1. ก F

2. scope
1.Anti-emetics drugs; ก ก F
2.Agents for treatment of peptic ulcer : ก
3.Antidiarrheal drugs : ก ก F F
4.Anticonstipation ; กF ก F ก -> laxatives and
cathartics
5.Antiflatulants ; ก F ˂

3. 1.Anti-emetics drugs; ก ก F

4. ก F
ก ก F ก ก
F F ก ก ก F ก F ก
2 F ˈ ก2 F ˈ ก
: F( F ) / /

5. ก ก ก F
Cerebral cortex(higher center)
NK1,GABA
Pain,smell,sight,taste→ ←Memory,fear,
hearing,stress,
thinking
Vomit center
H1,5-HT3,D2,M1
CTZ area postrema
D2,NK1,
5-HT3,M1,H1,opioid
Cytotoxic,opioid→
Cardiac glycoside
Nucleus tractus solitarius
Stomach
Small intestine
5-HT3,D2,NK1,
opioid
Gastric irritation
Infect at GI,Ipecac
cytotoxic,radiation
Nucleus tractus solitarius
(NTS)
5-HT3,D2,M1,H1,NK1
Glossopharyngeal nerve
Trigerminal nerve
F
Vestibular system
H1,M1
(motion sickness)
Vomiting reflex
Neuronal pathways
Factors cause N/V

6. F( F ) ก F ก ก N/V
Vomitting center ( F ) กก F
ก F( F ) F
1.Cerebral cortex (higher center) กF1.Cerebral cortex (higher center) กF
Stimulants N/V: ก ก F
ก ก

7. F( F ) ก F ก ก N/V
2.Chemoreceptor trigger zone (CTZ)
area postrema F Medulla ( F
Blood Brain Barrier) F กBlood Brain Barrier) F ก
CTZ
Stimulants N/V: opioid ,cardiac glycosides ,cytotoxic

8. F( F ) ก F ก ก F
3.Vestibular system ( ก F F )
vestibular F F ก
acetylcholine histamine F vomitting center Facetylcholine histamine F vomitting center F
ก
Stimulants N/V :ก (motion sickness)

9. 4.Stomach,small intestine F vagus nerve
F nucleus tractus solitarius (NTS) ก nucleus
F fibers F vomitting center
e.g.Cytotoxic ก serotonin ก
F( F ) ก F ก ก F
e.g.Cytotoxic ก serotonin ก
Enterochromaffin like cell F ก (+) 5-HT3
receptors F vagus nerve N/V
Stimulants N/V : cytotoxics , gastric irritation , ipecac,
ก GI, ก (radiation)

10. 5.Glossopharyngeal nerve Trigerminal nerve
F F nucleus tractus
solitarius (NTS) F F F vomitting center
F( F ) ก F ก ก F
solitarius (NTS) F F F vomitting center

11. ก F ก N/V
(neurotransmitters)
(receptor)
1.Acetylcholine
2.Dopamine
1.MuscarinicM1 receptor
2.Dopaminergic receptor (dopamine D2.Dopamine
3.Histamine
4.Serotonin (5-HT)
5.Substance P (SP)
2.Dopaminergic receptor (dopamine D2
receptor)
3.Histaminergic receptor (histamine H1
receptor)
4.5-HT receptor (5-HT3 receptor)
5.Neurokinin-1(NK1 receptor)

12. F ก F
F ...

13. Dystonia :
ก F ก F F ก ก
F F F F ˁ
Extrapyramidal side effect (EPS)
F F F F ˁ
1.http://www.youtube.com/watch?v=VHGzUxnuvwQ
2.http://www.youtube.com/watch?v=N_daWx-qcaw

14. Extrapyramidal side effect (EPS)
Parkinsonism:
ก ก F ก ก F / F
ก F (posture) กก F (posture) ก
http://www.youtube.com/watch?v=j86omOwx0Hk

15. Tardive dyskinesia :
ก F ก F F
F ˁ ก ก ก F ˈ
Extrapyramidal side effect (EPS)
F ˁ ก ก ก F ˈ
F F F F ก ก/
F กF

16. Extrapyramidal side effect (EPS)
Tardive dyskinesia :
ก ก ก ก ก
ʾ ก ก F ก กʾ ก ก F ก ก
ก ก 2 F
http://www.youtube.com/watch?v=FUr8ltXh1Pc

17. Anticipatory CINV
(Anticipatory chemo therapy-induced nausea and vomiting)
ˈ ก กF ก F
ก ก ก ก ก N/V กก ก ก ก ก N/V ก
กF F
Stimulants : ก F ก ก ก
ก ก ก F กF

18. Nausea and vomiting ก
Acute nausea and vomiting:
ก 24 F
ก ก 24ก ก 24

19. Nausea and vomiting ก
Delayed nausea and vomiting :
ก F F ก F 24 hr
F F 5-7 FF F 5-7 F

20. Anti-emetics drugs
1. Muscarinic M1 antagonist
2. Dopamine D2 antagonist
3. Histamine H1 antagonists
ʽ ก
(receptor) ก F F F
Histamine H1 antagonists
4. 5-HT3 antagonist
5. Substance P antagonist
6. Pyridoxine (Vit B6)
7. Benzodiazepines
8. Steroids

