What is the treatment for dyspepsia?
PPI up to 4 weeks
If no response to PPI - test for H. pylori
What should happen if a patient does not respond to a PPI for dyspepsia after 4 weeks?
Test for H. pylori
What is the treatment for mild GORD?
Antacids and alginates
PPI
PPIs preferred over H2 antagonists
PPI or H2 antagonist for GORD?
PPI is preferred over H2 antagonist
What is the treatment for severe GORD?
Continued PPI - lower dose once symptoms are under control
What is the treatment of GORD in pregnancy?
1) Lifestyle advice
2) Antacid
3) H2 antagonist (ranitidine)
4) Omeprazole - severe/complicated reflux disease
Name 3 types of medicine that may worsen the symptoms of GORD
Calcium channel blockers
Anti-depressants
NSAIDs
What times of day are antacids given?
After meals and at bedtime
What are the effects of aluminium-containing and magnesium-containing antacids
Magnesium - laxative
Aluminium - constipation
Antacid containing both bases can avoid this problem
What is the purpose of simeticone in antacids?
Relieve flatulence
What is the purpose of alginates in antacids?
Relieve symptoms of GORD - forms raft
How do antacids help to reduce the symptoms of GORD?
Neutralise gastric acid
Contain bases - aluminum, magnesium
What should be considered when deciding on an antacid in renal impairment?
Avoid antacids that contain magnesium or large amounts of sodium
What should be considered if a patient is using an antacid and is on other medication
Do not take antacid at the same time as other medicines
Leave 2-4 hours after taking antacid before taking other medicines
What is Maalox?
Antacid
Low sodium
Aluminium only
What do Gaviscon and Peptac contain?
Calcium carbonate (no Mg or Al)
Bicarbonate
Alginate
What does Gaviscon Advance contain?
Potassium bicarbonate
Alginate
What effect do anti-spasmodics have on the GIT?
Relax intestinal smooth muscle
Anti-muscarinics
What kind of drug are anti-spasmodics?
Anti-muscarinics
Name 2 conditions that antispasmodics are commonly used in
IBS
Diverticular disease - small bulges/sacs (diverticula) form in the wall of the colon
Name 4 examples of antispasmodics
Atropine
Hyoscine butylbromide
^^Antimuscarinics
Peppermint oil
Mebeverine
List 5 main side effects of antispasmodics
Typical of antimuscarinics: Constipation Bradycardia Urinary retention Dilated pupils Dry mouth
Name an antispasmodic that should not be used in pregnancy
Hyoscine butylbromide - Buscopan
Describe the legality surrounding the sale of Hyoscine Butylbromide (Buscopan)
POM
Can be sold for diagnosed IBS - 20mg up to QDS
Name a side effect of peppermint oil (IBS and diverticular disease)
Heartburn
Which antispasmodic can be used in pregnancy?
Peppermint oil capsules
How is H. pylori diagnosed?
Breath test or Stool sample or Blood test
Broadly, how is H. pylori eradicated?
Acid inhibition + antibacterial treatment
What must happen before H. pylori is treated?
Confirmation of H. pylori presence
Using breath test, stool sample or blood test
What is the treatment for H. pylori?
1 week triple therapy
- PPI
- Clarithromycin
- Amoxicillin / Metronidazole
If severe ulceration - continue PPI/H2 antagonist for another 3 weeks
What does H. pylori cause?
Duodenal and gastric ulcers
Most of these ulcers are caused by H. pylori, if not by NSAIDs
For H. pylori - why is 1 week triple therapy preferred over a 2 week regimen?
Increased eradication rates
BUT
Adverse effects are common
Compliance rates are lower
So not worth the extra week
What are the 2 main causes of gastric or duodenal ulcers?
H. pylori
NSAIDs
4 risk factors for NSAID-associated ulcers
1) Age - over 65
2) History of ulceration
3) Serious co-morbidity - CVD, diabetes, renal/hepatic impairment
4) Taking drug that increases risk of GI side effects
What should be done with the NSAID if it causes an ulcer?
Discontinue the NSAID
What can be used to prevent NSAID-associated ulcers?
PPI for non-selective NSAIDs
Name 2 non-selective NSAIDs
Diclofenac
Naproxen
Name a group of selective NSAIDs (COX-2 selective)
The -Coxibs
What should be changed with meds if an NSAID-ulcer occurs and the NSAID cannot be stopped?
PPI
Switch to COX-2 selective inhibitor
Misoprostol good in elderly
List 2 side effects of misoprostol
NSAID-associated ulcer
Colic
Diarrhoea (severe)
What effect do H2 receptor antagonists have?
