gastrointestinal pharmacotherapy.ppt final
DESCRIPTION
Lecture to physical therapy studentsTRANSCRIPT
Gastrointestinal Gastrointestinal PharmacotherapyPharmacotherapy
Sarah Nelson, Pharm.D.Sarah Nelson, Pharm.D.
March 3, 2009March 3, 2009
ObjectivesObjectives
Discuss the process of acid secretion Discuss the process of acid secretion in the gastrointestinal tractin the gastrointestinal tract
Differentiate medications used to Differentiate medications used to suppress gastric acid secretionsuppress gastric acid secretion
Explain the role of gastrointestinal Explain the role of gastrointestinal motility in disease statesmotility in disease states
Differentiate medications used to Differentiate medications used to account for impaired account for impaired gastrointestinal motilitygastrointestinal motility
Gastrointestinal tractGastrointestinal tract
http://www.nationmaster.com/encyclopedia/Gastrointestinal-tract
Disorders of the Disorders of the Esophagus and Esophagus and StomachStomach Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease
(GERD)(GERD)– Dyspepsia/Non-erosive reflux disease Dyspepsia/Non-erosive reflux disease
(NERD)(NERD)– Esophagitis (erosive)Esophagitis (erosive)
Peptic ulcerationPeptic ulceration– H. pylori associated peptic ulcersH. pylori associated peptic ulcers
Ali, T. Miner, P. New Developments in gastroesophageal reflux disease diagnosis and therapy. Curr Opin in Gastroenterology. 2008;24:502-508
Gastric SecretionGastric Secretion
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Stomach AnatomyStomach Anatomy
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Defense MechanismsDefense Mechanisms
Lower esophageal sphincterLower esophageal sphincter
Secretion of gastric mucusSecretion of gastric mucus– Stimulated by prostaglandin EStimulated by prostaglandin E22 and and
II22
Secretion of bicarbonate ionsSecretion of bicarbonate ions
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
GERDGERD
Definition: when the reflux of Definition: when the reflux of stomach contents causes stomach contents causes troublesome symptoms or troublesome symptoms or complicationscomplications
Diagnosis:Diagnosis:– Presence of symptomsPresence of symptoms– Demonstration of refluxDemonstration of reflux– Identification of existing damage from Identification of existing damage from
refluxrefluxAli, T. Miner, P. New Developments in gastroesophageal reflux disease diagnosis and therapy. Curr Opin in Gastroenterology. 2008;24:502-508
EpidemiologyEpidemiology
44% of adults in the US 44% of adults in the US experience heartburn experience heartburn ≥ 1 ≥ 1 time/monthtime/month
Up to 15-18% of adults in the US Up to 15-18% of adults in the US experience heartburn weeklyexperience heartburn weekly
Heartburn or substernal burning Heartburn or substernal burning is the most commonly recognized is the most commonly recognized manifestation of GERDmanifestation of GERD
Shaheen, N., Ransohoff, D.F. Gastroesophageal Reflux, Barrett Esophagus, and Esophageal Cancer: Scientific Review. JAMA. 2002;287(15):1972-1981
Risk Factors for GERDRisk Factors for GERD
ObesityObesity Food (spicy, chocolate, peppermint)Food (spicy, chocolate, peppermint) AgeAge SmokingSmoking CaffeineCaffeine AlcoholAlcohol PregnancyPregnancy
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
Stages of GERDStages of GERDStageStage DescriptionDescription Medical Medical
ManagementManagementI (NERD)I (NERD) sporadicsporadic
2-3 episodes/wk2-3 episodes/wk
Lifestyle Lifestyle modificationmodificationAntacids/H2 RA as Antacids/H2 RA as neededneeded
II II Frequent Frequent symptomssymptoms+/- esophagitis+/- esophagitis
PPI vs. H2RAPPI vs. H2RA
IIIIII Chronic, Chronic, unrelentingunrelentingImmediate relapse Immediate relapse off therapyoff therapyEsophageal Esophageal complicationscomplications
PPI once or twice PPI once or twice dailydaily
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Treatment of GERDTreatment of GERD