21. 1)Anti-emetics drugs ;Muscarinic M1 antagonist
e.g.Scopolamine (hyoscine)
ก ก : ʽ ก muscarinic M1 receptor
Common ADR: ADR ˈ ก antimuscarinicCommon ADR: ADR ˈ ก antimuscarinic
effect F ก F F F F ก

22. 2)Anti-emetics drugs;Dopamine D2 antagonist
e.g. Domperidone(Motilium®),Metoclopramide(Plasil®),
(Chlorpromazine,Perphenazine,Haloperidol,Droperidol)
ก ก :
1. ʽ ก dopamine D receptor CTZ NTS
ก ก :
1. ʽ ก dopamine D2 receptor CTZ NTS
( ก F domperidone F F Blood brain barrier ;
BBB) F F CTZ F )

23. 2)Anti-emetics drugs;Dopamine D2 antagonist
2. ʽ ก 5 HT3 receptors GI ,
e.g.Metoclopramide (high dose)
3. F Fก
ก / F (gastroprokinetic)
e.g.Domperidone , Metoclopramide

24. 2)Anti-emetics drugs;Dopamine D2 antagonist
ADR: F ก F ก ก ก F
Domperidone/metoclopramide
↑ก prolactin hyperprolactinemia-related side
effects F gynecomastia galactorrhea
↑ก prolactin hyperprolactinemia-related side
effects F gynecomastia galactorrhea
ก F domperidone .........
Metoclopramide ( Fdomperidone < F BBB;<EPS)
Extrapyramidal side effect (EPS) F F
esp. F ˁ (cause.tardive dyskinesia )

25. 2)Anti-emetics drugs;Dopamine D2 antagonist
Domperidone /metoclopramide ;
Take the tablets 30 minutes before each meal and
bedtimebedtime

26. 3)Anti-emetics drugs;Histamine H1 antagonists
e.g.Dimenhydrinate(Dramamine®)(+antimuscarinics)
,Diphenhydramine(Benadryl®), promethazine,meclizine
ก ก:ก ก:
ʽ ก histamine H1 receptor F vestibular system
/vomitting center
Common ADR: F ก F F ก

27. 4)Anti-emetics drugs;5-HT3 antagonist :
e.g.Ondansetron(Onsia®),Granisetron,Dolasetron,Tropisetron
ก ก:
ʽ ก 5-HT3 receptor F ก (CTZ, NTS)ʽ ก 5-HT3 receptor F ก (CTZ, NTS)
visceral afferent vagus nerve
Common ADR: F / F ก F
Serious ADR : QT prolong ( F ˁ ก ˂
ก ) cardiac arrhythmia

28. 4)Anti-emetics drugs;5-HT3 antagonist :
F ondansetron
first dose :30 minutes before the start of chemotherapy
1 to 2 hours before the start of radiation therapy1 to 2 hours before the start of radiation therapy
1 hour before surgery.
Additional doses are sometimes taken one to three times a
day during chemotherapy or radiation therapy and for 1 to 2
days after the end of treatment.

29. 5)Anti-emetics drugs;Substance P antagonist ; NK1 receptor antagonist:
e.g.aprepitant
ก ก :
ʽ ก F F substance P ก F NK1 receptor NTSʽ ก F F substance P ก F NK1 receptor NTS
ก cerebral cortex ก F
vomitting center
Common ADR : F F

30. 6)Anti-emetics drugs;Others; Pyridoxine (Vit B6)
ก ก:
B6 ˈ coenzyme F Glutamic decarboxylase
ก ก Glutamic acid ˈ GABAก ก Glutamic acid ˈ GABA
Glutamic acid((+)N/V) -------------------> GABA ((-)N/V)
ADR : F F if ≥2000 mg/day
Glutamic decarboxylase/B6

31. 7)Anti-emetics drugs ;Others;Benzodiazepines
e.g. lorazepam (Ativan®)
ก ก:
ก benzodiazepine GABAA-receptor ionorphoreก benzodiazepine GABAA-receptor ionorphore
complex F GABA F GABAA receptor
ก F ˂ ก Anticipatory CINV
amnestic antianxiety effects
Common ADR : F (amnesia)

32. 8)Anti-emetics drugs;Others;Steroids
e.g.Dexamethasone, Methylprednisolone
ก ก :
ก F 5-HT F กก F 5-HT F ก
Common ADR:
GI irritate, F , กก

33. 8)Anti-emetics drugs;Others;Steroids
F dexamethasone
Acute nausea and vomiting
/ กF F/ กF F
Delayed nausea and vomiting
: 2 3-4 ก F
ก F 24

34. ก ก F ก ก F
ก ก F
1.Motion
sickness ˆ ก
HistamineH1 antagonists:
e.g.dimenhydrinate,meclizine
Effective if take before ½ hr travel
( receptor
M1,H1)
Effective if take before ½ hr travel
MuscarinicM1 antagonists :
e.g.scopolamine ( F
Effective if take 4 hrs before travel
Effective : 3days

35. ก ก F ก ก F
ก ก F
2.Morning
sickness
N/V in pregnancy
Select safety to fetus
Vitamin
B6 +doxylamine (firstsickness Select safety to fetus B6 +doxylamine (first
line) or vit B6 only
H1 antagonists
e.g.dimenhydrinate
D2 antagonist
e.g.metoclopramide

36. ก ก F
3.Postoperative
N/V (PONV)
N/V after surgery
opioid:relief pain
opioid:(+)CTZ
5-HT3 antagonists (all.gold
standard)
D antagonists
ก ก F ก ก F
opioid:(+)CTZ D2 antagonists
e.g.metoclopramide,droperidol
M1 antagonists
e.g.scopolamine
H1 antagonist
e.g.promethazine

37. ก ก F ก ก F
ก ก F
4.Radiotherapy-
inducedN/V
(RINV)
Mechanism ~ cytotoxic D2 antagonists
e.g.metoclopramide
5-HT antagonists(all.)(RINV) 5-HT3 antagonists(all.)

