Chapter 1: GI system Flashcards
1
Q
Are patients with coeliac disease recommended to self medicate with OTC vitamin and mineral supplements?
A
No
2
Q
What are coeliac patients at increased risk of?
A
Malabsorption
Vitamin and mineral deficiency - could increase the risk of osteoporosis
3
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
4
Q
What is the treatment for uncomplicated diverticular disease?
A
Low residue (fibre) diet and bowel rest
5
Q
Are antibacterials recommended in uncomplicated diverticular disease?
A
No unless the patient presents with signs of infection/immunocompromised
6
Q
What is the treatment for complicated diverticular disease?
A
Hospital admission, IV antibacterials covering gram negative and anaerobes
Bowel rest
7
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
8
Q
What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?
A
Avoids the sulfonamide-related side effects of sulfasalazine
9
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
10
Q
What compound is mesalazine?
A
5-ASA
11
Q
Balsalazide is a pro drug of what?
A
5-ASA
12
Q
What are extraintestinal manifestations?
A
When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis
13
Q
- In a patient with a first presentation or single inflammatory Crohn’s exacerbation in a 12 month period, what 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
- Corticosteroid - prednisolone, methylprednisolone or IV hydrocortisone
- Budesonide or aminosalicylates. Not appropriate if severe presentation as they are less effective (even though they have fewer side effects)
14
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
15
Q
Is mercaptopurine licensed in severe UC and CD?
A
No
16
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
- Azathioprine
Mercaptopurine can be added but unlicensed
- Methotrexate
17
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
18
Q
What monoclonal antibodies are licensed for Crohn’s?
A
Adalimumab
Infliximab-can also be used for active fistulating CD
Vedolizumab
19
Q
- What is used for maintenance of remission for Crohn’s?
2. What would be second line and when would you use this?
A
- Azathioprine
Mercaptopurine (unlicensed)
- Methotrexate if the patient required it to induce remission, or if azathioprine/mercaptopurine is unsuitable
20
Q
Should steroids be used for the maintenance of remission for Crohn’s?
A
No- only to induce remission
21
Q
What can be used to manage Crohn’s associated diarrhoea?
A
Loperamide, codeine phosphate, colestyramine
22
Q
What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn’s?
A
Metronidazole and ciprofloxacin (unlicensed)
23
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
24
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
At least 1 year
25
Can you use loperamide and codeine phosphate in acute UC?
No- contraindicated as it increases the risk of toxic megacolon
26
What type of laxative may be useful for proximal faecal loading in proctitis?
Macrogol containing osmotic laxative
27
UC
1. What is first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctitis and proctosigmoiditis?
2. What would be second line?
1. Rectal aminosalicylates. Oral prednisolone should be considered for the treatment of patients with subacute proctitis or proctosigmoiditis.
2. Rectal corticosteroid or oral prednisolone
28
What aminosalicylates have rectal preparations?
Mesalazine or sulfasalazine
29
What is first line treatment for patients with acute exacerbation mild-moderate left-sided or extensive UC?
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.
30
Mild to moderate UC:
In patients being treated with aminosalicylates for UC, when would you add in oral prednisolone?
No improvements within 4 weeks of initial therapy
If patient is on beclometasone, discontinue this
31
Why does oral budesonide have fewer systemic side effects than corticosteroids?
It exerts its action topically in the colon
32
True or false:
| Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable
True
33
Are corticosteroids suitable for maintenance treatment of UC?
No because of their side effects
34
What should be given in acute severe UC?
IV corticosteroids
IV ciclosporin is an alternative (unlicensed)
Infliximab
Assess for surgery
35
What monoclonal antibodies are used for acute UC?
Adalimumab, golimumab, infliximab, vedolizumab
36
What can be used to maintain remission after an acute exacerbation of proctitis/proctosigmoiditis?
Rectal aminosalicylate can be started alone or in combination with oral aminisalicylate
37
What can be used to maintain remission after an acute exacerbation of left-sided or extensive UC?
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.
38
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.
True
39
What are the red flag side effects of aminosalicylates?
