A.

Drugs Acting on Respiratory System

ASTHMA

Asthma is characterized by reversible bronchospasm,

inflammation, and hyperactive airways.The hyperactivity is
triggered by allergens or nonallergic inhaled irritants, or by
factors such as exercise and emotions.The trigger causes an
immediate release of histamine, which results in bronchospasm in
about 10 minutes. The later response (3-5 hours) is cytokine-
mediated inflammation, mucus production, and edema contributing
to obstruction. Appropriate treatment depends on understanding
the early and late responses.
The extreme case of asthma is called status asthmaticus; this is
life-threatening bronchospasm that does not respond to usual
treatment and occludes airflow into the lungs.

Chronic obstructive pulmonary disease (COPD)

Nurses care for patients with COPD across the spectrum of

care, from outpatient to home care to emergency department,
critical care, and hospice settings.
Chronic Obstructive Pulmonary Disease (COPD) is a condition of
chronic dyspnea with expiratory airflow limitation that does not
significantly fluctuate.
Chronic Obstructive Pulmonary Disease has been defined by The
Global Initiative for Chronic Obstructive Lung Disease as “a
preventable and treatable disease with some significant
extrapulmonary effects that may contribute to the severity in
individual patients.”
This updated definition is a broad description of COPD and its
signs and symptoms.
Chronic Bronchitis
❖ Chronic bronchitis is a disease of the airways and is defined as
the presence of cough and sputum production for at least 3 months
in each of 2 consecutive years.
❖ Chronic bronchitis is also termed as “blue bloaters”.
❖ Pollutants or allergens irritate the airways and leads to the
production of sputum by the mucus-secreting glands and goblet
cells.
❖ A wide range of viral, bacterial, and mycoplasmal infections can
produce acute episodes of bronchitis.

Emphysema
❖ Pulmonary Emphysema is a pathologic term that describes an
abnormal distention of airspaces beyond the terminal bronchioles
and destruction of the walls of the alveoli.
❖ People with emphysema are also called “pink puffers”.
❖ There is impaired carbon dioxide and oxygen exchange, and the
exchange results from the destruction of the walls of
overdistended alveoli.

Bronchiectasis
❖ Chronic pulmonary disorders are the leading cause of morbidity
and mortality in the United States.
❖ Bronchiectasis is a chronic, irreversible dilation of the bronchi
and the bronchioles.
❖ Under the new definition of COPD, it is considered a disease
process separate from COPD.
❖ Bronchiectasis is usually localized, affecting a segment or lobe
of a lung, most frequently the lower lobes.
❖ Inflammation. The inflammatory process associated with pulmonary
infection damages the bronchial wall, causing a loss of its
supporting structure and resulting in thick sputum that
ultimately obstructs the bronchi.
❖ Collapse. The retention of secretions and subsequent obstruction
ultimately cause the alveoli distal to the obstruction collapse.
❖ Impairment. There is impairment in the match of ventilation to
perfusion and hypoxemia.

1. Bronchodilators
Bronchodilators or anti-asthmatics are medications used to
facilitate respiration by dilating the airways. They are helpful
in symptomatic relief or prevention of bronchial asthma and for
bronchospasm associated with COPD.

A. Xanthine Derivatives
 The xanthines come from a variety of naturally occurring
sources. These drugs were once the main treatment choices for
asthma and bronchospasm. However, because they have a relatively
narrow margin of safety and interact with many other drugs, they
are no longer considered the first-choice bronchodilators.

❖ Aminophylline (Truphylline)
❖ Dyphylline (Dilor)
❖ Theophylline (Theo-Dur)

Mechanism of Action
The desired actions of xanthines include:

✓ A direct effect on the smooth muscles of the respiratory

tract, both in the bronchi and in the blood vessels.
✓ A theory suggests that xanthines work by directly affecting
the mobilization of calcium within the cell.
✓ They do this by stimulating two prostaglandins, resulting
in smooth muscle relaxation, which increases the vital
capacity that has been impaired by the bronchospasm or air
trapping.
✓ They also inhibit the release of slow-reacting substance of
anaphylaxis and histamine, decreasing the bronchial
swelling and narrowing that occurs as a result of these two
chemicals.

Indications
Xanthines are indicated for the following:
✓ Relief of symptoms or prevention of bronchial asthma.
✓ Reversal of bronchospasm associated with COPD.

