Stress ulcer prophtlaxiss.pptx

medical information

1. Stress ulcer prophylaxis Cliical pharmacy gharbia group a lmojamaa eltibi alnamozagy hospital

2. Dosing: Adult Active duodenal ulcer:  Oral: 20 mg once daily for 4-8 weeks Gastric ulcers:  Oral: 40 mg once daily for 4-8 weeks Stress-ulcer prophylaxis (ICU patients; unlabeled use):  Oral: 40 mg once daily; periodically evaluate patient for continued need Prevention of rebleeding in peptic ulcer bleed (unlabeled use):  I.V.: 80 mg, followed by 8 mg/hour infusion for 72 hours.  Note:  A daily infusion of 40 mg does not raise gastric pH sufficiently to enhance coagulation in active GI bleeds IV: Continuous infusion: Loading dose of 80 mg, followed by 8 mg/hour continuous infusion for a total of 72 hours Oral: 30 mg once daily (Brophy 2010; Olsen 2008). Note: Intended for patients with associated risk factors ( eg , coagulopathy, mechanical ventilation for >48 hours, sepsis/septic shock); discontinue use once risk factors have resolved (Rhodes 2017 Dosing: Renal Impairment   No adjustment is required. Dosing: Hepatic Impairment   No adjustment is required. Dosing: Renal Impairment   No adjustment is required.     Hepatic Impairment: Adult   Oral : Mild to moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary . Severe impairment (Child-Pugh class C): Maximum: 20 mg daily .   Continuous infusion : Mild to moderate impairment (Child-Pugh class A or B): 80 mg over 30 minutes, followed by a maximum continuous infusion of 6 mg/hour for a total of 72 hours . Severe impairment (Child-Pugh class C): 80 mg over 30 minutes, followed by a maximum continuous infusion of 4 mg/hour for a total of 72 hours . Dosing: Renal Impairment   No adjustment is required. Pantoprazole is not removed by hemodialysis. Dosing: Hepatic Impairment   No adjustment is required.   Dosing: Renal Impairment   No adjustment is necessary. Dosing: Hepatic Impairment   Bioavailability is increased with chronic liver disease. Consider dosage adjustment, especially for maintenance of erosive esophagitis. Specific guidelines are not available

3. Lansoprazole may decrease the levels/effects of:  Acalabrutinib ; Atazanavir ; Bisphosphonate Derivatives; Bosutinib ; Capecitabine ; Cefditoren ; Cefpodoxime ; Cefuroxime ; Esomeprazole may increase the levels/effects of: Amphetamine; Cilostazol ; Citalopram; CloBAZam ; Dexmethylphenidate ; Dextroamphetamine ; Dichlorphenamide; Escitalopram; Fosphenytoin -Phenytoin; Itraconazole ; Methotrexate; Methylphenidate Clopidogrel: Pantoprazole may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Due to the possible risk for impaired clopidogrel effectiveness, clinicians should carefully consider the need for proton pump inhibitor therapy in patients receiving clopidogrel. Other acid-lowering therapies do not appear to share this interaction.  Risk D: Consider therapy modification Clopidogrel : Proton pump inhibitors may diminish the therapeutic effect of clopidogrel , thought to be due to reduced formation of the active metabolite of clopidogrel ; an increase in the risk of cardiovascular events may occur   Monitoring Parameters Hypersecretory disorders: Acid output measurements, target level <10 mEq/hour (<5 mEq/hour if prior gastric acid-reducing surgery)   Monitoring Parameters Hypersecretory disorders: Acid output measurements, target level <10 mEq /hour (<5 mEq /hour if prior gastric acid-reducing surgery)   Monitoring Parameters Hypersecretory disorders: Acid output measurements, target level <10 mEq/hour (<5 mEq/hour if prior gastric acid-reducing surgery) Internationa   Monitoring Parameters Hypersecretory disorders: Acid output measurements, target level <10 mEq /hour (<5 mEq /hour if prior gastric acid-reducing surgery) Internationa  