38. ก ก F ก ก F
ก ก F
5.Chemo
therapy-
induced
cytotoxic
1.CTZ
2. F ก
5-HT3 antagonist(all.acute/delayed)
gold standard
D antagonists (acute type)induced
N/V(CINV)
2. F ก D2 antagonists (acute type)
e.g.metoclopramide
*Steroids (acute/delayed)
e.g.dexamethasone,methylprednisolone
*Benzodiazepines (anticipatoryCINV)
e.g.lorazepam

39. ก ก F ก ก F
ก ก F
5.Chemo
therapy-induced
N/V(CINV)
*NK1 receptor antagonist(acute /delayed)
e.g.Aprepitant
N/V(CINV)
(*) ก F ˈ F
F ก 5-HT3 metoclopramide

40. ก ก F ก ก F
ก ก F
6.Combine tx
for Acute CINV
- 5-HT3antagonist+steroid(best treatment)
effective than single drug and lower S/E
than metoclopramide+steroid and others
for Acute CINV effective than single drug and lower S/E
than metoclopramide+steroid and others

41. ก ก F ก ก F
ก ก F
7.Gastroenteritis
( F ก )
- D2 antagonists
e.g. metoclopramide( F ก ) e.g. metoclopramide
8.Gastroparesis
(ก F ก
F )
- D2 antagonists
e.g. metoclopramide ,domperidone

42. ก
Agents for treatment of peptic ulcer
Antacid
Anti-secretory drug
Mucosal resistance(Cytoprotective)Mucosal resistance(Cytoprotective)
Misc.
-Rebamipide
- ก (Eradication) H.pylori
NSAIDs-induced peptic ulcer

43. Parietal cells mucosa ก
Receptor ( ) ก F ก ก ก
F ก ก F ก ก F
ก ก
F ก ก F ก ก F
receptor
Second messenger
F H+/K+ ATPase or gastric proton pump

44. ก F F ก ก ก
Receptor ก F ก
ก F (Receptor)
Histamine-2 receptor HistamineHistamine-2 receptor
(H2 receptor)
Histamine
Muscarinic -3 receptor Acetylcholine
CCK2 receptor Gastrin

45. F ก F
1.Second messenger
ก F F กก ก F
Second messenger กF F ก กSecond messenger กF F ก ก
F
Second messenger F ก
ก ก กก ก F

46. F ก F
2.Phosphate Binders
F ก phosphate
F phosphate form ˈ insolubleF phosphate form ˈ insoluble
compound ก ก

47. ก กก ก
1. receptor
2. F ก secondary messengers
Cyclic AMP (cAMP)Cyclic AMP (cAMP)
Calcium

48. ก กก ก
Histamine:
(+) F adenylate cyclase (ATP cAMP)
Gastrin ,acetylcholine:
ก calcium ก F cell
↑calcium cell
(+) F adenylate cyclase (ATP cAMP)
↑cAMP

49. ก กก ก
3.cAMP ↑, calcium ↑ (+) H+/K+ ATPase at
parietal cell membrane
4. F ก ก ก hydrogen ion4. F ก ก ก hydrogen ion
ก ก (H+) ก F parietal
cell ก F canaliculi
ก ก (K+) F F cell

50. ก กก ก ก parietal cell
: F hydrogen/potassium adenosine triphosphate (H+/K+ ATPase gastric proton pump )

51. Gastric pH <3 ( ˈ ก ก) ก ก F
1. ก gastrin
ก กก ก ก
2.Prostaglandin (PGE2 ) histamine ก
ก F adenylate cyclase

52. (peptic ulcer)
Peptic ulcer
ก/ ก ก / F ก F F +
ก ก กก ก ก
ˈ ก aggressive factor -defensive factor
imbalance

53. ˆ F ก ก peptic ulcer
Aggressive factor Defensive factor
ก parietal cell
mass
ก ก /bicarbonate
mass
ก
ก
F
mucosa (mucosa
ก ˈ
ก F ก
)

54. ˆ F ก ก peptic ulcer
Aggressive factor Defensive factor
ก F prostaglandin
inhibitor
ก
epithelial cell (cellinhibitor
(e.g.NSAIDs
protective prostaglandin)
epithelial cell (cell
ก ) ก
ก H.pylori Prostaglandin E2 (PGE2)

55. ก Peptic ulcer
F ʾˉ F ˈ ก
Duration : day/wk
ก ก ˈ F ก
ก ก DU/GU
F ก F
ก ( F )
ก ก ˈ F ก

