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Chapter 22: Respiratory and Gastrointestinal Drugs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Chapter 22 Outline Respiratory and gastrointestinal (GI) drugs Respiratory drugs Drugs used to treat respiratory diseases GI drugs Drugs used to treat GI diseases Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 2 Respiratory and Gastrointestinal Drugs Haveles (pp. 276-277) (Fig. 22-1) Medications given to treat these diseases can affect dental treatment The dental health care worker should be aware of The effect of these drugs on the patient How these drugs may alter the treatment plan Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 3 Respiratory Drugs Haveles (pp. 276-277) (Fig. 22-2) Respiratory diseases treated include asthma, chronic obstructive pulmonary disease (COPD), and upper respiratory tract infections Treated with a wide range of drug groups, from adrenergic drugs for bronchodilation to corticosteroids for reducing inflammation Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 4 Respiratory Diseases Noninfectious respiratory diseases are divided into asthma and COPD Haveles (pp. 276-277) COPD is divided further into chronic bronchitis and emphysema Other respiratory problems are related to viral or bacterial respiratory infections Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 5 Asthma Haveles (pp. 276-277) Characterized by reversible airway obstruction and associated with a reduction in expiratory airflow May be precipitated by allergens, pollution, exercise, stress, or upper respiratory tract infection In status asthmaticus, patients have persistent lifethreatening bronchospasm despite drug therapy Signs of asthma include shortness of breath and wheezing Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 6 Chronic Obstructive Pulmonary Disease Haveles (p. 278) Irreversible airway obstruction; occurs with either chronic bronchitis or emphysema Chronic bronchitis is a result of chronic inflammation of the airways and excessive sputum production Emphysema is characterized by alveolar destruction with airspace enlargement and airway collapse cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 7 Chronic Obstructive Pulmonary Disease For a normal person, breathing is stimulated by elevated partial pressure of carbon dioxide (PaCO2) For a person with COPD, breathing is stimulated by a decrease in partial pressure of oxygen (PaO2) If this person is given oxygen, the stimulus to breathing may be removed, and the possibility of inducing apnea occurs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 8 Drugs Used to Treat Respiratory Diseases Haveles (pp. 279-283) Metered-dose inhalers Sympathomimetic agents Corticosteroids Leukotriene modifiers Methylxanthines Anticholinergics Anti–immunoglobulin E (IgE) antibodies Agents used to manage upper respiratory tract infections Dental implications of the respiratory drugs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 9 Metered-Dose Inhalers Haveles (p. 279) (Fig. 22-5) Advantages include It delivers medication directly into the bronchioles Bronchodilator effect is greater than comparable oral dose Inhaled dose can be accurately measured Rapid and predictable onset of action Compact, portable, and sterile Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 10 Sympathomimetic Agents Produce bronchodilation by stimulation of βreceptors in the lungs Haveles (p. 279) β-Receptor activation results in accumulation of cyclic adenosine monophosphate (cAMP) in smooth muscles, producing a reduction in cytoplasmic calcium concentration and relaxation of smooth muscle Selective β2-agonists produce bronchodilation with fewer cardiac side effects Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 11 Short-Acting β2-Agonists Have specificity for the respiratory tree Haveles (p. 279) (Fig. 22-3; Table 22-1) Side effects include nervousness, tachycardia, and insomnia Short-acting β2-agonists such as albuterol, may be administered by inhalation or orally The first line of treatment for mild occasional asthma is a short-acting β2-agonist Short-acting β2-agonists are the drug of choice for the emergency treatment of an acute asthma attack cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 12 Short-Acting β2-Agonists Haveles (p. 279) (Fig. 22-3) Recent studies have found that overuse results in airway hyperresponsiveness and a decrease in the lung’s response to them Many asthmatics rely on the albuterol inhaler and omit using the steroid inhaler Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 13 U.S. Food and Drug Administration (FDA)-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Adrenergic agonists (inhaler) β2-Agonist Short-acting; used for an acute attack • albuterol (Proventil, Ventolin) • metaproterenol (Alupent, Metaprel) • levalbuterol (Xopenex HFA) • pirbuterol (Maxair Autohaler) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 14 Long-Acting β2-Agonists Haveles (pp. 279-280) (Fig. 22-1) A newer long-acting β2-agonist is salmeterol (Serevent) Onset is delayed and duration of action is sustained Not used for management of an acute