They reduce gastric acid secretion through H2 receptor blockade
To treat ulcers and relieve symptoms of GORD
2 main indications for H2 antagonists
Ulcers
GORD
Name 2 H2 receptor antagonists
Ranitidine
Cimetidine
3 side effect of H2 antagonists
Diarrhoea
Headache
Dizziness
What is important to consider regarding Cimetidine?
It is an enzyme inhibitor Increases plasma concentration of: - Carbamazepine - Warfarin - Phenytoin - Sodium valproate - Theophylline
What drugs does cimetidine affect?
Enzyme inhibitor - Carbamazepine Warfarin Phenytoin Sodium valproate Theophylline
Which H2 antagonist has the least interactions?
Ranitidine
Cimetidine has more interactions
What misoprostol?
Prostaglandin analogue
Anti-secretory and protective properties
Can prevent NSAID ulcers
Used in elderly patients who rely on NSAID continuing after ulcer formation
What is misoprostol used for?
Prevention of NSAID ulcers
Elderly patients - when NSAID cannot be stopped after ulcer formation
Consideration for misoprostol in women?
Should not be used in women of child-bearing age unless pregnancy ruled out
Potent uterine stimulant
Teratogenic
Can be sued for abortions and to induce labour
How do PPIs work?
Block hydrogen-potassium proton pump
List 8 groups of patient which are at an increased risk of osteoporosis
Family history
Underweight
Alcoholics
Corticosteroids - long term
Post-menopausal women
Rheumatoid arthritis
Crohn’s
Hyperthyroidism
How can those at risk of developing osteoporosis reduce their chances?
Maintain adequate intake of calcium + vitamin D
Adcal D3
What extra precautions should be taken if at risk of osteoporosis and on PPI
Maintain adequate intake of calcium + vitamin D
Adcal D3
Name 2 electrolytes which should be watched if on PPI
Magnesium
Sodium
PPIs can cause hypomagnaesia & hyponatraemia
Which electrolyte should be monitored if patient is on PPI + digoxin?
Magnesium
= Hypomagnaesia
Which electrolyte can digoxin affect?
Magnesium
Hypomagnaesia
Especially if on other drugs which affect Mg - e.g. PPI
List 6 side effects of PPIs
Nausea Vomiting Abdominal pain Flatulence Diarrhoea or constipation Headache
Name an adverse effect of using a PPI
Rebound acid hypersecretion
Which 2 PPIs should not be used in pregnancy or breastfeeding?
Lansoprazole + Pantoprazole
Should not be used in PG/BF
Which PPI can be used in pregnancy and breastfeeding?
Omeprazole
Can be used in PG + BF
When should PPIs be taken?
PPIs should be taken 30-60 minutes before food
What is the primary concern in acute diarrhoea?
Electrolyte depletion
Which group is anti motility drugs not recommended in for acute diarrhoea?
Young children
Should not be given anti-motility drugs
What are most cases of diarrhoea due to?
Viruses
Does not need antibiotics
Name the drug used for diarrhoea following ileal disease (Crohn’s) or resection
Colestyramine
What is colestyramine used for?
Diarrhoea following ideal disease (Crohn’s) or resection
What should be considered if patient taking colestyramine and other medicines?
Take other medicines an hour before or 4-6 hours after colestyramine
How do anti motility drugs work?
Anti-motility drugs work by:
Binding to the opioid receptors in the GIT
Name 3 anti-motility drugs
Loperamide
Codeine
Morphine/kaolin
From what age can morphine/kaolin be used?
Over 12 years old
What is the minimum age for loperamide?
POM = 4 years old OTC = 12 years old
How is inflammatory bowel disease treated?
Mild - oral aminosalicylate
Moderate - oral corticosteroid (prednisolone, budesonide)
Severe - immunosuppressant (ciclosporin, azathioprine, methotrexate)
No response - infliximab
How is mild inflammatory bowel disease treated?
Oral aminosalicylate alone
sulfasalzine, mesalazine
How is moderate inflammatory bowel disease treated?
Oral corticosteroid - prednisolone, budesonide
Name 2 oral corticosteroids used in the treatment of moderate inflammatory bowel disease
Prednisolone
Budesonide
How is severe inflammatory bowel disease treated?
Immunosuppressant:
- Azathioprine
- Ciclosporin
- Methotrexate
Name 3 immunosuppressants used in the treatment of severe inflammatory bowel disease
Azathioprine
Ciclosporin
Methotrexate
How do oral aminosalicylates work?
