Acid Controlling Drugs

Anatomy, Physiology and Disease Overview

(Acid Related Pathophysiology)

-The stomach secretes several substances with various physiologic function-
  • Hydrochloric acid, and acid that aids digestions and also serves as a barrier to infection
  • Bicarbonate, a base that is a natural mechanism to prevent hyper-acidity
  • Pepsinogen, an enzymatic precursor to pepsin (an enzyme that digests dietary proteins)
  • Intrinsic factor, a glycoprotein that facilitates gastric absorption of vitamin B12
  • Mucous, which protects the stomach lining from both hydrochloric acid and digestive enzymes
  • Prostaglandins, which have a variety of anti inflammatory and protective functions
    • Hint-Remember Cox 1

Glands of The Stomach: Named by Location!

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Cardiac
Pyloric
Gastric Glands
*Around cardiac Sphincter
*Pyloric Region
*Fundus
*The cells of the gastricgland are the largest
in number of primary importance when discussing
acid control

 Cells of the Gastric Gland

I. Parietal cells
  • *Produce and secrete hydrochloric acid (HCL)
  • *Primary site of action for many acid-controller drugs
II. Cheif cells
  • *Secrete pepsinogen which is a proenzyme that becomes pepsin
(pepsin is activated by exposure to acid)
What causes heartburn
What causes heartburn

III. Mucoid cells
(also called surface epithelial)
  • * Mucous secreting cells
  • * Protect against self-digestion by HCL
  • * Provides protective mucous coat

Keeping the Cells Balanced!




-When the balance of the cells and their secretions is impaired, acid-related diseases
can occur. The effcts of cell imbalance leads to:
1. Hypersecretion
  • *Most common condition is mild to moderate hypersecretion (indigestion,
sour stomach, heartburn, acid stomach)
  • *GERD (Gastroesophageal Reflux Disease) which is excessive
stomach acid backup into the lower esophagus which can lead to Barrett's Esophagus
2. Peptic Ulcer Disease (PUD)
3. Esophageal Cancer
- Hydrochloric Acid
  • Is an acid that is secreted by the parietal cells in the lining of the stomach
  • It is the primary substance secreted in the stomach that maintains the environment of the stomach that maintains the environment of the stomach at a pH of 1-4
  • Body's defense against microbial infection via the GI tract
  • Aids in the proper digestion of food
  • Hydrochloric acid secretions stimulated by:


Excessve Alcohol

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Emotional stress
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Large Fatty Meals
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Caffeine
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Chocolate

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Types of Acid-Controlling Agents

Antacids

Antacids are basic compound used to neutralize stomach acid. (Most commonly they are nonprescription salts of aluminum, magnesium, calcium and sodium.

Mechanism of Action
Drug Effects
Formulations
Indications
- Secretion of mucous, bicarbonate and prostaglandins
-They DO NOT prevent
overproduction of acid. Instead
they neutralize acid once its in the stomach
-Increases the resistance of the stomach lining
-Increases the tone of the cardiac sphincter >
which reduces reflux of the stomach
-Reducing acidity reduces pain
-can be used alone or in combination
with aluminum salts, calcium salts,
magnesium salts, and sodium bicarbonate
-It raises gastric pH from 1.3 to 1.6
neutralizes 50% of the gastric acid
-Raising gastric pH 1 point (1.3 to 2.3)
neutralizes 90% of gastric acid

Contraindications

-Severe renal failure
-Capsules
-Tablets
-Powders
-Chewable tablets
-Suspensions
-Effervescent granules
-Relief of pain associated with
PUD, gastritis, heartburn