```
Agranulocytosis
Bone marrow disorders
Neutropenia
Cardiac inflammation
Renal impairment - nephrotoxicity
```
40
What are the monitoring requirements for aminosalicylates?
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)
41
Within what time period during starting sulfasalazine treatment do haematological abnormalities often occur?
Within the first 3-6 months of starting treatment
| Discontinue if these occur
42
What should patients on sulfasalazine be aware of if they wear contact lenses?
May stain the lenses yellow/orange
43
What should a patient be screened for if starting vedolizumab?
TB
Contraindicated in those with TB
44
What is alverine citrate used for?
GI spasms
| Dysmenorrhoea
45
Why would lactulose not be suitable in a patient with IBS?
Causes bloating
46
In IBS patients who have had constipation the last 12 months but have not responded to laxatives, what can be used?
Linaclotide
47
What is 1st line for diarrhoea in IBS?
Loperamide
48
What is co-phenotrope used for and what is a main side effect of it?
Decreases faecal output
| Opioid that crosses BBB
49
Patients on colestyramine long term may need supplements of vitamins A, D, K, and folic acid. Why?
Can intefere with absorption of fat soluble vitamins
50
What is the advice around taking colestyramine with other drugs?
Manufacturer advises take other drugs at least 1 hour before, or 4–6 hours after, colestyramine.
51
What role does teduglutide have in short bowel syndrome?
Teduglutide is an analogue of human glucagon-like peptide-2 (GLP-2), which preserves mucosal integrity by promoting growth and repair of the intestine.
52
In patients with short bowel syndrome/stoma, what kinds of preparations would be unsuitable and why? (hint- types of release)
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.
53
Bran is a type of what laxative?
Bulk forming
54
Isphaghula husk is a type of what laxative?
Bulk forming
55
Methylcellulose is a type of what laxative?
Bulk forming (also acts as a faecal softener)
56
Sterculia is a type of what laxative?
Bulk forming
57
When is onset of action for bulk forming laxatives?
Within 72 hours
58
Bisacodyl is what type of laxative?
Stimulant
59
Sodium picosulfate is what type of laxative?
Stimulant
60
Senna is what type of laxative?
Stimulant
61
Docusate sodium is what type of laxative?
Stimulant laxative and faecal softener
62
What is co-danthramer and co-danthrusate used for and what patient group is it limited to? Why?
Constipation in palliative care
| Carcinogenicity and genotoxicity risks
63
Arachis oil enema would be contraindicated in patients with what allergy?
Peanuts
64
What are the warnings associated with liquid paraffin as a lubricant?
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
65
Lactulose is what type of laxative?
Osmotic
66
Macrogol is what type of laxative?
Osmotic
67
What is lubiprostone used for?
Licensed for the treatment of chronic idiopathic constipation in adults whose condition has not responded adequately to lifestyle changes
68
What is prucalopride used for?
It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
69
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?
1. Bulk forming
| 2. Stimulant laxative
70
1. In patients with opioid induced consitipation, what would be appropriate?
2. If these do not work, what can then be used?
1. Osmotic laxative and stimulant laxative
Docusate sodium can be used to soften the stools
2. Naloxegol
Methylnaltrexone bromide
71
What type of laxative should be avoided in opioid induced constipation?
Bulk forming
72
What is 1st line for constipation in pregnancy after dietary measures?
Bulk forming laxative
Or lactulose
Docusate sodium and glycerol suppositories can also be used
73
True or false:
Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause side-effects
True
74
What is 1st choice for constipation in breast feeding after dietary requirements?
Bulk forming laxative
Lactulose or macrogol can be used if stools remain hard
75
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?
1. Macrogol 3350 with KCL, sodium bicarbonate and NaCl
2. Add or change to a stimulant laxative
3. Lactulose or docusate
76
In children with chronic constipation, should laxatives be continued after regular bowel patterns has been established?
How should laxatives be stopped?
Yes- for several weeks after and then tapered gradually according to response
77
How many days classifies acute diarrhoea?
Less than 14 days
78
What is the maximum daily licensed dose for loperamide?