Contraindications and Cautions

✓ Co-morbidities. Caution should be taken with any patient
with GI problems, coronary disease, respiratory
dysfunction, renal or hepatic disease, alcoholism, or
hyperthyroidism because these conditions can be exacerbated
by the systemic effects of xanthines.
✓ Long-term parenteral use. Xanthines are available for oral
and parenteral use; the parenteral drug should be switched
to oral form as soon as possible because the systemic
effects of the oral form are less acute and more
manageable.
 ✓ Pregnancy. Although no studies are available of xanthine
effects on human pregnancy, they have been associated with
fetal abnormalities and breathing difficulties at birth in
animal studies, so use should be limited to situations in
which the benefit to the mother clearly outweighs the
potential risk to the fetus.
✓ Lactation. Because the xanthines enter breastmilk and could
affect the baby, another method of feeding the baby should
be selected if these drugs are needed during lactation.

Adverse Effects
CNS: Irritability, restlessness, dizziness.
Cardiovascular: Palpitations, life-threatening arrhythmias.
Others: Loss of appetite, fever, flushing.
GU: Proteinuria.
Respiratory: Respiratory arrest.
Interactions
✓ Nicotine. Nicotine increases the metabolism of xanthines in
the liver; xanthine dose must be increased in patients who
continue to smoke while using xanthines.

B. Beta2-Adrenergic Agonists (Sympathomimetics)

Sympathomimetics are drugs that mimic the effects of the
sympathetic nervous system. One of the actions of the
sympathetic nervous system is dilation of the bronchi with
increased rate and depth of respiration.
This is the desired effect when selecting a sympathomimetic as a
bronchodilator.
❖ Albuterol/Salbutamol (Proventil/Ventolin)
❖ Arformoterol (Brovana)
❖ Ephedrine
❖ Epinephrine
❖ Formoterol (Foradil)
❖ Indacaterol (Arcapta)
❖ Isoproterenol (Isuprel)
❖ Levalbuterol (Xopenex)
❖ Salmeterol (Serevent)
❖ Terbutaline (Brethaire)

Mechanism of Action
✓ At therapeutic levels, the action of most sympathomimetics
are specific to the beta-receptors found in the bronchi.
 ✓ Other systemic effects include increased blood pressure,
increased heart rate, vasoconstriction, and decreased renal
and GI blood flow- all actions of the sympathetic nervous
system.
✓ Epinephrine, the prototype drug, is the drug of choice for
adults and children for the treatment of acute
bronchospasm, including that caused by anaphylaxis; it is
also available for inhalation.

Indications
✓ Long-acting treatment and prophylaxis of bronchospasm and
prevention of exercise-induced bronchospasm in patients 2
years and older.
✓ Long-term maintenance treatment of bronchoconstriction in
COPD.
✓ Treatment of acute bronchospasm in adults and children,
although epinephrine is the drug of choice.
✓ Treatment and prophylaxis of acute asthma attacks in
children more than 6 years old.

Contraindications and Cautions

✓ Underlying conditions. These drugs are contraindicated or
should be used with caution, depending on the severity of
the underlying condition, in conditions that would be
aggravated by the sympathetic stimulation, including
cardiac disease, vascular disease, arrhythmias, diabetes,
and hyperthyroidism.
✓ Pregnancy and lactation. These drugs should be used during
pregnancy and lactation only if the benefits to the mother
clearly outweigh potential risks to the fetus or neonate.

Adverse Effects
CNS: Headache, restlessness.
Cardiovascular: Palpitation, tachycardia.
Skin: Pallor, local burning and stinging.
GU: Decreased renal formation.
Respiratory: Rebound congestion with nasal inhalation.
Psych: Fear, anxiety.

Interactions
✓ Special precautions should be taken to avoid the
combination of sympathomimetic bronchodilators with the
general anesthetics.
✓ Cyclopropane and halogenated hydrocarbons. Because these
drugs sensitize the myocardium to catecholamines, serious
cardiac complications could occur.

C. Anticholinergics
Patients who cannot tolerate the sympathetic effects of
sympathomimetics might respond to the anticholinergic drugs.
These drugs are not as effective as the sympathomimetics
but can provide some relief to those patients who cannot
tolerate the other drugs.
❖ Ipratropium (Atrovent)
❖ Tiotropium (Sprival)

Mechanism of Action
✓ Anticholinergics are used as bronchodilators because of
their effect on the vagus nerve, which sis to block or
antagonize the action of the neurotransmitter acetylcholine
at vagal-mediated receptor sites.
✓ By blocking the vagal effect, relaxation of smooth muscle
in the bronchi occurs, leading to bronchodilation.

