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2021 BNF > Chapter 1: Gastro-intestinal system > Flashcards

Chapter 1: Gastro-intestinal system Flashcards

1
Q

What are the monitoring and reporting requirements for Aminosalicylates

A

Monitoring: Renal function before starting, 3 months later and then annually Reporting: (All) Blood dyscrasia- sore throat, fever, rash, ulcers, bleeding Mesalazine: switching brands- advise to report any changes in symptoms

Sulfasalazine: colours body fluids orange/yellow

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2
Q

Why is liquid paraffin no longer recommended

A

Due to anal irritation and seepage of paraffin after prolonged use

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3
Q

What is Sucralfate used for and what is its caution

A

Benigh gastruc ulcers, Chronic Gastritis

Caution: BEZOAR formation- stone like mass found in GI system especially in critically ill patients in intensive care or with enteral feeds

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4
Q

What is Pancreatin and what are the appropriate counselling points

A

Creon - mixtures of enzymes used to aid digestion

  • Patients should adequate hydration at high doses
  • Capsules should be swallowed whole and not chewed
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5
Q

Which antacids can cause contipation and which can cause diarrhoea

A

Magnesium containing = laxative effects (diarrhoea)

Aluminium & Calcium containing= constipation effects

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6
Q

Which GI conditions are the following drugs used for

Hyoscine butylbromide

Alverine Citrate

Mebeverine

A

(All) Gastro-intestinal smooth muscle spasms

Hyoscine: IBS, Acute spasms

Mebeverine: IBS

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7
Q

Which electrolytes are affected by PPIs

A

Hyponatreamia

Long term use: Hypomagnesaemia (more common after 1 year but sometimes after 3 months)

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8
Q

What are some side effects of Loperamide and what is the MHRA alert

A

Flatulence, GI disorders, Nausea, Headache, Dizziness, Dry mouth

MHRA alert: Serious cardiovascular events (e.g. QT prolongation, TDP, cardiac arrest) with large overdose, naloxone can be given as an antidote

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9
Q

Name the bulk forming laxatives and some of their side effects

A

Ispahula husk, Methylcellulose and Sterculia

Flatulence, Abdominal distension (bloating), GI disorders

Take with atleast 150ml of water

Do not use for opioid induced constipation as can precipitate intestinal obstrution

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10
Q

Name the Stimulant laxatives and some of their side effects

A

Bisacodyl, Co-danthramer (palliative care only) Docusate (stool softening properties), Glycerol, Senna and sodium picosulfate

S/E: GI discomfort and Cramps

Co-danthramer and senna colours the urin red

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11
Q

Name the osmotic laxatives and some of their side effects

A

Lactulose, Macrogol, Magnesium hydroxide

S/Es: Nausea, vomitting, cramps, bloating, flatulence

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12
Q

What do the words “low Na+” on antacid preparations indicate?

A

Sodium content of less than 1mmol per tablet or 10ml dose. This is written on for people with hypertension

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13
Q

When would you advise patients to take antacids

A

Space doses out from other drugs (2 hour gap)

Alginates create a raft so should be taken after food (if taken before food, the food will penetrate the raft as they enter the stomach)

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14
Q

When should PPIs be taken?

A

At least 30 mins before food for optimal absorption

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15
Q

What drug, used for GI ulcers, should be avoided in all trimesters of pregnancy and in women of a child bearing age unless absolutely necessary?

A

Misoprostol

Used in GI for NSAID induced ulcers

Teratogenic - also used for termination of pregnancy

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16
Q

Safest PPI in pregnant women?

A

Omeprazole

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17
Q

Diarrhoea advice in a pregnant woman?

A

Avoid loperamide.

Lifestule advise best: Maintain adequate hydration

refer if present for more than 48 hours or more than 6 loose stools in 24 hours

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18
Q

Safest laxative in pregnant women?

A

If dietary and lifestyle advice fails you can use bulk forming (first line).

an osmotic (lactulose) can be used. Bisacodyl and senna should only be used if a stimulant effecct is necessary but their use near term should be avoided.

Docusate and glyercol suppositiories can be used.

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19
Q

How do you treat haemorrhoids in pregnant woman

A

No topical haemorrhoidal preparations are licensed for use during pregnancy. If required a simple, soothing product should be used.

Local anaesthetics and steroids should be avoided.

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20
Q

Which antiemetic drug can be purchased over the counter?

