BNF - Chapter 1 - GI System Flashcards
What is clostridium difficle infection?
This infection is caused by accumulation of clostridium difficile in the colon and the production of toxin.
Which antibiotics can cause/ induce C.difficile?
- Ampicillin
- Amoxicillin
- Co-amoxiclav
- cephalosporins
- Clindamycin
- Quinolones
Which drugs can be used to treat C.difficle?
- Vancomycin
- Metronidazole
- Fidaxomicin
What is the first line treatment for first episode mild, moderate or severe C.difficile infection as per NICE?
Vancomycin
125mg orally four times a day for 10 days
What is the second line treatment for a first episode mild moderate or severe c.difficile infection if vancomycin is ineffective?
Fidaxomicin
200mg orally twice a day for 10 days
What is the next step is first and second line treatment for C.difficile are ineffective?
Seek specialist advice. Specialists may initially offer:
Vancomycin:
Up to 500 mg orally four times a day for 10 days
With or without
Metronidazole:
500 mg intravenously three times a day for 10 days
Which drug would be used for a further episode of C.difficile infection within 12 weeks of symptom resolution?
Fidaxomicin:
200 mg orally twice a day for 10 days
Which drug would you use for a further episode of C.difficile infection more than 12 weeks after symptom resolution?
Vancomycin:
125 mg orally four times a day for 10 days
Or
Fidaxomicin:
200 mg orally twice a day for 10 days
Which drugs would be sued for life-threatening C.difficile?
Seek urgent specialist advice, which may include surgery. Antibiotics that specialists may initially offer are:
Vancomycin:
500 mg orally four times a day for 10 days
With
Metronidazole:
500 mg intravenously three times a day for 10 days
Can you provide antibiotics to prevent C.difficile infection?
No not for prevention
What is Coeliac disease?
This is an autoimmune condition associated with chronic inflammation of the small intestine.
- Gluten (dietary protein) present in wheat, barley and rye activates an abnormal immune response in the intestinal mucosa. This results in malabsorption of nutrients.
Coeliac disease is a condition where your immune system attacks your own tissues when you eat gluten. This damages your gut (small intestine) so you are unable to take in nutrients
what are the symptoms of coeliac disease?
diarrhoea, which may smell particularly unpleasant stomach aches bloating and farting (flatulence) indigestion constipation
Coeliac disease can also cause more general symptoms, including:
tiredness (fatigue) as a result of not getting enough nutrients from food (malnutrition)
unintentional weight loss
an itchy rash (dermatitis herpetiformis)
problems getting pregnant (infertility)
nerve damage (peripheral neuropathy)
disorders that affect co-ordination, balance and speech (ataxia)
As coeliac disease means there is an increased risk of malabsorption of key-nutrients e.g. calcium +vitamin D what should be monitored?
Risk of osteoporosis needs to be monitored.
Advise patients not to self-medicate with OTC vitamins or mineral supplements
Give two examples of Inflammatory bowel disease?
Chronic Inflammatory bowel diseases include Crohn’s disease (affecting any part of the G.I. tract) and Ulcerative colitis (limited to the colon).
For Chron’s disease what non-drug treatment advice can be given?
- Smoking cessation
What is the treatment steps for Chron’s disease and Ulcerative Colitis?
1st line = Aminosalicylates - sulfasalazine and mesalazine
2nd line = Azathioprine or Mercaptopurine
3rd line = Monoclonal antibodies (Adalimumab/ Infliximab)
With aminosalicylates - what change of urine colour can occur?
- orange/yellow staining of body fluids e.g. urine can also occur
Patient’s who are taking aminosalicylates should report which symptoms?
• Patients should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise during treatment which could indicate a blood disorder.
Is it safe to wear contact lenses while on aminosalicylate treatment?
• People taking Aminosalicylate’s should refrain from wearing their contact lenses as they can cause staining.
Are some mesalazine preparations more effective than others?
- No oral preparation of mesalazine is more effective than the other, however the delivery characteristics of oral mesalazine preparations may vary
If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report what?
Report any changes in symptoms
Sulfasalazine may discolour the urine to which colour?
may turn skin or urine to orange or yellow
Before initiating monoclonal antibodies for 3rd line treatment of IBD what must the patient be screened for?
Must be screened for tuberculosis prior to starting treatment.
If latent TB is diagnosed what must be done?
appropriate treatment must be initiated prior to starting treatment.
What if tuberculosis is diagnosed during IBD treatment with monoclonal antibodies?
- If tuberculosis is diagnosed during treatment, discontinue until infection resolved.
