BNF - Chapter 1 - GI System Flashcards
1
Q
What is clostridium difficle infection?
A
This infection is caused by accumulation of clostridium difficile in the colon and the production of toxin.
2
Q
Which antibiotics can cause/ induce C.difficile?
A
- Ampicillin
- Amoxicillin
- Co-amoxiclav
- cephalosporins
- Clindamycin
- Quinolones
3
Q
Which drugs can be used to treat C.difficle?
A
- Vancomycin
- Metronidazole
- Fidaxomicin
4
Q
What is the first line treatment for first episode mild, moderate or severe C.difficile infection as per NICE?
A
Vancomycin
125mg orally four times a day for 10 days
5
Q
What is the second line treatment for a first episode mild moderate or severe c.difficile infection if vancomycin is ineffective?
A
Fidaxomicin
200mg orally twice a day for 10 days
6
Q
What is the next step is first and second line treatment for C.difficile are ineffective?
A
Seek specialist advice. Specialists may initially offer:
Vancomycin:
Up to 500 mg orally four times a day for 10 days
With or without
Metronidazole:
500 mg intravenously three times a day for 10 days
7
Q
Which drug would be used for a further episode of C.difficile infection within 12 weeks of symptom resolution?
A
Fidaxomicin:
200 mg orally twice a day for 10 days
8
Q
Which drug would you use for a further episode of C.difficile infection more than 12 weeks after symptom resolution?
A
Vancomycin:
125 mg orally four times a day for 10 days
Or
Fidaxomicin:
200 mg orally twice a day for 10 days
9
Q
Which drugs would be sued for life-threatening C.difficile?
A
Seek urgent specialist advice, which may include surgery. Antibiotics that specialists may initially offer are:
Vancomycin:
500 mg orally four times a day for 10 days
With
Metronidazole:
500 mg intravenously three times a day for 10 days
10
Q
Can you provide antibiotics to prevent C.difficile infection?
A
No not for prevention
11
Q
What is Coeliac disease?
A
This is an autoimmune condition associated with chronic inflammation of the small intestine.
- Gluten (dietary protein) present in wheat, barley and rye activates an abnormal immune response in the intestinal mucosa. This results in malabsorption of nutrients.
Coeliac disease is a condition where your immune system attacks your own tissues when you eat gluten. This damages your gut (small intestine) so you are unable to take in nutrients
12
Q
what are the symptoms of coeliac disease?
A
diarrhoea, which may smell particularly unpleasant stomach aches bloating and farting (flatulence) indigestion constipation
Coeliac disease can also cause more general symptoms, including:
tiredness (fatigue) as a result of not getting enough nutrients from food (malnutrition)
unintentional weight loss
an itchy rash (dermatitis herpetiformis)
problems getting pregnant (infertility)
nerve damage (peripheral neuropathy)
disorders that affect co-ordination, balance and speech (ataxia)
13
Q
As coeliac disease means there is an increased risk of malabsorption of key-nutrients e.g. calcium +vitamin D what should be monitored?
A
Risk of osteoporosis needs to be monitored.
Advise patients not to self-medicate with OTC vitamins or mineral supplements
14
Q
Give two examples of Inflammatory bowel disease?
A
Chronic Inflammatory bowel diseases include Crohn’s disease (affecting any part of the G.I. tract) and Ulcerative colitis (limited to the colon).
15
Q
For Chron’s disease what non-drug treatment advice can be given?
A
- Smoking cessation
16
Q
What is the treatment steps for Chron’s disease and Ulcerative Colitis?
A
1st line = Aminosalicylates - sulfasalazine and mesalazine
2nd line = Azathioprine or Mercaptopurine
3rd line = Monoclonal antibodies (Adalimumab/ Infliximab)
17
Q
With aminosalicylates - what change of urine colour can occur?
A
- orange/yellow staining of body fluids e.g. urine can also occur
18
Q
Patient’s who are taking aminosalicylates should report which symptoms?
A
• Patients should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise during treatment which could indicate a blood disorder.
19
Q
Is it safe to wear contact lenses while on aminosalicylate treatment?
A
• People taking Aminosalicylate’s should refrain from wearing their contact lenses as they can cause staining.
20
Q
Are some mesalazine preparations more effective than others?
A
- No oral preparation of mesalazine is more effective than the other, however the delivery characteristics of oral mesalazine preparations may vary
21
Q
If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report what?
A
Report any changes in symptoms
22
Q
Sulfasalazine may discolour the urine to which colour?
A
may turn skin or urine to orange or yellow
23
Q
Before initiating monoclonal antibodies for 3rd line treatment of IBD what must the patient be screened for?
A
Must be screened for tuberculosis prior to starting treatment.
24
Q
If latent TB is diagnosed what must be done?
A
appropriate treatment must be initiated prior to starting treatment.
25
What if tuberculosis is diagnosed during IBD treatment with monoclonal antibodies?
- If tuberculosis is diagnosed during treatment, discontinue until infection resolved.
26
What's a common adverse effect of monoclonal antibodies ?
A flu-like infusion reaction which can be prevented or lessened by pre-treatment of an antihistamine and paracetamol with or without corticosteroid
27
Is contraception required during monoclonal antibodies treatment?
Effective contraception is required during and for at least 18 weeks after treatment.
28
Can you breastfeed while on monoclonal antibody treatment?
No
29
When on monoclonal antibody treatment for IBD what must be closely monitored?
Monitor closely for infection before, during and after treatment increased risk of opportunistic infections.
30
What is the aims of treatments for Coeliac disease?
To eliminate symptoms (such as diarrhoea, bloating and abdominal pain).
31
What is the only effective treatment for coeliac disease?
A strict diet - life long gluten free diet.
| A range of gluten free products is available for prescription.
32
What is Diverticulosis?
It is an asymptomatic condition characterised by the presence of diverticula (small pouches protruding from the walls of the large intestine).
Diverticulosis is a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon.
33
What is the prevalence of diverticulosis and which age does it tend to affect?
The prevalence is difficult to determine but it is age dependent, with majority of patients aged 40 years and over?
34
What is Diverticular disease?
It is a condition where diverticular are present with symptoms such as abdominal tenderness and/or mild, intermittent lower abdominal pain with constipation, diarrhoea, or occasional large rectal bleeds.
35
Symptoms of diverticular disease may overlap with which other conditions?
Conditions such as irritable bowel syndrome, colitis (bowel inflammation related to Chron's disease, Ulcerative Colitis, ischaemia or microscopic colitis), and malignancy.
36
When does acute diverticulitis?
Acute diverticulitis occurs when diverticula suddenly become inflamed or infected.
37
What are the signs and symptoms of acute diverticulitis?
- constant lower abdominal pain (usually severe) together with features such as fever, a sudden change in bowel habits and significant rectal bleeding,
- lower abdominal tenderness, or a palpable abdominal mass.
38
What does complicated acute diverticulitis refer to?
refers to diverticulitis associated with complications such as abscess, bowel perforation and peritonitis, fistula, intestinal obstruction, haemorrhage, or sepsis.
39
What is the aims of treatment of diverticular disease?
Treatment aims to relieve symptoms of diverticular disease, improve quality of life, manage episodes of acute diverticulitis, and reduce the risk of recurrence and complications.
40
What advice can be given to patients for non-drug management of diverticular disease?
Patients with diverticulosis or diverticular disease should be advised to eat a healthy, balanced diet including whole grains, fruit and vegetables. In patients with constipation and on a low fibre diet, a gradual increase of dietary fibre may minimise flatulence and bloating. Patients increasing dietary fibre should be advised to drink an adequate amount of fluid, especially if dehydration is a risk. Advice should also be given about the benefits of exercise, weight loss (if overweight or obese), and Smoking cessation, in reducing the risk of symptomatic disease and acute diverticulitis.
41
What should patients with diverticular disease be informed on regarding fibre?
Patients with diverticular disease should also be informed that it may take several weeks for the benefits of increasing fibre in their diet to be achieved and that if a high-fibre diet is tolerated, it should be continued for life.
42
Are there any drug treatment for diverticulosis?
No as diverticulosis is an asymptomatic condition, specific treatments are not recommended.
- bulk-forming laxatives can be considered for patients with constipation.
43
For diverticular disease, are antibacterial recommended?
not recommended
44
Which laxative can be considered for people with diverticular disease for patients which high-fibre diet is unsuitable or have persistent constipation?
A bulk-forming laxative
45
For diverticular disease, what drugs should be considered for abdominal pain/ abdominal cramps?
Consider the use of simple analgesia such as paracetamol in patients with ongoing abdominal pain, and antispasmodics in those with abdominal cramps.
46
Can NSAIDs or opioids be used safely in diverticular disease?
Non-steroidal anti-inflammatory drugs and opioid analgesics are not recommended as their use may increase the risk of diverticular perforation.
47
What is the treatment for acute diverticulitis?
- Offer simple analgesia such as paracetamol to patients with acute diverticulitis who are systemically well. Consider a watchful waiting and a no antibacterial prescribing strategy, and advise patients to re-present if symptoms persist or worsen.
- Patients with persistent or worsening symptoms should be reassessed in primary care and considered for referral to hospital for further assessment.
48
Can aminosalicylates or prophylactic antibacterials be used to prevent recurrent acute diverticulitis?
Treatment with aminosalicylates or prophylactic antibacterials are not recommended to prevent recurrent acute diverticulitis.
49
What part of the body does Chron's disease affect?
can affect the whole of the GI tract
50
Which part of the body dose Ulcerative colitis affect?
Mainly the colon
51
What is sulfasalazine (aminosalicylate) a combination of?
Combination of 5-aminosalicylic acid (5-ASA) and sulfapyridine. Sulfapyridine acts only as a carrier to the colonic site of action but still causes side-effects.
52
What are the newer aminosalicylates?
- Mesalazine (5-aminosalicylic acid)
- Balsalazide sodium (a pro-drug of 5 aminosalicylic acid)
- osalazine sodium (a dimer of 6-aminosalicylic acid which cleaves in the lower bowel)
The sulfonamide-related side effects of sulfalazine are avoided, but 5-aminosalicylic acid alone can still cause side-effects including blood disorders and lupus-like syndrome also seen with sulfasalazine.
53
What is lupus-like syndrome?
Drug-induced lupus (DIL) is a disorder with clinical, histological, and immunological features similar to idiopathic systemic lupus erythematosus, but that occurs when certain drugs are taken and resolved after discontinuation of the offending agent.
54
What are the symptoms of lupus-like syndrome?
muscle and joint pain sometimes with swelling
flu-like symptoms of fatigue and fever
serositis (inflammation around the lungs or heart that causes pain or discomfort)
certain laboratory test abnormalities
While the symptoms of drug-induced lupus are similar to those of systemic lupus, only rarely will any major organs be affected.
55
What is Chron's disease characterised by?
By thickened areas of the gastro-intestinal wall with inflammation extending through all layers, deep ulceration and fissuring of the mucosa, and the presence of granulomas.
56
What are some of the complications of Crohn's disease?
include intestinal strictures, abscesses in the wall of the intestine or adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in children.
57
What extra-intestinal manifestation can Chron's disease be associated with?
the most common are arthritis and abnormalities of the joints, eyes, liver and skin.
58
Chron's disease is also a cause of secondary ..........?
