1. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients andMajor Effects Major Uses Contraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug NameClassNeutralize- Treat indigestion, Contraindications: abdominal pain of unknown- Absorption: minimally absorbed gastric acid, reflux origin, heart failure, hypertension, and gastric outletInformation:- Distribution: distributed throughout the GI tract thereby esophagitis, and obstruction.Anti-ulcerativesPrecautions: potential high-sodium content; - Metabolism: unknown increasing pH peptic ulcers in the GI tractassociated with acid rebound; possible milk-alkali- Excretion: excreted in feces; some may be - Bind dietary syndrome if high-dose calcium carbonate or sodiumAntacids phosphate in excreted in breast milk.bicarbonate; avoid antacid-analgesic combinations of renal failure- Antacids have many potential drugchronic pain syndrome; use with caution in (calcium interactions. Consult a drug reference for morealuminumpregnancy and renal failure. carbonate) complete information.hydroxide Side effects: constipation, diarrhea, electrolyte(AlternaGEL,- Use of aluminum-containing antacids mayimbalancesAmphogel) result in increased effectiveness ofbenzodiazepines and decreased effectivenessof allopurinol, corticosteroids, chloroquine,aluminumdiflunisal, ethambutol, histamine H2-receptorhydroxide and antagonists, penicillamine, digoxin, isoniazid,magnesium phenothiazines, ticlopidine, tetracyclines, andhydroxide thyroid hormone.(Gaviscon,- Use of calcium-containing antacids may resultGelusil, Maalox,in increased effectiveness of quinidine andMylanta)decreased effectiveness of fluoroquinolones,hydantoins, iron, salicylates, and tetracyclines.calcium - use of magnesium-containing antacids maycarbonate result in increased effectiveness of dicumarol,(Tums)quinidine, and sulfonylureas and decreasedeffectiveness of benzodiazepines, ticlopidine,magaldratechloroquinine, histamine H2-receptor(aluminum-antagonists, penicillamine, corticosteroids,magnesium digoxin, hydantoins, iron, nitrofurantoin,complex)phenothiazines, and tatracyclines.[Riopan]- Use of magnesium and aluminum-containingantacids may result in increased effectivenessof levodopa, quinidine, valproic acid, andmagnesium sulfonylureas; and decreased effectiveness ofhydroxide (Mag- benzodiazepines, ticlopidine, captopril,Ox, Milk of corticosteroids, histamine H2-receptorMagnesia) antagonists, fluoroquinolones, hydantoins,iron, ketoconazole, penicillamine,phenothiazines, salicyaltes, and tatracyclines.- Antacids can cause premature dissolution ofenteric-coated tablets. Give antacids as least 1hour apart from enteric-coated tablets.12/24/2012Page 1 of 16

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GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major EffectsMajor Uses Contraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Name - Instruct the patient to shake the suspension well, or, if taking chewable tablets, to chew them thoroughly and then drink half a glass of water to promote passage to the stomach. - Evaluate the patient for epigastric or abdominal pain, frank bleeding, and occult bleeding.Class Inhibits - Long-termContraindications: breast-feeding those with known - Absorption: most drugs absorbed rapidly andgastric acid treatment of hypersensitivity to individual agents or other H2- completely.Information:secretion by pathologic receptor antagonists.Histamine-2- Distribution: widely distributed throughoutinhibiting the hypersecretory Precautions: possible decreased clearance withreceptor body; cimetidine crosses placental barrier andaction ofconditions kidney or liver disease; reduce dosage for renalantagonistsappears in breast milk.histamine at (Zollinger-Ellison impairment, including elderly; symptomatic responsehistamine-2syndrome)does not exclude gastric malignancy; follow gastric- Metabolism: metabolized by the liver.cimetidine(H2)ulcer patients closely; reversible CNS effects may - Excretion: primarily excreted in bile. - Promote healingoccur such as confusion or anxiety; in(Tagamet, receptors in - H2-receptor antagonists have many potential of duodenal andimmunocompromised, may increase risk ofTagamet HB) gastricdrug interactions. Consult a drug reference for gastric ulcers strongyloidiasis; use in pregnancy only when benefitparietal cells more complete information. - Decrease gastric outweighs risk to fetus.famotidine acid production - H2-receptor antagonists may increase plasma(Pepcid, Pepcid Side effects: headache, dizziness, confusion, mild and prevent ethanol levels.AC) diarrhea, rash. stress ulcers in- Antacids, anticholinergics, and severely illmetoclopramide may decrease absorption ofnizatidine (Acid)patients andthese drugs. Avoid simultaneous those with reflux administration. esophagitis or - Inform phenylketonurics that some productsranitidine upper GI may contain phenylalanine.(Zantac) bleeding - H2-receptor antagonists may increase the - Treat heartburn, bioavailability of certain cephalosporins, such acid indigestion, as cephalexin, cefpodoxime, and cefuroxime. and sour stomach (over-- H2-receptor antagonists may impair oral the-counter absorption of ketoconazole and iron. Give iron preparations) at least 1 hour before H2-receptor antagonists. - prevention of - Cimetidine may cause increased serum levels aspirationand consequent toxicity of benzodiazepines, pneumonitis calcium channel blockers, tricyclic antidepressants, procainamide, lidocaine, oral - part of a anticoagulants, phenytoin, propranolol, multidrug quinidine, and theophylline. regimen to eradicate H.- Cimetidine administered with carmustine pylori in the increases the risk of bone marrow toxicity.12/24/2012Page 2 of 16 3. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major UsesContraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Nametreatment of - Teach the patient that smoking worsens ulcerpeptic ulcer disorders and counteracts the effects of H2- receptor antagonists. - Dont give an antacid within 1 hour of administering drug; may decrease absorption of the drug. - Caution the patient about possible dizziness; recommend avoidance of hazardous activities that require alertness. - Evaluate for epigastric or abdominal pain, frank bleeding, and occult bleeding. - Teach the patient to avoid gastric irritants (smoking, alcohol, products containing aspirin, caffeine, NSAIDs. and foods that cause GI irritation), which may counteract the drug effects and worsen the ulcer.Class Blocks gastric- Treat erosive Contraindications: patients with known - Absorption: rapidly absorbed in the smallacidesophagitis and hypersensitivity.intestine.Information:secretions by GERDPrecautions: Pregnancy and breast-feeding;Proton pump symptomatic response does not exclude gastric- Distribution: highly protein-boundinhibiting acid - Treat duodenalinhibitorsmalignancy; vitamin B12 deficiency possible. - Metabolism: extensively metabolized in thepump in ulcergastric Side effects: abdominal pain, nausea, vomiting,liver.parietal cells- Short-termdiarrhea and rash. - Excretion: eliminated by kidneysesomeprazoletreatment of(Nexium) - Proton pump inhibitors may interfere withactive gastriculcerabsorption of ketoconazole, ampicillin, iron salts, digoxin, and cyanocobalamin.lansoprazole- Long-term(Prevacid)treatment of - Decreased bioavailability itraconzole orhypersecretory ketoconazole may result if used with PPIs;conditions avoid concomitant administration.omeprazole- Eradicate H. - More rapid dissolution and increased gastric(Prilosec,pylori infection side effects of enteric-coated salicylates mayPrilosec OTC)(esomeprazole, result if used with PPIs.lansoprazole,- Altered PT measures may result if warfarin ispantoprazoleomeprazole, andused with PPIs; monitor INR and PT.(Protonix)rabeprazole) - May interfere with metabolism of diazepam,- Prevent and treatphenytoin, and warfarin, increasing their half-rabeprazole NSAID-relatedlives and plasma levels.(Aciphex) gastric ulcers - Monitor for diarrhea and abdominal pain.(lansoprazole) - Instruct the patient to swallow capsules whole and to not chew or crush them.12/24/2012Page 3 of 16 4. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major UsesContraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Name - Administer 1 hour before meals. - Instruct the patient to avoid gastric irritants (smoking, alcohol, products containing aspirin, caffeine, NSAIDs, and foods that cause GI irritation), which may counteract drug effects and worsen the ulcer.Class Protect - Short-termContraindications: patients with known- Absorption: only 3-5% of drug is absorbedgastric treatment and hypersensitivity.after oral administrationInformation:mucosa by prevention of Precautions: pregnancy, breast-feeding and chronicLocal-actingrenal failure. - Distribution: acts locally at ulcer site.coating the gastric, duodenaldrugs- Metabolism: unknownulcer craterand stress ulcers Side effects: constipation - Excretion: excreted in feces.sucralfate - Binds with other drugs in GI tract; may(Carafate) decrease absorption of cimetidine, phenytoin, tetracycline, warfarin, and theophylline. - Antacids increase gastric pH and may decrease drug effectiveness. - Sucralfate decreases absorption of lansoprazole; separate doses of drugs by giving lansoprazole 30 minutes before sucralfate. - Give at least 2 hours apart from cimetidine, digoxin, phenytoin, tetracyclines, theophylline, or warfarin. - Dont administer with an antacid; separate administration times by at least 30 minutes. - Administer drug at least 1 hour before meals and at bedtime for maximum effectiveness. - Evaluate for epigastric or abdominal pain, frank bleeding, occult bleeding and constipation. - Instruct the patient to avoid gastric irritants (smoking, alcohol, products containing aspirin, caffeine, NSAIDs, and foods that cause GI irritation), which may counteract drug effects and worsen the ulcer. - Know that sucralfate is poorly water-soluble; administering drug through an NG tube requires special preparation by the pharmacist.12/24/2012Page 4 of 16 5. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major EffectsMajor Uses Contraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug NameClass Inhibit GI - Adjunctive Contraindications: children, breast-feeding; angle- - Absorption: poorly absorbed from GI tractmotility and therapy for peptic closure glaucoma; uncontrolled tachycardia; urinary (about 10-25%).Information:gastriculcer diseaseor GI tract obstruction; hypersensitivity; severeCholinergic - Distribution: Rapidly distributed.secretionsulcerative colitis; myasthenia gravis; tachycardiablockers- Metabolism: Unknown.caused by cardiac insufficiency or thyrotoxicosis;acute or severe hemorrhage; or unstable - Excretion: Unknown.glycopyrrolatecardiovascular status- Use with similar-acting drugs causes additive(Robinul) Precautions: elderly, Down syndrome, brainanticholinergic effects.damage, spasticity, hypertension, hyperthyroidism,pregnancy.- Antacids may decrease absorption ofmepenzolate anticholineric antiulceratives.(Cantil)Side effects: tachycardia, dry mouth, constipation,urine retention, and urinary hesitancy- Evaluate for epigastric or abdominal pain,frank bleeding, and occult bleeding.methscopolamine - Instruct the patient to avoid gastric irritants(Pamine)(smoking, alcohol, caffeine, aspirin containingproducts, NSAIDs, and foods that cause GIirritation); may counteract drug effects andpropanthelineworsen the ulcer.(Pro-Banthine)Class Bismuth- Adjunct to Contraindications: known hypersensitivity.- Absorption: misoprostol is extensively andsubsalicylate: antibiotic therapy Misoprostol contraindicated in pregnancy or breast- rapidly absorbed.Information:reduces GI to eradicate H.feeding and those allergic to prostaglandinsMiscellaneous Precautions: pregnancy, breast-feeding, chronic - Distribution: unknownmotility and pylori (bismuthantiulceratives renal failure; liver impairment.