Indications
✓ Maintenance and treatment of bronchospasm for adults with
COPD.
✓ Long-term, once-daily maintenance and treatment of
bronchospasm associated with COPD in adults.

Contraindications
✓ Co-morbidities. Caution should be used in any condition
that would be aggravated by the anticholinergic or
atropine-like effects of the drug, such as narrow-angle
glaucoma, bladder neck obstruction or prostatic
 hypertrophy, and conditions aggravated by dry mouth and
throat.
✓ Allergy. The use of ipratropium or tiotropium is
contraindicated in the presence of known allergy to the
drug or to soy products or peanuts to prevent
hypersensitivity reactions.
✓ Pregnancy and lactation. These drugs are not usually
absorbed systematically, but as with all the drugs, caution
should be used in pregnancy and lactation because of the
potential for adverse effects on the fetus or nursing baby.

Adverse Effects
CNS: Dizziness, headache.
GI: Nausea, gastrointestinal distress.
Cardiovascular: Palpitations.
Respiratory: Cough.
Others: Nervousness.

Nursing Considerations for Bronchodilators

• Perform a physical examination to establish baseline data for
assessing the effectiveness of the drug and the occurrence of any
adverse effects associated with drug therapy.
• Monitor blood pressure, pulse, cardiac auscultation, peripheral
perfusion, and baseline electrocardiogram to provide a baseline
for effects on the cardiovascular system.
• Evaluate serum theophylline levels to provide a baseline
reference and identify conditions that may require caution in the
use of xanthines.
• Evaluate urinary output and prostate palpation as appropriate to
monitor anticholinergic effects.
• Relieve GI upset. Administer oral drug with food or milk to
relieve GI irritation if GI upset is a problem.
• Monitor drug response. Monitor patient response to the drug
(e.g., relief of respiratory difficulty, improved airflow) to
determine the effectiveness of the drug dose and to adjust dose
as needed.
• Provide comfort. Provide comfort measures including rest periods,
quiet environment, dietary control of caffeine, and headache
therapy as needed, to help the patient cope with the effects of
drug therapy.
• Provide follow-ups. Provide periodic follow-up, including blood
tests, to monitor serum theophylline levels.
• Individual drug response. Reassure patient that the drug of
choice will vary with each individual; these sympathomimetics are
 slightly different chemicals and are prepared in a variety of
delivery systems; a patient may have to try several different
sympathomimetics before the most effective one is found.
• Proper administration and dosage. Advise the patient to use the
minimal amount needed for the shortest period necessary to
prevent adverse effects and accumulation of drug levels.
• Proper use of sympathomimetics. Teach the patients who use one of
these drugs for exercise-induced asthma to use it 30 to 60
minutes before exercising to ensure peak therapeutic effects when
they are needed.
• Use of adrenergic blockers. Alert the patient that long-acting
adrenergic blockers are not for use during acute attacks because
they are slower acting and will not provide the necessary rescue
in a state of acute bronchospasm.
• Increase oral fluid intake. Ensure adequate hydration and provide
environmental controls such as the use of a humidifier, to make
the patient more comfortable.
• Encourage voiding. Encourage the patient to void before each dose
of medication to avoid urinary retention related to drug effects.
• Small, frequent meals. Provide small, frequent meals and
sugarless lozenges to relieve dry mouth and GI upset.
• Use of inhalator. Review the use of inhalator with the patient;
caution the patient not to exceed 12 inhalations in 24 hours to
prevent serious adverse effects.
• Educate the patient. Provide thorough patient teaching, including
the drug name and prescribed dosage measures to help avoid
adverse effects, warning signs that may indicate problems, and
the need for periodic monitoring and evaluation, to enhance
patient knowledge about drug therapy and to promote compliance.
• Provide patient support. Offer support and encouragement to help
the patient cope with the disease and the drug regimen.

The common cold

The viruses that cause the common cold invade the tissues
of the upper respiratory tract, initiating the release of
histamine and prostaglandins, causing an inflammatory response.
• As a result of the inflammatory response, the mucous
membranes become engorged with blood, the tissues swell,
and the goblet cells increase the mucus production.
• These effects cause the person with a common cold to
complain of sinus pain, nasal congestion, runny nose,
sneezing, watery eyes, scratchy throat, and headache.
• The swelling can block the outlet of the eustachian tube,
which drains the inner ear and equalizes pressure across
the tympanic membrane.
 • If this outlet becomes blocked, feelings of ear stuffiness
and pain can occur.

