Gastrointestinal Pharmacotherapy.Ppt Final

Lecture to physical therapy students

1. Gastrointestinal Gastrointestinal
PharmacotherapyPharmacotherapy
Sarah Nelson, Pharm.D.Sarah Nelson, Pharm.D.
March 3, 2009March 3, 2009

2. ObjectivesObjectives
Discuss the process of acid secretion in Discuss the process of acid secretion in
the gastrointestinal tractthe 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 account Differentiate medications used to account
for impaired gastrointestinal motilityfor impaired gastrointestinal motility

3. Gastrointestinal tractGastrointestinal tract
http://www.nationmaster.com/encyclopedia/Gastrointestinal-tract

4. Disorders of the Disorders of the
Esophagus and StomachEsophagus and Stomach
Gastroesophageal Reflux Disease (GERD)Gastroesophageal Reflux Disease (GERD)
–Dyspepsia/Non-erosive reflux disease (NERD)Dyspepsia/Non-erosive reflux disease (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

5. Gastric SecretionGastric Secretion
http://www.nature.com/nrd/journal/v2/n2/images/nrd1010-f2.gif

6. Stomach AnatomyStomach Anatomy
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19223.jpg

7. Defense MechanismsDefense Mechanisms
Lower esophageal sphincterLower esophageal sphincter
Secretion of gastric mucusSecretion of gastric mucus
–Stimulated by prostaglandin EStimulated by prostaglandin E
22 and I and I
22
Secretion of bicarbonate ionsSecretion of bicarbonate ions
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

8. GERDGERD
Definition: when the reflux of stomach Definition: when the reflux of stomach
contents causes troublesome symptoms contents causes troublesome symptoms
or complicationsor complications
Diagnosis:Diagnosis:
–Presence of symptomsPresence of symptoms
–Demonstration of refluxDemonstration of reflux
–Identification of existing damage from Identification of existing damage from
refluxreflux
Ali, T. Miner, P. New Developments in gastroesophageal reflux disease diagnosis and therapy.
Curr Opin in Gastroenterology. 2008;24:502-508

9. EpidemiologyEpidemiology
44% of adults in the US experience 44% of adults in the US experience
heartburn heartburn ≥ 1 time/month≥ 1 time/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 is the Heartburn or substernal burning is the
most commonly recognized most commonly recognized
manifestation of GERDmanifestation of GERD
Shaheen, N., Ransohoff, D.F. Gastroesophageal Reflux, Barrett Esophagus, and Esophageal Cancer: Scientific Review. J
AMA. 2002;287(15):1972-1981

10. 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. 6
th
Edition. USA; McGraw-Hill Company, 2005.

11. Stages of GERDStages of GERD
PPI once or twice
daily
Chronic, unrelenting
Immediate relapse
off therapy
Esophageal
complications
III
PPI vs. H2RAFrequent symptoms
+/- esophagitis
II
Lifestyle modification
Antacids/H2 RA as
needed
 sporadic
 2-3 episodes/wk
I (NERD)
Medical
Management
DescriptionStage
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

12. Treatment of GERDTreatment of GERD
Decrease acidity of stomach contentsDecrease acidity of stomach contents
–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.
11
th
Edition. USA; McGraw-Hill Company, 2006.

13. AntacidsAntacids
Chemically neutralize stomach acidChemically neutralize stomach acid
Base (OH)Base (OH)
33 or CO or CO
3 3 + Al, Ca, or Mg+ Al, Ca, or Mg
–CaCOCaCO
33= calcium carbonate (Tums= calcium carbonate (Tums®)®)
–Al Al (OH)(OH)
33 + Mg (OH) + Mg (OH)
22 = Maalox = Maalox®®
Some contain simethicone (a surfactant)Some contain simethicone (a surfactant)
–Al Al (OH)(OH)
33 + Mg (OH) + Mg (OH)
22 + simethicone = Mylanta + simethicone = Mylanta®®
Site GI chapter

14. 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 AlCl
33 + 3H + 3H
22OO
CaCOCaCO
33 + 2 HCl CaCl + 2 HCl CaCl
22 + 2H + 2H
220 + CO0 + CO
22
Site GI chapter

15. 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 needed With other acid suppressants on an as needed
basisbasis
–Calcium supplementationCalcium supplementation
Site GI chapter

16. HH
22-Receptor Antagonists-Receptor Antagonists
Block histamine from binding to HBlock histamine from binding to H
22
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 secretionBlocks basal and bolus acid secretion
–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.
11
th
Edition. USA; McGraw-Hill Company, 2006.

