Pharmaceutical Care: Gastrointestinal Patients 1 Flashcards
What is dyspepsia?
Any upper GI symptoms present for 4 weeks or more
What are the symptoms of dyspepsia?
- Heartburn
- Fullness
- Early satiety
- Upper abdominal pain or ache- ulcer
- Flatulence
- Hiccups coughing
- Belching
What are the medicines which may cause dyspepsia?
- Calcium antagonists
- Nitrates
- Theophylline
- Bisphosphonates
- NSAIDS
What are the causes and signs where you should refer someone with dyspepsia?
- Chronic GI bleeding
- Progressive unintentional weight loss
- Persistent vomiting
- Progressive difficulty swallowing
- Iron deficient anaemia
- Epigastric mass
- Suspicious barium meal
What does each letter in ALARM stand for and what is it for?
A- Age- over 55
L- significant and unintentional weight loss
A- Anaemia
R- Recurrent vomiting and difficulty swallowing
M- Maleana- production of dark sticky faeces
Noticing early signs of gastric cancer
When should you give antacids and what does the magnesium and aluminium laxative do?
- Antacids: best given when symptoms occur or are expected
- Magnesium = laxative
- Aluminium = constipating
How do alginates work?
- Protects against acid reflux by building a raft
2. Increases viscosity of stomach contents taken in combination with antacids
What are the problems which can occur when antacids are used with enteric coating?
Damaged by antacids
Pre mature dissolution
Speeding up the time to dissolve by increasing pH
What are the lifestyle changes required to handle dyspepsia?
- Smoking
- Alcohol
- Coffee
- Chocolate
- Fatty foods
- Weight
- Raise head of bed
- Do not eat too late
What are the causes of GORD?
- Failure of the lower oesophageal sphincter (LOS)- a ring of muscle towards the bottom of the oesophagus
- Acts like a valve to let food fall into the stomach- closes to prevent acid leaking out of stomach to oesophagus
- This doesn’t close probably which causes acid to leak out of stomach
What are the know risk factors for GORD?
- Overweight or obese
- Pregnant
- High fat diet
What is the role of the pharmacist against GORD- lifestyle factors and medication?
- Simple advice regarding lifestyle factor
- Smaller meals
- Do not eat too late into evening
- Weight management
- Smoking cessation
- Raise head of bed by 4 inches- acid doesn’t travel as far in oesophagus
- Stress management - Reviewing patient’s medication- avoid drugs that cause or exacerbate symptoms:
- Theophylline
- Nitrates
- Calcium channel blockers
- Beta blockers
- Alpha Blockers
- Anti cholinergics
How do proton pump inhibitors work, what are the cautions, side effects and
- Inhibit gastric secretion by blocking H+/K+ ATP enzyme system
- Can mask signs of gastric cancer
- Prescribed at lowest effective dose- shortest time period
- Side effects: GI disturbances, increased risk of fractures and reduces gastric acidity (C difficile infections)
What is the dosing for omeprazole?
20 to 40mg OD for 4 weeks (max 8 weeks)
then 20mg OD
What is the medicines management issues with proton pump inhibitors?
- High dose of PPI hasn’t be reviewed
- Clostridium Difficile
- Polypharmacy
- Just extra medicine to take
- Capsule size
- Taste
- Drug interactions
What is ulcerative colitis?
- Chronic and UNPREDICTABLE- relapsing remitting non infectious inflammatory disease
- Mucosa of the rectum and a variable length of the colon are inflamed
What is Crohn’s disease?
- Chronic relapsing and remitting, non infectious inflammatory disease
- The inflammation involves discrete parts of gastro-intestinal tract
What is inflammatory bowel disease?
- A encompassing term for the diseases of ulcerative colitis and Crohn’s disease
- Chronic disease of inflammation of the gut
Where does Ulcerative Colitis mainly effect, its symptoms, endoscope findings and complications?
- Site: colon only
- Symptoms:
Bleeding, diarrhoea, abdominal pain - Endoscope:
Rectal involvement
Inflammation: Continuous, diffuse erythema and ulceration in inflamed mucosa - Complications:
Uncommon fistulas, no strictures (restriction on purpose or activity)
Where does Crohn’s disease mainly effect, its symptoms and endoscope findings?
- Any part of the GI tract
- Symptoms:
Diarrhoea, Abdominal pain, growth failure - Endoscope:
- Doesn’t really involve rectum,
Inflammation: Discontinuous, patchy lesions, discrete ulcers in normal mucosa - Complications:
Frequent Fistulas, common strictures, increased cancer risk
What are the ways to diagnose Ulcerative colitis or Crohn’s disease?
- Stool sample
- Temperature
- Sigmoidoscopy or colonoscopy (image of whats in bowel)
- Faecal calprotectin- released into intestines in excess where there is most inflammation (most useful to differentiate between IBS or inflammatory bowel disease)
- Differential diagnosis of IBD and IBS as similar symptoms
What is the Harvey Bradshaw index?
