Gastrointestinal Gastrointestinal PharmacotherapyPharmacotherapy

Sarah Nelson, Pharm.D.Sarah Nelson, Pharm.D.

March 3, 2009March 3, 2009

ObjectivesObjectives

Discuss the process of acid secretion Discuss the process of acid secretion in the gastrointestinal tractin the 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 Differentiate medications used to account for impaired account for impaired gastrointestinal motilitygastrointestinal motility

Gastrointestinal tractGastrointestinal tract

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

Disorders of the Disorders of the Esophagus and Esophagus and StomachStomach Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease

(GERD)(GERD)– Dyspepsia/Non-erosive reflux disease Dyspepsia/Non-erosive reflux disease

(NERD)(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

Gastric SecretionGastric Secretion

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

Stomach AnatomyStomach Anatomy

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19223.jpg

Defense MechanismsDefense Mechanisms

Lower esophageal sphincterLower esophageal sphincter

Secretion of gastric mucusSecretion of gastric mucus– Stimulated by prostaglandin EStimulated by prostaglandin E22 and and

II22

Secretion of bicarbonate ionsSecretion of bicarbonate ions

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

GERDGERD

Definition: when the reflux of Definition: when the reflux of stomach contents causes stomach contents causes troublesome symptoms or troublesome symptoms or complicationscomplications

Diagnosis:Diagnosis:– Presence of symptomsPresence of symptoms– Demonstration of refluxDemonstration of reflux– Identification of existing damage from Identification of existing damage from

refluxrefluxAli, T. Miner, P. New Developments in gastroesophageal reflux disease diagnosis and therapy. Curr Opin in Gastroenterology. 2008;24:502-508

EpidemiologyEpidemiology

44% of adults in the US 44% of adults in the US experience heartburn experience heartburn ≥ 1 ≥ 1 time/monthtime/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 Heartburn or substernal burning is the most commonly recognized is the most commonly recognized manifestation of GERDmanifestation of GERD

Shaheen, N., Ransohoff, D.F. Gastroesophageal Reflux, Barrett Esophagus, and Esophageal Cancer: Scientific Review. JAMA. 2002;287(15):1972-1981

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

Stages of GERDStages of GERDStageStage DescriptionDescription Medical Medical

ManagementManagementI (NERD)I (NERD) sporadicsporadic

2-3 episodes/wk2-3 episodes/wk

Lifestyle Lifestyle modificationmodificationAntacids/H2 RA as Antacids/H2 RA as neededneeded

II II Frequent Frequent symptomssymptoms+/- esophagitis+/- esophagitis

PPI vs. H2RAPPI vs. H2RA

IIIIII Chronic, Chronic, unrelentingunrelentingImmediate relapse Immediate relapse off therapyoff therapyEsophageal Esophageal complicationscomplications

PPI once or twice PPI once or twice dailydaily

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

Treatment of GERDTreatment of GERD

Decrease acidity of stomach Decrease acidity of stomach contentscontents– 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. 11th Edition. USA; McGraw-Hill Company, 2006.

AntacidsAntacids

Chemically neutralize stomach acidChemically neutralize stomach acid

Base (OH)Base (OH)33 or CO or CO3 3 + Al, Ca, or Mg+ Al, Ca, or Mg

– CaCOCaCO33= calcium carbonate (Tums= calcium carbonate (Tums®)®)

– Al Al (OH)(OH)33 + Mg (OH) + Mg (OH)22 = Maalox = Maalox®®

Some contain simethicone (a Some contain simethicone (a surfactant)surfactant)– Al Al (OH)(OH)33 + Mg (OH) + Mg (OH)22 + simethicone = Mylanta + simethicone = Mylanta®®

Site GI chapter

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 AlCl33 + 3H + 3H22OO

CaCOCaCO33 + 2 HCl CaCl + 2 HCl CaCl22 + 2H + 2H220 + CO0 + CO22

Site GI chapter

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 With other acid suppressants on an as

needed basisneeded basis– Calcium supplementationCalcium supplementation

Site GI chapter

HH22-Receptor -Receptor AntagonistsAntagonists Block histamine from binding to HBlock histamine from binding to H22

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 Blocks basal and bolus acid secretionsecretion– 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. 11th Edition. USA; McGraw-Hill Company, 2006.

