pharmaceutical care of patients with disorders of digestive system functions heartburn constipation
TRANSCRIPT
Pharmaceutical care of patients with disorders of digestive
system functions
HeartburnConstipation
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Epidemiology
The diseases of digestive system are widely spread in all types of population and different age groups
The 30-40% of the population of industrialized countries complaint on dyspepsia
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Epidemiology (the causes of widespread)
stress
ecology, physical andchemical factors of external environment
unnecessary and uncontrolled use of medicaments,
which affect the microflora of the body
poor nutrition reduction in immunological reactivity
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Heartburn
The burning sensation in The burning sensation in the epigastric region and the epigastric region and the sternum associated the sternum associated with reflux of stomach with reflux of stomach contents into the lower contents into the lower esophagusesophagus
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Heartburn
The 61.7%61.7% men and 63.6%63.6% women meet with heartburn , with 10.3% and 15.1% - frequently or constantly
The global pharmaceutical market of antacids is about $5 billion
Sales volume of antacids in the U.S. is about $ 900 million a year
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Factors, which promote heartburn:
smoking sleep or rest lying
down immediately after eating
wearing of tight clothes
hypodynamia obesity weight lifting
alcohol abuse
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Heartburn can occur:
in healthy people in patients with digestive system diseases
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The heartburn causes in people without digestive system diseases:
irrational, inexpedient nutrition:
– over-nutrition
– a quick meal "on the fly", in a stressful environment
– abuse of rich, oily, hot and spicy food
– consumption of large quantities of sweets and foods containing caffeine (coffee, tea, chocolate)
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The heartburn causes in people without digestive system diseases:
the individual sensitivity to some foods – citrus fruits, onion, garlic, tomato products (juice, pasta, sauces)
pregnancy
medicament intake (euphylline, COCs, antispasmodics, cholinergics)
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The heartburn causes in people with digestive system diseases:
gastroesophadeal reflux disease chronic gastritis (H.pilory associated,
hyperacidic, type B) peptic gastric and/or
duodenum ulcer chronic cholecystitis
and biliary dyskinesia hiatal hernia
Normal
Esophagus
Hernia
Stomach
Diaphragm
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«Threatening» symptoms of heartburn:
permanent heartburn during some weeks
heartburn is accompanied with abdomen pain permanent heartburn associated with
progressive weight loss heartburn is accompanied with
breathlessness, sweating, dysphagia heartburn caused with
some medicaments heartburn is accompanied with
pain behind of the breastbone and irradiation to the left arm
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«Threatening» symptoms of heartburn:
heartburn is accompanied with vomiting, which has “coffee grounds” colour or mixed with blood
heartburn is accompanied with dark (black, tar-like) stool
NBNB!!
Severe complication – gastrointestinal bleedinggastrointestinal bleeding
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The approaches of drug and non-drug treatments of heartburn
symptomatic therapy – neutralization of symptomatic therapy – neutralization of hydrochloric acid - antacidshydrochloric acid - antacids
pathogenetic therapy:
– blokage of Н2-histamine receptors, the suppressing of hydrochloric acid formation
– inhibition of Н+-К+-АТP-ase, suppressing of hydrochloric acid output
– acceleration of gastric emptying,
prophylactic therapy (diet, features of taking drugs, avoiding harmful habits)
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Antacids – first line drugs for symptomatic treatment of heartburn
