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Pharmacy Practice 1 PHCY 280

Spring 2016/17 Gastrointestinal Disorders- Part 2

Ms. Beena Jimmy

Pharmacy Practice

Topics for discussion

Objectives

Dyspepsia

Hemorrhoids

Summary

Objectives

By the end of the topic, the student should be able to:

• Develop history taking and perform physical examination of a patient with Gastrointestinal disease such as dyspepsia and hemorrhoids

• Distinguish diagnosis and formulate management strategies for a patient with gastrointestinal disease

• Recognize when to refer a patient to a doctor • Choose appropriate OTC management options for

the above mentioned diseases

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The GIT Tract

Abdominal Pain

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Dyspepsia

• Also referred to as indigestion

• Often self-diagnosed by patients

• Pharmacists are “first point of contact”

• Symptoms- vague abdominal discomfort (ache above the umbilicus) associated with belching, bloating, flatulence, feeling of fullness and heartburn.

• Symptoms may be increased by particular foods, medical conditions, alcohol, or medication (e.g. aspirin)

• Obtain a good description of the pain

• Enquire about precipitating or aggravating factors

• Differentiate symptoms from a heart attack

Causes: • Medicine induced dyspepsia- NSAIDs (Aspirin, Ibuprofen), ACE

Inhibitors, Iron, Macrolide antibiotics, Metronidazole

• Increased acid production (Gastritis)- spicy food, fatty food, excess food/over eating, eating fast, stress, high fiber food

• Few medical conditions that may present as indigestion - Heartburn usually due to esophageal sphincter incompetence- Pregnancy. (Reflux esophagitis) - In presence of Helicobacter pylori, patients may develop

Duodenal &/or Gastric Ulcers (Peptic Ulcer Disease – PUD)

• Alcohol

• Smoking predisposes to, and may cause, indigestion and ulcers

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Questions to Ask

• Location of pain – centrally located, above umbilicus, general discomfort & difficult to pinpoint

• Nature of pain – aching and feeling uncomfortable localised not radiating

• Any associated symptoms, would indicate other GIT disorders

• Life style – alcohol consumption, eating fast, smoking, coffee, stressful occupation contribute to dyspepsia

When to Refer

• Pain which is severe, sharp, radiating and which wakes up the patient during sleep

• Associated symptoms e.g. severe vomiting, change of bowel movement of long duration

• Pain radiating to arms/ worsening or increasing on effort

• Age over 45, if symptoms develop for first time

• Symptoms are persistent (longer than 5 days) or recurrent

• Abdominal Pain that is severe

• Blood in vomit or stools

• OTC Treatment has failed even after 2 weeks of treatment

• Prescription drug –ADR is suspected

• Children

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Management

• After excluding serious disease, consider management with antacids or a H2-antagonist

• Medicinal Preparation is selected based on patients symptoms, preferred dosage form and other disease conditions

• Avoid constipating antacids in elderly and pregnant patients

Antacids- to neutralize stomach acid

• Available as liquids, solids

• Liquids are more effective antacids than are solids; they are easier to take, work quicker and have a greater neutralising capacity.

• Solids have to be well chewed before swallowing.

• Best to be taken after food, as the effect would last longer

• Increases the chances of drug-drug interactions

Sodium bicarbonate

Aluminum hydroxide

Magnesium trisilicate

Magnesium hydroxide

Calcium carbonate

Dimethicone

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Sodium bicarbonate

- fast-acting, but has a short duration of action

- should be avoided in patients if sodium intake should be restricted (heart disease, high Blood Pressure (BP), renal problem)

- long-term use of sodium bicarbonate may lead to systemic alkalosis and renal damage

- 1 to 4 tablets ORALLY every 4 hours; MAX 24 tablets/24 hours

- Effervescent powder- dissolve in one-half glass of cool water; take while effervescing

- ADR- systemic alkalosis

Aluminum and magnesium salts

• Slower acting but longer duration of action

• Aluminum hydroxide tend to be constipating

• Magnesium salts are more potent acid neutralisers than aluminum, but may cause diarrhoea

• In combination they cause minimum bowel disturbance/ may reduce the incidence of constipation and diarrhea

• Dried Aluminum hydroxide 220 mg+ Magnesium hydroxide 195 mg/5mL -10 to 20 mL (2 to 4 teaspoonful) PO 4 times per day 1 hr after food; MAX dose, 80 mL/day; not longer than 2 weeks

• Previous combination along with Simeticone 25 mg/5 ml; 5-10 mL q.i.d.

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Management

Calcium carbonate • Acts quickly, has a prolonged action • If taken over long periods at high doses, can cause

hypercalcaemia • Calcium carbonate and sodium bicarbonate can, if

taken in large quantities with a high intake of milk, result in the milk–alkali syndrome.

• This involves hypercalcaemia, metabolic alkalosis and renal insufficiency;

• Its symptoms in patients’ are nausea, vomiting, anorexia, headache and mental confusion.