HH22-Receptor -Receptor AntagonistsAntagonists Cimetidine (TagametCimetidine (Tagamet®®))

– Not used often due to drug Not used often due to drug interactionsinteractions

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. 11th Edition. USA; McGraw-Hill Company, 2006.

HH22-Receptor -Receptor AntagonistsAntagonists 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. 11th Edition. USA; McGraw-Hill Company, 2006.

Proton Pump InhibitorsProton Pump Inhibitors

Most potent inhibitors of acid Most potent inhibitors of acid secretionsecretion– Decrease daily acid secretion 80-95%Decrease daily acid secretion 80-95%

Require activation by acid in Require activation by acid in stomachstomach

Irreversibly binds and inactivates Irreversibly binds and inactivates the Hthe H++/K/K++-ATPase -ATPase – HH++/K/K++-ATPase is the pump molecule -ATPase is the pump molecule

that secretes acid from the parietal cell that secretes acid from the parietal cell into the lumen of the stomachinto the lumen of the stomachBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.

11th Edition. USA; McGraw-Hill Company, 2006.

Proton Pump InhibitorsProton Pump InhibitorsDrugDrug Healing Healing PreventionPreventionOmeprazole Omeprazole (Prilosec(Prilosec®®))

20-40mg daily20-40mg daily 20mg daily20mg daily

Esomeprazole Esomeprazole (Nexium(Nexium®®))

20-40mg daily20-40mg daily 20mg daily20mg daily

Lansoprazole Lansoprazole (Prevacid(Prevacid®®))

15-30mg daily15-30mg daily 15 mg daily15 mg daily

Pantoprazole Pantoprazole (Protonix(Protonix®®))

40mg daily40mg daily 20-40mg daily20-40mg daily

Rabeprazole Rabeprazole (Aciphex(Aciphex®®))

20mg daily20mg daily 20mg daily20mg dailySite GI chapter

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 Prevent NSAID-associated gastric

ulcersulcers

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

MiscellaneousMiscellaneous

Other medications used for GERDOther medications used for GERD– Prostaglandin analogues (i.e. misoprostol)Prostaglandin analogues (i.e. misoprostol)

Bind a EPBind a EP33 receptor on parietal cells, receptor on parietal cells, decreasing cAMP (energy) available for Hdecreasing cAMP (energy) available for H++/K/K++--ATPase ATPase

– SucralfateSucralfate Sucrose + Al(OH)Sucrose + Al(OH)33 which forms a viscous layer which forms a viscous layer

on the gastric mucosaon the gastric mucosa Prevents acid from contacting mucosaPrevents acid from contacting mucosa

– MetoclopramideMetoclopramide Stimulates gastric motilityStimulates gastric motility increased increased

clearance of stomach acidclearance of stomach acidSite GI chapter

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

H. Pylori InfectionH. Pylori Infection

Gram-negative rodGram-negative rod Not always associated with an Not always associated with an

active ulceractive ulcer 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 promote healing of ulcer and to prevent recurrenceprevent recurrence

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

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 Patient compliance is difficult with intense

regimensregimensBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.

Acid-rebound Acid-rebound PhenomenonPhenomenon Chronic suppression of acid Chronic suppression of acid

secretion leads to secretion leads to hypergastrinemiahypergastrinemia– Gastrin stimulates ECL cells to Gastrin stimulates ECL cells to

release histaminerelease histamine increased acid increased acid secretion from activation of secretion from activation of histamine receptor on parietal cellhistamine receptor on parietal cell

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

Disorders of the Lower Disorders of the Lower GI TractGI Tract ConstipationConstipation

DiarrheaDiarrhea

Gastrointestinal Gastrointestinal MotilityMotility

The GI tract is in a continuous The GI tract is in a continuous contractile, absorptive, & secretory contractile, absorptive, & secretory statestate

Muscle, CNS, ENS (enteric nerve Muscle, CNS, ENS (enteric nerve system), and humoral pathways system), and humoral pathways control GI movementcontrol GI movement

4 phases to movement in the GI tract4 phases to movement in the GI tract– Peristalsis is most important, moves Peristalsis is most important, moves

contents through GI tractcontents through GI tract

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

GI MotilityGI Motility

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increased transit time

- Increased water absorption constipation

decreased transit time

-Decreased water and nutrient absorption diarrhea

ConstipationConstipation

Affects up to 27% of AmericansAffects up to 27% of Americans Accounts for 2.5 mil. physician Accounts for 2.5 mil. physician

visits/yearvisits/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, infrequent stool, difficult stool passage, or bothor both

Cash, B. et al. Update on the Management of Adults with Chronic Idiopathic Constipation. The Journal of Family Practice. 2007;56(6):S13-20

ConstipationConstipation

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

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

Treatment of Treatment of ConstipationConstipation 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. 11th Edition. USA; McGraw-Hill Company, 2006.