2. Antitussives
Antitussives are drugs that suppress the cough reflex.
Persistent coughing can be exhausting and can cause muscle
strain and further irritation of the respiratory tract. Many
disorders of the respiratory tract are accompanied by an
uncomfortable, unproductive cough. Coughing is a naturally
protective way to clear the airway of secretions or any
collected material, and antitussives prevent these actions.
Antitussives act on the cough-control center in the medulla
to suppress the cough reflex; if the cough is nonproductive and
irritating, an antitussive may be taken.
❖ Benzonatate (Tessalon)
❖ Codeine
❖ Dextromorphan (Benylin)
❖ Hydrocodone (Hycodan)

Mechanism of Action
Acts directly on the medullary cough center of the brain to
depress the cough reflex.
Because they are centrally acting, they are not the drugs of choice
for anyone who has a head injury or could be impaired by central
nervous system depression.

Indication
✓ Local anesthetic on the respiratory passages, lungs, and pleurae,
blocking the effectiveness of the stretch receptors that
stimulate a cough reflex.
✓ For relief of moderate to moderately severe pain.
✓ For the treatment of dry cough, drug withdrawal syndrome, opioid
type drug dependence, and pain.

Contraindications and Cautions

✓ Patent airways. Patients who need to cough to maintain the
airways (e.g., postoperative patients and those who have
undergone abdominal or thoracic surgery) to avoid respiratory
distress.
✓ Asthma and emphysema. Patients with asthma and emphysema are
contraindicated because cough suppression could lead to
accumulation of secretions and a loss of respiratory reserve.
✓ Addiction. Patients who are hypersensitive to or have a history
of addiction to narcotics; codeine is a narcotic and has
addiction potential
 ✓ Sedation. Patients who need to drive or be alert should use
codeine, hydrocodone, and dextromethorphan with extreme caution
because these drugs can cause sedation and drowsiness.
✓ Pregnancy. Patients who are pregnant and lactating, because of
the potential for adverse effects on the fetus or baby, including
sedation and CNS depression.

Adverse Effects
CNS: Drowsiness and sedation.
GI: Nausea, constipation, dry mouth, GI upset.

Interactions
✓ Monoamine oxidase inhibitors (MAOI). Dextromethorphan should not
be used with MAOIs because hypotension, fever, nausea, myoclonic
jerks, and coma could occur.

Nursing Considerations for Antitussives

• Assess respirations and adventitious sounds.
• Prevent overdosage. Ensure that the drug is not taken any longer
than recommended to prevent serious adverse effects and severity
respiratory tract problems.
• Assess underlying problems. Arrange for further medical
evaluation for coughs that persist or are accompanied by high
fever, rash, or excessive secretions; To detect the underlying
cause of coughing, and to arrange for appropriate treatment of
the underlying problem.
• Provide other relief measures from cough. These nursing
interventions may include humidifying the room, providing fluids,
use of lozenges, and cooling room temperature.
• Monitor patient response to the drug (control of non-productive
cough).
• Educate the patient. Provide thorough patient teaching, including
the drug name and prescribed dosage, measures to help avoid
adverse effects, warning signs that may indicate problems, and
the need for periodic monitoring and evaluation, to enhance
patient knowledge about drug therapy and promote compliance.

3. Expectorants
Expectorants are drugs that liquefy the lower respiratory
tract secretions. They are used for the symptomatic relief of
respiratory conditions characterized by a dry, nonproductive
cough.
Expectorants increase productive cough to clear the
airways. They liquefy lower respiratory tract secretions,
reducing the viscosity of these secretions and making it easier
to cough them up. Expectorants are available in many OTC
preparations, making them widely available to the patient
without advice from a health care provider.
❖ Guaifenesin (Mucinex)

Mechanism of Action
Enhances the output of respiratory tract fluids by reducing
the adhesiveness and surface tension of these fluids, allowing
easier movement of the less viscous secretions.

Indications
Symptomatic relief of respiratory conditions characterized
by a dry, nonproductive cough.

Contraindications and Cautions

✓ Allergy. This drug should not be used in patients with a
known allergy to the drug to prevent hypersensitivity
reactions.
✓ Pregnancy or lactation. This drug should be used with
caution in pregnancy and lactation because of the potential
adverse effects on the fetus or baby.
✓ Cough. This drug should not be used with persistent coughs,
which could be indicative of an underlying medical problem.
Adverse Effects
GI: Nausea, vomiting, anorexia.
CNS: Headache, dizziness.
Underlying cough: The most important consideration in the use of
these drugs is discovering the cause of the underlying cough;
prolonged use of the OTC preparations could result in the
masking of important symptoms of a serious underlying disorder.
Respiratory: Rhinorrhea, bronchospasm.
Skin: Rash.