- Metabolism: unknowngastricsalicylate)secretions - Prevent gastricSide effects: darkened tongue or stools (bismuth);- Excretion: unknownbismuth (Pepto-ulcers resulting diarrhea (most common), abdominal pain, flatulence, - Bismuth increases action of warfarin and oralBismol)from use ofdyspepsia, infertility, nausea and vomiting, vaginalhypoglycemic agonists.Misoprostol:spotting, uterine cramping, and miscarriagereplaces NSAIDs or treat- Bismuth and misoprostol decrease absorption duodenal ulcers(misoprostol).misoprostol gastric of tetracyclines.(Cytotec) prostaglandinnot responding to- Administer misoprostol with food or after mealss andother medicationand at bedtime to decrease the risk ofenhances regimensdiarrhea.natural local(misoprostol)- Observe for diarrhea.protectivemechanisms- Evaluate for epigastric or abdominal pain,frank bleeding, and occult bleeding.- Instruct the patient to avoid gastric irritants(smoking, alcohol, caffeine, aspirin-containingproducts, NSAIDs, and foods that cause GIirritation); may counteract drug effects orworsen the ulcer.Class Adsorbents:- Antidote for oralContraindications: activated charcoal - Absorption: not absorbed into body; actscontraindicated in patients with acute poisoning from12/24/2012 Page 5 of 16 6. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major EffectsMajor UsesContraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug NameInformation:attract andingestion ofmineral acids, alkalines, cyanide, ethanol, methanol, locally on GI tract and excreted whole.adsorbents, binds to toxins that can iron, inorganic acids, or organic solvents; pancrelipase contraindicated in hypersensitivity to - Distribution: not distributed.antiflatulents, toxins in GI lead to poisoningtract, thereby or overdose pork protein or enzymes acute exacerbation of - Metabolism: not metabolized.and digestantspreventing (activatedchronic pancreatic disease. - Excretion: excreted unchanged in feces.absorption charcoal) Precautions: pancrelipsase associate with colonic - Activated charcoal decreases absorption ofAdsorbents:fibrotic strictures, especially in cystic fibrosis; avoid oral medications.activatedskin or mucous membrane exposure; possibleAntiflatulents:- Treat conditionsnausea, abdominal cramps, or diarrhea if dose - Antacids reduce effects of pancreaticcharcoalcauseinvolving excessive; if pregnant use only if clearly needed; useenzymes.foamingexcessive air orwith caution in breast-feeding. - Pancreatic enzymes decrease absorption ofAntiflatulents: action in GI gas in thefolic acid and iron. Side effects: blackened stools and constipationsimethicone tract, creatingstomach or(activated charcoal); abdominal cramping, biliary - Know that a patient who has recently eaten will(Flatulex, Gas-X, a film onintestines, suchcolic, diarrhea and nausea (digestive enzymes). require an increased amount of activatedMaalox Anti-intestines thatas gastric charcoal.gas, Mylantahelps to bloating,disperse diverticular- Be aware that multiple doses of activatedGas, Mylicon,mucus- disease, or charcoal may be needed to treat severePhazyme)enclosed gas spastic orpoisoning involving certain drugspockets andirritable colon (acetaminophen, digoxin, phenobarbital,Digestants: to prevent (simethicone) phenytoin, theophylline, carbamazepine,dehydrocholic theirdapsone, and quinidine).acid, formation. - Shake simethicone well before administration - Treatpancreatic to thoroughly mix drug. constipation andenzymes Digestants:promote bile flow - Administer drug at appropriate time:(pancreatine, resembles(dehydrocholico Simethicone: after meals and atpancrealipase,action ofacid) bedtime[Pancreas], deficientlipase, protease,o Pancreatic enzyme: with mealssubstanceamylase)(bile acid,- SupplementoDehydrocholic acid: after mealswhichdeficient naturalincreasespancreaticoutput of bile enzymes, suchin the liver, or as occurs inpancreatic patients withenzymes) pancreatitis ornormally cystic fibrosisproduced by(pancreaticthe body.enzymes)Class Aprepitant,- Nausea andContraindications: hypersensitivity to drug or other- Absorption: usually well absorbed from GI tractdronabinol,vomitingantidopaminergic derivatives; severe CNSInformation: - Distribution: widely distributedgranisetronm,associated with depression, subcortical brain damage, bone marrowAntiemetics- Metabolism: extensively metabolized by liverondansetron, chemotherapydepression, first trimester of pregnancy12/24/2012Page 6 of 16 7. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients andMajor EffectsMajor Uses Contraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Name palonosetron,(aprepitant, (chlorpromazine, perphenazine, prochlorperazine, - Excretion: excreted in urine and feces phenothiazinepalonosetron,metoclopramide, promethazine, trimethobenzamide,aprepitant dimehydrinate). GI hemorrhage, obstruction, or - Additive CNS depression may result if alcohol,(Emend)s, and ondansetron,barbiturates, or other sedatives, opiates or trimethobenz granisetron, and perforation; pheochromocytoma; epilepsy, use of drugs that cause EPS (metoclopramide). Comatoseother analgesics, or general anesthetics are amide: act ondronabinol) used with antidopaminergic.dimenhydrinate CNS tostate; treatment of lower respiratory tract symptoms,- Motion sicknessincluding asthma (promethazine).Do not use with- An acute encephalopathic syndrome may(Dramamine)prevent(dimenhydrinate, nausea andpimozide, terfenadine, astemizole, or cisaprideresult if lithium is used with antidopaminergics.meclizine) (aprepitant). Known or suspected QT prolongation vomiting - A lowered seizure threshold may result ifdronabinol- tube feedings(Droperidol). sensitivity to dronabinol, any antidopaminergics are used with(Marinol) (metoclopramide) cannabinoid or sesame oil (dronabinol) anticonvulsants. Dimenhydrate - Diabetic Precautions: associated with extrapyramidal , meclizine, - Patients receiving prolonged high-dosedroperidolgastroparesisreactions, tardive dyskinesia, cerebral edema, andtherapy