medical information

1. STRESS ULCER
PROPHYLAXIS
Cliical pharmacy gharbia group
almojamaa eltibi alnamozagy hospital

2. Dosing: Adult
Active duodenal ulcer: Oral: 20
mg once daily for 4-8 weeks
Gastric ulcers: Oral: 40 mg
once daily for 4-8 weeks
Stress-ulcer prophylaxis (ICU
patients; unlabeled use): Oral:
40 mg once daily; periodically
evaluate patient for continued
need
Prevention of
rebleeding in peptic
ulcer bleed (unlabeled
use): I.V.: 80 mg,
followed by 8 mg/hour
infusion for 72
hours. Note: A daily
infusion of 40 mg does
not raise gastric pH
sufficiently to enhance
coagulation in active GI
bleeds
IV: Continuous infusion: Loading dose
of 80 mg, followed by 8 mg/hour
continuous infusion for a total of 72
hours
Oral: 30 mg once daily
(Brophy 2010; Olsen
2008). Note: Intended
for patients with
associated risk factors
(eg, coagulopathy,
mechanical ventilation
for >48 hours,
sepsis/septic shock);
discontinue use once
risk factors have
resolved (Rhodes 2017
Dosing: Renal
Impairment
No adjustment is required.
Dosing: Hepatic
Impairment
No adjustment is required.
Dosing: Renal
Impairment
No adjustment is required.
Hepatic Impairment: Adult
Oral
:
Mild to moderate impairment (Child-
Pugh class A or B): No dosage
adjustment necessary
.
Severe impairment (Child-Pugh class C):
Dosing: Renal
Impairment
No adjustment is required.
Pantoprazole is not removed by
hemodialysis.
Dosing: Hepatic
Impairment
No adjustment is required.
Dosing: Renal
Impairment
No adjustment is necessary.
Dosing: Hepatic
Impairment
Bioavailability is increased with
chronic liver disease. Consider
dosage adjustment, especially for
maintenance of erosive
esophagitis. Specific guidelines are
not available

3. Lansoprazole may decrease the
levels/effects of: Acalabrutinib;
Atazanavir; Bisphosphonate Derivatives;
Bosutinib; Capecitabine; Cefditoren;
Cefpodoxime; Cefuroxime
;
Esomeprazole may increase the
levels/effects of: Amphetamine;
Cilostazol; Citalopram; CloBAZam;
Dexmethylphenidate;
Dextroamphetamine; Dichlorphenamide;
Escitalopram; Fosphenytoin-Phenytoin;
Itraconazole; Methotrexate;
Methylphenidate
Clopidogrel: Pantoprazole may
decrease serum concentrations of
the active metabolite(s) of
Clopidogrel. Management: Due to
the possible risk for impaired
clopidogrel effectiveness, clinicians
should carefully consider the need
for proton pump inhibitor therapy in
patients receiving clopidogrel. Other
acid-lowering therapies do not
appear to share this interaction. Risk
D: Consider therapy modification
Clopidogrel: Proton pump
inhibitors may diminish the
therapeutic effect of
clopidogrel, thought to be due
to reduced formation of the
active metabolite of clopidogrel;
an increase in the risk of
cardiovascular events may
occur
Monitoring Parameters
Hypersecretory disorders: Acid
output measurements, target level
<10 mEq/hour (<5 mEq/hour if
prior gastric acid-reducing surgery)
Monitoring Parameters
Hypersecretory disorders: Acid
output measurements, target level
<10 mEq/hour (<5 mEq/hour if
prior gastric acid-reducing surgery)
Monitoring Parameters
Hypersecretory disorders: Acid
output measurements, target level
<10 mEq/hour (<5 mEq/hour if
prior gastric acid-reducing surgery)
Internationa
Monitoring Parameters
Hypersecretory disorders: Acid
output measurements, target level
<10 mEq/hour (<5 mEq/hour if
prior gastric acid-reducing surgery)
Internationa