asthmatic episode Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 15 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Adrenergic agonists (inhaler) β2-Agonist Long-acting • salmeterol (Serevent Diskus) • formoterol (Foradil Aerolizer) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 16 Corticosteroids Typical side effects seen with corticosteroid therapy do not occur with topical aerosol administration Haveles (p. 281) Patients have a significant improvement in pulmonary function with a decrease in wheezing, tightness, and cough Reduce inflammation, secretions and swelling in the lungs after an asthma attack Prolonged inhalation may cause candidiasis Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 17 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Adrenergic agonists (inhaler) Corticosteroids Corticosteroids, inhaled • beclomethasone (QVAR) • budesonide (Pulmicort) • ciclesonide (Alvesco) • flunisolide (AeroBid) • fluticasone (Flovent HFA) • mometasone furoate (Asmanex Twisthaler) • triamcinolone (Azmacort) cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 18 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Adrenergic agonists (inhaler) Corticosteroids Corticosteroids, oral • prednisone (Deltasone, Meticorten)[PO] cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 19 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Adrenergic agonists (inhaler) Inhaled corticosteroids/long-acting β2-agonists Corticosteroid/β2-agonist • fluticasone/salmeterol (Advair HFA) • budesonide/formoterol (Symbicort HFA) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 20 Leukotriene Modifiers Haveles (pp. 281-282) Overview: leukotrienes (LTs) are produced by inflammatory cells and produce bronchoconstriction, increased mucus secretion, mucosal edema, and increased bronchial hyperreactivity Leukotriene pathway inhibitors block the effects of the release of LTs Used to manage asthma not controlled by β2-agonists and corticosteroid inhalers cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 21 Leukotriene Modifiers Adverse reactions include irritation of stomach mucosa, headache, and alteration of liver function tests Zafirlukast has an interaction with erythromycin and aspirin • Increases the effect of warfarin Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 22 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) LT antagonists LT pathway antagonist • zafirlukast (Accolate) (PO) • montelukast (Singulair) LT pathway synthesis inhibitor (LPI) • zileuton (Zyflo) (PO) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 23 Cromolyn Haveles (p. 282) Used only for prophylaxis of asthma and not an acute asthma attack Prevents the antigen-induced release of histamine, LTs, and other substances from sensitized mast cells The least toxic of all asthma medications May be used prophylactically by patients with chronic asthma or taken before exercise-induced asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 24 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Mast cell degranulation inhibitors Mast cell stabilizers • cromolyn (Intal) (Nasalcrom) IH • nedocromil (Tilade) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 25 Methylxanthines Consist of theophylline, caffeine, and theobromine Haveles (p. 282) Theophylline is used to treat chronic asthma and the bronchospasm associated with chronic bronchitis and emphysema Mechanism of action of xanthines is complex Involves antagonism of the receptor mediated action of adenosine, inhibition of cyclic nucleotide phosphodiesterase, mobilization of intracellular calcium pools, protein kinase activity modulation, and inhibition of prostaglandins (PGs) cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 26 Methylxanthines Side effects include central nervous system (CNS) stimulation, cardiac stimulation, increased gastric secretion, and diuresis Erythromycin can increase the serum levels of theophylline Intravenous aminophylline and rapidly absorbed oral liquid preparations are used to manage acute asthmatic attacks and status asthmaticus Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 27 FDA-Approved Drugs Used to Manage Asthma Haveles (p. 280) (Table 22-1) Methylxanthines Methylxanthines • theophylline (Theo-Dur, Slo-Bid) (PO) • aminophylline-theophylline ethylene diamine Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 28 Anticholinergics Haveles (p. 282) Atropine is an old remedy for asthma; newer anticholinergics have fewer side effects; ipratropium (Atrovent) has several advantages over atropine Low lipid solubility limits its bioavailability and makes it bronchoselective, with minimal side effects The drug of choice for long-term management of COPD; also for patients with poorly controlled asthma or those who do not tolerate the side effects of β-agonists Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 29 Anti–Immunoglobulin E Antibodies Haveles (p. 282) omalizumab (Xolair) is the first in a new class of medications introduced to treat asthma due to allergens A recombinant humanized monoclonal antibody Prevents IgE from binding to mast cells and basophils Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 