PPT_Chapter_29.ppt - Drugs That Affect the Gallbladder and Intestine Chapter 29 Copyright \u00a9 2013 Wolters Kluwer Health | Lippincott Williams Wilkins

PPT_Chapter_29.ppt - Drugs That Affect the Gallbladder and...

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Unformatted text preview: Drugs That Affect the Gallbladder and Intestine Chapter 29 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Gallstone-Solubilizing Drugs Suppress the manufacture of cholesterol and cholic acid by the liver Result is a decrease in the size of radiolucent gallstone Examples: ursodiol and chenodiol Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Gallstones Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Gallstone-Solubilizing Drugs Used in the nonsurgical treatment of radiolucent gallstones Not effective for all types of gallstones May require many months of use to produce results Recommended only for carefully selected and closely monitored patients Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of GallstoneSolubilizing Drugs Diarrhea Cramps Nausea Vomiting Reduction in dose may reduce or eliminate adverse reactions Prolonged use may result in hepatotoxicity Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Gallstone-Solubilizing Drug Contraindications: Chenodiol: pregnancy Precautions: Known hypersensitivity to the drug or to bile salts, liver impairment, calcified stones, radiopaque stones or radiolucent bile pigment stones, severe acute cholecystitis, biliary obstruction, gallstone pancreatitis Ursodiol: lactation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Gallstone-Solubilizing Drug Interactions: Ursodiol: bile acid-sequestering drugs, aluminumcontaining antacids, clofibrate, estrogens, oral contraceptives Chenodiol: aluminum-based antacids, bile acid sequestrants, clofibrate, oral contraceptives, warfarin Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Gallstone-Solubilizing Drug Potentially hepatotoxic; therefore, patient must have routine liver function tests performed Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Gallstone-Solubilizing Drug Periodic laboratory tests and ultrasound or radiologic examinations may be scheduled If diarrhea, contact health care provider If symptoms of gallbladder disease occur, contact health care provider Do not take with aluminum-containing antacids Take antacids 2–3 hours after ursodiol or chenodiol Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Antidiarrheals Decrease intestinal peristalsis, which is usually increased in patients with diarrhea Examples: Difenoxin with atropine (schedule IV) Diphenoxylate with atropine (schedule VI) Loperamide (Rx and OTC) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Antidiarrheals Treatment of diarrhea Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Antidiarrheals Diphenoxylate Anorexia, nausea, vomiting, constipation, rash, dizziness, drowsiness, sedation, euphoria, headache Sedative, and euphoric effects Potential for drug dependence Combined with atropine, which causes dry mouth and other mild adverse reactions to discourage abuse Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Antidiarrheals Loperamide Abdominal discomfort, pain, and distention These symptoms also occur with severe diarrhea; therefore, difficult to distinguish from an adverse drug reaction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Antidiarrheals Contraindications: Diarrhea associated with organisms that can harm the intestinal mucosa Patients with pseudomembranous colitis, abdominal pain of unknown origin, or obstructive jaundice Precautions: Severe liver disease Inflammatory bowel disease Lactation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Antidiarrheals Interactions: CNS depression with alcohol, antihistamines, narcotics, sedatives, hypnotics Additive cholinergic effects with other drugs that have anticholinergic activity MAOIs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Antidiarrheals May need to be given after each loose bowel movement Bowel movements need to be inspected before a decision is made to administer Drowsiness or dizziness may occur and the patient may need help walking and with self-care activities For chronic diarrhea, drink extra fluids Fluid intake and output should be monitored Oral electrolyte replacement may be ordered Cleanse perianal area for irritation or apply emollient Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Antidiarrheals • Do not exceed recommended dose • May cause drowsiness – caution driving or performing hazardous tasks • Do not drink alcohol or other CNS depressants • Do not use OTCs without approval • Notify health care provider if diarrhea persists or becomes more severe Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Constipation Having fewer than three bowel movements per week Stools are usually hard and dry Stools are usually small in size and difficult to eliminate Bowel movements may be painful Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Laxatives Bulk-producing laxatives Not digested by the body Add bulk and water to the contents of the intestines Added bulk stimulates peristalsis Examples: psyllium and polycarbophil Onset: 12–24 hours but may take up to 3 days Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Laxatives Emollient laxatives Lubricate the intestinal walls and soften the stool Enhance passage of fecal material Example: mineral oil Onset of action: 6–8 hours Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Laxatives Fecal softeners Promote water retention in the fecal mass and soften the stool Fecal softeners promote retention of water in the stool, but emollient laxatives do not Examples: docusate sodium, docusate calcium Onset of action: 24–72 hours Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Laxatives Hyperosmolar drugs Dehydrate local tissues, which causes irritation and increased