A

Prochlorperazine: Buccastem (for migraines)

Motion sickness

Hyoscine: Kwells (10+), Kwells Kids (4+), Joy Rides (3+), scopoderm patches (10+)

Cinnarizine: Sturgeron (5+)

Promethazine: Phenergan (2+)

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21
Q

What laxative and what anti-emetic are recommended for use in terminally ill patients?

A

Laxative: co-danthromer/ co-danthrusate (can colour urine red) It is locally irritant- avoid contact with skin

Anti-emetic: Ondansetron, Haloperidol- these are good for opioid induce N&V (Haloperidol also used first line for delirium in palliative care- this is very common)

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22
Q

Which laxative should be used where there is faecal impaction?

A

Osmotic laxatives

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23
Q

What is the MHRA saftey alert with PPIs

A

Subacute cutaneous lupus erythematosus (SCLE)

development of lesions with associated athralgia

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24
Q

When is metoclopromide contraindicated for treating sickness?

A

3 - 4 days after Gastrointestinal surgery

GI heamorrhage

GI obstruction

Under 18 years due to neurological effects

Epilepsy

Parkinsons

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25
Q

Which laxatives are used in opioid induced constipation/ immobility

A

Osmotic or Stimulant

do not use bulk forming

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26
Q

What is Colestipol?

When should other medications be taken in relation to this drug?

A

A bile acid sequestrant used to lower cholesterol (LDL specifically)

Take other medication 1 hour before or 4 hours after this medication as it can effect absorption

can affect the absorption of Vitamins A D E K and Folic acid

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27
Q

Which of the following is not a typical symptom of IBS?

A. Abdominal pain

B. Bloating

C. Constipation

D. Diarrhoa

E. Emesis (vomiting)

A

Emesis (vomiting)

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28
Q

Why can Crohns disease cause secondary osteoporosis?

A

Reduced absorption of dietary vitamins and minerals.

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29
Q

What is fistulating Crohn’s disease?

A

When there is the formation of a fistula between the intestine and adjacent structures, such as the perianal skin, bladder, and vagina. It occurs in about 1/4 patients, mostly when the disease involves the ileocolonic area.

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30
Q

What common harmful lifestyle factor can make Crohn’s worse?

A

Smoking

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31
Q

In the treatment of acute Crohn’s, what is used to induce remission in patients with a first presentation or a single inflammatory exacerbation of Crohn’s in a 12-month period?

A

A corticosteroid (either prednisolone, methylprednisolone or intravenous hydrocortisone).

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32
Q

Acute Crohns: In patients with distal ileal, ileocaecal or right-sided colonic disease, in whom a conventional corticosteroid is unsuitable or contra-indicated, what can be considered and why?

A

Budesonide can be considered, it is less effective but may cause fewer side-effects than other corticosteroids as the systemic exposure is limited.

Aminosalicylates (sulfasalazine and mesalazine) are an alternative option. But less effective.

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33
Q

When would add-on treatment be used in Acute Crohn’s?

A

If there are two or more inflammatory exacerbations in a 12-month period, or if the corticosteroid dose cannot be reduced.

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34
Q

Acute Crohn’s: What can be added to a corticosteroid or budesonide to induce remission?

A

Azathioprine or mercaptopurine can be added. Azathioprine or mercaptopurine [unlicensed indications] can be added to a corticosteroid or budesonide to induce remission. In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, methotrexate can be added to a corticosteroid.

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35
Q

Acute Crohn’s: Add-on treatment: In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, what can be added to a corticosteroid?

A

Methotrexate

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36
Q

Under specialist supervision, monoclonal antibody therapies with what are options for the treatment of severe, active Crohn’s disease, following inadequate response to conventional therapy?

A

Adalimumab, Infliximab

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37
Q

How does adalimumab work?

A

anti TNF

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38
Q

How does infliximab work?

A

Anti TNF

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39
Q

What BMI is required for treatment with orlistat

A

30 kg/m2 or more

OR

28 kg/m2 or more in the presence of other risk factors such as type 2 diabetes, hypertension or hypercholesterolaemia

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40
Q

The absorption of which vitamins is impaired during treatment with orlistat

A

A D E K

&

Folic acid

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41
Q

In the maintenance of remission in Crohn’s, which drugs used as unlicensed monotherapy can maintain remission

A

Azathioprine and mercaptopurine

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42
Q

What are the symptoms of Crohn’s relapse?

A

Weight loss, abdominal pain, diarrhoea and general ill-health.

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43
Q

Methotrexate should only be used in patients to maintain remission if what?

A

if they are intolerant of or not suitable for azathioprine or mercaptopurine treatment.