30 Agents Used to Manage Upper Respiratory Tract Infections Haveles (pp. 282-283) Nasal decongestants Expectorants and mucolytics Antitussives Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 31 Nasal Decongestants Haveles (pp. 44, 282) (Table 4-5) Adrenergic agonists that act by constricting blood vessels in nasal mucous membranes Chronic use may result in rebound swelling and congestion • phenylephrine (Neo-Synephrine, Sinex, Allerest) (α) is used topically as a nasal spray • phenylpropanolamine is used systemically as a decongestant (α-agonist action) • pseudoephedrine (Sudafed, Sucrets, in Actifed) (α/β) is used systemically Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 32 Expectorants and Mucolytics Haveles (pp. 282-283) Expectorants promote removal of exudate or mucus from respiratory passages Liquefying expectorants decrease the viscosity of mucus Mucolytics destroy or dissolve mucus Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 33 Antitussives Haveles (p. 283) May be opioids or related agents used for symptomatic relief of nonproductive cough Codeine-containing cough preparations are commonly used, but their histamine-releasing properties may precipitate bronchospasm Dextromethorphan, an opioid-like compound, suppresses the cough reflex by its direct effect on the cough center • It does not cause release of histamine Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 34 Dental Implications of the Respiratory Drugs Haveles (p. 283) (Box 22-1) About 10% of the population has some form of pulmonary disease With severe COPD, a person can develop pulmonary hypertension, increasing the risk for cardiac arrhythmias Stress should be minimized and adrenal supplementation instituted if the patients are taking certain doses of steroids and the procedure is likely to produce severe stress Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 35 Gastrointestinal Drugs Haveles (pp. 283-288) Both over-the-counter and prescription drugs are used for GI diseases Some are used for specific diseases, others are for symptomatic relief Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 36 Gastrointestinal Diseases Haveles (p. 283) Ulcers and gastroesophageal reflux disease (GERD) are common GI diseases The GI tract is highly susceptible to emotional changes because it is innervated by the vagus nerve associated with the autonomic nervous system Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 37 Gastroesophageal Reflux Disease Haveles (p. 283) GERD, or “heartburn,” is the most prevalent GI disease in the U.S. population Stomach contents flow back up into the esophagus Irritation, inflammation, and erosion can occur cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 38 Gastroesophageal Reflux Disease Treated by decreasing the acid in the stomach or by constricting the cardiac sphincter Histamine2 (H2)-blockers and proton-pump inhibitors (PPIs) reduce or eliminate stomach acid GI stimulants increase the tone in the cardiac sphincter Antacids are used for relief of acute symptoms Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 39 Ulcers Haveles (pp. 283-284) May occur in the stomach or small intestine Most ulcers are related to the presence of Helicobacter pylori • Many can be cured by using a combination of one or more antibiotics and an H2-blocker or a PPI to reduce the stomach acid Some are related to chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) because NSAIDs inhibit synthesis of PGs, which are cytoprotective to the stomach • Treatment is a PG (PGE2α) misoprostol (Cytotec) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 40 Drugs Used to Treat Gastrointestinal Diseases Haveles (pp. 284-288) H2-blocking agents PPIs Mixed antiinfective therapy for ulcer treatment Antacids Miscellaneous GI drugs Laxative and antidiarrheals Antiemetics Agents used to manage chronic inflammatory bowel disease Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 41 Histamine2-Blocking Agents Haveles (p. 284) (Table 22-2) Block and inhibit gastric acid secretion by competitive inhibition of histamine at the H2receptors of parietal cells cimetidine (Tagamet) is the prototype Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 42 Uses of Cimetidine Haveles (pp. 284-285) Indicated for treatment of ulcers and management of symptoms of ulcers and GERD Antacids inhibit absorption and should not be administered within 1 hour of H2-blockers Cimetidine is also used as an adjunct in management of urticaria Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 43 Adverse Reactions of Cimetidine Haveles (p. 285) Side effects include CNS effects such as slurred speech, delusions, confusion, and headache Cimetidine binds with androgen receptors; ranitidine and famotidine have not been found to possess antiandrogenic activity Cimetidine inhibits liver microsomal enzymes responsible for hepatic metabolism of some drugs (cytochrome P-450 oxidase system), resulting in a delay in elimination and an increase in serum levels of some drugs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 44 Dental Drug Interactions of Cimetidine Metabolism of these may be reduced