Decrease acidity of stomach Decrease acidity of stomach contentscontents– AntacidsAntacids– H2 receptor antagonistsH2 receptor antagonists– Proton pump inhibitorsProton pump inhibitors
Protect gastric mucosaProtect gastric mucosa– sucralfatesucralfate
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
AntacidsAntacids
Chemically neutralize stomach acidChemically neutralize stomach acid
Base (OH)Base (OH)33 or CO or CO3 3 + Al, Ca, or Mg+ Al, Ca, or Mg
– CaCOCaCO33= calcium carbonate (Tums= calcium carbonate (Tums®)®)
– Al Al (OH)(OH)33 + Mg (OH) + Mg (OH)22 = Maalox = Maalox®®
Some contain simethicone (a Some contain simethicone (a surfactant)surfactant)– Al Al (OH)(OH)33 + Mg (OH) + Mg (OH)22 + simethicone = Mylanta + simethicone = Mylanta®®
Site GI chapter
AntacidsAntacids
Mechanism of Action:Mechanism of Action:
Antacid + HCl Antacid + HCl salt + water salt + water ExamplesExamples
Al(OH)Al(OH)33 + 3 HCl + 3 HCl AlCl AlCl33 + 3H + 3H22OO
CaCOCaCO33 + 2 HCl CaCl + 2 HCl CaCl22 + 2H + 2H220 + CO0 + CO22
Site GI chapter
AntacidsAntacids
Side EffectsSide Effects– Constipation (Al containing products)Constipation (Al containing products)– Diarrhea (Mg containing products)Diarrhea (Mg containing products)– Electrolyte imbalancesElectrolyte imbalances– Decreases absorption of other drugsDecreases absorption of other drugs
Place in TherapyPlace in Therapy– Minor, infrequent dyspepsiaMinor, infrequent dyspepsia– With other acid suppressants on an as With other acid suppressants on an as
needed basisneeded basis– Calcium supplementationCalcium supplementation
Site GI chapter
HH22-Receptor -Receptor AntagonistsAntagonists Block histamine from binding to HBlock histamine from binding to H22
receptors on parietal cellreceptors on parietal cell– Decrease rate of activation by Decrease rate of activation by histamine histamine decreased acid secretiondecreased acid secretion
Blocks basal and bolus acid Blocks basal and bolus acid secretionsecretion– Basal: continuous acid secretionBasal: continuous acid secretion– Bolus: secretion in response to stimuli Bolus: secretion in response to stimuli
(food, etc)(food, etc)Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
HH22-Receptor -Receptor AntagonistsAntagonists Cimetidine (TagametCimetidine (Tagamet®®))
– Not used often due to drug Not used often due to drug interactionsinteractions
Ranitidine (ZantacRanitidine (Zantac®®))– 150-300mg by mouth twice daily150-300mg by mouth twice daily
Famotidine (PepcidFamotidine (Pepcid®®))– 20-40mg by mouth twice daily20-40mg by mouth twice daily
Nizatidine (AxidNizatidine (Axid®®))– 150-300mg by mouth twice daily150-300mg by mouth twice daily
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
HH22-Receptor -Receptor AntagonistsAntagonists Side EffectsSide Effects
– Well toleratedWell tolerated– Many drug interactions, esp. with HIV Many drug interactions, esp. with HIV
medicationmedication– Tolerance can develop with long term useTolerance can develop with long term use
Place in TherapyPlace in Therapy– As needed for minor dyspepsiaAs needed for minor dyspepsia– Daily to control frequent symptomsDaily to control frequent symptoms
Low dose for symptoms w/o esophagitisLow dose for symptoms w/o esophagitis High dose for symptoms w/ esophagitisHigh dose for symptoms w/ esophagitis
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Proton Pump InhibitorsProton Pump Inhibitors
Most potent inhibitors of acid Most potent inhibitors of acid secretionsecretion– Decrease daily acid secretion 80-95%Decrease daily acid secretion 80-95%
Require activation by acid in Require activation by acid in stomachstomach
Irreversibly binds and inactivates Irreversibly binds and inactivates the Hthe H++/K/K++-ATPase -ATPase – HH++/K/K++-ATPase is the pump molecule -ATPase is the pump molecule
that secretes acid from the parietal cell that secretes acid from the parietal cell into the lumen of the stomachinto the lumen of the stomachBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11th Edition. USA; McGraw-Hill Company, 2006.
