Pharmaceutical Care of Gastrointestinal patients 1 dyspepsia and GORD

Question 1

Define : Dyspepsia

Answer 1

any symptom of the upper GI tract, present for 4 weeks or more, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea or vomiting

Question 2

list the symptoms of dyspepsia

Answer 2

1) Heartburn
2) Fullness
3) Early satiety
4) Upper abdominal pain or ache
5) Flatulence
6) Hiccups coughing
7) Belching

Question 3

list some drugs that cause dyspepsia

Answer 3

1) Calcium antagonists
2) Nitrates
3) Theophylline
4) Bisphosphonates
5) NSAIDs
- Review medications as possible cause

Question 4

Urgent specialist referral, is indicated for patients of any age with dyspepsia when presenting with certain alarm symptoms. list some of these alarm symptoms

Answer 4

Urgent referral for endoscopic investigation:

1) Chronic GI bleed
2) Progressive, unintentional weight loss
3) Progressive difficulty swallowing
4) Persistent vomiting
5) Iron deficient anaemia
6) Epigastric mass
7) Suspicious barium meal

Question 5

what does the acronym ALARM stand for with regards to dyspepsia

Answer 5

1) Age >55
2) L significant and unintentional weight loss
3) Anemia
4) Recurrent vomiting/difficulty swallowing
5) Malaena - dark sticky faeces containing partly digested blood

Question 6

what Medicines can be used to treat dyspepsia?

Answer 6

1) Antacids (contain aluminium or magnesium)
- Best given when symptoms occur or are expected: With meals/bedtime
2) Magnesium = laxative
3) Aluminium = constipating
4) Alginates
- Increases the viscosity of the stomach contents taken in combination with antacids
- Protects against acid-reflux - Raft

Question 7

what effect do antacids have on EC tablets?

Answer 7

Antacids damage enteric coatings designed to prevent dissolution in the stomach

Question 8

discuss what you should consider when recommending a particular formulation for the treatment of dyspepsia to a consumer.

Answer 8

1) Patient choice
2) Practicality- do they want tablets or a liquid?
3) Taste!
4) Effectiveness- double action?

Question 9

list the different formulations Gaviscon is available as

Answer 9

1) Gaviscon Liquid, tablets, liquid sachets
2) Gaviscon Double action liquid, tablets, liquid sachets
3) Gaviscon Advance liquid, tablets

Question 10

list the lifestyle changes recommended for patients who suffer from dyspepsia

Answer 10

1) Smoking
2) Alcohol
3) Coffee
4) Chocolate
5) Fatty foods
6) Weight
7) Raise head of bed
8) Don’t eat too late

Question 11

what is GORD?

• who is normally affected?
• what is the treatment?

Answer 11

1) gastro-oesophageal reflux disease refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease.
2) GORD is a common digestive condition.
3) Adults aged 40 years or over are mainly affected
4) Offer patients who have GORD a full-dose PPI for 1 or 2 months.
5) If symptoms recur – low dose PPI

Question 12

Discuss the causes of GORD and outline the known risk factors

Answer 12

1) Most common is the failure of the lower oesophageal sphincter (LOS)
2) This acts like a valve, opening to let food fall into the stomach, then closing to prevent acid leaking out of the stomach back into the oesophagus.
3) In GORD, this sphincter doesn’t close properly, allowing acid to leak up out of the stomach.
4) Known risk factors for GORD include:
- being overweight or obese
- being pregnant
- eating a high-fat diet

Question 13

outline the role of a pharmacist in the treatment of GORD

Answer 13

1) advice regarding lifestyle factors that may affect reflux:
- Smaller meals, eat earlier in the evening
- Weight management
- Smoking cessation
- If practical, advise the person to try raising the head of their bed
- Stress management
2) Review the person’s medication and, if possible, avoid drugs that may cause or exacerbate symptoms.

Question 14

list the drugs that reduce lower oesophageal sphincter pressure

Answer 14

1) Theophylline
2) nitrates
3) calcium-channel blockers
4) beta-blockers
5) alpha-blockers
6) benzodiazepines
7) tricyclic antidepressants
8) anticholinergics

Question 15

how do PPI’s work and why should you use them with caution?

- what is the dosage and treatment period?

Answer 15

1) Inhibit gastric secretion by blocking hydrogen-potassium adenosine triphosphatase enzyme system
2) Caution: can mask signs of gastric cancer – ALARM
3) Prescribed at lowest effective dose and for shortest period of time

Question 16

what are the side effects of PPI’s?

Answer 16

1) GI disturbances,
2) Rarely: hyponatraemia and hypomagnesaemia (usually >1 year)
3) By reducing gastric acidity = increased risk of GI infections for example Clostridium difficile.
4) Increased risk of fractures, particularly in elderly

Question 17

list 3 PPI’s and state their doses

Answer 17

1) Esomeprazole: 40mg OD 4 weeks (max 8 weeks) then 20mg OD
2) Lansoprazole: 30mg OD 4 weeks (max 8 weeks) then 15-30mg OD
3) Omeprazole: 20-40mg OD for 4 weeks (max 8 weeks) then 20mg OD
- 8mg/hr 72 hours (IV infusion)

Question 18

what counselling advice would you provide for Esomeprazole

Answer 18

1) oral : Do not crush/chew. Can be dispersed in water if taken within 30 mins
2) Granules ( Gastric tube/ difficulty swallowing/ children): Disperse in 15ml water. Stir and leave to thicken and use within 30 mins, rinse 15ml water to obtain full dose

Question 19

what counselling advice would you provide for Lansoprazole

Answer 19

1) capsules: Do not take indigestion remedies 2 hours before/after taking medicine. Take 30-60 mins before food. Swallow whole
2) FasTab (dispersable tabs) Gastric tube/ difficulty swallowing Children: Place tablet on tongue, allow disperse and swallow.

Question 20

what counselling advice would you provide for Omeprazole

Answer 20

1) Capsules: swallow whole
2) MUPS capsules- gastric tube: Disperse contents in sodium bicarbonate administer gastric tube
3) MUPS tablets- Swallowing difficulty/children: Disperse in water or mix with fruit juice/ yogurt

Question 21

discuss the Medicines management issues with regards to PPI’s

Answer 21

1) High dose PPI not reviewed
2) Clostridium difficile
3) Polypharmacy
4) Just an extra medicine to take?
- Capsule size, Taste,Drug interactions

Question 22

1) What is the duration of PPI treatment recommended in GORD?
2) Avoiding precipitating factors should NOT be recommended – True or False?
3) H2 antagonists should be recommended first line for the treatment of GORD – True or False?
4) The highest dose of PPI should be prescribed – True or False?

Answer 22

1) offer patients who have GORD a full-dose PPI for 1 or 2 months.
2) false
3) false
4) false - prescribed at lowest effective dose and for shortest period of time