56. ก Peptic ulcer
F ก (Duodenal ulcer;DU)
ก ก F F F
กF กกF ก
Relief : / F ก
ก (Gastric ulcer;GU)
ก ก F F F 1-3

57. F ก ก
ก
F
ก ก ˈก ก ˈ
ก ก F ก ˈ
e.g.haemorrhage ,obstruction ( ก scar),perforation

58. ก
Agents for treatment of peptic ulcer
Antacid
Anti-secretory drug
Mucosal resistanceMucosal resistance
Misc.
-Rebamipide
- ก (Eradication) H.pylori (HP)
NSAIDs-induced peptic ulcer

59. 1.Antacids ( ก )
e.g. aluminium salt , magnesium salt, sodium bicarbonate
ก ก:
1.ก ก (acid neutralizing effects)1.ก ก (acid neutralizing effects)
2.ก ก F ก ก
2.1 ∆ pepsinogen pepsin
2.2 ก ก H.pylori

60. 1.Antacids ( ก )
F ก F F F
rapid onset : within 5-15 min
duration : 15 min-1 hrduration : 15 min-1 hr
F ก
F F F
ก F F ก F ก
ก F F

61. 1.Antacids ( ก )
ADR : Aluminium salt ( F ก), Magnesium salt
( F )
Drug interaction (DI) :Drug interaction (DI) :
↓ absorption F F (absorption & dissolution
depend on acid)
enteric coated F กF ก

62. 1.Antacids ( ก )
antacid (aluminium salt) ก phosphate ก
phosphate F ˈ phosphate binder F ˁ
Drug interaction (DI) :
phosphate F ˈ phosphate binder F ˁ
ก sucralfate ก gastric mucosa

63. 2.1 H2 receptor antagonist (H2RA)
2.2 Proton pump inhibitor (PPI)
2.Anti-secretory drugs ; ก ก

64. 2.1 H2 receptor antagonist (H2RA)
e.g.ranitidine, famotidine, nizatidine, cimetidine
ก ก
F histamine ก ก H receptorF histamine ก ก H2receptor
competitive/reversible ก F cyclic AMP

65. cimetidine ranitidine nizatidine famotidine
1 4-10 4-10 20-50
Dose of
treatment
400 bid
800 hs
150 bid
300 hs
150 bid
300 hs
40 hs
2.1 H2 receptor antagonist (H2RA)
treatment
(mg)
400 bid
800 hs
150 bid
300 hs
150 bid
300 hs
40 hs
Dose of
recurrent
prophylaxis*
(at least 1 ʾ)
400 hs 150 hs 150 hs 20 hs

66. 2.1 H2 receptor antagonist (H2RA)
food : not affect to absorption
Treatment
DU : 6-8 wk if not cure F F ก 2-4 wkDU : 6-8 wk if not cure F F ก 2-4 wk
GU : 8 wk if large ulcer F 12 wk
* if recurrent > 3 / ʾ

67. ADR:
F F / F ก F
F F F
2.1 H2 receptor antagonist (H2RA)
F F F
cimetidine (antiandrogen effect) in men/high dose
/long term ก gynecomastia/impotence

68. 2.1 H2 receptor antagonist (H2RA)
Drug interaction (DI)
antacid , sucralfate : ↓ absorption of H2RA
F antacid/sucralfate F ก H RA F FF antacid/sucralfate F ก H2RA F F
2 hr

69. 2.2 Proton pump inhibitor (PPI)
e.g.omeprazole(Losec®),lansoprazole(Prevacid®),
pantoprazole(Controloc®),rabeprazole(Pariet®),
esomeprazole (Nexium®)esomeprazole (Nexium )
ก ก
parent compound(not active)-------->active metabolites
F ก H+/K+ATPase non-competitive
/irriversible ( ; ก F F F)
can use once daily before meal ~ 1/2 hr
ACID CONDITION

70. ก / ก F H2RA
Food delays absorption
ADR :
2.2 Proton pump inhibitor (PPI)
ADR :
F F F ˁ F F F F F F ก
F

71. 2.2 Proton pump inhibitor (PPI)
Drug interaction (DI)
PPIs ก metabolize ก Cytochrome
P450 enzyme (CYP450)
ก ก metabolize F CYP450
P450 enzyme (CYP450)
ก ก metabolize F CYP450
F ก F ↑warfarin,phenytoin level
- monitor response phenytoin
- maybe adjust dose of warfarin/monitor INR,PT

72. ก F PPI (enteric coated tablet) F ˁ F NG tube
NG tube (Nasogastric tube )
ก F F ก
F กF ก
F
F / กF F ˁ F
F ก

73. Enteric coated tablet/granules
F ก F ก F ก
ก ก (capsule) ก กก ก (capsule) ก ก
Enteric coating ก F F F
F ก
ก granules ก F ก กF
ก F ก+ ก

74. omeprazole (miracid® )
delayed-release capsule/multiple unit granules system
enteric-coated granules
ก F PPI (enteric coated tablet) F ˁ F NG tube
enteric-coated granules
Capsule :dissolves in gastric acid
Granules :base-labile coating dissolves in small
intestine