Crohn's disease is also a cause of secondary osteoporosis and those at greatest risk should be monitored for osteopenia and assessed for the risk of fractures.
59
What is fistulating Crohn's disease?
Fistulating Crohn's disease is a complication that involves the formation of a fistula between the intestine and adjacent structures, such as perianal skin, bladder, and vagina. It occurs in about one quarter of patients, mostly when the disease involves the ileocolonic area.
60
What is the aims of Chron's disease treatment?
Treatment is largely directed at the induction and maintenance of remission and the relief of symptoms.
The aims of drug treatment are to reduce symptoms and maintain or improve quality of life, while minimising toxicity related to drugs over both the short and long term
61
What about in fistulating Crohn's disease? what are the aims of treatment?
In fistulating Crohn's disease, surgery and medical treatment aim to close and maintain closure of the fistula.
62
What are non-drug treatment options for Crohn's disease?
management options for Crohn's disease include Smoking cessation and attention to nutrition, which plays an important role in supportive care.
63
What is the treatment for acute disease of Crohn's disease?
Monotherapy
- A corticosteroid (either prednisolone or methylprednisolone or intravenous hydrocortisone), is used to induce remission in patients with a first presentation or a single inflammatory exacerbation of Crohn's disease in a 12-month period.
64
In patients with distal ileal, ileocaecal or right-sided colonic disease in which cotricosteroid is unsuitable or contraindicated, what drug may be considered?
Budesonide
65
Is budesonide more or less effective than other corticosteroids?
Budesonide is less effective but may cause fewer side-effects than other corticosteroids, as systemic exposure is limited.
- Also aminosalicylates such as sulfasalazine and mesalazine are an alternative option in these patients. They are less effective than a corticosteroid or budesonide, but may be preferred because they have fewer side-effects.
66
Can budesonide and aminosalicylates be used for severe presentations or exacerbations of Crohn's disease?
Aminosalicylates and budesonide are not appropriate for severe presentations or exacerbations.
67
When is add on treatment prescribed?
If there are two or more inflammatory exacerbations in a 12-month period, or the corticosteroid dose cannot be reduced.
68
Which drugs can be used as add on to induce remission?
Azathioprine or mercaptopurine [unlicensed indications] can be added to a corticosteroid or budesonide to induce remission.
69
When can methotrexate be used as an add on therapy for the inducing remission of Crohn's disease?
In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, methotrexate can be added to a corticosteroid.
70
Under severe supervision, what treatment options are there for severe active Crohn's disease?
Under specialist supervision, the tumour necrosis factor-alpha inhibitors adalimumab and infliximab are options for the treatment of severe, active Crohn's disease, following inadequate response to conventional therapies or in those who are intolerant of or have contra-indications to conventional therapy.
71
When are vedolizumab and ustekinumab indicated?
Vedolizumab is recommended for moderate to severely active Crohn's disease when therapy with adalimumab or infliximab is unsuccessful, is contra-indicated or not tolerated. Ustekinumab is recommended for moderate to severely active Crohn's disease when conventional therapy or therapy with adalimumab or infliximab is unsuccessful, is contra-indicated or not tolerated.
72
Can Adalimumab and infliximab be used as monotherapy or only as combined with an immunosuppressant?
Adalimumab and infliximab can be used as monotherapy or combined with an immunosuppressant although there is uncertainty about the comparative effectiveness and long-term side-effects of therapy.
73
What is the treatment for maintenance of remission of Crohn's?
Patients who choose not to receive maintenance treatment during remission should be made aware of the symptoms that may suggest a relapse (most frequently unintended weight loss, abdominal pain, diarrhoea and general ill-health). For those who choose not to receive maintenance treatment during remission, a suitable follow up plan should be agreed upon and information provided on how to access healthcare if a relapse should occur.
74
Which drugs can be used for maintenance of remission of Crohn's
- Offer azathioprine or mercaptopurine as monotherapy to maintain remission when previously used with a conventional glucocorticosteroid or budesonide to induce remission.
- Consider methotrexate (follow BNF/BNFC cautions) to maintain remission only in people who:
needed methotrexate to induce remission or
have tried but did not tolerate azathioprine or mercaptopurine for maintenance or
have contraindications to azathioprine or mercaptopurine (for example, deficient thiopurine methyltransferase [TPMT] activity or previous episodes of pancreatitis).
75
Which drugs should not be offered to maintain remission of Crohn's?
Do not offer a conventional glucocorticosteroid or budesonide to maintain remission.
76
Which drugs are used to maintain remission following surgery?
Azathioprine in combination with up to 3 months' postoperative metronidazole [unlicensed indication] should be considered to maintain remission in patients with ileocolonic Crohn's disease who have had complete macroscopic resection within the previous 3 months. Azathioprine alone should be considered for patients who cannot tolerate metronidazole.
77
Which drug is licensed for the relief of diarrhoea associated with Crohn's disease?
Cholestyramine
78
What is the treatment for fistulating Chron's disease?
When Fistulae are symptomatic. local drainage and surgery may be required in conjunction with medical therapy.
79
What is Ulcerative Colitis?
It is a chronic inflammatory condition, characterised by diffuse mucosal inflammation - it has a relapsing-remitting pattern.
80
Is ulcerative colitis a life long disease?
Yes that is associated with significant morbidity
81
Which ages is ulcerative colitis most common?
15 and 25 years of age although diagnosis can be made at any age.
82
What is meant by proctitis?
Inflammation of the rectum is referred to as proctitis.
83
What is meant by proctosigmoiditis?
Inflammation of the rectum and sigmoid colon as proctosigmoiditis.
84
What does left-sided colitis refer to?
Refers to disease involving the colon distal to the splenic flexure.
85
What does Extensive colitis affect?
Affects the colon proximal to the splenic flexure, and includes pan-colitis, where the whole colon is involved.
86
What are the common symptoms of active UC or relapse?
- bloody diarrhoea
- diarrhoea
- an urgent need to defaecate
- Abdominal pain
87
What are some of the complications of UC?
- Increased risk of colorectal cancer
- Secondary osteoporosis
- Venous thromboembolism
- Toxic Megacolon
88
Which measurement is used to classify the severity of UC?
Classed as mild, moderate or severe using the Truelove and Witts' Severity Index.
89
Whats does the Truelove and Witts' severity index take into account?
- bowel movements
- heart rate
- erythrocyte
- sedimentation rate and the presence of pyrexia
- melaena
- anaemia
90
When choosing the route of administration for aminosalicylates and corticosteroids what should be considered?
- The extend of disease should be considered when choosing the route of administration; whether oral treatment, topical treatment or both are to be used.
91
If the inflammation is distal which preparation is adeuqate?
A rectal preparation is adequate
92
If the inflammation is extended then what route is required?
Systemic medication is required.
| Either suppositories or enemas can be offered, taking into account the patient's preference.
93
When patients find it difficult to retain liquid enemas what can be used instead?
- Rectal foam preparations and suppositories can be used instead.
94
What is contraindicated in treatment of acute ulcerative colitis?
Anti-diarrhoeal drugs (such as loperamide or codeine) are contraindicated in acute ulcerative colitis as they can increase the risk of toxic megacolon.
95
What may be useful for proximal faecal loading in proctitis?
- A macrogol-containing osmotic laxative (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride).
96
Are oral aminosalicylates for treatment of ulcerative colitis available in different preparations?
- yes available in different preparations and release forms.
97
When Aminosalicylates are used to maintain remission, is single daily doses or multiple daily dosing preferred?
single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.
98
What is the usual duration of corticosteroid course?
Usually 4 to 8 weeks - depends on the corticosteroid chosen
99
What is recommended first-line for patients with mild-moderate initial presentation of inflammatory exacerbation of proctitis?
- A topical aminosalicylate
- If remission is not achieved within 4 weeks, adding an oral aminosalicylate should be considered.
- If response remains inadequate, consider addition of a topical or an oral corticosteroid for 4 to 8 weeks.
100
For treatment of proctitis in UC - if aminosalicylates are not suitable what should be considered?
A topical or an oral corticosteroid for 4 to 8 weeks should be considered.
101
For Proctosigmoditis and left-sided ulcerative colitis, what are the treatment steps?
1) A topical aminosalicylate is first line.
2) If remission is not achieved within 4 weeks, consider adding a high-dose oral aminosalicylate, or switching to a high-dose oral aminosalicylate and 4 to 8 weeks of a topical corticosteroid.
102
What are the treatment steps for extensive ulcerative colitis?
1) A topical aminosalicylate and a high dose oral aminosalicylate are recommended first line
2) If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
103
Can biologics be used for treatment of UC?
Yes as third line
104
Is acute severe ulcerative colitis of any extent?
Acute severe ulcerative colitis of any extent can be life threatening and is regarded as a medical emergency. Immediate hospital admission is required for treatment.
105
What is the treatment for acute severe ulcerative colitis?
Intravenous corticosteroids (such as hydrocortisone or methylprednisolone) should be given to induce remission in patients with acute severe ulcerative colitis.
106
What if intravenous corticosteroids are contra-indicate, declined or cannot be tolerated?
1) Then intravenous ciclosporin or surgery should be considered.
2) A combination of intravenous ciclosporin with intravenous corticosteroids, or surgery is second line therapy for patients who have little or no improvement within 72 hours of starting intravenous corticosteroids or whose symptoms worsen despite treatment.
107
What if ciclosporin is contraindicated or clinically inappropriate?
Infliximab can be used to treat acute exacerbations of severely active ulcerative colitis if ciclosporin is contra-indicated or clinically inappropriate.
108
What if patients who experience an initial response to steroids followed y deterioration?
In patients who experience an initial response to steroids followed by deterioration, stool cultures should be taken to exclude the presence of pathogens; cytomegalovirus activation should be considered.
109
To maintain remission in UC what is recommended and what should not be used?
To reduce the chances of relapse occurring, maintenance therapy with an aminosalicylate is recommended in most patients.
Corticosteroids are not suitable for maintenance treatment because of their side-effects.
A low dose of oral aminosalicylate is given to maintain remission in patients after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis.
110
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, what medications can be considered?
- Oral azathioprine
| - mercaptopurine
111
Can methotrexate be used in UC?
There is no evidence to support the use of methotrexate to induce or maintain remission in ulcerative colitis, though its use is common in clinical practice.
112
Summarise the three treatment steps for Crohn's and ulcerative disease?
1. 1st Line: Aminosalicylate’s – Sulfasalazine, Mesalazine
2. 2nd Line: Azathioprine or Mercaptopurine
3. 3rd Line: Monoclonal antibodies (Adalimumab/Infliximab)
113
What colour can body fluids be stained by amniosalicylates?
- Orange/yellow
114
When taking aminosalicylates - patient should be advised to report any of which symptoms?
- Any unexplained bleeding, bruising, purpura, sore throat, fever or malaise should be advised to report these as it could indicate a blood disorder.
115
People taking aminosalicylates should refraining from wearing what?
- Should refrain from wearing their contact lenses as they can cause staining.
116
What are the side effects of aminosalicylates?
Common or very common - arthralgia, cough, diarrhoea, dizziness, fever GI discomfort, nausea, skin reactions, vomiting
- Uncommon = Alopecia, depression, dyspnoea, myalgia, thrompocytopenia
- Rare or very rare = agranulocytosis, bone marrow disorders, neutropenia,
117
For those on aminosalicylate treatment, what should be done if there is a suspicion of a blood dyscrasia?