The pharmacological effect of antacids applies only to already secreted acidalready secreted acid
Antacids don’t affectdon’t affect the intensity of acid secretion
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Neutralization of hydrochloric acid:
Аl(OН)3 + 3HCl = АlCl3 + 3H2O
Mg(OН)2 + 2HCl = MgCl2 + 2H2O
Reduction of activity of pepsin and its absorption
Binding of bile acids and lysolecithin
Inhibition of growth of H. pylori and the binding of the products of its vital activity
Gastroprotective action
The mechanism of action of antacids
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Antacids – first line drugs for symptomatic treatment of heartburn
AbsorbableAbsorbable Non-absorbableNon-absorbable
NaHCO3, CaCO3
aluminum-containing (phosphate, hydroxide),
magnesium (oxide, hydroxide, trisilicate)
fast HCl neutralization
mechanical protection of mucous coat of stomach,
absence of rebound phenomena, prolonged effect
AdvantagesAdvantages
short effect, rebound phenomena,
systemic alkalosis, constipation (Ca2+),
sodium and water retention
bone affection, constipation, encephalopathy (Alzheimer's
disease-like), muscle weakness
DisadvantagesDisadvantages
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Description of components of antacids
Name Advantages Disadvantages
Sodium bicarbonateNaHCO3
Very rapid onset of action
Short-term actionRebound phenomenaSystemic alkalosisNephrolithiasisArterial hypertension
Calcium carbonateСаСО3
Rapid onset of action
Short-term actionRebound phenomena,
meteorism, belchingSystemic alkalosisNephrocalcinosis
Intermittent use don’t exceed the dose more than 1 g
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Description of components of antacids
Name Advantages Disadvantages
Magnesium oxide or hydroxideMgO or Mg(OH)2
Doesn’t cause the rebound phenomena
Doesn’t violate the acid-base balance
Slow onset of action Acceleration of the peristalsis of GI
canal (diarrhea) Neurological and cardiovascular
disorders in case of chronic renal failure
Aluminum hydroxideAl(OH)3
Has enveloping and absorbing effect
Doesn’t complete neutralize of HCl
Adsorbs the bile salts Enhances the PG
synthesis Doesn’t violate the
acid-base balance
Slow onset of action Accumulation and encephalopathy
in case of its long-term usage and chronic renal failure in history
Hypophosphatemia, hyperphosphaturia, hypercalciuria, calcium nephrolithiasis
Slowing down of the peristalsis of GI canal (constipation)
It’s recommended for patients with predisposition to
constipation
• It’s recommended for patients with predisposition to diarrhea
• In long-term use it should be combined with calcium glycerophosphate and diet should contain enough amount of protein
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Description of antacids
Trade name Composition
Phosphalugel Aluminum phosphate Al2(PO4)3
Talcid
Ruracid
Gastal
Hydrotalcite (magnesium aluminum hydrocarbonate)
Mg6Al2(OH)16CO34H2O
Almagel T
Riopan
Magaldrate
Al5Mg10(OH)31(SO4)2xH2O
Gelusil-Lac Simaldrate 2MgOAl2O33SiO2nH2O
Rennie
Anre
Calcium carbonate, magnesium carbonateCaCO3, MgCO3
Maalox
Almagel
Alumag
Aluminum hydroxide, magnesium hydroxide
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Description of antacids
Trade name Composition
Almagel AAluminum hydroxide, magnesium hydroxide, benzocainebenzocaine
MantiTrivinAlmagel Neo
Aluminum hydroxide, magnesium hydroxide, simeticonsimeticon
RelcerAluminum hydroxide, magnesium hydroxide, simeticonsimeticon, powder, powder of of root root of of licoricelicorice
GestidAluminum hydroxide, magnesium hydroxide, magnesium trisilicate, simeticonsimeticon
ContracidAluminum hydroxide, magnesium trisilicate, dimeticondimeticon
DigelMagaldrate, simeticonsimeticon
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Description of the OTC-drugs for heartburn treatment
Trade name Composition Dose
Ranigast 75 ranitidine 75 mg
Quamatel mini famotidine 10 mg
Gastromax
famotidine
calcium carbonate
magnesium hydroxide
10 mg
800 mg
165 mg
TECTA Control pantoprazole 10 mg
Omez, Gasec, Omealox omeprazole 10 mg
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Gastromax
successful combination of antisecretory drug and antacids
