ก

scope

1.Anti-emetics drugs; %ก& ก '()* +,- ./

2.Agents for treatment of peptic ulcer : %ก& 7 '89(:

3.Antidiarrheal drugs : ก% & ก - =

4.Anticonstipation ; 8ก- ก - 9?ก -> laxatives and
cathartics
5.Antiflatulants ; ก - ) AB
1.Anti-emetics drugs; ก ก
 ก '()* +,- ./

ก ก ก !" #$ %& ก& ' ( #$

)* ก ก & +, "ก - * ก! .!!/0 ก
2 #-0"&20' ก
C , : ( ) /# #( & .# /)- !
 ก ก ก 5 (0 #* "6 0
Pain,smell,sight,taste→ Cerebral cortex(higher center) ←Memory,fear,
NK1,GABA hearing,stress,
Cytotoxic,opioid→ CTZ area postrema thinking
Cardiac glycoside D2,NK1, Vomit center
5-HT3,M1,H1,opioid H1,5-HT3,D2,M1

Nucleus tractus solitarius

(NTS) Vomiting reflex
Stomach 5-HT3,D2,M1,H1,NK1
Small intestine
Vestibular system
5-HT3,D2,NK1,
H1,M1
opioid Glossopharyngeal nerve
Gastric irritation Trigerminal nerve
Infect at GI,Ipecac " V" V
! $"-U/!'0*
(motion sickness)
Neuronal pathways
cytotoxic,radiation
Factors cause N/V
ก(+กก ก '()* +,- ./

#$ ก .)Y*0/emetogenic drug/toxin ก .)Y*0 receptors Z [Z0 \ "ก -ก!ก N/V

ก ' neurotransmitter ) ] ก

(+)vomiting center (medulla oblongata)

vomiting center # ก .%#& .# ก

"ก$,ก ก .)Y*0'0* * ก.! ก ." .

' ' , '
N/V
D? (E = ) /* ก/* =H- ก% ก N/V

Vomitting center ([Z0 \ "6 0) VZกก .)Y*0+, #__ U

6 ก[Z0 \('0- )) ]
1.Cerebral cortex (higher center) ! $"-Uก* 0#
Stimulants N/V: 5- 5$, ก "'`0 ก ,* $0
5- "5 , ก ! #' ( ก $0
D? E( = ) /* ก/* =H- ก% ก N/V
2.Chemoreceptor trigger zone (CTZ)
! "$ -U area postrema /0# #-0 Medulla (ab
Blood Brain Barrier) 6b -) # "5 %& ก& /0" ( ,
# c# CTZ
Stimulants N/V: opioid ,cardiac glycosides ,cytotoxic
D? E( = ) /* ก/* =H- ก% ก '()* +,- ./
3.Vestibular system (5-!5Y ก )- Z/0#-0'Z)
+, .!! vestibular 6.# "#*0/ & .# ก '
acetylcholine % . histamine &#Z vomitting center d /'*
"ก$, "6 0
Stimulants N/V :ก " V " " ( (motion sickness)
D? E( = ) /* ก/* =H- ก% ก '()* +,- ./
4.Stomach,small intestine 9 U vagus nerve
#Z nucleus tractus solitarius (NTS) % .6 ก nucleus 0e
/'* fibers #Z vomitting center
e.g.Cytotoxic " $ ก ' serotonin 6 ก
Enterochromaffin like cell /0 d #*" `ก (+) 5-HT3
receptors Z!0& & .# vagus nerve N/V
Stimulants N/V : cytotoxics , gastric irritation , ipecac,
ก )$,"g(e h! 0 GI, # กi (radiation)
D? E( = ) /* ก/* =H- ก% ก '()* +,- ./
5.Glossopharyngeal nerve 8( Trigerminal nerve
=Y: - ab 6.# #__ U & nucleus tractus
solitarius (NTS) % *-6b " * #Z vomitting center
, ,)* C , 8( %= % /* ก/* =H- ก% N/V
, ,)* C , %= % (receptor)
(neurotransmitters)
1.Acetylcholine 1.Muscarinic M1 receptor
2.Dopamine 2.Dopaminergic receptor (dopamine D2
receptor)
3.Histamine 3.Histaminergic receptor (histamine H1
receptor)
4.Serotonin (5-HT) 4.5-HT receptor (5-HT3 receptor)
5.Substance P (SP) 5.Neurokinin-1 (NK1 receptor)
UD%] E /* ก/* =H-

5d 0e %& - . 0....
Extrapyramidal side effect (EPS)

Dystonia :
ก * "0(e "ก ` )- d /'*#-0 ก "ก ` 0e0
"5 ( 0 '-aed ] !$, ' ( Z/0 d /'*cZ*&k-
"6`!&-,
1.http://www.youtube.com/watch?v=VHGzUxnuvwQ
2.http://www.youtube.com/watch?v=N_daWx-qcaw
Extrapyramidal side effect (EPS)

Parkinsonism:
ก #0 ก * "0(e "ก ` ก "5 ( 0 '-0* /g* % .
กiU. (posture)c$,&ก)$

http://www.youtube.com/watch?v=j86omOwx0Hk
Extrapyramidal side effect (EPS)

Tardive dyskinesia :
ก "5 ( 0 '- ก # V5-!5Y ,*
cZ* &k - 6. ก "5 ( 0 '-%!!ก .)Y ก "&2 0
6 '-. 5 0 * " `-% .5 ,5."0 ,* "ก$, U. ก/
U. )e /66."5 ( 0 '-
'0* ) !Z,!be -,5$e- %ก*
Extrapyramidal side effect (EPS)

Tardive dyskinesia :
ก . $!) "& ( ก) ก .)Yก "5e - #Z,& ก " % .
,Z, $ yz & ก % ! $e 0 ก 5 * ก 6!% ก
! ก ก e 2 *

http://www.youtube.com/watch?v=FUr8ltXh1Pc
Anticipatory CINV
(Anticipatory chemo therapy-induced nausea and vomiting)

"&20 ก !ก 0ก ,* ! "5 !d !,
ก"ก$,6 กc ก กi N/V /0ก ! "5 !d !,
5eก0 ,
Stimulants : ก ,* !ก $0 # ' ( ก 0bกVb ' (
5- ก - "ก -ก! "5 !d !, ,* !5 e ก 0
Nausea and vomiting . ก 'U/ a %

Acute nausea and vomiting:

"ก$, be0| /0 24 g-+ ' ,* ! "5 !d !,
ก ก, be0| /0 24 g-+
Nausea and vomiting . ก 'U/ a %

Delayed nausea and vomiting :