4. Storage/Stability
Capsules
:
Esomeprazole magnesium: Store at
25°C
.)
Powder for injection: Store at 25°C
Protect from light.
following reconstitution, solution for
injection prepared in NS, and solution for
infusion prepared in NS or LR should be
used within 12 hours; solution for
infusion prepared in D5W should be used
within 6 hours. Refrigeration is not
required following reconstitution
.
Additional stability data: Following
reconstitution, solutions for infusion
prepared in D5W, NS, or LR in PVC bags
are chemically and physically stable for
48 hours at room temperature (25°C) and
for at least 120 hours under refrigeration
Tablets: Store at 20°C to 25°C
Storage/Stability
Oral: Store tablet and oral suspension at
20°C to 25°C
.)
IV: Prior to reconstitution, store at 20°C
to 25°C (68°F to 77°F);
Do not freeze. Protect from light prior to
reconstitution; upon reconstitution,
protection from light is not required. Do
not freeze reconstituted solution. Per
manufacturer's labeling, reconstituted
solution is stable at room temperature
for up to 6 hours; further diluted
(admixed) solution in D5W, LR, or NS
should be stored at room temperature
and used within 24 hours from the time
of initial reconstitution
Storage/Stability
Capsules, tablets: Store at 15°C to 30°C
Protect from light and moisture
.
Granules for oral suspension: Store at
25°C
.)
Powder for suspension
.
OTC capsules: Store at 20°C to 25°C
(protect from moisture
Storage/Stability
Capsules, orally disintegrating tablets:
Store at 25°C (77°F); excursions
permitted to 15°C to 30°C (59°F to
86°F). Protect from light and moisture
.

5. Dosing: Renal Impairment
No adjustment is required.
Pantoprazole is not removed by
hemodialysis.
Dosing: Hepatic
Impairment
No adjustment is required.
Dosing: Renal Impairment
No adjustment is necessary.
Dosing: Hepatic
Impairment
Bioavailability is increased with
chronic liver disease. Consider
dosage adjustment, especially for
maintenance of erosive esophagitis.
Specific guidelines are not available
Dosing: Renal
Impairment
No adjustment is required.
Hepatic Impairment: Adult
Oral
:
Mild to moderate impairment (Child-
Pugh class A or B): No dosage
adjustment necessary
.
Severe impairment (Child-Pugh class C):
Maximum: 20 mg daily
.
Continuous infusion
:
Mild to moderate impairment (Child-
Pugh class A or B): 80 mg over 30
minutes, followed by a maximum
continuous infusion of 6 mg/hour for a
total of 72 hours
.
Dosing: Renal
Impairment
No adjustment is required.
Dosing: Hepatic
Impairment

6. Administration
Oral: Best if administered before
breakfast.
Oral suspension: Following
reconstitution, the
suspension should be left
to thicken for 2-3
minutes and administered
within 30 minutes. If any
material remains after
administration, add more
water, stir, and
administer immediately.
Tablet: Should be swallowed
whole; do not crush or
chew.
Nasogastric/orogastric (NG/OG)
tube administration:Pour the
contents of one or two 20 mg
omeprazole delayed release
capsules (depending on the dose)
into a syringe (after removing
plunger); withdraw 10-20 mL of an
8.4% sodium bicarbonate solution
into the syringe; allow 30 minutes
for the enteric-coated omeprazole
granules to break down. Shake the
resulting milky substance prior to
administration. Flush the NG tube
with 5-10 mL of water and clamp
for at least 1 hour.
I.V.: Flush I.V. line before and
after administration. In-line
filter not required.
2-minute infusion: The volume
of reconstituted solution
(4 mg/mL) to be injected
may be administered
intravenously over at
least 2 minutes.
15-minute infusion: Infuse
over 15 minutes at a rate
not to exceed 7
mL/minute (3
mg/minute).
Oral:
Tablet: Should be swallowed
whole, do not crush or
chew. Best if taken
before breakfast.
Flush line prior to and after
administration with NS, LR, or D5W
.
Treatment of GERD: May be
administered by injection (≥3 minutes),
intermittent infusion (10 to 30 minutes
)
Peptic ulcer disease, treatment of
bleeding ulcers: May be administered as
continuous infusion or intermittent
infusion (infuse over 30 minutes),
depending on risk of rebleeding
Powder for injection
:
For IV injection (≥3 minutes): Adults:
Reconstitute powder with 5 mL NS
.
For IV infusion (10 to 30 minutes):
Initially reconstitute powder with 5 mL
of NS, LR, or D5W, then further dilute to
a final volume of 50 mL
.
For IV infusion (loading dose and
continuous infusion): Prepare the 80 mg
loading dose by reconstituting two 40
mg vials with NS (5 mL each); the
contents of the two vials should then be
further diluted in NS 100 mL. To
prepare the continuous infusion, also
reconstitute two 40 mg vials with NS (5
mL each); the contents of the two vials
should then be further diluted in NS 100
Administer 30 to 60 minutes before a
meal; best if taken before breakfast
(ACG [Katz 2013]). If administering
twice daily, first dose should be
administered before breakfast and the
second dose before dinner (ACG [Katz
2013]; Hershcovici 2010). The intact
granules should not be chewed or
crushed; however, several options are
available for those patients unable to
swallow capsules
:

7. administration
efficacy
Safety
Drugs
Mechanism of action
Family
orally, via
nasogastric tube, or
intravenously
-significantly
lower rate of
GI bleeding
than antacids -
decreased overt
GI bleeding
compared to
sucralfate
ventilatorassociated
pneumonia was more
frequent in the H2
blocker group, than
sucralfate
cimetidine,
famotidine ranitidine
nizatidine
Histamine-2 receptor
antagonists (H2 blockers)
antagonize the H2 receptors on
the parietal cell, resulting in
diminished gastric acid
secretion.
H2 blockers
orally, via
nasogastric tube, or
intravenously
less GI bleeding
than H2
blockers
higher incidence of
nosocomial
pneumonia among
patients who received
a PPI than among
those who received an
H2 blocke
omeprazole,
lansoprazole ,
pantoprazole ,
esomeprazol e
block acid secretion by
irreversibly binding to and
inhibiting the
hydrogenpotassium ATPase
pump that resides on the
luminal surface of the parietal
cell membrane.
Proton pump
inhibitor
orally or via _
nasogastric tube
Associated with
fewer
nosocomial
pneumonia s
than PPI and
H2 blockers.
lower rate of clinically
important GI bleeding
than antacids
Sulfated polysaccharide
complexed with aluminum
hydroxide. It exerts its effects by
coating and protecting the
gastric mucosa, without altering
gastric acid secretion
Sucralfate
orally or via _
nasogastric tube
Higher
incidence of
nosocomial
pneumonia than
Higher GI bleeding
than H2 blockers and
PPI and sucralfate
Carbonate
bicarbonat
Aluminum
hydroxide:
neutralize gastric acid and
protect the gastric mucosa
Antacids

8. nizatidine famotidine cimetidine,
Duodenal ulcer: Oral
:
Treatment: 300 mg once daily at
bedtime or 150 mg twice daily
for up to 8 weeks
Maintenance of healing: 150 mg
once daily at bedtime
Gastric ulcer, benign: Oral: 150
mg twice daily or 300 mg once
daily at bedtime for up to 8
weeks
Stress ulcer prophylaxis in select
critically ill patients (off-label
use): Note: For ICU patients with
associated risk factors for GI
bleeding (including
coagulopathy, mechanical
ventilation for >48 hours,
traumatic brain injury, history of
GI ulceration or bleeding within
past year, extensive burns);
discontinue prophylaxis once
risk factors have resolved
(Rhodes 2017; Weinhouse
2019
.)
Oral or via nasogastric (NG) tube
(alternative to enteral PPI): 20
mg twice daily (ASHP 1999;
Weinhouse 2019
)
IV: 20 mg twice daily (ASHP
1999; Weinhouse 2019
)
Stress ulcer prophylaxis in
critically ill patients (off-label
use): Oral or NG tube: 300 mg 4
times daily (ASHP
1999). Note: Intended for
patients with associated risk
factors (eg, coagulopathy,
mechanical ventilation for >48
hours, sepsis/septic shock);
discontinue use once risk factors
have resolved (Rhodes 2017
.)
Serious hypersensitivity (eg,
anaphylaxis) to famotidine,
other H2 antagonists, or any
component of the formulation
Serious hypersensitivity (eg,
anaphylaxis) to famotidine,
other H2 antagonists, or any
component of the formulation
Serious hypersensitivity (eg,
anaphylaxis) to famotidine,
other H2 antagonists, or any
component of the formulation

9. Preparation for Administration: Adult
Solution for injection
:
IV push: Dilute 2 mL (20 mg) with NS (or another
compatible solution) to a total of 5 to 10 mL. May also
administer undiluted (Lipsy 1995
.)
Infusion: Dilute 2 mL (20 mg) with 100 mL of D5W or
another compatible solution
diluted with most commonly used intravenous
solutions, e.g., Sodium Chloride Injection (0.9%),
Dextrose Injection (5% or 10%), Lactated Ringer’s
Injection, 5% Sodium Bicarbonate Injection,
Cimetidine Injection, USP should not be used after
more than 48 hours of storage at room temperature.
Administration: IV
Administer IV push over at least 2 minutes. Administer
IV infusion over 15 to 30 minutes
Administration: Oral
Administer without regard to meals. May administer
with antacids
.
Suspension: Shake vigorously before use
.
Tablet (OTC): Do not chew; dose may be taken 10 to 60
minutes before eating food or drinking beverages
known to cause heartburn
..
Administration: Oral
Administer with meals. For stress ulcer prophylaxis in
critically-ill patients (off-label use), may administer via
NG tube