Composition famotidine 10 mg calcium carbonate 800 mg magnesium hydroxide 165 mg
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Advantages of Gastromax
Rapid onset of antacidic action
Long-term effect
Antipeptic effect
Easy use
OTC-drug
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Description of antacids
Trade name Composition
Effects
antiacidic
adsorbing
enveloping
stypticcytoprotecti
ve
antipeptic
pepsin-binding
AlmagelAlumagMaalox
Al(OH)3 + Mg(OH)2 + + + - + - +
Almagel AAl(OH)3 + Mg(OH)2
sorbitol, benzocaine + + + - + - +
TalcidRutacid
Hydrotalcid + + + - +/- - +
Phosphalugel Aluminum phosphate, pectin + + + - + + +
Гелусил-лак Simaldrate + + + + + + +
Ренни
АнреCaCO3, MgCO3 + + + - - - -
It has local anesthetic action
It doesn’t include sugar and can be prescribed to patient with diabetes mellitus
It doesn’t include sugar and can be prescribed to patient with diabetes mellitus
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Alginate-containing antacids are drugs with different mechanisms of action
Gaviscon is used more than 30 years
It’s the leader of sales in Great Britain among OTC-antacides and Н2-blockers)
Composition Gaviscon Mint Suspension
sodium alginate 250 mg/5 mlsodium bicarbonate 133,5 mg/5 mlcalcium carbonate 80 mg/5 ml
Gaviscon Mint Tablets
sodium alginate 250 mgsodium bicarbonate 133,5 mgcalcium carbonate 80 mg
Gaviscon Forte Mint Suspension
sodium alginate 500 mg/5 mlpotassium bicarbonate 100 mg/5 ml
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Gaviscon
Alginates are natural polysaccharide polymers extracted from brown algae (kelp).
Mechanisms of action:In an acidic environment, alginates form a viscous gel – raft. Bicarbonate (K or Ca, Na) participates in the formation of CO2.
Carbon dioxide bubbles convert a gel into foam, thus, provide floatation. Also bicarbonate neutralizes acid.
Effects: Provides the reflux of the alginic raft into the esophagus
before gastric content. Coats the esophagus with rafts, which can later act as
cytoprotector. Forms a physical barrier that prevents GERD. The duration of acting up to 4 hours.
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The algorithm of conversation of pharmacist and customers, who complains on heartburn
Is heartburn followed with pain and heaviness in epigastric area, nausea, vomiting, bitter taste in the mouth, abdominal distention ?
You need to see a doctor. For the temporary relief of symptoms you can take antacids
Does heartburn occur when certain foods are taken or under certain conditions ?
The cause of heartburn could be: irrational diet habit to lying down after meal
You need to change of lifestyle and diet. To relief the symptom you can take
antacids
Yes No
Yes No
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Are you pregnant ?
During pregnancy, you can occasionally take antacids. If there is necessity of its prolonged use, you should consult with
obstetrician
Is the occurrence of heartburn accompanied by painful difficulty of swallowing, belching, regurgitation, painful sensations in the epigastric
area?
You certainly need to see a doctor. For the temporary relief of symptoms
you can take antacids
Is your condition:
connected with stress
followed by sensation of lump in the throat
followed by sleeplessness
Perhaps your condition is associated with chronic stress. Consult with physician. To eliminate acid reflux you can take antacids.
Ask for consultation to physician
Yes No
Yes No
Yes
NoIf after 3 days of self-treatment the heartburn will not disappear or reduce you need to seek immediate medical care!
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Basic approaches to the symptomatic treatment of heartburn
Antacids are used only when it necessary (in case of heartburn occurrence).
It is necessary to exclude dietary factors that provoke the development of acid reflux.
OTC drugs, which contain low doses of H2-blockers (ranitidine, famotidine) possess antisecretory activity.
For pregnant women for short-term/occasionally use the drugs of choice are Rennie, Anré, Talcid, Rutacid, Phosphalugel.
Long-term use of aluminum-containing antacids is not recommended for elderly people (risk of Alzheimer's-like disease).