What’s a common adverse effect of monoclonal antibodies ?
A flu-like infusion reaction which can be prevented or lessened by pre-treatment of an antihistamine and paracetamol with or without corticosteroid
Is contraception required during monoclonal antibodies treatment?
Effective contraception is required during and for at least 18 weeks after treatment.
Can you breastfeed while on monoclonal antibody treatment?
No
When on monoclonal antibody treatment for IBD what must be closely monitored?
Monitor closely for infection before, during and after treatment increased risk of opportunistic infections.
What is the aims of treatments for Coeliac disease?
To eliminate symptoms (such as diarrhoea, bloating and abdominal pain).
What is the only effective treatment for coeliac disease?
A strict diet - life long gluten free diet.
A range of gluten free products is available for prescription.
What is Diverticulosis?
It is an asymptomatic condition characterised by the presence of diverticula (small pouches protruding from the walls of the large intestine).
Diverticulosis is a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon.
What is the prevalence of diverticulosis and which age does it tend to affect?
The prevalence is difficult to determine but it is age dependent, with majority of patients aged 40 years and over?
What is Diverticular disease?
It is a condition where diverticular are present with symptoms such as abdominal tenderness and/or mild, intermittent lower abdominal pain with constipation, diarrhoea, or occasional large rectal bleeds.
Symptoms of diverticular disease may overlap with which other conditions?
Conditions such as irritable bowel syndrome, colitis (bowel inflammation related to Chron’s disease, Ulcerative Colitis, ischaemia or microscopic colitis), and malignancy.
When does acute diverticulitis?
Acute diverticulitis occurs when diverticula suddenly become inflamed or infected.
What are the signs and symptoms of acute diverticulitis?
- constant lower abdominal pain (usually severe) together with features such as fever, a sudden change in bowel habits and significant rectal bleeding,
- lower abdominal tenderness, or a palpable abdominal mass.
What does complicated acute diverticulitis refer to?
refers to diverticulitis associated with complications such as abscess, bowel perforation and peritonitis, fistula, intestinal obstruction, haemorrhage, or sepsis.
What is the aims of treatment of diverticular disease?
Treatment aims to relieve symptoms of diverticular disease, improve quality of life, manage episodes of acute diverticulitis, and reduce the risk of recurrence and complications.
What advice can be given to patients for non-drug management of diverticular disease?
Patients with diverticulosis or diverticular disease should be advised to eat a healthy, balanced diet including whole grains, fruit and vegetables. In patients with constipation and on a low fibre diet, a gradual increase of dietary fibre may minimise flatulence and bloating. Patients increasing dietary fibre should be advised to drink an adequate amount of fluid, especially if dehydration is a risk. Advice should also be given about the benefits of exercise, weight loss (if overweight or obese), and Smoking cessation, in reducing the risk of symptomatic disease and acute diverticulitis.
What should patients with diverticular disease be informed on regarding fibre?
Patients with diverticular disease should also be informed that it may take several weeks for the benefits of increasing fibre in their diet to be achieved and that if a high-fibre diet is tolerated, it should be continued for life.
Are there any drug treatment for diverticulosis?
No as diverticulosis is an asymptomatic condition, specific treatments are not recommended.
- bulk-forming laxatives can be considered for patients with constipation.
For diverticular disease, are antibacterial recommended?
not recommended
Which laxative can be considered for people with diverticular disease for patients which high-fibre diet is unsuitable or have persistent constipation?
A bulk-forming laxative
For diverticular disease, what drugs should be considered for abdominal pain/ abdominal cramps?
Consider the use of simple analgesia such as paracetamol in patients with ongoing abdominal pain, and antispasmodics in those with abdominal cramps.
Can NSAIDs or opioids be used safely in diverticular disease?
Non-steroidal anti-inflammatory drugs and opioid analgesics are not recommended as their use may increase the risk of diverticular perforation.
What is the treatment for acute diverticulitis?
- Offer simple analgesia such as paracetamol to patients with acute diverticulitis who are systemically well. Consider a watchful waiting and a no antibacterial prescribing strategy, and advise patients to re-present if symptoms persist or worsen.
- Patients with persistent or worsening symptoms should be reassessed in primary care and considered for referral to hospital for further assessment.
Can aminosalicylates or prophylactic antibacterials be used to prevent recurrent acute diverticulitis?
Treatment with aminosalicylates or prophylactic antibacterials are not recommended to prevent recurrent acute diverticulitis.
What part of the body does Chron’s disease affect?
can affect the whole of the GI tract
Which part of the body dose Ulcerative colitis affect?
