1. Makerere University
College of Health Sciences
Department Of Pharmacy
PHARMACY OF GASTROINTESTINAL
SYSTEM, NUTRITION AND
METABOLISM
Kalidi Rajab
Clinical pharmacy Unit
2. Makerere University
College of Health Sciences
Department Of Pharmacy
Objectives
• Describe the pathophysiology and epidemiology of selected diseases of
the GIT, nutrition and metabolism.
• Describe the investigative procedures in GI, nutrition and metabolic
disorders
• Discuss the goals of therapy, treatment modes and monitoring in the
management of GI, nutrition and metabolic disorders
• Learn clinical skills related to the treatment of patients with disorders of
the GIT, nutrition, and metabolism in a practice laboratory setting
• Practice the pharmaceutical care skills related to the treatment of
patients with disorders of the gastrointestinal system, nutrition, and
metabolism in health care setting
3. Makerere University
College of Health Sciences
Department Of Pharmacy
Course content
• Gastrointestinal infections: Cholera, Amoebiasis, giardiasis,
typhoid, Diarrheal diseases/dysentery, cryptosporidiosis
• Peptic ulcer disease, gastro-esophageal reflux disease
• Irritable bowel syndrome and inflammatory bowel syndrome
• Constipations, intestinal worms (Nematodes, cestodes &
trematodes)
• Nutritional disorders: Kwarshiokor, marasmus, vitamin and
mineral deficiencies
• Liver diseases. Cirrhosis, hepatitis
4. Makerere University
College of Health Sciences
Department Of Pharmacy
Course content….
• Clinical Pharmacology and medicinal chemistry of anti-ulcer,
laxatives/purgatives, anti-diarrhea agents, motility enhancing
agents, medicines used in crohn’s disease and ulcerative colitis
• Tube feeding and administration of medicines through tube feeds
• Total parenteral nutrition (TPN)
• Pharmacokinetic alterations in liver disease
• Investigative procedures; stool, urine and blood examination,
Radiology Biopsies
6. Makerere University
College of Health Sciences
Department Of Pharmacy
Meet JS!
• JS is a 45 year old male
• He LOVES Nile Special Beer and has been drinking 5-6 500 mL
bottles per day for 15 years!
• Lately, he has been having RUQ abdominal pain, darkened urine,
nausea, difficulty sleeping, and has noticed spider veins on his
chest and swelling in his abdomen
• He is presenting to your clinic today for information regarding
cirrhosis, its complications, and its effects on medications
7. Makerere University
College of Health Sciences
Department Of Pharmacy
What is Cirrhosis
• Scarring of the liver and poor liver function
• Final phase of chronic liver disease
• Normal tissue becomes fibrotic over time and eventually
consumes the whole liver
• Occurs slowly over time (due to large reserve capacity of
the liver)
9. Makerere University
College of Health Sciences
Department Of Pharmacy
What PK changes do you expect?
• Absorption
• Bioavailability
• Distribution
• Metabolism
• Elimination
10. Makerere University
College of Health Sciences
Department Of Pharmacy
Effect of liver dysfunction on
pharmacokinetics
• Important role in the absorption and disposition kinetics of most
drugs.
• Liver blood flow, binding to plasma proteins, biliary excretion
depend on liver function.
• Age, genetics and drug interactions can result in variability in liver
function
• Comorbidities – e.g CHF
11. Makerere University
College of Health Sciences
Department Of Pharmacy
Volume of Distribution (Vd)
• Chronic liver disease – hypoalbuminaemia – effect on
binding? Drug factors?
• Accumulation of bilirubin + endogenous products of
metabolism – displacement of drugs from their binding
sites.
• In liver failure, the free fraction may rise at the same
time as the liver has decreased capacity to remove the
drug.
12. Makerere University
College of Health Sciences
Department Of Pharmacy
Causes
• Chronic Hepatitis C infection
• Long term alcohol use (similar to JS)
• Autoimmune hepatitis
• Hepatitis B
• Biliary diseases
• Medications
13. Makerere University
College of Health Sciences
Department Of Pharmacy
Signs and Symptoms
• Which symptoms does JS have that suggest cirrhosis?
• What are some othersymptoms?
14. Makerere University
College of Health Sciences
Department Of Pharmacy
Symptoms
• Confusion
• Weight loss, weakness
• Nosebleeds / bleeding gums
• Nausea / Vomiting
• RUQ abdominal pain, Ascites, Spider Veins
• Pale or bloody stool, dark urine
• Jaundice
15. Makerere University
College of Health Sciences
Department Of Pharmacy
Investigations
• CBC
• Electrolytes
• Liver Enzymes and Function Tests
• ALT, AST, ALP, GGT
• INR, Albumin, Bilirubin, Glucose
• Ultrasound of abdomen
• Endoscopy
• CT Scan
16. Makerere University
College of Health Sciences
Department Of Pharmacy
General Treatment
• Stop drinking alcohol!
• Limit salt in the diet
• Eat a nutritious diet
• Get vaccinated for influenza, hepatitis A, hepatitis B,
pneumococcal pneumonia
• Avoid hepatotoxic medications
• ASK YOUR PHARMACIST!
17. Makerere University
College of Health Sciences
Department Of Pharmacy
Complications
• Encephalopathy
• Esophageal Varices (Portal Hypertension)
• Ascites
• Hepatorenal Syndrome (kidney failure)
• Liver Cancer
18. Makerere University
College of Health Sciences
Department Of Pharmacy
Encephalopathy
• Confusion, altered level of consciousness
• Accumulation of toxic substances in the bloodstream that are
normally removed by liver
• Nitrogen waste products (ammonia)
• Always make sure there are no drugs causing or contributing to
symptoms
• Treatment – Lactulose 15 mL po QID until 2-3 bowel movements
per day
20. Makerere University
College of Health Sciences
Department Of Pharmacy
Portal Hypertension
• Manifests as esophageal varices
• RISK: Varices will rupture and result in hemorrhage (may be life
threatening)
• ALL patients should have:
• Endoscopy to search for varices
• Banding if varices are present
• Prophylaxis therapy with a beta blocker or calcium
channel blocker IF they had a previous BLEED
• Propranolol 20 mg po BID
22. Makerere University
College of Health Sciences
Department Of Pharmacy
Ascites
• Accumulation of fluid in abdomen
• Due to decreased plasma proteins
• (Liver synthesizes proteins such as albumin)
• High portal pressure also contributes
• RISKS: Spontaneous Bacterial Peritonitis
• Treatment:
• Paracentesis
• Diuretics
• Furosemide 40 mg and Spironolactone 25 mg po daily
• Limit Salt intake
23. Makerere University
College of Health Sciences
Department Of Pharmacy
Hepatorenal Syndrome
• In cirrhosis, less urine is removed from the body
• Results in build up of nitrogen waste products in the
blood-stream (AZOTEMIA)
• Patients at greater risk at times of dehydration (orthostatic
hypotension, diuretic use, etc)
• Investigations: Renal Function Tests
• Treatment: STOP ALL NEPHROTOXIC DRUGS, maintain hydration,
dialysis
24. Makerere University
College of Health Sciences
Department Of Pharmacy
Summary
• Complicated disease state!
• Treatment focused on symptoms and complications patients
present with
• Avoid hepatotoxic medications:
• Acetaminophen/paracetamol, statins, isoniazid,
rifampin, alcohol, etc
• Remember principles of PK and PD!