Secretions

-Mucus creates a protective barrier
-Bicarbonate helps buffer acidic
properties of HCL
-Prostaglandins prevent activation
of proton pump
Aluminum Salts
  • Aluminum Carbonate: Basaljel
  • Hydroxide salt: AlternaGEL
Used for discomfort associated with hyperacidity
Dissovles slowly in the stomach
S/E- Constipation and acid rebound
Caffeine, alcohol, harsh spices and black pepper may aggrevate condition
Important: with impaired renal function, aluminum is retained
Magnesium Salts
  • Hydroxide salt: Magnesium hydroxide (Milk of Magnesia)
  • Combination products: Maalox, Mylanta (aluminum and magnesium)
Used for discomfort associated with hyperacidity
S/E-Diarrhea. DO NOT USE WITH RENAL FAILURE of HF
*Failing [[Acid Controlling & Bowel Disorder Drugs#|kidney]] cannot excrete extra magnesium resulting in accumulation
[[Acid Controlling & Bowel Disorder Drugs#|Calcium]] Salts
  • Tums-Calcium
Used for discomfort associated with hyperacidity
S/E- Constipation, gas/belching, kidney stones, rebound hyperacidity
Sodium Bicarbonate
  • Alka-Seltzer
  • Baking Soda
Indication- Buffers the acidic properties of HCL and it is used for dicomfort associated with hyperacidity
The most rapidly acting antacid (Quick onset, but short duration)
S/E- Metabolic alkalosis, irritability, muscle twitching, numbness and tingling, cyanosis, and slow/shallow respirations

Antiflatulents: Used to relieve painful symptoms associated with gas

  • Simethcone

Used for excessive gas production
Used often, but there are limited data to support effectiveness
*Often added to antacid combination products
Nursing Implications
  1. Give medications 1-2 hours after giving an antacid
  2. Give with at least 8 ounces of water
  3. Monitor side effects: Nausea, vomiting, abdominal pain, diarrhea
  4. Caffiene, alcohol, harsh spices and black pepper may aggravate the underlying GI condition
Pathophysiology Part 2
Proton Pump
  • Moves Potassium ions into the cell and hydrogen ions out of the proton pump
  • Responsible for release of Intrinsic factor B12
Why is Hydrochloric acid so important?
  1. We need B12 for RBC production, Maintenence of CNS and PNS and cognitive functions
  2. We need acid to digest food
  3. We need it to zap food-borne pathogens
  4. we need it to help absorb calcium
H2 Antagonists (Most popular drug)
What they do? Reduce acid secretion
Drugs: Cimetidine, Famotidine, Ranitidine
Are they available? Yes, they are available in lower doses for OTC brands
Mechanism of action
Indications
Side Effects
Drug Interactions
Nursing Implications
-Block histamine at the receptors of acid-producing parietal cells
-Production of hydrogen ions is reduced, resulting in decreased production of HCL
-GERD
-PUD
-Erosive Esophagitis
-Adjunct therapy in control of upper GI bleeding
Headache, lethargy, confusion, diarrhea, urticaria, sweating, flushing

Cimetidine: Impotence and Gynecomastia
Smoking decreases effectiveness
-Take an hour before or after antacids
-Decreases absorption of drugs that require an acidic GI environment
-Use with caution in patients who are confused, disoriented or elderly

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Proton Pump Inhibitors

Drugs:
Prevacid, Prilosec, Aciphex, Protonix, Nexium
Indications:
GERD, Erosive esophagitis, short term treatment of active duodenal and benign gastric ulcers, NSAID induced ulcers
Side Effects:
Safe for short term therapy, good prevention for stress ulcers
Nurse Implications:
May increase serum levels, take before meals, may be given with antacids, Treatment is SHORT TERM

References

Lilley, Collins, R., Harringtoon, & Snyder. (2011). Pharmacology and the Nursing Process. St. Louis: Elsevier.
Maton, P. N., & Burton, M. (1999). Antacids Revisited. Adis INternational Limited , 855-867.

