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Gastric mucosal protective agents: Nursing Pharmacology

Notes

Notes

GASTRIC MUCOSAL PROTECTIVE AGENTS
DRUG NAME
misoprostol (Cytotec)
sucralfate (Carafate)
bismuth subsalicylate (Pepto-Bismol)
CLASS
Gastric mucosal protective agents
MECHANISM OF ACTION
  • Prostaglandin analogue
  • Stimulates production of gastric mucus and bicarbonate
  • Decreases gastric acid secretion
  • Forms protective barrier over gastric mucosa
  • Stimulates prostaglandin and bicarbonate production
  • Forms protective coating over ulcerated tissue
  • Increases production of mucus, prostaglandins, and bicarbonate
  • Antimicrobial properties
INDICATIONS
  • Peptic ulcers
  • NSAID-induced ulcers 
  • GERD
  • Combination treatment for H. pylori infection
ROUTE(S) OF ADMINISTRATION
  • PO
SIDE EFFECTS
  • Nausea, vomiting, diarrhea
  • Diaphoresis
  • Headaches
  • Cardiac arrhythmias
  • Thrombotic events
  • Constipation
  • Headaches
  • Dizziness
  • Dry mouth
  • Back pain
  • Hyperglycemia
  • Black tongue
  • Black stool
  • Ototoxicity: hearing loss, tinnitus
CONTRAINDICATIONS AND CAUTIONS
  • Boxed warning: pregnancy loss
  • Glaucoma
  • Cardiovascular disease
  • Respiratory disease
  • Hepatic disease
  • Renal disease
  • Renal disease
  • Uncontrolled diabetes mellitus
  • Impaired swallowing or gag reflex
  • Adult clients taking aspirin
NURSING CONSIDERATIONS:
GASTRIC MUCOSAL PROTECTIVE AGENTS
DRUG NAME
misoprostol (Cytotec)
sucralfate (Carafate)
bismuth subsalicylate 
(Pepto-Bismol)
ASSESSMENT AND MONITORING
All mucosal protective agents
  • Assess current symptoms
    • Pain location, quality, duration and severity, triggers; nausea, bloating, reflux
    • Epigastric tenderness
  • Laboratory test results
    • CBC
    • Stool testing for occult blood
  • Diagnostic test results
    • Upper gastrointestinal endoscopy
  • Monitor
    • Symptom resolution
    • Side effects
    • Signs of worsening condition; e.g., increased pain, and indications of gastric bleeding
  • Baseline laboratory test results
    • Hepatic function
    • Renal function
    • Negative pregnancy test for your female clients
  • Baseline laboratory test results
    • Renal function
    • Blood glucose level

CLIENT EDUCATION
All mucosal protective agents
  • Lifestyle modifications
    • Avoid alcohol, spicy or greasy foods, excessive caffeine, and tobacco products
    • Report increasing abdominal pain, bloody or coffee-ground emesis, black or tarry stools, feeling dizzy, fast heart beat
  • Medication stimulates production of gastric mucus and bicarbonate
  • Take four times each day with meals and at bedtime
  • Side effects:  report stomach cramps, nausea, diarrhea; pregnancy loss
    • Female clients: reliable form of birth control required; provide both verbal and written information
  • Medication forms a protective coating over ulcer
  • Take on an empty stomach one hour before meals; wait at least 30 minutes before also taking an antacid; separate sucralfate and other medications by at least two hours
  • Side effects: constipation
    • Increase fluid, fiber, physical activity
  • Medication forms a protective coating over the stomach; reduces gastric inflammation
  • Chewable tablets: chew thoroughly and dissolve completely before swallowing
  • Non-chewable tablets: take  with a full glass of water
  • Liquid: shake well; dispense using oral medication syringe or medication cup
  • Side effects
    • Temporary black discoloration of tongue or stool
    • Ototoxicity: report hearing loss, tinnitus or ringing in the ears,  dizziness
Memory Anchors and Partner Content
Transcript

Mucosal protective agents are medications that protect the mucosal lining of the stomach from gastric acid, and are used to treat conditions like peptic ulcers, NSAID-induced ulcers, and gastroesophageal reflux disorder or GERD.

Mucosal protective agents are also used as a part of the combination treatment against the bacterium H. pylori. Now, these medications can be broadly divided into three classes; prostaglandin analogues, sucralfate, and bismuth compounds.

Starting with prostaglandin analogues, these include misoprostol, which is a synthetic analog of prostaglandin E1 that can be taken orally.

Once administered, misoprostol stimulates the production of gastric mucus, as well as bicarbonate, which helps neutralize the gastric acid.

At the same time, misoprostol acts directly on the parietal cells of the stomach to decrease their secretion of gastric acid.

Common side effects of prostaglandin analogues include stomach cramps and diarrhea. Other side effects may include diaphoresis, headaches, cardiac arrhythmias, and thrombotic events.

As a boxed warning, prostaglandin analogues are contraindicated during pregnancy, since they can induce abortion. They should also be avoided by clients of childbearing age that do not use contraception.

In addition, prostaglandin analogues must be used with caution in clients with glaucoma, cardiovascular disease, respiratory disease like asthma, and hepatic or renal disease, since they can exacerbate these conditions.

Next is sucralfate, this is taken orally. The way it works is by forming a protective barrier over the ulcer, which prevents damage by gastric acid.

In addition, similarly to prostaglandin analogues sucralfate also stimulates mucosal protective mechanisms and bicarbonate production.

Now, sucralfate contains aluminum hydroxide, which can inhibit smooth muscle contraction in the gastrointestinal tract, leading to side effects like constipation. Other side effects include headaches, dizziness, dry mouth, back pain, and hyperglycemia.

In terms of contraindications, prolonged use of sucralfate should be avoided in clients with renal disease, since aluminum may build up and even cause toxicity! Other contraindications include uncontrolled diabetes mellitus, and impaired swallowing or gag reflex.

Finally, there’s bismuth compounds, which are usually given orally in the form of bismuth subsalicylate. Much like sucralfate, bismuth forms a protective coating over the gastric lining and ulcerated tissue, and also increases the production of mucus, prostaglandins, and bicarbonate.

In addition, bismuth subsalicylate has antiinflammatory and antimicrobial properties. For side effects, bismuth subsalicylate can cause the tongue and stool to turn black temporarily.

In addition, since it contains salicylate, it is associated with ototoxicity, which may result in hearing loss and tinnitus.

Bismuth subsalicylate should be avoided in children recovering from a viral infection like the flu, since salicylate can cause a life-threatening encephalopathy called Reye syndrome. Finally, bismuth subsalicylate should be used with caution in adult clients taking aspirin.

Now, if your client with an NSAID-induced gastric ulcer is prescribed a mucosal protective agent, first ask your client about the symptoms they are experiencing, including pain location, quality, duration and severity, and as well as any triggers that bring on episodes of pain.

Also ask about symptoms that accompany their pain such as nausea, bloating, or gastric reflux. Next, perform a focused gastrointestinal assessment, noting the presence of epigastric tenderness.

Sources
  1. "Focus on Nursing Pharmacology" LWW (2019)
  2. "Pharmacology: A Patient-Centered Nursing Process Approach (8e)" Elsevier Health Sciences (2014)
  3. "Mosby's 2021 Nursing Drug Reference" Mosby (2021)
  4. "Saunders Comprehensive Review for the NCLEX-RN Examination" Saunders (2020)
  5. "Goodman & Gilman's: The Pharmacological Basis of Therapeutics (13e)" McGraw-Hill Education  (2018)