FAMOTIDINE
Pepcid® AC [OTC]; Pepcid®
DOSING IN ADULTS
Esophagitis and accompanying symptoms due to GERD: 20 mg or 40 mg twice daily for up to 12 weeks
Duodenal ulcer: Acute therapy: 40 mg/day at bedtime for 4-8 weeks; maintenance therapy: 20 mg/day at bedtime
GERD: 20 mg twice daily for 6 weeks
Heartburn, indigestion, sour stomach: OTC labeling: 10-20 mg every 12 hours; dose may be taken 15-60 minutes before eating foods known to cause heartburn
DOSING IN RENAL IMPAIRMENT Administer 50% of dose or increase the dosing interval to every 36-48 hours
DOSAGE FORMS
Pepcid® AC: 10 mg
Powder for oral suspension:
Pepcid®: 40 mg/5 mL (50 mL) [contains sodium benzoate; cherry-banana-mint flavor]
Tablet: 10 mg [OTC], 20 mg, 40 mg
Pepcid®: 20 mg, 40 mg
ADMINISTRATION
May be taken with or without food.
SIGNIFICANT ADVERSE REACTIONS
Headache
Dizziness
Diarrhea
Agranulocytosis
Bronchospasm
Rash
Seizure
CONTRAINDICATIONS — Hypersensitivity to famotidine, other H2 antagonists, or any component of the formulation
DRUG INTERACTIONS
Antifungal agents (azole derivatives, systemic): Histamine H2 antagonists may decrease the absorption of azole antifungal.
Atazanavir: Histamine H2 antagonists may decrease the absorption of atazanavir.
Cefpodoxime: Histamine H2 antagonists may decrease the absorption of cefpodoxime; separate oral doses by at least 2 hours.
Cefuroxime: Histamine H2 antagonists may decrease the absorption of cefuroxime; separate oral doses by at least 2 hours.
Cyclosporine: Histamine H2 antagonists may increase the serum concentration of cyclosporine; monitor.
Iron Salts: Histamine H2 antagonists may decrease the absorption of iron salts.
PREGNANCY RISK FACTOR — B
LACTATION — Enters breast milk/not recommended.
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ESOMEPRAZOLE
(Nexium®)
DOSING IN ADULTS
Erosive esophagitis (healing): Initial: 20-40 mg once daily for 4-8 weeks; if incomplete healing, may continue for an additional 4-8 weeks; maintenance: 20 mg once daily
Maintenance of healing of erosive esophagitis: 20 mg once daily; clinical trials evaluated therapy for ≤6 months
Symptomatic gastroesophageal reflux: 20 mg once daily for 4 weeks; may consider an additional 4 weeks of treatment if symptoms do not resolve
Peptic ulcer disease: Eradication of Helicobacter pylori: 40 mg once daily for 10 days; requires combination therapy
Prevention of NSAID-induced gastric ulcers: 20-40 mg once daily for up to 6 months
DOSING IN RENAL IMPAIRMENT No adjustment is necessary.
DOSING IN HEPATIC IMPAIRMENT
Mild-to-moderate hepatic impairment -No dosage adjustment needed.
Severe hepatic impairment -Dose should not exceed 20 mg/day.
DOSAGE FORMS
Capsule, delayed release, as magnesium:
Nexium®: 20 mg, 40 mg
Granules, for oral suspension, delayed release, as magnesium:
Nexium®: 10 mg/packet (30s); 20 mg/packet (30s); 40 mg/packet (30s)
ADMINISTRATION
Capsule: Should be swallowed whole and taken at least 1 hour before eating (best if taken before breakfast). Capsule can be opened and contents mixed with 1 tablespoon of applesauce. Swallow immediately; mixture should not be chewed or warmed.
Granules: Empty into container with 1 tablespoon of water and stir; leave 2-3 minutes to thicken. Stir and drink within 30 minutes. If any medicine remains after drinking, add more water, stir and drink immediately.
SIGNIFICANT ADVERSE REACTIONS
Abdominal pain
Headache
Hypertension
Chest pain
CONTRAINDICATIONS — Hypersensitivity to esomeprazole, substituted benzimidazoles (ie, lansoprazole, omeprazole, pantoprazole, rabeprazole), or any component of the formulation
DRUG INTERACTIONS
Antifungal agents : Proton pump inhibitors may decrease the absorption and thus the levels/effects of itraconazole and ketoconazole; avoid concomitant use.
Antiretroviral: Proton pump inhibitors may decrease the absorption of atazanavir and Indinavir.