Mainly the colon
What is sulfasalazine (aminosalicylate) a combination of?
Combination of 5-aminosalicylic acid (5-ASA) and sulfapyridine. Sulfapyridine acts only as a carrier to the colonic site of action but still causes side-effects.
What are the newer aminosalicylates?
- Mesalazine (5-aminosalicylic acid)
- Balsalazide sodium (a pro-drug of 5 aminosalicylic acid)
- osalazine sodium (a dimer of 6-aminosalicylic acid which cleaves in the lower bowel)
The sulfonamide-related side effects of sulfalazine are avoided, but 5-aminosalicylic acid alone can still cause side-effects including blood disorders and lupus-like syndrome also seen with sulfasalazine.
What is lupus-like syndrome?
Drug-induced lupus (DIL) is a disorder with clinical, histological, and immunological features similar to idiopathic systemic lupus erythematosus, but that occurs when certain drugs are taken and resolved after discontinuation of the offending agent.
What are the symptoms of lupus-like syndrome?
muscle and joint pain sometimes with swelling
flu-like symptoms of fatigue and fever
serositis (inflammation around the lungs or heart that causes pain or discomfort)
certain laboratory test abnormalities
While the symptoms of drug-induced lupus are similar to those of systemic lupus, only rarely will any major organs be affected.
What is Chron’s disease characterised by?
By thickened areas of the gastro-intestinal wall with inflammation extending through all layers, deep ulceration and fissuring of the mucosa, and the presence of granulomas.
What are some of the complications of Crohn’s disease?
include intestinal strictures, abscesses in the wall of the intestine or adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in children.
What extra-intestinal manifestation can Chron’s disease be associated with?
the most common are arthritis and abnormalities of the joints, eyes, liver and skin.
Chron’s disease is also a cause of secondary ……….?
Crohn’s disease is also a cause of secondary osteoporosis and those at greatest risk should be monitored for osteopenia and assessed for the risk of fractures.
What is fistulating Crohn’s disease?
Fistulating Crohn’s disease is a complication that involves the formation of a fistula between the intestine and adjacent structures, such as perianal skin, bladder, and vagina. It occurs in about one quarter of patients, mostly when the disease involves the ileocolonic area.
What is the aims of Chron’s disease treatment?
Treatment is largely directed at the induction and maintenance of remission and the relief of symptoms.
The aims of drug treatment are to reduce symptoms and maintain or improve quality of life, while minimising toxicity related to drugs over both the short and long term
What about in fistulating Crohn’s disease? what are the aims of treatment?
In fistulating Crohn’s disease, surgery and medical treatment aim to close and maintain closure of the fistula.
What are non-drug treatment options for Crohn’s disease?
management options for Crohn’s disease include Smoking cessation and attention to nutrition, which plays an important role in supportive care.
What is the treatment for acute disease of Crohn’s disease?
Monotherapy
- A corticosteroid (either prednisolone or methylprednisolone or intravenous hydrocortisone), is used to induce remission in patients with a first presentation or a single inflammatory exacerbation of Crohn’s disease in a 12-month period.
In patients with distal ileal, ileocaecal or right-sided colonic disease in which cotricosteroid is unsuitable or contraindicated, what drug may be considered?
Budesonide
Is budesonide more or less effective than other corticosteroids?
Budesonide is less effective but may cause fewer side-effects than other corticosteroids, as systemic exposure is limited.
- Also aminosalicylates such as sulfasalazine and mesalazine are an alternative option in these patients. They are less effective than a corticosteroid or budesonide, but may be preferred because they have fewer side-effects.
Can budesonide and aminosalicylates be used for severe presentations or exacerbations of Crohn’s disease?
Aminosalicylates and budesonide are not appropriate for severe presentations or exacerbations.
When is add on treatment prescribed?
If there are two or more inflammatory exacerbations in a 12-month period, or the corticosteroid dose cannot be reduced.
Which drugs can be used as add on to induce remission?
Azathioprine or mercaptopurine [unlicensed indications] can be added to a corticosteroid or budesonide to induce remission.
When can methotrexate be used as an add on therapy for the inducing remission of Crohn’s disease?
In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, methotrexate can be added to a corticosteroid.
Under severe supervision, what treatment options are there for severe active Crohn’s disease?
Under specialist supervision, the tumour necrosis factor-alpha inhibitors adalimumab and infliximab are options for the treatment of severe, active Crohn’s disease, following inadequate response to conventional therapies or in those who are intolerant of or have contra-indications to conventional therapy.
When are vedolizumab and ustekinumab indicated?