with antidopaminergics should(Inapsine)(metoclopramide) sensitivity reactions, including cholestatic jaundice, scopolamine: undergo periodic ophthalmologic elevated liver function studies, blood dyscrasias, reduce examinations. laryngeal edema, laryngospasm, bronchospasm, andgranisetronmotionanaphylactoid reactions; sedation, seizures, - Avoid contact with oral solutions and injections(Kytril) sickness by hypotension, tachycardia, dizziness, syncope, ECGto prevent contact dermatitis. inhibitingchanges and cardiac arrest, sudden death possible; if- The elderly are particularly sensitive to impulses from used with other antipsychotics, potential foradverse nervous system effects (such asmeclizineinner ear toneuroleptic malignant syndrome, includingtardive dyskinesia, motor restlessness,(Antivert, the vestibularhyperthermia, rigidity, altered mental status, coma, parkinsonian features, and sedation),Bonine)pathway.hypertension, tachycardia, arrhythmia, anticholinergic effects, and cardiovascular rhabdomyolysis, and renal failure; associated with effects, such as orthostatic hypotension;metoclopramide leukopenia, pruritus, photosensitivity, urticarial,initiate drug at low doses and observe closely. Metocloprami(Reglan) eczema, exfoliative dermatitis, corneal and lens - Advise patient to exercise caution while driving de: increases changes, weight gain, hyperprolactinemial; use withor performing other tasks requiring alertness. the rate if caution if severe cardiovascular disorder, breastondansetrongastric- Avoid excessive exposure to ultraviolet light. cancer, hypocalcemic, severe asthma, emphysema,(Zofran) emptying and acute respiratory infection, history of seizures or- Increased phenytoin levels may result if enhances taking anticonvulsants; avoid use if orthostatic chlorpromazine used with phenytoin. gastroesophapalonosetron hypotension; if pregnant, use only if benefit- Increased levels of perphenazine may result if geal sphincter(Aloxi)outweighs risk to fetus; if breast-feeding, do not use used with drugs that inhibit hepatic CYP2D6, tone. drug (chlorpromazine, perphenazine,such as TCAs, fluoxetine, sertraline, andphenothiazines prochlorperazine, metoclopramide, promethazine,paroxetine.(chlorpromazine trimethobenzamide, dimenhydrinate). Associated with[Thorazine] , - Use of metoclopramide in Parkinson disease is rare hypersensitivity reactions, includingperphenazinerelatively contraindicated. bronchospasm, shortness of breath, urticarial,[Trilafon]) - Increased rate of absorption of alcohol or hypotension, shock and anaphylaxis (ondansetron, granisetron, palonosetron, aprepitant, droperidol, cyclosporine may result if used withprochlorperazine dronabinol); if pregnant use only if benefit outweighs metoclopramide.(Compazine)risk to fetus; use with caution if breast-feeding. If- Decreased levels of cimetidine and digoxin severe hepatic impairment, adjust dose; if abdominal may result if used with metoclopramide. surgery, potential for masking ileus or gastric12/24/2012Page 7 of 16 8. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients andMajor Effects Major Uses Contraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Namepromethazinedistention (ondansetron). use with caution if hepatic- Increased neuromuscular blockade may result(Phenergan) impairment; chronic continuous use not if metoclopramide used with succinylcholine.recommended(aprepitant); associated with reducedpulmonary pressure, QT prolongation, torsade de- Decreased levels of metoclopramide mayscopolamine pointes, and serious arrhythmias, potentially fatal; result if used with anticholinergics or narcotic(Scopace) screen for prolonged QT prior to initiation; monitor for analgesics.arrhythmias prior to and for 2 to 3 hours following- Metoclopramide releases catecholamines anddrug administration; administer with extreme caution should be used with caution, if at all, with MAOthiethylperazineif cardiovascular disease, diuretic use, cardiac inhibitors.(Torecan)hypertrophy, hypokalemia, hypomagnesemia, heart- Impaired mental or physical abilities may resultrate less than 50 beats per minute, treatment with from use of metoclopramide; use caution iftrimethobenza class I and III antiarrhythmics or MAO inhibitors, other driving or operating machinery.mide (Tigan)drugs known to decrease QT; observe for - Transient flushing without vital sign alterationhypotension and neuroleptic malignant syndrome; may occur with IV administration of high dosesuse with caution if renal or hepatic impairment; use in of metoclopramide.pregnancy only if benefit outweighs risk to fetus; usewith caution if breast-feeding(droperidol); use with - Decreased vasopressor effect of ephedrinecaution if cardiovascular disorder, history of may result if used with promethazine; do notsubstance abuse, mania, depression, schizophrenia, use ephedrine to treat hypotension associatedconcomitant sedatives, hypnotics, or other with promethazine.psychoactive drugs, pregnant, nursing, or elderly; - Use anticholinergics with caution in patientspotential for abuse; if pregnant, use only if benefittaking promethazine.outweighs risk to fetus; not recommended if breast-- Increased incidence of EPS may result iffeeding (dronabinol).promethazine is used with MAO inhibitors.Side effects: motor restlessness, hyperpyrexia,diaphoresis, drowsiness, erectile dysfunction, -Use promethazine with caution in patients withgalactorrhea, urinary retention, decreased sweating, seizure disorders or who are using drugs thatinsomnia, restlessness, anxiety, agitation, euphoria,lower seizure thresholds such as narcotics ordry mouth, blurred vision, hyperthermia, hypothermia,local anesthetics.depression, headache, dizziness, weakness- Avoid use or promethazine in patients with(chlorpromazine, perphenazine, prochlorperazine, respiratory compromise such as COPD ormetoclopramide, promethazine, trimethobenzanide, sleep apnea.dimenhydrinate); nausea, diarrhea, urinary frequency - Avoid