16mg
79
What is the MHRA advice regarding loperamide?
Reports of serious cardiac adverse reactions with high doses associated with abuse
QT prolongation, torsades de points, cardiac arrest
80
Is kaolin recommended for acute diarrhoea?
No
81
What role do antacids play in dyspepsia?
Symptomatic relief
82
What is a side effect of magnesium?
Laxative effect
83
What is a side effect of aluminium?
Constipation
84
Why is bismuth containing antacids not recommended ?
Neurotoxic, causing encephalopathy, tends to be constipating
85
What are the side effects associated with calcium containing antacids?
Can induce rebound acid secretion
Hypercalcaemia
Alkalosis
Constipation
86
What role do alginates play with an antacid?
Can protect mucosa from acid reflux
| Some form a viscous gel raft that floats to surface of stomach contents
87
What would be a standard treatment for a H.Pylori patient who is not penicillin allergic?
7 day course
PPI, choice of two: amoxicillin and clarithromycin or metronidazole
88
Would you continue with PPI cover after treatment of H.Pylori?
What is the exception to this?
No
| However if the ulcer is large or complicated by haemorrhage or perforation, then it is continued for a further 3 weeks
89
H.Pylori treatment:
What antibiotics are prone to resistance during the course?
Clarithromycin and metronidazole
90
What is the disadvantage over 2 week triple therapy for H.Pylori over 1 week?
Even though the eradication rate is higher, adverse effects and poor compliance are common problems
91
What could be used as an alternative to metronidazole in H.Pylori treatment?
Tinidazole
92
What would be the dose of ranitidine in prophylaxis against NSAID related ulcers?
What would be an alternative?
300mg BD
Misoprostol
93
In patients with NSAID related ulcer where the NSAID can be discontinued, which of the following promotes the most rapid healing:
H2 receptor antagonists
Misoprostol
PPI
PPI
94
What is sucralfate used for?
Gastric/duodenal ulceration
Gastritis
Prophylaxis of stress ulceration
95
What is the main caution with sucralfate?
Bezoar formation- solid mass of indigestible material that accumulates and can cause a blockage
96
In Zollinger-Ellison syndrome, should a PPI or a H2 receptor antagonist be used?
PPIs as they are more effective
97
What is the only H2 receptor antagonist that can be given IV?
Ranitidine
98
What can be used to reduce the degradation of pancreatic enzyme supplements in CF patients?
PPI
99
What is the MHRA warning associated with PPIs?
Risk of subacute lupus erythematosus
Patients may present with skin lesions, especially in sun-exposed areas of the skin along with athralgia (pain in joint).
If they develop lesions - Should counsel them to avoid exposing the skin to sunlight and consider discontinuing (as symptoms resolve after withdrawing medicine)
100
What can PPIs increase the risk of?
Increases risk of fractures and osteoporosis so consider preventative therapy if appropriate
Increases risk of GI infections e.g. C Diff
May mask the symptoms of gastric cancer
101
What 2 electrolytes can drop if on PPIs?
Sodium and magnesium
102
Do PPIs or H2 receptor antagonists provide more relief of GORD symptoms?
PPIs
103
For mild symptoms of GORD, what can be used?
Antacids
May need PPI or H2 receptor antagonist but should be titrated down to a level which maintains remission
104
For severe symptoms of GORD, what should be used?
PPI - re-assess if still symptomatic after 4-6 weeks
| Should be titrated down to a level which maintains remission
105
1. How do you manage GORD in pregnancy?
| 2. If this is ineffective, what can be tried?
1. Diet and lifestyle changes
Antacid/alginate
2. Ranitidine
106
When would you give a pregnant lady omeprazole for GORD?
Severe or complicated reflux disease.
107
How should a child with oesophagitis be treated?
H2 receptor antagonist
If this does not work, omeprazole
108
What is licensed as an adjunct to dietary avoidance in patients with food allergy?
(hint- not an epi-pen)
Sodium cromoglicate
109
What antihistamine is licensed for the symptomatic control of food allergy?