10. Breast-Feeding Considerations
Cimetidine is excreted in breast milk. Breastfeeding is
not recommended by the manufacturer
Breast-Feeding Considerations
Cimetidine is excreted in breast milk. Breastfeeding is
not recommended by the manufacturer
Breast-Feeding Considerations
Cimetidine is excreted in breast milk. Breastfeeding is
not recommended by the manufacturer
.
Hepatic Impairment: Adult
There are no dosage adjustments
Renal Impairment: Adult
Manufacturer's labeling
:
Mild to moderate renal impairment: There are no
dosage adjustments provided in the manufacturer’s
labeling; use with caution
.
Severe renal impairment: 300 mg every 12 hours; may
increase frequency with caution. When hepatic
impairment is also present, further reductions in dosage
may be necessary
.
Dosing: Hepatic renal Impairment: Adult
There are no dosage adjustments provided in the
manufacturer's labeling
.
Hepatic Impairment: Adult
There are no dosage adjustments provided in the
manufacturer's labeling
Dosing: Renal Impairment: Adult
Manufacturer's labeling
:
Active treatment
:
CrCl >50 mL/minute: No dosage adjustment necessary
.
CrCl 20 to 50 mL/minute: 150 mg once daily
CrCl <20 mL/minute: 150 mg every other day

11. Drug Interactions: Avoid Concomitant Use
clinically relevant drug interaction
potential; Inhibits CYP1A2 (weak), CYP2C19 (weak),
CYP2D6 (weak), CYP3A4 (weak
)
Avoid concomitant use of Cimetidine with any of the
following: Cefuroxime; Chloroquine; Dasatinib;
Delavirdine; Dofetilide; EpiRUBicin; PAZOPanib;
Pimozide; Risedronate
Drug Interactions: Increased Effect/Toxicity
Drug Interactions: Increased Effect/Toxicity
Famotidine may increase the levels/effects
of: Dexmethylphenidate; Itraconazole;
Methylphenidate; Risedronate; Saquinavir; Varenicline
Drug Interactions: Increased Effect/Toxicity
Storage/Stability Storage/Stability
Oral
:
Powder for oral suspension: Prior to reconstitution,
store at 25°C (77°F). Reconstituted oral suspension is
stable for 30 days at room temperature; do not freeze
.
Tablet: Store at 25°C (77°F); excursions permitted to
15°C to 30°C (59°F to 86°F). Protect from light
.
IV
:
Solution for injection: Prior to use, store at 2°C to 8°C
(36°F to 46°F). If solution freezes, allow to solubilize at
room temperature. Protect from light
.
IV push: Following preparation, solutions for IV push
Store at 20°C to 25°C (68°F to 77°F); excursions
permitted to 15°C to 30°C (59°F to 86°F
.)

12. SACRULFATE
Administration: Oral
Administer on an empty stomach. Shake suspension well before use. Do not administer antacids within 30 minutes of
administration of sucralfate. In general, separate administration of other oral medications and sucralfate by at least 2 hours;
consult drug interactions database for additional information
.
Breast-Feeding Considerations
It is not known if sucralfate is present in breast milk
.
Sucralfate is only minimally absorbed following oral administration. Although the manufacturer recommends that caution be
exercised when administering sucralfate to breastfeeding women, use is considered acceptable
Hypersensitivity to sucralfate or any component of the formulation
Suspension, tablet: Initial: 1 g 4 times daily for 4 to 8 weeks
.
Maintenance therapy: Tablet: 1 g twice daily
.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or
avoidance. Consult drug interactions database for more information
.
Hepatic & renal impairment
There are no dosage adjustments provided in the manufacturer's labeling
Drug Interactions: Decreased Effect
Sucralfate may decrease the levels/effects of: Baloxavir Marboxil; Bictegravir; Bisphosphonate Derivatives; Cabotegravir;
Cholic Acid; Deferiprone; Digoxin; Dolutegravir; Eltrombopag; Elvitegravir; Furosemide
;
Storage/Stability

13. Sodium bicarbonate
Oral
:
Products containing aluminum hydroxide 200 mg,
magnesium hydroxide 200 mg, and simethicone 25 mg
per tablet: 1 to 4 tablets 4 times daily; may also take as
needed, up to 12 to 16 tablets/24 hours
Administer 1 hour after meals or between meals
.
Suspension: Shake well prior to use
Administration: Oral
Administer after meals and at bedtime (up to 4 times daily).
Shake suspension well before use. Tablets should be chewed
thoroughly before swallowing
Dosing: Renal Impairment: Adult
There are no dosage adjustments provided in the
manufacturer's labeling; aluminum and/or magnesium
may accumulate in renal impairment
.
Contraindications
Hypersensitivity to sodium bicarbonate, sodium alginate,
calcium carbonate, or any component of the formulation
(including methyl/propyl paraben [suspension only])
Dietary Considerations
Should be taken after meals. Products contain significant
amounts of sodium and calcium
.
Dosing: Hepatic & renal
Impairment: Adult