Compounds contain 5-ASA (API)
Interferes with body’s response to inflammation
Sulfasalazine - 5-ASA bonded to sulfapyridine
Sulfapyridine delivers 5-ASA to intestine
Which 2 conditions does IBD cover?
Crohn’s
Ulcerative colitis
Why is sulfapyridine (in sulfasalazine) not an ideal compound?
Side effects of sulfapyridine:
Headache
Nausea
Rash
What are the 2 main compounds in sulfasalazine?
5-ASA (5-aminosalicylic acid)
Sulfapyridine
Why may certain aminosalicylates be preferred to others? (IBD)
1) Tolerance (sulfapyridine side effects)
2) Formulation - area of 5-ASA delivery
What different formulations of aminosalicylate are available?
Enema - left-sided disease (colon)
Suppository - rectum to sigmoid colon
Delayed release/extended release - small intestine/ileum/colon
List 8 side effects of sulfasalzine
Headache Nausea Rash Loss of appetite Vomiting Fever Decreased WBC count Decreased sperm production
Mesalazine and renal function
Caution in kidney disease/renal impairment
Monitor eGFR annually
2 indications of mesalazine
Treatment of ulcerative colitis
Maintenance of remission of ulcerative colitis
What symptoms should be reported when on aminosalicylates?
Unexplained bleeding/bruising Sore throat Fever Malaise Purpura - purple spots on skin caused by burst small blood vessels
^^ signs of blood dyscrasias
List 4 signs of possible blood dyscracias
Unexplained bruising/bleeding
Sore throat
Temperature
Malaise
What is important in the prescribing of mesalazine?
Brand-specific
Asacol
Octasa
Pentasa
What is used in IBD if patients do not respond to aminosalicylates/steroids/immunosuppressants?
Infliximab
Which drugs can be used for maintenance of remission in inflammatory bowel disease?
Aminosalicylates + immunosuppressants
Can be used to maintain remission in IBD
Which drugs should not be used to maintain remission in inflammatory bowel disease?
Corticosteroids
Aminosalicylates and immunosuppressants for maintenance of remission in IBD
What should be used for constipation in inflammatory bowel disease?
Movicol
For constipation in IBD
What should be used for diarrhoea in inflammatory bowel disease?
Colestyramine
For diarrhoea in IBD
What should be used for constipation and diarrhoea in IBD?
Movicol - constipation
Colestyramine - diarrhoea
Which drugs are used in the treatment of C. diff?
Vancomycin or metronidazole
What is a common cause of C. diff?
Antibiotic therapy:
- Fluoroquinolones
- Cephalosporins
- Penicillins
- Clindamycin
Response to diarrhoea following course of Clindamycin?
Immediate referral
Possible C. diff
Clindamycin is a common cause of C. diff
Which 4 drugs/classes are known to commonly cause C. diff?
Cephalosporins
Fluoroquinolones
Penicillins
Clindamycin
What is diverticular disease?
When small bulges/sacs (diverticula) form in the wall of the colon
What is the treatment of diverticular disease?
Ispaghula husk (Fybogel)
Antispasmodics (Buscopan)
Antibacterials - if infected
Which class of GI drug should not be used in diverticular disease?
Antimotility drugs should not be used diverticular disease:
- Loperamide
- Codeine
- Morphine/kaolin
How does irritable bowel syndrome usually present?
IBS usually presents as:
- Pain
- Constipation
- Diarrhoea
Why may antidepressants be useful in irritable bowel syndrome?
Aggravating psychological factors
Why may amitriptyline be useful in irritable bowel syndrome?
Reduce abdominal pain
Which tricyclic antidepressant may be used in irritable bowel syndrome?
Amitriptyline
Reduces abdominal pain
List 4 drugs that may be used in IBS
Fybogel (husk)
Movicol
Loperamide
Buscopan (hyoscine butylbromide)
Which laxatives are recommended for irritable bowel syndrome (IBS)?
Fybogel (ispaghula husk)
Movicol
Which anti motility drug is recommended for irritable bowel syndrome?
Loperamide
Which antispasmodic is recommended for use in irritable bowel syndrome?
Buscopan (hyoscine butylbromide)
When are laxatives most appropriate?
Drug-induced constipation
Straining issue - haemorrhoids, angina
Avoid in healthy individuals
How should constipation be treated in infants?
Prune juice
Lactulose
Movicol
Glycerol suppositories
How should constipation be treated in children?
Prune juice Lactulose Movicol Glycerol suppositories Stimulant laxative if no response (Senna, bisacodyl, sodium picosulphate)
List 6 stimulant laxatives
Senna
Bisacodyl
Sodium picosulphate
Docusate sodium (stimulant & faecal softener)
Glycerol suppositories (rectal stimulant & lubricant)
Co-danthramer - palliative use only
How do stimulant laxatives work?