"ก$, be0' ,* ! "5 !d !,% *-0 0ก- 24 hr
65 Z ,*0 0Vb 5-7-0' ,* ! "5 !d !,
Anti-emetics drugs
1. Muscarinic M1 antagonist
2. Dopamine D2 antagonist ~0 &•,กe0)- !
(receptor) ก - * )*0
3. Histamine H1 antagonists
4. 5-HT3 antagonist
5. Substance P antagonist
6. Pyridoxine (Vit B6)
7. Benzodiazepines
8. Steroids
1)Anti-emetics drugs ;Muscarinic M1 antagonist

e.g.Scopolamine (hyoscine)
ก(+ก : &•,กe0 muscarinic M1 receptor #
Common ADR: ADR "&20c 6 ก• ‚$ƒ antimuscarinic
effect "g0 & ก%'* - ab ) * cZก
2)Anti-emetics drugs;Dopamine D2 antagonist
e.g. Domperidone(Motilium®),Metoclopramide(Plasil®),
(Chlorpromazine,Perphenazine,Haloperidol,Droperidol)
ก(+ก :
1.Ch ก%i dopamine D2 receptor /0 CTZ % . NTS
( ก"-*0 domperidone ab c 0 Blood brain barrier ;
BBB) 6b c ) '0- CTZ )
2)Anti-emetics drugs;Dopamine D2 antagonist

2.Ch ก%i 5 jHT3 receptors /* GI , ,U

e.g.Metoclopramide (high dose)

3.U/ C , ,= C( /* a : ก- '()* + =
H ก ] /(a +,- ]*UHki (gastroprokinetic)
e.g.Domperidone , Metoclopramide
2)Anti-emetics drugs;Dopamine D2 antagonist

ADR: - ab ก,# #-0ก ก .-0ก .- * "#

Domperidone/metoclopramide
↑ก c )$ prolactin hyperprolactinemia-related side
effects "g0 gynecomastia % . galactorrhea
6b ก /g* domperidone/0'_$ ' 5 ,!Y) " ( .........
Metoclopramide (%)domperidone <c 0 BBB;<EPS)
Extrapyramidal side effect (EPS) 6b 5- /g* 0 0
esp./0cZ*&k- #Z Y (cause.tardive dyskinesia V - )
2)Anti-emetics drugs;Dopamine D2 antagonist

Domperidone /metoclopramide ;
Take the tablets 30 minutes before each meal and
bedtime
3)Anti-emetics drugs;Histamine H1 antagonists
e.g.Dimenhydrinate(Dramamine®)(+antimuscarinics)
,Diphenhydramine(Benadryl®), promethazine,meclizine
ก(+ก:
&•,กe0 histamine H1 receptor /0#-0 vestibular system
/vomitting center
Common ADR: - ab & ก%'* * cZก
4)Anti-emetics drugs;5-HT3 antagonist :
e.g.Ondansetron(Onsia®),Granisetron,Dolasetron,Tropisetron
ก(+ก:
&•,กe0 5-HT3 receptor # #-0ก (CTZ, NTS)
& .# visceral afferent vagus nerve /0 ",$0 '
Common ADR: &-,'- * "# / * cZก 0"
Serious ADR : QT prolong ( ก !
" ก#") cardiac arrhythmia
4)Anti-emetics drugs;5-HT3 antagonist :

"g0 ondansetron
first dose :30 minutes before the start of chemotherapy
1 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.
5)Anti-emetics drugs;Substance P antagonist ; NK1 receptor antagonist:

e.g.aprepitant
ก(+ก :
&•,ก0e /'* substance P ก .)Y*0 NK1 receptor/0 NTS
! e #__ U6 ก cerebral cortex ก .)Y*0
vomitting center
Common ADR : 0" 0b * "#
6)Anti-emetics drugs;Others; Pyridoxine (Vit B6)

ก(+ก:
B6 "&20 coenzyme " 0 a \ Glutamic decarboxylase
/0&‡$ก$ $ ก "& 0 Glutamic acid &"&20 GABA

Glutamic acid((+)N/V) -------------------> GABA

Glutamic decarboxylase/B6
((-)N/V)
ADR :g ) & & .# "g0 " * if ≥2000 mg/day
7)Anti-emetics drugs ;Others;Benzodiazepines
e.g. lorazepam (Ativan )
®

ก(+ก:
6!ก! benzodiazepine GABAA-receptor ionorphore
complex d /'*" $ • ‚$ƒ GABA ) GABAA receptor
ก U/g*&‰ ก0 Anticipatory CINV [ • ‚$ƒ
amnestic % . antianxiety effects
Common ADR : - ab ' ( (amnesia)
8)Anti-emetics drugs;Others;Steroids
e.g.Dexamethasone, Methylprednisolone
ก(+ก :
! e ก # * 5-HT /0# #-0ก
Common ADR:
GI irritate,0 0 ' !,-$)กก -
8)Anti-emetics drugs;Others;Steroids
"g0 dexamethasone
Acute nausea and vomiting
!& . 0/' ," ( ,,d ก 0/'*"5 !d !,
Delayed nausea and vomiting
!& . 0 : -0 . 2 5 e 0 0 3-4 -0 +, ก" $ /'*
' 6 ก/'* "5 !d !,"# `6#$e0 24 g-+
ก () ก:m- %ก& ก '()* +,- ./

ก , n *'/ = () ก:m-
1.Motion " V" " ( Histamine H1 antagonists:
sickness &Š _ ' ก e.g.dimenhydrinate,meclizine
)- Effective if take before ½ hr travel
('Z receptor Muscarinic M1 antagonists :
M1,H1) e.g.scopolamine (%c0%&.c$-'0
Effective if take 4 hrs before travel
Effective : 3days
ก () ก:m- %ก& ก '()* +,- ./

ก , n
2.Morning N/V in pregnancy
sickness Select safety to fetus
/*'= () ก:m-
Vitamin
B6 +doxylamine (first
line) or vit B6 only
H1 antagonists
e.g.dimenhydrinate
D2 antagonist
e.g.metoclopramide
ก () ก:m- %ก& ก '()* +,- ./
ก , n /*'= () ก:m-
3.Postoperative N/V after surgery 5-HT3 antagonists (all.gold
N/V (PONV) opioid:relief pain standard)
opioid:(+)CTZ D2 antagonists
e.g.metoclopramide,droperidol
M1 antagonists
e.g.scopolamine
H1 antagonist
e.g.promethazine
ก () ก:m- %ก& ก '()* +,- ./
ก , n *'/ = () ก:m-
4.Radiotherapy- Mechanism ~ cytotoxic D2 antagonists
induced N/V e.g.metoclopramide
(RINV) 5-HT3 antagonists(all.)
ก () ก:m- %ก& ก '()* +,- ./
ก , n /*'= () ก:m-
5.Chemo cytotoxic 5-HT3 antagonist(all.acute /delayed)
therapy- 1.CTZ gold standard
induced 2. d #*" `ก D2 antagonists (acute type)
N/V(CINV) e.g.metoclopramide
*Steroids (acute/delayed)
e.g.dexamethasone,methylprednisolone
*Benzodiazepines (anticipatory CINV)
e.g.lorazepam
ก () ก:m- %ก& ก '()* +,- ./
ก , n *'/ = () ก:m-
5.Chemo *NK1 receptor antagonist(acute /delayed)
therapy-induced e.g.Aprepitant
N/V(CINV)

