Reply to Leetal Pharmacology

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    Disorders such as peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and irritable bowel syndrome (IBS) can be painful and often interferes with daily life. PUD occurs when excessive gastric acid secretion eats away at the inner surface of the stomach or small intestine (Kavitt et al., 2019). Conversely, GERD involves mucosal damage to the esophagus due to lower esophageal dysfunction resulting in abnormal reflux of gastric contents (Chen & Brady, 2019). The exact pathophysiology of IBS is unclear; however, some theorize it to be a result of altered gastrointestinal motility, visceral hypersensitivity, brain-gut reactions, bacterial overgrowth, and intestinal inflammation (Camilleri, 2021).

            Pantoprazole (Protonix) is a medication in the class of proton pump inhibitors (PPIs) that are most commonly used to treat PUD. One systematic review and meta-analysis determined that daily oral administration of pantoprazole is just as effective as when given intravenously. Researchers included several randomized controlled trials (RCTs) involving over 2,000 participants. They concluded that long-term relief was obtained with a PPI in addition to a decrease in the risks of bleeding (Csiki et al., 2021). Although rare, patients with previously diagnosed systemic lupus erythematosus (SLE) and/or a family history of SLE may be at risk of PPI-induced cutaneous lupus erythematosus. Severity is usually associated with the type of drug the individual is exposed to and clinically presents with “non-scarring, erythematous, annular polycyclic or papulosquamous cutaneous eruption so sun-exposed areas” (Aggarwal, 2016). This medication can be used short and long-term; however, patients who are prescribed pantoprazole long-term for more than one year should be monitored for bone loss, fractures, and Clostridium difficile-associated diarrhea (Lexicomp, n.d.). Magnesium levels should also be checked periodically for concomitant use with digoxin or diuretics (Lexicomp, n.d.). Side effects may include diarrhea, constipation, abdominal pain, and headache (Archangelo et al., 2022).

            Treatment for GERD can also be accomplished with PPIs, yet histamine-2 receptor antagonists (H2RAs) are also frequently used. Cimetidine (Tagamet) has been effective in treating patients with this condition. Unlike PPIs, H2RAs provide relief much faster than their counterparts but do not last as long (Song et al., 2021). Prior to prescribing this medication, I would confirm that the patient does not have renal insufficiency, as dosing would need to be tailored according to their creatinine clearance. Cimetidine is commonly used for short-term relief, especially in older adults, due to its adverse effects of confusion, dizziness, drowsiness, and headache (Lexicomp, n.d.). Monitoring parameters should include a complete blood cell count, gastric pH, any signs of occult bleeding, and kidney function for patients with renal disease (Lexicomp, n.d.).

            Understanding the different types of IBS and the patient’s predominant stool pattern is vital before prescribing medication for this disorder. Depending on the severity of the patient’s symptoms can help on whether or not dietary and lifestyle changes are needed or pharmacological therapy is warranted. When a patient exhibits signs of constipation, magnesium citrate (Citroma) can be used to aid in colonic distension, further promoting an increase in peristalsis (Archangelo et al., 2022). Magnesium citrate is highly contraindicated in patients with end-stage renal disease as it can alter serum electrolytes (Lexicomp, n.d.). With this being said, as a practitioner, it is essential also to know that this medication should be used with caution with certain neuromuscular diseases such as myasthenia gravis (Lexicomp, n.d.). Citroma should only be used short-term due to a high incidence of laxative dependence (Archangelo, 2022). Adverse effects that may be associated with magnesium citrate are abdominal pain, cramping, and nausea (Archangelo, 2022).