Increase intestinal motility by stimulating nerves involved in peristalsis
What is a common side effect of stimulant laxatives?
Abdominal cramp
Why is co-danthramer limited to palliative care only?
Co-danthramer is:
- Carcinogenic
- Genotoxic
How do glycerol suppositories have their laxative effect?
Irritant action of glycerol
Rectal stimulant and lubricant
List 3 bulk-forming laxatives
Ispaghula husk
Methylcellulose (also faecal softener)
Bran
When are bulk-forming laxatives particularly useful
Adults with small, hard stools where fibre cannot be increased
How long is the onset of action for bulk-forming laxatives?
72 hours
3 common side effects of bulk-forming laxatives
Flatulence
Bloating
Abdominal cramp
What must be ensured to avoid intestinal obstruction with bulk-forming laxatives
Adequate fluid intake
Main counselling point of bulk-forming laxatives
Adequate fluid intake to avoid intestinal obstruction
All info on bulk-forming laxatives
- Ispaghula husk, methylcellulose, bran
- Absorbs liquid in intestine = softer stool, peristalsis
- 72 hours for onset of action
- Good for adults with small hard stools where fibre cannot be increased
- Side effects: flatulence, bloating, abdominal pain
- Adequate fluid intake must be maintained - intestinal obstruction
How do bulk-forming laxatives work?
Absorb/retain liquid in intestine
= Softer stool - easier to pass
And stimulates peristalsis
All info on stimulant laxatives
- Senna, bisacodyl, sodium picosulfate, docusate sodium, glycerol suppositories, co-danthramer
- Most common side effect = abdominal cramp
- Avoid in intestinal obstruction
- Stimulate nerves involved in peristalsis
- Co-danthramer = carcinogenic & genotoxic
How do faecal softeners work?
Reduce surface tension of faecal mass and increasing fluid penetration into it
Name 5 drugs that act as faecal softeners
Docusate sodium Glycerol suppositories Arachis oil enema (nut oil) Methylcellulose Liquid paraffin
How do archis oil enemas work?
Lubricates and softens impacted to faeces and encourages bowel movements
What kind of laxative is docusate sodium?
Stimulant and faecal softener
What kind of laxative is glycerol suppositories?
Stimulant - rectal irritant
Faecal softener
What kind of laxative is methyl cellulose?
Bulk-forming
Faecal softener
Why should liquid paraffin be used with caution as a laxative/faecal softener?
Used as a lubricant
Adverse effects - anal seepage, granulomatous disease
All info on faecal softeners
Reduce surface tension and increase fluid penetration of faecal mass
Docusate sodium, glycerol suppositories, methylcellulose, arachis oil, liquid paraffin
Arachis oil = nuts
Liquid paraffin - caution - seepage, granulomatous disease
How do osmotic laxatives work?
Increase water content of stool in the large bowel
By drawing water from body into bowel or retaining water present
Name 3 osmotic laxatives
Lactulose
Macrogols
Polyethylene glycol
Why is lactulose useful in hepatic encephalopathy?
Not absorbed from GIT
Lowers faecal pH
Discourages proliferation of ammonia-producing bacteria
Ammonia worsens HE
What is a common side effect of macrogols? (osmotic)
Dehydration
Can be reduced by giving with fluid
How can dehydration from use of macrogols be reduced?
Give with fluid
When should a bulk-forming laxative be used?
Short duration constipation
Where dietary measures are ineffective
If stools remain hard - add or switch to osmotic laxative
Ensure adequate fluid intake
Which type of laxative should be used for short-duration constipation?
Bulk-forming laxative for short-duration constipation
Where dietary measures are ineffective
If still hard stools - add or switch to osmotic laxative
Ensure adequate fluid intake
Which type of laxative for soft stool but difficult to pass?
Bulk-forming + Stimulant laxative
Which type of laxative for inadequate emptying?
Bulk-forming + Stimulant laxative
Which type of laxative in opioid-induced constipation?
Osmotic + stimulant laxative
Docusate sodium can be used in place of osmotic
For opioid induced constipation
Which type of laxative should be avoided in opioid induced constipation?
Bulk-forming laxatives
Should be avoided for opioid-induced constipation
Which laxative should be used in opioid induced constipation if no response to 1st line approach?
Naloxegol
When should naloxegol be used?
Opioid induced constipation
If no response to 1st line (osmotic/docusate + stimulant)
How should chronic constipation be treated?