Vedolizumab is recommended for moderate to severely active Crohn’s disease when therapy with adalimumab or infliximab is unsuccessful, is contra-indicated or not tolerated. Ustekinumab is recommended for moderate to severely active Crohn’s disease when conventional therapy or therapy with adalimumab or infliximab is unsuccessful, is contra-indicated or not tolerated.
Can Adalimumab and infliximab be used as monotherapy or only as combined with an immunosuppressant?
Adalimumab and infliximab can be used as monotherapy or combined with an immunosuppressant although there is uncertainty about the comparative effectiveness and long-term side-effects of therapy.
What is the treatment for maintenance of remission of Crohn’s?
Patients who choose not to receive maintenance treatment during remission should be made aware of the symptoms that may suggest a relapse (most frequently unintended weight loss, abdominal pain, diarrhoea and general ill-health). For those who choose not to receive maintenance treatment during remission, a suitable follow up plan should be agreed upon and information provided on how to access healthcare if a relapse should occur.
Which drugs can be used for maintenance of remission of Crohn’s
- Offer azathioprine or mercaptopurine as monotherapy to maintain remission when previously used with a conventional glucocorticosteroid or budesonide to induce remission.
- Consider methotrexate (follow BNF/BNFC cautions) to maintain remission only in people who:
needed methotrexate to induce remission or
have tried but did not tolerate azathioprine or mercaptopurine for maintenance or
have contraindications to azathioprine or mercaptopurine (for example, deficient thiopurine methyltransferase [TPMT] activity or previous episodes of pancreatitis).
Which drugs should not be offered to maintain remission of Crohn’s?
Do not offer a conventional glucocorticosteroid or budesonide to maintain remission.
Which drugs are used to maintain remission following surgery?
Azathioprine in combination with up to 3 months’ postoperative metronidazole [unlicensed indication] should be considered to maintain remission in patients with ileocolonic Crohn’s disease who have had complete macroscopic resection within the previous 3 months. Azathioprine alone should be considered for patients who cannot tolerate metronidazole.
Which drug is licensed for the relief of diarrhoea associated with Crohn’s disease?
Cholestyramine
What is the treatment for fistulating Chron’s disease?
When Fistulae are symptomatic. local drainage and surgery may be required in conjunction with medical therapy.
What is Ulcerative Colitis?
It is a chronic inflammatory condition, characterised by diffuse mucosal inflammation - it has a relapsing-remitting pattern.
Is ulcerative colitis a life long disease?
Yes that is associated with significant morbidity
Which ages is ulcerative colitis most common?
15 and 25 years of age although diagnosis can be made at any age.
What is meant by proctitis?
Inflammation of the rectum is referred to as proctitis.
What is meant by proctosigmoiditis?
Inflammation of the rectum and sigmoid colon as proctosigmoiditis.
What does left-sided colitis refer to?
Refers to disease involving the colon distal to the splenic flexure.
What does Extensive colitis affect?
Affects the colon proximal to the splenic flexure, and includes pan-colitis, where the whole colon is involved.
What are the common symptoms of active UC or relapse?
- bloody diarrhoea
- diarrhoea
- an urgent need to defaecate
- Abdominal pain
What are some of the complications of UC?
- Increased risk of colorectal cancer
- Secondary osteoporosis
- Venous thromboembolism
- Toxic Megacolon
Which measurement is used to classify the severity of UC?
Classed as mild, moderate or severe using the Truelove and Witts’ Severity Index.
Whats does the Truelove and Witts’ severity index take into account?
- bowel movements
- heart rate
- erythrocyte
- sedimentation rate and the presence of pyrexia
- melaena
- anaemia
When choosing the route of administration for aminosalicylates and corticosteroids what should be considered?
- The extend of disease should be considered when choosing the route of administration; whether oral treatment, topical treatment or both are to be used.
If the inflammation is distal which preparation is adeuqate?
A rectal preparation is adequate
If the inflammation is extended then what route is required?
Systemic medication is required.
Either suppositories or enemas can be offered, taking into account the patient’s preference.
When patients find it difficult to retain liquid enemas what can be used instead?
- Rectal foam preparations and suppositories can be used instead.
What is contraindicated in treatment of acute ulcerative colitis?
Anti-diarrhoeal drugs (such as loperamide or codeine) are contraindicated in acute ulcerative colitis as they can increase the risk of toxic megacolon.
What may be useful for proximal faecal loading in proctitis?
- A macrogol-containing osmotic laxative (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride).
Are oral aminosalicylates for treatment of ulcerative colitis available in different preparations?