75. rabeprazole (pariet®)
delayed-release tablet or enteric-coated tablet
drug is absorbed in the intestine
ก F PPI (enteric coated tablet) F ˁ F NG tube
drug is absorbed in the intestine
** F / rabeprazole F NG tube**
Coated ; ก ก

76. Omeprazole
1. ก capsule
2. granules NG F
Gastric : ˈ ก
ก F PPI (enteric coated tablet) F ˁ F NG tube
Gastric : ˈ ก (protect the base-labile granules)
e.g. F F flush ก F
Small intestine : ˈ F ( F ก )
e.g.8.4%NaHCO3 F flush F ก F

77. Mucosal resistance ;Cytoprotective
ก ก ˂ ก F F ก
ก F
Cytoprotective agents :Cytoprotective agents :
Sucralfate
Bismuth preparation
Prostaglandin analogues

78. Sucralfate
ก ก:
1.sucralfate กก (viscous substance)
ก กก ก
ก ˂ ก ก ก

79. Sucralfate
2.ก F endogenous prostaglandin
ก PGE2 F
- F ก ˂ ก- F ก ˂ ก
- gastric mucus secretion F ก F
3. F F F ก ก

80. Sucralfate
ADR:
sucralfate ก ก F F ก ก F
systemic F ก F F กF F ก Fsystemic F ก F F กF F ก F
F F ก F ˈ ก F
F

81. Sucralfate
Drug interaction:
ก
F sucralfate F F (กFF sucralfate F F (กF
1 )

82. Bismuth preparation
e.g.bismuth subsalicylate (GASTRO-BISMOL®),
ranitidine bismuth citrate
ก กก ก
1. ก bismuth ก ก
ก F F ˈ ก
local gastroprotective effect

83. Bismuth preparation
2.ก F ก F prostaglandin, bicarb, ก
3.ก ก H.pylori
4. F neutralize ก4. F neutralize ก
ADR ;
- ˆ
-bismuth accumulate neurotoxic :not for recurrent
prophylaxis;long time

84. Prostaglandin analogues
e.g.Prostaglandin E analogues (misoprostol;cytotec®)
ก ก:
ก prostaglandin receptor parietal cellก prostaglandin receptor parietal cell
- ก ก
- (mucosa)
-ก F ก bicarb
- ก mucosa

85. Prostaglandin analogues
ADR;
F F (4-38%)
F F N/VF F N/V
ก F F F F
(FDA pregnancy category X )

86. Prostaglandin analogues;misoprostol;cytotec®
ก F off-label
F F
F กF ก
ก ก (postpartum hemorrhage)
F off-label F ก ก ก F F ก

87. Misc. ;Rebamipide (mucosta®):
ก ก ( / ):
↑ PGE2 ก F ก
↑ ก/ ก ก
↑ก ก ก↑ก ก ก
F ก F ก
F ก F F ก/ F ก
ก F interleukin-8 (IL-8) ก
ก Helicobacter pylori F (IL-8- inflammation)

88. Misc.; Rebamipide (mucosta®):
ADR;
leukopenia ( ก F ก ) ,
thrombocytopenia ( ก )thrombocytopenia ( ก )
hepatic dysfunction and jaundice (↑AST,ALT)
rash
constipation, diarrhea , N/V
heartburn

89. Combination treatment
Single (2-3 wk)+eradicate risk factors not cure
combine

90. ก (Eradication) H.pylori (HP)
Helicobacter pylori :
ก ก
F F ก ก กF F ก ก ก
(urease enz.) F urea ammonia+CO2
ammonia : ก ก , ก acid
hypersecretion , F ก gastric atrophy
ก ˈ cancer cell F

91. ก (Eradication) H.pylori (HP)
ก H. pylori
( )
PPI-based triple therapy
PPI bid + amoxicillin 1 g bid + clarithromycin 500
7-14PPI-based triple therapy
PPI bid + amoxicillin 1 g bid + clarithromycin 500
mg bid
PPI bid + metronidazole400 mg bid +
clarithromycin500 mg bid
PPI bid + amoxicillin1 g bid + metronidazole400
mg bid
7-14

92. ก (Eradication) H.pylori (HP)
ก H. pylori
( )
Bismuth-basedquadruple therapy
PPI bid + bismuth 240-525 mg bid +
14
PPI bid + bismuth 240-525 mg bid +
metronidazole400 mg bid or tid + tetracycline500
mg qid
PPI bid + bismuth 240-525 mg bid +metronidazole
400 mg bid or tid + clarithromycin500 mg bid

93. ก (Eradication) H.pylori (HP)
ก H. pylori
( )
Sequentialtherapy
PPI bid + amoxicillin 1 g bid ˈ 5 F F
10
PPI bid + amoxicillin 1 g bid ˈ 5 F F
PPI bid + metronidazole400-500 mg bid +
clarithromycin 1000 mg od 500 mg bid ˈ
5

94. ก (Eradication) H.pylori (HP)
ก H. pylori
( )
Levofloxacin-basedtriple therapy 10Levofloxacin-basedtriple therapy
PPI bid + levofloxacin250 mg (or 500 mg) bid +
amoxicillin1 g bid
10
Rifabutin-basedtriple therapy: 7-10 days
PPI bid + rifabutin 150 mg bid + amoxicillin1 g bid
10