An index for severity of Crohn’s disease
What is the colon and different areas of the small intestine used for in terms of absorption?
- Colon- water absorption
- Duodenum- iron and calcium irons
- Jejunum- folic acid
- Ileumn- fat and vitamin B12
What are the treatment options for pain in GI problems?
- First line: Paracetamol
- NSAIDS
- Opioids
What are the indication of steroids, long term risks, how it’ll be used (dosage form) and when it is generally used?
- Crohn’s disease and ulcerative colitis in moderate severe relapse
- Long term risk of osteoporosis
- Dosage form: rectal steroids when oral steroids are not being kept in the body long enough
- Generally used when patient does not respond to rectal mesalazine
- Hydrocortisone
- Prednisolone- different formulations= different site of action
- Steroid rescue- Hydrocortisone 100mg QDS
When should you use a suppository dosage form?
Rectum
Proctitis
When should you use foam dosage form?
Sigmoid colon
Proctosigmoiditis
When should you use an enema dosage form?
Descending colon to splenic fixture
Left sided colitis
Describe the mechanism of action of Mesalazine (5-aminosalicylic acid) and where it’s normally absorbed?
- Orally would be extensively absorbed from the upper GIT with little of the drug reaching the colon
- Modified release preparations can release the drug in the terminal ileum and colon
- Anti-inflammatory dru structurally related to salicylate
- Inhibits prostaglandins and leukotriene synthesis, release of reactive oxygen species and other actions
When sulfasalazine is taken into the body, what does colonic bacteria metabolise it into?
5 Aminosalicyclic acid
Sulfapyridine- waste product
What are each of the dosage forms of Mesalazine coated in and what are they each for in GI?
Asacol MR- terminal ileum and large bowel
Ethylcellulose coated microgranules- duodenum to rectum
Octasa MR/EC- terminal ileum and colon
Sulfasalazine- colon
What are the other considerations that must be taken into account when treating inflammatory bowel disease?
- Opportunisitic infections- vaccines may be needed
- Anaemia- side effects of drugs can cause losing blood count
- Nutrition
- Side effects- DVT risk
- Osteoporosis risk- using steroids
- Optimise treatment
How does tablet size and frequency affect adherence? And how can you solve this?
- Tablet size can be a problem when patient is acutely unwell
- Large tablet or many tablets overwhelming
- Talking to patient to aid adherence and compliance to their treatment regimens
What are Thiopurines and what must be checked after using them?
- Immunosuppressant drugs and side effects must be monitored after use
- Assess the TPMT activity before offering drugs such as azathioprine or mercaptopurine
- This level cannot be low
What is the MoA of azathioprine and severe side effect
Immunosuppressive drug
Purine analogue
Prodrug for mercaptopurine (active metabolite)
Severe side effect; bone marrow suppression, not used in conjunction with purine analogues
What is Methotrexate used for and the dose?
- Used in active and relapsing Crohn’s disease
- 25mg per week orally or IV
- Monitor FBC and LFTS
- Maintenance dose to prevent remission
What is ciclosporin used for?
Therapy for acute severe ulcerative colitis
Can be used alongside intravenous corticosteroids in one mix who have little or no improvement after use of steroids within 72 hours
How do you treat mild to moderate ulcerative colitis
Adding tacrolimus to oral prednisolone to induce remission
Give an example of a monoclonal antibody and its use in inflammatory bowel disease?
- Example: Infliximab licensed for management of severe active Crohn’s disease and severe ulcerative colitis
- Used when not respond to corticosteroid treatment and it’s conventional drug that affects the immune system response
- Planned treatment is 12 months
What is the mechanism of action of monoclonal antibodies?
- TNF-alpha has been implicated in numerous autoimmune diseases
- Regulates inflammation
- Infliximab is a chimeric monoclonal antibody that binds to TNF alpha
- Inactivates TNF alpha and inflammatory process is diminished significantly
What is a stoma?
- Artificial opening of the bowel to remove waste which can be permanent or temporary
- Can bypasses the entire bladder system
What are the three main types of stoma and what do they mean?
Ileostomy- opening from small bowl to allow large faeces to leave body (no need to pass through large bowel)
Colostomy- opening from large bowel to allow faeces to leave body without passing through anus
Urostomy- opening from ureters to allow urine to leave body without passing bladder
What are the effect of medicines on the bowel of stoma and give examples of these sorts of medicines?
- Effect may be on drug absorption and action or stoma function
- Medicines for pharmacokinetics:
- Slow release preparations- drug might not be absorbed
- Enteric coated preparations- drug might not be absorbed
- Film coatings- excreted in stoma bag
For stoma patients, what is the diet that is recommended?
- Encourage to maintain varied diet as possible
- Patients should chew food regularly to aid digestion
- Eat regularly as it regulates stoma function
- Drink larger amounts of water and ensure you have enough salt in diet
- High fibre foods may cause stomal discharge and stimulate gut to give you diarrhoea or blockage