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44
Q

What drugs should not be used for the maintenance of remission in Crohn’s?

A

Corticosteroids or budenoside.

use to induce remission only

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45
Q

What drug is licensed for the relief of diarrhoea associated with Crohn’s disease?

A

Colestyramine

loperamide and codeine can also be used.

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46
Q

Are patients with coeliac disease recommended to self medicate with OTC vitamin and mineral supplements?

A

No

should be refered so their requirements can be assessed. OTC strengths may not be enough

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47
Q

What are coeliac patients at increased risk of?

A

Malabsorption

Vitamin and mineral deficiency - can increase the risk of osteoporosis

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48
Q

What is diverticular disease?

A

Diverticula (sac-like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain in the absence of inflammation or infection. Can cause large rectal bleeds

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49
Q

What is the treatment for diverticular disease

A

high fibre diet or bulking forming laxatives for constipation symptoms

Paracetamol for pain and antispasmodics

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50
Q

What is not recommended in uncomplicated diverticular disease?

A

Antibiotics unless the patient presents with signs of infection/immunocompromised

the use of NSAIDS or opioids is not recommended in uncomplicated diverticular disease

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51
Q

What is the treatment for complicated diverticular disease?

A

Hospital admission required - IV antibacterials covering gram negative and anaerobes & Bowel rest

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52
Q

True or false:

There is insufficient evidence to justify the role of fibre, rifaximin, antispasmodics, mesalazine, and probiotics in the prevention or treatment of diverticulitis.

A

TRUE

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53
Q

What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?

A

Avoids the sulfonamide-related side effects of sulfasalazine

(sulphonamides are CYP inhibitors)

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54
Q

Sulfasalazine is a combination of what two compounds?

A

5-ASA and sulfapyridine

Sulfapyridine acts only as a carrier to the colonic site of action but still causes side effects

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55
Q

What compound is mesalazine?

A

5-ASA

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56
Q

Balsalazide is a pro drug of what?

A

5-ASA

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57
Q

What are extraintestinal manifestations?

A

When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis

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58
Q

In a patient with a first presentation or single inflammatory Crohn’s exacerbation in a 12 month period, what drug is used?

If this is not suitable, or if the patient has right-sided colonic disease, what could be used? When would these not be appropriate and why?

A
  1. Corticosteroid - prednisolone, methylprednisolone or IV hydrocortisone
  2. Budesonide or aminosalicylates. Not appropriate if severe presentation as they are less effective (even though they have fewer side effects)
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59
Q

When would you add in additional treatment (on top of steroid monotherapy) in a Crohn’s disease exacerbation?

What would you add?

A

2 or more inflammatory exacerbations in 12 months, or if the steroid dose cannot be reduced

Azathioprine or mercaptopurine

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60
Q

Is mercaptopurine licensed in severe UC or CD?

A

No

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61
Q

What can be added to a steroid to induce remission in a Crohn’s patient?

If these are not suitable, what could be used?

A
  1. Azathioprine, Mercaptopurine (unlicensed)
  2. Methotrexate
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62
Q

What test do you need to do before starting someone on azathioprine or mercaptopurine?

A

TPMT levels. If activity is deficient, it may not be suitable

FBC weekly for 4 week, then every 3 months

Patients should be advised to monitor for signs of bone marrow suppresion

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63
Q

What monoclonal antibodies are licensed for Crohn’s?

A

Adalimumab

Infliximab - can also be used for active fistulating CD

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64
Q

Should steroids be used for the maintenance of remission for Crohn’s?

A

No- only to induce remission

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65
Q

What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn’s?

A

Metronidazole and ciprofloxacin (unlicensed)

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66
Q

If metronidazole is given for fistulating Crohn’s, how long for and what are the associated risks?

A

1 month (no longer than 3) due to risk of peripheral neuropathy

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67
Q

What is used to control the inflammation in fistulating Crohn’s disease (and continued for maintenance)? How long should they be on this for?

A

Azathioprine or mercaptopurine (unlicensed) or infliximab

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68
Q

Can you use loperamide and codeine phosphate in acute UC?

A

No- contraindicated as it increases the risk of toxic megacolon

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69
Q

What type of laxative may be useful for proximal faecal loading in proctitis?

A

Macrogol

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70
Q

What is first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctitis and proctosigmoiditis?

What would be second line?

A
  1. Rectal aminosalicylates. Oral prednisolone should be considered for the treatment of patients with subacute proctitis or proctosigmoiditis.
  2. Rectal corticosteroid or oral prednisolone
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71
Q

Which aminosalicylates have rectal preparations?