- yes available in different preparations and release forms.
When Aminosalicylates are used to maintain remission, is single daily doses or multiple daily dosing preferred?
single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.
What is the usual duration of corticosteroid course?
Usually 4 to 8 weeks - depends on the corticosteroid chosen
What is recommended first-line for patients with mild-moderate initial presentation of inflammatory exacerbation of proctitis?
- A topical aminosalicylate
- If remission is not achieved within 4 weeks, adding an oral aminosalicylate should be considered.
- If response remains inadequate, consider addition of a topical or an oral corticosteroid for 4 to 8 weeks.
For treatment of proctitis in UC - if aminosalicylates are not suitable what should be considered?
A topical or an oral corticosteroid for 4 to 8 weeks should be considered.
For Proctosigmoditis and left-sided ulcerative colitis, what are the treatment steps?
1) A topical aminosalicylate is first line.
2) If remission is not achieved within 4 weeks, consider adding a high-dose oral aminosalicylate, or switching to a high-dose oral aminosalicylate and 4 to 8 weeks of a topical corticosteroid.
What are the treatment steps for extensive ulcerative colitis?
1) A topical aminosalicylate and a high dose oral aminosalicylate are recommended first line
2) If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
Can biologics be used for treatment of UC?
Yes as third line
Is acute severe ulcerative colitis of any extent?
Acute severe ulcerative colitis of any extent can be life threatening and is regarded as a medical emergency. Immediate hospital admission is required for treatment.
What is the treatment for acute severe ulcerative colitis?
Intravenous corticosteroids (such as hydrocortisone or methylprednisolone) should be given to induce remission in patients with acute severe ulcerative colitis.
What if intravenous corticosteroids are contra-indicate, declined or cannot be tolerated?
1) Then intravenous ciclosporin or surgery should be considered.
2) A combination of intravenous ciclosporin with intravenous corticosteroids, or surgery is second line therapy for patients who have little or no improvement within 72 hours of starting intravenous corticosteroids or whose symptoms worsen despite treatment.
What if ciclosporin is contraindicated or clinically inappropriate?
Infliximab can be used to treat acute exacerbations of severely active ulcerative colitis if ciclosporin is contra-indicated or clinically inappropriate.
What if patients who experience an initial response to steroids followed y deterioration?
In patients who experience an initial response to steroids followed by deterioration, stool cultures should be taken to exclude the presence of pathogens; cytomegalovirus activation should be considered.
To maintain remission in UC what is recommended and what should not be used?
To reduce the chances of relapse occurring, maintenance therapy with an aminosalicylate is recommended in most patients.
Corticosteroids are not suitable for maintenance treatment because of their side-effects.
A low dose of oral aminosalicylate is given to maintain remission in patients after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis.
If there has been two or more inflammatory exacerbations in a 12 month period that required treatment with systemic corticosteroids, or if remission is not maintained by aminosalicylates, or following a single acute severe episode, what medications can be considered?
- Oral azathioprine
- mercaptopurine
Can methotrexate be used in UC?
There is no evidence to support the use of methotrexate to induce or maintain remission in ulcerative colitis, though its use is common in clinical practice.
Summarise the three treatment steps for Crohn’s and ulcerative disease?
- 1st Line: Aminosalicylate’s – Sulfasalazine, Mesalazine
- 2nd Line: Azathioprine or Mercaptopurine
- 3rd Line: Monoclonal antibodies (Adalimumab/Infliximab)
What colour can body fluids be stained by amniosalicylates?
- Orange/yellow
When taking aminosalicylates - patient should be advised to report any of which symptoms?
- Any unexplained bleeding, bruising, purpura, sore throat, fever or malaise should be advised to report these as it could indicate a blood disorder.
People taking aminosalicylates should refraining from wearing what?
- Should refrain from wearing their contact lenses as they can cause staining.
What are the side effects of aminosalicylates?
Common or very common - arthralgia, cough, diarrhoea, dizziness, fever GI discomfort, nausea, skin reactions, vomiting
- Uncommon = Alopecia, depression, dyspnoea, myalgia, thrompocytopenia
- Rare or very rare = agranulocytosis, bone marrow disorders, neutropenia,
For those on aminosalicylate treatment, what should be done if there is a suspicion of a blood dyscrasia?
A blood count should be performed and the drug stopped immediately if there is a suspicion of a blood dyscrasia.
What monitoring requirements are there for aminosalicylates?
- Rena function should be monitored before starting on oral aminosalicylate, at 3 months of treatment and then annually during treatment.
