Chapter 1: GI system Flashcards
Are patients with coeliac disease recommended to self medicate with OTC vitamin and mineral supplements?
No. Although recommended daily intake of Calcium is 1000mg and Vit D 10ug if this is not achieved through diet.
What are coeliac patients at increased risk of?
Malabsorption
Vitamin and mineral deficiency - could increase the risk of osteoporosis
Risk of OS causes need for active treatment of bone disease and should be part of ongoing treatment.
What is diverticular disease?
What conditions might its symptoms overlap with?
Diverticula (sac-like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain with constipation, diarrhoea, or occasional large rectal bleeds. in the absence of inflammation or infection.
Diff D: IBS, colitis, and malignancy
What is the treatment for diverticular disease
- symptomatic diverticular disease
- uncomplicated diverticulitis
- complicated severe D
- Symp DD: Constipation= high fibre diet or bulking forming laxatives paracetamol for pain and antispasmodics
- Uncomp D: low residue diet and bowel rest. Antibacterials only if pt has infection, inflammation or is immunocompromised.
- Complicated severe ppt: hospital IV antibacterials for anaerobes and G-ve bacteria as well as bowel rest
What is not recommended in uncomplicated diverticular disease?
Antibiotics
unless the patient presents with signs of infection/immunocompromised
Nsaids or opioids
What is the treatment for complicated diverticular disease?
Hospital admission, IV antibacterials covering gram negative and anaerobes
Bowel rest
True or false: There is sufficient evidence to justify the role of fibre, rifaximin, antispasmodics, mesalazine, and probiotics in the prevention or treatment of diverticulitis.
False
What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?
Avoids the sulfonamide-related side effects of sulfasalazine; NOT DOSE RELATED: male infertility (reversible), haemolytic anaemia, hypersensitivity, bone marrow suppression, hepatitis and DRUG DOSE RELATED: n+v, dyspepsia, malaise, headache
5-ASA however still causes same SE as sulfasalazine such as blood dyscrasias and lupus like syndrome
Sulfasalazine is a combination of what two compounds?
5-ASA and sulfapyridine
Sulfapyridine acts only as a carrier to the colonic site of action but still causes side effects
What compound is mesalazine?
What is Balsalazide?
What is olsalazine?
5-ASA
prodrug of 5-ASA
dimer of 5-ASA
Non operative management of acute Diverticulitis FAILS or diffuse peritonitis requires ..
URGENT sigmoid colectomy is required
What are extraintestinal manifestations? Crohns
When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis
- 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?
- 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)
Budesonide less effective but fewer SE than corticosteroids as systemic effect limited. ASA less effective than corticosteroid or budesonide but preferable due to fewer SE.
When would you add in additional treatment (on top of steroid monotherapy) in a Crohn’s disease exacerbation?
What would you add?
2 or more inflammatory exacerbations in 12 months, or if the steroid dose cannot be reduced
Azathioprine or mercaptopurine
Is mercaptopurine licensed in severe UC and CD?
No
- What can be added to a steroid to induce remission in a Crohn’s patient?
- If these are not suitable, what could be used?
- Azathioprine
Mercaptopurine can be added but unlicensed
- Methotrexate
What test do you need to do before starting someone on azathioprine or mercaptopurine?
TPMT levels
If activity is deficient, it may not be suitable
What monoclonal antibodies are licensed for Crohn’s?
Adalimumab
Infliximab- active fistulating CD
Vedolizumab - rec for mod-sev active crohns disease when other two unsuitable/CI
- What is used for maintenance of remission for Crohn’s?
2. What would be second line and when would you use this?
- Azathioprine or Mercaptopurine (unlicensed)
2. Methotrexate if the patient required it to induce remission, or if azathioprine/mercaptopurine is unsuitable
Should steroids be used for the maintenance of remission for Crohn’s?
No- only to induce remission
What can be used to manage Crohn’s associated diarrhoea?
Loperamide, codeine phosphate, colestyramine
What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn’s?
Metronidazole and ciprofloxacin (unlicensed)
If metronidazole is given for fistulating Crohn’s, how long for and what are the associated risks?
1 month (no longer than 3) due to risk of peripheral neuropathy
What is used to control the inflammation in fistulating Crohn’s disease (and continued for maintenance)? How long should they be on this for?
Azathioprine or mercaptopurine (unlicensed) or infliximab. Infliximab should be used after ensuring that all sepsis is actively draining.
At least 1 year
Can you use loperamide and codeine phosphate in acute UC?
No- contraindicated as it increases the risk of toxic megacolon but can be used in non acute UC
What type of laxative may be useful for proximal faecal loading in proctitis?
