Gastrointestinal Elimination
7.5 Anti-Ulcer Medications
Hyperacidity Medication Classes
There are four major classes of medications used to treat hyperacidity conditions: antacids, H2-receptor antagonists, proton pump inhibitors, and mucosal protectants. Each class of medication is further described below.
As part of the administration of anti-ulcer medications, nurses should record abdominal assessments and bowel patterns. During therapy, the nurse should continue to assess for potential medication interactions and side effects and be aware that vitamin B12 malabsorption may occur whenever stomach acidity levels are altered.
Other interventions to prevent hyperacidity can also be recommended, such as smoking cessation and avoiding food and beverages that can cause increased acidity (alcohol, high-fat or spicy foods, and caffeine). [1][2][3][4]
Antacids
Indications
Antacids (see Figure 7.5a)[5]) reduce the symptoms of heart burn.
Mechanism of Action
Neutralize stomach acid
Specific Administration Considerations
There are many OTC medications available for this purpose, such as calcium carbonate, aluminum hydroxide, and magnesium hydroxide. Calcium carbonate is the prototype discussed as an example. Many antacids also contain simethicone, an antiflatulent used for gas relief. Simethicone is further described in the medication grid below. In general, clients should be reminded to take OTC meds appropriately as prescribed and should not exceed the maximum dose.
Client Teaching & Education
Be sure to read drug label information regarding antacids as you administer them because each type has its own specific side effects.
H2-Receptor Antagonist
A common H2-receptor antagonist is famotidine (see Figure 7.5b).[6] It is available OTC and is also often prescribed orally or as an IV injection in the hospital setting. Other H2-receptor antagonists include cimetidine and ranitidine. Cimetidine has a high risk of drug interactions, especially in elderly clients because of its binding to cytochrome P-450 enzymes in the liver, which affects the metabolism of other drugs.
Indications
Famotidine is used to treat GERD, peptic ulcer disease, erosive esophagitis, and hypersecretory conditions, or as an adjunct treatment for the control of upper GI bleeding. OTC famotidine is also used to treat heartburn or sour stomach.
Mechanism of Action
H2-receptor antagonists block histamine’s action at the H2 receptor of the parietal cell, thus reducing the production of hydrochloric acid.
Specific Administration Considerations
To prevent symptoms, oral famotidine is taken 15 to 60 minutes before eating foods or drinking drinks that may cause heartburn. Preexisting liver and kidney disease may require dosage adjustment. Famotidine is supported by evidence as safe for use in pediatric clients younger than 1 year old, as well as in geriatric clients.[7]
Client Teaching & Education
Clients taking the oral suspension should be instructed to shake it vigorously for 5 to 10 seconds prior to each use.[8][9] The medication may cause constipation, so fluids and a high-fiber diet should be encouraged. Additionally, smoking interferes with histamine antagonists and should be discouraged.[10][11]
Proton Pump Inhibitors
A common proton pump inhibitor (PPI) is pantoprazole (see Figure 7.5c[12]). It may be prescribed in various routes including orally, with an NG tube, or as an IV injection in the hospital setting. Other PPIs include esomeprazole, lansoprazole, and omeprazole. PPIs are more powerful than antacids and H2-receptor antagonists.
Indications
Pantoprazole is used to treat damage from gastroesophageal reflux disease (GERD) in adults and children five years of age and older by allowing the esophagus to heal and prevent further damage. It is also used to treat conditions where the stomach produces too much acid, such as Zollinger-Ellison syndrome in adults. PPIs may also be given in combination with antibiotics to treat H.Pylori infections, a common cause of duodenal ulcers.
Mechanism of Action
PPIs bind to the hydrogen-potassium ATPase enzyme system of the parietal cell, also referred to as the “proton pump” because it pumps hydrogen ions into the stomach. PPIs inhibit the secretion of hydrochloric acid, and the antisecretory effect lasts longer than 24 hours.
Specific Administration Considerations
Packets of delayed-release granules must be mixed with applesauce or apple juice and taken by mouth or given through a feeding tube. Consult the labeling of concomitantly used drugs to obtain further information about interactions because PPIs can interfere with the liver metabolism of other drugs. IV pantoprazole can potentially exacerbate zinc deficiency, and long-term therapy can cause hypomagnesemia, so the nurse should monitor for these deficiencies. [13]
Client Teaching & Education
In addition to the considerations above, instruct clients to call their provider if their condition does not improve or gets worse, especially if bleeding occurs.[14][15] Use of alcohol, NSAIDS, or foods that cause GI irritation should be discouraged.[16][17]
Mucosal Protectants
Sucralfate is a mucosal protectant used to cover and protect gastrointestinal ulcers.
Indications
Used in the treatment of ulcers.
Mechanism of Action
Sucralfate locally covers the ulcer site in the GI tract and protects it against further attack by acid, pepsin, and bile salts. It is minimally absorbed by the gastrointestinal tract.
Specific Administration Considerations
Administer sucralfate on an empty stomach, 2 hours after or 1 hour before meals. Constipation may occur. Sucralfate should be cautiously used with clients with chronic renal failure or those receiving dialysis due to impaired excretion of small amounts of absorbed aluminum that can occur with sucralfate.
Client Teaching & Education
In addition to the considerations above, instruct clients to call their provider if their condition does not improve or gets worse.[18][19][20][21]
Antiflatulent
Simethicone is an antiflatulent that is commonly found in other OTC antacids (see Figure 7.5d[22]). It is also safe for use in infants. Gas commonly occurs in the GI tract due to digestive processes and the swallowing of air. Gaseous distension can also occur postoperatively.