95. ก (Eradication) H.pylori (HP)
ก H. pylori
( )
Concomitanttherapy 10Concomitanttherapy
PPI bid + amoxicillin1 g bid + clarithromycin500
mg bid + metronidazole 400 mg tid
10
* ก ก ก ก *
* ก F ˁ ก ก ก ก ˈ ก*

96. ก (Eradication) H.pylori (HP)
PPI-based triple therapy sequential therapy
Bismuth-based quadruple therapy
Levofloxacin-based triple therapy
ก F F
or
Levofloxacin-based triple therapy
Rifabutin-based triple therapy
Concomitant therapy
or
or
or

97. NSAIDs-induced peptic ulcer

98. ก กก ก NSAIDs-induced peptic ulcer
ก F prostaglandin
- F mucosal blood flow- F mucosal blood flow
-mucus secretion , HCO3 secretion
ก /pepsin/NSAIDs : ก
ก

99. NSAIDs-induced peptic ulcer
ก ˂ ก (prophylaxis)
F ˈ F Fก ˂ ก F ˁ
F NSAIDs กF NSAIDs ก

100. NSAIDs-induced peptic ulcer

101. ˆ (High risk)
> 60 ʾ
ก F
ก/ ก ก /ก/ ก ก /
F NSAIDs F ก corticosteroids
F NSAIDs ก F ก F
NSAIDs กก F 1 F ก
F F ก anticoagulants eg. warfarin

102. NSAIDs induced peptic ulcer
ก ก (Treatment)
1. NSAIDs : H2RA ∼ PPIs
2. F NSAIDs F : Drugs of choice :PPIs2. F NSAIDs F : Drugs of choice :PPIs
Drugs of choice ; ก F ˈ ก ก ก ก F F
F F

103. ก ก F F (antidiarrheal drugs)

104. ก F F (diarrhea)
F F ˈ กก F
3 /
F ก F F 1
24

105. F F (diarrhea)
1. F
2. F F ก กก F
antibiotic (eg.clindamycin,tetracycline),antibiotic (eg.clindamycin,tetracycline),
ก
ก F
ก F
กก
F F colon cancer, hyperthyroidism

106. ก ก ก F F
1. ก F กF
ก F ( ˁ / )
F IV :F IV :
ORS (oral rehydration salt) :
(Electrolyte=Na,K,Cl,HCO3) + ก

107. ก ก ก F F
F F
F F
F FF F
ก F F

108. ก ก ก F F
2.ก ก ก F F กก
2.1 F F ก (toxigenic diarrhea)
ก epithelial cell F F ก Fก epithelial cell F F ก F
enterotoxin ก
ก e.g.Vibrio cholerae ,E.Coli F F ˁ
F ˈ ก
*Enterotoxin :toxin ก F F F ก ก F *

109. ก ก ก F F
2.2 F F กก ก F F
(invasive diarrhea)
ก ก ก Fก ก ก F
ก e.g.shigella, salmonella, E.coli

110. ก ก ก F F
F ก ˈ
Shigella ( F )
e.g.TMP/SMX (bactrim®),norfloxacin,ciprofloxacine.g.TMP/SMX (bactrim®),norfloxacin,ciprofloxacin
Salmonella typhi ( F ก F F F )
e.g.TMP/SMX (bactrim®),ceftriaxone,ciprofloxacin
Vibrio cholerae( ก )
e.g.TMP/SMX(bactrim®),doxycycline,norfloxacin

111. ก ก ก F F
3. ก ก ก F F
ก F / ก F F F
3.1 ก F3.1 ก F
3.2 F ก ก
3.3 Intraluminal agents
3.4 Bulk forming agents
3.5 Bile acid binder

112. 3.1 ก F
Opioid derivatives -Loperamide; Imodium®
-Diphenoxylate+atropine;Lomotil®
ก ก :ก F opioid receptors Fก ก :ก F opioid receptors F
ก
ก F ก F
ก ก F F
/

113. 3.1 ก F
Diphenoxylate ก atropine ˂ ก ก
F
Atropine : ก atropinism
e.g. F F F
F

114. 3.1 ก F
ADR:
opioid F / F F
FF
F loperamide ก F ก F ก F
Diphenoxylate

115. 3.1 ก F
ก F F F
ก F F
2 F ก F2 F ก F
F ˁ ก F กก invasive diarrhea
F F F
F ก ก F F
F ก F Fก F

116. 3.2 F ก ก
Activated charcoal
Kaolin-pectin (Kaolin and pectin®)
Diosmectite (Smecta®)

117. 3.2 F ก ก
ก ก : F ก F F ก
F F F
ˈ ก F F Fˈ ก F F F
ก F
ADR : F ก F F F
ก ˈ F F ก F

118. 3.3 Intraluminal agents
e.g.Bismuth subsalicylates (GASTRO-BISMOL®)
ก ก : ก ก F
ADRADR
salicylism ( )
N/V
/

119. 3.4 Bulk forming agents
e.g.Psylium(AGIOLAX®,METAMUCIL®,FYBOGEL®)
F F/ ก ก ก F
F กF ก
ก ก : F ˈ กF F
ADR F F F ก F

120. 3.5 Bile acid binder
e.g.Cholestyramine (Questran®)
ก ก : ก ก toxin (clostridium
difficile toxin)difficile toxin)
F ก antibiotic associated diarrhea F F
ก ก F
ADR: F ก F ก