Proton Pump InhibitorsProton Pump InhibitorsDrugDrug Healing Healing PreventionPreventionOmeprazole Omeprazole (Prilosec(Prilosec®®))
20-40mg daily20-40mg daily 20mg daily20mg daily
Esomeprazole Esomeprazole (Nexium(Nexium®®))
20-40mg daily20-40mg daily 20mg daily20mg daily
Lansoprazole Lansoprazole (Prevacid(Prevacid®®))
15-30mg daily15-30mg daily 15 mg daily15 mg daily
Pantoprazole Pantoprazole (Protonix(Protonix®®))
40mg daily40mg daily 20-40mg daily20-40mg daily
Rabeprazole Rabeprazole (Aciphex(Aciphex®®))
20mg daily20mg daily 20mg daily20mg dailySite GI chapter
Proton Pump InhibitorsProton Pump Inhibitors
Side EffectsSide Effects– Well toleratedWell tolerated– Takes multiple doses to get full effectTakes multiple doses to get full effect
Place in TherapyPlace in Therapy– Symptomatic GERD with esophagitisSymptomatic GERD with esophagitis– Promote healing of gastric ulcersPromote healing of gastric ulcers– Hypersecretory conditionsHypersecretory conditions– Prevent NSAID-associated gastric Prevent NSAID-associated gastric
ulcersulcers
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
MiscellaneousMiscellaneous
Other medications used for GERDOther medications used for GERD– Prostaglandin analogues (i.e. misoprostol)Prostaglandin analogues (i.e. misoprostol)
Bind a EPBind a EP33 receptor on parietal cells, receptor on parietal cells, decreasing cAMP (energy) available for Hdecreasing cAMP (energy) available for H++/K/K++--ATPase ATPase
– SucralfateSucralfate Sucrose + Al(OH)Sucrose + Al(OH)33 which forms a viscous layer which forms a viscous layer
on the gastric mucosaon the gastric mucosa Prevents acid from contacting mucosaPrevents acid from contacting mucosa
– MetoclopramideMetoclopramide Stimulates gastric motilityStimulates gastric motility increased increased
clearance of stomach acidclearance of stomach acidSite GI chapter
Complications of GERDComplications of GERD
Ulceration (w/ or w/o H. pylori)Ulceration (w/ or w/o H. pylori) Asthma exacerbationsAsthma exacerbations Esophageal stricturesEsophageal strictures AdenocarcinomaAdenocarcinoma Barrett EsophagusBarrett Esophagus
Shaheen, N., Ransohoff, D.F. Gastroesophageal Reflux, Barret Esophagus, and Esophageal Cancer: Scientific Revies. JAMA. 2002;287(15):1972-1981Dougherty, R., Fahy, J. Acute exacerbations of asthma: epidemiology, biology and the exacerbation-prone phenotype. Clinical and Experimental Allergy. 2009;39(2):193-202
H. Pylori InfectionH. Pylori Infection
Gram-negative rodGram-negative rod Not always associated with an Not always associated with an
active ulceractive ulcer Associated with gastritis, leads to:Associated with gastritis, leads to:
– Gastric/duodenal ulcersGastric/duodenal ulcers– Gastric adenocarcinomaGastric adenocarcinoma– Gastric B-cell lymphomaGastric B-cell lymphoma
Eradication is standard of care to Eradication is standard of care to promote healing of ulcer and to promote healing of ulcer and to prevent recurrenceprevent recurrence
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
H. Pylori InfectionH. Pylori Infection
3 Drug Combination3 Drug Combination– Proton pump inhibitor (high dose)Proton pump inhibitor (high dose)– 2 antibiotics (clarithromycin + amoxicillin OR 2 antibiotics (clarithromycin + amoxicillin OR
metronidazolemetronidazole 4 Drug Combination4 Drug Combination
– Proton pump inhibitor (high dose)Proton pump inhibitor (high dose)– 2 antibiotics (metronidazole + tetracycline OR 2 antibiotics (metronidazole + tetracycline OR
amoxicillin OR clarithromycin)amoxicillin OR clarithromycin)– Bismuth subsalicylateBismuth subsalicylate
All regimens 14 days in durationAll regimens 14 days in duration– Patient compliance is difficult with intense Patient compliance is difficult with intense
regimensregimensBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Acid-rebound Acid-rebound PhenomenonPhenomenon Chronic suppression of acid Chronic suppression of acid
secretion leads to secretion leads to hypergastrinemiahypergastrinemia– Gastrin stimulates ECL cells to Gastrin stimulates ECL cells to
release histaminerelease histamine increased acid increased acid secretion from activation of secretion from activation of histamine receptor on parietal cellhistamine receptor on parietal cell
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Disorders of the Lower Disorders of the Lower GI TractGI Tract ConstipationConstipation
DiarrheaDiarrhea
Gastrointestinal Gastrointestinal MotilityMotility