Chlorphenamine
110
Buscopan contains what active ingredient?
Hyoscine butylbromide
111
Kwells contains what active ingredient?
Hyoscine hydrobromide
112
What is the MHRA alert associated with hyoscine butylbromide injection (IM, IV, SC)?
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
113
What is cholestasis?
An impairment of bile formation and/or bile flow
114
What is the drug of choice for cholestatic pruritus?
Colestyramine
115
What is the drug of choice for intrahepatic cholestatic pruritus in pregnancy?
Ursodeoxycholic acid
116
Can you give NSAIDs in patients with symptomatic gallstones?
Yes
117
What is the recommended medicine to use for primary biliary cholangitis?
(progressive destruction of bile ducts within the liver)
Ursodeoxycholic acid
118
What is the MHRA alert associated with obeticholic acid?
Serious liver injuries in patients with moderate-severe hepatic impairment
Need to be adequately dose adjusted according to LFTs
119
What is used for oesophageal varice bleeding?
Terlipressin
| Vasopressin
120
Orlistat is licensed in patients with what BMI?
BMI of 30
| or BMI of 28 in the presence of other risk factors
121
When should discontinuation of Orlistat be considered? (when do you know it is not effective)
After 12 weeks if weight loss has not exceeded 5% since starting the treatment
122
How does Orlistat work?
Lipase inhibitor so reduces absorption of dietary fat
123
What vitamin may you need to be on if taking Orlistat and why?
D as orlistat may reduce absorption of fat soluble vitamins
124
What laxatives should be used in acute anal fissures and why?
Bulk forming
Osmotic can be an alternative
To make sure stools are soft and easily passed
125
When would an anal fissure be classed as chronic?
6 weeks or longer
126
What topical preparation can be used in acute anal fissures?
Local anaesthetic e.g. lidocaine
127
What topical preparation can be used in chronic anal fissures?
```
GTN rectal ointment
Diltiazem ointment
Nifedipine ointment
(Unlicensed)
```
128
If a patient with haemorrhoids is suffering from constipation, what type of laxative should be used?
Bulk forming
129
What type of analgesics should not be used in haemorrhoid patients and why?
Opioids as they cause constipation
130
What pain relief class of medicines should be avoided in patients with rectal bleeding?
NSAIDs
131
Topical rectal preparations containing local anaesthetics such as lidocaine should only be used for a few days- why?
May cause sensitisation of the anal skin
132
Topical corticosteroids are suitable for short term use in haemorrhoid patients- what is the max number of days this should be used for?
No more than 7 days
133
If a pregnant lady with haemorrhoids is suffering from constipation, what type of laxative should be used?
Bulk forming
134
Are topical haemorrhoidal preparations licensed in pregnancy?
No
135
How do you manage exocrine pancreatic insufficiency?
Pancreatin - contains lipase, amylase and protease
136
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?
Fibrosing colonopathy (presents with abdominal pain, vomiting etc)
No more than 10,000 units/kg/day of lipase
137
In stoma patients, why should medicine preparations containing sorbitol be avoided?
Laxative effects
138
What would be the most appropriate diuretic to use in stoma patients and why?
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.
139
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?
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
140
What is the danger with stoma patients taking digoxin?
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.
141
Why should daily doses of liquid formulations be split in stoma patients?
To avoid osmotic diarrhoea
142
What 3 antibiotics can you use for C.Diff infection?
1st line: Metronidazole
2nd line: Vancomycin
3rd line: Fidaxomicin
143
What is the suggested duration of antibiotic treatment for C.Diff?
10-14 days
144
If a patient has an aspirin sensitivity, would aminosalicylates be appropriate for them?
No - sulfasalazine and mesalazine are derivatives of salicylates, like aspirin.
145
What colour does your urine turn if on sulfasalazine?
Yellow/orange
146
What age is Mintec peppermint capsules licensed for?
> 18 years
147
What age is Colpermin peppermint capsules licensed for?
>15 years
148
Liquid paraffin is indicated for constipation, but what is its main side effects?