ACID-CONTROLLING DRUGS
Drug Name
Indication / Mechanism of Action
Side Effects / Adverse Effects
Nursing Implications
Cimetidine (Tagamet)
H2 Antagonist.
-Duodenal & gastric ulcers, GERD, upper GI hemorrhage.
-Works by inhibiting histamine action at the histamine H(2) receptors of the parietal cells, thus lowering basal gastric acid secretion.
Gynecomastia, headache, agranulocytosis, leukopenia, seizure, psychotic disorder.
Oral. Monitor CBC. Drug interactions: Metformin & Roflumilast. Large potential to cause drug interactions; has been largely replaced by ranitidine and famotidine.
Ranitidine (Zantac)
H2 Antagonist.
-Duodenal & gastric ulcers, gastric hypersecretion, H. Pyloria GI tract infection, indigestion.
Abdominal pain, constipation, diarrhea, headache, bradycardia, thrombocytopenia, hepatitis, abnormal liver function tests.
IV or oral. Monitor CBC. Drug interactions: Didanosine. Most widely-used H2 antagonist.
Famotidine (Pepcid)
H2 Antagonist.
-Duodenal ulcer disease, GERD, gastric hypersecretion, indigestion, gastiric ulcer.
-Primarily inhibits both the concentration and volume of gastric secretion.
Constipation, diarrhea, dizziness, headache.
IV, oral tablet, oral powder. Monitor CBC. Drug interactions: Atazanavir, Dasatinib.
Omeprazol (Prilosec)
Proton Pump Inhibitor. GERD, Zollinger-Ellison syndrome, various types of ulcers, heartburn. Blocks the hydrogen/potassium ATP enzyme system, AKA proton pump; directly responsible for secreting H+ ions into the gastric lumen; decreases the amount of acid in the stomach.
Stomach pain, N/V/D, constipation, flatulence, headache, fever, rash, hives, itching, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, difficulty breathing or swallowing, and hoarseness.
Orally administered PPIs work best when taken 30-60 minutes before meals.
Lansoprazole (Prevacid)
Proton Pump Inhibitor. Ulcers, GERD, Zollinger-Ellison syndrome, heartburn. Blocks the hydrogen/potassium ATP enzyme system, AKA proton pump; directly responsible for secreting H+ ions into the gastric lumen; decreases the amount of acid in the stomach.
Stomach pain, N/D, constipation, flatulence, headache, dizziness, rash, hives, blistering or peeling skin, swelling of the eyes, face, lips, mouth, tongue, or throat, difficulty breathing or swallowing, and hoarseness.
Available in a delayed-release capsule, granules for oral suspension, and orally disintegrating tablets.
Pantoprazole (Protonix)
Proton Pump Inhibitor. GERD, Zollinger-Ellison syndrome. Blocks the hydrogen/potassium ATP enzyme system, AKA proton pump; directly responsible for secreting H+ ions into the gastric lumen; decreases the amount of acid in the stomach.
Headache, dizziness, diarrhea, stomach pain, N/V, gas, joint pain, blistering or peeling skin, rash, hives, itching, swelling of the eyes, face, lips, mouth, throat, or tongue, difficulty breathing or swallowing, hoarseness.
For NG tube administration, the tube must be at least a size 16 due to large granules.
Sucralfate (Carafate)
-Used as a mucosal protectant in the treatment of active stress ulcerations and long-term therapy for peptic ulcer disease.
Uncommon, but include nausea, constipation, and dry mouth.
Acts locally, not systemically. Drug interactions can be avoided by taking other medications 2 hours before sucralfate. Give 1 hour before meals and at bedtime.
Misoprostol (Cytotec)
Prostaglandin E Analogue.
-Reduces the incidence of gastric ulcers in patients taking NSAIDs.
-Inhibit gastric acid secretion and protect the gastric mucosa.
Headache, GI distress, and vaginal bleeding.
Misoprostol must be used in dosages that usually produce adverse effects such as abdominal cramps and diarrhea. Usual dose is 200 mcg QID with meals.
Simethicone (Mylicon)
Antiflatulent Drug.
-Used to reduce discomforts of gastric or intestinal gas and aid in its release via the mouth or rectum.
-It works by altering the elasticity of mucus-cated gas bubbles, which causes them to break into smaller ones.
No listed adverse effects.
No listed drug interactions or pharmacokinetic parameters. Available only for oral use; usually 1-2 tablets 4-6 times daily PRN.



Bowel Disorder Drugs
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Diarrhea and associated diseases count for up to 8 million deaths per year in infants and small children and are among the leading causes of death and morbidity in developing countries.

The Key Symptoms of GI diseases are abdominal pain, nausea and/or vomiting and diarrhea.

GI tract:

- Responsibilities

o Ingestion of dietary intake, digestion of dietary intake into basic nutrients, absorption of basic nutrients, storage and removal of fecal

material via defecation

- Large intestine responsibilities

o Forming the stool by removing excess water from the fecal material, temporarily storing the stool until defecation, extracting essential

vitamins from the intestinal bacteria

Acute Diarrhea:

- Sudden onset in a previously healthy individual

- Causes: drugs, bacteria, viruses, nutritional factors, and protozoa

Chronic Diarrhea:

- Lasts for longer than 3 to 4 weeks and is associated with recurrent passage of diarrheal stools, possible fever, loss of appetite, nausea, vomiting, weight reduction and chronic weakness