The GI tract is in a continuous The GI tract is in a continuous contractile, absorptive, & secretory contractile, absorptive, & secretory statestate
Muscle, CNS, ENS (enteric nerve Muscle, CNS, ENS (enteric nerve system), and humoral pathways system), and humoral pathways control GI movementcontrol GI movement
4 phases to movement in the GI tract4 phases to movement in the GI tract– Peristalsis is most important, moves Peristalsis is most important, moves
contents through GI tractcontents through GI tract
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
GI MotilityGI Motility
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increased transit time
- Increased water absorption constipation
decreased transit time
-Decreased water and nutrient absorption diarrhea
ConstipationConstipation
Affects up to 27% of AmericansAffects up to 27% of Americans Accounts for 2.5 mil. physician Accounts for 2.5 mil. physician
visits/yearvisits/year $400 million spent on OTCs annually$400 million spent on OTCs annually
DefinitionDefinition– Unsatisfactory defecation that results in Unsatisfactory defecation that results in
infrequent stool, difficult stool passage, infrequent stool, difficult stool passage, or bothor both
Cash, B. et al. Update on the Management of Adults with Chronic Idiopathic Constipation. The Journal of Family Practice. 2007;56(6):S13-20
ConstipationConstipation
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Causes of ConstipationCauses of Constipation
GI disordersGI disorders– Irritable bowel syndrome, hernia, anal Irritable bowel syndrome, hernia, anal
fissuresfissures Metabolic disordersMetabolic disorders
– Diabetes with neuropathy, hypothyriodismDiabetes with neuropathy, hypothyriodism PregnancyPregnancy Psychogenic disordersPsychogenic disorders MedicationsMedications
– Analgesics, antacids, iron preparationsAnalgesics, antacids, iron preparations
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
Treatment of Treatment of ConstipationConstipation Lifestyle modificationsLifestyle modifications
– Fiber-rich dietFiber-rich diet– Adequate fluid intakeAdequate fluid intake– Appropriate bowel habits and trainingAppropriate bowel habits and training– ExerciseExercise
MedicationsMedications– Bulk-forming laxativesBulk-forming laxatives– Stimulant laxativesStimulant laxatives– Hyperosmotic laxativesHyperosmotic laxatives– Stool softenersStool softeners
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Bulk-Forming Bulk-Forming LaxativesLaxatives 3 kinds3 kinds
– Psyllium (MetamucilPsyllium (Metamucil®®))– Methylcelluose (CitrucelMethylcelluose (Citrucel®®))– Calcium polycarbophil (FiberconCalcium polycarbophil (Fibercon®®))
Increases colonic mass which Increases colonic mass which triggers peristalsistriggers peristalsis
Increases water content of stool Increases water content of stool via hydrophilic forcesvia hydrophilic forces
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Stimulant LaxativesStimulant Laxatives
Induce low-grade inflammation in the small and Induce low-grade inflammation in the small and large intestinelarge intestine– Promotes accumulation of water and Promotes accumulation of water and
stimulates motilitystimulates motility Provides Provides soft or semifluidsoft or semifluid stool in stool in 6-12 hours6-12 hours Bisacodyl (DulcolaxBisacodyl (Dulcolax®®))
– 5-15 mg by mouth daily; 10mg rectally daily 5-15 mg by mouth daily; 10mg rectally daily (rectal administration effective within 1 (rectal administration effective within 1 hour)hour)
Castor OilCastor Oil Senna (SenokotSenna (Senokot®®))
– 8.6mg sennosides 1-2 times per day (1-2 8.6mg sennosides 1-2 times per day (1-2 tablets once or twice daily)tablets once or twice daily)
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
Hyperosmotic Hyperosmotic LaxativesLaxatives Osmotically mediated water retention (via Osmotically mediated water retention (via
cations-Al, Mg, etc) which stimulates cations-Al, Mg, etc) which stimulates peristalsisperistalsis
Provides Provides waterywatery fecal evacuation in fecal evacuation in 1-6 1-6 hourshours
Magnesium hydroxide (Milk of Mag)Magnesium hydroxide (Milk of Mag)– 5-15mL by mouth four times daily5-15mL by mouth four times daily
Polyethylene glycol (MiralaxPolyethylene glycol (Miralax®®))– Dose used depends on level of evacuationDose used depends on level of evacuation
Sodium phosphate (Fleets PhosphosodaSodium phosphate (Fleets Phosphosoda®®))
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
Stool Stool Softeners/LubricantsSofteners/Lubricants Docusate (ColaceDocusate (Colace®®))