Bulk-Forming Bulk-Forming LaxativesLaxatives 3 kinds3 kinds

– Psyllium (MetamucilPsyllium (Metamucil®®))– Methylcelluose (CitrucelMethylcelluose (Citrucel®®))– Calcium polycarbophil (FiberconCalcium polycarbophil (Fibercon®®))

Increases colonic mass which Increases colonic mass which triggers peristalsistriggers peristalsis

Increases water content of stool Increases water content of stool via hydrophilic forcesvia hydrophilic forces

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

Stimulant LaxativesStimulant Laxatives

Induce low-grade inflammation in the small and Induce low-grade inflammation in the small and large intestinelarge intestine– Promotes accumulation of water and Promotes accumulation of water and

stimulates motilitystimulates motility 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 5-15 mg by mouth daily; 10mg rectally daily (rectal administration effective within 1 (rectal administration effective within 1 hour)hour)

Castor OilCastor Oil Senna (SenokotSenna (Senokot®®))

– 8.6mg sennosides 1-2 times per day (1-2 8.6mg sennosides 1-2 times per day (1-2 tablets once or twice daily)tablets once or twice daily)

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

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

Hyperosmotic Hyperosmotic LaxativesLaxatives 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 1-6 hourshours

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. 11th Edition. USA; McGraw-Hill Company, 2006.

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

Stool Stool Softeners/LubricantsSofteners/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 intestinal tract, leading to increase stool water contentwater content

– 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 days1-3 daysBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics. 11th Edition. USA; McGraw-Hill Company, 2006.

Diarrhea Diarrhea

Prevalence of diarrhea varies in Prevalence of diarrhea varies in developed vs. non-developed countriesdeveloped vs. non-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 Can be associated with an infectious

causecause– Shigella, Salmonella, E. Coli among most Shigella, Salmonella, E. Coli among most

commoncommon Most diarrhea is self-limitingMost diarrhea is self-limiting Defined as an increase in stool frequency Defined as an increase in stool frequency

or water contentor water contentDipiro, Joseph et al. Pharmacotherapy: A Pathophysiologic Approach. 6th Edition. USA; McGraw-Hill Company, 2005.

DiarrheaDiarrhea

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

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

AdsorbentsAdsorbents

Non-selectively absorbs intestinal Non-selectively absorbs intestinal fluidfluid– 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 space out from others by 2 to 3 hourshoursBrunton, Laurence. Goodman & Gillman’s The Pharmacological Basis of Therapeutics.

11th Edition. USA; McGraw-Hill Company, 2006.

Bismuth SalicylateBismuth Salicylate

Anti-secretory, anti-inflammatory, Anti-secretory, anti-inflammatory, antimicrobial effectsantimicrobial effects

Used for the prevention and Used for the prevention and treatment of traveler’s diarrheatreatment of traveler’s diarrhea

PeptoBismolPeptoBismol®®

– 30mL (2 tabs) every hour as needed 30mL (2 tabs) every hour as needed (up to 8 times/day)(up 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. 11th Edition. USA; McGraw-Hill Company, 2006.

ProbioticsProbiotics

Replaces normal colonic microfloraReplaces normal colonic microflora– Restores intestinal function and Restores intestinal function and

suppresses the growth of pathogenic suppresses the growth of pathogenic bacteriabacteria

Lactobacillus acidophilus (LactinexLactobacillus acidophilus (Lactinex®®))– 2 tabs or 1 packet of granules 3-4 times 2 tabs or 1 packet of granules 3-4 times

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

ConclusionConclusion

Approximately 1/3 of your patients Approximately 1/3 of your patients will be taking a medication for GERDwill be taking a medication for GERD

Approximately ¼ of your patients Approximately ¼ of your patients will be taking a medication for will be taking a medication for constipationconstipation

GERD, constipation, and diarrhea GERD, constipation, and diarrhea affect a patient’s quality of lifeaffect a patient’s quality of life

Questions?Questions?