by cimetidine Haveles (p. 285) Ketoconazole and itraconazole: concurrent administration with H2-receptor antagonists may result in a marked reduction of absorption Alcohol: cimetidine may raise blood alcohol level if the person has ingested alcoholic beverages Benzodiazepines: metabolism may be slower Other H2-receptor antagonists Other H2-blockers are unlikely to produce important dental drug interactions Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 45 Drugs Used to Treat Peptic Ulcer Disease and Gastroesophageal Reflux Disease Haveles (p. 284) (Table 22-2) Acid reducers H2-blockers • cimetidine (Tagamet) • famotidine (Pepcid) • ranitidine (Zantac) • nizatidine (Axid) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 46 Proton-Pump Inhibitors Haveles (p. 285) omeprazole (Prilosec) was the first PPI marketed and is the prototype Inhibitor of gastric acid secretion, heals both gastric and duodenal ulcers, and is approved for GERD Inhibits the H+/K+ ATPase enzyme system at the surface of the gastric parietal cell Side effects of omeprazole include headache and abdominal pain Mucosal atrophy of the tongue and dry mouth have been reported Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 47 Drugs Used to Treat Peptic Ulcer Disease and Gastroesophageal Reflux Disease Haveles (p. 284) (Table 22-2) Acid reducers PPIs • omeprazole (Prilosec) • lansoprazole (Prevacid) • esomeprazole (Nexium) • pantoprazole (Protonix) • rabeprazole (AcipHex) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 48 Mixed Antiinfective Therapy for Ulcer Treatment Haveles (p. 285) To treat ulcers, a combination of two or three antiinfective agents, an acid reducer, an H2blocker or a PPI, and bismuth subsalicylate (Pepto-Bismol) may be used Newer combinations often use one antibiotic and a PPI, such as esomeprazole and clarithromycin Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 49 Antacids Haveles (pp. 285-286) Acute gastritis (heartburn) and symptoms of ulcers are sometimes managed with antacids Partially neutralize hydrochloric acid in the stomach By raising the pH to 3 or 4, the erosive effect of the acid is decreased and pepsin activity is reduced cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 50 Antacids Classified as systemic or nonsystemic, depending on the amount of absorption from the GI tract Sodium bicarbonate is the only systemic antacid • Alkalosis can occur • It also contains sodium and is contraindicated in cardiovascular patients who are to minimize sodium intake Active ingredients in nonsystemic antacids include calcium carbonate, aluminum and magnesium salts, and magnesium-aluminum hydroxide gels Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 51 Drugs Used to Treat Peptic Ulcer Disease and Gastroesophageal Reflux Disease Haveles (p. 284) (Table 22-2) Antacids Sodium bicarbonate Magnesium hydroxide Aluminum hydroxide Calcium carbonate Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 52 Miscellaneous Gastrointestinal Drugs misoprostol (Cytotec) is prostaglandin PGE2α and is indicated for NSAID-induced ulcers Haveles (p. 286) Increases gastric mucus and inhibits gastric acid secretion sucralfate (Carafate): used to treat duodenal ulcers Combines with proteins, forming a complex that binds preferentially with the ulcer site cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 53 Miscellaneous Gastrointestinal Drugs Haveles (p. 286) metoclopramide (Reglan): a dopaminergic antagonist Facilitates cholinergic effects in the GI tract Stimulates motility of upper GI tract without stimulating secretions Increases motility in the duodenum and results in accelerated gastric emptying time simethicone (Mylicon, Gas-X): used to relieve flatulence Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 54 Laxatives and Antidiarrheals Haveles (pp. 286-287) Laxatives: indicated for short-term, occasional use for constipation and before diagnostic procedures (barium enema) Bulk laxatives: contain polysaccharides or cellulose derivatives that combine with intestinal fluids to form gels Lubricants: mineral oil is no longer recommended; can be absorbed and interfere with absorption of fat-soluble vitamins Stimulants: produce local irritation of intestinal mucosa Stool softeners (emollients): wets and softens stool by accumulating water in the intestine Osmotic (saline) laxatives: osmotically hold water Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 55 Drugs Used to Treat Peptic Ulcer Disease and Gastroesophageal Reflux Disease Haveles (p. 284) (Table 22-2) Laxatives Bulk • psyllium seed (Metamucil) • carboxymethylcellulose • methylcellulose (Citrucel) • polycarbophil (FiberCon) Stool softeners, emollient • docusate (dioctyl sodium sulfosuccinate, DSS, Colace) cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 56 Drugs Used to Treat Peptic Ulcer Disease and Gastroesophageal Reflux Disease Haveles (p. 284) (Table 22-2) Laxatives Stimulants • magnesium hydroxide (Milk of magnesia [MOM]) • bisacodyl (Dulcolax) • cascara sagrada • senna • casanthranol • castor oil • phenolphthalein cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 57 Drugs Used to Treat Peptic