abdominal pain A healthy, high-fiber diet and increased fluid intake should be encouraged as an alternative to laxative use Long-term use of laxatives often results in decreased bowel tone and may lead to dependency All laxative tablets should be swallowed whole, not crushed or chewed, especially if enteric coated Laxatives: Nursing Implications Patients should take all laxative tablets with 6 to 8 ounces of water Patients should take bulk-forming laxatives as directed by the manufacturer with at least 240 mL (8 ounces) of water Bisacodyl and cascara sagrada should be given with water due to interactions with milk, antacids, and juices Patients should contact their physician if they experience severe abdominal pain, muscle weakness, cramps, and/or dizziness, which may indicate possible fluid or electrolyte loss Monitor for therapeutic effect

Common Causes of Acute Diarrhea

Infection Diet Stress Drugs Antimicrobials -Adrenergic blockers Cholinergic agents Misoprostol

Colchicine Cancer chemotherapy Magnesium-containing products Laxatives Treatment Plan for Diarrhea

Administer antidiarrheals to reduce frequency Replenish fluid and electrolyte loss Diagnose and treat the underlying cause Restore intestinal flora

Antidiarrheals Mechanism of Action: Adsorbents

Coat the walls of the GI tract Bind to the causative bacteria or toxin, which is then eliminated through the stool Examples: bismuth subsalicylate =Pepto-Bismol kaolin-pectin, activated charcoal, attapulgite, others
Antimotility drugs: anticholinergics

Decrease intestinal muscle tone and peristalsis of GI tract Result: slowing the movement of fecal matter through the GI tract Examples: belladonna alkaloids, atropine, hyoscyamine, hyoscine
Antimotility drugs: opiates

Decrease bowel motility and relieve rectal spasms Decrease transit time through the bowel, allowing more time for water and electrolytes to be absorbed Reduce pain by relief of rectal spasms Examples: paregoric, opium tincture, codeine, Loperamide= Immodium (OTC) diphenoxylate+ atropine= Lomotil
Intestinal flora modifiers

Probiotics or bacterial replacement drugs Bacterial cultures of Lactobacillus organisms work by: Supplying missing bacteria to the GI tract Suppressing the growth of diarrhea-causing bacteria Example: L. acidophilus (Lactinex)
Antidiarrheals Adverse Effects: Adsorbents

Anticholinergics

Increased bleeding time Constipation, dark stools Confusion, twitching Hearing loss, tinnitus, metallic taste, blue gums Urinary retention, hesitancy, impotence Headache, dizziness, confusion, anxiety, drowsiness Dry skin, rash, flushing Blurred vision, photophobia, increased intraocular pressure

Opiates

Hypotension, hypertension, bradycardia, tachycardia Drowsiness, sedation, dizziness, lethargy Nausea, vomiting, anorexia, constipation Respiratory depression Bradycardia, palpitations, hypotension Urinary retention Flushing, rash, urticaria

Antidiarrheals: Interactions

Adsorbents decrease the absorption of many drugs, including digoxin, clindamycin, quinidine, hypoglycemic drugs, others Adsorbents cause increased bleeding time and bruising when given with anticoagulants Antacids can decrease effects of anticholinergic antidiarrheal drugs Many other interactions
Antidiarrheals Nursing Implications:

Obtain thorough history of bowel patterns, general state of health, and recent history of illness or dietary changes, and assess for allergies DO NOT give bismuth subsalicylate to children or teenagers with chickenpox because of the risk of Reyes syndrome Use adsorbents carefully in elderly patients or those with decreased bleeding time, clotting disorders, recent bowel surgery, confusion Anticholinergics should not be administered to patients with a history of narrow angle glaucoma, BPH, urinary retention, recent bladder surgery, cardiac problems, myasthenia gravis Antidiarrheals: Nursing Implications Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes Assess fluid volume status, I&O, and mucous membranes before, during, and after initiation of treatment Teach patients to notify their physician immediately if symptoms persist Monitor for therapeutic effect
Inflammatory Bowel Disease

Ulcerative colitis: inflammation and ulceration of the colon and rectum Crohns disease: inflammation of segments of the GI tract

Characterized by chronic, recurrent inflammation of the intestinal tract Periods of remission interspersed with periods of exacerbation Cause is unknown No cure Treatment relies on medications to treat inflammation and maintain remission