4. Storage/Stability   Capsules : Esomeprazole magnesium: Store at 25°C ). Powder for injection: Store at 25°C Protect from light. following reconstitution, solution for injection prepared in NS, and solution for infusion prepared in NS or LR should be used within 12 hours; solution for infusion prepared in D5W should be used within 6 hours. Refrigeration is not required following reconstitution . Additional stability data: Following reconstitution, solutions for infusion prepared in D5W, NS, or LR in PVC bags are chemically and physically stable for 48 hours at room temperature (25°C) and for at least 120 hours under refrigeration Tablets: Store at 20°C to 25°C         Storage/Stability   Oral: Store tablet and oral suspension at 20°C to 25°C ). IV: Prior to reconstitution, store at 20°C to 25°C (68°F to 77°F); Do not freeze. Protect from light prior to reconstitution; upon reconstitution, protection from light is not required. Do not freeze reconstituted solution. Per manufacturer's labeling, reconstituted solution is stable at room temperature for up to 6 hours; further diluted (admixed) solution in D5W, LR, or NS should be stored at room temperature and used within 24 hours from the time of initial reconstitution Storage/Stability   Capsules, tablets: Store at 15°C to 30°C Protect from light and moisture . Granules for oral suspension: Store at 25°C ). Powder for suspension . OTC capsules: Store at 20°C to 25°C (protect from moisture Storage/Stability   Capsules, orally disintegrating tablets: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from light and moisture .

5. Dosing: Renal Impairment No adjustment is required. Pantoprazole is not removed by hemodialysis. Dosing: Hepatic Impairment No adjustment is required.   Dosing: Renal Impairment No adjustment is necessary. Dosing: Hepatic Impairment Bioavailability is increased with chronic liver disease. Consider dosage adjustment, especially for maintenance of erosive esophagitis. Specific guidelines are not available Dosing: Renal Impairment No adjustment is required.     Hepatic Impairment: Adult   Oral : Mild to moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary . Severe impairment (Child-Pugh class C): Maximum: 20 mg daily .   Continuous infusion : Mild to moderate impairment (Child-Pugh class A or B): 80 mg over 30 minutes, followed by a maximum continuous infusion of 6 mg/hour for a total of 72 hours . Dosing: Renal Impairment No adjustment is required. Dosing: Hepatic Impairment

6. Administration Oral: Best if administered before breakfast. Oral suspension: Following reconstitution, the suspension should be left to thicken for 2-3 minutes and administered within 30 minutes. If any material remains after administration, add more water, stir, and administer immediately. Tablet: Should be swallowed whole; do not crush or chew. Nasogastric/ orogastric (NG/OG) tube administration:Pour the contents of one or two 20 mg omeprazole delayed release capsules (depending on the dose) into a syringe (after removing plunger); withdraw 10-20 mL of an 8.4% sodium bicarbonate solution into the syringe; allow 30 minutes for the enteric-coated omeprazole granules to break down. Shake the resulting milky substance prior to administration. Flush the NG tube with 5-10 mL of water and clamp for at least 1 hour. I.V.: Flush I.V. line before and after administration. In-line filter not required. 2-minute infusion: The volume of reconstituted solution (4 mg/mL) to be injected may be administered intravenously over at least 2 minutes. 15-minute infusion: Infuse over 15 minutes at a rate not to exceed 7 mL/minute (3 mg/minute). Oral: Tablet: Should be swallowed whole, do not crush or chew. Best if taken before breakfast.       Flush line prior to and after administration with NS, LR, or D5W . Treatment of GERD: May be administered by injection (≥3 minutes), intermittent infusion (10 to 30 minutes ) Peptic ulcer disease, treatment of bleeding ulcers: May be administered as continuous infusion or intermittent infusion (infuse over 30 minutes), depending on risk of rebleeding   Powder for injection : For IV injection (≥3 minutes): Adults: Reconstitute powder with 5 mL NS . For IV infusion (10 to 30 minutes): Initially reconstitute powder with 5 mL of NS, LR, or D5W, then further dilute to a final volume of 50 mL . For IV infusion (loading dose and continuous infusion): Prepare the 80 mg loading dose by reconstituting two 40 mg vials with NS (5 mL each); the contents of the two vials should then be further diluted in NS 100 mL. To prepare the continuous infusion, also reconstitute two 40 mg vials with NS (5 mL each); the contents of the two vials should then be further diluted in NS 100 mL       Administer 30 to 60 minutes before a meal; best if taken before breakfast (ACG [Katz 2013]). If administering twice daily, first dose should be administered before breakfast and the second dose before dinner (ACG [Katz 2013]; Hershcovici 2010). The intact granules should not be chewed or crushed; however, several options are available for those patients unable to swallow capsules :