Macrogol containing osmotic laxative
Acute treatment to induce UC remission generally consists of ?
In acute mild-mod extensive UC can oral and rectal ASA be given 1st line?
ASA +/- corticosteroid
YES. Oral and rectal ASA in combo can be used 1st line in pt with acute mild-mod extensive UC - this is assoc with higher rates of improvement in disease activity
What ASA have rectal preparations?
Mesalazine or sulfasalazine
What is first line treatment for patients with acute exacerbation mild-moderate left-sided or extensive UC?
BNF: High induction dose of an oral ASA, with additional rectal ASA/oral Beclometasone if necessary.
Online BnF: topical ASA 1st line. If no remission in 4 weeks add ^dose oral ASA or switch to ^dose oral ASA and 4-8 weeks of topical corticosteroid. If response inadequate stop topical treatment and offer oral ASA and 4-8 weeks of oral corticosteroid.
Oral pred. alone is rec for pts who cannot tolerate/decline/CI ASA or in pts with subacute left-sided or extensive ulcerative colitis.
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
Why does oral budesonide have fewer systemic side effects than corticosteroids? (UC)
It exerts its action topically in the colon
UC
True or false:
Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable
True
Are corticosteroids suitable for maintenance treatment of UC?
No because of their side effects G - Glaucoma (topical) L - Limb muscle atrophy/myopathy U - Peptic Ulcer C - Cataract (systemic) O - OS (dose/duration dep) C - Cushings (moon face, fat, striae) O - Osteonecrosis R - Retardation of growth in children + ^BP (^mineralocorticoid => salt and water retention. and ^vascular reactivity) T - Thinning skin = easy bruising I - Infections <= immunosuppression C - changes in mood/psyche O - oedema (mineralocorticoid action salt water retention) I - impaired healing of wounds D - Diabetes Mellitus (^hyperglycaemia) S - Suppression of HPA (long term use; acute adrenal insufficiency if steroids withdrawn)
What should be given in acute severe UC?
IV corticosteroids
IV ciclosporin is an alternative (unlicensed)
Infliximab
Assess for surgery
What monoclonal antibodies are used for acute UC?
Adalimumab, golimumab, infliximab, vedolizumab
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
What can be used to maintain remission after an acute exacerbation of left-sided or extensive UC?
Low dose oral ASA
Oral azathioprine or mercaptopurine [unlicensed indications] can be considered to maintain remission, if there has been 2 or more inflammatory exacerbations in 12-months that required tx with systemic corticosteroids, or if remission is not maintained by ASAs, or following a single acute severe episode.
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
What are the red flag side effects of aminosalicylates?
Agranulocytosis Bone marrow disorders Neutropenia Cardiac inflammation Renal impairment - nephrotoxicity
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)
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
What should patients on sulfasalazine be aware of if they wear contact lenses?
May stain the lenses yellow/orange
What should a patient be screened for if starting vedolizumab?
TB
Contraindicated in those with TB
What is alverine citrate used for?
GI spasms
Dysmenorrhoea
Why would lactulose not be suitable in a patient with IBS?
Causes bloating
In IBS patients who have had constipation the last 12 months but have not responded to laxatives, what can be used?
Linaclotide
What is 1st line for diarrhoea in IBS?
Loperamide
What is co-phenotrope used for and what is a main side effect of it?
Decreases faecal output
Opioid that crosses BBB
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
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.
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.
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.
Methylcellulose is a type of what laxative?
Bulk forming (also acts as a faecal softener)
Sterculia is a type of what laxative?
Bulk forming
When is onset of action for bulk forming laxatives?
___________ has onset of action of 8 to 12 hours. Note that ___________ has an onset of action of 10-12 hours
Within 72 hours
Senna has onset of action of 8 to 12 hours. Note that bisacodyl has an onset of action of 10-12 hours
Bisacodyl is what type of laxative?
Stimulant
Sodium picosulfate is what type of laxative?
Stimulant
Senna is what type of laxative?
Stimulant
Docusate sodium is what type of laxative?
Stimulant laxative and faecal softener
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
Arachis oil enema would be contraindicated in patients with what allergy?
Peanuts
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
What is lubiprostone used for?
Licensed for the treatment of chronic idiopathic constipation in adults whose condition has not responded adequately to lifestyle changes
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.
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?
- Bulk forming
2. Stimulant laxative
- In patients with opioid induced consitipation, what would be appropriate?
- If these do not work, what can then be used?
- Osmotic laxative and stimulant laxative
Docusate sodium can be used to soften the stools - Naloxegol
Methylnaltrexone bromide
What type of laxative should be avoided in opioid induced constipation?