A blood count should be performed and the drug stopped immediately if there is a suspicion of a blood dyscrasia.
118
What monitoring requirements are there for aminosalicylates?
- Rena function should be monitored before starting on oral aminosalicylate, at 3 months of treatment and then annually during treatment.
119
Give some examples of aminosalicylates?
- Balsalazide sodium
- Mesalazine
- Osalazine sodium
- Sulfasalazine
120
What are the expert advice for a possible way of administration instructions for osalazine sodium?
Expert sources advise capsules can be opened and contents sprinkled on food.
121
Sulfasalazine is often confused with which drug?
- Sulfadiazine so care must be taken to ensure the correct drug is prescribed and dispensed.
122
What is the mechanism of action of Vedolizumab?
Vedolizumab is a monoclonal antibody that binds specifically to the alpha4,beta7 integrin, which is expressed on gut homing T helper lymphocytes and causes a reduction in gastrointestinal inflammation.
123
What is the description of irritable bowel syndrome?
IBS is a common chronic, relapsing, and often life-long condition, mainly affecting people aged between 20 and 30 years.
124
Is IBS more common in men or women?
In women
125
What are some of the symptoms of IBS?
- Abdominal pain or discomfort
- Disordered defaecation (either diarrhoea or constipation with straining, Urgency and incomplete evacuation)
- passage of mucus
- bloating
Symptoms are usually relieved by defaecation
126
What is the aim of treatment if IBS?
focused on symptom control, in order to improve quality of life.
127
What are some dietary and lifestyle advice that can help with IBS?
- encourage to increase physical activity
| - eat regularly, without missing meals or leaving long gaps between meals
128
What should dietary advice on IBS also include?
- limiting fresh fruit consumption to no more than 3 portions per day
- The fibre intake of patients with IBS should be reviewed.
129
If a high fibre diet is needed for someone with IBS what advice regarding type of fibre should be given?
- Soluble fibre such as ispaghula husk, or foods high in soluble fibre such as oats, are recommended.
Intake of insoluble fibre (e.g. bran) and 'resistant starch' should be reduced or discouraged as they may exacerbate symptoms.
130
How much fluids such be recommended for someone with IBS?
Fluid intake (mostly water) should be increased to at least 8 cups each day and the intake of caffeine, alcohol and fizzy drinks reduced.
131
With patients with diarrhoea which sweetener should be avoided?
Sorbitol
132
If probiotics are used for IBS patient how long should they continue to use it while monitoring the effects?
at least 4 weeks.
133
Can most of IB symptoms be treated OTC?
Yes
134
Antispasmodic drugs can be used in addition to dietary lifestyle changes for IBS. Give some examples of antispasmodics that can be used?
- Alverine Citrate
- Mebeverine Hydrochloride
- Peppermint oil
135
For IBS can peppermint oil be used in pregnancy?
Yes it is not known to be harmful
136
For IBS a laxative can be used to treat constipation. Which laxative should not be used?
Lactulose should not be used as it may cause bloating
137
Patients who have not responded to laxatives from different classes and who have had constipation for atleast 12 months, can be treated with which drug?
Linaclotide
138
For IBS what is the first line for treatment of diarrhoea?
Loperamide hydrochloride
139
For patients who have not responded to antispasmodics, anti-motility drugs or laxatives for abdominal pain or discomfort associated with IBS, what drug can be used as second line?
A low dose tricyclic antidepressant such as amitriptyline
140
What if the patient does not respond to TCA what can be used next?
A selective serotonin reuptake inhibitor may be considered.
141
Who can psychological intervention be offered to?
To patients who have no relief of IBS symptoms after 12 months of drug treatment.
142
For Mebeverine with ispaghula husk how much water is it recommended to mic one sachet in?
approx. 150mls of cold water and drunk immediately
143
With peppermint oil, what advice should be given about adminstration?
Manufacturer advises capsules should not be broken or chewed because peppermint oil may irritate mouth or oesophagus.
144
What dispensing information about linaclotide should be known?
Capsules should be dispensed in original container (contain desiccant); discard any capsules remaining 18 weeks after opening.
145
What is short bowel syndrome?
Patients with a shortened bowel due to large surgical resection (with or without stoma formation) may require medical management to ensure adequate absorption of nutrients and fluid.
146
In people with short bowel syndrome what is also impaired?
Absorption of oral medication is also often impaired.
147
What is the aim of treatment of short bowel syndrome?
- The management of short bowel syndrome focuses on ensuring adequate nutrition and drug absorption, thereby reducing the risk of complications resulting from these effects.
148
What may patents with short bowel require?
Replacement of vitamins and mineral depending on the extent and position of the bowel resection.
Deficiencies in vitamins A,B12,D,E and K, essential fatty acids, zinc and selenium can occur.
149
In short bowel, what other low electrolyte imbalance is common?
Hypomagnesaemia - and it is treated with oral or intravenous magnesium supplementation.
150
What can administration of oral magnesium cause?
May cause diarrhoea
151
As diarrhoea is common in short bowel, what can be used in order to promote adequate hydration?
The use of oral rehydration salts.
152
For short bowel (associated diarrhoea) which drugs can be used?
Loperamide and codeine can be used as they reduce intestinal motility and thus exert antidiarrheal actions
153
Which is preferred, loperamide or codeine?
Loperamide hydrochloride is preferred as it is not sedative and does not cause dependence or fat malabsorption.
154
What if loperamide is not providing the desired response, what can be done?
High doses of loperamide hydrochloride may be required in patients with a short bowel due to disrupted enterohepatic circulation and rapid gastrointestinal transit time. If the desired response is not obtained with loperamide hydrochloride, codeine phosphate may be added to therapy.
155
What does the drug co-phenotrope do?
Co-phenotrope has traditionally been used alone or in combination with other medications to help decrease faecal output.
156
What limits the use of co-phenotrope?
Co-phenotrope crosses the blood–brain barrier and can produce central nervous system side-effects, which may limit its use; the potential for dependence and anticholinergic effects may also restrict its use.
157
In patients with an intact colon and less than 100cm of illeum resected, what can be used?
Colestyramine can be used to bind the unabsorbed bile salts and reduce diarrhoea.
158
When colestryamine is given to these patient, what is it important to monitor?
Monitor for evidence of fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies
159
Which antisecretory drugs can be used in short bowel syndrome?
Omeprazole is readily absorbed in the duodenum and upper small bowel, but if less than 50 cm of jejunum remains, it may need to be given intravenously.
Use of a proton pump inhibitor alone does not eliminate the need for further intervention for fluid control (such as antimotility agents, intravenous fluids, or oral rehydration salts).
160
Which GLP-2 is licensed for use in the management of short bowel syndrome?
Teduglutide is an analogue of endogenous human glucagon-like peptide 2 (GLP-2) which is licensed for use in the management of short bowel syndrome.
It may be considered after a period of stabilisation following surgery, during which intravenous fluids and nutritional support should have been optimised.
161
Is drug absorption affected by short bowel syndrome?
Many drugs are incompletely absorbed by patients with a short bowel and may need to be prescribed in much higher doses than usual (such as levothyroxine, warfarin, oral contraceptives and digoxin) or may need to be given intravenously.
162
What is the most important site of absorption?
the small intestine, with its large surface area and high blood flow
163
In short bowel syndrome what affects drug absorption more?
The larger the amount of the small intestine that has been removed, the higher the possibility that the drug absorption will be affected.
Other factors, such as gastric emptying and gastric transit time, also affect drug handling.
164
Can enteric-coated or modified release preparations be used with short bowel syndrome?
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.
165
before prescribing liquid formulations, what should the prescribers consider?
- the osmolarity
- excipient content
- the volume required
166
Which liquids can result in fluid loss?
Those that are hyperosmolar and some excipients (such as sorbitol) can result in fluid loss.
167
Does the calorie density of oral supplements matter?
yes this should be considered as it will influence the volume to be taken.
168
List some drugs that are used for bowel cleansing?
- Citric acid with magnesium (Osmotic laxative)
- Macrogol 3350 with anhydrous sodium sulfate, ascorbic acid, potassium chloride, sodium ascorbate and sodium chloride (osmotic laxative)
- Magnesium citrate with sodium picosulfate (stimulant laxative)
-
169
What is constipation defined as?
Constipation is defaecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defaecation.
170
Who is constipation more common in?
- Women
- The elderly
- During pregnancy
171
Which symptoms of constipation indicate need for immediate referral (RED FLAGs?)
- New onset constipation, especially in patient over 50 years of age
- accompanying symptoms such as anaemia, abdominal pain, weight loss, or overt or occult blood in the stool
172
What non drug treatment is advised for contipation?
- Increase dietary fibre
- Adequate fluid intake
- exercise
- diet should be balanced and contain whole grains, fruits and vegetables.
- Drink plenty of water
173
Why should fibre intake be increased gradually?
To minimise flatulence and bloating
174
How long does effects of fibre for constipation take to work?
The effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks.
175
What can laxative abuse lead to?
Hypokalaemia
176
Give few examples of bulk-forming laxatives?
- Bran, ispaghula husk (fybogel)
- Methycellulose
- Sterculia
177
What is the onset of action for bulk-forming laxatives?
72 hours
178
With bulk-forming laxative use which symptoms may be exacerbated?
- flatulence
- bloating
- cramping
179
When using bulk-forming laxative - what key counselling advice needs to be given?
Adequate fluid intake must be maintained to avoid intestinal obstruction.
Advise patients to not take immediately before bed.
180
What does methylcellulose also act as?
A faecal softener
181
Give examples of stimulant laxatives?
- Bisacodyl
- sodium picosulfate
- Members of the anthraquinone group (senna, co-danthramer and co-danthrusate)
182
How do stimulant laxatives work and what is their onset of action?
- stimulant laxatives increase intestinal motility and often cause abdominal cramps
- Very fast acting: 8-12 hours
- Bisacodyl 10-12 hours
183
What is a general side effect of all laxatives?
Cause abdominal pain
184
Can stimulant laxatives be used in intestinal obstruction?
No manufacturer advises to avoid
185
What is the use of co-danthramer and co-danthrusate limited to?
Limited to constipation in terminally ill patients because of potential carcinogenicity (based on animal studies) and evidence of genotoxicity.
186
Docusate sodium is believed to act as two types of laxatives, which ones?
- Stimulant laxative and as a faecal softener
187
How do Glycerol suppositories work?
Act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol
188
How do faecal softeners work?
Faecal softeners are claimed to act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass.
189
What does arachis oil do?
Enemas containing arachis oil (ground-nut oil, peanut oil) lubricate and soften impacted faeces and promote a bowel movement.
190
Liquid paraffin has also been used as a lubricant for the passage of stools, why does manufacturer advice it should be used with caution?
- hould be used with caution because of its adverse effects, which include anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.
191
What is the onset of action of faecal softeners?
Fastest onset of action - within 15 minutes
192
How do osmotic laxatives work?
They increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.
193
Is lactulose a disaccharide?
Yes it is a semi-synthetic disaccharide which is not absorbed from the GI tract.
194
Why is lactulose used in hepatic encephalopathy?