7. administration efficacy Safety Drugs Mechanism of action Family orally, via nasogastric tube, or intravenously -significantly lower rate of GI bleeding than antacids -decreased overt GI bleeding compared to sucralfate ventilatorassociated pneumonia was more frequent in the H2 blocker group, than sucralfate cimetidine, famotidine ranitidine nizatidine Histamine-2 receptor antagonists (H2 blockers) antagonize the H2 receptors on the parietal cell, resulting in diminished gastric acid secretion. H2 blockers orally, via nasogastric tube, or intravenously less GI bleeding than H2 blockers higher incidence of nosocomial pneumonia among patients who received a PPI than among those who received an H2 blocke omeprazole, lansoprazole , pantoprazole , esomeprazol e block acid secretion by irreversibly binding to and inhibiting the hydrogenpotassium ATPase pump that resides on the luminal surface of the parietal cell membrane. Proton pump inhibitor orally or via _ nasogastric tube Associated with fewer nosocomial pneumonia s than PPI and H2 blockers. lower rate of clinically important GI bleeding than antacids   Sulfated polysaccharide complexed with aluminum hydroxide. It exerts its effects by coating and protecting the gastric mucosa, without altering gastric acid secretion Sucralfate orally or via _ nasogastric tube Higher incidence of nosocomial pneumonia than sucralfate Higher GI bleeding than H2 blockers and PPI and sucralfate Carbonate bicarbonat Aluminum hydroxide: neutralize gastric acid and protect the gastric mucosa Antacids

8. nizatidine famotidine cimetidine, Duodenal ulcer: Oral :   Treatment: 300 mg once daily at bedtime or 150 mg twice daily for up to 8 weeks   Maintenance of healing: 150 mg once daily at bedtime   Gastric ulcer, benign: Oral: 150 mg twice daily or 300 mg once daily at bedtime for up to 8 weeks Stress ulcer prophylaxis in select critically ill patients (off-label use): Note: For ICU patients with associated risk factors for GI bleeding (including coagulopathy, mechanical ventilation for >48 hours, traumatic brain injury, history of GI ulceration or bleeding within past year, extensive burns); discontinue prophylaxis once risk factors have resolved (Rhodes 2017; Weinhouse 2019 ). Oral or via nasogastric (NG) tube (alternative to enteral PPI): 20 mg twice daily (ASHP 1999; Weinhouse 2019 ) IV: 20 mg twice daily (ASHP 1999; Weinhouse 2019 ) Stress ulcer prophylaxis in critically ill patients (off-label use): Oral or NG tube: 300 mg 4 times daily (ASHP 1999). Note: Intended for patients with associated risk factors ( eg , coagulopathy, mechanical ventilation for >48 hours, sepsis/septic shock); discontinue use once risk factors have resolved (Rhodes 2017 ). Serious hypersensitivity (eg, anaphylaxis) to famotidine, other H2 antagonists, or any component of the formulation Serious hypersensitivity (eg, anaphylaxis) to famotidine, other H2 antagonists, or any component of the formulation Serious hypersensitivity ( eg , anaphylaxis) to famotidine, other H2 antagonists, or any component of the formulation

9. Preparation for Administration: Adult   Solution for injection : IV push: Dilute 2 mL (20 mg) with NS (or another compatible solution) to a total of 5 to 10 mL. May also administer undiluted ( Lipsy 1995 ). Infusion: Dilute 2 mL (20 mg) with 100 mL of D5W or another compatible solution diluted with most commonly used intravenous solutions, e.g., Sodium Chloride Injection (0.9%), Dextrose Injection (5% or 10%), Lactated Ringer’s Injection, 5% Sodium Bicarbonate Injection, Cimetidine Injection, USP should not be used after more than 48 hours of storage at room temperature. Administration: IV   Administer IV push over at least 2 minutes. Administer IV infusion over 15 to 30 minutes Administration: Oral   Administer without regard to meals. May administer with antacids . Suspension: Shake vigorously before use . Tablet (OTC): Do not chew; dose may be taken 10 to 60 minutes before eating food or drinking beverages known to cause heartburn .. Administration: Oral   Administer with meals. For stress ulcer prophylaxis in critically-ill patients (off-label use), may administer via NG tube

10. Breast-Feeding Considerations   Cimetidine is excreted in breast milk. Breastfeeding is not recommended by the manufacturer Breast-Feeding Considerations   Cimetidine is excreted in breast milk. Breastfeeding is not recommended by the manufacturer Breast-Feeding Considerations   Cimetidine is excreted in breast milk. Breastfeeding is not recommended by the manufacturer . Hepatic Impairment: Adult   There are no dosage adjustments   Renal Impairment: Adult   Manufacturer's labeling : Mild to moderate renal impairment: There are no dosage adjustments provided in the manufacturer’s labeling; use with caution . Severe renal impairment: 300 mg every 12 hours; may increase frequency with caution. When hepatic impairment is also present, further reductions in dosage may be necessary . Dosing: Hepatic renal Impairment: Adult   There are no dosage adjustments provided in the manufacturer's labeling . Hepatic Impairment: Adult   There are no dosage adjustments provided in the manufacturer's labeling   Dosing: Renal Impairment: Adult   Manufacturer's labeling : Active treatment : CrCl >50 mL/minute: No dosage adjustment necessary . CrCl 20 to 50 mL/minute: 150 mg once daily CrCl <20 mL/minute: 150 mg every other day Maintenance treatment : CrCl >50 mL/minute: No dosage adjustment necessary CrCl 20 to 50 mL/minute: 150 mg every other day