Ulcerative Colitis Clinical Manifestations

Autoimmune disease Antigen initiates the inflammation; actual tissue damage is from inappropriate sustained immune response Genetic and environmental factors play a role Bloody diarrhea Abdominal pain

 Tenesmus Spasmodic contraction of the anal sphincter with pain and the persistent desire to empty the bowel with involuntary, ineffectual straining efforts Rectal bleeding

Crohns Disease Clinical Manifestations Depend on the anatomic site of involvement, extent of the disease process, and presence/absence of complications

Diarrhea (nonbloody) Colicky abdominal pain Malabsorption Nutritional deficiencies Inflammatory Bowel Disease

Goals of treatment

Drug therapy

Rest the bowel Control inflammation Combat infection Correct malnutrition Alleviate stress Symptomatic relief Improve quality of life Inflammatory Bowel Disease

Aminosalicylates and corticosteroids are mainstays of treatment for ulcerative colitis Sulfasalazine (Azulfidine) Decreases GI inflammation Effective in achieving and maintaining remission Mild to moderately severe attacks o Corticosteroids Decrease inflammation Used to achieve remission Helpful for acute flareups o Antimicrobials Prevent or treat secondary infection o Immunosuppressants o Suppress immune response o Most useful in those who do not respond to aminosalicylates, antimicrobials, or corticosteroids o Requires regular CBC monitoring

Biologic therapies Inhibit tumor necrosis factor

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Induce and maintain remission Antidiarrheals o GI motility

Hematinics and vitamins o Correct iron deficiency o Promote healing

Irritable Bowel Syndrome=IBS

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Common problem affecting 10% to 15% of Western populations 2 to 2.5 times as many women as men seek health care services Characterized by intermittent and recurrent abdominal pain and stool pattern irregularities Altered intestinal and colonic motility Altered response to stress May be due to alterations in the enteric nervous system and/or autonomic nervous system Pain/discomfort from visceral hypersensitivity Stool or gas in GI tract stimulates visceral afferent fibers Neurochemicals involved in bowel symptoms Serotonin

Etiology and Pathophysiology

Clinical Manifestation

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Diarrhea Constipation Alternating diarrhea/constipation Abdominal distention Excessive flatulence Bloating Continual defecation urge, urgency Sensation of incomplete evacuation Malabsorption (gluten intolerance) Dietary factors Infection Colorectal cancer Inflammatory bowel disease Psychologic disorders Gynecologic disorders Peptic ulcer disease Celiac disease Based on dominant symptoms and their severity and on psychosocial factors Diet Fiber therapy (20 g/day) Antispasmodics Antidiarrheals Laxatives Serotonergic agents Psychologic or behavioral options Antidepressants

IBS Differential Diagnoses

IBS Collaborative Care Medical management

IBS Drug Therapy: Antispasmodics

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Consider predominant symptom pattern Diarrhea Constipation Pain Anticholinergics Dicyclomine (Bentyl) Reduce colonic motility after meals Take before meals Side effects Dry mouth, urinary retention, tachycardia Loperamide (Imodium) Decrease intestinal transit Enhances intestinal water absorption and sphincter tone

Drug Therapy: Antidiarrheals

Drug Therapy: Antidepressants Symptomatic treatment: Pain Reserved for patients with severe or refractory pain IBS Drug Therapy: Serotonin Agonist 5-HT3 receptor blockers Urgency, pain, and diarrhea in diarrhea-prominent women Alosetron (Lotronex) FDA approved for women only Must be monitored due to potential side effects IBS tegaserod (Zelnorm) Sertonin Agonist Used in women with constipation- predominant IBS Current widespread use suspended by FDA July 2007 FDA approved for women under age 55 with no preexisting cardiac problems For Chronic Constipation lubiprostone= Amitiza Targets chlorine channels in the intestinal tract Promotes fluid secretion into the intestinal lumen without altering serum electrolyte levels Improves abdominal bloating and discomfort and increases the number of spontaneous BMs per week Chronic Constipation in Adults lubiprostone= Amitiza Targets chlorine channels in the intestinal tract Promotes fluid secretion into the intestinal lumen without altering serum electrolyte levels Improves abdominal bloating and discomfort and increases the number of spontaneous BMs per week

This is a non-systemic drug Should be take with meal or shortly after Common side effects are diarrhea, headache and nausea ( nausea decreased when taken with food)