CYP2C8 Substrates: may increase the levels/effects of CYP2C8 substrates. Example substrates include amiodarone, paclitaxel, pioglitazone, repaglinide, and rosiglitazone.
CYP2C19 inducers: May decrease the levels/effects of Nexium. Example inducers include aminoglutethimide, carbamazepine, phenytoin, and rifampin.
CYP2C19 substrates: May increase the levels/effects of CYP2C19 substrates. Example substrates include citalopram, diazepam, methsuximide, phenytoin, propranolol, and sertraline.
CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of rabeprazole. Example inducers include aminoglutethimide, carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin, and rifamycins.
HMG-CoA reductase inhibitors: Proton pump inhibitors may increase the serum concentration of HMG-CoA reductase inhibitors; monitor for rhabdomyolysis.
Iron salts : Proton pump inhibitors may decrease the absorption.
Methotrexate: Proton pump inhibitors may decrease the excretion of methotrexate; monitor for increased toxic effects
PREGNANCY RISK FACTOR — B
LACTATION — Excretion in breast milk unknown/not recommended.
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Bentyl
DOSING IN ADULTS
10-20 mg 4 times/day . Administer 30-60 minutes before a meal.
DOSAGE FORMS
Bentyl Capsule, as hydrochloride: 10 mg
Syrup, as hydrochloride: 10 mg/5 mL (480 mL)
Bentyl Tablet, as hydrochloride: 20 mg
SIGNIFICANT ADVERSE REACTIONS
Palpitations
Dizziness
Rash
Suppression of lactation
Xerostomia
Urinary retention
Blurred vision
Use caution in hot weather and/or exercise as Dicyclomine decreases sweating
CONTRAINDICATIONS — Hypersensitivity to dicyclomine or any component of the formulation; obstructive diseases of the gastrointestinal and urinary tract ; unstable cardiovascular status in acute hemorrhage; obstructive
uropathy; narrow-angle glaucoma; myasthenia gravis; breast-feeding; should not be used in infants <6 months of age
DRUG INTERACTIONS
Anticholinergic agents: The anticholinergic effects of dicyclomine are additive with other anticholinergic agents, including antihistamines, amantadine, opioids, phenothiazines, and tricyclic antidepressants.
Acetylcholinesterase inhibitors (central): Effects of dicyclomine may be diminished
PREGNANCY RISK FACTOR — B
LACTATION — Enters breast milk/contraindicated.
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Gastroesophageal reflux disease: Oral: 400 mg 4 times/day or 800 mg twice daily for 12 weeks
Short-term treatment of active ulcers:
300 mg 4 times/day or 800 mg at bedtime or 400 mg twice daily for up to 8 weeks
Duodenal ulcer prophylaxis: 400 mg at bedtime
Heartburn, acid indigestion, sour stomach (OTC labeling): 200 mg up to twice daily; may take 30 minutes prior to eating foods or beverages expected to cause heartburn or indigestion
DOSING IN RENAL IMPAIRMENT –decrease by 50%
DOSING IN HEPATIC IMPAIRMENT Safe in mild liver disease but use with caution and in reduced dosage in severe liver disease
DOSAGE FORMS
Tablet: 200 mg [OTC], 300 mg, 400 mg, 800 mg
Tagamet® HB 200: 200 mg
ADMINISTRATION
Administer with meals so that the drug’s peak effect occurs at the proper time
SIGNIFICANT ADVERSE REACTIONS
Headache
Dizziness
Gynecomastia
Diarrhea
Hypotension
Pancreatitis
Confusion
CONTRAINDICATIONS — Hypersensitivity to cimetidine, any component of the formulation, or other H2 antagonists
DRUG INTERACTIONS
Amiodarone: Serum concentration of amiodarone is increased; avoid concurrent use.
Antiretrovirals: Histamine H2 antagonists may decrease the absorption of atazanavir
Benzodiazepines (except lorazepam, oxazepam, temazepam): Serum concentration of the benzodiazepine is increased; consider alternative H2 antagonist or monitor for benzodiazepine toxicity.
Beta-blockers (except atenolol, betaxolol, bisoprolol, nadolol, penbutolol): Effects of the beta-blocker may be increased
Calcium channel blockers (except amlodipine and nicardipine): Serum concentration of the CCB is increased
Carbamazepine: Plasma concentration of carbamazepine may increase transiently (1 week). Monitor for carbamazepine toxicity or use an alternative H2 antagonist.