- Causes: tumors, AIDS, diabetes mellitus, hyperthyroidism, Addison’s disease, and irritable bowel syndrome

Antidiarrheals:

- drugs used to treat diarrhea

- divided into groups based on mechanism of action:

o adsorbents: coat the walls of the GI tract and bind to problem causing agent to remove it

o anticholingeric drugs: slow peristalsis by reducing the rhythmic contractions and smooth muscle tone of the GI tract

o intestinal flora modifiers: suppress the growth of diarrhea-causing bacteria

o opiates: reduce bowel motility

Laxatives

- treatment of constipation

- mechanism of action

o affecting fecal consistency, increasing fecal movement through the colon or facilitation defecation through the rectum

o bulk-forming laxatives: absorb water into the intestines, which increases bulk and distends the bowel to initiate the bowel activity

o emollient laxatives: lowers the surface tension of GI fluids

o hyperosmotic laxatives: increasing fecal water content which increases peristalsis

o stimulant laxatives: stimulates the nerves that innervate the intestines

Irritable Bowel Syndrome

- only one drug: Lubiprostone (Amitiza)

o chloride channel activator

Nursing Assessment:

- obtain a thorough health and history report

- listen to bowel sounds in all four quadrants before and after medication administration

- complaints of abdominal pain, bloody stools, confirmation of hypoactive to no bowel sounds, and/ or fever should be reported to prescriber

immediately

Nursing Diagnosis:

- constipation related to improper diet and fluid intake

- diarrhea related to GI irritation from food, bacteria or viruses, or pathology

- Fluid volume deficit related to excessive diarrhea and loss of fluids and electrolytes caused by frequent, loose stools

- Risk for injury related to the adverse effects of medication

- Noncompliance related to lack of knowledge about and/or experience with the medication regimen

Lilley, L., Collins, S., Harrington, S., & Snyder, J. (2011). Pharmacology and the nursing process. St Louis, MO: Mosby Elsevier