Give some examples of aminosalicylates?
- Balsalazide sodium
- Mesalazine
- Osalazine sodium
- Sulfasalazine
What are the expert advice for a possible way of administration instructions for osalazine sodium?
Expert sources advise capsules can be opened and contents sprinkled on food.
Sulfasalazine is often confused with which drug?
- Sulfadiazine so care must be taken to ensure the correct drug is prescribed and dispensed.
What is the mechanism of action of Vedolizumab?
Vedolizumab is a monoclonal antibody that binds specifically to the alpha4,beta7 integrin, which is expressed on gut homing T helper lymphocytes and causes a reduction in gastrointestinal inflammation.
What is the description of irritable bowel syndrome?
IBS is a common chronic, relapsing, and often life-long condition, mainly affecting people aged between 20 and 30 years.
Is IBS more common in men or women?
In women
What are some of the symptoms of IBS?
- Abdominal pain or discomfort
- Disordered defaecation (either diarrhoea or constipation with straining, Urgency and incomplete evacuation)
- passage of mucus
- bloating
Symptoms are usually relieved by defaecation
What is the aim of treatment if IBS?
focused on symptom control, in order to improve quality of life.
What are some dietary and lifestyle advice that can help with IBS?
- encourage to increase physical activity
- eat regularly, without missing meals or leaving long gaps between meals
What should dietary advice on IBS also include?
- limiting fresh fruit consumption to no more than 3 portions per day
- The fibre intake of patients with IBS should be reviewed.
If a high fibre diet is needed for someone with IBS what advice regarding type of fibre should be given?
- Soluble fibre such as ispaghula husk, or foods high in soluble fibre such as oats, are recommended.
Intake of insoluble fibre (e.g. bran) and ‘resistant starch’ should be reduced or discouraged as they may exacerbate symptoms.
How much fluids such be recommended for someone with IBS?
Fluid intake (mostly water) should be increased to at least 8 cups each day and the intake of caffeine, alcohol and fizzy drinks reduced.
With patients with diarrhoea which sweetener should be avoided?
Sorbitol
If probiotics are used for IBS patient how long should they continue to use it while monitoring the effects?
at least 4 weeks.
Can most of IB symptoms be treated OTC?
Yes
Antispasmodic drugs can be used in addition to dietary lifestyle changes for IBS. Give some examples of antispasmodics that can be used?
- Alverine Citrate
- Mebeverine Hydrochloride
- Peppermint oil
For IBS can peppermint oil be used in pregnancy?
Yes it is not known to be harmful
For IBS a laxative can be used to treat constipation. Which laxative should not be used?
Lactulose should not be used as it may cause bloating
Patients who have not responded to laxatives from different classes and who have had constipation for atleast 12 months, can be treated with which drug?
Linaclotide
For IBS what is the first line for treatment of diarrhoea?
Loperamide hydrochloride
For patients who have not responded to antispasmodics, anti-motility drugs or laxatives for abdominal pain or discomfort associated with IBS, what drug can be used as second line?
A low dose tricyclic antidepressant such as amitriptyline
What if the patient does not respond to TCA what can be used next?
A selective serotonin reuptake inhibitor may be considered.
Who can psychological intervention be offered to?
To patients who have no relief of IBS symptoms after 12 months of drug treatment.
For Mebeverine with ispaghula husk how much water is it recommended to mic one sachet in?
approx. 150mls of cold water and drunk immediately
With peppermint oil, what advice should be given about adminstration?
Manufacturer advises capsules should not be broken or chewed because peppermint oil may irritate mouth or oesophagus.
What dispensing information about linaclotide should be known?
Capsules should be dispensed in original container (contain desiccant); discard any capsules remaining 18 weeks after opening.
What is short bowel syndrome?
Patients with a shortened bowel due to large surgical resection (with or without stoma formation) may require medical management to ensure adequate absorption of nutrients and fluid.
In people with short bowel syndrome what is also impaired?
Absorption of oral medication is also often impaired.
What is the aim of treatment of short bowel syndrome?
- The management of short bowel syndrome focuses on ensuring adequate nutrition and drug absorption, thereby reducing the risk of complications resulting from these effects.
What may patents with short bowel require?
Replacement of vitamins and mineral depending on the extent and position of the bowel resection.
Deficiencies in vitamins A,B12,D,E and K, essential fatty acids, zinc and selenium can occur.
In short bowel, what other low electrolyte imbalance is common?
Hypomagnesaemia - and it is treated with oral or intravenous magnesium supplementation.
What can administration of oral magnesium cause?