17. HH
22-Receptor Antagonists-Receptor Antagonists
Cimetidine (TagametCimetidine (Tagamet
®®
))
–Not used often due to drug interactionsNot used often due to drug interactions
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.
11
th
Edition. USA; McGraw-Hill Company, 2006.

18. HH
22-Receptor Antagonists-Receptor Antagonists
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.
11
th
Edition. USA; McGraw-Hill Company, 2006.

19. Proton Pump InhibitorsProton Pump Inhibitors
Most potent inhibitors of acid secretionMost potent inhibitors of acid secretion
–Decrease daily acid secretion 80-95%Decrease daily acid secretion 80-95%
Require activation by acid in stomachRequire activation by acid in stomach
Irreversibly binds and inactivates the Irreversibly binds and inactivates the
HH
++
/K/K
++
-ATPase -ATPase
–HH
++
/K/K
++
-ATPase is the pump molecule that -ATPase is the pump molecule that
secretes acid from the parietal cell into secretes acid from the parietal cell into
the lumen of the stomachthe lumen of the stomach
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

20. Proton Pump InhibitorsProton Pump Inhibitors
20mg daily20mg dailyRabeprazole (Aciphex
®
)
20-40mg daily40mg dailyPantoprazole (Protonix
®
)
15 mg daily15-30mg dailyLansoprazole (Prevacid
®
)
20mg daily20-40mg dailyEsomeprazole (Nexium
®
)
20mg daily20-40mg dailyOmeprazole (Prilosec
®
)
PreventionHealing Drug
Site GI chapter

21. 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 ulcersPrevent NSAID-associated gastric ulcers
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

22. MiscellaneousMiscellaneous
Other medications used for GERDOther medications used for GERD
–Prostaglandin analogues (i.e. misoprostol)Prostaglandin analogues (i.e. misoprostol)
Bind a EPBind a EP
33 receptor on parietal cells, decreasing receptor on parietal cells, decreasing
cAMP (energy) available for HcAMP (energy) available for H
++
/K/K
++
-ATPase -ATPase
–SucralfateSucralfate
Sucrose + Al(OH)Sucrose + Al(OH)
33 which forms a viscous layer on which forms a viscous layer on
the gastric mucosathe gastric mucosa
Prevents acid from contacting mucosaPrevents acid from contacting mucosa
–MetoclopramideMetoclopramide
Stimulates gastric motilityStimulates gastric motilityincreased increased
clearance of stomach acidclearance of stomach acid
Site GI chapter

23. 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. J
AMA. 2002;287(15):1972-1981
Dougherty, R., Fahy, J. Acute exacerbations of asthma: epidemiology, biology and the exacerbation-prone phenotype.
Clinical and Experimental Allergy. 2009;39(2):193-202

24. H. Pylori InfectionH. Pylori Infection
Gram-negative rodGram-negative rod
Not always associated with an active Not always associated with an active
ulcerulcer
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 prevent promote healing of ulcer and to prevent
recurrencerecurrence
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

25. 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 regimensPatient compliance is difficult with intense regimens
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

26. Acid-rebound PhenomenonAcid-rebound Phenomenon
Chronic suppression of acid secretion Chronic suppression of acid secretion
leads to hypergastrinemialeads to hypergastrinemia
–Gastrin stimulates ECL cells to release Gastrin stimulates ECL cells to release
histaminehistamine increased acid secretion increased acid secretion
from activation of histamine receptor on from activation of histamine receptor on
parietal cellparietal cell
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

27. Disorders of the Lower GI Disorders of the Lower GI
TractTract
ConstipationConstipation
DiarrheaDiarrhea

28. Gastrointestinal MotilityGastrointestinal Motility
The GI tract is in a continuous contractile, The GI tract is in a continuous contractile,
absorptive, & secretory stateabsorptive, & secretory state
Muscle, CNS, ENS (enteric nerve system), Muscle, CNS, ENS (enteric nerve system),
and humoral pathways control GI and humoral pathways control GI
movementmovement
4 phases to movement in the GI tract4 phases to movement in the GI tract
–Peristalsis is most important, moves contents Peristalsis is most important, moves contents
through GI tractthrough GI tract
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

29. GI MotilityGI Motility
http://img.tfd.com/vet/thumbs/gr294.jpg
 increased transit time
- Increased water
absorption
constipation
 decreased transit time
-Decreased water and
nutrient absorption diarrhea

30. ConstipationConstipation
Affects up to 27% of AmericansAffects up to 27% of Americans
Accounts for 2.5 mil. physician visits/yearAccounts for 2.5 mil. physician visits/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, or infrequent stool, difficult stool passage, or
bothboth
Cash, B. et al. Update on the Management of Adults with Chronic Idiopathic Constipation.
The Journal of Family Practice. 2007;56(6):S13-20

31. ConstipationConstipation
http://www.helpfulhealthtips.com/Images/C/constipation1.jpg

32. 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. 6
th
Edition. USA; McGraw-Hill Company, 2005.