Ulcer Disease and Gastroesophageal Reflux Disease Haveles (p. 284) (Table 22-2) Laxatives Hyperosmotic • glycerin • lactulose • salts (magnesium citrate, hydroxide, oxide, or sulfate; sodium phosphate) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 58 Laxatives and Antidiarrheals Haveles (p. 287) Antidiarrheals: either adsorbents or opioidlike drugs, used to minimize fluid and electrolyte imbalances The most common absorbent is kaolin and pectin (Kaopectate) Opioids, such as diphenoxylate with atropine (Lomotil) and loperamide (OTC Imodium), are the most effective antidiarrheal agents • Decrease peristalsis by acting directly on smooth muscle of the GI tract Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 59 Drugs Used to Treat Other Gastrointestinal Disorders Haveles (p. 286) (Table 22-4) Antidiarrheals Opioid-like agents • loperamide (Imodium) • diphenoxylate (in Lomotil) Adsorbents • kaolin and pectin (Kaopectate) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 60 Antiemetics Haveles (p. 287) (Fig. 22-6) Drugs used to induce vomiting and to prevent vomiting are used for certain GI tract problems cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 61 Antiemetics Haveles (p. 287) Ipecac is used to induce vomiting after ingestion of a harmful substance Has been abused by individuals with bulimia Over time, with chronic use, the body becomes resistant to the emetic effect and the ipecac is absorbed Cardiac toxicity produced by retained ipecac has been fatal to patients with bulimia cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 62 Antiemetics Haveles (p. 287) Vomiting may occur due to a variety of situations such as motion sickness, pregnancy, drugs, infections, or radiation therapy Phenothiazines: used to control severe nausea • Side effects include sedation and extrapyramidal symptoms, including tardive dyskinesia • Used in dentistry to treat nausea and vomiting associated with surgery and anesthesia Anticholinergics: can be used for nausea and vomiting associated with motion sickness and labyrinthitis cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 63 Antiemetics Antihistamines: diphenhydramine (Benadryl) , an antihistamine with antiemetic properties, commonly produces sedation • hydroxyzine (Atarax) is used as an antiemetic or antianxiety agent trimethobenzamide (Tigan): has an antiemetic effect mediated through the chemoreceptor trigger zone • Produces sedation, agitation, headache, and dry mouth metoclopramide (Reglan): can control nausea and vomiting of patients receiving cancer chemotherapeutic agents • Also indicated for gastric motility disorders such as diabetic gastric stasis benzquinamide (Emete-Con): has antiemetic, antihistaminic, anticholinergic, and sedative effects • Used to treat nausea associated with anesthesia during surgery Cannabinoids: dronabinol (Marinol) and nabilone (Cesamet) are indicated to treat nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond to conventional antiemetic therapy Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 64 Drugs Used to Treat Other Gastrointestinal Disorders Haveles (p. 286) (Table 22-4) Antiemetics Phenothiazines • prochlorperazine (Compazine) Antihistamines • meclizine (Bonine) • dimenhydrinate (Dramamine) • trimethobenzamide (Tigan) Cannabinoids • dronabinol (Marinol) • nabilone (Cesamet) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 65 Agents Used to Manage Chronic Inflammatory Bowel Disease (IBD) Haveles (p. 288) Divided into ulcerative colitis and Crohn disease; an autoimmune response is thought to be associated with ulcerative colitis Crohn disease extends through all layers of the intestinal wall, whereas ulcerative colitis involves only the mucosa Crohn disease can involve the whole intestine, but the colon is most commonly affected Ulcerative colitis involves the rectum and may involve the distal part of the colon but does not involve the small intestine cont’d… Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 66 Agents Used to Manage Chronic Inflammatory Bowel Disease Haveles (p. 288) Drugs used to treat IBD include laxatives, colonic stimulants, and osmotic agents; indicated for patients who do not respond to fiber supplementation Antidiarrheal agents: also used to treat IBD in patients with diarrhea-predominant irritable bowel syndrome Antispasmodics: best used for acute attacks of abdominal pain or before meals in patients with postprandial symptoms Serotonin 5-hydroxytryptamine modulators: play a major role in the regulation of intestinal motility, secretion, and visceral sensitivity Tricyclic antidepressants: used when diarrhea-persistent IBS is moderate to severe Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 67 Drugs Used to Treat Other Gastrointestinal Disorders Haveles (p. 286) (Table 22-4) Agents in the treatment of IBD Nonaspirin salicylates • sulfasalazine (Azulfidine) • mesalamine (Rowasa, Pentasa, Asacol) • olsalazine (Dipentum) Adrenocorticosteroids • prednisone Immune modifiers • cyclosporine • azathioprine • mercaptopurine (6-MP, Purinethol) Antibiotics • metronidazole (Flagyl) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 68