prolonged ultraviolet exposure.and incontinence, rash, urticarial, amenorrhea, - Masking of ototoxic symptoms may result ifimpotence, hypotension, hypertension, drugs with ototoxic potential, such as certainsupraventricular tachycardia, fluid retention, acute antibiotics, are used with dimenhydrinate.CHF, visualdisturbances(metoclopramide);drowsiness, blurred - Do not inject dimenhydrinate intra-arterially.vision, dizziness, increased or decreased blood- Decreased levels and effect of ondansetronpressure, tachycardia, bradycardia, dry mouth, may result if used with rifampin.nausea, vomiting, asthma, nasal congestion, tremors, - Increased aprepitant levels may result if usedphotosensitivity, urticarial, dermatitis (promethazine); with drugs that inhibit CPY3A4 such asblurred vision, drowsiness, headache, muscle clarithromycin, diltiazem, ketoconazole,cramps, diarrhea, depression (trimethobenzamide);12/24/2012Page 8 of 16 9. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major Uses Contraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Name drowsiness, dizziness, dry mouth, nose and throat;nefazodone, ritonavir, and troleandomycin. blurred vision, difficult or painful urination, headache, anorexia, nervousness, skin rash, restlessness, - Decreased aprepitant levels may result if used insomnia, thickened bronchial secretions, with drugs that induce CYP3A4 such as tachycardia, lassitude, nausea, excitationcarbamazepine, phenytoin, and rifampin. (dimenhydrinate); hypotension, arrhythmias, - Increased levels of drugs that metabolized headache, EPS, chills, musculoskeletal pain, woundCYP3A4 (such as dexamethasone, problems, shivers (ondansetron); CNS stimulation, methylprednisolone, midazolam, triazolam, anorexia, nausea, vomiting, somnolence, leukopenia, paclitaxel, imatinib, vinblastine, and vincristine) anemia, thrombocytopenia, shivers, alopecia,may result of used with aprepitant. hypertension (granisetron); headache, constipation- Reduce dexamethasone and (palonosetron); dizziness, diarrhea, fatigue, hiccups,methylprednisone doses when used with stomatitis, dyspepsia (aprepitant); hypotension,aprepitant. tachycardia, dysphoria, drowsiness, restlessness, - Decreased levels of paroxetine and aprepitant hallucinations, EPS signs and symptoms (droperidol); may result if they are co-administered. tachycardia, palpitations, facial flush, anxiety, confusion, amnesia, ataxia, dizziness, euphoria,- Decreased levels of warfarin, tolbutamide, or paranoia, somnolence, nausea, vomiting, abdominal phenytoin may result if used with aprepitant. pain, asthenia (dronabinol) - Closely monitor INR in patients receiving warfarin. - Decreased efficacy or oral contraceptives may result if used with aprepitant. - Reserve droperidol for patients unresponsive to other adequate treatments. - Individualize dosage. Reduce dose for elderly or debilitated patients and in patients receiving other CNS depressants. - Increased risk of QT prolongation may result from the use of droperidol with class I or III antiarrhythmics, certain antihistamines, antimalarials. Calcium channel blockers, certain neuroleptics, antidepressants, and drugs that can cause hypokalemia or hypomagnesemia such as diuretics, laxatives, and drugs with mineralcorticoid properties. - Additive CNS effects may result if droperidol is used with barbiturates, tranquilizers, opioids, or general anesthetics. - Paradoxically increased droperidol-induced hypotension may result if droperidol is used with ephedrine. - Hypertension may result if droperidol is used12/24/2012Page 9 of 16 10. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major Uses Contraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug Name with fentanyl or other parenteral analgesics. - Monitor vital signs and EKG routinely. - Increase dose gradually to minimize potential for disturbing psychiatric symptoms. - Apprise patients of possible changes in mood and other adverse behavioral effects. - Closely observe patient, especially those with no prior experience with marijuana or dronabinol. - Patients using dronabinol should not drive, operate machinery, or engage in hazardous activity until individual response to drug and safety in performing these tasks are established. - Additive hypertension, tachycardia, or cardiotoxicity may result if dronabinol is used with amphetamines, cocaine, or sympathomimetics. - Additive tachycardia or drowsiness may result if dronabinol is used with anticholinergics or antihistamines. - Additive CNS effects may result if dronabinol is used with alcohol, sedatives, hypnotics, or psychomimetics. - Hypomanic reactions may result if dronabinol is used with disulfiram or fluoxetine. - Decreased levels of theophylline may result if theophylline is used with dronabinol.Class Camphorated - Control andContraindications: Hypersensitivity to drug or its- Absorption: opium preparations are absorbedopium relieve symptoms components; Contraindicated in patients withsystemically; others are absorbed readily formInformation:tincture, of acute orabdominal pain of unknown cause, especially ifthe GI tract, except for loperamide.Antidiarrheals accompanied by fever; hypersensitivity todifenoxin,chronic- Distribution: varies with drug.diphenoxylate nonspecificdicyclomine or anticholinergic drugs; narrow angle, and diarrhea.glaucoma, GI obstruction, ileus, severe ulcerative- Metabolism: metabolized by liver.bismuth (Pepto-Bismol) loperamide:colitis, toxic megacolon, hepatic or renal disease, - Excretion: opium preparations are excreted by- Treatment of obstructive uropathy, myasthenia gravis, myocardialslow intestinal irritable bowelkidneys; others are excreted primarily in feces.motility,ischemia, unstable cardiovascular status in acute(Bentyl, - Bismuth may decrease absorption ofcamphorated ultimately hemorrhage (dicyclomine); hypersensitivity toDonnatal)tetracyclines.opium tinctureincreasing diohenoxylate or atropine; diarrhea due to(Paregoric)pseudomembranous enterocolitis or enterotoxin-- Discontinue bismuth if used with otherwater salicylate containing products and ringing in12/24/2012Page 10 of 16 11. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major EffectsMajor Uses Contraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Nameabsorptionproducing bacteria; (diphenoxylate/atropine);the ears occurs.from stools hypersensitivity to loperamide, patients who mustdifenoxin (with avoid constipation (loperamide); glaucoma, bowel - Do not use bismuth of allergic to salicylatesatropineobstruction, paralytic ileus, severe ulcerative colitis, unless instructed to do so by a physician.[Motofen])Bismuth,obstructive uropathy, unstable cardiovascular status - Increased effects of atenolol and digoxin maykaolin andin acute hemorrhage, hiatal hernia with reflux result if used with dicyclomine.diphenoxylate pectinesophagitis, acute intermittent porphyria, and patients- Decreased antipsychotic effects of(with atropinemixture, andin whom phenobarbital; produces excitement,phenothiazines may result if used with[Lomotil])polycarbophil:restlessness dicyclomine.reduce fluid(phenobarbital/hycosamine/atropine/scopolamine);content of - Dicyclomine may increase anticholinergic sidePrecautions: fecal impaction possible if debilitatedkaolin and pectin stools effects of other medications includingpatient; potential for interference with radiologicmixtureamantadine, phenothiazines, and TCAs.examinations (bismuth); associated with allergic(Kapectolin)reaction (including anaphylaxis), heat prostration is- Elderly patients are particularly prone toOctreotide:excitement, agitation and other adverse eventsused in a hot environment, and anticholinergicdecreaseswhen they use dicyclomine.loperamidepsychosis (including confusion, disorientation,volume of(Imodium) memory loss, hallucinations, ataxia, euphoria, and - Use caution when driving or performing tasksgastric andcoma); use with caution if renal or hepatic disease, that require alertness, coordination, or physicalintestinalhypertension, coronary artery disease, arrhythmias,dexterity.secretionsoctreotideCHF, hiatal hernia with reflux, ileus, ulcerative colitis,and diarrhea - Local irritation may occur with use of(Sandostatin) prostatic hypertrophy, glaucoma, hyperthyroidism,secondary to parenteral dicyclomine.autonomic neuropathy, asthma, allergies, Downvasoactive - Dicyclomine is usually taken 30 to 60 minutessyndrome, brain damage, spastic paralysis, orpolycarbophil intestinal prior to meals.debilitated patients with chronic lung disease; if(FiberCon)tumors (suchpregnant, use only if benefits outweigh risk to fetus; - Hypertensive crisis may result ifas carcinoiddo not use if breast-feeding (dicyclomine); if diphenoxylate/atropine is used with MAOtumors)dicyclomine ulcerative colitis, toxic megacolon possible; potentialinhibitors.(Bentyl)for anaphylaxis, ileus, pancreatitis, dehydration, and - Diphenoxylate increases effect of MAOelectrolyte imbalance; use with extreme caution if inhibitors, barbiturates, tranquilizers, andadvanced hepatorenal disease or hepaticalcohol.phenobarbital/hyc impairment; addiction with high doses possible; ifosamine/atropine - Use caution when driving or performing taskspregnant use only if benefit outweighs risk to fetus;/scopolamine that require alertness, coordination, or physicaluse caution if breast-feeding(Donnatal) dexterity while taking diphenoxylate.(dipehnoxylate/atropine); do not use if acutedysentery, including high fever and blood in stools; - If no improvement of acute diarrhea occurspotential for toxic megacolon if acute ulcerative colitiswithin 48 hours of loperamide therapy,or pseudomembranous colitis; stop drug rapidly ifdiscontinue the drug.abdominal distention, constipation, or ileus occur; if - Octreotide may decrease blood level ofhepatic impairment, monitor for CNS toxicity; if cyclosporine.pregnant, use only if clearly needed; use with caution - Dose adjustments of insulin, oral hypoglycemicif breast-feeding (loperamide); associated withagents, beta-blockers, calcium channelgallstones or sludge; if renal failure with dialysis,blockers, or drugs that control fluid andadjust octreotide dose; bradycardia, arrhythmias,electrolyte balance may be necessary duringcardiac conduction abnormalities, EKG changes12/24/2012 Page 11 of 16 12. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major UsesContraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug Name(including prolonged QT interval), pancreatitis,use of octreotide.depressed vitamin B12 levels, hyperglycemia,hypoglycemia, or hypothyroidism possible; if- Monitor vitamin B12 levels during chronicpregnant use only if clearly needed; use with caution therapy with octreotide.if breast-feeding (octreotide); associated with heat- Increased effects of atenolol and digoxin mayprostration in hot environment, drowsiness, blurred result if used with Donnatal.vision; use with caution if autonomic neuropathy, - Decreased antipsychotic effects ofhepatic, or renal disease, hyper thyroidism, coronary phenothiazines may result if used withartery disease, CHF, arrhythmias, tachycardia, or Donnatal.hypertension; if pregnant use only if clearly needed;- Donnatal may increase anticholinergic sideuse with caution if breast-feedingeffects of other medications including(phenobarbital/hycosamine/atropine/scopolamine);amantadine, phenothiazines, and TCAs.Side effects: darkening of tongue or stool (bismuth);- Donnatal may decrease the effects ofpalpitations, headache, flushing, drowsiness,anticoagulants.restlessness, tremor, confusion, urinary retention,impotence, dry mouth, constipation, blurred vision, - Caution patients taking Donnatal who aredilated pupils, nasal congestion, decreased sweatingexperiencing drowsiness or blurred vision(dicyclomine); dry skin or mucous membranes,against engaging in activities that areflushing, hyperthermia, tachycardia, urinary retention, hazardous or require metal