4. Mucolytics
Mucolytics increase or liquefy respiratory secretions to
aid the clearing of the airways in high-risk respiratory
patients who are coughing up thick, tenacious secretions.
Patients may be suffering from conditions such as chronic
obstructive pulmonary disease (COPD), cystic fibrosis,
pneumonia, or tuberculosis.
❖ Acetylcysteine (Mucomyst)
❖ Dornase alfa (Pulmozyme)
❖
Mechanism of Action
 Protect liver cells from being damaged during episodes of
acetaminophen toxicity because it normalizes hepatic glutathione
levels and binds with a reactive hepatotoxic metabolite of
acetaminophen.
Affects the mucoproteins in the respiratory secretions by
splitting apart disulfide bonds that are responsible for holding
the mucus material together. The result is a decrease in the
tenacity and viscosity of the secretions.
Dornase alfa is a mucolytic prepared by recombinant DNA
techniques that selectively break down respiratory tract mucus
by separating extracellular DNA from proteins.
Indication
✓ Liquefaction of secretions in high-risk respiratory
patients who have difficulty moving secretions including
postoperative patients (e.g., patients with tracheostomies
to facilitate airway clearance and suctioning).
✓ Clearing of secretions for diagnostic tests (e.g.,
diagnostic bronchoscopy).
✓ Used orally to protect the liver from acetaminophen
toxicity.
✓ Treatment of atelectasis from thick mucus secretions.

Contraindications and Cautions

✓ Medical conditions. Caution should be used in cases of
acute bronchospasms, peptic ulcer, and esophageal varices
because the increased secretions could aggravate the
problem.

Adverse Effects
GI: Nausea, vomiting, anorexia.
CNS: Headache, dizziness.
Underlying cough: The most important consideration in the use of
these drugs is discovering the cause of the underlying cough;
prolonged use of the OTC preparations could result in the
masking of important symptoms of a serious underlying disorder.
Respiratory: Rhinorrhea, bronchospasm.
Skin: Rash.

Nursing Considerations for Expectorants and Mucolytics

• Assess for possible contraindications and cautions: any
history of allergy to the drug; persistent cough due to
smoking, asthma, or emphysema, which would be cautions to
 the use of the drug; and very productive cough, which would
indicate an underlying problem that should be evaluated.
• Monitor temperature to assess for underlying infection.
• Assess respirations and adventitious sounds to evaluate the
respiratory response to the drug effects.

For Expectorants
• Proper administration. Caution the patient not to use these
drugs for longer than 1 week and to seek medical attention
if the cough persists after that time to evaluate for any
underlying medical condition and to arrange for appropriate
treatment.
• Prevent GI upset. Advise the patient to take small,
frequent meals to alleviate some of the GI discomfort
associated with these drugs.
• Ensure safety. Advise the patient to avoid driving or
performing dangerous tasks if dizziness and drowsiness
occur to prevent patient injury.
• Avoid overdosage. Alert the patient that these drugs may be
found in OTC preparations and that care should be taken to
avoid excessive doses.
• Provide health education. Provide thorough patient
teaching, including the drug name and prescribed dosage,
measures to help avoid adverse effects, warning signs that
may indicate problems, and the need for periodic monitoring
and evaluation, to enhance patient knowledge about drug
therapy and to promote compliance.

For Mucolytics
• Ensure drug effectiveness. Avoid combining other drugs in
the nebulizer to avoid the formation of precipitates and
potential loss of effectiveness of either drug.
• Proper drug delivery. Dilute concentrate with sterile water
for injection if buildup becomes a problem that could
impede drug delivery.
• Prevent skin breakdown. Note that patients receiving
acetylcysteine by face mask should have the residue wiped
off the face mask and off the face with plain water to
avoid skin breakdown.
• Proper use of nebulizer. Review use of the nebulizer with
patients receiving dornase alfa at home to ensure the most
effective use of the drug.
 • Proper storage. Patients should be cautioned to store the
drug in the refrigerator, protected from light.
• Dornase alfa use. Caution cystic fibrosis patients
receiving dornase alfa about the need to continue all
therapies for their cystic fibrosis because dornase alfa is
only a palliative therapy that improves respiratory
symptoms, and other therapies are still needed.
• Provide health education. Provide thorough patient
teaching, including the drug name and prescribed dosage,
measures to help avoid adverse effects, warning signs that
may indicate problems, and the need for periodic monitoring
and evaluation, to enhance patient knowledge about drug
therapy and to promote compliance.