Bowel Disorder Drugs
Drug Name
& Drug Class
Indication & Mechanism of Action
Side Effects &
Adverse Effects
Nursing Implications
Bismuth Subsalicylate (Pepto-Bismol)
Adsorbent
-Diarrhea, Heartburn, H. Pylori GI infection, Indigestion, Nausea, Upset Stomach.
-Exact mechanism has not been determined. May exert its antidiarrheal action by stimulating absorption of fluid and electrolytes across the intestinal wall and inhibiting synthesis of a prostaglandin responsible for intestinal inflammation and hypermotility.
Constipation, Diarrhea, Nausea, Stool color abnormal, Grayish-black, Tongue discoloration, Grayish-black, Vomiting, Neurotoxicity (rare)
-Contraindicated: Children or teens with or recovering from influenza or varicella; hypersensitivity to the bismuth subsalicylate or salicylates.
Donnatal (Belladonna Alkaloid)
Anticholinergic
-Irritable bowel syndrome and ulcers in the intestine.
-Reduced muscle spasms in the digestive or urinary tract and reduced secretions from certain glands or organs.
Diarrhea, Painful or difficult urination, Fast or pounding heartbeats, Blurred vision with eye pain or seeing halos around lights, Feeling faint, Mouth sores, Red or bleeding gums, Tooth decay, Drowsiness, Dry Mouth, Decreased taste sensation, Decreased sweating or urination, HA, Dizziness, Weakness, Insomnia, N/V, Constipation, Bloating, Restlessness, Impotence, Loss of interest in sex, trouble having an orgasm.
-Take with a full glass of water.
-This medication can case unusual results with certain medical tests.
-Drug of abuse.
-Contraindicated: blockage in intestines or digestive tract, paralytic ileus, active bleeding, severe ulcerative colitis or toxic megacolon, myasthenia gravis, hiatal hernia or reflux disease, and porphyria.
Diphenoxylate with atropine (Lomotil, Lonox)
Opiate
-Diarrhea, Adjunct.
-Probably acts both locally and centrally to reduce intestinal motility.
Abd discomfort, N/V, Dizziness, Sedation, Somnolence, Euphoria, Malaise, Pancreatitis, Toxic megacolon, Anaphylaxis
-Atropine has anticholinergic activity; however, in this preparation atropine is included in doses below the therapeutic level in an attempt to prevent abuse by deliberate overdosages.
-Contraindicated: Diarrhea associated with eterotoxin-producing bacteria or psudomembranous enterocolitis, may prolong and/or worsen diarrhea; hypersensitivity to diphenoxylate or atropine products; obstructive jaundice, may precipitate hepatic coma.
Loperamide (Imodium A-D)
Opiate
-Diarrhea, acute or chronic, High output ileostomy, Traveler's diarrhea, Proctocolectomy
Hyperglycemia, Abd pain, N/V, Xerostomia, Dizziness, Somnolence, Fatigue, Necrotizing enterocolitis in fetus OR newborn (rare).
-Available OTC.
-Periodic F&E status determinations in long term therapy. CNS toxicity in pts with hepatic impairment.
-Contraindicated: Abd pain in the absence of diarrhea, bacterial enterocolitis, dystenery (acute), hypersensitivity to loperamide or to any of the excipients, infants <24 months, pseudomembranous colitis, ulcerative colitis.
Lactobacillus acidophilus (Bacid)
Intestinal Flora Modifier
-Yeast infections, UTIs.
-Helps maintain an acidic environment in the body, which can prevent the growth of harmful bacteria.
Allergic reaction: hives, difficulty breathing, swelling of face, lips, tongue, throat. Less serious S/E may be more likely, but there may be none at all.
-Has not been approved by the FDA to treat any disease and should not be substituted for prescription medications.
-Talk to MD if any other medical conditions, allergies, other medications or herbal supplements.
-Talk to MD first if you are/may become pregnant or breastfeeding.
Methylcellulose (Citrucel)
Bulk-Forming Laxative
-Constipation
-Absorbs liquid in the intestines and makes a bulky, softer stool which is easier to pass.
Uncommon but serious: allergic reaction (dyspnea, closing of throat), chest pain, dysphagia, rectal bleeding, severe abdominal pain, N/V.
-Take with at least 8oz of liquid.
Mix methylcellulose powder with at least 8oz of noncarbonated beverage, mix briskly and drink promptly
Psyllium (Metamucil)
Bulk-Forming Laxative
-Constipation
-It absorbs liquid in the intestines, swells, and forms a bulky stool, which is easy to pass.
Difficulty breathing, Stomach pain, Difficulty swallowing, Skin rash, Itching, N/V
-Powder, granules, capsule, liquid, and wafer. Usually taken TID.
-Powder and granules must be mixed with 8 oz of liquid.
Do not take for longer than 1 week unless approved by MD.
Docusate Salts (Calcium and Sodium)
Emollient Laxative
-Constipation
-Stool softener laxative used for temporary relief of constipation by actively drawing water into the stool, thus softening the stool and achieving ease in bowel movement.
Abnormal taste in mouth, Bitter, Diarrhea, Nausea, Cramp, Hepatotoxicity (rare)
-BM in 12-72 hours. Reassess if rectal bleeding or no BM after laxative.
-Contraindicated: Hypersensitivity to docusate products, concomitant use of mineral oil, intestinal obstruction, acute abd pain, N/V
Mineral Oil (Kondremul Plain)
Emollient Laxative
-Constipation, stool softener, hemorrhoids or anal fissures.
-May allow absorption of mineral oil and some medications from the intestine, which collects in the tissues of the body (lymph nodes and liver).
-Slow onset of action (24-48 hours). Do not use longterm.
-Do not use with Docusate.
-May also increase absorption of other medications.
-Risk of hepatotoxicity.
-May take a week or more to be effective.
Glycerin (Fleet Babylax)
Hyperosmotic Laxative
-Relieving occasional constipation.
-Irritates the lining of the intestine and increases the amount of fluid, making it easier for stools to pass.
-Anal irritation; burning sensation; diarrhea; gas; nausea; stomach cramps.
-Severe allergic reactions (rash; hives; difficulty breathing; tightness in chest; swelling of mouth, face, lips, or tongue); rectal bleeding.
Do not use if: allergic to any ingredients in Fleet Babylax Enema, blockage in digestive system, or undiagnosed abdominal pain.
Lactulose (Chronulac)
Hyperosmotic Laxative
-Constipation
-Synthetic sugar. It is broken down in the colon into products that pull water out from the body and into the colon, which softens stools.
-Diarrhea, Gas, Nausea, Stomach pain or cramps, Vomiting.
-Keep in original container, tightly closed, at room temperature away from excess heat and moisture.
-Tell MD: prescription and nonprescription meds, diabetes, pregnant, plan to become pregnant, breastfeeding, surgery or tests on colon or rectum.
Polyethylene Glycol 3350 (GoLYTELY)
Hyperosmotic Laxative
-Used to clean the bowel before colonoscopy, a barium x-ray, or other intestinal procedures.
-Increases the amount of water in the intestinal tract to stimulate bowel movements.
-Allergic reaction: hives, difficulty breathing, swelling of face, lips, tongue, or throat.
-Other serious S/E: severe stomach pain or bloating, no BM within 2 hours after use, gagging, choking, or vomiting.
-Less serious S/E: mild stomach cramps, gas, or bloating, rectal pain or irritation, nausea, or passing gas.
-This medication contains potassium, sodium, and other minerals to replace electrolytes that are passed from the body in the stool.
-Do not use if you have: a perforated bowel, a bowel obstruction or severe constipation, colitis or toxic megacolon, an eating disorder.
-Tell MD if you have: N/V, trouble swallowing, or a history of: bowel obstruction, diverticulitis, ulcerative colitis, or other chronic bowel disease.
Magnesium Salts (Milk of Magnesia)
Saline Laxative
-Short-term basis to treat constipation.
-Stomach cramps, Upset stomach, Vomiting, Diarrhea.
-Comes as a tablet & a liquid.
-Before taking, tell MD: if allergic, any prescription or nonprescription meds, if hx of kidney disease, if pregnant, plan to become pregnant, or breastfeeding.
Bisacodyl (Dulcolax)
Stimulant Laxative
-Short-term basis to treat constipation. Empty bowels before surgery and examinations such as X-rays using barium enemas.
-Stomach cramps, Upset stomach, Diarrhea, Stomach and intestinal irritation, Faintness, Irritation or burning in the rectum (from suppositories).
-PO or suppository. To empty the bowels, PO at night and rectally the morning of the surgery.
-Tablets normally cause a BM in 6-8 hours, suppositories in 15-60 minutes, and eema in 3-5 minutes.
Senna (Senokot)
Stimulant Laxative
-Used to treat constipation or before rectal or bowel examinations or surgery.
-Work by increasing the movement in the bowel.
-Yellow-brown discoloration of urine, Diarrhea, N/V, Irritation, Stomach cramping, Bloody stools, Severe cramping, Pain, Weakness, Dizziness, Unusual tiredness, Rectal bleeding.
-Liquids, powders, granules, tablets, and suppositories.
-Take on empty stomach with 8oz of water. Food slows the effect.
QUIZ
1. The nurse will teach patients that antacids are effective in treatment of hyperaciditiy because they:
A) Neutralize gastric acid.
B) Decrease stomach motility.
C) Decrease gastric pH.
D) Decrease duodenal pH.