It produces an osmotic diarrhoea of low faecal pH, and discourages the proliferation of ammonia-producing organisms. It is therefore useful in the treatment of hepatic encephalopathy.
195
Give examples of osmotic laxatives?
Lactulose and macrogol
196
What are macrogols?
Macrogols (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) are inert polymers of ethylene glycol which sequester fluid in the bowel; giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives.
197
What is linaclotide licensed for?
Linaclotide is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate to severe irritable bowel syndrome associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain.
198
What is prucalopride and what is it licensed for?
Prucalopride is a selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
199
What is in macrogol 3350?
- potassium chloride
- sodium bicarbonate
- sodium chloride
200
When are bowel cleansing preparations used?
- Before colonic surgery
- colonoscopy
- before radiological examination to ensure the bowel is free of solid contents
201
Are bowel cleansing treatments also treatments for constipation?
No
202
What is the management steps of short term constipation?
1st line = bulk forming laxative (ensuring adequate fluid intake)
2nd line = If stools remain hard, add to or switch to an osmotic laxative
3rd = If stools are soft but difficult to pass or patient complains of inadequate emptying, a stimulant laxative should be added.
203
For opioid-induced constipation, what type of laxative is recommended?
Osmotic laxative (e.g. lactulose) or docusate sodium to soften the stool and a stimulant laxative is recommended
204
Which laxatives should be avoided in opioid-induced constipation?
- Avoid bulk-forming laxatives
205
When can naloxegol be used in opioid-induced constipation?
- when response to other laxatives is inadequate
206
When can methylnaltrexone be used?
Methylnaltrexone bromide is licensed for the treatment of opioid-induced constipation when response to other laxatives is inadequate. Manufacturer advises that in patients receiving palliative care, methylnaltrexone bromide should be used as an adjunct to existing laxative therapy.
207
What does the treatment of faecal impaction depend on?
- depends on the stool consistency
208
For faecal impaction, in patients with hard stools what can be considered?
A high dose of an oral macrogol may be considered.
209
What about those with soft stools, or with hard stools after a few days treatment with macrogol?
An oral stimulant laxative should be started or added to the previous treatment
210
What if response to oral laxatives is still inadequate?
- For soft stools consider rectal administration of bisacodyl
- For hard stools rectal administration of glycerol alone or glycerol plus bisacodyl
Alternatively, a docusate sodium or sodium citrate enema may be tried.
211
For faecal impaction if there is still insufficient response to previous treatments what can be used?
For hard faeces it can be helpful to give the arachis oil enema overnight before giving a sodium acid phosphate with sodium phosphate or sodium citrate enema the following day. Enemas may need to be repeated several times to clear hard impacted faeces.
212
What is the management steps of chronic constipation?
1) bulk-forming laxative should be started ensuring good hydration
2) if stools remain hard, add or change to an osmotic laxative such as macrogol
Lactulose is an alternative if macrogols are not effective or not tolerated.
3) If response is inadequate, a stimulant laxative can be added.
213
how should the dose of laxative be adjusted?
Gradually to produce one or two soft, formed stools per day.
214
Which drug can be considered if at least wo laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months?
The used of prucalopride (in WOMEN only) should be considered.
215
When should the patient be re-examined when on prucalopride treatment?
If treatment with prucalopride is not effective after 4 weeks, the patient should be re-examined and the benefit of continuing treatment reconsidered.
216
How should laxatives be stopped if a combination of laxatives has been used?
One at a time
217
Which laxative if possible should be stopped first?
Reduce the stimulant laxative first.
| However, it may be necessary to also adjust the dose of the osmotic laxative to compensate.
218
What is first line treatment for constipation in pregnancy and breast feeding?
- If dietary and lifestyle changes fail to control constipation in pregnancy, fibre supplements in the form of bran or wheat are likely to help women experiencing constipation in pregnancy, and raise no serious concerns about side-effects to the mother or fetus.
219
What is first line drug laxative used for constipation in pregnant women?
A bulk forming laxative is first choice if fibre supplements fail.
220
Which other laxative can be used?
An osmotic laxative such as lactulose
221
Which laxative should be avoided in pregnancy?
Bisacodyl or senna may be suitable if a stimulant effect is necessary but use of senna should be avoided near term or if there is a history of unstable pregnancy.
Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause side-effects (diarrhoea and abdominal discomfort), reducing their acceptability to patients.
222
Can docusate sodium and glycerol suppositories be used in pregnant women?
Yes
223
What is the treatment steps of constipation for breast-feeding women?
1) A bulk-forming laxative is the first choice during breast-feeding, if dietary measures fail.
2) Lactulose or a macrogol may be used if stools remain hard.
3) As an alternative, a short course of a stimulant laxative such as bisacodyl or senna can be considered.
224
What is the first line treatment for children with constipation?
the use of a laxative in combination with dietary modification or with behavioural interventions. Diet modification alone is not recommended as first-line treatment.
225
Is diet modification alone recommended as first line treatment for children with constipation?
No
226
Why is unprocessed bran not recommened?
may cause bloating and flatulence and reduces the absorption of micronutrients) so is not recommended
227
What is the drug treatment steps for a child with constipation?
1) A macrogol is preferred as fist line management
2) If the response is inadequate, add a stimulant laxative or change to a stimulant laxative if the first-line therapy is not tolerated.
3) If stools remain hard, lactulose or another laxative with softening effects, such as docusate sodium can be added.
228
How long should laxatives be used in children with chronic constipation?
In children with chronic constipation, laxatives should be continued for several weeks after a regular pattern of bowel movements or toilet training is established. The dose of laxatives should then be tapered gradually, over a period of months, according to response. Some children may require laxative therapy for several years.
229
What may treatment of faecal impaction in children initially increase symptoms of?
of soiling and abdominal pain
230
What is the treatment for faecal impaction in children?
n children over 1 year of age with faecal impaction, an oral preparation containing a macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) is used to clear faecal mass and to establish and maintain soft well-formed stools, using an escalating dose regimen depending on symptoms and response.
231
If disimpaction is not achieved after 2 weeks what should be added?
a stimulant laxative can be added or if stools are hard, used in combination with an osmotic laxative such as lactulose.
232
Is long term use of laxative recommended for faecal impaction in children?
Long-term regular use of laxatives is essential to maintain well-formed stools and prevent recurrence of faecal impaction; intermittent use may provoke relapses.
233
To summarise, What is the MOA of bulk-forming laxatives?
e. g. Ispaghula husk, stericulia
| - increase faecal mass which stimulates peristalsis.
234
What advice about faecal softener oral suspension must be given?
- Should not be taken immediately before going to bed.
235
What does manufacturer advise about administration of glycerol for use in constipation?
-Moisten suppositories with water before insertion
236
What is the dose of glycerol suppositories for constipation for infants, children and adults?
Child 1-11 months = 1g as required
Child 1-11 years = 2g as required
Child 12-17 years = 4g as required
Adult = 4g as required
237
What is the MAO for Senna?
Senna is a stimulant laxative.
After metabolism of sennosides in the gut the anthrone component stimulates peristalsis thereby increasing the motility of the large intestine
238
Which age is senna syrup not licensed for use in?
Not licensed for udner 2 years of age
239
What is the OTC age restriction of stimulant laxative?
Should not be used under 12 years of age without prescription.
In children aged 12-17 years, products can be supplied under the supervision of the pharmacist.
240
What is the MAO of sodium picosulfate?
Sodium picosulfate is a stimulant laxative.
| After metabolism in the colon it stimulates the mucosa thereby increasing the motility of the large intestine.
241
What is the MAO of methylnaltrexone bromide?
Methylnaltrexone bromide is a peripheral opioid receptor antagonist.
It therefore blocks the GI (constipating) effects of opioids without altering their central analgesic effects.
242
What is the MAO of naldemedine and naloxegol?
Naldemedine is a peripherally acting opioid receptor antagonist. It therefore decreases the constipating effects of opioids without altering their central analgesic effects.
243
What is diarrhoea?
It is the abnormal passing of loose or liquid stools with increased frequency, increased volume, or both.
244
What is acute diarrhoea?
Acute diarrhoea is that which lasts less than 14 days, but symptoms usually improve within 2-4 days.
245
What are some causes of diarrhoea?
- side effect of a drug
- acute symptom of chronic GI disorder (e.g. IBD)
- may also result from the accumulation of non-absorbed osmotically active solutes in the GI lumen (e.g. lactase deficiency)
- enterotoxins from an infection
- also can occur when intestinal motility or morphology is altered
246
What are some red flags of diarrhoea symtpoms?
- unexplained weight loss
- rectal bleeding
- persistent diarrhoea
- systemic illness
- received recent hospital treatment or antibiotic treatment
- following a foreign travel
247
What is the aim of treatment for diarrhoea?
- Prevention or reversal of fluid and electrolyte depletion and the management of dehydration when it is present.
- This is particularly important in infants, frail and elderly patients, when excessive water and electrolytes loss and dehydration can be life threatening.
248
What is used to achieve the primary aim of diarrhoea treatment (electrolyte depletion/ dehydration)
Oral rehydration therapy (ORT, such as disodium hydrogen citrate with glucose, potassium chloride and sodium chloride; potassium chloride with sodium chloride; potassium chloride with rice powder, sodium chloride and sodium citrate ) is the mainstay of treatment for acute diarrhoea to prevent or correct diarrhoea dehydration and to maintain the appropriate fluid intake once rehydration is achieved.
249
What about those with severe dehydration and unable to drink?
Hospital admission is required and urgent replacement treatment with an intravenous rehydration fluid is recommended.
250
Which antimotility drug can be used as standard treatment?
- loperamide
These drugs prolong the duration of intestinal transit by binding to opioid receptors in the GI tract.
251
Can loperamide be used in chidlren?
Yes
252
What is one advantage and reason why loperamide is recommended?
- Loperamide does not cross the blood-brain-barrier.
253
What is also used for mild-moderate travellers' diarrhora?
Loperamide
254
In which type of diarrhoea symptoms should loperamide be avoided?
should be avoided in bloody or suspected inflammatory diarrhoea (febrile patients) and in cases of significant abdominal pain (which also suggests inflammatory diarrhoea).
255
What is a unlicensed first line indication of lepramide?
Treatment for patients with faecal incontinence after the underlying cause of incontinence has been addressed.
256
What is racecadotril licensed for?
As an adjunct to rehydration for the symptomatic treatment of uncomplicated acute diarrhoea in adults and children over 3 months.
257
Are adsorbent preparations such as kaolin recommended for acute diarrhoea?
There is insufficient evidence to recommend adsorbent preparations (such as kaolin) in acute diarrhoea.
258
What is occasionally used for prophylaxis of travellers' diarrhoea?
Ciprofloxacin but routine is not recommended
259
What is the age licensing for loperamide CAPSULES?
Capsules are not licensed for use in children under 8 years.
260
What has been reported with overdose of loperamide?
Serious cardiovascular effects (such as QT prolongation, torsades de pointes, and cardiac arrest), including fatalities, have been reported in association with large overdoses of loperamide.
261
If symptoms of overdose are suspected due to loperamide, what can be used as an antidote?
Naloxone
- The duration of action of loperamide is longer than that of naloxone (1-3 hours),s so repeated treatment with naloxone might be indicated
262
During treatment of loperamide overdose with naloxone what should be closely monitored?