Citalopram: Serum concentration of citalopram is increased
Clozapine: Cimetidine may increase levels/effects; consider alternative H2 antagonist
Cyclosporine: Serum concentration of cyclosporine may increase; monitor cyclosporine levels.
CYP1A2 substrates: Cimetidine may increase the levels/effects of CYP1A2 substrates. Example substrates include aminophylline ropinirole, theophylline, and trifluoperazine.
CYP2C19 substrates: Cimetidine may increase the levels/effects of CYP2C19 substrates. Example substrates include citalopram, diazepam, phenytoin, propranolol, and sertraline.
CYP2D6 substrates: Cimetidine may increase the levels/effects of CYP2D6 substrates. Example substrates include amphetamines, selected beta-blockers, fluoxetine, lidocaine, mirtazapine, nefazodone, risperidone, ritonavir, tricyclic antidepressants, and venlafaxine.
CYP2D6 prodrug substrates: Cimetidine may decrease the levels/effects of CYP2D6 prodrug substrates. Example prodrug substrates include codeine, hydrocodone, oxycodone, and tramadol.
CYP3A4 substrates: Cimetidine may increase the levels/effects of CYP3A4 substrates. Example substrates include benzodiazepines, calcium channel blockers, cyclosporine, mirtazapine, nateglinide, nefazodone, sildenafil ,tacrolimus, and venlafaxine.
Ketoconazole, fluconazole, itraconazole (especially capsule): Decreased serum concentration; avoid concurrent use with H2 antagonists.
Lidocaine: Serum concentration of lidocaine is increased; use alternative H2 antagonist.
Metformin: Serum levels/effects may be increased by cimetidine; monitor for hypoglycemia.
Phenytoin: Serum levels/effects may be increased by cimetidine; avoid concurrent use.
Procainamide: Cimetidine may increase levels/effects; monitor.
Quinolones: Renal elimination of quinolone antibiotics may be decreased.
Selective serotonin reuptake inhibitors (eg, paroxetine, citalopram): Serum concentrations may be increased by cimetidine; monitor.
Sulfonylureas: Cimetidine may increase levels/effects; monitor for hypoglycemia
Tricyclic antidepressants: Serum concentration is increased; consider alternative H2 antagonist or monitor for TCAs toxicity.
Thioridazine: Serum levels/effects may be increased by cimetidine; concurrent use contraindicated by manufacturer.
Warfarin: INR is increased; cimetidine’s effect is dose related. Use an alternative H2 antagonist if possible or monitor INR closely and adjust warfarin dose as needed.
PREGNANCY RISK FACTOR — B
LACTATION — Enters breast milk/not recommended.
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Imuran, Azasan
DOSING: ADULTS
Initial: 50 mg daily; may increase by 25 mg/day every 1-2 weeks as tolerated to target dose of 2-3 mg/kg/day
DOSING IN RENAL IMPAIRMENT
Decrease by 50%
DOSAGE FORMS
Tablet [scored]: 50 mg
Azasan: 75 mg, 100 mg
Imuran: 50 mg
SIGNIFICANT ADVERSE REACTIONS
Alopecia
Rash
Diarrhea
Pancreatitis
Leukopenia- Patients with genetic deficiency of thiopurine methyltransferase (TPMT) may be sensitive to myelosuppressive effects. Patients on concurrent therapy with drugs which may inhibit TPMT (eg, olsalazine) or xanthine oxidase (eg, allopurinol) may be sensitive to myelosuppressive effects.
Macrocytic anemia
Hepatotoxicity
Infection secondary to immunosuppression
Malignancy
CONTRAINDICATIONS
Hypersensitivity to azathioprine or any component of the formulation; pregnancy
DRUG INTERACTIONS
ACE inhibitors: Concomitant therapy may induce anemia and severe leukopenia.
Allopurinol: May increase serum levels of azathioprine’s active metabolite (mercaptopurine). Decrease azathioprine dose to ~25% of the normal dose; monitor for toxic effects of azathioprine.
Aminosalicylates (olsalazine, mesalamine, sulfasalazine): May inhibit TPMT, increasing toxicity/myelosuppression of azathioprine.
Mercaptopurine: Azathioprine is metabolized to mercaptopurine; concomitant use may result in profound myelosuppression and should be avoided.
Warfarin: Effect may be decreased by azathioprine.
PREGNANCY RISK FACTOR D. Azathioprine crosses the placenta in humans; congenital anomalies, immunosuppression, and intrauterine growth retardation have been reported. There are no adequate and well-controlled studies in pregnant women.