' "')Y (*) ก/g*"&20 "# $ +, /g*

- ก! 5-HT3 ' ( metoclopramide
ก () ก:m- %ก& ก '()* +,- ./
ก , n /*'= () ก:m-
6.Combine tx - 5-HT3antagonist+steroid(best treatment)
for Acute CINV effective than single drug and lower S/E
than metoclopramide+steroid and others
ก () ก:m- %ก& ก '()* +,- ./
ก , n /*'= () ก:m-
7.Gastroenteritis - D2 antagonists
( d #* ก"#!) e.g. metoclopramide
8.Gastroparesis - D2 antagonists
(ก$ %& ก ' ( ' e.g. metoclopramide ,domperidone
) )
 ก% & 7 '89(:
Agents for treatment of peptic ulcer
Antacid
Anti-secretory drug
Mucosal resistance(Cytoprotective)
Misc.
-Rebamipide
- กd 6,"g(e (Eradication) H.pylori
NSAIDs-induced peptic ulcer
ก (%* ก H
Parietal cells ge0 mucosa ก ." . '
Receptor ()- !) "ก - * ก!ก ' ก ,
# | /0 ก 6.ก .)Y*0ก ' ก ,+, c 0
receptor "h ."6 .6 , )
Second messenger
" 0 a \ H+/K+ ATPase or gastric proton pump
 ก ก ก ก

Receptor , /*. ก n- ก (%*

ก 9 %= % (Receptor)
Histamine-2 receptor Histamine
(H2 receptor)
Muscarinic -3 receptor Acetylcholine
CCK2 receptor Gastrin
 UD%] E /* ก/* =H-
1.Second messenger
# VZก# * be0/0"a \6 กก ก .)Y*0)- !
Second messenger 6.ก /'*"ก$,ก "& 0%& ' (
) !#0 "a \
, 0e0 Second messenger 6b d '0* "# ( 0)-ก /0
ก ก• ‚$ƒ6 กก ก .)Y*0)- !
 UD%] E /* ก/* =H-
2.Phosphate Binders
# /g*6!ก! phosphate /0 ' /0 ",$0
' c /'* phosphate % . form )-"&20 insoluble
compound % .VZก ! ก
ก(+กก (%* ก H
1.# 6! receptor
2. c /'*"ก$, secondary messengers 5(
Cyclic AMP (cAMP)
Calcium
ก(+กก (%* ก H
+,
Histamine:
(+)" 0 a \ adenylate cyclase (ATP cAMP)
↑cAMP

Gastrin ,acetylcholine:
ก ' calcium 6 ก%' #.# | /0 cell
↑calcium /0 cell
ก(+กก (%* ก H
3.cAMP ↑, calcium ↑ (+) H+/K+ ATPase at
parietal cell membrane
4.6." &‡$ก$ $ ก % ก"& 0 hydrogen ion 5(
"ก$,ก 5,' +& ) 0 (H+) 6 ก,* 0/0 parietal
cell ก#Z canaliculi
% ก ก!+&%)#"a (K ) " * #Z cell
+
 ก(+กก (%* ก . ก parietal cell

' "')Y :" 0 a \ hydrogen/potassium adenosine triphosphate (H+/K+ ATPase ' ( gastric proton pump )
ก(+กก % %i ก (%* ก H

Gastric pH <3 ("&20ก , ก) 6. ก ก "g0

1. ! e ก ' gastrin
2.Prostaglandin (PGE2 ) 6. ! e histamine /0ก
ก .)Y*0 adenylate cyclase
89(: (peptic ulcer)
Peptic ulcer
%)ก/% ก ก ." . ' / d #*" `ก#-0)*0+
!-0ก ก"#!"ก$, be0)
"&20c 6 ก aggressive factor -defensive factor
imbalance
Co..% /*9( ก ก peptic ulcer

Aggressive factor Defensive factor

ก " $ be0 parietal cell ก ' " ( ก /bicarbonate
mass
ก "& 0%& "( & $ U" ( , ' " e
" (ก mucosa " (mucosa 5(
" ( " ( ก ab "&2 0 ge 0 !Y c$ -
"ก - * /0ก ,Z,ab % .'
# )
Co..% /*9( ก ก peptic ulcer
Aggressive factor Defensive factor
ก ,* ! prostaglandin ก " 6 $ _ " )$ ! + )
inhibitor epithelial cell (cell g0$,'0b
(e.g.NSAIDs 6. , .,! /0ก ." . ' ) " ( ก
protective prostaglandin) ! ,"6`! ",$0 '
ก )$,"g(e H.pylori Prostaglandin E2 (PGE2)
 ก Peptic ulcer

&-,! $"-U/)* $e0&zŽ &-,%#! ] * 0 ] &-,"&20 ก ]

Duration : day/wk
ก 6' &" % .ก !"&20aed ,* ก
ก 8 กC p DU/GU
# ก * ,Z%c
ก (,Z%0-+0* )
 ก Peptic ulcer
89(: (a +,- (rก (Duodenal ulcer;DU)
ก&-,) 0ก ." . ' - "g0 .'- (e
' ก 00 0' ( ) 0,bก
Relief : !& . 0 ' / ,* ! ,ก ,
89(: ก ] (Gastric ulcer;GU)
"- "ก$, ก &-, %00 0 !! | /0 1-3
g-+ ' !& . 0 '
.n C , 'E: ก %ก&
! " ก &-,
d /'*%c ' " `- be0
,ก ก !"&20aed
, ก % กa* 0 6."ก$, e0b ) ' "&20%c
e.g.haemorrhage ,obstruction (c 6 ก scar),perforation
 ก% & 7 '89(:
Agents for treatment of peptic ulcer
Antacid
Anti-secretory drug
Mucosal resistance
Misc.
-Rebamipide
- กd 6,"g(e (Eradication) H.pylori (HP)
NSAIDs-induced peptic ulcer
1.Antacids ( ก )
e.g. aluminium salt , magnesium salt, sodium bicarbonate
ก(+ก:
1.ก #." $0ก , (acid •neutralizing effects)
2.ก ก be0ก!ก ,

2.1 ! e ∆ pepsinogen pepsin

2.2 ก,ก "6 _
$ ")$!+) H.pylori
1.Antacids ( ก )
g- ! " ก &-, * #! *
rapid onset : within 5-15 min
duration : 15 min-1 hr
H- .a ก%
g- d /'*%c ' " `- be0
ก/g* - ก ! ( 0" ( /'* ก &-,' " ` - be 0
% . ก #! * , be0
1.Antacids ( ก )
ADR : Aluminium salt ( * cZก), Magnesium salt
( * "# )
Drug interaction (DI) :
↓ absorption /g* - (absorption & dissolution
depend on acid)
enteric coated $ $ ก ก $
1.Antacids ( ก )

Drug interaction (DI) :

antacid (aluminium salt) 6!ก! phosphate ,ก
,Z,ab phosphate /g*"&20 phosphate binder /0cZ*&k-
)-
,ก 6! sucralfate ก! gastric mucosa
2.Anti-secretory drugs ; !ก ก