Patient should be closely monitored for at least 48 hours to detect possible CNS depression.
263
Give an example of antispasmodic drug?
```
Hyoscine butylbromide (Buscopan)
Used to treat abdominal cramps
```
264
Which drug classes should be avoided in young chilren with gastro-enteritis?
Antispasmodics and Anti-emetics should be avoided in young children with gastro-enteritis as they are rarely effective and have troublesome side effects.
265
What is causative organism for most diarrhoea?
Due to viruses and do not need antibiotic treatment
266
When is colestryamine used for diarrhoea?
Used following ileal disease or resection.
267
Can patients taking colestryamine take other medications at the same time?
Should take other medications an hour before, or 4 to 6 hours after each dose.
268
What is the licensing (ages) of loperamide?
Can be used for children over 4 but OTC it is only licesed for use in children over 12.
269
What is Dyspepsia (indigestion)?
Dyspepsia describes a range of upper gastro-intestinal symptoms, which are typically present for 4 or more weeks.
270
What are the symptoms of dyspepsia?
not limited to :
- upper abdominal pain
- Discomfort
- Heartburn
- Gastric reflux
- bloating
- Nausea and/or vomiting
- feeling full (satiety)
- often occurring after eating or drinking
271
What is functional dyspepsia?
- where an underlying cause cannot be identified and endoscopy findings are normal.
272
What does un-investigated dyspepsia refer to?
- describes symptoms in patients who have not had an endoscopy
273
What is the aim of dyspepsia treatment?
- to manage symptoms and where possible, to treat the underlying cause of dyspepsia
274
What are some of the non-drug treatment for dyspepsia?
- Lifestyle measures such as healthy eating, weight loss (if obese), avoiding any trigger foods, eating smaller meals, eating the evening meal 3-4 hours before going to bed, raising the head of the bed.
- Smoking cessation and reducing alcohol consumption may improve symptoms.
- Stress, anxiety or depression, as these conditions may exacerbate symptoms
275
What are the red flag symptoms of dyspepsia?
- significant acute GI bleeding
- recurrent vomiting
- unexpected weight loss
- Dysphagia
- over the age of 55 with unexplained, recent-onset dyspepsia that has not responded to treatment
276
Which drugs can cause dyspepsia that should be reviewed?
alpha-blockers, antimuscarinics, aspirin, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, nitrates, non-steroidal anti-inflammatory drugs (NSAIDs), theophyllines, and tricyclic antidepressants, should be reviewed. The lowest effective dose should be used and if possible, stopped.
277
For dyspepsia can antacids and/or alginates be used?
Antacids and/or alginates may be used for short-term symptom control, but long-term, continuous use is not recommended.
278
What is the initial drug management for uninvestigated dyspepsia?
- A proton pump inhibitor should be taken for 4 weeks.
| - patients with dyspepsia should be tested for Helicobacter pylori (H.pylori) infection, and treated if positive
279
What is the initial drug management for functional dyspepsia?
- Patients should be tested for H.pylori infection and treated if positive.
- If patients not infected with H.pylori, a proton pump inhibitor or hitamine2-receptor antagonist (H2-receptor antagonist) should be taken for 4 weeks.
280
What is recommended next if symptoms of dyspepsia persist or recur following initial drug management?
- A proton pump inhibitor (PPI) or H2-receptor antagonist therapy should be used at the lowest dose needed to control symptoms.
The patient may use the treatment on a 'as-needed' basis.
281
What frequency of review of dyspepsia is recommended?
An annual review should be performed for patients with dyspepsia to assess their symptoms and treatment. A 'step down' approach, or stopping treatment, should be encouraged if possible and clinically appropriate. A return to self-treatment with antacid and/or alginate therapy may be appropriate.
282
What does eradication of H.pylori involve?
- Acid inhibition and antibacterial treatment. Treatment should not be carried out unless presence of H.pylori is present.
283
How can H.pylori be diagnosed?
Using breath test, stool sample or blood test
284
Which two things means patients cannot be tested for H.pylori?
- Patient cannot be tested for H.pylori if they have been on antibiotics in the last 4 weeks OR
- an anti-secretory in the last 2 weeks
285
What is the initial treatment of H.pylori (which drugs)?
One week triple therapy
PPI + two antibiotics
PP + clarithromycin and amoxicillin or metronidazole
This treatment usually works, but if ulceration is bad then treatment with a PPI or H2 Antagonist
may need to be continued for a further 3 weeks.
286
Can antacids be taken with other medications?
No should be spaced 2 hours apart from other medications.
287
What do antacids usually contain?
- Usually contain aluminium or magnesium compounds
288
What can antacids be used for?
Often used to relive symptoms in ulcer dyspepsia and in non-erosive gastro-oesophageal reflux.
289
When are antacids best given?
When symptoms occur or when are expected, usually between meals and at bedtime, although additional doses may be required.
290
What do conventional doses of liquid magnesium-aluminium antacids promote?
Promote ulcer healing but less well than antisecretory drugs
291
In regards to antacids, are liquid preparations more effective than tablet preparations?
Yes
| Liquid>tablet
292
Are aluminium and magnesium containing antacids soluble in water?
No, they are insoluble in water and are long-acting if retained in the stomach.
293
What do magnesium containing antacids tend to be?
- tend to be laxative
294
What do aluminium compounds tend to be?
May be constipating
295
What can prevent these two problems?
Antacids containing both magnesium and aluminium can avoid this problem.
296
Do preparations that contain more than one antacid have greater acid-neutralising capacity?
- no
| - may have the same acid-neutralising capacity as simpler preparations
297
Can sodium bicarbonate be used alone for dyspepsia?
No but it is present as an ingredient in many indigestion remedies.
However, it retains a place in the management of urinary-tract disorders and acidosis.
298
Can bismuth-containing antacids be used for dyspepsia?
(unless chelates) bismuth-containing antacids are not recommended because absorbed bismuth can be neurotoxic, causing encephalopathy; they tend to be constipating.
299
What effect can calcium containing antacids have?
- they can induce rebound acid secretion;
- With prolonged high doses it also causes hypercalcaemia and alkalosis.
- can precipitate the milk-alkaili syndrome
300
What is simeticone and activated version of?
- Simeticone = activated dimeticone
301
What is the role of simeticone in antacids?
added as an anti-foaming agent to relieve flatulence.
302
What may simeticone be used for in palliative care?
May be useful for the relief of hiccups in palliative care
303
What is the effect of alginate being added to an antacid?
It increases the viscosity of stomach acid contents and can protect the oesophageal mucosa from acid reflex.
Some alginate-containing preparations form a viscous gel (‘raft’) that floats on the surface of the stomach contents, thereby reducing symptoms of reflux.
304
In renal impairment which in antacids means those need to be avoided?
- magnesium or large containing amounts of sodium antacids.
305
Why should antacids not be taken at the same time as other drugs?
- as they damage their enteric coating so antacids should be spaced 2 hours apart from other medications.
306
What does gaviscon contain?
Gaviscon = A, B, C
- Sodium Alginate
- Sodium Bicarbonate
- Calcium carbonate
307
What is the difference in ingredients between gaviscon and gaviscon advance?
Gaviscon advance contains potassium bicarbonate which normal Gaviscon does NOT.
308
What is the risk of renal impairment and aluminium containing antacids?
There is a risk of accumulation and aluminium toxicity with antacids containing aluminium salts.
309
What is peptic ulcer?
Peptic ulcer includes gastric or duodenal ulceration - which is a breach in the epithelium of the gastric or duodenal mucosa.
310
What are the symptoms of peptic ulcer?
Main symptoms include upper abdominal pain
- Other less common symptoms include nausea, indigestion, heartburn, loss of appetite, weight loss and a bloating feeling.
311
What are the most common causes of peptic ulcer?
- NSAIDs use
- H.pylori infection
- smoking and alcohol consumption and stress may also contribute to the development of peptic disease
312
Which factor may have an additive effect if there is a co-existent H.pylori infection?
- NSAIDs, increasing the risk of peptic ulceration
313
Is risk of upper-gastro intestinal side effects same with all NSAIDs?
NO it varies between individual NSAIDs and is influenced by the dose and duration of use.
314
What are some of the complications of peptic ulcer disease?
- Gastric outlet obstruction
| - potentially life threatening gastro-intestinal perforation and haemorrhage
315
Patient are considered at high risk if they have a history of complicated peptic ulcer or have more than how many risk factors?
More than 2 risk factors
316
What are the risk factors for peptic ulcer disease?
- Age over 65 years
- high doses NSAIDs
- Other drugs that increase the risk of gastro-intestinal adverse effects (e.g. anticoagulants, corticosteroids, selective reuptake inhibitors);
- Serious co-morbidity (e.g. CVD, hypertension, diabetes, renal or hepatic impairment);
- Heavy smoker
- Excessive alcohol consumption
- Previous adverse reaction to NSAIDs
- Prolonged requirements to NSAIDs
317
What are the aims of treatment of peptic ulcer disease?
- To promote healing
- to manage symptoms
- to treat H.pylori infection if detected and reduce risk of ulcer complications and recurrence
318
What are the non-drug treatment for peptic ulcer disease? (what advice can be given)?
- lifestyle measures such as eat healthy
- weight loss (if obese)
- avoid trigger foods
- eating smaller meals
- eating the evening meal 3-4 hours before going to bed
- raising the head of the bed
- smoking cessation
- reducing alcohol consumption
319
What should the patient be assessed for which could exacerbate the symptoms of peptic ulcer?
- Stress
- Anxiety
- Depression
320
Which symptoms are red flags of peptic ulcer disease which require urgent endoscopic investigation?
- patients with dysphagia
- significant acute gastrointestinal bleeding
- those aged 55 years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia
321
Which drugs can induce peptic ulcers that should be reviewed and stopped, if clinically appropriate?
- NSAIDs
- Immunosuppressive agents (e.g. corticosteroids)
- Selective reuptake inhibitors (SSRIs)
- recreational drugs such as crack cocaine
322
For initial treatment of peptic ulcer disease what should the patient be tested for?
- Get tested for H.pylori
323
What is the treatment of peptic ulcer if it is associated with NSAID use?
- use a proton pump inhibitor or H2-receptor antagonist for 8 weeks
- followed by helicobacter pylori infection eradication treatment if the patient has tested positive for H.pylori
324
What is the treatment for peptic ulcer disease if a patient has tested negative for H.pylori and have no history of NSAID use?
- use a proton pump inhibitor or histamine 2 receptor antagonist for 4-8 weeks
325
After peptic ulcer disease treatment, how often should the use of NSAIDs be reviewed?
- At least every 6 months and use on a limited 'as-needed' basis trialled.
- should consider reducing the dose, substituting the NSAID with paracetamol, or use of an alternative analgesic or low dose ibuprofen
326
In patients with previous ulceration, for whom NSAID continuation is necessary, or those at high risk of GI side effects (3 or more risk factors), which type of drug should be considered instead?
- Selective Cyclo-oxygenase (COX-2 inhibitor) instead of a standard NSAID.
(COX-2) enzyme helps with the production of the protective stomach lining.
327
Give some examples of COX-2 inhibitors?
- Celecoxib
- Rofecoxib
- Valdecoxib
328
What should always be co-prescribed in high risk patients for peptic ulcer disease who are on NSAID therapy?