c. Drugs Acting on gastrointestinal System

Gastroesophageal reflux (GERD) is when the esophageal sphincter
is relaxed and allows gastric contents to be regurgitated back
into the esophagus.
• In pediatric gastroesophageal reflux, immaturity of lower
esophageal sphincter (LES) function is manifested by
frequent transient lower esophageal relaxations (tLESRs),
which result in the retrograde flow of gastric contents
into the esophagus.
• Thus, gastroesophageal reflux represents a common
physiologic phenomenon in the first year of life; as many
as 60-70% of infants experience emesis during at least 1
feeding per 24-hour period by age 3-4 months.
• The distinction between this “physiologic” gastroesophageal
reflux and “pathologic” gastroesophageal reflux in infancy
and childhood is determined not merely by the number and
severity of reflux episodes (when assessed by
intraesophageal pH monitoring), but also, and most
importantly, by the presence of reflux-related
complications, including failure to thrive, erosive
esophagitis, esophageal stricture formation, and chronic
respiratory disease.

Peptic Ulcer Disease

• A peptic ulcer may be referred to as a gastric, duodenal,
or esophageal ulcer, depending on its location.
 • A peptic ulcer is an excavation that forms in the mucosal
wall of the stomach, in the pylorus, in the duodenum, or in
the esophagus.
• The erosion of a circumscribed area may extend as deep as
the muscle layers or through the muscle to the peritoneum.
• Gastric ulcer. Gastric ulcer tend to occur in the lesser
curvature of the stomach, near the pylorus.
• Duodenal ulcer. Peptic ulcers are more likely to occur in
the duodenum than in the stomach.
• Esophageal ulcer. Esophageal ulcer occur as a result pf the
backward flow of HCl from the stomach into the esophagus.

1. Histamine-2 Receptor Antagonist

Histamine-2 (H2) receptor antagonists block the release of
acid in response to gastrin or parasympathetic release.
Histamine-2 antagonists block the release of hydrochloric acid
in response to gastrin.
❖ Cimetidine (Tagamet)
❖ Ranitidine (Zantac)
❖ Famotidine (Pepcid)
❖ Nizatidine (Axid)

Mechanism of Action
✓ Selectively block H2 receptors located on the parietal
cells.
✓ Prevents the release of gastrin, a hormone that causes
local release of histamine (due to stimulation of histamine
receptors), ultimately blocking the production of
hydrochloric acid.
✓ Decreases pepsin production by the chief cells.

Indication
✓ Short-term treatment of active duodenal ulcer or benign
gastric ulcer.
✓ Treatment of pathological hypersecretory conditions such as
Zollinger-Ellison syndrome (blocking the overproduction of
hydrochloric acid that is associated with these
conditions).
✓ Prophylaxis of stress-induced ulcers and acute upper GI
bleeding in critical patients (blocking the production of
acid protects the stomach lining, which is at risk because
of decreased mucus production associated with extreme
stress).
 ✓ Treatment of erosive gastroesophageal reflux (decreasing
the acid being regurgitated into the esophagus will promote
healing and decrease pain).
✓ Relief of symptoms of heartburn, acid indigestion, and sour
stomach.

Contraindications and Cautions

✓ Allergy. The H2 antagonists should not be used with known
allergy to any drugs of this class to prevent
hypersensitivity reactions.
✓ Pregnancy or lactation. Caution should be used during
pregnancy or lactation because of the potential for adverse
effects on the fetus or nursing baby.
✓ Hepatic or renal dysfunction. Caution should be used in
patients with hepatic or renal dysfunction, which could
interfere with drug metabolism and excretion.
✓ Prolonged or continual use. Care should also be taken if
prolonged or continual use of these drugs is necessary
because they may be masking serious underlying conditions.

Adverse Effects
CNS: Dizziness, confusion, headache, somnolence.
Cardio: Cardiac arrhythmias, cardiac arrest.
GI: Diarrhea.
Reproductive: Impotence.
Skin: Rash.
Misc: Gynecomastia.