Bulk forming
What is 1st line medication for constipation in pregnancy after dietary measures?
Bulk forming laxative
Or lactulose [osmotic)
Stimulant effect: bisacodyl/senna but do not use senna near term or if history of unstable pregnancy. Stimulants more effective than bulk but SE diarrhoea/abdo discomfort reduce acceptability.
Docusate sodium and glycerol suppositories can also be used
True or false:
Stimulant laxatives are more effective than bulk-forming laxatives but more likely to cause side-effects
True
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. alternative, a short course of a stimulant laxative such as bisacodyl or senna can be considered.
- What is 1st line for constipation in children after dietary measures?
- If response is inadequate, what can be tried?
- If stools remain hard, what can be used?
- Macrogol 3350 with KCL, sodium bicarbonate and NaCl
- Add or change to a stimulant laxative
- Lactulose or docusate
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 over months
How many days classifies acute diarrhoea? How long do symptoms last? What could be the causes?
Less than 14 days but symptoms usually improve in 2-4 days. Can result from infection, drug SE or acute symptom of chronic GI disorder, accumulation of non absorbed osmotically active solutes in GI lumen (eg lactase deficiency) or GI effects of secretory stimuli or when intestinal motility/morphology is altered
What is the maximum daily licensed dose for loperamide?
16mg
Adult dose 4mg initially followed by 2mg up to 5 days. dose taken after each loose stool. usually 6-8mg daily.
What is the MHRA advice regarding loperamide?
What can be given in event of an overdose?
Serious cardiac ADR with high doses associated with abuse.
QT prolongation, torsades de points, cardiac arrest.
Overdose: naloxone antidote. loperamide duration is longer than naloxone (1-3) hours so repeated treatment may be indicated. Monitor for 48 hrs for possible CNS depression.
Pharmacists should advise pts not to take more than recommended dose on label
Is kaolin recommended for acute diarrhoea?
No - insufficient evidence to recommend adsorbent preparations
What role do antacids play in dyspepsia?
Symptomatic relief
What is a side effect of magnesium?
Laxative effect
What is a side effect of aluminium?
Constipation
Why is bismuth containing antacids not recommended ?
Neurotoxic, causing encephalopathy, tends to be constipating
What are the side effects associated with calcium containing antacids?
Can induce rebound acid secretion
Hypercalcaemia
Alkalosis
Constipation
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
What would be a standard treatment for a H.Pylori patient who is not penicillin allergic?
7 day course
1. PPI + Amox AND choice of: clarithromycin or metronidazole (exclude amox if pen allergy, keep clarithromycin and metronidazole)
2. (switch latter for 2nd treatment of ongoing symptoms)
2. for pt who received prev treatment with clarithromycin and metronidazole
PPI + Amox + tetracycline [unlicenced] OR levofloxacin [unlicenced]
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
H.Pylori treatment:
What antibiotics are prone to resistance during the course?
Clarithromycin and metronidazole
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
What could be used as an alternative to metronidazole in H.Pylori treatment?
Tinidazole
What would be the dose of ranitidine in prophylaxis against NSAID related ulcers?
What would be an alternative?
300mg BD
Misoprostol
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
What is sucralfate used for?
Gastric/duodenal ulceration
Gastritis
Prophylaxis of stress ulceration
What is the main caution with sucralfate?
Bezoar formation- solid mass of indigestible material that accumulates and can cause a blockage
In Zollinger-Ellison syndrome, should a PPI or a H2 receptor antagonist be used?
PPIs as they are more effective
What is the only H2 receptor antagonist that can be given IV?
Ranitidine
What can be used to reduce the degradation of pancreatic enzyme supplements in CF patients?
PPI
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
What 2 electrolytes can drop if on PPIs?
Sodium and magnesium
Do PPIs or H2 receptor antagonists provide more relief of GORD symptoms?
PPIs
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
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
- How do you manage GORD in pregnancy?
2. If this is ineffective, what can be tried?
- Diet and lifestyle changes
Antacid/alginate - Ranitidine
When would you give a pregnant lady omeprazole for GORD?
Severe or complicated reflux disease.
How should a child with oesophagitis be treated?
H2 receptor antagonist
If this does not work, omeprazole
What is licensed as an adjunct to dietary avoidance in patients with food allergy?
(hint- not an epi-pen)
Sodium cromoglicate
What antihistamine is licensed for the symptomatic control of food allergy?
Chlorphenamine
Buscopan contains what active ingredient?
Hyoscine butylbromide
Kwells contains what active ingredient?
Hyoscine hydrobromide