pharmacy practice 1 phcy 280 spring 2016/17 ... · gastrointestinal disorders- part 2 ms. beena...
TRANSCRIPT
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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