may take three to four days for full acid-inhibiting effects to be realized. Similarly, it may take the same amount of time, after stopping dosage for acid secretion to return to normal. Proton pump inhibitors are largely metabolized by the liver and are eliminated in urine. The drug may not be appropriate for individuals with substantial liver or renal dysfunction. Proton pump inhibitors are effective in the treatment of both non-erosive and erosive reflux disease (GERD) and its related esophageal complications, including peptic stricture or Barrett’s esophagus, and related effects outside the esophagus. One dose daily typically provides relief from symptoms and encourages healing in up to 90 percent of patients. Individuals with erosive esophagitis may experience recurrence after discontinuing proton pump inhibitors. Use of daily or twice daily dosage with proton pump inhibitors for a period of at least three months may be used to relieve non-esophageal reflux-disease-related complications and symptoms such as cough, asthma, or laryngitis. Proton pump inhibitors assist in the healing of both duodenal and gastric ulcers, healing over 90 percent of ulcers within 8 weeks. Ulcers may be caused by H pylori or associated with the use of NSAIDs (non-steroidal anti-inflammatory drugs), like aspirin. In the case of H pylori infection, the therapeutic strategy is two-fold: to eliminate the bacteria and heal the ulcer. Elimination of the organism is produced through the proton pump inhibitor’s ability to substantially raise environmental pH in the body, allowing antibiotics to effectively combat H pylori. Proton pump inhibitors are combined with the antibiotic clarithromycin and amoxicillan (or metronidazole) to clear the infection. Use of proton pump inhibitors is typically used for up to six weeks to assure healing. Ulcers associated with NSAID use can be effectively healed by proton pump inhibitors. In cases where NSAID use is discontinued, more effective ulcer healing occurs. While continued use of NSAID reduces the amount of healing, some positive effects are still seen. Proton pump inhibitors are used among some populations daily, to prevent potential complications from NSAID use, like bleeding or perforation. Proton pump inhibitors administered orally once or twice daily for a period of up to five days significantly reduces ulcer re- bleeding (the reoccurrence of bleeding from peptic ulcers). Side effects of proton pump inhibitors are reported in 1-5 percent of individuals using them. Typical symptoms are diarrhea, abdominal pain, and/or headache. A reduction in acid due to proton pump inhibitor use may contribute to lowered vitamin B12 absorption from food. The reduction in acid may also produce a slightly increased risk to enteric infections like salmonella. Decreased gastric acidity tends to increase gastric bacterial concentration in individuals taking proton pump inhibitors. It also alters the absorption of some drugs that require intragastic acidity. Drugs for motility disorders Cisapride (Propulsid) dolasetron (Anzemet); metoclopramide (Reglan). Drugs that stimulate gastrointestinal motility (prokinetic agents) are useful for a number of reasons: they may enhance lower esophageal pressure in the treatment of GERD, by improving gastric passage and emptying, and may be useful in the treatment of constipation. The prokinetic activity of metoclopramid, cisapride, and domperidone is a function of cholinergic stimulation. These agents increase esophageal peristalsis, increase lower esophageal sphincter (LES) pressure and increase gastric emptying. Both metoclopramide and domperidone (see below) also provide effective anti-nausea and anti-emetic action. Cisapride also increases small bowel and colonic action. Only metoclopramide is available for use in the U.S., while domperidone is available in many other countries. Prokinetic agents are typically used together with antisecretory drugs to
treat regurgitation or refractory heartburn. All three agents are useful in the treatment of GERD, but not in the case of erosive esophagitis. Metoclopromide is used to treat individuals with delayed gastric emptying (due to surgery or diabetes) and is sometimes administered to hospitalized individuals using feeding tubes to promote movement of food from the stomach to the duodenum. Metoclopromide may also provide some relief from symptoms of chronic dyspepsia, for the prevention and treatment of emesis (nausea), and to prevent vomiting. Metoclopramide side effects are associated with central nervous system functions, with effects such as restlessness, sleepiness or insomnia, anxiety or agitation in up to 20 percent of users, and even more pronounced in elderly populations. Long-term use should be avoided, especially among the elderly. Laxative drugs* Bisacodyl (Dulcolax), cascara sagrada, castor oil, docusate (Colace), glycerin liquid (Fleet), lactulose (Chronulac), magnesium hydroxide (Milk of Magnesia, Epsom Salt), methylcellulose, mineral oil, polycarbophil (Equalactin), polyethylene glycol electrolyte solution (CoLyte), psyllium (Metamucil), senna (ExLax). Many people use over-the-counter laxatives instead of a high-fiber diet, adequate hydration, and exercise to maintain regularity. Laxatives work though one of four mechanisms: bulk-forming, stool softening, osmotic or stimulant laxatives. Bulk-forming laxatives cannot be digested; instead they absorb water within the body, turning into a bulky gel that stimulates peristalsis. Bulk-forming laxatives are made from plants like psyllium and methylcellulose, and synthetic fibers like polycarbophil. In the case of plant fibers, digestion can cause bloating and increased gas emissions. Stool surfactant agents, or “softeners,” allow the entry of water and lipids into the stool, softening the material. Docusate (oral or enema) is typically prescribed in hospitalized individuals to prevent constipation. Glycerin suppositories and mineral oil are also commonly used stool softeners. Mineral oil is used by some to prevent and treat constipation or impaction in children or debilitated adults. Long-term use may reduce absorption of vitamins A, D, E, and K. Osmotic laxatives are nonabsorbable solutions that result in increased liquidity of the stool. Nonabsorbable sugars and salts, like magnesium oxide, are commonly used for the treatment of acute constipation or the prevention of chronic constipation. It should not be used long-term due to its potential for magnesium poisoning. Sorbital and lactulose are nonabsorbable sugars used to regulate bowel movements, but because they are metabolized by bacteria in the colon, they produce side effects of cramps and increased gas. Osmotic laxatives taken in high dosages produce rapid bowel evacuation (purgatives) within a number of hours, which can be useful in cases of constipation. The most commonly used purgatives are sodium phosphate and magnesium citrate, which may cause electrolyte imbalance in elderly or frail individuals or with cardiac disease. Polyethylene glycol (PEG) is used for colonic cleansing prior to endoscopic procedures. This solution contains a nonabsorbable, osmotically active sugar and salts that do not produce electrolyte shifts or cause the individual to retain fluids, so are safer. For the treatment or prevention of chronic constipation, small doses of PEG may be taken by mouth daily, with minimal cramping or gassy side effects. Stimulant laxatives are also called cathartics . They are used to induce bowel movements in individuals with neurological impairment or bed-bound patients. Stimulant laxatives that are produced from plants, like aloe and senna, are poorly absorbed, producing bowel movement in under 12 hours (oral) and 2 hours (rectal). Long-term use causes harmless
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