Indications
Simethicone is used to treat the symptoms of gas such as uncomfortable or painful pressure, fullness, and bloating.
Mechanism of Action
Simethicone works by altering the elasticity of the mucous-coated gas bubbles, which cause them to break into smaller bubbles, thus reducing pain and facilitating expulsion.
Specific Administration Considerations
Simethicone is usually taken four times a day, after meals and at bedtime. For liquid form, shake drops before administering.
Client Teaching & Education
Clients can be instructed about other measures to assist with gas expulsion such as changing position, ambulation, avoiding the use of straws, and tapering intake of beans and cruciferous vegetables. [23],[24][25][26]
Interactive Activity
Now let’s take a closer look at the medication grids comparing medications used to treat hyperacidity in Table 7.3a.[27][28],[29] [30]
Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below. Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med. On the home page, enter the drug name in the search bar to read more about the medication.
Medication Card 7.5: Comparing Hyperacidity Medications[31][32][33][34][35]
Generic Prototype (Brand)
- Antacid
- H2 blocker
- Proton Pump Inhibitor
- Mucosal protectants
- Anti-flatulent
Mechanism
- Antacid
- Neutralizes hydrochloric acid in gastric secretions.
- H2 blocker
- Inhibits H2- receptors and therefore inhibits gastric secretion
- Proton Pump Inhibitor
- Suppresses the final step in gastric acid production
- Mucosal protectants
- Creates protective barrier to pepsin and bile, inhibits diffusion of gastric acid.
- Anti-flatulent
- Changes surface tension of gas allowing for easier elimination
Indication & Therapeutic Effect
- Antacid
- Decreased symptoms of heartburn
- H2 blocker
- GERD
- Gastric and duodenal ulcer
- Heartburn
- Proton Pump Inhibitor
- GERD
- Mucosal protectants
- Gastric and duodenal ulcer
- Prevents recurrence of ulcers
- Anti-flatulent
- Relief of gas discomfort
Contraindications
- Antacid
- Drug interaction with ceftriaxone
- High calcium and low phosphate levels.
- Kidney stones
- H2 blocker
- Hypersensitivity to H2-receptor antagonists.
- Proton Pump Inhibitor
- Concurrent infection with clostridium difficile bacteria
- Osteoporosis
- Interstitial nephritis
- Mucosal protectants
- Hypersensitivity
- End stage renal disease
- Anti-flatulent
- Hypersensitivity
Side Effects
- Antacid
- Constipation
- Hypercalcemia
- Rebound hyperacidity when discontinued
- H2 blocker
- headache, dizziness, constipation, and diarrhea
- Immediately report increased pain or signs of bleeding (coughing/ vomiting of blood)
- Proton Pump Inhibitor
- Anaphylaxis and serious skin reactions
- Zinc, magnesium, or B12 deficiency
- Headache, abdo pain, diarrhea, constipation
- Renal dysfunction
- OP- bone fracture
- Mucosal protectants
- Constipation
- Hyperglycemia
- Several drug interactions
- Anti-flatulent
- Diarrhea, nausea, vomiting, headache
Administration and Nursing Considerations
- Antacid
- Don’t admin within 1-2 hrs of other meds
- Drink a full glass of water after admin
- Use cautiously with renal disease
- H2 blocker
- Give 15 to 60 mins before foods or drink
- Adjust dosage for pre-existing liver and kidney disease
- Report any signs of GI bleed
- Proton Pump Inhibitor
- Delayed release
- Can be taken with or without food
- Report any signs of GI bleed.
- Mucosal protectants
- Administer on an empty stomach, 2 hrs after or 1 hr before meals
- Use cautiously used clients with chronic renal failure
- Anti-flatulent
- Shake drops before administering
A client who recently underwent surgery has a medication order for daily pantoprazole. The nurse reviews the client’s medical history and finds no history of GERD or peptic ulcer disease. The client does not report any symptoms of heartburn, stomach pain, or sour stomach. The nurse reviews the physician’s orders for an indication for this medication before calling the provider to clarify.
What is the likely indication for this drug therapy for this client?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.
- Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 443-454. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https://medlineplus.gov/ency/anatomyvideos/000068.htm ↵
- "Antacid-L478.jpg" by Midnightcomm is licensed under CC BY-SA 3.0 ↵
- "My Still LIfe" by Bast Productions is licensed under CC BY-NC-ND 2.0 ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 443-454. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https://medlineplus.gov/ency/anatomyvideos/000068.htm ↵
- "Prilosec Box 001" by cygnus921 is licensed under CC BY 2.0 ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 443-454. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27; https://medlineplus.gov/ency/anatomyvideos/000068.htm ↵
- Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A Patient-Centered Nursing Process Approach. p.188-194 and 604-633. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https://medlineplus.gov/ency/anatomyvideos/000068.htm ↵
- "Gelusil Antacid and Anti-Gas" by Wellspring Pharmaceutical is licensed under CC BY 2.0 ↵
- Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 443-454. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https://medlineplus.gov/ency/anatomyvideos/000068.htm ↵
- Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 443-454. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https://medlineplus.gov/ency/anatomyvideos/000068.htm ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- RNPedia. (2021). https://www.rnpedia.com ↵
- DailyMed from US National Library of Medicine. www.dailymed.com ↵
- OpenMD.Com at openmd.com ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
Used to neutralize stomach acid and reduce the symptoms of heartburn.
Enzymes produced from the cytochrome P450 genes involved in the formation (synthesis) and breakdown (metabolism) of various molecules, chemicals, and medications within cells.
Binds to the hydrogen-potassium ATPase enzyme system of the parietal cell and inhibit the release of hydrogen ions into the stomach.