Lipoid pneumonia
| Granuloma
149
What is the MHRA advice surrounding PPIs?
Very low risk of subacute cutaneous lupus erythematosus
Drug-induced SCLE can occur weeks, months or even years
after exposure to the drug.
If a patient on PPIs develops lesions in sun-exposed areas
accompanied with arthralgia;
- Advise them to avoid sun exposure
- Consider SCLE as a possible diagnosis
150
What antiplatelet interacts with omeprazole?
Clopidogrel
151
What is the administration counselling points for isphaghula?
Preparations that swell in contact with liquid should always be carefully
swallowed with water and should not be taken immediately before going to bed.
152
What are some counselling points for taking antacids?
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.
153
What is the advice given to patients around taking Pancreatin?
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
154
True or false:
| Coeliacs are at a higher risk of malabsorption of key nutrients such as calcium and Vitamin D
True - important to assess for osteoporosis
155
What are long term complications of ulcerative colitis?
Colorectal cancer
Osteoporosis - from dietary change, corticosteroid medication
VTE
Toxic megacolon
156
The use of loperamide or codeine in an acute flare up of UC increases the risk of what?
Toxic megacolon
157
What are the complications of Crohn's Disease?
Intestinal strictures, abscesses, fistulae
Malnutrition
Anaemia
Colorectal and small bowel cancers
Growth failure and delayed puberty in children
Arthritis
Secondary osteoporosis - from steroid meds
158
Can you use loperamide and codeine for diarrhoea in Crohn's?
Yes
159
What is the patient counselling with aminosalicylates?
Report any unexplained bleeding, bruising
Salicylate hypersensitivity e.g. itching, hives
Yellow/orange bodily fluids - may stain contact lenses
160
What is the interaction between lactulose and mesalazine?
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.
161
What are the red flag symptoms of constipation?
New onset in > 50 years
Anaemia
Abdominal pain
Unexplained weight loss
162
True or false:
Excessive use of stimulant laxatives causes hyperkalaemia
False- causes hypokalaemia
163
What kind of laxative is co-danthramer?
Stimulant
164
What kind of laxative should you avoid in opioid-induced constipation?
Bulk forming
165
What are the red flag symptoms of dyspesia?
Anaemia
Loss of weight
Recent/unexplained dyspepsia in 55+ unresponsive to treatment
Malaena (blood in stool)
166
What is a side effect of calcium salt antacids?
Can induce rebound acid secretion and constipation
167
What classes of drugs do antacids interact with?
Tetracyclines
Quinolones
Bisphosphonates
168
What groups of patients are antacids cautioned in?
Fluid retention can occur due to high sodium content so cautioned in hypertension, heart, liver or kidney failure
Avoid in sodium restricted diet e.g. lithium
169
What PPI is safe in pregnancy?
Omeprazole
170
Is Cimetidine an enzyme inducer or inhibitor?
Enzyme inhibitor
171
What is the advice with enteral feeds and food when taking sucralfate?
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.
172
What is the advice surrounding when to do a 13C urea breath test in terms of if the patient has had antibacterial therapy/antisecretory drug?
Do not perform test within 4 weeks of antibacterial
Do not perform test within 2 weeks of antisecretory drug
173
What are the side effects of antimuscarinics?
```
Blurred vision
Arrhythmias
Pupil dilation (mydriasis)
Urinary retention
Constipation
Dry mouth
Angle-closure glaucoma
Drowsiness, confusion
```
174
Do antimuscarinics cause dry eyes?
No
175
When should pancreatin be given and why?
Immediately before meals as pancreatin is inactivated by gastric acid
176
True or false:
Enteric coated pancreatin delivers higher pancreatin levels
True
177
What is the advice with pancreatin and mixing with food and drink?
Pancreatin is inactivated by heat
If mixed with foods or liquids, do not keep for more than 1 hour
178
How often is the PPI dosing in H Pylori treatment?
BD
179
All the antibiotic and PPI triple therapies are BD dosing. What combination is the exception to this?
Omeprazole 20mg BD
Amoxicillin 500mg TDS
Metronidazole 400mg TDS