2.1 H2 receptor antagonist (H2RA)

2.2 Proton pump inhibitor (PPI)
2.1 H2 receptor antagonist (H2RA)

e.g.ranitidine, famotidine, nizatidine, cimetidine

ก(+ก
&% histamine /0ก 6!ก! H2receptor %!!
competitive/reversible ,ก # * cyclic AMP
2.1 H2 receptor antagonist (H2RA)
g( cimetidine ranitidine nizatidine famotidine
'= U8 1 4-10 4-10 20-50
Dose of 400 bid 150 bid 150 bid 40 hs
treatment 800 hs 300 hs 300 hs
(mg)
Dose of 400 hs 150 hs 150 hs 20 hs
recurrent
prophylaxis*
(at least 1 +)
2.1 H2 receptor antagonist (H2RA)

food : not affect to absorption

Treatment
DU : 6-8 wk if not cure /'*) ก 2-4 wk
GU : 8 wk if large ulcer /g*"- 12 wk
' "')Y * if recurrent > 3 5 e /&z
2.1 H2 receptor antagonist (H2RA)

ADR:
* - / * cZก &-,'- b0 - 0 0 #!#0
'-/6")*0g* 5- ,0+ '$))d '-/6")*0c$,6 '-.
cimetidine (antiandrogen effect) in men/high dose
/long term "ก$, gynecomastia/impotence
2.1 H2 receptor antagonist (H2RA)

Drug interaction (DI)

antacid , sucralfate : ↓ absorption of H2RA
, 0e0 /'* antacid/sucralfate ' 6 ก H2RA 0*
2 hr
2.2 Proton pump inhibitor (PPI)
e.g.omeprazole(Losec®),lansoprazole(Prevacid®),
pantoprazole(Controloc®),rabeprazole(Pariet®),
esomeprazole (Nexium®)
ก(+ก ACID CONDITION
parent compound(not active)-------->active metabolites
# * 0‚.ก! H+/K+ATPase %!! non-competitive
/irriversible (• ‚$ƒ0 0; ก # * " 0 a \ be0 /' )
can use once daily before meal ~ 1/2 hr
2.2 Proton pump inhibitor (PPI)

) ก ' %c ,/' " -` ก- H2RA

Food delays absorption
ADR :
5 !% .cZ*&k- 0 ,* "g0 5 (0 #* * - * cZก
&-, * &-,'- 0b
2.2 Proton pump inhibitor (PPI)
Drug interaction (DI)
PPIs VZก metabolize )!+, 6!ก! Cytochrome
P450 enzyme (CYP450)
!ก-0ก metabolize (0 )* [ CYP450
"g0ก0 "g0 ↑warfarin,phenytoin level
% %i - monitor response phenytoin
- maybe adjust dose of warfarin/monitor INR,PT
ก : - PPI (enteric coated tablet): 9?-Ct= :, NG tube

NG tube (Nasogastric tube )

5( ก /# # " * &/0ก ." .
' c 0 Z6 Zก
-)VY& .# 5\
" ( /'* ' / %กcZ*&k- # V
!& . 0 ,* & ก
Enteric coated tablet/granules
)* ก /'* ก• ‚$ƒ/0 d #*" `ก
5YU# !)$
"& ( ก0 ก (capsule) . +, ก ,/0ก ." .
Enteric coating 0ก , %) 0,
)- 0ก ,
ก !, granules VZก d ,*- ก ,ก 0 6.
VZก,Z,ab d #*" `ก+# Y,)0" . 6.6!)-ก0
ก : - PPI (enteric coated tablet): 9?-Ct= :, NG tube

omeprazole (miracid® )
delayed-release capsule/multiple unit granules system
enteric-coated granules
Capsule :dissolves in gastric acid
Granules :base-labile coating dissolves in small
intestine
ก : - PPI (enteric coated tablet): 9?-Ct= :, NG tube

rabeprazole (pariet®)
delayed-release tablet or enteric-coated tablet
drug is absorbed in the intestine

** - /$'$ rabeprazole (%. / NG tube**

Coated 6.#Z_"# #| ; 6.+,0ก ,/0ก ." . d
ก : - PPI (enteric coated tablet): 9?-Ct= :, NG tube

Omeprazole
1.%ก. capsule
2. . granules /0# . +, & # NG Z
Gastric :# . • ‚$ƒ"&20ก , (protect the base-labile granules)
e.g.0ed #!&. , 0ed #* 0ed Y0% . flush ก5 e ' /'*

Small intestine :# . • ‚$ƒ"&20, (/'* %)ก)- 0 )

e.g.8.4%NaHCO3 % *- flush ,*- 0ed ก5 e ' /'*
Mucosal resistance ;Cytoprotective

" $ ก &ก&‰ " ( !Yก ." . ' /'*VZก d

+, ก ,' ( 0ed
Cytoprotective agents :
Sucralfate
Bismuth preparation
Prostaglandin analogues
Sucralfate

ก(+ก:
1.sucralfate VZกก , # "'0 - (viscous substance)
6!ก!+ " กY +& )0 %c /0 ",$0 '
"ก .&‰ ก0• ‚$ƒ ก , "&!a$0% ."ก ( 0ed ,
Sucralfate

2.ก .)Y*0 endogenous prostaglandin

ก ." . ' PGE2 '0*
-g- &ก&‰ " ( !Yก ." . '
-" $ gastric mucus secretion d /'* 0ก , ,*,
3.%) c ) ก ' ก ,
Sucralfate
ADR:
sucralfate VZก,Z,ab 6 ก d #*0* ก ก * "5
systemic 0* ก ! ,* ,*%ก * cZก 5 0( #*
&-,'- ' & ก%'* 6b "&20 5- " ( ก/g*
/0'_$ )e 5 |\
Sucralfate

Drug interaction:
6!ก!+& )0' ( ” #"”)/0 '
, 0e0 5- /'* sucralfate ) 0 * - (ก 0 '
1 g-+ )
Bismuth preparation

e.g.bismuth subsalicylate (GASTRO-BISMOL ),

®

ranitidine bismuth citrate

ก(+ก
1."ก ( bismuth - ก!+& )0 ก ." .
# & .ก ! . 0ed /0#$ %-, * "&20ก ,
local gastroprotective effect
Bismuth preparation
2.ก .)Y*0ก # * prostaglandin, bicarb, Zก
3.ก,ก "6 $_")$!+) H.pylori
4. c ! e ' ( neutralize ก ,
ADR ;
- $e0 ”Š0 Y66 .,d
-bismuth accumulate neurotoxic :not for recurrent
prophylaxis;long time
Prostaglandin analogues
e.g.Prostaglandin E analogues (misoprostol;cytotec )
®

ก(+ก:
6!ก! prostaglandin receptor parietal cell c
-!eก ' ก,
-" $ 5- % ` % " ( !Y ",$0 ' (mucosa)
-ก .)Y*0ก c $) bicarb
-5-!5Y ก ' "- 0" ( ,/0 mucosa
Prostaglandin analogues