- GI protection with acid suppression therapy
1) proton pump inhibitor is first choice
2) other options include H2-receptor antagonist or misoprostol but side effects of misoprostol limit its use.
329
Patients with peptic ulcer disease who are on long-term treatment should be reviewed how often?
- Should receive an annual review of their symptoms and treatment
330
In patient's over 65 years of age who are taking NSAID what may we see about the dose of their PPI?
- May be taking a double dose of PPI ie. omeprazole 1 BD instead of 1 OD.
331
What type of drug is misoprostol?
- prostaglandin analogue
332
Can misoprostol be used in the elderely?
Yes in those who are on long term NSAIDs e.g. Aspirin
333
Can Misoprostol be used in pregnancy?
No it is contraindicated in pregnancy as it can induce labour or abortion.
334
For the management of peptic ulcer disease can antacids be used?
Antacids and/or alginates may be sued for short-term symptom control, but long-term, continuous use is not recommended
335
What are common symptoms with bismuth subsalicylate?
- black faeces, black tongue,
336
What type of drug is bismuth subsalicylate?
It is an antacid
337
Which ages is bismuth subsalicylate contraindicated in?
Children under 16 years (risk of Reye's syndrome)
338
Sucralfate may be used in the treatment of peptic ulcers. What type of drug is sucralfate?
(Chelates and complexes)
- Sucralfate may act by protecting the mucosa from acid-pepsin attack in gastric and duodenal ulcers. It is a complex of aluminium hydroxide and sulfated sucrose but has minimal antacid properties.
339
With Sucralfate use, what has there been reports of?
- Bezoar formation (foreign body resulting from accumulation of ingested material)
Therefore, caution is advised in seriously ill patients, especially those receiving enteral feeds or those with delayed gastric emptying
340
Should sucralfate be given with meals?
No - one hour before meals
341
How do H2-receptor antagonists work?
- They heal gastric and duodenal ulcers reducing gastric output as a result histamine H2 receptor bloackade; they are also used to releive symptoms of GORD
342
For Zollinger-Ellison syndrome, is H2-receptor antagonists preferred over PPI?
No - for this syndrome PPIs are used as they are more effective and H2 receptor antagonists should not be used
343
In obstetric patients at delivery (Mendelson's syndrome), what does H2-receptor antagonists help reduce?
- reduces the risk of acid aspiration
344
Why do H2-receptor antagonists need to be used with caution in people with gastric cancer?
- As they might mask symptoms of gastric cancer, particular care is required in patients presenting with 'alarm feature' in such cases gastric malignancy should be ruled out before treatment.
345
What does malignancy refer to?
The term "malignancy" refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues
346
List a few examples of H2-receptor antagonists?
- Cimetidine
- Famotidine
- Nizatidine
- Ranitidine
347
When Cimetidine is used in hepatic impairment, what is there a risk of?
- increase risk of confusion
348
Can Cimetidine be purchased OTC?
YEs to adults and children over 16 years of age provided there are no more than 2 weeks supply in the pack
(Max 200mg per dose, 800mg daily dose max)
349
What about famotidine can that be purchased OTC?
Yes to children and adults over the age of 16 provided packs do not contain more than 2 weeks supply - max per dose 10mg, max daily dose 20mg.
350
Which class of drug is misoprostol from?
It is a prostaglandin analogue.
351
What is a brief summary of the MAO of misoprostol?
Misoprostol is a synthetic prostaglandin analogue that has ant secretory and protective properties promoting healing of peptic ulcers.
352
Can misoprostol be used in child bearing women?
Manufacturer advises to avoid unless pregnancy has been excluded; patients must use effective contraceptive during treatment, and be informed of the risks of taking misoprostol if pregnant.
353
Can misoprostol be used in pregnancy?
NO - Teratogenic in first trimester
| - Induces uterine contractions and associated with abortions
354
What advice about driving and performing skilled tasks about misoprostol needs to be given?
- be caution of the effects of driving and performance of skilled tasks as they increase the risk of dizziness
355
Following endoscopic treatment of severe peptic ulcer bleeding what does a high dose intravenous PPI reduce the risk of ?
Reduces the risk of bleeding and the need for surgery
356
In cystic fibrosis, what may a PPI be useful for?
- To reduce the degradation of pancreatic enzyme supplements in patients with cystic fibrosis.
357
What is a brief summary of the MAO of PPI?
PPIs inhibit gastric acid secretion by blocking the hydrogen-potassium adenosine triphosphate enzyme system ('the proton pump) of the gastric parietal cell.
358
MHRA in 2015 released an alert of a low risk of what from the use of PPIs?
Very infrequent cases of subacute cutaneous lupus erythematosus (SCLE) can occur weeks, months or years after exposure to the drug.
359
If a patient treated with a PPI develops leisons- especially in sun-exposed areas of the skin - and it is accompanied by arthlagia what should be done?
- advise them to avid exposing skin to sunlight
- consider SCLE as possible diagnosis
- consider discontinuing PPI treatment it is imperative for a serious acid related condition
- in most cases, symptoms resolve on PPI withdrawal; topical or systemic steroids might be necessary for treatment of SCLE only if there are no signs of remission after a few weeks or months.
360
When PPI is used in the elderly what is there a risk of (hint - caution on the BNF)?
- can increase the risk of fractures (particularly) when used at high doses for over a year in the elderly.
- caution in patients with a risk of osteoporosis
361
Can use of PPI increase the risk of GI infections?
Yes so needs to be used with caution (including increasing risk of C.difficile infection)
362
What may PPIs mask the symptoms of?
Gastric cancer
363
What advice or management needs to be in place for patients at risk of osteoporosis who are going to be on PPI?
- should maintain an adequate intake of calcium and vitamin D, and if necessary, receive other preventative therapy.
364
With PPI use, which electrolyte should be monitored?
- serum magnesium should be considered before and during prolonged treatment especially when used with other drugs that cause hypomagnesaemia or with digoxin
365
List few examples of PPIs?
- Esomeprazole
- Lansoprazole
- Omeprazole
- Pantoprazole
- Rabeprazole sodium
366
Can omeprazole be used in pregnancy?
Yes - not known to be harmful same with breastfeeding
367
How much omeprazole can be sold OTC?
Omeprazole 10mg tabs can be sold to the public in adults over 18 mx. daily dose 20mg for max 4 weeks and pack size of 28
368
Can Esomeprazole be used in pregnancy?
Manufacturer advises avoid as there is information available
369
Can Lansoprazole be used in pregnancy?
Manufacturer advises avoid
370
Can pantoprazole be used in pregnancy?
Manufacturer advises avoid unless potential benefit outweighs risk - fetotoxic in animals
371
Can rabeprazole be used in pregnancy?
Manufacturer advises to avoid as there is nor information available.
372
What is Gastro-oesophageal reflux disease (GORD)?
It is usually a chronic condition where there is reflux of gastric contents (particularly acid, bile and pepsin) back into the oesophagus causing symptoms of heartburn and acid regurgitation.
373
What are some other but less common symptoms of GORD?
- Chest pain
- Hoarseness
- Cough
- Wheezing
- asthma
- dental erosions
can occur if acid reflux reaches the oropharynx and/or respiratory tract
374
What is non-erosive GORD?
when a person has symptoms of GORD but the endoscopy is normal
375
What is erosive oseophagitis?
When oesophageal inflammation and mucosal erosions are seen at endoscopy.
376
What are risk factors that can lead to GORD?
- consumption of trigger and fatty foods
- pregnancy
- Hiatus hernia
- Family history of GORD
- Increased intra-gastric pressure from straining and cough
- stress
- anxiety
- obesity
- drug side-effects
- smoking
- alcohol consumption
377
What are the complications of GORD?
- oesophageal inflammation (oesophagitis),
- ulceration
- Haemorrhage
- stricture formation
- Anaemia due to chronic blood loss
- Aspiration pneumonia
- Barrett's oesophagus
378
What is the aim of GORD treatment?
Management of symptoms of GORD and reduce the risk of recurrence and complications associated with the disease.
379
What are the non-drug treatment of GORD?
- Lifestyle measures:
- healthy eating
- Weight loss (if obese)
- Avoiding trigger foods
- eating smaller meals
- eating the evening meal 3-4 hours before going to bed
- raising the head of the bed
- Smoking cessation
- reducing alcohol consumption
Assess patient for stress and anxiety
380
What are the red flag symptoms of GORD that require urgent endoscopic investigation?
- dysphagia
- significant acute GI bleed
- Those aged 55 years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia.
381
Which drugs can exacerbate the symptoms of GORD?
alpha-blockers, anticholinergics, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), nitrates, theophyllines, and tricyclic antidepressants should be reviewed. The lowest effective dose should be used and if appropriate, stopped.
382
Is long term continuous use of antacids recommend for GORD?
No not for long term
383
What should patients with uninvestigated GORD be treated as having?
Patients with uninvestigated symptoms which suggest GORD should be managed as uninvestigated Dyspepsia.
384
What is the drug treatment for patients with an endoscopy confirmed diagnosis of GORD?
- A PPI should be offered for 4-8 weeks. If there is no response to PPI then offer H2-receptor antagonist
385
What should severe oesophagitis be treated with?
Should be treated with a PPI for 8 weeks taking into consideration patient preference and factors such as underlying health conditions and possible interactions with other drugs.
386
What containing antacids may be helpful for GORD?
Antacids containing alginates can form a 'raft' to reduce acid reflux
387
For GORD are PPIs more effective than H2-receptor antagonists?
Yes
388
What are the options for refactory GORD?
- further course of the initial PPI dose for 1 month
- Double the initial PPI dose for 1 month
- Addition of H2-receptor antagonist at bedtime for nocturnal symptoms or for short term use
389
What should be tried next if 8 weeks treatment with PPI fails for severe oesophagitis?
- use a higher dose of the same PPI
| - or switch to another PPI
390
What is the first line management of GORD in pregnancy?
Dietary and lifestyle advice
391
What are the management steps for GORD in pregnancy?
1) dietary and lifestyle advice
2) An antacid or an alginate
3) Omeprazole or ranitidine (unlicensed)
392
What are the treatment steps for GORD in children?
Common in infancy
1) Lifestyle advice: change the frequency + volume of feed : a feed thickener or thickened formula can be used
2) Pharmacological treatment: Antacids (alginate)
3) Children who do not respond to these measures must be referred to hospital. A H2 receptor antagonist may be used to reduce acid secretion. If the patient is resistant, omeprazole can be used.
393
What is the most common cause of Peptic ulcer disease?
H.pylori is most common cause
394
Before starting H.pylori eradication treatment what should be confirmed?
- The presence of H.pylori
395
Which patients would require or indicate that they should be tested for H.pylori?
- Patients with uncomplicated dyspepsia and no alarm symptoms who are unresponsive to lifestyle changes and antacids, following a single one month treatment course with a proton pump inhibitor;
- Patients considered to be at high risk of H. pylori infection (such as older people, individuals of North African ethnicity, and those living in a known high risk area) should be tested for H. pylori infection first, or in parallel with a course of a proton pump inhibitor;
- Previously untested patients with a history of peptic ulcers or bleeds;
- Prior to initiating NSAIDs in patients with a prior history of peptic ulcers or bleeds;
- Patients with unexplained iron-deficiency anaemia after endoscopic investigation has excluded malignancy, and other causes have been investigated.