121. Cholestyramine ก bile acid
ก F F ก F F ก
ก bile acid ก
ก ก ก F ก F bile acid
3.5 Bile acid binder
ก ก ก F ก F bile acid
(cholesterol ˈ )
↓cholesterol
ก ↑LDL receptor
↑ ก catabolism LDL
↓ LDL ก

122. F ก F
Catabolism :
ก ก F
ก ก ˈ ก กก ก ˈ ก ก
ˈ F ก F / F F F
F

123. Antibiotic associated diarrhea
ก ก ก F F F
ก ก F F ก
F F ก F

124. Antibiotic associated diarrhea
F ก diarrhea F ก ก e.g.
1. Osmotic diarrhea
2. Bile salt diarrhea2. Bile salt diarrhea
3. ↑Small intestine motility
4. Microorganism infection

125. 1.Osmotic diarrhea
↓ (non absorbable carbohydrate) F F
F F non absorbable carbohydrate FF F non absorbable carbohydrate F
osmotic diarrhea

126. 2. Bile salt diarrhea
↓ F F( )
F bile salt F F
↑ bile salt↑ bile salt
ก F ก colonic fluid ก
F

127. 3. ↑↑↑↑Small intestine motility
F e.g. erythromycin
ก F motilin receptor F กก F motilin receptor F ก
F ก
F

128. 4. Microorganism infection
e.g. Clostridium perfrigen type A
Clostridium difficile

129. Antibiotic associated diarrhea
Cause
Drug : ampicilln,amoxycilln,cefixime,
fluoroquinolone(1-2%) bactrim (<1%)fluoroquinolone(1-2%) bactrim (<1%)
Organism : Clostridium difficle infection
*10% of total.cause but serious complication
then Death ก F Clostridium difficile diarrhea*

130. ก ก Clostridium difficile diarrhea
ก F : +supportive tx
ก :metronidazole (oral) 10-14
*If not relieve ,no tolerance to drug ,pregnancy,*If not relieve ,no tolerance to drug ,pregnancy,
<10 years old , severe colitis*
vancomycin (oral) 10-14

131. ก ก F ก ก F F
ก
F opioid derivative (eg.+atropine) :serious S/E
F F ก / กF F ก / ก
: F ก ก + ก
/
/ ก F e.g. ORS

132. ก ก F ก ก F F
F
:
FF
loperamide (limited safety information)
diphenoxylate ( ก )

133. Anticonstipation ; กF ก F ก->laxatives/cathartics

134. ก F ก (constipation)
ก F ˁ
F F F ( F ก F 3 F F)
ˈ F Fˈ F F
F ก F F F
F ก F ก

135. ก ก
1. ก / F
ก ก ก F
ก กก กก กก ก
F ก (aluminium hydroxide)
ก F ʽˉ (tramadol,morphine,codeine,
fentanyl), bismuth , trihexyphenidyl
Pregnancy, Hypothyroidism, DM

136. ก ก
2. ก
ก ก : F ก
กก
ก กก ก F

137. ก ก
3.ก F
Bulk forming laxatives
LubricantLubricant
Stool softeners /emollient laxatives
Stimulant laxatives
Osmotic laxatives
Others ; ก (enemas)

138. Bulk -forming laxatives
F ˈ กF ก ก e.g.
ก ก ก
FF
ก ก (Ispaghula seed ,Plantago,
Psyllium) ;AGIOLAX®,METAMUCIL®,FYBOGEL®
F
ก F F methylcellulose

139. ก ก
F ก F / F ก GI
ก F F ˈ ก
Bulk -forming laxatives
ก F F ˈ ก
F ˈ กF F F
ก F ก F F F
F F F

140. F F 1 wk
Fก ก F ก F F F
Bulk -forming laxatives

141. ADR;
fiber F ( F) gas
F F F
Bulk -forming laxatives
F F F
fiber + F F
Drug interaction ; ก ก
F ก 2 hr
** ก ก ก F ก F/ **

142. Lubricant laxatives
F ˈ ก e.g.
Mineral oil (synonym)
F (synonym)F (synonym)
liquid paraffin (synonym)
ELP(Emulsion of liquid paraffin) (synonym)

143. ก ก ;
F F F ก
F F
Lubricant laxatives
F F
ก ก F F F ก ˈ ก
ก ˈ ก F F

144. ADR;
lipoid pneumonia ( ก ) ก ก
F
Lubricant laxatives
F
- F F กF
- F F กF F ˁ F F
- ก F : ก ก/ F ˁ / F ˁ

145. ก ก F ˀˊ
F F
F F F ( ;drug interaction)
Lubricant laxatives
F F F ( ;drug interaction)
Drug interaction;
ก F
(vit D def. F ก
) F F

146. Stool softeners /emollient laxatives
e.g. Docusate
ก ก
F F F FF F F F
กF F F F
ก ก F
** F F F F ก ; F/
**

147. ADR ; F ก F
F F F
Stool softeners /emollient laxatives
Drug interaction;
ก F mineral,phenolpthalein
Toxic of mineral oil, phenolpthalein