alertness.dizziness, drowsiness, headache, malaise, euphoria,depression, confusion, anorexia, nausea, vomiting,abdominal discomfort, puritus, gum swelling,angioneurotic edema, urticarial(diphenoxylate/atropine); hypersensitivity reaction,abdominal distention or discomfort, nausea, vomiting,constipation, tiredness, drowsiness, dizziness, drymouth (loperamide); diarrhea, abdominal pain ordiscomfort, flatulence, constipation, nausea, vomiting(octreotide); dry mouth, insomnia, dizziness,drowsiness, blurred vision, mental confusion, urinaryretention, tachycardia, palpitations, nervousness,headache, constipation, allergic or idiosyncraticreactions, including anaphylaxis, decreasedsweating, excitement, agitation, impotence(phenobarbital/hycosamine/atropine/scopolamine)Class Bulk-forming- ConstipationContraindications: hypersensitivity to drug or- Absorption: minimally absorbedlaxatives:product components; persistent or severe abdominalInformation:- Bowel - Distribution: distributed in intestinesincreasepain of unknown cause, especially whenLaxatives preparation for accompanied by fever; bowel obstruction, fecal- Metabolism: metabolized by intestinalwater content radiologic orof stools,impaction, symptoms or signs of appendicitis. microfloraendoscopicGalactosemia (lactulose); colostomy, ileostomy,Bulk-formingforming a procedures- Excretion: excreted in feceslaxatives:viscous ulcerative colitis, diverticulitis (magnesium hydroxide);- Manage chronic- Lactulose use with nonabsrobale antacids maysolution that concomitant use of mineral oil and docusate sodiummethylcellulose inhibit the desirable lactulose induced12/24/2012 Page 12 of 16 13. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients andMajor EffectsMajor Uses Contraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug Name(Citrucel) promotes watery diarrhea(mineral oil).reduction in colonic pH. peristalsis(methylcellulose Precautions: use with caution if diabetes mellitus,polycarbophilmonitor electrolyte imbalance (lactulose); use with - Patients undergoing electric cautery during(FiberCon) and improves and psyllium)colonoscopy or proctoscopy should first elimination caution if renal insufficiency, hypernatremia,psyllium- Adjunctive hyperphosphatemia, acidosis, hypocalcemia, or undergo thorough bowel cleansing with a rate.treatment in solution that is not fermented.(Fiberall, sodium restriction (sodium phosphate); can becomeKonsyl, managing habit-forming; may result in loss of normal bowel - Do not use with other laxatives with lactulose,Metamucil, Lubricanthepaticfunction (senna); use with caution in renal especially during the initial stages of treatmentPerdiem) laxatives: encephalopathy insufficiency) (magnesium hydroxide); may decreasefor portal-systemic encephalopathy. increase (lactulose)absorption of fat-soluble vitamins; lipid pneumonia - Monitor electrolytes with sodium phosphate water may result from aspiration (mineral oil); consume a use.Lubricantretention infull glass (240 ml) of fluids with each doselaxatives: stools, - Urine or colonic mucosal discoloration may (methylcellulose and psyllium); altered fluid and prevent water result from use of senna compounds. electrolyte balance possible; use with caution in renalmineral oil (Fleet absorptioninsufficiency (magnesium citrate); if used with milk, - If used with magnesium hydroxide, decreasedmineral oilfrom stools,antacids, H2-receptor antagonists, or proton pump effect of benzodiazepines, corticosteroids,enema, and lubricate inhibitors, then gastric irritation or dyspepsia possible digoxin, hydantoins, iron, nitrofurantoin,Kondremul) and soften(bisacodyl) phenothiazines, tetracyclines, histamine H2- intestinalreceptor antagonists, but increased effects of Side effects: nausea, vomiting, and abdominal contents. dicumarol, quinindine, and sulfonylureas.Hyperosmotic cramping; esophageal obstruction or intestinal obstruction (bulk-forming laxatives); lipid pneumonia - Magnesium hydroxide may later fluid andlaxatives: Hyperosmoticand nutritional deficiencies (lubricant laxatives); electrolyte balance. laxatives:cramps, distention, flatulence and belching (osmotic- Surfactants, including docusate, may facilitatelactuloseincreaselaxatives); dehydration and electrolyte imbalancesabsorption of mineral oil, increasing toxicity of(Cephulac, water content (saline cathartic laxatives); possible permanent loss mineral oil.Chronulac) of stools and of colonic motility, laxative dependence, and - Avoid use of milk, antacids, H2-receptor soften stools;electrolyte imbalances with long-term use or abuse of antagonists, or proton pump inhibitors 1 to 2 lactulose alsolaxatives.hours before taking bisacodyl.Saline catharticlaxatives: inhibits - Swallow bisacodyl tablets whole. diffusion of ammoniamagnesiumfrom thecitratecolon into the blood, reducingmagnesium serumhydroxide (Milk ammoniaof Magnesia) levels in patients withmagnesiumliversulfatedysfunctionpolyethylene Saline12/24/2012 Page 13 of 16 14. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients andMajor EffectsMajor Uses Contraindications, Precautions, and Side Effects Drug Interactions and Other NotesDrug Nameglycol and catharticelectrolytes laxatives:(GoLYTELY, draw waterHalfLytely,into theMiraLax) bowel, increasing the bulk ofsodium intestinalphosphates contents and(sodiumstimulatingphosphate andperistalsis.sodiumbiphosphate[Fleet Phophso-Stimulantsoda]) laxatives: stimulates peristalsisStimulantand inhibitlaxatives: water and electrolytebisacodylreabsorption(Dulcolax) from intestine.cascara sagradaStool softeners: allow morecastor oil fluid and fat to penetrateglycerin feces.suppositoriesProducing a softer fecal mass.senna (Senokot)Stool softeners:docusate calcium(Surfak)docusatepotassium,docusate sodium12/24/2012Page 14 of 16 15. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major Uses Contraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug Name(Colace, Peri-Colace)Class Block 5-HT3 - Treatment of Contraindications: Contraindicated in constipation, - Absorption: orally absorbed(serotonin) severe diarrhea- hypersensitivity to alosetron, abnormal GI anatomy,Information: - Distribution: widely distributedreceptors inpredominanthistory of Crohns disease, ulcerative colitis or5-HT3-receptor diverticulitis- Metabolism: metabolized in the liverGI tract, irritable bowelantagonistsPrecautions: serious adverse reactions have - Excretion: excreted in urine and bilethereby syndrome (IBS)increasingin females occurred in patients taking the drug; the drug - Use with other drugs that decrease GI motilityalosetron colonic transitmay be prescribed only by practitioners- Not intended for may worsen constipation(Lotronex)time and registered in the prescribing program with thefemales with manufacturer; patents must sign a practitioner- - Explain to the patient that she/he must signdecreasing GI anatomic orpatient agreement before taking the drug. and follow the practitioner-patient agreementmotility; may biochemical GI while taking alosetron.also decrease tractSide effects: anxiety, tremors, headache, sweating,perception ofabdominal pain, nausea, constipation, and fatigue.- Monitor for adverse reactions.abnormalities;pain andalso not intendedSerious, potentially fatal GI complications, including- Teach the patient the signs and symptoms ofdiscomfort in as first-line drug ischemic colitis, and serious complications ofpossible adverse effects, includingGI tract.constipation (such as obstruction, perforation, and constipation, ischemic colitis, intestinal toxic megacolon)obstruction, and perforation.Class Reduces - Ulcerative colitisContraindications: Hypersensitivity to - Absorption: absorbed in small and largeinflammation sulfasalazine, its metabolites, sulfonamides, orintestineInformation:- Rheumatoidin the salicylatesl intestinal or urinary obstruction, porphyriaUlcerativearthritis(sulfasalazine); hypersensitivity to salicylates- Distribution: crosses placenta; enters breastcolon(sulfasal(sulfasalazine)milkcolitis(olsalazine); hypersensitivity to salicylates, productazine)medicationscomponents or metabolites (balsalazide);- Metabolism: metabolized in the liver hypersensitivity to salicylates of any components of- Excretion: excreted in urineReducesmesalamine.sulfasalazine- Evaluate renal function prior to delayed-inflammation Precautions: associated with deaths due to(Azulfadine) release or controlled-release mesalamine usepossibly byhypersensitivity reactions, agranulocytosis, aplasticblocking and periodically thereafter. anemia, renal or hepatic injury, neuromuscular orolsalazinecyclooxygena CNS changes, or fibrosing alveolitis; critically- Swallow delayed-release mesalamine tablets(Dipentum)se and appraise need for drug if blood dyscrasia or renal or whole without breaking the outer coating.inhibiting hepatic impairment; if pregnant use only if clearly - Use of olsalazine with warfarin may result inprostaglandinneeded; use with caution if breast-feedingincreased PT.balsalazide production (sulfasalazine); nephrotoxicity, diarrhea, or - Monitor renal function of the patient on(Colazal) (olsalazineexacerbation of colitis symptoms possible; if pregnantolsalazine if patient has history of renalanduse only if benefit outweighs risk to fetus; use with disease.mesalaminemesalamine)caution if breast-feeding (olsalazine); exacerbation of colitis symptoms, nephrotoxicity possible; use- Take olsalazine with food in evenly divided(Pentasa) cautiously if renal impairment or history of renaldoses.Reduces disease; potential for prolonged drug capsule gastric - Use of balsalazide with antibiotics may resultinflammation retention in pyloric stenosis; if pregnant, use only if in interference with colonic drug release.possibly by clearly needed, encephalopathy, diarrhea, - Safety and efficacy of balsalazide beyond 12blocking hypermagnesemia if renal failure (balsalazide); weeks therapy have not been established.12/24/2012Page 15 of 16 16. GASTROINTESTINAL MEDICATIONS GASTROINTESTINAL CORE GUIDE NURSING EDUCATION MODULEGenericIngredients and Major Effects Major Uses Contraindications, Precautions, and Side EffectsDrug Interactions and Other NotesDrug Nameproduction ofhypersensitivity reaction possible; if hepatic- Sulfasalazine use with digoxin or folic acid maycolonicimpairment, use delayed-release or controlled-result in decreased levels of digoxin or folicarachidonicrelease drug with caution; if pyloric stenosis, acid.acid prolonged delayed-release gastric retention and delayed colonic drug release possible; associated - Sulfasalazine use with cyclosporine may result with abdominal pain, cramping, and bloody diarrheain decreased cyclosporine levels and on initiation of drug; if pregnant, use only if clearly increased risk of nephrotoxicity. needed, use with caution in breast-feeding- Sulfasalazine use with methotrexate may (mesalamine). result in increased risk of bone marrow Side effects: anorexia, headache, nausea, vomiting, suppression. gastric distress, arthritis (sulfasalazine); diarrhea,- Sulfasalazine use with sulfonylureas or abdominal pain, rash, itching, nausea, arthralgia warfarin may result in enhanced sulfonylurea (olsalazine); dyspepsia, rash, constipation, pruritus,or warfarin effects. insomnia, conjunctivitis, arthritis (mesalamine); - Sulfasalazine use with azathioprine or headache, abdominal pain, diarrhea, nausea, mercaptopurine may result in increased risk of vomiting, arthralgia, respiratory tract infection leukopenia. (balsalazide). - Assess CBC and liver function tests before starting sulfasalazine and per schedule thereafter. - Assess urinalysis and renal function periodically during sulfasalazine treatment. - Discontinue use of delayed-release sulfasalazine tablets if they pass un- disintegrated. - Swallow enteric-coated tablets whole and take sulfasalazine in evenly divided doses, preferably after meals. - Apprise patients that sulfasalazine may induce an orange-yellow discoloration of skin or urine.12/24/2012Page 16 of 16