ADR;
* - (4-38%)
&-, * ).5 $- * N/V
, Zก!!)- % * , 0e0 '* /g*/0'_$ )e 5 |\
(FDA pregnancy category X )
Prostaglandin analogues;misoprostol;cytotec®

ก /0 &/g*%!! off-label #Z)$0 "-g " (

d /'*% *
"'0 -0d /'* ก 5 ,
กi | -.)ก" ( ,' 5 ,(postpartum hemorrhage)

U n/g*%!! off-label /g* /0 กiU. 0 ก"'0( 6 ก .!Y/0 * ! ge/0h ก

Misc. ;Rebamipide (mucosta®):
ก(+ก (/0'0Z/50):
↑& $ U PGE2 6 ก| /0"a \" ( !Yก ." . '
↑& $ Uge0" ( !Y" ( ก/" ( ก c$-/0ก ." .
↑ก ' "- 0 " ( ,/0" ( !Y" ( ก ก ." .
" ก ' , /0ก ." .
" ก %! )-"a \" ( !Y" ( ก/" $ 6d 0-0"a \" ( !Yc$-/0ก ." .
! e ก c $)% .& ,& # interleukin-8 (IL-8)/0" ( " ( ก!Y
ก ." . ' ab "g(e Helicobacter pylori Z (IL-8- inflammation)
Misc.; Rebamipide (mucosta®):
ADR;
leukopenia (| -. " `," ( , -)d ก- &ก)$) ,
thrombocytopenia (| -."ก `," ( ,)d )
hepatic dysfunction and jaundice (↑AST,ALT)
rash
constipation, diarrhea , N/V
heartburn
Combination treatment
Single (2-3 wk)+eradicate risk factors not cure
combine
 ก" #! (Eradication) H.pylori (HP)
Helicobacter pylori :
"g(e ! a$ # Z&"ก - %ก !
[ Z/0#-0 bก • Zก•"'0( " ( !Yก ." .
"g(e (urease enz.) ab urea ammonia+CO2
ammonia :" ( !Yก ." . ' ก"#! ,"ก$, acid
hypersecretion , "a \"# #| "ก$, gastric atrophy
% .ก #| "&20 cancer cell ,*
 ก" #! (Eradication) H.pylori (HP)

,? กa .% H. pylori =(
(=% )
PPI-based triple therapy 7-14
PPI bid + amoxicillin 1 g bid + clarithromycin 500
mg bid
PPI bid + metronidazole 400 mg bid +
clarithromycin 500 mg bid
PPI bid + amoxicillin 1 g bid + metronidazole 400
mg bid
 ก" #! (Eradication) H.pylori (HP)

,? กa .% H. pylori =(
(=% )
Bismuth-based quadruple therapy 14
PPI bid + bismuth 240-525 mg bid +
metronidazole 400 mg bid or tid + tetracycline 500
mg qid
PPI bid + bismuth 240-525 mg bid +metronidazole
400 mg bid or tid + clarithromycin 500 mg bid
 ก" #! (Eradication) H.pylori (HP)

,? กa .% H. pylori =(
(=% )
Sequential therapy - 10
PPI bid + amoxicillin 1 g bid "&20"- 5 -0) ,*-
PPI bid + metronidazole 400-500 mg bid +
clarithromycin 1000 mg od ' ( 500 mg bid "&20"-
5 -0
 ก" #! (Eradication) H.pylori (HP)
,? กa .% H. pylori =(
(=% )

Levofloxacin-based triple therapy 10

PPI bid + levofloxacin 250 mg (or 500 mg) bid +
amoxicillin 1 g bid
Rifabutin-based triple therapy: 7-10 days 10
PPI bid + rifabutin 150 mg bid + amoxicillin 1 g bid
 ก" #! (Eradication) H.pylori (HP)

,? กa .% H. pylori =(
(=% )

Concomitant therapy 10
PPI bid + amoxicillin 1 g bid + clarithromycin 500
mg bid + metronidazole 400 mg tid
*5- ) -6" ( (0 0c ก กd 6,"g(e ' #$e0#Y,ก กi *
*' กcZ*&k- 5 ก )$,"g(e 6. + ก #"ก$,%c ก !"&20aed #Z ก*
ก" #! (Eradication) H.pylori (HP)

PPI-based triple therapy ' ( sequential therapy

'ก ,*c
Bismuth-based quadruple therapy
or
Levofloxacin-based triple therapy
or
Rifabutin-based triple therapy
or
Concomitant therapy
NSAIDs-induced peptic ulcer
ก(+กก ก NSAIDs-induced peptic ulcer
• ‚$ƒ+, )
! e ก # * prostaglandin
-/'* mucosal blood flow ,
-mucus secretion , , HCO3 secretion ,

ก ,/pepsin/NSAIDs : ก"#!
"ก$,%c
NSAIDs-induced peptic ulcer
8 = : ก CB ก% (prophylaxis)
5- 6d "&2 0 6.)* /'* ก &‰ ก 0/0cZ* &k -
,* ! NSAIDs Yก
NSAIDs-induced peptic ulcer
Co..% ,/* ,? (High risk)

Y > 60 &z
& .- )$ % c /0ก ." . ' % .%c /0 d #*
" `ก/& .-)$" ( , ก/0ก ." . ' / %c . Y
/g* NSAIDs - ก! corticosteroids
/g* NSAIDs /0 0 , #Z ก- &ก)$' ( /g*
NSAIDs กก- 1 )- - ก0
/g* - ก! anticoagulants eg. warfarin
NSAIDs induced peptic ulcer

8 = : ก %ก& (Treatment)
1.' Y, NSAIDs : & .#$ ‚$| H2RA ∼ PPIs
2./'* NSAIDs ) : Drugs of choice :PPIs

Drugs of choice ; 6." ( ก/g*"&20)-% ก/0ก กi ก 0e0 ,*

& .#$ ‚$| #Z c * "5 0* "' .# #Y,
%ก& ก - = (antidiarrheal drugs)
ก - = (diarrhea)

| -. V Y66 . - "&200ed กก-

3 5 e /-0
'(
V Zก' ( &0" ( , 0* 1 5 e
/0 24 g-+
, n - = (diarrhea)
1.)$,"g(e "g0 %!5 " - # +& +)a-
2. ,*"ก$,6 กก )$,"g(e "g0
antibiotic (eg.clindamycin,tetracycline),
ก h #
ก % * '
5- c$,&ก)$ .!! '
5- -$)กก - 5- "5 ,
+ 5! "g0 colon cancer, hyperthyroidism
ก %ก& ก - =

1. ,% 0ก #Z_"# 0ed % . $" 5+) \ % .%ก*

| -.# ,Y ก ,, ( , ) &k- /) )
/'*# 0ed IV : ,0ed Y0%
ORS (oral rehydration salt) :
(Electrolyte=Na,K,Cl,HCO3) + 0ed ) ก +Z 5#
ก %ก& ก - =