May cause diarrhoea
As diarrhoea is common in short bowel, what can be used in order to promote adequate hydration?
The use of oral rehydration salts.
For short bowel (associated diarrhoea) which drugs can be used?
Loperamide and codeine can be used as they reduce intestinal motility and thus exert antidiarrheal actions
Which is preferred, loperamide or codeine?
Loperamide hydrochloride is preferred as it is not sedative and does not cause dependence or fat malabsorption.
What if loperamide is not providing the desired response, what can be done?
High doses of loperamide hydrochloride may be required in patients with a short bowel due to disrupted enterohepatic circulation and rapid gastrointestinal transit time. If the desired response is not obtained with loperamide hydrochloride, codeine phosphate may be added to therapy.
What does the drug co-phenotrope do?
Co-phenotrope has traditionally been used alone or in combination with other medications to help decrease faecal output.
What limits the use of co-phenotrope?
Co-phenotrope crosses the blood–brain barrier and can produce central nervous system side-effects, which may limit its use; the potential for dependence and anticholinergic effects may also restrict its use.
In patients with an intact colon and less than 100cm of illeum resected, what can be used?
Colestyramine can be used to bind the unabsorbed bile salts and reduce diarrhoea.
When colestryamine is given to these patient, what is it important to monitor?
Monitor for evidence of fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies
Which antisecretory drugs can be used in short bowel syndrome?
Omeprazole is readily absorbed in the duodenum and upper small bowel, but if less than 50 cm of jejunum remains, it may need to be given intravenously.
Use of a proton pump inhibitor alone does not eliminate the need for further intervention for fluid control (such as antimotility agents, intravenous fluids, or oral rehydration salts).
Which GLP-2 is licensed for use in the management of short bowel syndrome?
Teduglutide is an analogue of endogenous human glucagon-like peptide 2 (GLP-2) which is licensed for use in the management of short bowel syndrome.
It may be considered after a period of stabilisation following surgery, during which intravenous fluids and nutritional support should have been optimised.
Is drug absorption affected by short bowel syndrome?
Many drugs are incompletely absorbed by patients with a short bowel and may need to be prescribed in much higher doses than usual (such as levothyroxine, warfarin, oral contraceptives and digoxin) or may need to be given intravenously.
What is the most important site of absorption?
the small intestine, with its large surface area and high blood flow
In short bowel syndrome what affects drug absorption more?
The larger the amount of the small intestine that has been removed, the higher the possibility that the drug absorption will be affected.
Other factors, such as gastric emptying and gastric transit time, also affect drug handling.
Can enteric-coated or modified release preparations be used with short bowel syndrome?
Enteric-coated and modified-release preparations are unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy, as there may not be sufficient release of the active ingredient.
before prescribing liquid formulations, what should the prescribers consider?
- the osmolarity
- excipient content
- the volume required
Which liquids can result in fluid loss?
Those that are hyperosmolar and some excipients (such as sorbitol) can result in fluid loss.
Does the calorie density of oral supplements matter?
yes this should be considered as it will influence the volume to be taken.
List some drugs that are used for bowel cleansing?
- Citric acid with magnesium (Osmotic laxative)
- Macrogol 3350 with anhydrous sodium sulfate, ascorbic acid, potassium chloride, sodium ascorbate and sodium chloride (osmotic laxative)
- ## Magnesium citrate with sodium picosulfate (stimulant laxative)
What is constipation defined as?
Constipation is defaecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defaecation.
Who is constipation more common in?
- Women
- The elderly
- During pregnancy
Which symptoms of constipation indicate need for immediate referral (RED FLAGs?)
- New onset constipation, especially in patient over 50 years of age
- accompanying symptoms such as anaemia, abdominal pain, weight loss, or overt or occult blood in the stool
What non drug treatment is advised for contipation?
- Increase dietary fibre
- Adequate fluid intake
- exercise
- diet should be balanced and contain whole grains, fruits and vegetables.
- Drink plenty of water
Why should fibre intake be increased gradually?
To minimise flatulence and bloating
How long does effects of fibre for constipation take to work?
The effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks.
What can laxative abuse lead to?
Hypokalaemia
Give few examples of bulk-forming laxatives?
- Bran, ispaghula husk (fybogel)
- Methycellulose
- Sterculia
What is the onset of action for bulk-forming laxatives?
72 hours
With bulk-forming laxative use which symptoms may be exacerbated?
- flatulence
- bloating
- cramping
When using bulk-forming laxative - what key counselling advice needs to be given?
Adequate fluid intake must be maintained to avoid intestinal obstruction.