LACTATION — Enters breast milk/not recommended.
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The gut have several mechanisms that help prevent ulcers from developing, including a protective coating of mucus layer and certain chemicals produced by the stomach to protect the cells lining the stomach.
If the mucous layer is damaged or if acid neutralizing substances are not present in normal amounts, digestive juices can cause breakdown of the lining stomach or duodenum, causing ulcers to form.
Peptic ulcers affect more than 4 million people each year in the United States.
Most ulcers heal while others can be serious or even life-threatening.
SYMPTOMS
Pain or discomfort (usually in the upper abdomen)
Throwing up blood or passing dark stool
Early sense of fullness with eating
Lack of appetite
Nausea
Vomiting
Anemia
Not everyone with ulcer symptoms has an ulcer.
Similar symptoms can be caused by acid reflux, gallbladder problems, and stomach cancer.
CAUSES
The two most common causes of peptic ulcers are:
Helicobacter pylori, a bacteria that is frequently found in the stomach
Nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirin
Helicobacter pylori infection
Helicobacter pylori, also known as H. pylori, is the most common chronic bacterial infection in humans. H pylori is now recognized to be an important cause of gastric and duodenal ulcers.
H pylori disrupts the mucous layer and causes the release of certain enzymes and toxins injure the cells of the stomach or duodenum.
Nonsteroidal anti-inflammatory drugs such as ibuprofen ,naproxen etc
The risk of developing an ulcer depends upon the specific type of NSAID, the dose and duration of use, and individual factors
Other factors
Duodenal ulcers patients are more likely to have family members with duodenal ulcers
Tobacco
Alcohol abuse
Certain viral infections (eg, cytomegalovirus, herpes virus )
DIAGNOSIS
The most common test is an upper endoscopy, in which a small flexible tube with a camera is passed through the mouth to examine the lining of the stomach and the duodenum.
TREATMENT
Most ulcers can be healed with medications.
Surgery is rarely needed, except when complications have developed.
People who have H. pylori are treated with multiple antibiotics and a medication that reduces acid production.
Smoking,NSAIDs and caffeine-containing foods (such as coffee, tea, and chocolate ) should be discontinued.
For more information , please see
www.nlm.nih.gov/medlineplus/healthtopics.html
www.niddk.nih.gov/
www.cdc.gov/
www.gastro.org
www.acg.gi.org
www.helico.com/
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Nonalcoholic steatohepatitis (NASH) is a condition that causes inflammation and accumulation of fat and fibrous tissue in the liver.
It is diagnosed in about 7 to 9 percent of people in the United States.
NASH is seen more often in women than in men.
CONDITIONS ASSOCIATED WITH NASH
Obesity
Diabetes
Hyperlipidemia
Insulin resistance
Medications such as amiodarone, tamoxifen
SYMPTOMS
Fatigue can be one of the common symptoms although most people with NASH have no symptoms. Most serious complication of NASH is cirrhosis.
DIAGNOSIS
NASH is most often discovered on routine blood or imaging tests.
A liver biopsy is required to confirm NASH.
TREATMENT
Weight reduction, lipid lowering therapy , insulin sensitizers are commonly used.
For more information please see
www.gastro.org
www.acg.gi.org
www.aasld.org
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IBS is the most commonly diagnosed gut condition causing abdominal pain and altered bowel habits such as constipation and/or diarrhea.
10 to 20 percent of people in the general population experience symptoms of IBS.
IBS usually begins in young adulthood.
Women are twice as likely as men to be diagnosed with IBS in the United States.
CAUSES
Many researchers THINK that IBS is caused by increased sensitivity of the intestines to normal sensations so that even normal amounts of gas or movement are perceived as excessively painful.
SYMPTOMS
Abdominal pain
Abdominal pain is typically crampy, varying in intensity, and located in the lower left abdomen.
Some IBS patients notice an association between pain episodes and their menstrual cycle.
Altered bowel habits
These include diarrhea, constipation, or alternating diarrhea and constipation.
Diarrhea-often with mucus, is often preceded by a sense of extreme urgency and followed by a feeling of incomplete evacuation.
DIAGNOSIS
There is no single diagnostic test for IBS.
A comprehensive medical history, physical exam and simple blood tests are done to rule out Colitis.
TREATMENT
Try eliminating foods that may aggravate IBS.
Avoid lactose containing products , gas-producing foods are legumes (such as beans) and cruciferous vegetables (such as cabbage, cauliflower, and broccoli) to see if it helps.
Increasing dietary fiber can relieve symptoms in those with who have constipation.