A

Mesalazine and sulfasalazine

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72
Q

What is first line treatment for patients with acute exacerbation mild-moderate left-sided or extensive UC?

A

High induction dose of an oral aminosalicylate, with addition of a rectal aminosalicylate or oral beclometasone dipropionate if necessary.

Oral prednisolone alone is recommended for patients who cannot tolerate or who decline aminosalicylates, in whom aminosalicylates are contra-indicated or in patients with subacute left-sided or extensive ulcerative colitis.

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73
Q

In patients being treated with aminosalicylates for UC, when would you add in oral prednisolone?

A

No improvements within 4 weeks of initial therapy. If patient is on beclometasone, discontinue this

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74
Q

Why does oral budesonide have fewer systemic side effects than corticosteroids?

A

It exerts its action locally in the colon

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75
Q

True or false: Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable

A

TRUE

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76
Q

Are corticosteroids suitable for maintenance treatment of UC?

A

No because of their side effects

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77
Q

What should be given in severe acute UC?

A

IV corticosteroids

IV ciclosporin is an alternative (unlicensed)

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78
Q

What monoclonal antibodies are used for acute UC?

A

Adalimumab, golimumab, infliximab, vedolizumab

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79
Q

What can be used to maintain remission after an acute exacerbation of proctitis/proctosigmoiditis?

A

Rectal aminosalicylate can be started alone or in combination with oral aminisalicylate

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80
Q

What can be used to maintain remission after an acute exacerbation of left-sided or extensive UC?

A

Low dose oral aminosalicylate

Oral azathioprine or mercaptopurine [unlicensed indications] can be considered to maintain remission, 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.

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81
Q

True or false: When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.

A

TRUE

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82
Q

What are the red flag side effects of aminosalicylates?

A

Agranulocytosis, Bone marrow suppression, Neutropenia, Cardiac inflammation, nephrotoxicity

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83
Q

What are the monitoring requirements for aminosalicylates?

A

Renal function should be monitored before starting treatment, at 3 months, and then annually Patients should report any unexplained bleeding/bruising/fever/malaise during treatment

FBC - drug should be stopped immediately if any indication of blood dyscrasia (disease/disorder of the blood)

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84
Q

Within what time period during starting sulfasalazine treatment do haematological abnormalities often occur?

A

Within the first 3-6 months of starting treatment Discontinue if these occur

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85
Q

What should patients on sulfasalazine be aware of if they wear contact lenses?

A

May stain the lenses yellow/orange

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86
Q

What should a patient be screened for if starting vedolizumab?

A

TB Contraindicated in those with TB

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87
Q

What is alverine citrate used for?

A

GI spasms Dysmenorrhoea

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88
Q

Why would lactulose not be suitable in a patient with IBS?

A

Causes bloating

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89
Q

In IBS patients who have had constipation the last 12 months but have not responded to laxatives, what can be used?

A

Linaclotide

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90
Q

What is 1st line for diarrhoea in IBS?

A

Loperamide

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91
Q

What is co-phenotrope used for and what is a main side effect of it?

A

Decreases faecal output

Opioid that crosses BBB

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92
Q

Patients on colestyramine long term may need supplements of vitamins A, D, K, and folic acid. Why?

A

Can intefere with absorption of fat soluble vitamins

93
Q

What is the advice around taking colestyramine with other drugs?

A

Manufacturer advises take other drugs at least 1 hour before, or 4–6 hours after, colestyramine.

94
Q

What role does teduglutide have in short bowel syndrome?

A

Teduglutide is an analogue of human glucagon-like peptide-2 (GLP-2), which preserves mucosal integrity by promoting growth and repair of the intestine.

95
Q

In patients with short bowel syndrome/stoma, what kinds of preparations would be unsuitable and why? (hint- types of release)

A

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.

for patients with a stoma, use loperamide melts rather than capsules

96
Q

Bran is a type of what laxative?

A

Bulk forming

97
Q

Isphaghula husk is a type of what laxative?

A

Bulk forming

98
Q

Methylcellulose is a type of what laxative?

A

Bulk forming (also acts as a faecal softener)

99
Q

Sterculia is a type of what laxative?

A

Bulk forming

100
Q

What is onset of action for bulk forming laxatives?

A

Within 72 hours

101
Q

Bisacodyl is what type of laxative?

A

Stimulant

102
Q

Sodium picosulfate is what type of laxative?

A

Stimulant

103
Q

Senna is what type of laxative?

A

Stimulant

104
Q

Docusate sodium is what type of laxative?