• 2 to 4 chewable tablets (calcium carbonate 750 mg [elemental calcium 300 mg] per tablet) ORALLY as symptoms occur; max 10 tabs/day

• ADR- constipation, flatulence

• Simethicone/ Dimeticone- allows easier elimination of gas from the gut

Alginates in contact with stomach contents form sponge like matrix thereby reducing the symptoms of reflux • Most useful in gastritis & reflux (liquid & tablets) • Liquid- sodium alginate 250 mg+ calcium carbonate 80 mg +

Sodium bicarbonate 133.5 mg/5mL • Dose- 10- 20 mL after meals and at bed time • If symptoms have not improved within 5 days of treatment

with OTC drugs- refer

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• Some drugs concentration are affected when taken with antacids: azithromycin, cefaclor, ciprofloxazin, itraconazole and ketoconazole, iron preparations, ACE inhibitors, phenothiazines, gabapentin and phenytoin

• Taking the doses of antacids and other drugs at least 1-2 hours apart will minimize the drug- drug interaction.

Management

H2 receptor antagonist

- controls the production of stomach acid (Ranitidine, Famotidine, Cimetidine)

- Ranitidine- 75 to 150 mg ORALLY once or twice daily half hour before food, MAX 300 mg/day

- ADR- abdominal pain, constipation, diarrhoea, rash, headache, hepatitis

- Proton pump inhibitors are also effective- Omeprazole, Pantoprazole.(not OTC) • ADR- gastro intestinal side effects and headache

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Management Non-pharmacological management:

• Try to lose weight.

• Eat small portions and chew thoroughly

• Avoid fatty or greasy foods or Avoid troublesome foods.

• Avoid tight-fitting clothing.

• Life style modification e.g. smoking, alcohol consumption, coffee, sedentary life etc.

• Eat smaller, well balanced meals.

• Elevate the head of your bed.

• Avoid medications if you can/ if it causes.

• Don't lie down for 2 or 3 hours after eating.

• Smoking, alcohol - advise accordingly

Hemorrhoids

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Hemorrhoids (PILES)

• Symptoms include- itching, burning, pain, swelling and discomfort in the perianal area and anal canal and rectal bleeding

• Haemorrhoids are swollen veins, which protrude into the anal canal (internal piles)

• When it swells too much it may hang down outside the anus (external piles).

• Bleeding is a common feature

• Haemorrhoids are often caused or exacerbated by inadequate dietary fibre or fluid intake

Prevalence/Epidemiology

• Occurs at any age but rare < 20 yrs

• Most common in the elderly starting at age 40 yrs

• Pregnancy leads to higher incidences in women

• Consider treating haemorrhoids of up to 3 weeks’ duration; A recent examination by the doctor that has excluded serious symptoms- consider OTC management

• Dull aching pain- usual complaint

• Sharp/stabbing pain during defecation is due to anal fissure or tear

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• Constipation leads to straining during defecation.

• Pregnancy lead to persistent closure & relaxation of sphincter

• Pain while passing stool stop patients going to the toilet

• This causes constipation, causing severe abdominal pain and painful defecation; continuous cycle

• Hemorrhoids may be exacerbated by drug-induced constipation

Bleeding

• Common during passing of stool

• Bright red in colour

• Small amount of blood

• Large amount of blood, or mixed with stool or bleeding occurring without passing of stool – REFER IMMEDIATELY

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When to refer

• Duration of longer than 3 weeks

• Presence of large amount of blood in the stools

• Change in bowel habit (persisting alteration from normal bowel habit)

• Suspected drug-induced constipation

• Associated abdominal pain/vomiting

Management • Commonly a wide range of therapeutic products-

anaesthetics, astringents, anti-inflammatories, protectorants- for short period of time

• Usually a combination of suppositories and cream may be given to patients;

Local anaesthetics- lidocaine, tetracaine, cinchocaine, pramocaine. • It can help to reduce the pain and itching associated with

haemorrhoids, • Do not use for more than 2 weeks Skin protectors (e.g. zinc oxide and kaolin) have emollient and protective properties. • Protection of the perianal skin form a barrier on the skin

surface, helping to prevent irritation and loss of moisture from the skin.

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Astringents such as zinc oxide, hamamelis helps to relieve irritation and inflammation

• They tend to shrink or constrict body tissues/blood vessels there by reduce bleeding

• OTC medicines not for more than a week as these products can cause side effects, such as skin rash, inflammation and skin thinning.

Topical steroids- Hydrocortisone acetate-reduces inflammation and swelling to give relief from itching and pain

• Directions for the use of suppository- refer lab notes

• Sitz bath for symptom relief

• Fibre rich diet should be taken

• The short-term use of a laxative to relieve constipation might be considered

• If symptoms have not improved after 1 week- refer

• Surgery

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Management

Summary • Discussed dyspepsia and identified the other

conditions considered as dyspepsia

• Reviewed the symptoms of dyspepsia and how to differentiate it from PUD

• Recognise life style modification is an important addition to pharmacological management

• Antacids are the main treatment agents

• Described hemorrhoids, symptoms & diagnosis & Identified its treatment