396
What three testing options are there for H.pylori?
- Urea (13C) breath test
- Stool helicobacter Antigen Test (SAT)
- A laboratory-based serology (blood test)
397
When does PHE advise that the urea breath test and SAT should not be performed for when testing for H.pylori?
- Should not be performed within 2 weeks of treatment with PPI or within 4 weeks of antibacterial treatment, as this can lead to false negatives.
398
Is routine testing for H.pylori in people with functional dyspepsia recommended?
NO it is not recommended
399
In which circumstances does PHE recommend retesting for H.pylori?
- If compliance is poor, or there are high local resistance rates;
The patient has persistent symptoms and the initial test was performed within 2 weeks of treatment with a proton pump inhibitor, or within 4 weeks of antibacterial treatment;
In patients with an associated peptic ulcer, MALT lymphoma, or after resection of an early gastric carcinoma;
Patients taking aspirin without concomitant treatment with a proton pump inhibitor;
Patients with severe persistent or recurrent symptoms, particularly if not typical of gastro-oesophageal reflux disease
400
After how long should retesting for H.pylori be done?
- at least 4 weeks (ideally 8 weeks) after treatment.
401
In patients requiring gastric acid suppression what should be used?
- H2 receptor antagonist
402
When retesting for H.pylori which test out of the three should be used?
- The urea (13C) breath test should be used for retesting
403
In general what does treatment for H.pylori involve?
- A PPI
| - + 2 antibacterials
404
An additional course of which antibiotics increases the risks of H.pylori resitance?
- clarithromycin
- Metronidazole
- Quinolone
405
Who should you consider referring to in patients who remain H.pylori positive after second-line eradication therapy?
Refer to a specialist
PHE also advise that patients should be referred for an endoscopy, culture and susceptibility testing if the choice of antibacterial treatment is reduced due to hypersensitivity, there are known high local resistance rates, or patients have previously received treatment with clarithromycin, metronidazole, and a quinolone.
406
When treating for H.pylori if diarrhoea develops what other infection can this be an indication of?
- Clostridioides difficile infection
407
For a patient with no penicillin allergy what is the first line treatment for H.pylori?
- Oral first line for 7 days
- A PPI
- Amoxicillin and either clarithromycin or metronidazole
(In second line can use either clarithromycin or metronidazole one which wasn't used during first treatment)
408
What is the first line treatment for someone with a penicillin allergy?
- Oral first line for 7 days
| - A PPI + clarithromycin + metronidazole
409
What is the description of a food allergy?
It is an adverse immune response to a food, commonly associated with cutaneous and gastro-intestinal reactions, and les frequently associated with respiratory reactions and anaphylaxis.
410
How is food allergy distinct from food intolerance?
Food intolerance is non-immunological
411
Which foods are the most common allergens?
Cow’s milk, hen’s eggs, soy, wheat, peanuts, tree nuts, fish, and shellfish are the most common allergens
412
Give an example of cross-reactivity of food allergens that can occur?
- allergy to other mammalian milk in patients with cow's milk allergy.
413
What is the usual management of food allergies?
Allergy caused by specific foods should be managed by strict avoidance of the causal food.
Educating patients about appropriate nutrition, food preparation, and the risks of accidental exposure is recommended, such as food and drinks to avoid, ensuring adequate nutritional intake, and interpreting food labels.
414
What is the drug treatment for food allergies?
Chlorphenamine is licensed for the symptomatic control of food allergy.
415
In the case of food-induced anaphylaxis what should be administered?
- Intramuscular adrenaline/epinephrine is the first-line treatment
416
Which class of drugs are used to control symptoms associated with GI smooth muscle spasm?
Antispasmodics
417
What are the two classifications of antispasmodics?
- Antimuscarinics
| - Smooth muscle relaxants
418
What were antimuscarinics formerly knowns as?
Anticholinergics
419
MAO of Antimuscarinics?
- reduce intestinal motility and are used for GI smooth muscle spasm
420
Give examples of antimuscarinics?
- Tertiary amines (atropine sulfate and Dicyloverine hydrochloride)
- quaternary ammonium compounds (propantheline bromide and hyoscine butlybromide)
421
Which is less lipid soluble, quaternary ammonium compounds or tertiary amines?
Quaternary ammonium compounds are less lipid soluble and are less likely to cross the blood-brain barrier; therefore have a lower risk for central nervous system side effects. They are also less well absorbed from the GI tract.
422
Dicycloverine hydrochloride vs atropine sulfate, which has more antimuscarinic action?
Dicycloverine hydrochloride has a much less marked antimuscarinic action than atropine sulfate and may also have some direct action on smooth muscle.
423
Is Hyoscine butlybromide well absorbed in GI?
No poorly absorbed
424
Give examples of direct acting intestinal smooth muscle relaxants?
- Alverine Citrate
- Mebeverine Hydrochloride
- Peppermint oil
- These may be used to relieve abdominal pain or spasm in IBS
425
Is Dicycloverine hydrochloride a POM only medication?
Generalyl yes but there is an exception as dycloverine hydrochloride can be sold to the public provided that max single dose is 10mg and max daily dose is 60mg.
426
What is the licencing age of hyoscine butylbromide?
- Tablets not licensed for use in children under 6 years.
427
Can hyoscine butlybromide injections be used in children?
No it is not licensed for use in children (age range not specified by manufacturer).
428
What MHRA alert was given regarding hyoscine butylbromide injections?
The injection can cause serious adverse effects including tachycardia, hypotension, and anaphylaxis several reports have shown that anaphylaxis is more likely to be fatal in patients with underlying coronary heart disease,
429
Which patients is hyoscine butylbromide contraindicated in?
CI in patients with tachycardia and should be used with caution in patients with cardiac disease.
430
Under what conditions can Hyoscine butylbromide be sold to sold OTC?
Can be sold to the public for medically confirmed irritable bowel syndrome, provided single dose does not exceed 20mg, daily dose does not exceed 80mg, and pack does not contain a total of more than 240mg.
431
Are mebeverine tablets and capsules licensed for use in children?
Tablets and modified-release capsules not licensed for use in children.
432
What is the OTC dose of mebeverine?
One (135mg) tablet three times a day
433
List a few examples of Liver disorders and related conditions as listed in the BNF?
- Cholestasis
- Gallstones
- In born errors of primary bile acid synthesis
- Primary biliary cholangitis
- Oesophageal Varices
434
What is cholestasis?
It is an impairment of bile formation and/or bile flow, which may clinically present with fatigue, pruritus, dark urine, pale stools and in its most overt form, jaundice and signs of fat soluble vitamin deficiencies.
435
What is the treatment for cholestatic pruritis?
- Cholestyramine is the drug of choice
| - It is an anion-exchange resin that is not absorbed from the GI tract
436
How does cholestyramine help treat cholestatic pruritus?
- It relieves pruritus by forming an insoluble complex in the intestine with bile acids and other compounds - the reduction of serum bile acid levels reduces excess deposition in the dermal tissue with a resultant decrease in pruritus.
437
Which other drug can be used but is known to have a small and variable impact on cholestatic pruritus?
- Ursodeoxycholic acid
438
What are some unlicensed medications that can be used to treat cholestasis pruritus?
- - where previous therapy has proved ineffective or was not tolerate
- Sertraline (unlicensed indication) and naltrexone hydrochloride (unlicensed use) may be used to treat cholestatic pruritus
439
What is the treatment for intrahepatic cholestasis in pregnancy?
- Ursodeoxycholic acid is effective for the treatment of this.
440
At which stage of pregnancy does intrahepatic cholestasis usually occur?
In late pregnancy and is associated with adverse fetal outcomes
441
Is ursodeoxycholic safe to use in pregnancy?
There is no evidence that ursodeoxycholic acid used in late pregnancy affects birth weight in the infant or the risk of preterm delivery. There is limited data about the effect of fetal exposure during the first trimester.
442
What is the medical term for gallstones?
Cholelithiasis
443
What are gallstones?
These occur when hard mineral or fatty deposits form in gallbladder.
444
What is Gallstone disease?
It is a general term that describes the presence of one or more stones in the gallbladder or in the bile duct.
445
Do all patients with gallstones show symptoms?
No majority of patients with gallstones remain asymptomatic
446
What symptoms may a patient experience due to gallstones?
When the stones irritate the gallbladder or block part of the biliary system, the patient can experience symptoms such as pain, or infection and inflammation that if left untreated, can lead to severe complications such as biliary colic, acute cholecystitis, cholangitis, pancreatitis, and obstructive jaundice.
447
Do asymptomatic gallbladder need to be treated?
No unless symptoms develop.
448
What is the definitive treatment of symptomatic gallstones (and all bile duct stones)?
- Surgical removal by laparoscopic cholecystectomy
449
Which drugs can be offered to manage treatment of gallstones?
- Analgesia for pain (paracetamol and NSAIDs)
- Intramuscular diclofenac sodium can begiven for severe pain or, if not suitable, an intramuscular opioid (such as morphine or pethidine hydrochloride)
450
Can ursodeoxycholic acid be used for the management of gallstone disease?
Yes it has been used but there is no evidence to support its use.
451
What are inborn errors of primary bile acid synthesis?
They are a group of diseases in which the liver does not produce enough primary bile acids due to enzyme deficiencies.
These acids are the main components of the bile, and include cholic acid and chenodeoxycholic acid.
452
Which two drugs are licenced for the treatment of inborn errors in primary bile acid synthesis?
- Cholic acid and chenodoxycholic acid.
453
How does cholic acid work?
- It acts by replacing some of the missing bile acids, therefore relieving the symptoms of the disease.
454
What can Ursodeoxycholic acid be used for?
- it can be used to dissolve gallstones (minerals or fatty deposits in the gallbladder).
- It can also be used to treat primary biliary cirrhosis (an autoimmune disease of the liver which progressively destroys the small bile ducts of the liver causing bile and other toxins to build up the liver.
455
What is another name for biliary cholangitis?
Primary biliary cirrhosis
456
What is the description of primary biliary cholangitis?
- it is a chronic cholestatic disease which develops due to progressive destruction of small and intermediate bile ducts within the liver, subsequently evolving to fibrosis and cirrhosis.
457
What is the treatment management for primary biliary cholangitis?
- Ursodeoxycholic acid, including those with asymptomatic disease
- It slows disease progression but the effect in on overall survival is uncertain.
458
What can be considered in patients with advanced primary biliary cholangitis?
- liver transplantation
459
What is the predominant primary bile acid in humans?
Cholic acid which can be used to provide a source of bile acid in patients with inborn deficiencies in bile acid synthesis.
460
What is the monitoring requirements for cholic acid?
- monitor serum an or urine bile acid concentrations every 3 months for the first year then every 6 months for 3 years then annually; monitor liver function at the same or greater frequency
461
What is the drug action for obeticholic acid?
- Obeticholic acid is a selective farnesoid X receptor agonist, which decreases circulating bile acid.
462
When is obeticholic aicd used?
It is used in primary biliary cholangitis in combination with ursodeoxycholic acid when response to ursodeoxycholic acid has been inadequate, or as monotherapy in patients intolerant of ursodeoxycholic acid
463
What is the monitoring requirements for ursodeoxycholic acid?