A

Stimulant laxative and faecal softener

105
Q

What is co-danthramer and co-danthrusate used for and what patient group is it limited to? Why?

A

Constipation in palliative care only (carcinogenic)

106
Q

Arachis oil enema would be contraindicated in patients with what allergy?

A

Peanuts

107
Q

What are the warnings associated with liquid paraffin as a lubricant?

A

Anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.Should not be taken immediately before going to bed

108
Q

Lactulose is what type of laxative?

A

Osmotic

109
Q

Macrogol is what type of laxative?

A

Osmotic

110
Q

What is lubiprostone used for?

A

Licensed for the treatment of chronic idiopathic constipation in adults whose condition has not responded adequately to lifestyle changes

111
Q

What is prucalopride used for?

A

It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.

112
Q

What is 1st line for short duration constipation where dietary measures have not helped?If stools are soft but difficult to pass, what would be more appropriate?

A
  1. Bulk forming 2. Stimulant laxative
113
Q
  1. In patients with opioid induced consitipation, what would be appropriate?
  2. If these do not work, what can then be used?
A
  1. Osmotic laxative and stimulant laxative

Docusate sodium can be used to soften the stools

  1. Naloxegol, Methylnaltrexone bromide
114
Q

What type of laxative should be avoided in opioid induced constipation?

A

Bulk forming

115
Q

What is 1st line for constipation in pregnancy after dietary measures?

A

Bulk forming laxativeOr lactuloseDocusate sodium and glycerol suppositories can also be used

116
Q

True or false: Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause side-effects

A

TRUE

117
Q

What is 1st choice for constipation in breast feeding after dietary requirements?

A

Bulk forming laxative

Lactulose or macrogol can be used if stools remain hard

118
Q
  1. What is 1st line for constipation in children after dietary measures?
  2. If response is inadequate, what can be tried?
  3. If stools remain hard, what can be used?
A
  1. Macrogol 3350 with KCL, sodium bicarbonate and NaCl (if you forget, remember peadiatric movicol exists)
  2. Add or change to a stimulant laxative (OTC restrictions changed for stimulant laxatives Aug 2020)
  3. Lactulose or docusate (lactulose has a high sugar content)
119
Q

In children with chronic constipation, should laxatives be continued after regular bowel patterns has been established?How should laxatives be stopped?

A

Yes- for several weeks after and then tapered gradually according to response

120
Q

What is the duration of acute diarrhoea

A

Less than 14 days

121
Q

What is the maximum daily licensed dose for loperamide?

A

16mg (8 x 2mg capsules)

122
Q

What is the MHRA advice regarding loperamide?

A

Reports of serious cardiac adverse reactions with high doses associated with abuse QT prolongation, torsades de points, cardiac arrest

123
Q

Is kaolin recommended for acute diarrhoea?

A

No

124
Q

What role do antacids play in dyspepsia?

A

Symptomatic relief

125
Q

What is a side effect of magnesium?

A

Laxative effect

126
Q

What is a side effect of aluminium?

A

Constipation

127
Q

Why are bismuth containing antacids not recommended?

A

Neurotoxic, causing encephalopathy, tends to be constipating

128
Q

What are the side effects associated with calcium containing antacids?

A

Can induce rebound acid secretion

Hypercalcaemia

Alkalosis

Constipation

129
Q

What role do alginates play with an antacid?

A

Can protect mucosa from acid reflux

Some form a viscous gel raft

130
Q

What would be a standard treatment for a H.Pylori patient who is not penicillin allergic?

A

7 day course of PPI + 2Abx.

See table below

131
Q

Would you continue with PPI cover after treatment of H.Pylori?What is the exception to this?

A

No However if the ulcer is large or complicated by haemorrhage or perforation, then it is continued for a further 3 weeks

132
Q

H.Pylori treatment:What antibiotics are prone to resistance during the course?

A

Clarithromycin and metronidazole

133
Q

What is the disadvantage over 2 week triple therapy for H.Pylori over 1 week?

A

Even though the eradication rate is higher, adverse effects and poor compliance are common problems

134
Q

What could be used as an alternative to metronidazole in H.Pylori treatment?

A

Tinidazole

135
Q

In patients with NSAID related ulcer where the NSAID can be discontinued, which of the following promotes the most rapid healing:

H2 receptor antagonists (remember Ranitidine is no longer available)

Misoprostol

PPI

A

PPI

136
Q

What is sucralfate used for?

A

Gastric/duodenal ulceration

Gastritis

Prophylaxis of stress ulceration

137
Q

What is the main caution with sucralfate?

