Chapter 1: GI System Flashcards
Mr. S. presents in your pharmacy and asks for advice. He suffers constipation due to intake of co-codamol tablets (opiod-induced constipation). He is otherwise fit and well. He has tried taking more fruits and vegetables but to no avail. He would like your advice. Select the most appropriate option below.
A. Give lifestyle advice only.
B. Sell lactulose solution.
C. Recommend senna tablets
D. Recommend both senna and lactulose solution.
E. Refer to GP for naloxegol
After lifestyle changes, recommend and osmotic (lactulose) and stimulant (senna) combined as effective treatment.
D. Recommend both senna and lactulose solution.
Then, referral for Rx of Naloxegol.
Mr Dean, a 52-year-old man presents at your pharmacy with a prescription for omeprazole 20mg gastro-resistant capsules. He explains that his GP has prescribed this to take alongside naproxen 250mg tablets which he is taking for swollen foot injury. The prescription is dispensed, and you conduct a final check.
Which of the following information should be included on the dispensing label for Omeprazole 20mg gastro-resistant capsules?
A. Take with or just after food
B. This medicine may colour your urine. This is harmless
C. Do not take indigestion remedies 2 hours before or after you take this medicine
D. The form of medicine
E. Total quantity dispensed
Cautionary labels for PPI
C. Do not take indigestion remedies 2 hours before or after you take this medicine
=>do not chew, crush or break capsules
A. should be taken at least 30 min before food.
B. does not cause urine changes
D/E. not necessary
Coeliac Disease
~Gluten activates an abnormal immune response in the intestine, must avoid gluten
~Increased risk of malabsorption of nutrients like vitamin A and D (fat soluble), do not sell OTC, must refer to prescriber
~Increased risk of osteoporosis (due to long-term low vitamin D levels, malabsorption of calcium), must given supplements
~Advise patients not to self medicate with over-the-counter vitamins and mineral supplement (need to be monitored, should be done by GP)
~If patient relapses/exposure to gluten, treat with prednisolone in early case of refractory coeliac disease
IBD: Choose a statement which is not true about Aminosalicylates.
A. Aminosalicylates should be prescribed by BRAND as per legal requirements.
B. Aminosalicylates can cause side-effects such as purpura, sorethroat, fever and unexplained bleeding.
C. Sulfasalazine can change urine colour to orange colour.
D. One of the most important monitoring requirements with aminosalicylates is renal function checks.
E. Patients on mesalazine should be advised to maintain adequate intake of water
A. Aminosalicylates should be prescribed by BRAND as per legal requirements.
It is good practice to stick to same brand, but not a legal requirement (lithium, biological/biosimilar, insulin, enoxaparin (LMWH), theophylline/aminophyline, cyclosporine)
Irritable Bowel Disease (IBD)
~Ulcerative colitis (affects large intestine, colon) and Crohns disease (affects mouth to anus)
~Treatment: 1st line (Aminosalicylate: mesalazine, sulphasalazine), methotrexate, azothioprine
~can cause Blood disorders Rx (bleeding, unexplained bruising, purpura, sore throat, fever, ulcers)=>stop and REFER for immediate medical attention; carbimazole, methotrexate, vancomycin, trimethoprim, mirtazipine
~Monitoring - full blood blood, renal (before, 3mths and annual) and liver function tests.
~Mesalazine granules should be placed on tongue and washed down with water or orange juice.
~Sulfasalzine can colour contact lenses and bodily fluids (urine changes to orange, tears).
~G6PD deficiency: increased risk of bleeding with Sulfasaline
IBS: Mary is a 25 year old patient who suffers from IBS. She complains to your during your shift about abdominal pain , bloating, diarrhoea and constipation as well as incomplete evacuation. You decide to give her lifestyle advice to help manage her condition. Which of the following is NOT CORRECT lifestyle advice to give Mary?
A. Reduce intake of caffeine, alcohol and fizzy drinks.
B. Increase intake of fluids especially water to about 8 cups per day.
C. Increase intake of dietary fibre such as bran such be encouraged.
D. Limit fresh fruit consumption to about 3 portions a day.
E. Eat small regular meals as opposed to large meals seldomly.
Fresh fruits contain acid (lemon, lime), so limited.
Small portions easily digested.
C. Increase intake of dietary fibre such as bran such be encouraged.
Recommend soluble fiber (oats, vegetables) and less insoluble fibres (ie bran)
IBS: A university student on placement in your pharmacy wants to learn more about drugs which can be used in the management of IBS symptoms. Which of the following drugs is least appropriate for a patient with IBS?