Interactions
Cimetidine, famotidine, and ranitidine can slow down the
metabolism of the following drugs, leading to increased serum
levels and possible toxic reactions:

• Warfarin.
• Anti-coagulants.
• Phenytoin.
• Beta-adrenergic blockers.
• Alcohol.
• Quinidine.
• Lidocaine.
• Theophylline.
• Chloroquine.
 • Benzodiazepines.
• Nifedipine.
• Pentoxifylline.
• TCAs.
• Procainamide.
• Carbamazepine.

Nursing Considerations
• Ensure therapeutic levels. Administer drug with or before
meals and at bedtime (exact timing varies with product) to
ensure therapeutic levels when the drug is most needed.
• Prevent serious toxicity. Arrange for decreased dose in
cases of hepatic or renal dysfunction to prevent serious
toxicity.
• Monitor IV doses carefully. Monitor the patient continually
if giving IV doses to allow early detection of potentially
serious adverse effects, including cardiac arrhythmias
• Assess for potential drug-drug interactions. Assess the
patient carefully for any potential drug-drug interactions
if given in combination with other drugs because of the
drugs effects on liver enzyme systems.
• Provide patient’s comfort. Provide comfort, including
analgesics, ready to access bathroom facilities, and
assistance with ambulation, to minimize possible adverse
effects.

2. Proton Pump Inhibitors

The gastric acid pump or proton pump inhibitors suppress
gastric acid secretion by specifically inhibiting the hydrogen-
potassium adenosine triphosphate enzyme system on the secretory
surface of the gastric parietal cells. Proton pump inhibitors
suppress the secretion of hydrochloric acid into the lumen of
the stomach.
❖ Dexlansoprazole (Kapidex)
❖ Esomeprazole (Nexium)
❖ Lansoprazole (Prevacid)
❖ Omeprazole (Prilosec)
❖ Pantoprazole (Protonix)
❖ Rabeprazole (Aciphex)

Mechanism of Action
 ✓ Blocks the final step of acid production, lowering the acid
levels in the stomach.
✓ Inhibits the hydrogen-potassium adenosine triphosphate
enzyme system on the secretory surface of the gastric
parietal cells.

Indication
✓ Treatment and maintenance of erosive esophagitis, treatment
of heartburn associated with GERD.
✓ Treatment of GERD, severe erosive esophagitis, duodenal
ulcers, and pathological hypersecretory condition.
✓ Treatment of gastric ulcer.
✓ Maintenance therapy for healing duodenal ulcers and
esophagitis.
✓ In combination therapy for eradicating Helicobacter pylori
infection.
✓ Approved for use in children for treatment of GERD, peptic
ulcer, and Zollinger-Ellison syndrome.

Contraindications and Cautions

✓ Allergy. These drugs are contraindicated in the presence of
a known allergy to either the drug or the drug components
to prevent hypersensitivity reactions.
✓ Pregnant or lactating women. Caution should be used in
pregnant or lactating women because of the potential for
adverse effects on the fetus or neonate.
✓ Patients 18 years old and below. The safety and efficacy of
these drugs have not been established for patients younger
than 18 years of age, except for lansoprazole, which is the
proton pump inhibitor of choice if one is needed for a
child.

Adverse Effects
CNS: Headache, dizziness, vertigo, insomnia.
Skin: Rash.
GI: Diarrhea, abdominal pain, nausea, vomiting.
Respiratory: Upper respiratory infections, cough.

Interactions
✓ Benzodiazepines, phenytoin, warfarin: There is a risk of
increased serum levels and increased toxicity of
benzodiazepines, warfarin, and phenytoin if these are
 combined with these drugs; patients should be monitored
closely.
✓ Ketoconazole and theophylline. Decreased levels of
ketoconazole and theophylline have been reported when
combined with these drugs, leading to loss of
effectiveness.
✓ Sucralfate. Sucralfate is not absorbed well in the presence
of these drugs, and doses should be spaced at least 30
minutes apart if this combination is used.
✓ Clopidogrel. There is an increased risk of cardiovascular
events if proton pump inhibitors are combined with
clopidogrel; this combination should be avoided.

Nursing Considerations
• Proper administration. Administer drug before meals to
ensure that the patient does not open, chew, or crush
capsules; they should be swallowed whole to ensure the
therapeutic effectiveness of the drug.
• Safety and comfort measures. Provide appropriate safety and
comfort measures if CNS effects occur to prevent patient
injury.
• Institute a bowel program. Monitor the patient for diarrhea
or constipation in order to institute an appropriate bowel
program as needed.
• Monitor nutritional status. Monitor the patient’s
nutritional status; use of small frequent meals may be
helpful if GI upset is a problem.
• Ensure follow-up. Arrange for medical follow-up if symptoms
are not resolved after 4 to 8 weeks of therapy because
serious underlying conditions could be causing the
symptoms.
• Provide patient support. Offer support and encouragement to
help the patient cope with the disease and the drug
regimen.