A

Bezoar formation- solid mass of indigestible material that accumulates and can cause a blockage

138
Q

In Zollinger-Ellison syndrome, should a PPI or a H2 receptor antagonist be used?

A

PPIs as they are more effective

139
Q

What can be used to reduce the degradation of pancreatic enzyme supplements in CF patients?

A

PPI

140
Q

What can PPIs increase the risk of?

A

Increases risk of fractures and osteoporosis so consider preventative therapy if appropriateIncreases risk of GI infections e.g. C DiffMay mask the symptoms of gastric cancer

141
Q

What 2 electrolytes can drop if on PPIs?

A

Sodium and magnesium

142
Q

For mild symptoms of GORD, what can be used?

A

Antacids

May need PPI or H2 receptor antagonist but should be titrated down to a level which maintains remission

Ranitidine no longer available

143
Q

For severe symptoms of GORD, what should be used?

A

PPI - re-assess if still symptomatic after 4-6 weeks

Should be titrated down to a level which maintains remission

144
Q

How do you manage GORD in pregnancy?

A

Diet and lifestyle changes

Antacid/alginate

145
Q

When would you give a pregnant lady omeprazole for GORD?

A

Severe or complicated reflux disease.

146
Q

How should a child with oesophagitis be treated?

A

PPI

147
Q

What is licensed as an adjunct to dietary avoidance in patients with food allergy?(hint- not an epi-pen)

A

Sodium cromoglicate

148
Q

What antihistamine is licensed for the symptomatic control of food allergy?

A

Chlorphenamine

149
Q

Buscopan contains what active ingredient?

A

Hyoscine butylbromide

150
Q

Kwells contains what active ingredient?

A

Hyoscine hydrobromide

151
Q

What is the MHRA alert associated with hyoscine butylbromide injection (IM, IV, SC)?

A

Can cause serious side effects such as tachycardia, hypotension, anaphylaxis (which is likely to be fatal in patients with CHD)It is therefore contraindicated in patients with tachycardia and should be used in caution in those with cardiac disease

152
Q

What is cholestasis?

A

An impairment of bile formation and/or bile flow

153
Q

What is the drug of choice for cholestatic pruritus?

A

Colestyramine

154
Q

What is the drug of choice for intrahepatic cholestatic pruritus in pregnancy?

A

Ursodeoxycholic acid

155
Q

Can you give NSAIDs in patients with symptomatic gallstones?

A

Yes

156
Q

What is the recommended medicine to use for primary biliary cholangitis?(progressive destruction of bile ducts within the liver)

A

Ursodeoxycholic acid

157
Q

What is the MHRA alert associated with obeticholic acid?

A

Serious liver injuries in patients with moderate-severe hepatic impairment Need to be adequately dose adjusted according to LFTs

158
Q

What is used for oesophageal varice bleeding?

A

Terlipressin & Vasopressin

159
Q

When should discontinuation of Orlistat be considered? (when do you know it is not effective)

A

After 12 weeks if weight loss has not exceeded 5% since starting the treatment

160
Q

How does Orlistat work?

A

Lipase inhibitor so reduces absorption of dietary fat

161
Q

What vitamin may you need to be on if taking Orlistat and why?

A

D as orlistat may reduce absorption of fat soluble vitamins

162
Q

What laxatives should be used in acute anal fissures and why?

A

Bulk forming

Osmotic can be an alternative To make sure stools are soft and easily passed

163
Q

When would an anal fissure be classed as chronic?

A

6 weeks or longer

164
Q

What topical preparation can be used in acute anal fissures?

A

Local anaesthetic e.g. lidocaine

165
Q

What topical preparation can be used in chronic anal fissures?

A

GTN rectal ointment

Diltiazem ointment

Nifedipine ointment(Unlicensed)

166
Q

If a patient with haemorrhoids is suffering from constipation, what type of laxative should be used?

A

Bulk forming

167
Q

What type of analgesics should not be used in haemorrhoid patients and why?

A

Opioids as they cause constipation

168
Q

What pain relief class of medicines should be avoided in patients with rectal bleeding?

A

NSAIDs

169
Q

Topical rectal preparations containing local anaesthetics such as lidocaine should only be used for a few days- why?

A

May cause sensitisation of the anal skin

170
Q

Topical corticosteroids are suitable for short term use in haemorrhoid patients- what is the max number of days this should be used for?

A

No more than 7 days

171
Q

If a pregnant lady with haemorrhoids is suffering from constipation, what type of laxative should be used?