A. Hyoscine butylbromide
B. Mebeverine + fybogel.
C. Senna tablets
D. Peppermint oil capsules
E. Lactulose oral solution
E. Lactulose oral solution as it increases risk of bloating
IBS Symptoms (constant change in symptoms, not stable) and Drug Treatment (no cure, only management)
cramps , diarrhoea, constipation , pain, bloating
Alverine citrate – antispasmodics
Mebeverine plus ispaghula (know doses: 135mg, 200mg MR)
Hyoscine butylbromide (most common, buscopan, different license: 6yrs+ not IBS/Buscopan Cramps, 12yrs+ Buscopan IBS)
Peppermint
Laxative but no lactulose
loperamide
Off License: TCA (amitryptiline), SSRI
Mrs. Jones. presents in your pharmacy and asks for advice. She is currently 3 months pregnant and suffers constipation. She is otherwise fit and well. She has tried taking more fruits and vegetables but to no avail. She would like your advice. Select the most appropriate option below.
A. Recommend Ispaghula husks.
B. Sell lactulose solution.
C. Recommend senna tablets
D. Refer to A & E
E. Refer to GP
A. Recommend Ispaghula husks (bulk-forming agent)
Lifestyle Advice
1st choice: Bulk-forming agent
2nd choice: Lactulose
Constipation
Lifestyle advice: more fruits and vegetables (fiber), more fluids/water, increase exercise, reduce starchy foods (rice, pasta, bread),
Magnesium content (causes diarrhoea) and aluminium content (causes constipation, opioids, TCAs, indigestion products)
Types and examples
BOSS G: Bulk forming, Osmotic, Stimulant, Stool Softeners (docusate), Glycerine (suppository: fastest acting in 15 min)
Which laxative is first line RX in pregnancy? 1st: Bulk 2nd: Osmotic
What is the onset of action of senna, lactulose ? Senna: up to 8 hrs, Lactulose: up to 48 hrs, Bulk: up to 72 hrs
Laxative abuse can lead to ………………..? Weight loss, low potassium (hypokalaemia), weak bowels (incontinence),
What are the two uses of lactulose? Constipation, Hepatic Encephalopathy (liver disease that affects the brain at high doses to reduce toxins)
Treatment for opioid induced constipation? lifestyle advice, stimulant and osmotic combined, then refer to GP for naloxegol
Diarrhoea: GABBY is a 35-year-old patient who travelled to Kenya on holiday for two weeks. He returned to the UK last week but has been suffering from diarrhoea with - no blood in his stools ,for four days straight. He comes to your pharmacy to seek your advice . What is the most appropriate advice to give Gabby?
A. Do nothing as the symptoms are self limiting.
B. Refer Gabby straight to his GP.
C. Give Gabby advice on his diet and other lifestyle advice.
D. Sell Gabby some dioralyte sachets and ask him to rest at home for 4 days.
E. Sell Gabby some dioralyte together with Immodium capsules
B. Refer Gabby straight to his GP=>Traveler’s Diarrhoea
Diarrhoea
Symptoms
RED-FLAG SYMPTOMS- persistent diarrhoea (less than 1 yr more than 24hrs, less than 3 yrs more than 48 hrs, everyone else more than 72 hrs), blood in stools, travellers diarrhoea (always refer if outside of these regions: Western Europe (France, Denmark, Germany, Belgium), USA, Australia, New Zealand, Canada), systemic illness (lethargic, vomitting, malaise, fatigue)
life style advice: plain foods (can take bug about 4 days to be alleviated, toast, biscuits, bread, banana, BRAT), stay hydrated/ORS, maintain proper hygiene (wash hands to reduce spreading)
Drug treatment
Diarlyte, O.R.S
loperamide (12yrs+)
Pepto bismo: OOS, out of stock
When to refer to GP? Food poisoning/Red Flag Symptoms
Dyspepsia
An umbrella term: acid reflux, heartburn, indigestion, stomach ulcers, GERD/GORD
RED-FLAG SYMPTOMS- first time presenting symptoms of dyspepsia over 55 yrs=>Refer
1st: Alginates (Gaviscon, Peptic: form a raft neutralising acid), H2 antagonists (ranitidine discontinued due to NDMA cancer causing contaminant, famotidine), PPIs (omeprazole, lansoprazole, pantoprazole, OTC: Nexium–esomeprazole, short term)
PPIs complications: Girls Love Going On Holiday=mask Gastric cancer, Lupus, GI Infections (C. Diff), Osteoporosis, Hypomagnesaemia
H-Pylori eradication: main cause of ulcers/NSAID-induced. 2antibiotics+1PPI
GORD: sphincter is damaged/faulty doesn’t properly close causing heartburn/indigestion, lifestyle advice and medication=>sleep raised, last meal 4 hrs before bed, cut down fatty foods/alcohol/soda/coffee/caffeine, lose weight
Gaviscon contains sodium and Blood Pressure/Hypertension, if controlled for short-term use only, not controlled then refer
Dyspepsia: Which of the following is least favorable for women of childbearing age in the management of dyspepsia symptoms?