2. Which drug category blocks the hydrogen/potassium ATP enzyme system?
A) H2 Antagonists.
B) Proton Pump Inhibitors
C) Antiflatulent Drugs.
D) Opiate

3. Which statemtn demonstrates understanding of patient teaching regarding the use of histamine 2-receptor antagonists?
A) "Since I am taking this medication, it is okay for me to eat spicy foods."
B) "Smoking decreases the effects of this medication, so I should look into cessation programs."
C) "I should take this medication 1 hour after each meal in order to maximally decrease gastric acidity."
D) "I should decrease bulk and fluids in my diet to prevent diarrhea."

4.Which drug would be most effective in treating yeast infections or urinary tract infections (UTIs)?
A)Pepto-Bismol
B) Mineral Oil
C) Bacid
D) Senokot

5. Bismuth subsalicylate (Pepto-Bismol), as an adsorbent, has which mechanism of action?
A)Decreased GI motility
B) Decreased gastric secretions
C) Increased fluid absorption
D) Binding to diarrhea-causing bacteria for excretion

6. Milk of Magnesia alleviates constipation by which action?
A) Increasing water absorption into the colon.
B) Lubricating the passage of stool.
C) Increasing bulk within t he colon.
D) Stimulating nerves that regulate defecation.

7. T/F: To avoid fecal impaction, Metamucil should be administered with at least 8 oz of fluid.

Answers
1. A
2. B
3. B
4. C
5. D
6. A
7. T