phillips pt case pres chronic diarrhea
TRANSCRIPT
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CHRONIC DIARRHEA: WORKING WITH OLDER PATIENTS TO MEET PATIENT SPECIFIC NEEDS
Presented By: Cory Phillips
March 24, 2011
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CASE SUMMARY
JS is an 82 yo WF whose husband presented to the compounding pharmacy looking for paregoric. JS had chronic, severe diarrhea and possibly IBS. The patient had used paregoric in the past, but was unable to find it because the manufacturers stopped supplying the medication. The husband stated that “She had tried everything!” She was set on getting paregoric because she had used this medication for years and it had worked well for her. In her opinion this was the only medication that helped.
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PATIENT HISTORY
82 yo WF Average height Average weight NKDA KNA No nicotine, alcohol, or recreational drug use Overall good health for an 82 yo woman ROS: chronic diarrhea
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PRIMARY PROBLEM
The patient had chronic diarrhea with possible IBS.
The manufacturer of paregoric no longer supplies the drug.
The patient’s husband presented to the compounding pharmacy in hopes of being able to have paregoric compounded.
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BACKGROUND ON DISEASE STATE (IBS)
Chronic, episodic GI disorder Affects gut motility Characterized by
Abdominal pain Discomfort Defecation disturbances Bloating
~ 10-15% of adult population has symptoms consistent with IBS
Prevalence of IBS 2x higher in females than males
Symptoms present by age 35
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BACKGROUND ON DISEASE STATE (IBS)
Causes unknown Alteration in
Intestinal motility Visceral
hypersensitivity Brain response to
visceral stimuli May follow bacterial
gastroenteritis in 7-30% of cases
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PA
REG
OR
IC
•Paregoric, or camphorated opium tincture, is a schedule C-III controlled substance
•When compounded it becomes a C-II substance
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HISTORY OF PAREGORIC Camphorated opium
tincture or tincture of paregoric
Oral alcoholic solution containing morphine
Opium obtained from Papaver somniferum Linne or album De Candolle
Contains several alkaloids not less than 9.5% anhydrous morphine
Small amounts of codeine, noscapine, papaverine, and thebaine
Paregoric 25x less potent than opium tincture
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OLDER GENERATION USES One of the first agents
used for teething in babies
Use declined due to known and potential toxic effects of ingredients
Used to treat diarrhea or severe withdrawal in neonates born to women addicted to opiates
More effective and/or safer agents for the treatment of diarrhea have largely replaced paregoric
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MECHANISM OF ACTION
Activity due to opiate agonist morphine Increase smooth muscle tone
Antral portion of stomach Small intestine (especially the duodenum) Large intestine Sphincters
Decrease secretions Stomach Pancreas Biliary tract
Results in constipation and delayed digestion
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CONTRAINDICATIONS/PRECAUTIONS Sedation
Use caution when driving or operating machinery CI
Patients with diarrhea secondary to poisoning Infectious diarrhea
Use cautiously in pts with GI disease Obstruction Ulcerative colitis Pre-existing constipation
Biliary spasms Avoid in pts with severe pulmonary disease
Acute or chronic asthma COPD
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SIDE EFFECTS (CHOLINERGIC)
Bradycardia Peripheral vasodilation
Problematic in pts with cardiac disease Urinary retention Oliguria
Pregnancy Category C
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CNS depressants Mixed opiate
agonists/antagonists Opiate antagonists
Lightheadedness Dizziness Sedation N/V Constipation Ileus GI obstruction Dry mouth Blurred vision Miosis Respiratory depression/arrest Apnea Circulatory depression Coma Shock Cardiac arrest Physical dependence
following prolonged use
Drug Interactions Adverse Reactions
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COMPOUNDING OF PAREGORIC
Ingredient Amount
Morphine Sulfate USP CII (Pentahydrate)
0.05317 gm
Glycerin USP (Natural) 4.0 mL
Flavor, Anise Oil FCC 0.1 mL
Ethyl Alcohol, 190 Proof USP 47 mL
Purified Water, USP q.s. 100 mL
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OTHER OPTIONS FOR DIARRHEA
Individualized treatment
Lifestyle changes Dietary changes Cognitive-behavioral
therapies Complementary
therapies in ajunct to drug therapy
Atropine; Difenoxin Atropine;
Diphenoxylate Attapulgite Bismuth Subsalicylate Kaolin; Pectin Loperamide Loperamide;
Simethicone Opium Tincture
Nonpharmacological Pharmacological
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SUMMARY OF PRIMARY LITERATURE
No recent literature due to paregoric being an older drug
Some early 2000s studies on paregoric in neonatal withdrawal syndrome
2008 Brazilian phase I study investigated the safety of Elixir paregoric® Investigated whether administration causes any
noticable toxic effects in healthy volunteers No serious adverse reactions were reported
following administration Mild adverse effects resolved themselves
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RECOMMENDATIONS/SOLUTION
The solution was to compound the drug Compounded as a CII
prescription
The dosage given was 5—10 ml PO 1—4 times per day
Recommend the patient see her physician if problem persists Might have IBS which is
treated differently than diarrhea alone
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CONCLUSION/FOLLOW-UP
The patient is satisfied with the paregoric which is working well for her.
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APPLICATION
Pearls of Wisdom Pharmacists need to be able to work with a variety
of patients, including older patients, to meet patient specific needs.
It is important for pharmacists to have knowledge of older generation drugs and what they are indicated for.
Critical pharmacy problems can be solved when the pharmacist has a strong knowledge of the patient population and drugs associated with this population.
Pharmacy should not be limited to what drug manufacturers have to offer. We have access to a plethora of chemicals that can be compounded to fit patient specific needs.
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REFERENCES
Patient and Preceptor (Dr. Randall Allen) Gold Standard, Inc. Clinical Pharmacology
[database online]. Tampa, FL: Gold Standard, Inc.; 2011. Available at http://clinicalpharmacology-ip.com/Defalt.aspx. Accessed March 19, 2011.
Irritable Bowel Syndrome. DISEASEDEX. [database online]. Available at http://www.thomsonhc.com. New York: Thomson Reuters; 2011. Accessed March 19, 2011.
MEA de Moraes, Bezerra MM, Bezerra FAF, et al. Safety evaluation of Elixir paregorico® in healthy volunteers: a phase I study. Human & Experimental Toxicity. 2008; 27(10): 751-756.