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Pharmaceutical care when treating heartburn
Do not take horizontal or flexed position after meals
Do not eat late at night or just before bedtime
Eat slowly, carefully chewing
For patients who are overweight the weight loss is recommended
Cigarette cessation
Do not wear tight clothes
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Pharmaceutical care when treating heartburn The use of products that
contribute to gas formation (a sweet pastries, soufflés, carbonated drinks) should be limited
Excess of aluminum due to prolonged intake of high doses can result in renal failure
Nonabsorbable antacids should be intake up to 2 hours before or 2 hours after administration of other drugs
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With prolonged use of antacids there is a tendency to infections of the digestive tract due to reduce of the protective role of hydrochloric acid
Patients with stone disease should not take antacids containing silicon (magnesium trisilicate). While going out in the urine, trisilicate promotes the formation of stones.
All nonabsorbable antacids violate the absorption of concomitant medications (antibiotics, NSAIDs, glucocorticoids, etc.)
Patients with hypertension, chronic heart failure is contraindicated for reception of absorbable antacids
Pharmaceutical care when treating heartburn
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Control question
What medicament are not recomended for symptomatic treatment of heartburn for patient with stone disease?
Maalox Alumag Contracid Rutacid Talcid
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Control question
What antacid is contraindicated for patients with arterial hypertension, chronic heart failure?
Maalox Sodium bicarbonate Almagel Gelusil-Lac Talcid
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Control question
What medicament can cause the heartburn in people with predisposition?
Euphyllin Enterosgel Smekta Rennie Ranitidine
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Constipation
disorder of intestine functiondisorder of intestine function, , is characterized by an increase is characterized by an increase in the intervals between acts of in the intervals between acts of defecation (more than 48 hoursdefecation (more than 48 hours, , compared to the individual compared to the individual physiological norm ) or physiological norm ) or systematic lack of bowel systematic lack of bowel movementsmovements
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Factors, which promote constipation
Inactive, sedentary lifestyle Pregnancy (second part) Peculiarities of the profession, life habits
(psychogenic constipation) Long-term immobilization Abuse of cleansing enemas Long-term use of laxatives
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Causes of constipation
Gastrointestinal canal diseases:- colitis
- hemorrhoids
- anal fissures
- megacolon
- intestinal polyposis
- Crohn's disease
- chronic gastritis type B
- peptic ulcer of the duodenum
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Causes of constipation
Feeding features:- abrupt change of diet
- lack of fiber in the diet
- excess fat in the diet
- inadequate fluid intake
- excess iron in the diet
- folic acid deficiency
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Causes of constipation
Medicaments intake:- aluminum-containing antacids
- calcium-containing and iron-containing medicaments
- calcium channel blockers
- antispasmodics
- opiates
- cytostatics
- neuroleptic drugs, psychotropics, antidepressants
- antibacterial drugs
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Causes of constipation
Metabolism disorders:- dehydration
- hypothyroidism
- hypofunction of adrenal glands
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«Threatening» symptoms of constipation:
temperature rise blood in the stool severe abdominal pain sharp abdominal distension nausea, vomiting unmotivated weight loss
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Laxatives
1. Stimulating the motor function of the intestine (chemical stimulants):
Anthraquinone glycosides – senna-containing products (Regulax, Senalex, Xena,
Senade, Senadex, Senadexin, Senade, leaves of senna)– Frángula álnus - buckthorn products (bark of buckthorn,
buckthorn syrup)– Ononis arvensis L. (Tinktura Ononidis arventis)
Chemical stimulants– bisacodyl (Stadalax, Laxbene)– sodium picosulfate (Guttalax, Picolax, Laxigal,
Regulax pico drops)– castor oil
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Laxatives2. Lubricants and stool softeners
– liquid paraffinliquid paraffin– plant oilsplant oils
3. Bulk laxatives Plant fibre
– Sterculia platanifolia products - Normacol (microclyster, Sterculia platanifolia products - Normacol (microclyster, granules)granules)
– Plantago maior (psyllium) seeds products – Mukofalk Plantago maior (psyllium) seeds products – Mukofalk orange orange
Osmotic agents– lactulose (Normaze, Dufalak)lactulose (Normaze, Dufalak)– macrogol (Forlax, Fortrans)macrogol (Forlax, Fortrans)– inorganic salts (magnesium sulfate, sodium sulfate, sodium inorganic salts (magnesium sulfate, sodium sulfate, sodium
phosphate)phosphate)– sodium docusate/Csodium docusate/C2020HH3737NaONaO77S (Norgalax)S (Norgalax)
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Basic approaches to the symptomatic treatment of constipation
Laxatives of the same group should not be taken more than 2 weeks
It’s necessary to alternate laxatives with different mechanisms of action
The most safety laxatives for pregnant women are bulk laxatives with plant fibers (excluding Laminaria) or lactulose
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Basic approaches to the symptomatic treatment of constipation
The lactulose is the drug of choice for children, children 5-7 years old can take bulk laxatives, sodium picosulphate isn’t indicated for newborns
Osmotic laxatives are indicated for poisoning treatment, preparation for diagnostic procedures
The use of drugs stimulating the motility of the intestine are absolutely contraindicated for pregnant women and patients with spastic constipation
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The algorithm of conversation of pharmacist and customers, who complains on constipation
Do following symptom exit:• fever• trace of blood in feces• severe pain in abdomen (spastic pain)• nausea, vomiting• sharp abdominal distension• weight loss• pain during defecation• occupational hazards (work with lead,
mercury, etc.)?
