ANTACIDS

Gastric acid secretion is a complex, continuous process in which multiple central and peripheral
factors contribute to a common end point: the secretion of H+ by parietal cells.

 Neuronal (acetylcholine, ACh),

 paracrine (histamine), and
 Endocrine (gastrin) factors all regulate acid secretion.

Their specific receptors (M3(muscarinic), H2, and CCK2, respectively) are on the basolateral
membrane of parietal cells in the body and fundus of the stomach.

In close proximity to the parietal cells are gut endocrine cells called enterochromaffin like (ECL)
cells. ECL cells also have receptors for gastrin and acetylcholine, which stimulate histamine
release.

Histamine binds to the H2 receptor on the parietal cell, resulting in activation of adenylyl cyclase,
which increases intracellular cyclic adenosine monophosphate (cAMP) and activates protein
kinases that stimulate acid secretion by the H+/K+-ATPase.

When acetylcholine (from vagal postganglionic nerves) or gastrin (released from

antral G cells into the blood) bind to the parietal cell receptors, they cause an increase in
cytosolic calcium, which in turn stimulates protein kinases that stimulate acid secretion from
a H+/K+-ATPase (the proton pump) on the canalicular surface.

Dyspepsia: Barriers to the reflux of gastric contents into the esophagus comprise the primary
esophageal defense. If these protective barriers fail and reflux occurs, dyspepsia and/or erosive
esophagitis may result.

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How to combat with excess acid?

Antacids are weak bases that react with gastric hydrochloric acid to form a salt and water. Their
principal mechanism of action is reduction of intragastric acidity. After a meal, approximately 45
mEq/h of hydrochloric acid is secreted.

A single dose of 156 mEq of antacid given 1 hour after a meal effectively neutralizes gastric acid
for up to 2 hours.

The acid-neutralization capacity among different proprietary formulations of antacids is highly

variable, depending on their

 rate of dissolution (tablet versus liquid),

 water solubility,
 rate of reaction with acid, and
 rate of gastric emptying.

Drugs neutralizing gastric acid secretion:

1. systemic antacids

Sodium bicarbonate:

Sodium bicarbonate (eg, baking soda, Alka Seltzer) reacts rapidly with hydrochloric acid (HCl) to
produce carbon dioxide and sodium chloride.

Formation of carbon dioxide results in gastric distention and belching.

Unreacted alkali is readily absorbed, potentially causing metabolic alkalosis( (Metabolic alkalosis
is a metabolic condition in which the pH of tissue is elevated beyond the normal range (7.35–
7.45). This is the result of

 decreased hydrogen ion concentration,

 leading to increased bicarbonate
 alternatively a direct result of increased bicarbonate concentrations.))

when given in high doses or to patients with renal insufficiency.

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Sodium chloride absorption may exacerbate fluid retention in patients with heart failure,
hypertension, and renal insufficiency.

It can cause rebound acidity.

2. Non systemic antacids

 Buffer type antacids

I. Aluminum hydroxide
II. Magnesium trisilicate
III. Magaldrate
 Non buffer type antacids
I. Calcium carbonate
II. Magnesium hydroxide
 Other antacids
I. Simethicone

Calcium carbonate:

Calcium carbonate (eg, Tums, Os-Cal) is less soluble and reacts more slowly than sodium
bicarbonate with HCl to form carbon dioxide and calcium chloride (CaCl2). Like sodium
bicarbonate, calcium carbonate may cause belching or metabolic alkalosis.

Excessive doses of either sodium bicarbonate or calcium carbonate with calcium-containing dairy
products can lead to hypercalcemia, renal insufficiency, and metabolic alkalosis (milk-alkali
syndrome)

Magnesium hydroxide and aluminum hydroxide:

Formulations containing magnesium hydroxide or aluminum hydroxide react slowly with HCl to
form magnesium chloride or aluminum chloride and water. Because no gas is generated, belching
does not occur.

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Metabolic alkalosis is also uncommon because of the efficiency of the neutralization reaction.

Because unabsorbed magnesium salts may cause an osmotic diarrhea and aluminum
salts may cause constipation, these agents are commonly administered together in
proprietary formulations (eg, Gelusil, Maalox, Mylanta) to minimize the impact on bowel function.

Both magnesium and aluminum are absorbed and excreted by the kidneys. Hence, patients with
renal insufficiency should not take these agents long-term.

H2-RECEPTOR ANTAGONISTS

Four H2 antagonists are in clinical use: cimetidine, ranitidine, famotidine, and nizatidine (FRCN).

Histamine H2 receptor antagonists mechanism:

The hormone histamine stimulates the release of acid by interacting with histamine receptor 2,
or H2 receptor.H2RA inhibit acid secretion by competitively and reversibly blocking H2 receptor.

H2 antagonists reduce acid secretion stimulated by histamine as well as by gastrin and

cholinomimetic agents through two mechanisms. First, histamine released from ECL cells by
gastrin or vagal stimulation is blocked from binding to the parietal cell H2 receptor. Second, direct
stimulation of the parietal cell by gastrin or acetylcholine has a diminished effect on acid secretion
in the presence of H2-receptor blockade.

All of these antagonists inhibit 60–70% of total 24-hour acid secretion.

It is less potent than PPI.

H2 antagonists are especially effective at inhibiting nocturnal acid secretion.

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PROTON PUMP INHIBITORS:

Six PPIs are available for clinical use: omeprazole, esomeprazole, lansoprazole, dexlansoprazole,
rabeprazole, and pantoprazole.

Omeprazole and lansoprazole are racemic mixtures of R- and S-isomers. Esomeprazole is the S-
isomer of omeprazole and dexlansoprazole the R-isomer of lansoprazole. All are available in oral
formulations. Esomeprazole and pantoprazole are also available in intravenous formulations.

PPIs are administered as inactive prodrugs. To protect the acidlabile prodrug from rapid
destruction within the gastric lumen, oral products are formulated for delayed release as acid-
resistant, enteric-coated capsules or tablets. After passing through the stomach into the alkaline
intestinal lumen, the enteric coatings dissolve and the prodrug is absorbed.

After absorption into the systemic circulation, the prodrug diffuses into the parietal cells of the
stomach and accumulates in the acidic secretory canaliculi.

Here, it is activated by proton-catalyzed formation of a tetracyclic sulfonamide, trapping the drug

so that it cannot diffuse back across the canalicular membrane.

The activated form then binds covalently with sulfhydryl groups of cysteines in the H+, K+-
ATPase, irreversibly inactivating the pump molecule.

Acid secretion resumes only after new pump molecules are synthesized and inserted into the
luminal membrane, providing a prolonged (up to 24- to 48-hour) suppression of acid secretion.
About 80-90%.

Simethicone:

It is a silicone polymer and therefore has water repellent properties. It acts as an antifoaming
agent and reduces gastric flatulence.

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This medication is used to treat the symptoms of too much stomach acid such as stomach upset,
heartburn, and acid indigestion. It is also used to relieve symptoms of extra gas such as belching,
bloating, and feelings of pressure/discomfort in the stomach/gut.

Simethicone helps break up gas bubbles in the gut. Aluminum and magnesium antacids work
quickly to lower the acid in the stomach. Liquid antacids usually work faster/better than tablets
or capsules.

It may be used alone or with other medications that lower acid production (e.g., H2 blockers
such as cimetidine/ranitidine and proton pump inhibitors such as omeprazole).

So simethicone is used with antacids so that strength of antacid is increased.

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