33. Treatment of ConstipationTreatment of Constipation
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.
11
th
Edition. USA; McGraw-Hill Company, 2006.

34. Bulk-Forming LaxativesBulk-Forming Laxatives
3 kinds3 kinds
–Psyllium (MetamucilPsyllium (Metamucil
®®
))
–Methylcelluose (CitrucelMethylcelluose (Citrucel
®®
))
–Calcium polycarbophil (FiberconCalcium polycarbophil (Fibercon
®®
))
Increases colonic mass which triggers Increases colonic mass which triggers
peristalsisperistalsis
Increases water content of stool via Increases water content of stool via
hydrophilic forceshydrophilic forces
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

35. Stimulant LaxativesStimulant Laxatives
Induce low-grade inflammation in the small and large Induce low-grade inflammation in the small and large
intestineintestine
–Promotes accumulation of water and stimulates Promotes accumulation of water and stimulates
motilitymotility
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 (rectal 5-15 mg by mouth daily; 10mg rectally daily (rectal
administration effective within 1 hour)administration effective within 1 hour)
Castor OilCastor Oil
Senna (SenokotSenna (Senokot
®®
))
–8.6mg sennosides 1-2 times per day (1-2 tablets 8.6mg sennosides 1-2 times per day (1-2 tablets
once or twice daily)once or twice daily)
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6
th
Edition. USA; McGraw-Hill Company, 2005.

36. Hyperosmotic LaxativesHyperosmotic Laxatives
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 hours1-6 hours
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.
11
th
Edition. USA; McGraw-Hill Company, 2006.
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6
th
Edition. USA; McGraw-Hill Company, 2005.

37. Stool Softeners/LubricantsStool Softeners/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 water intestinal tract, leading to increase stool water
contentcontent
–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 1-3
daysdays
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

38. Diarrhea Diarrhea
Prevalence of diarrhea varies in developed vs. Prevalence of diarrhea varies in developed vs.
non-developed countriesnon-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 causeCan be associated with an infectious cause
–Shigella, Salmonella, E. Coli among most commonShigella, Salmonella, E. Coli among most common
Most diarrhea is self-limitingMost diarrhea is self-limiting
Defined as an increase in stool frequency or Defined as an increase in stool frequency or
water contentwater content
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6
th
Edition. USA; McGraw-Hill Company, 2005.

39. DiarrheaDiarrhea
http://www.ghi.com/WebMD/topics/diarrhea.jpg

40. 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 chapter
Dipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6
th
Edition. USA; McGraw-Hill Company, 2005.

41. AdsorbentsAdsorbents
Non-selectively absorbs intestinal fluidNon-selectively absorbs intestinal fluid
–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 hoursspace out from others by 2 to 3 hours
Brunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.
11
th
Edition. USA; McGraw-Hill Company, 2006.

42. Bismuth SalicylateBismuth Salicylate
Anti-secretory, anti-inflammatory, Anti-secretory, anti-inflammatory,
antimicrobial effectsantimicrobial effects
Used for the prevention and treatment Used for the prevention and treatment
of traveler’s diarrheaof traveler’s diarrhea
PeptoBismolPeptoBismol
®®
–30mL (2 tabs) every hour as needed (up 30mL (2 tabs) every hour as needed (up
to 8 times/day)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.
11
th
Edition. USA; McGraw-Hill Company, 2006.

43. ProbioticsProbiotics
Replaces normal colonic microfloraReplaces normal colonic microflora
–Restores intestinal function and suppresses the Restores intestinal function and suppresses the
growth of pathogenic bacteriagrowth of pathogenic bacteria
Lactobacillus acidophilus (LactinexLactobacillus acidophilus (Lactinex
®®
))
–2 tabs or 1 packet of granules 3-4 times daily2 tabs or 1 packet of granules 3-4 times daily
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. 6
th
Edition. USA; McGraw-Hill Company, 2005.

44. ConclusionConclusion
Approximately 1/3 of your patients will Approximately 1/3 of your patients will
be taking a medication for GERDbe taking a medication for GERD
Approximately ¼ of your patients will Approximately ¼ of your patients will
be taking a medication for constipationbe taking a medication for constipation
GERD, constipation, and diarrhea GERD, constipation, and diarrhea
affect a patient’s quality of lifeaffect a patient’s quality of life

45. Questions?Questions?