)* , ' ' ( 0
%)5- !& . 0 ' 0]

/0 ก/'*,( 0 % ' ( "6( 6 0

5 b '0b
ก %ก& ก - =

2.ก กi ก * - 6 กก )$,"g(e
2.1 * - 6 ก# $i "g(e (toxigenic diarrhea)
"g(e "ก .)$, epithelial cell d #* % *- ก &
enterotoxin ก
"g(e # "')Y' ก e.g.Vibrio cholerae ,E.Coli d /'*cZ*&k-
V Y66 ."&200ed & $ U ก
*Enterotoxin :toxin ก• ‚$ƒ) .!! ",$0 ' % . d #* d /'*"ก$, ก * "# *
ก %ก& ก - =

2.2 * - 6 กก Yก ed "g(e " * &/0" ( !Y d #*

(invasive diarrhea)
! "$ -U "g(e Yก ed 6. ก ก"#! " ( !Y d #*
"g(e # "')Y' ก e.g.shigella, salmonella, E.coli
ก %ก& ก - =
/'* &‡$g-0. ) ก!g0$, "g(e "&20# "')Y
Shigella (!$, )-)
e.g.TMP/SMX (bactrim®),norfloxacin,ciprofloxacin
Salmonella typhi ( * ก# ,0* ' ( * ” ,\ )
e.g.TMP/SMX (bactrim®),ceftriaxone,ciprofloxacin
Vibrio cholerae( '$- )ก+ 5)
e.g.TMP/SMX(bactrim®),doxycycline,norfloxacin
ก %ก& ก - =
3. ก กi ' ( . ! ก * - " ( ,5- V
ก V 6Y 6 ./ . ! ก * - /'* ,
3.1 ,ก "5 ( 0 '- d #*
3.2 # /g*/0ก ,Z,a!"g(e ' ( # i$ 6 ก"g(e
3.3 Intraluminal agents
3.4 Bulk forming agents
3.5 Bile acid binder
3.1 ( ก '()* + =H (a +,-
Opioid derivatives -Loperamide; Imodium®
-Diphenoxylate+atropine;Lomotil®
ก(+ก :ก .)Y*0 opioid receptors d #*
!eก ' "' -
ก .)Y*0ก ,Z,ab "' -/0 d #*
,ก ',)- ก * "0(e " ! d #*
9( 5( & $ U0ed / "' -/0 6Y 6 . ,
3.1 ( ก '()* + =H (a +,-

Diphenoxylate c# ก! atropine " ( &‰ ก0ก 0d &

/g*/0 c$,

Atropine : ก atropinism
e.g. * 5- ,0+ '$)#Z '0* %, 0)
'-/6")*0" `- ) ' /6" `- & .# ' 0
3.1 ( ก '()* + =H (a +,-
ADR:
opioid /g* . ."- 0 0//g*! ] "# )$,
- "a( ab
%) loperamide ก,& .# # #-0ก 0* ก-
Diphenoxylate
3.1 ( ก '()* + =H (a +,-
' ก !& . 0 % *- * &-, * Y0% ' (
Y66 . " ( ,&0' ( ก * "# , be0| /0
2 -0 /'* !& bกi % \
cZ*&k- ก * "# 6 กก )$,"g(e invasive diarrhea
0%& 1 22 $ 3 4&
d /'*"ก$, ก * - Y0% be0
"# ) "g(e ก .6 " * #Zก .%#" ( , ,*
3.2 , :/* m-: ก ? v% m)i ) , ]&. ก m)i
Activated charcoal

Kaolin-pectin (Kaolin and pectin®)

Diosmectite (Smecta )
®
3.2 , /*:m-: ก ? v% m)i ) , ]&. ก m)i

ก(+ก : 6. VZก,Z,ab %)6. d '0* 6!ก!0ed

# ' # i$ % .0ed ) ] d /'* Y66 .
% ` be0 "&20"0(e ก be0 %)6. d /'*6d 0-05 e
ก V ,
ADR : !0* กVb $i " . ,Z,ab %) 6
c ,ก ,Z,ab # ' 6d "&20) ก ,*
3.3 Intraluminal agents
e.g.Bismuth subsalicylates (GASTRO-BISMOL®)
ก(+ก : ! e ก ' # 6 ก d #*
ADR
salicylism ( "# /0'Z)
N/V
$e0/ Y66 . #,d
3.4 Bulk forming agents
e.g.Psylium(AGIOLAX ,METAMUCIL ,FYBOGEL )
® ® ®

#-0 ”"! \/" ( " ( ก #ก,6 ก" ( 'Y* " ,`

)*0" 0"ก `,'
ก(+ก :,Z,0ed d /'* Y66 ."&20ก* 0 "' - Y66 .
% ` be0
ADR * (, %00 * ก Y,)0 d #*
3.5 Bile acid binder
e.g.Cholestyramine (Questran®)
ก(+ก : 6!ก!0ed ,% .6!ก! toxin (clostridium
difficile toxin)
/g* กi antibiotic associated diarrhea ' ( * -
"ก$,6 ก0ed , ,*
ADR: * cZก 5 (0 #* "!( ' Y66 . 0 ก
3.5 Bile acid binder
Cholestyramine !-ก- bile acid
3 'ก - 0" 5 /. 6ก 54 3 ก
(". ก - bile acid ก/ !7 ! '
ก" ก ก '#7 ก 3 2 ' bile acid
(cholesterol #- 8 #67 "-)
↓cholesterol /.3'3 #-
#-!4 ก # -3 1 ↑LDL receptor
↑ # ก catabolism LDL
↓ ' - LDL ก ')3 $%
 UD%] E /* ก/* =H-

Catabolism :
9"ก" " 2 /& /. ก" 5$$ 3". 0 #"
9"ก" " 3$ 3 0 1 $ก7$ 8 3 1 $ก7$ $:ก
8 $ ก 3 / $ ($ /. 5$$ 0
Antibiotic associated diarrhea
+ 50e"ก$,6 ก"g(e %!5 " ab &ก)$ ! Z/0#d #*/'_
VZก !ก-0+, &‡$g-0. # c /'* ก
"& 0%& g0$,% .& $ U "g(e %!5 " /0
d #* % . d /'*"ก$, * "# )
Antibiotic associated diarrhea

d /'*"ก$, diarrhea ,*' ก ก e.g.

1. Osmotic diarrhea
2. Bile salt diarrhea
3. ↑Small intestine motility
4. Microorganism infection
1.Osmotic diarrhea

↓%!5 " (non absorbable carbohydrate) /0 d #*/'_

d #* # V,Z,ab non absorbable carbohydrate ,*

osmotic diarrhea
2. Bile salt diarrhea

↓%!5 " /0 d #*/'_(c &‡$g-0.)