peristalsis Results in evacuation of the fecal mass Examples: glycerin Onset of action: 24–48 hours orally, within 15 minutes if used rectally Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Laxatives Irritant or stimulant laxatives Increase peristalsis by direct action on the intestine Examples: senna Onset of action: 6–12 hours orally, 15–60 minutes as a suppository, 3–5 minutes as an enema Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Laxatives Saline laxatives Attract or pull water into the intestine Increase pressure in the intestine followed by an increase in peristalsis Example: magnesium hydroxide Onset of action: 30 minutes to 3 hours Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Laxatives • Short-term relief or prevention of constipation • Certain stimulants, emollients, and saline laxatives – empty colon for rectal and bowel exams • Fecal softeners or mineral oil – prevent constipation in patients who should not strain during defecation • Psyllium – used in patients with irritable bowel syndrome and diverticular disease Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Laxatives • Polycarbophil – may be used for constipation or diarrhea associated with irritable bowel syndrome and diverticulosis • Mineral oil – relief of fecal impaction • Docusate – to prevent dry, hard stools • Constipation may occur as an adverse drug reaction to some drugs, such as narcotic analgesics – Stool softeners or other laxatives are used to prevent constipation during the drug therapy Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Laxatives • Prolonged or high doses can cause diarrhea and a loss of water and electrolytes. • Can cause abdominal pain or discomfort, nausea, vomiting, perianal irritation, flatulence, and cramps • Patient may develop a “laxative habit” and not be able to have bowel movement without the medication, especially with stimulants • Some of these products contain tartrazine, which may cause allergic-type reactions Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Laxatives Bulk-forming laxatives may cause obstruction of the esophagus, stomach, small intestine, and colon if not taken with adequate fluid intake or in patients with intestinal stenosis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Laxatives Contraindications: Known hypersensitivity, persistent abdominal pain, nausea, vomiting of unknown cause, signs of acute appendicitis, fecal impaction, intestinal obstruction, acute hepatitis Precautions: Excessive or prolonged use may cause dependence Rectal bleeding, lactation Magnesium hydroxide: renal impairment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Laxatives Interactions: May reduce absorption of other drugs present in the GI tract Mineral oil: fat-soluble vitamin absorption impaired, surfactants Bisacodyl: milk, antacids, H2 antagonists, proton pump inhibitors Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Laxatives Bulk-producing and fecal-softening laxatives should be taken with a full glass of water or juice. An increase in foods high in fiber is encourage as prevention. Mineral oil should be given on an empty stomach at bedtime. Powders, flakes, and granules should be mixed immediately prior to administration. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Laxatives Unpleasant or salty taste may be disguised by chilling, adding to juice, or pouring over cracked ice. Magnesium citrate can be chilled and mixed with lemon juice or other fruit juices. Notify health care provider if excessive bowel movements or severe prolonged diarrhea occur or if the laxative is ineffective. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Laxatives Avoid long-term use, except for bulk-forming laxatives and stool softeners. Read and follow directions on label. Do not use if have abdominal pain, nausea, and vomiting. Notify health care provider if constipation is not relieved or if rectal bleeding occurs. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Laxatives • To prevent constipation, drink plenty of fluids, exercise, and eat foods high in bulk or roughage • Bulk-producing or fecal-softening laxatives – drink with a full glass of water and drink plenty of water after use • Bisacodyl: do not chew or take within 1 hour of an antacid or milk • Senna: urine may turn pink-red, red-violet, redbrown, yellow-brown, or black Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Bowel Evacuants Induce diarrhea and result in a rapid cleansing of the bowel Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Bowel Evacuants • Polyethylene glycol (PEG) solution: used to treat constipation • Polyethylene glycol with electrolytes: used as a bowel cleansing prior to a GI exam Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Bowel Evacuants Nausea Abdominal fullness Bloating Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Bowel Evacuants Contraindications: Known allergy to PEG Known or suspected GI obstruction, gastric retention, bowel perforation, toxic colitis, megacolon, or ileus Precautions: Ulcerative colitis Patients who are unconscious or semiconscious Interactions: Any medication taken within 1 hour Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Bowel Evacuants • If adverse reactions become severe, notify health care provider. • Bowel prep should be performed exactly as prescribed. • Prolonged, frequent, or excessive use may result in electrolyte imbalance and “laxative habit.” Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Bowel Evacuants Educate about good defecatory habits Educate about diet and lifestyle changes to prevent constipation Diet high in fiber, plenty of fluids, regular exercise PEG should be dissolved in 8 ounces of water May take 2–4 days before PEG produces a bowel movement Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Miscellaneous Drugs • Mesalamine, balsalazide, olsalazine, and sulfasalazine – exert a topical anti-inflammatory effect in the bowel – Exact mechanism of action is unknown • Infliximab – neutralizes the biological activity of tumor necrosis factor-alpha in Crohn disease – Decreases the infiltration of inflammatory cell and TNF-alpha production in the areas of the intestine that are inflamed Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Miscellaneous Drugs • Lubiprostone – increases intestinal motility by acting on the chloride channel activator, which increases chloriderich intestinal fluid secretion • Orlistat – inhibits lipase in the stomach and small intestine – Prevents breakdown of dietary fat – Undigested triglycerides are not absorbed and pass through the intestine Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Miscellaneous Drugs • Dicyclomine – anticholinergic – Acts on the cholinergic receptors on the smooth muscle of the GI tract and slows GI motility Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Miscellaneous Drugs • Mesalamine – treatment of chronic inflammatory bowel disease • Olsalazine – treatment of ulcerative colitis in those allergic to sulfasalazine • Sulfasalazine – treatment of Crohn disease and ulcerative colitis • Balsalazide – treatment of mild to moderate ulcerative colitis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Miscellaneous Drugs • Lubiprostone – treat chronic idiopathic constipation and irritable bowel syndrome with constipation • Orlistat – obesity management • Infliximab – variety of GI disorders including Crohn disease and ulcerative colitis • Dicyclomine – irritable bowel syndrome Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Miscellaneous Drugs Balsalazide, olsalazine, sulfasalazine orally: Abdominal pain, nausea, headache, diarrhea Mesalamine orally: Headache, abdominal cramps, nausea, tiredness, weakness, malaise, fatigue Sulfasalazine (same as sulfonamides) Rectal administration: Headache, abdominal discomfort, flu-like syndrome, weakness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Miscellaneous Drugs • Lubiprostone – Headache, diarrhea, abdominal pain, nausea • Orlistat – Fatty or oily stools, fecal incontinence, fecal urgency, flatus with discharge, increased defecation, oily evacuation, oily spotting • Infliximab – Myalgia, fever, increased susceptibility to infection – Injection – infusion-site reactions • Dicyclomine – anticholinergic effects Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Miscellaneous Drugs Contraindications: Mesalamine, balsalazide, olsalazine, sulfasalazine: hypersensitivity to sulfonamides and salicylates, intestinal obstruction, children younger than 2 Infliximab: live vaccines Lubiprostone: known hypersensitivity, mechanical GI obstruction, severe diarrhea Dicyclomine: ulcerative colitis, myasthenia gravis, glaucoma, GI or urinary obstruction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Miscellaneous Drugs Precautions: Known hypersensitivity Mesalamine, olsalazine, sulfasalazine: crosssensitivity with furosemide, sulfonylurea, antidiabetic drugs, carbonic anhydrase inhibitors Lubiprostone: moderate to severe hepatic disease Dicyclomine: hot or humid environments may result in heat prostration; patients with an existing cardiovascular disease Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Miscellaneous Drugs Interactions: Sulfasalazine: Increase risk of toxicity of oral hypoglycemic drugs, zidovudine, methotrexate, phenytoin Increased risk of crystalluria with methenamine Decrease in absorption of iron and folic acid Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Miscellaneous Drugs Interactions: Orlistat: Fat-soluble vitamins Lubiprostone Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Miscellaneous Drugs Dosage forms should be swallowed whole Some capsules may be opened and sprinkled on food Notify health care provider if condition does not improve or adverse reactions worsen Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Miscellaneous Drugs • Sulfasalazine – May discolor the urine to an orange-yellow color – will go away when drug is discontinued • Lubiprostone – May cause dyspnea within an hour of the first dose – symptoms should resolve but may reappear with repeat dosing • Infliximab – Report signs and symptoms of infection immediately Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Miscellaneous Drugs Orlistat Should be combined with a reduced-calorie and lowfat diet Only indicated for patients with a BMI of 30 kg/m2 or more or a BMI of 27 kg/m2 in patients with other risk factors (diabetes, dyslipidemia) Mesalamine Should have regular blood tests (complete blood count, liver function) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Miscellaneous Drugs Dicyclomine May cause dry mouth Suck on hard candy, eat ice chips, or use artificial saliva May cause dry eyes Lubricating drops or artificial tears may be useful Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Miscellaneous Drugs Olsalazine If diarrhea, notify health care provider Mesalamine Swallow tablets whole; do not chew Partially intact tablets may be found in the stool Educate on proper suppository insertion Educate on proper use of suspension foam Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Miscellaneous Drugs Balsalazide Swallow capsules whole Capsule may be opened and sprinkled on food but not chewed Infliximab Instruct on aseptic technique and how to properly reconstitute vials and deliver medication Should be administered over at least 2 hours Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Miscellaneous Drugs Sulfasalazine Take after meals Enteric-coated tablet should be swallowed whole Urine may be discolored orange-yellow Lubiprostone Capsules should be taken twice daily with food and water Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Miscellaneous Drugs • Orlistat – T...
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