- in primary biliary cirrhosis, monitor liver function every 4 weeks for 3 months, then every 3 months.
464
Just to summarise what is the definition of primary biliary cirrhosis?
It is an autoimmune disease of the liver, which progressively destroys the small bile ducts of the liver causing bile and other toxins to build up in the liver.
465
What is obesity classified as (BMI??)??
BMI of more than or equal to 30kg/m2,
(though BMI should be interpreted with caution as it is not a direct measure of adiposity, particularly in patients who are very muscular or have muscle weakness or atrophy.
466
What else should be considered to provide an indication of total body fat?
Waist circumference should also be considered as it may provide an indication of total body fat and a risk of obesity-related health problems
467
What are the waist circumference ranges that increase risk of obesity-related health problems?
Men with a waist circumference ≥ 94 cm (≥ 90 cm for Asian men),
- Women with a waist circumference of ≥ 80 cm
A waist circumference of ≥ 102 cm in men and ≥ 88 cm in women indicates a very high risk of obesity-related health problems.
468
During obesity management which parameters should be monitored?
- changes in weight
- Changes in blood pressure
- Blood lipids
- and other associated conditions
469
What initial assessment should be carried out for obesity?
- An initial assessment should be carried out to consider potential underlying causes such as hypothyroidism and a review of appropriateness of current medications which are known to cause weight gain, e.g. atypical antipsychotics, beta-adrenoreceptor blocking drugs, insulin (when used in the treatment of type 2 diabetes), lithium carbonate, lithium citrate, sodium valproate, Sulphonylureas, thiazolidinediones, and tricyclic antidepressants.
470
Which general lifestyle changes should be addressed for management of obesity?
- strategies to change behaviour
- increase physical activity
- improve diet and eating behaviour
471
Can drug treatment be used as the only form of management for obesity?
No it should never be used as the sole element of treatment and should be used as part of an overall weight management plan.
472
An anti-obesity drug should be considered only in which BMI range?
Those with a BMI of more than or equal to 30kg/m2, in whom diet, exercise and behaviour changes fail to achieve a realistic reduction in weight.
473
What BMI range may an anti-obesity drug be considered if the patient associated risk factors?
BMI of ≥ 28 kg/m2
474
Which supplements maybe considered in these patients if there is a concern about inadequate micronutrient intake?
- A vitamin and mineral supplement
475
Rates of weight loss maybe slower in patients with which medical condition?
In patients with type 2 diabetes, so less strict goals than in those without diabetes may be appropriate.
476
Which is the only drug currently available in UK for management of obesity?
Orlistat
477
How does orlistat work?
It reduces the absorption of dietary fat
478
In which patients is orlistat licensed to be used in?
Orlistat is licensed for use as an adjunct in the management of obesity in patients with a BMI of ≥ 30 kg/m2, or, in individuals with a BMI of ≥ 28 kg/m2 in the presence of other risk factors.
479
Can orlistat be used to maintain weight loss rather than just lose weight?
Yes, treatment with orlistat may also be used to maintain weight loss rather than to continue to lose weight.
480
After how many weeks should Orlistat be considered to be discontinued if weight loss has not exceeded 5% since the start of treatment
After 12 weeks
481
Which drugs (unlicensed use) can be used to produce a feeling of satiety?
- Methylcellulose
- Sterculia
but there is little evidence for their efficacy
482
In which patients may surgery be considered in?
Bariatric surgery may be considered for patients who have a BMI of ≥ 40 kg/m2 (Obesity III, morbid obesity), or between 35–39.9 kg/m2 (Obesity II) and a significant disease (such as type 2 diabetes or high blood pressure) which could be improved with weight loss, and if all appropriate non-surgical measures have been tried but clinically beneficial weight loss has not been achieved or maintained.
483
What is the OTC dose of orlistat?
Orlistat 60mg
| - Given to those over 18 years old and with a BMI > 28kg/m2
484
What dose of orlistat is usually given on prescription?
120mg up to three times a day
485
What is the directions for administration of orlistat?
- doses to be taken immediately before, during or up to 1 hour after each main meal.
- If a meal is missed or contains no fat, the dose of orlistat should be omitted.
486
In which two conditions is orlistat contraindicated?
- Cholestasis
| - Chronic malabsorption syndrome
487
Which other drug (which comes a combination of two drugs) can be used as an adjunct therapy in the management of obesity?
- Naltrexone and bupropion
| - Each tablet contains 8mg naltrexone with 90mg bupropion
488
When on orlistat treatment which vitamin in particular may be a concern and may need supplementing?
Vitamin D may be considered if there is a concern about deficiency of fat-soluble vitamins.
489
What is an anal fissure?
It is a tear or ulcer in the lining of the anal canal, immediately within the anal margin.
490
What are the clinical features of an anal fissure?
- bleeding
- persistent pain on defecation
- linear split in the anal mucosa
491
What is classes as an acute anal fissure?
- Present for less than 6 weeks
492
What is the focus of acute anal fissure management?
To ensure that stools are soft and easily passed.
493
What is the management for anal fissures?
- Bulk forming laxatives (such as ispaghula husk) are recommended and an osmotic laxative (such as lactulose) can be considered as an alternative.
Short-term use of a topical preparation containing a local anaesthetic (such as lidocaine hydrochloride) or a simple analgesic (such as paracetamol or ibuprofen) may be offered for prolonged burning pain following defecation.
494
What is classes as chronic anal fissure?
those which last longer than 6 weeks.
495
What are some unliscened drugs which can be used for chronic anal fissures?
- Glyceral trinitrate
- Diltiazem hydrochloride
- Nifedipine
(Rectal Ointments^)
496
What is the final option for anal fissures for those that have not responded to drug treatments?
Surgery
497
What are haemorrhoids?
Also known as piles are abnormal swellings of the vascular mucosal anal cushions around the anus.
498
When do internal haemorrhoids become painful?
Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated
499
When are women predisposed to developing haemorrhoids?
During pregnancy
500
What are non drug management of harmorrhoids?
- Stool should be kept soft and easy to pass (to minimise straining) by increasing dietary fibre and fluid intake.
501
For haemorrhoids simple analgesic such as paracetamol can be used for pain relief. Which analgesics should be avoided?
Opioid analgesics as they can cause constipation
502
If rectal bleeding is present which pain killers should be avoided?
NSAIDs
503
HOw long should preparations containing local anesthetics (lidocaine, benzocaine, cinchocaine and pramocaine) be used for when treating haemorrhoids?
For few days only as they may cause sensitisation of the anal skin.
504
How long can topical cotricosteroids be used for in treating haemorrhoids?
No more than 7 days after exclusions of infections (such as perianal streptococcal infection, herpes simplex or perianal thrush).
505
What can long term use of corticosteroid creams for haemorrhoids cause ?
May cause ulceration or permanent damage due to thinning of the perianal skin and should be avoided.
Continuous or excessive use carries a risk of adrenal suppression and systemic corticosteroid effects.
506
what are some of the treatments available for haemorrhoids by specialists?
- rubber band ligation
- Injection sclerotherapy (using phenol in oil)
- Infrared coagulation/ photocoagulation
- Bipolar diathermy
- Direct current electrotherapy
- Haemorrhoidectomy
- Stapled haemorrhoidectomy
haemorrhoidal artery ligation
507
During pregnancy can topical haemorrhoids products be used?
No - none are licensed for use during pregnancy
- Bulk forming laxatives can be used to soften stool
If treatment with a topical haemorrhoidal preparation is required, a soothing preparation containing simple, soothing products (not local anaesthetics or corticosteroids) can be considered.
508
How long should ointments/ suppositories for haemorrhoids be used maximum for?
Maximum 7 days
| Apply day and night and additional applications after a bowel movement
509
What main ingredients are in Scheriproct?
Cinchocaine and prednisolone
510
What is exocrine pancreatic insufficiency?
- it is characterised by reduced secretion of pancreatic enzymes into the duodenum
511
What are the main clinical manifestations of exocrine pancreatic insufficiency?
- Maldigestion and malnutrition
- associated with low circulating levels of micronutrient, fat-soluble vitamins and lipoproteins
- Patients also present with GI symptoms such as diarrhoea, abdominal cramps and steatorrhea?
512
What is Steatorrhoea?
- It is a result of fat malabsorption
| - Causes pale, bulky and malodorous stools, which float and are difficult to flush
513
In healthy individuals less than how much fat is excreted daily in stools?
Less than 6g
514
What can exocrine pancreatic insufficiency result from?
- Chronic pancreatitis
- Cystic fibrosis
- Obstructive pancreatic tumours
- Coeliac disease
- Zollinger-Ellison syndrome
- GI or pancreatic surgical resection
515
What is the main treatment choice for exocrine pancreatic insuffiency?
- Pancreatin
516
Which three main enzymes are contained in Pancreatin?
- Lipase - fat
- Amylase - carbohydrates
- Protease - Proteins
517
SHould Pancreatin be taken with or without food?
It should be administered with meals and snacks
518
With patients with cystic fibrosis who are taking high dose pancreatic enzyme replacement therapy what has been reported?
- Fibrosing colonopathy
519
What are risk factors for fibrosing colonopathy?
Possible risk factors are gender (in children, boys are at greater risk than girls), more severe cystic fibrosis, and concomitant use of laxatives. The peak age for developing fibrosing colonopathy is between 2 and 8 years.
520
In people with cystic fibrosis what should the total units of pancreatin dose not exceed?
10,000 units/kg of lipase
521
Give an example of a brand name of pancreatin preparation
Creon
522
What strengths Creon are there?
Creon 10 000
Creon 25 000
Creon 40 000
523
What non drug treatment advice can be given to someone with exocrine pancreatic insufficiency?
- Food should be distributed between three main meals per day and two or three snacks
- Food that is difficult to digest should be avoided such as legumes (peas, beans, lentils) and high-fibre foods
- Alcohol should be avoided completely
524
Are reduced fat diets recommended for exocrine pancreatic insufficieny?
- No not recommended
525
How should pancreatin be taken?
With foods or snacks as presence of gastric acid can inactivate pancreatin
526
In patients receiving higher strength pancreatin what is it important for patients to maintain an adequate supply of?
Stay hydrated
527
What is a stoma?
A stoma is an artificial opening of the abdomen to divert flow of faeces or urine into an external pouch located outside of the body
- This procedure may be temporary or permanent
528
What are the most common forms of stoma?
- Colostomy and ileostomy
| - but a gastrostomy, jejunostomy, duodenostomy, or caecostomy may also be performed
529
Should prescribing decision be considered with people with stoma?
special care due to modifications in drug delivery, resulting in a higher risk of sub-optimal absorption.
530
Which form of medications are unsuitable for patients with stoma?
Enteric coated and modified release medicines, particularly in patients with ileostomy, as there may be insufficient release of the active ingredient.
531
Instead which forms should be used in patients with a stoma bag?
Preparation forms with quick dissolution and absorption should be used. Liquids, capsules, and uncoated or soluble tablets are usually well absorbed.. When a solid-dose form such as a capsule or a tablet is given, the contents of the stoma bag should be checked for any remnants.
532
Patients with a stoma are susceptible to what?
- Fluid and sodium depletion which can often lead to hypokalaemia; potassium supplements are not usually required
Hypokalaemia may cause an increased sensitivity to digoxin