3. Antacids
Antacids are used to chemically react with and neutralize
the acid in the stomach. They can provide rapid relief from
increased acid levels. Antacids are a group of inorganic
chemicals that neutralize stomach acid.
Antacids are available OTC, and many patients use them to self-
treat a variety of GI symptoms.
❖ Calcium Carbonate (Tums)
 ❖ Aluminum Hydroxide (Gaviscon)
❖ Magnesium Hydroxide

Mechanism of Action
✓ Neutralize stomach acid by direct chemical reaction.
✓ Symptomatic relief of an upset stomach associated with
hyperacidity, as well as the hyperacidity associated with
peptic ulcer, gastritis, peptic esophagitis, gastric
hyperacidity, and hiatal hernia.
Indication
✓ Symptomatic relief of GI hyperacidity, treatment of
hyperphosphatemia, prevention of formation of phosphate
urinary stones.
✓ Treatment of calcium deficiency, prevention of
hypocalcemia.
✓ Prophylaxis of stress ulcers, relief of constipation.
Contraindications and Cautions
✓ Allergy. The antacids are contraindicated in the presence
of any known allergy to antacid products or any component
of the drug to prevent hypersensitivity reactions.
✓ Co-morbidities. Caution should be used in the following
instances: any condition that can be exacerbated by
electrolyte or acid-based imbalance to prevent
exacerbations and serious adverse effects; any electrolyte
imbalance, which could be exacerbated by the electrolyte-
changing effects of these drugs; GI obstruction which could
cause systemic absorption of the drugs and increase adverse
effects; renal dysfunction, which could lead to electrolyte
disturbance if any absorbed antacid is neutralized
properly.
✓ Pregnancy and lactation. Antacids are contraindicated for
pregnant and lactating women because of the potential for
adverse effects on the fetus or neonate.

Adverse Effects
GI: Gastric rupture.
Systemic alkalosis: headache, nausea, irritability, weakness,
tetany, confusion.
Misc: Hypokalemia.

Interactions
✓ Alkalinity. Most drugs are prepared for an acidic
environment, and an alkaline environment can prevent them
 from being broken down for absorption or can actually
neutralize them so that they cannot be absorbed.

Nursing Considerations
✓ Inspect the abdomen; auscultate bowel sounds to ensure GI
motility.
✓ Assess mucous membrane status to evaluate potential
problems with absorption and hydration.
✓ Adequate drug absorption. Administer the drug apart from
any other oral medications approximately 1 hour before or 2
hours after to ensure adequate absorption of the other
medications.
✓ Ensure therapeutic levels. Have the patient chew tablets
thoroughly and follow with water to ensure that therapeutic
levels reach the stomach to decrease acidity.
✓ Perform diagnostic testing. Obtain specimens for periodic
monitoring of serum electrolytes to evaluate drug effects.
✓ Prevent imbalances. Assess the patient for any signs of
acid-base or electrolyte imbalance to ensure early
detection and prompt interventions.
✓ Institute a bowel program. Monitor the patient for diarrhea
or constipation to institute a bowel program before severe
effects occur.

4. GI Protectant
Sucralfate is a mucosal protectant used to cover and
protect gastrointestinal ulcers.

Mechanism of Action
Sucralfate locally covers the ulcer site in the GI tract
and protects it against further attack by acid, pepsin, and bile
salts. It is minimally absorbed by the gastrointestinal tract.

Indications
Sucralfate is used in the treatment of ulcers.
Specific Administration Considerations
Administer sucralfate on an empty stomach, 2 hours after or
1 hour before meals. Constipation may occur. Sucralfate should
be cautiously used with patients with chronic renal failure or
those receiving dialysis due to impaired excretion of small
amounts of absorbed aluminum that can occur with sucralfate.

4. Laxatives
5. Antiemetic Agents
Antiemetic drugs are medicines that ease nausea or
vomiting. A person might use an over-the-counter or prescription
version.
Prokinetics
❖ Metoclopramide (Plasil)
❖ Domperidone
❖ Prochlorperazine

Serotonin Antagonists
❖ Ondansetron
❖ Granisetron
❖ Ramosetron
❖ Palonosteron