A

Bulk forming

172
Q

Are topical haemorrhoidal preparations licensed in pregnancy?

A

No

173
Q

How do you manage exocrine pancreatic insufficiency?

A

Pancreatin - contains lipase, amylase and protease

174
Q

What is the risk of CF patients taking high dose pancreatic enzymes?What is therefore the guidelines of how many units of lipase to have a day?

A

Fibrosing colonopathy (presents with abdominal pain, vomiting etc)No more than 10,000 units/kg/day of lipase

175
Q

In stoma patients, why should medicine preparations containing sorbitol be avoided?

A

Laxative effects

176
Q

What would be the most appropriate diuretic to use in stoma patients and why?

A

Potassium sparing

Diuretics should be used with caution in patients with an ileostomy or with urostomy as they may become excessively dehydrated and potassium depletion may easily occur.

177
Q

What is the danger with using laxatives in a stoma patient?If they do need a laxative after increasing fluid intake and dietary fibre, what can be used?

A

May cause rapid and severe loss of water and electrolytes.

Bulk forming laxatives

If this does not work, a small dose of stimulant e.g. senna with caution

178
Q

What is the danger with stoma patients taking digoxin?

A

Patients with a stoma are particularly susceptible to hypokalaemia if taking digoxin, due to fluid and sodium depletion. Potassium supplements or a potassium-sparing diuretic may be advisable with monitoring for early signs of toxicity.

179
Q

Why should daily doses of liquid formulations be split in stoma patients?

A

To avoid osmotic diarrhoea

180
Q

What 3 antibiotics can you use for C.Diff infection?

A

1st line: Metronidazole

2nd line: Vancomycin (use first line if severe)

3rd line: Fidaxomicin

181
Q

What is the suggested duration of antibiotic treatment for C.Diff?

A

10-14 days

182
Q

If a patient has an aspirin sensitivity, would aminosalicylates be appropriate for them?

A

No - sulfasalazine and mesalazine are derivatives of salicylates, like aspirin.

183
Q

What colour does your urine turn if on sulfasalazine?

A

Yellow/orange

184
Q

What age is Mintec peppermint capsules licensed for?

A

> 18 years

185
Q

What age is Colpermin peppermint capsules licensed for?

A

>15 years

186
Q

Liquid paraffin is indicated for constipation, but what is its main side effects?

A

Lipoid pneumonia

Granuloma

187
Q

What is the MHRA advice surrounding PPIs?

A

Very low risk of subacute cutaneous lupus erythematosus

Drug-induced SCLE can occur weeks, months or even yearsafter exposure to the drug.If a patient on PPIs develops lesions in sun-exposed areasaccompanied with arthralgia;- Advise them to avoid sun exposure- Consider SCLE as a possible diagnosis

188
Q

What antiplatelet interacts with omeprazole?

A

Clopidogrel

189
Q

What is the administration counselling points for isphaghula?

A

Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.

have with at least 150ml of water

190
Q

What are some counselling points for taking antacids?

A

They are best taken when symptoms occur or are expected, usually between meals or at bedtime. They should preferably not be taken at the same time as other drugs since they may impair absorption. Antacids can damage enteric coatings on tablets. The words ‘low Na+’ added after some preparations indicates a sodium content of less than 1mmol per tablet or 10ml dose. This is directed for people with hypertension.

191
Q

What is the advice given to patients around taking Pancreatin?

A

It is important to ensure adequate hydration at all times in patients receiving higher-strength pancreatin preparations.Pancreatin is inactivated by gastric acid therefore manufacturer advises pancreatin preparations are best taken with food (or immediately before or after food).Enteric-coated preparations deliver a higher enzyme concentration in the duodenum- Manufacturer advises gastro-resistant granules should be mixed with slightly acidic soft food or liquid such as apple juice, and then swallowed immediately without chewing

192
Q

True or false:Coeliacs are at a higher risk of malabsorption of key nutrients such as calcium and Vitamin D

A

True - important to assess for osteoporosis

193
Q

What are long term complications of ulcerative colitis?

A

Colorectal cancer, Osteoporosis - from dietary change, corticosteroid medication,VTE,Toxic megacolon

194
Q

The use of loperamide or codeine in an acute flare up of UC increases the risk of what?

A

Toxic megacolon

195
Q

What are the complications of Crohn’s Disease?

A

Intestinal strictures, abscesses, fistulae, Malnutrition Anaemia, Colorectal and small bowel cancers, Growth failure and delayed puberty in children, Arthritis, Secondary osteoporosis - from steroid meds

196
Q

Can you use loperamide and codeine for diarrhoea in Crohn’s?