1) Bulk-forming laxative
2) + or change to osmotic laxative (macrogol)
3) Lactulose - if macrogol ineffective/not tolerated
4) + stimulant
Dose adjusted to = 1-2 soft stools a day
When and how can laxatives be withdrawn in chronic constipation?
Slowly withdraw
When regular bowel movements occur without difficulty
If combination laxatives have been used - reduce and stop 1 at a time
Reduce stimulant laxative first
How should constipation in pregnancy be managed?
1) Dietary fibre, lifestyle changes
2) Fibre supplements - bran, wheat
3) Bulk-forming laxative - ispaghula
4) Lactulose
5) Senna, bisacodyl if stimulant effect necessary - but avoid near full term/history of unstable pregnancy
6) Docusate sodium, glycerol suppositories
Stimulant laxatives more effective than bulk-forming but more likely to cause side effects (diarrhoea, abdominal discomfort)
Why are bulk-forming laxatives preferred to stimulant laxatives in pregnancy?
Stimulant more effective than bulk-forming
But more likely to cause side effects - diarrhoea, abdominal discomfort
How should constipation be managed during breastfeeding?
1) Dietary measures
2) Bulk-forming laxative
3) Lactulose or macrogol (osmotic)
4) Short course stimulant laxative - Senna/bisacodyl
How should constipation in children be managed?
1) Macrogol laxative + dietary modifications/behavioural interventions
- Fibre
- Fluids
- Exercise
Unprocessed bran is not recommended - bloating, flatulence, reduced micronutrient absorption
2) Add stimulant if inadequate, change to stimulant if not tolerated
3) If stools remain hard - add lactulose or softener (docusate)
What is 1st line for constipation in children?
Macrogol laxative + dietary modification/behavioural intervention
Dietary modification alone not enough for 1st line
Why is unprocessed bran not recommended for constipation in children?
Flatulence
Bloating
Micronutrients not absorbed
How should chronic constipation be managed in children?
Continue laxatives for several weeks after regular bowel habits return
Taper dose gradually over months
Which type of laxative can be used for diarrhoea in diverticular disease?
Fybogel - bulk forming
Which electrolyte may become imbalanced by excessive use of laxatives?
Potassium
Hypokalaemia
5 red flags for constipation
Red flags for constipation:
- Over 50 years old
- Anaemia
- Abdominal pain
- Weight loss
- Blood in stool
Is lactulose suitable for diabetic patients
Yes
Even though it is a synthetic sugar - not absorbed from GIT
What is the onset of action for lactulose?
48 hours
What is the main difference between Crohn’s and Ulcerative Colitis?
UC = just colon
Crohn’s any part of GIT
Where does Crohn’s affect?
Any part of GIT
Where does UC affect?
Limited to the colon
How do symptoms differ in dyspepsia vs GORD?
Dyspepsia:
- Upper abdominal pain
- Bloating
- Nausea
GORD:
- Heartburn
- Acid regurgitation
- Ulceration
What is ursodeoxycholic acid used for?
- Dissolution of gall stones
- Primary biliary cirrhosis
What drug is used for the dissolution of gall stones?
Ursodeoxycholic acid
What is Terlipressin used for?
Oesophageal varices
Vasoconstrictor
Reduce portal hypertension
What is the BMI at above which a person is considered ‘obese’?
Over 30 kg/m2
When is Orlistat used?
Obese patient - <30 kg/m2
When diet, excercise and behaviour changes fail to reduce weight
What is the licensing of Orlistat in terms of BMI?
> 30 kg/m2
or
28 kg/m2 if also other risk factors
When should orlistat be discontinued?
Discontinue after 12 weeks if weight loss has not exceeded 5% of starting weight
Which laxative is recommended in haemorrhoids?
Bulk-forming laxatives for haemorrhoids
Osmotic as alternative
Focus on soft and easily passed stools
What should be used for haemorrhoids in pregnancy?
No licensed preparations
Consider simple soothing solution
What are the indicators of exocrine pancreatic insufficiency?
Maldigestion
Malnnutrition
Low levels of micronutrients, fat soluble vitamins & lipoproteins
Also - diarrhoea, abdominal cramps, steatorrhoea (fat in faeces)
What is the main treatment for exocrine pancreatic insufficiency?
Pancreatic enzyme replacement therapy
When are pancreatic enzymes given?
With meals and snacks
What does pancreatin contain?
Amylases
Lipases
Proteases
Assists digestion of starch, fats, proteins
What should be considered regarding choice of food when taking pancreatin?
Its enzymes are denatured by heat + gastric acid
Avoid excessive heat
Best taken with food