148. e.g. ก(senna) , bisacodyl (dulcolax®),phenolpthalein,
F (castor oil), dehydrocholic acid(Decholin® )
ก ก;
Stimulant laxatives
ก ก;
ก F ก F
F ก ก ก F
ก / F
ก ก / ก F F ก ก

149. ADR;
Bisacodyl e.g. F F
Phenolpthalein e.g. ˆ ˈ
Stimulant laxatives
Phenolpthalein e.g. ˆ ˈ
Castor oil ( F ) e.g. ก ** F F
F F F F**
ก dehydrocholic acid e.g. F

150. Drug interaction; e.g.
bisacodyl (enteric coated tablet F ก F F)
F ก
Stimulant laxatives
F ก
ก / F
F ก F ก ก /
ก F ก F F 1

151. F
F F F ก > 1 wk
ก F ˈ ʾ F ก F
Stimulant laxatives
ก F ˈ ʾ F ก F
/ ก cathartic colon
(ก F ) F F F ก F F

152. F
enteric coated tablet F / ˂ ก ก ก
ก ( ก F F)
Stimulant laxatives
ก ( ก F F)
F ก F

153. Osmotic laxatives
ˈ ก e.g.
ก F ก
-Magnesium sulfate, citrate, hydroxide-Magnesium sulfate, citrate, hydroxide
(M.O.M/milk of magnesia)
-Sodium phosphate (xubil®;Monobasic Na phosphate,
dibasic Na phosphate)

154. Osmotic laxatives
Glycerine
Sorbitol
LactuloseLactulose
Lactitol

155. Osmotic laxatives
ก ก; ( ก F F F ก GI)
F F F F ก
(osmotic action) F ก ก ก(osmotic action) F ก ก ก
F
ADR; e.g. N/V, F ˂ F F F

156. Osmotic laxatives
Drug interation ;
ก F ก F F ก ˆ F ก
FF

157. Osmotic laxatives
F
ก F ก : F ˁ ก ก
- F ˁ- F ˁ
-
-
- ก F

158. Osmotic laxatives
F ก F ก F F
ก ก F ก electrolyte
imbalance ก F M.O.M F Fimbalance ก F M.O.M F F
ก F lactulose F ˁ
ˈ galactose F

159. Hepatic encephalopathy
ก
ก
↓
↓
ก F F
↓
ก ก ˆ
F
ก metabolize ˈ

160. Hepatic encephalopathy
eg. cirrhosis
↓
ก metabolize ˈ
↓
↓
↓
Hepatic encephalopathy

161. ก hepatic encephalopathy
ก ก F F F
FF
ก F ก ก

162. ก F lactulose ก hepatic encephalopathy

163. Others ; ก (enemas)
e.g.
(tap water)
ก =NaCl = eg.unison enemaก =NaCl = eg.unison enema
sorbitol
F (soap solution)
ก ก; ก ก
F ก F ก F
ก 15-30

164. ก ก F
:
bulk forming agents + life modification
(ก ก กก ก ʿกก F ˈ ) F F ∆ laxatives(ก ก กก ก ʿกก F ˈ ) F F ∆ laxatives
F ก :
/ ก F F
bisacodyl /senna /M.O.M >1 wk F F
ก F

165. ก ก F
F ˁ ก ก ก F
bulk forming agents
ก ก F ก ก Fก ก F ก ก F
lubricant/stool softener F ก F bulk forming agents
F ก ก e.g. F F
saline laxatives (high dose)

166. ก ก F
F ˁ / F
bulk forming agents F F bisacodyl
/senna/M.O.M/(lactulose;low dose) F F F F F/senna/M.O.M/(lactulose;low dose) F F F F F
F ( F F F F ก )
docusate/bulk forming agent
**stimulant laxatives use if necessary but not use
Castor oil**

167. ก ก F
ก ก ก ก :
ก ก e.g.glycerin
suppo/ กsuppo/ ก
F F F F F F ; M.O.M./senna
F ˁ F ก :
saline laxatives e.g.magnesium sulfate,osmotic laxatives

168. ก F ˂ (antiflatulants)

169. ก F ˂ (flatulence)
ก F ก F F F
กF
e.g.e.g.
F ก F
/ F ก F e.g. peptic ulcer

170. ก F ˂ (antiflatulants)
ก F (volatile oils)
ก F F ก ก (defoaming agent)

171. ก F (volatile oils)
e.g. pepermint oil , fennel oil ,cinnamon oil,
Cardamom, (stomachica mixture),
ก F ˂ (antiflatulants)
Cardamom, (stomachica mixture),
F F (carminative mixture)

172. ก F (volatile oils)
ก ก
F F ก F
ก F ˂ (antiflatulants)
F กF F ก F
F ก กF ก
:ก F
F ก

173. ก F ˂ (antiflatulants)
F F Mixture Carminative Fก
ก F ก Alcohol ก
F F 8.8 F กF F 8.8 F ก
ก F F F ก
F กF ก

174. ก F F ก ก (defoaming agent)
e.g.Simeticone tab,susp.
Trade name :AIR-X , Belcid compound
ก F ˂ (antiflatulants)
Trade name :AIR-X , Belcid compound
ก ก : กF F
ก กF
: F กF ก

175. F ˂ ก ก F ˂
ก ก F ก กF e.g.
F
F FF F
F