One defecation in 2 days is physiologycal
Yes No
Is defecation absent more than 48 hours ?
Yes No
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The algorithm of conversation of pharmacist and customers, who complains on constipation
To obtain more accurate diagnosis you need immediately to see a physician
Are you pregnant ?
The violation of the intestinal activity may occur at the early stages of pregnancy.You need to increase physical activity, increase the liquid and fiber consumption in the diet, dairy products.Laxatives is possible after consultation with the doctor only
Are you currently taking any medications:
• aluminum-containing antacids• blockers of H2-receptors• antidepressants• neuroleptics• calcium channel blockers• iron- and calcium containing drugs• opiates (codeine) etc.?
Yes No
Yes No
YesNo
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The algorithm of conversation of pharmacist and customers, who complains on constipation
YesNoIs constipation bothering
you constantly (chronic constipation)?
Intake of these drugs can cause a "medical" constipation. You need to see your doctor
No Yes
You need to see your doctor.You should follow recommendation to change your lifestyle and diet.You can intake a laxatives.
You can intake any laxatives
If after 3 days of self-treatment the constipation will not disappear or reduce you need to seek
immediate medical care!
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The algorithm of conversation of pharmacist and customers, who complains on constipation
The success of the treatment of chronic constipation depends on :
– the completeness of identification of causes of defecation delay and its elimination
– the patient's willingness to change lifestyle, eating habits, to follow recommendations of the physician or pharmacist (compliance)
– qualification of a doctor and pharmacist
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Pharmaceutical care when treating constipation
It is recommended to increase physical activity
It is recommended to change the diet (intake food, which is rich with fiber - fruits, vegetables, whole-grain bread, bran, cereals, dairy milk products)
The adequate water regime – at least 1.5-2 liters per day – is recommended (in case of absence of arterial hypertension, chronic heart failure, chronic renal failure)
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Pharmaceutical care when treating constipation
The anthraglycoside-containing laxatives act in 8-12 hours
The effect of osmotic laxatives develops in 2-4 hours
The laxative effect of castor, paraffin oil appears in 5-6 hours
The use of sodium picosulphate in newborns, babies is ineffective
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Pharmaceutical care when treating constipation
During the application of bulk laxatives the patient should consume at least 1.5-2 liters of fluid a day
During long-term use of paraffin oil the malabsorption of vitamins A and D decreases and the risk of formation of malignant tumors of the gastrointestinal tract increases
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Control question
The constipation is common for: Acute gastritis Chronic atrophic gastritis (type A) Chronic non-atrophic gastritis (type B) Enterocolitis All mentioned
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Control question
What laxative is ineffective in newborn?
Lactulose Sodium picosulfate Castor oil Paraffin oil Plantex
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Control question
What laxative is contraindicated in pregnancy?
Lactolose Macrogol Glycerol suppositories Senna All mentioned