A

Yes

197
Q

What is the patient counselling with aminosalicylates?

A

Report any unexplained bleeding, bruising Salicylate hypersensitivity e.g. itching, hivesYellow/orange bodily fluids - may stain contact lenses

198
Q

What is the interaction between lactulose and mesalazine?

A

The manufacturers of some mesalazine gastro-resistant and modified-release medicines suggest that preparations that lower stool pH (e.g. lactulose) might prevent the release of mesalazine.

199
Q

What are the red flag symptoms of constipation?

A

New onset in > 50 years

Anaemia

Abdominal pain

Unexplained weight loss

Change in bowel habit

200
Q

True or false: Excessive use of stimulant laxatives causes hyperkalaemia

A

False- causes hypokalaemia

201
Q

What kind of laxative is co-danthramer?

A

Stimulant

202
Q

What kind of laxative should you avoid in opioid-induced constipation?

A

Bulk forming

203
Q

What are the red flag symptoms of dyspesia?

A

Anaemia

Loss of weight

Recent/unexplained dyspepsia in 55+

unresponsive to treatment

Malaena (blood in stool)

204
Q

What is a side effect of calcium salt antacids?

A

Can induce rebound acid secretion and constipation

205
Q

What classes of drugs do antacids interact with?

A

Tetracyclines

Quinolones

Bisphosphonates

206
Q

What groups of patients are antacids cautioned in?

A

Fluid retention can occur due to high sodium content so cautioned in hypertension, heart, liver or kidney failureAvoid in sodium restricted diet e.g. lithium

207
Q

What PPI is safe in pregnancy?

A

Omeprazole

208
Q

Is Cimetidine an enzyme inducer or inhibitor?

A

Enzyme inhibitor

209
Q

What is the advice with enteral feeds and food when taking sucralfate?

A

Administration of sucralfate and enteral feeds should be separated by 1 hour and for administration by mouth, sucralfate should be given 1 hour before meals.

210
Q

What are the side effects of antimuscarinics?

A

Blurred vision Arrhythmias Pupil dilation (mydriasis) Urinary retention Constipation Dry mouth Angle-closure glaucoma Drowsiness, confusion

211
Q

Do antimuscarinics cause dry eyes?

A

No

212
Q

When should pancreatin be given and why?

A

Immediately before meals as pancreatin is inactivated by gastric acid

213
Q

True or false:Enteric coated pancreatin delivers higher pancreatin levels

A

TRUE

214
Q

What is the advice with pancreatin and mixing with food and drink?

A

Pancreatin is inactivated by heatIf mixed with foods or liquids, do not keep for more than 1 hour

215
Q

How often is the PPI dosing in H Pylori treatment?

A

BD

216
Q

All the antibiotic and PPI triple therapies are BD dosing. What combination is the exception to this?

A

Omeprazole 20mg BD Amoxicillin 500mg TDS Metronidazole 400mg TDS

217
Q

What is coeliac disease?

A

It is a autoimmune condition= chronic inflammation of the small intestine

218
Q

What is coeliac disease caused by?

A

Gluten= rye, wheat and barley

219
Q

What are symptoms of coeliac disease?

A

Diarrhoea, bloating and abdominal pain

220
Q

Treatment of coeliac disease

A

Avoid gluten Prednisolone in refractory coeliac disease

221
Q

What is diverculosis and treatment?

A

Asymptomatic Forms diverticula= small pouches protruding from large intestineTreatmentBulking forming laxatives if they have constipation

222
Q

What is acute diverticulitis

A

Sudden inflammation of diverticula Can be infected = pain, fever, rectal bleeding

223
Q

What is complicated acute diverticulitis

A

Access, bowel perforation, fistula, intestinal obstruction, haemorrhage, sepsis

224
Q

What is treatment for acute diverticulitis

A

Paracetamol if no systemic symptoms, antibacterials if needed and low fibre diet generally in diverticulitis

225
Q

What is treatment for complicated acute diverticulitis

A

Hospital

226
Q

What is not recommended in complicated acute diverticulitis

A

Aminosalicylates and propylactic antibacterials

227
Q

What is first line treatment for Coeliacs disease

A

Life long gluten free diet

228
Q

What drugs are used in IBD

A

Aminosalicylates: Sulfaslazine, sulfapyridine, mesalazine, balsalazide, olsalazine

Cytokine modulators: Infliximab, adalimumab, golimumab

2021 BNF (19 decks)

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