Medications
Many drugs are available primarily to relieve symptoms.
Antidepressants relieve pain and depression in many IBS patients.
Anticholinergic (Dicyclomine (Bentyl) and hyoscyamine (Levsin) help to reduce severe cramps and irregular contractions of the colon.
Lubiprostone (Amitiza) is available for treatment of severe constipation and irritable bowel syndrome in women >18 years who have not responded to other treatments. It works by increasing intestinal fluid secretion.
Commonly used drugs
Hyoscyamine (Anaspaz, Levbid, Levsin/SL, Levsinex, Levsin, NuLev)
Dicyclomine ( Bentyl)
Polyethylene glycol 3350 ( GlycoLax, MiraLax)
Lubiprostone ( Amitiza) |
For more information , please see
www.nlm.nih.gov/medlineplus/healthtopics.html
www.niddk.nih.gov/
www.cdc.gov/
www.gastro.org
www.acg.gi.org
www.iffgd.org
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About 2.7 million people in the United States have hepatitis C.
Chronic hepatitis C is the most common chronic liver disease and accounts for 8,000 to 13,000 deaths each year.
The majority of liver transplants performed in the US are done for people with chronic hepatitis C.
TRANSMISSION
The virus is spread by contact with blood such as blood transfusions and unprotected intercourse.
Hepatitis C transmission can occur by sharing household items that carry the virus such as toothbrushes and razors.
Please note that there is 5 to 6 % risk of transmitting virus to fetus during pregnancy.
SYMPTOMS
Many people with chronic hepatitis C have no symptoms, even if there is significant liver damage.
Nonspecific symptoms such as fatigue , nausea, lack of appetite and weight loss are seen.
20 percent of people will develop cirrhosis 20 years after becoming infected.
DIAGNOSIS
Hepatitis C is diagnosed with a blood test because a person has risk factors for the infection such as
Anyone who was given donated blood or organs before July 1992 or blood clotting factors before
1987
Recent exposure to blood infected with HCV (eg, an accidental needle stick)
Being HIV positive
Past or current sexual partner of a person with HCV
Previous or current use of IV drugs
Previous or current use of hemodialysis for kidney failure
TREATMENT
- Avoid using alcohol and hepatotoxic drugs
- Vaccinate against hepatitis A and B unless already immune
- Influenza vaccination is recommended once per year
- Pneumococcal vaccine is recommended every five years
- Diphtheria and tetanus booster immunizations every ten years
- Pegylated interferon and ribavirin
For more information please see
www.gastro.org
www.acg.gi.org
www.aasld.org
www.cdc.gov
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There are 300 million carriers of the hepatitis B virus in the world, with over 500,000 dying annually from liver disease.
The prevalence of HBV carriers varies from 0.1 to 2 % in low prevalence areas such as the US to 10 to 20 % in high prevalence areas such as southeast Asia and China.
TRANSMISSION
In the US the virus is most commonly transmitted by needle sharing during injection drug use or by unprotected sexual intercourse.
In regions of the world where hepatitis B is prevalent, perinatal transmission (transmission from a mother to her baby) is the most common type of transmission.
Hepatitis B transmission can occur through close personal contact and by sharing household items that carry the virus such as toothbrushes and razors.
Organ transplantation and blood transfusion are uncommon modes of transmission.
SYMPTOMS
Many infected people have no specific symptoms for many years.
Fatigue, loss of appetite, nausea, jaundice are common in acute infection while fluid accumulation in the abdomen and legs, bleeding and mental confusion are seen in chronic stage.
All persons who have chronic infection with hepatitis B are at increased risk of developing complications such as cirrhosis and liver cancer.
DIAGNOSIS
Generally based upon medical history, physical examination, and the results of diagnostic tests.
Special hepatitis markers found in the blood can confirm hepatitis B infection.
Liver biopsy is used for monitoring the progression of liver damage in people with chronic hepatitis and for detecting cirrhosis or liver cancer.
TREATMENT
- Avoid using alcohol and hepatotoxic drugs
- Vaccinate against hepatitis A unless already immune
- Influenza vaccination is recommended once per year
- Pneumococcal vaccine is recommended every five years
- Diphtheria and tetanus booster immunizations every ten years
- Antivirals such as lamivudine, adefovir, entecavir, telbivudine, interferon-alpha, and pegylated interferon-alpha
For more information please see
www.gastro.org
www.acg.gi.org
www.aasld.org
www.cdc.gov/ncidod/diseases/hepatitis/index.htm
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