Advise patients to not take immediately before bed.
What does methylcellulose also act as?
A faecal softener
Give examples of stimulant laxatives?
- Bisacodyl
- sodium picosulfate
- Members of the anthraquinone group (senna, co-danthramer and co-danthrusate)
How do stimulant laxatives work and what is their onset of action?
- stimulant laxatives increase intestinal motility and often cause abdominal cramps
- Very fast acting: 8-12 hours
- Bisacodyl 10-12 hours
What is a general side effect of all laxatives?
Cause abdominal pain
Can stimulant laxatives be used in intestinal obstruction?
No manufacturer advises to avoid
What is the use of co-danthramer and co-danthrusate limited to?
Limited to constipation in terminally ill patients because of potential carcinogenicity (based on animal studies) and evidence of genotoxicity.
Docusate sodium is believed to act as two types of laxatives, which ones?
- Stimulant laxative and as a faecal softener
How do Glycerol suppositories work?
Act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol
How do faecal softeners work?
Faecal softeners are claimed to act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass.
What does arachis oil do?
Enemas containing arachis oil (ground-nut oil, peanut oil) lubricate and soften impacted faeces and promote a bowel movement.
Liquid paraffin has also been used as a lubricant for the passage of stools, why does manufacturer advice it should be used with caution?
- hould be used with caution because of its adverse effects, which include anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.
What is the onset of action of faecal softeners?
Fastest onset of action - within 15 minutes
How do osmotic laxatives work?
They increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.
Is lactulose a disaccharide?
Yes it is a semi-synthetic disaccharide which is not absorbed from the GI tract.
Why is lactulose used in hepatic encephalopathy?
It produces an osmotic diarrhoea of low faecal pH, and discourages the proliferation of ammonia-producing organisms. It is therefore useful in the treatment of hepatic encephalopathy.
Give examples of osmotic laxatives?
Lactulose and macrogol
What are macrogols?
Macrogols (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) are inert polymers of ethylene glycol which sequester fluid in the bowel; giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives.
What is linaclotide licensed for?
Linaclotide is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate to severe irritable bowel syndrome associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain.
What is prucalopride and what is it licensed for?
Prucalopride is a selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
What is in macrogol 3350?
- potassium chloride
- sodium bicarbonate
- sodium chloride
When are bowel cleansing preparations used?
- Before colonic surgery
- colonoscopy
- before radiological examination to ensure the bowel is free of solid contents
Are bowel cleansing treatments also treatments for constipation?
No
What is the management steps of short term constipation?
1st line = bulk forming laxative (ensuring adequate fluid intake)
2nd line = If stools remain hard, add to or switch to an osmotic laxative
3rd = If stools are soft but difficult to pass or patient complains of inadequate emptying, a stimulant laxative should be added.
For opioid-induced constipation, what type of laxative is recommended?
Osmotic laxative (e.g. lactulose) or docusate sodium to soften the stool and a stimulant laxative is recommended
Which laxatives should be avoided in opioid-induced constipation?
- Avoid bulk-forming laxatives
When can naloxegol be used in opioid-induced constipation?
- when response to other laxatives is inadequate
When can methylnaltrexone be used?
Methylnaltrexone bromide is licensed for the treatment of opioid-induced constipation when response to other laxatives is inadequate. Manufacturer advises that in patients receiving palliative care, methylnaltrexone bromide should be used as an adjunct to existing laxative therapy.
What does the treatment of faecal impaction depend on?
- depends on the stool consistency
For faecal impaction, in patients with hard stools what can be considered?
A high dose of an oral macrogol may be considered.
What about those with soft stools, or with hard stools after a few days treatment with macrogol?
An oral stimulant laxative should be started or added to the previous treatment
What if response to oral laxatives is still inadequate?
- For soft stools consider rectal administration of bisacodyl
- For hard stools rectal administration of glycerol alone or glycerol plus bisacodyl
Alternatively, a docusate sodium or sodium citrate enema may be tried.
For faecal impaction if there is still insufficient response to previous treatments what can be used?
For hard faeces it can be helpful to give the arachis oil enema overnight before giving a sodium acid phosphate with sodium phosphate or sodium citrate enema the following day. Enemas may need to be repeated several times to clear hard impacted faeces.
What is the management steps of chronic constipation?
1) bulk-forming laxative should be started ensuring good hydration
2) if stools remain hard, add or change to an osmotic laxative such as macrogol
Lactulose is an alternative if macrogols are not effective or not tolerated.
3) If response is inadequate, a stimulant laxative can be added.