11. Drug Interactions: Avoid Concomitant Use   clinically relevant drug interaction potential; Inhibits CYP1A2 (weak), CYP2C19 (weak), CYP2D6 (weak), CYP3A4 (weak ) Avoid concomitant use of Cimetidine with any of the following: Cefuroxime; Chloroquine; Dasatinib ; Delavirdine ; Dofetilide ; EpiRUBicin ; PAZOPanib ; Pimozide ; Risedronate   Drug Interactions: Increased Effect/Toxicity   Drug Interactions: Increased Effect/Toxicity   Famotidine may increase the levels/effects of:  Dexmethylphenidate ; Itraconazole ; Methylphenidate; Risedronate ; Saquinavir ; Varenicline Drug Interactions: Increased Effect/Toxicity   Storage/Stability   Storage/Stability   Oral : Powder for oral suspension: Prior to reconstitution, store at 25°C (77°F). Reconstituted oral suspension is stable for 30 days at room temperature; do not freeze . Tablet: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from light . IV : Solution for injection: Prior to use, store at 2°C to 8°C (36°F to 46°F). If solution freezes, allow to solubilize at room temperature. Protect from light . IV push: Following preparation, solutions for IV push should be used immediately, or may be stored in refrigerator and used within 48 hours . Infusion: Following dilution in D5W, D10W, NS or LR, may be stored for up to 48 hours under refrigeration; however, solutions for infusion have been found to be physically and chemically stable for 7 days at room temperature (maintains at least 90% of initial potency ). Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F ).

12. SACRULFATE Administration: Oral   Administer on an empty stomach. Shake suspension well before use. Do not administer antacids within 30 minutes of administration of sucralfate. In general, separate administration of other oral medications and sucralfate by at least 2 hours; consult drug interactions database for additional information   . Breast-Feeding Considerations   It is not known if sucralfate is present in breast milk . Sucralfate is only minimally absorbed following oral administration. Although the manufacturer recommends that caution be exercised when administering sucralfate to breastfeeding women, use is considered acceptable Hypersensitivity to sucralfate or any component of the formulation Suspension, tablet: Initial: 1 g 4 times daily for 4 to 8 weeks . Maintenance therapy: Tablet: 1 g twice daily . Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information . Hepatic & renal impairment There are no dosage adjustments provided in the manufacturer's labeling Drug Interactions: Decreased Effect   Sucralfate may decrease the levels/effects of: Baloxavir Marboxil; Bictegravir; Bisphosphonate Derivatives; Cabotegravir; Cholic Acid; Deferiprone; Digoxin; Dolutegravir; Eltrombopag; Elvitegravir; Furosemide ; Storage/Stability   Suspension: Store at 20°C to 25°C (68°F to 77°F); do not freeze . Tablet: Store at 15°C to 30°C (59°F to 86°F ). Monitoring Parameters   Blood glucose levels (in diabetic patients receiving oral suspension ).  

13.   Sodium bicarbonate   Oral :   Products containing aluminum hydroxide 200 mg, magnesium hydroxide 200 mg, and simethicone 25 mg per tablet: 1 to 4 tablets 4 times daily; may also take as needed, up to 12 to 16 tablets/24 hours Administer 1 hour after meals or between meals .   Suspension: Shake well prior to use Administration: Oral   Administer after meals and at bedtime (up to 4 times daily). Shake suspension well before use. Tablets should be chewed thoroughly before swallowing Dosing: Renal Impairment: Adult There are no dosage adjustments provided in the manufacturer's labeling; aluminum and/or magnesium may accumulate in renal impairment . Contraindications   Hypersensitivity to sodium bicarbonate, sodium alginate, calcium carbonate, or any component of the formulation (including methyl/propyl paraben [suspension only])   Dietary Considerations   Should be taken after meals. Products contain significant amounts of sodium and calcium . Dosing: Hepatic & renal Impairment: Adult   There are no dosage adjustments provided in the manufacturer’s labeling torage/Stability Store at room temperature . Storage/Stability   Tablets: Store at ≤25°C (77°F) (flip-top lid containers) or ≤30°C (86°F) (blister trays) in original package . Suspension: Store at ≤30°C (86°F). Do not refrigerate or freez Drug Interactions: Avoid Concomitant Use Avoid concomitant use of Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone with any of the following: Baloxavir Marboxil; Calcium Polystyrene Sulfonate; Deferasirox; MiSOPROStol; QuiNINE; Raltegravir; Sodium Polystyrene Sulfonate; Vitamin D Analogs