# bile salt ,*
↑ bile salt
&ก .)Y*0ก ' colonic fluid ก
* "#
3. ↑Small intestine motility

&‡$g-0.! e.g. erythromycin

ก .)Y*0 motilin receptor d #*" `ก

d #*"5 ( 0 '- ก be0

* "#
4. Microorganism infection

e.g. Clostridium perfrigen type A

Clostridium difficile
Antibiotic associated diarrhea

Cause
Drug : ampicilln,amoxycilln,cefixime,
fluoroquinolone(1-2%) bactrim (<1%)
Organism : Clostridium difficle infection
*10% of total.cause but serious complication
then Death " ก- Clostridium difficile diarrhea*
ก %ก& Clostridium difficile diarrhea
ก 0Y % :' Y, &‡$g-0.+supportive tx , be0
ก 7 ) :metronidazole (oral) 10-14 -0
*If not relieve ,no tolerance to drug ,pregnancy,
<10 years old , severe colitis*

vancomycin (oral) 10-14 -0

ก () ก:m- %ก& ก - =
กr
+U8 a opioid derivative (eg.+atropine) :serious S/E
+U8 a /g*/0ก ,Z,a!"g(e /# $i6 ก"g(e
: ก [bกi Vb & .#$ ‚$| " + ,ก ,Z,ab
# ' / &‡$g-0.
8 a # 0ed / $" `ก+ )\ ,% 0 e.g. ORS
ก () ก:m- %ก& ก - =

w %i ' pE
%0.0d : • ‚$ƒ,Z,a!
%0.0d
loperamide (limited safety information)
diphenoxylate ( ก-$ Z&)
Anticonstipation ; ก ก %&ก->laxatives/cathartics
ก - 9?ก (constipation)

ก cZ&* k- Y66 .% `
V Y66 . ! (0* ก- 3 5 e ) #&, '\)
5- 6d "&20)* "! Y66 .
5- #Z* bก- V Y66 . "# `6
/g*"- /0ก V Y66 .0 0 ก
ก %ก&
1. , n8( %ก& / (/* , n m
ก$0 ' ก ก/ 0*
,ก กกd ก
! g0$, "g0 ,ก , (aluminium hydroxide)
‚ )Y"' ก` 0Y 0‚Y\y•Ž0 (tramadol,morphine,codeine,
fentanyl), bismuth , trihexyphenidyl
Pregnancy, Hypothyroidism, DM
ก %ก&

2.C % C(/* ] ก U
!& . 0 ' ก ก : c * cก ‚_ (g
%. & ก ;
ก กกd ก "g0 ",$0 -$
ก %ก&
3.ก :m-
Bulk•forming laxatives
Lubricant
Stool softeners /emollient laxatives
Stimulant laxatives
Osmotic laxatives
Others ; #-0 - '0ก (enemas)
Bulk -forming laxatives
d /'* Y66 ."&20ก* 0' ( " $ ก ก e.g.
# #ก,6 ก" ,` % ก
-Y*0
" `,6d -ก" 0"ก `,' (Ispaghula seed ,Plantago,
Psyllium) ;AGIOLAX®,METAMUCIL®,FYBOGEL ®
d *-
# กb 0Y 0‚\ "a +Z # "g0 methylcellulose
Bulk -forming laxatives
ก(+ก
VZก / VZก,Z,ab GI 6b 5- # V
/0ก ,Z,0ed " * -*/0)-" "&20ก " $ & $ U 6Y 6 .
d /'* Y66 ."&20ก* 0 00Y be0
ก .)Y*0ก !!)- d #* d /'* Y66 ."5 ( 0c 0
| /0 d #*/'_ ,*" `- be0
Bulk -forming laxatives

)* /g*"- & . U 1 wk 6b 6."'`0c

/g*ก! ก * cZก%!! Y0% 5 ,*c
Bulk -forming laxatives
ADR;
fiber # +, %!5 " ( d #*) gas
* (, &-, * /0 *
fiber + ,( 0ed " d #* Y,)0
Drug interaction ; !ก-0ก ,Z,ab (0
, 0e0 5- !& . 0' 6 ก (0 2 hr
**"' ./0ก กi ก * cZก/0'_$ 5 |\/' 5 ,!Y) **
Lubricant laxatives

( ()* "&20 -ก0ed 0 e.g.

Mineral oil (synonym)
0ed 0% (synonym)
liquid paraffin (synonym)
ELP(Emulsion of liquid paraffin) (synonym)
Lubricant laxatives

ก(+ก ;
"5 ( ! Y66 . d /'*' (0% .V 6Y 6 . ก
,* 0be
! e ก ,Z,ab 0ed ก !" * #Z ก "&20ก " $
0ed '0ก 6Y 6 . "&20ก ,"- Y66 . Z/0 d #*
Lubricant laxatives
ADR;
lipoid pneumonia (& , ก"#!) " ( ก #d ก
" * & , , 0e0
- %0.0d /'* ก 00 0
- %0.0d /'* %กcZ*&k- Z/0 0 0
- .- ก /g*/0 :",`ก" `ก/cZ*&k- #Z Y/cZ*&k- 0 0")
Lubricant laxatives
- ก - '0ก d /'*50% ."& ."&–— 0
"#(e c* ,*
'* /g*/0'_$ )e 5 |\ ("')Yc ;drug interaction)
Drug interaction;
6. ,ก ,Z,ab -$) $0 . /0 0 "g0 " ,
"5 (vit D def.6. c ) ก ,Z,ab %5 "a % .
” #” #) , 0e0 5- !& . 0 U. * -
Stool softeners /emollient laxatives
e.g. Docusate
ก(+ก
,% )b c$- d /'*0ed % .0ed 0# Vab c 0" * #Z
ก* 0 Y66 . d /'* 6Y 6 . 00Y
" $ ก ' 0ed % . $" `ก+ )\
** ,Z,ab " * #Z ก ;"' .#d ' !'_$ )e 5 |\/
'_$ ' 5 ,!Y) **
Stool softeners /emollient laxatives

ADR ; 0* .5 "5( ! $"-U d 5 &-,"ก ` *

#! * c(0% *

Drug interaction;
" $ ก ,Z,ab (0 ] "g0 mineral,phenolpthalein
Toxic of mineral oil, phenolpthalein
Stimulant laxatives
e.g. . % ก(senna) , bisacodyl (dulcolax ®),phenolpthalein,
0ed 0 .'Y (castor oil), dehydrocholic acid(Decholin® )
ก(+ก;
ก .)Y*0ก "5 ( 0 '- d #*
d /'*"ก$,ก .5 "5( " ( " ( ก!Y d #*
" $ ก ' 0ed / "' -/0 Z" 0 d #*
! e ก ,Z,ก ! 0ed / $" `ก+ )\ d /'*"ก$,ก 5
"' -/0 ",$0 '
Stimulant laxatives

ADR;
Bisacodyl e.g.&-, * 5 (0 #*
Phenolpthalein e.g.&Š## -."& 0#"&20g Z' ( %,
Castor oil (0ed 0 .'Y ) e.g. , Zก',)- **'* /g*/0
'_$ )e 5 |\ d /'*% * ,***
ก , dehydrocholic acid e.g.&-, *
Stimulant laxatives
Drug interaction; e.g.
bisacodyl (enteric coated tablet /'*%)ก)- d #*/'_)
˜| -., •6. d # "5 ( !!0c$- %)ก)-/0
ก ." . ' .5 "5( /&-, -0 *
, 0e0 5- ก$0 0e - ก! ,ก ,/0 #, ' ( 5-
ก$0' ก0 0* 1 g-+
Stimulant laxatives