A. Omeprazole
B. Ranitidine
C. Misoprostol
D. Pantoprazole
E. Sucralfate
C. Misoprostol: 1st use: Dyspepsia, 2nd use: high doses to induce labor/abortion (child-bearing age to use effective contraception)
PPIs
USES – Acid reflux, gastric ulcers, H-pylori eradication
H-pylori induced and NSAID induced ulcer
only give omeprazole in pregnancy
Monitoring
5 COMPLICATIONS–G.L.G.O.H.
G.I infections (e.g. C-diff), lupus erythematosus, gastric cancer
(masking) , osteoporosis, hypomagnesaemia
H-pylori eradication – PPI plus amox , metronidazole or clarith
Drug interactions: cyclosporin interacts with clarithromycin (enzyme inhibitor), QT prolongation risk avoid clarithromycin, Statins avoid clarithromycin, if INR is stable on warfarin can take metronidazole, metronidazole interacts with alcohol, amoxicillin/penicillins interacts with methotrexate by increasing methotrexate toxicity, penicillin allergy avoid amoxicillin, omeprazole can interact With MECCi: warfarin, escitalopram, reduces clopidogrel increasing blood clots, citalopram
Piles
Hemorrhoids/Piles
2 types – internal (suppository) and external (Anusol, Geminoid, Prep H: cream, ointment)
causes: straining/constipation, pregnancy, lifting heavy objects, sitting on the loo for long periods
TREATMENT Options
Avoid lidocaine and steroids in pregnancy (can get absorbed into bloodstream)
Evidence Based:
Which statement(s) is backed by EVIDENCE?
A. Ursedeoxycholic acid use in the dissolution of gallstones.
B. The use of Vitamin C in the amelioration of cold and flu symptoms.
C. The use of St. John’s wort to treat Depression
D. The use of Tamoxifen in the treatment of infertility
E. The use of pancreatin in the management of pancreatic insufficiency
D. The use of Tamoxifen in the treatment of infertility=>treats breast cancer, leads to multiple babies
E. The use of pancreatin (Creon) in the management of pancreatic insufficiency
BMI: A 43-year-old diabetic patient weighs 233lbs, height 6ft . He would like to lose weight despite making lifestyle changes and wants your advice on the options available to him on the NHS. You decide to do an assessment to find out what treat he is eligible for. Calculate his BMI and choose an option.
A. Give him some lifestyle advice only.
B. Sell him some orlistat Over the counter.
C. REFER HIM TO HIS GP FOR SOME ORLISTAT.
D. Inform him he qualifies for bariatric surgery on the NHS
E. His BMI is of normal weight. He does not need to worry.
Under:
Normal: 18.5-24.9
Over: 25-29.9
Obese: 30+
When patient has a comorbidity, must refer. Does not qualify for bariatric (BMI: 35+ w/comorbidity, BMI: w/o comorbidity 40+)
Obesity
Directly linked to many health problems. E.g diabetes type 2, CVD, GORD, gallstones etc
waist circumference target - <94cm men, <80cm women and <90 Asian men
Stages of obesity i (30-34.9) , ii (35-39.9), iii (40+)
Underlying causes e.g. thyroid prob, heart failure, drugs (LOBBI: lithium, olanzapine, beta blockers, insulin) etc
Lifestyle changes: diet, exercise 30min 5x’s, alcohol intake, manage stress
Drug treatment – Alli (60mg Orlistat) OTC not more than 6 months, BMI: 28+ w/o comorbidity, w/comorbiity REFER…ozempic (semiglutide) for weightless
Which counselling point or statement about orlistat is INCORRECT
A. Orlistat can cause malabsorption of Fat soluble vitamins, must be given supplements ADEK.
B. Orlistat should be taken with low fat, mild hypocaloric diet. If patient misses a meal, must not take medication.
C. A side-effect of orlistat is flatulence, anxiety.
D. Maximum daily dose of OTC orlistat (Alli) is 180mg (60mg TDS)
E.Treatment with OTC orlistat (Alli) should not exceed 12 months.
E.Treatment with OTC orlistat (Alli) should not exceed 12 months.
Pancreatin
Replacement if patient has insufficiency, pancreatic cancer, auto-immune disease, pancrease removed.
Pancreatin/ Creon – capsules or granules
Take with food – just before or just after food – due to gastric acid inactivation
Avoid excess heat
Mixture of pancreatin and food cannot be taken after one hour
For infants mix micro granules with milk on a spoon –DO NOT add to baby bottle, prevent choking
Religious reasons – consider powder or other non-gelatin forms
Stoma: Mr. Chan is a patient who uses a stoma bag. He would like some information as regards the use of stoma bags. Consider the statements below regarding patients with Stoma. Which of the following statements is NOT CORRECT.
A. Enteric coated and modified release medicines are more suitable than soluble tablets for patients with stoma.
B. Preparations which contain sorbitol should be avoided if possible.
C. Inform patients with stoma that Sorbitol has laxative effects.
D. Patients with stoma are susceptible to hypokalaemia and must be careful if taking digoxin.
E. Gastric acid secretion increases stoma output.
A. Enteric coated and modified release medicines are more suitable than soluble tablets for patients with stoma=>parts of intestine removed, given MR releasing itself throughout GI tract, not beneficial to patient