– Stool softenerStool softener– Mixes aqueous and fatty material in the Mixes aqueous and fatty material in the
intestinal tract, leading to increase stool intestinal tract, leading to increase stool water contentwater content
– Used to prevent constipation or strainingUsed to prevent constipation or straining 1-2 capsules by mouth once or twice daily1-2 capsules by mouth once or twice daily
Mineral Oil (NujolMineral Oil (Nujol®®))– LubricantLubricant– Coats stool and allows for easier passageCoats stool and allows for easier passage– 15-30mL orally as needed15-30mL orally as needed– Causes Causes softening and passage of stoolsoftening and passage of stool in in
1-3 days1-3 daysBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
Diarrhea Diarrhea
Prevalence of diarrhea varies in Prevalence of diarrhea varies in developed vs. non-developed countriesdeveloped vs. non-developed countries– 1.3 billion episodes/yr in developing countries1.3 billion episodes/yr in developing countries
4 million deaths4 million deaths Can be associated with an infectious Can be associated with an infectious
causecause– Shigella, Salmonella, E. Coli among most Shigella, Salmonella, E. Coli among most
commoncommon Most diarrhea is self-limitingMost diarrhea is self-limiting Defined as an increase in stool frequency Defined as an increase in stool frequency
or water contentor water contentDipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
DiarrheaDiarrhea
http://www.ghi.com/WebMD/topics/diarrhea.jpg
Opioid DerivativesOpioid Derivatives
Bind the Bind the µµ-receptor on enteric nerves, -receptor on enteric nerves, epithelium, and muscleepithelium, and muscle– Decrease GI motilityDecrease GI motility– Increase absorption of water from the bowelIncrease absorption of water from the bowel
Diphenoxylate (LomotilDiphenoxylate (Lomotil®®))– 5mg by mouth 4 times daily (max 20mg/day)5mg by mouth 4 times daily (max 20mg/day)
Loperamide (ImmodiumLoperamide (Immodium®®))– 4mg by mouth first, then 2mg by mouth after 4mg by mouth first, then 2mg by mouth after
each loose stool (max 16mg/day)each loose stool (max 16mg/day)
Site GI chapterDipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
AdsorbentsAdsorbents
Non-selectively absorbs intestinal Non-selectively absorbs intestinal fluidfluid– Regulates stool texture and viscosityRegulates stool texture and viscosity– Bind bacterial toxins and bile saltsBind bacterial toxins and bile salts
Attapulgite (KaopectateAttapulgite (Kaopectate®®))– 30-120mL after each loose stool30-120mL after each loose stool
Can bind other medications, must Can bind other medications, must space out from others by 2 to 3 space out from others by 2 to 3 hourshoursBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11th Edition. USA; McGraw-Hill Company, 2006.
Bismuth SalicylateBismuth Salicylate
Anti-secretory, anti-inflammatory, Anti-secretory, anti-inflammatory, antimicrobial effectsantimicrobial effects
Used for the prevention and Used for the prevention and treatment of traveler’s diarrheatreatment of traveler’s diarrhea
PeptoBismolPeptoBismol®®
– 30mL (2 tabs) every hour as needed 30mL (2 tabs) every hour as needed (up to 8 times/day)(up to 8 times/day)
– Excessive use can lead to salicylate Excessive use can lead to salicylate poisioningpoisioning
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.
ProbioticsProbiotics
Replaces normal colonic microfloraReplaces normal colonic microflora– Restores intestinal function and Restores intestinal function and
suppresses the growth of pathogenic suppresses the growth of pathogenic bacteriabacteria
Lactobacillus acidophilus (LactinexLactobacillus acidophilus (Lactinex®®))– 2 tabs or 1 packet of granules 3-4 times 2 tabs or 1 packet of granules 3-4 times
dailydaily Dairy ProductsDairy Products
– 200-400 grams of lactose200-400 grams of lactose– Special ‘lactobacillus’ containing yogurtsSpecial ‘lactobacillus’ containing yogurts
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.
ConclusionConclusion
Approximately 1/3 of your patients Approximately 1/3 of your patients will be taking a medication for GERDwill be taking a medication for GERD
Approximately ¼ of your patients Approximately ¼ of your patients will be taking a medication for will be taking a medication for constipationconstipation
GERD, constipation, and diarrhea GERD, constipation, and diarrhea affect a patient’s quality of lifeaffect a patient’s quality of life
Questions?Questions?