H- '= =%
5- /g* )$,) ก0 > 1 wk
' ก/g*"- 0 0"&20&z 6. d /'* .!!ก !V )
‚ g )$"& 0 &/' Y,ก d 0 cathartic colon
(ก )$, V ) d /'*)* /g* .! /0ก !V Z
"#
Stimulant laxatives
H- '= =%
enteric coated tablet 5- !,/"5e - &‰ ก0ก %)ก
)- ก ." . (% 0 6. ก• ‚$ƒ d #*/'_) % . 6
d /'* .5 "5( ก ." . ' ,*
Osmotic laxatives
5YU# !)$"&20# #+ )$ก e.g.
ก Y "ก (
-Magnesium sulfate, citrate, hydroxide
(M.O.M/milk of magnesia)
-Sodium phosphate (xubil®;Monobasic Na phosphate,
dibasic Na phosphate)
Osmotic laxatives

Glycerine
Sorbitol
Lactulose
Lactitol
Osmotic laxatives

ก(+ก; (VZก,Z,ab ,*0* ' ( VZก,Z,ab /0 GI)

,b 0ed /'* Z/0 ",$0 ' ,*- % #+ )$ก
(osmotic action) d #* 0ed ก be0 "ก$,ก "5 ( 0 '-
d #*
ADR; e.g. N/V, * (, "”‰ &-, * #! *
Osmotic laxatives

Drug interation ;
ก Y "ก ( " ( /g* - ก! !&Š## -. 6 d /'*"ก$,
| -. ,0ed Y0% ,*
Osmotic laxatives
H- '= =%
" ก /g*"ก ( +a", :/0cZ*&k- 6d ก,"ก (
- cZ*&k- 5- ,0+ '$)#Z
-+ 5'-/6
- | -.!-
- )!ก
Osmotic laxatives

" /g* ก Y "ก ( /0'_$ /'*0 !Y) '_$ )e 5 |\

" . VZก ! ก 0ed 0 % . d /'*"ก$, electrolyte
imbalance ก"-*0 M.O.M # V/g* ,*
.- ก /g* lactulose /0cZ*&k- "! '- 0 " .
# V"& 0"&200ed ) galactose ,* 0ed ) /0
" ( ,#Z 0be
Hepatic encephalopathy
p = Cก
ก , . $+0' ( +& )0
#
↓
% + "0
" * )!
↓
VZก6!,*- "a \)!
VZก metabolize "& 0"&20
↓
Z" VZก ! ก &Š## -.
Hepatic encephalopathy
p = % ,)* U eg. cirrhosis
% + "0
VZก metabolize "& 0"&20
↓
Z"
↓
% + "0
↓
Hepatic encephalopathy
ก H hepatic encephalopathy

#!#0 ก .#!ก .# ' ( Z," * "6*

"h "
-
ก * "0(e #0 gก"ก `
' /6" `-
' ,#)$
ก :m- lactulose ก% & hepatic encephalopathy
Others ; #-0 - '0ก (enemas)
e.g.
0ed (tap water)
0ed "ก ( =NaCl = eg.unison enema
sorbitol
0ed #!Z (soap solution)
ก(+ก; h,#-0 - '0ก "ก$,% ,0 c0
#* ) ก .)Y* 0 ก ',) - #* )
! Y66 . ก | /0 15-30 0
ก () ก:m-

' %*=+C :
bulk forming agents + life modification
(ก ก/ ,( 0ed กกd ก y™กก !V "&20"- ) ,*c ∆ laxatives
- 9?ก y/ ](% :
"'0`!/ #-0 - '0ก ,*c
bisacodyl /senna /M.O.M >1 wk ,*c
& กb i % \" ( ' # "')Y
ก () ก:m-

9?-Ct= ก/* U/* /ก ก: -

bulk forming agents
n.. (%ก&Y 8Hr U ก ) - (/ก (/* ก
lubricant/stool softener ,*c ,ก- bulk forming agents
- ก '= U r=: ก e.g. / U(a +,- ])* 9 %
saline laxatives (high dose)
ก () ก:m-
9?-Ct= / /9?-,? n
bulk forming agents ,*c bisacodyl
/senna/M.O.M/(lactulose;low dose) %) ,*/'*!
' ! () ( *+ & ,-* . &+ + ก )
docusate/bulk forming agent
**stimulant laxatives use if necessary but not use
Castor oil**
ก () ก:m-

rก ก ) rก (rก :
& !"& 0 ' " $ ก ก/ "'0`! e.g.glycerin
suppo/ #-0 - '0ก
V* ,*c ' ( * )*0 ; M.O.M./senna
9?-Ct= /* - ก H% , ]& :
saline laxatives e.g.magnesium sulfate,osmotic laxatives
ก - ) AB (antiflatulants)
 ก - ) AB (flatulence)

"ก$,5- #Z* bก)b %00 b, , #! * 6" .

กš a/0 ",$0 '
# "')Y e.g.
.!! ' !ก
' ! & ."|
+ 5/#| -. ก ! e.g. peptic ulcer
! g0$,
 ก - ) AB (antiflatulants)

ก Y 0ed 0' ."' (volatile oils)

ก Y )* 0ก "ก$,” (defoaming agent)
 ก - ) AB (antiflatulants)
ก(nU ia U% U (volatile oils)
e.g. pepermint oil , fennel oil ,cinnamon oil,
Cardamom, ‚ )Y0ed %, (stomachica mixture),
$ "6 \ 5 \ $"0 ” (carminative mixture)
 ก - ) AB (antiflatulants)

ก(nU ia U% U (volatile oils)

ก(+ก
d /'* Z*#bก 0Y ",$0 ' Z*#bก#! be0
g- /0ก !กš a ก
0ed 0' ."' :ก .)Y*0 .!!& .#
 ก - ) AB (antiflatulants)

5- /g* Mixture Carminative 5\ก "|#g

ก /0'_$ 5 |\ "0( 6 ก Alcohol & .ก !
Z& . U * . 8.8 ab #) 5 |\5- ' ก"
% ก › \ % */0& $ U0* ก`)
" -,ก 0ก$0
 ก - ) AB (antiflatulants)

ก(nU - ก ก A (defoaming agent)

e.g.Simeticone tab,susp.
Trade name :AIR-X , Belcid compound
ก(+ก : ,% )b c$- ” กš a/0 ",$0 ' g-
กd 6,กš a
'a 8 a : " `,/'*"5e -ก 0ก (0
H- '= Cz % ])* CB ก% ก - ) AB

' ก" ก !& . 0 ' d /'*"ก$,กš a e.g.

V-) ] 0ed ,
!& . 0 '
"5e - ' /'* ." ,