Dyspepsia: Community Pharmacy Guide PDF

Community pharmacy DR/Sherin Lec 10 Dyspepsia It is therefore an umbrella term generally used by healthcare professionals to refer to a group of upper abdominal symptoms that arise from five main cond...

Community pharmacy DR/Sherin Lec 10 Dyspepsia It is therefore an umbrella term generally used by healthcare professionals to refer to a group of upper abdominal symptoms that arise from five main conditions: 1. Non-ulcer dyspepsia/functional dyspepsia (indigestion). 2. Gastro-esophageal reflux disease (GORD, heartburn). 3. Gastritis. 4. Duodenal ulcers. 5. Gastric ulcers. These five conditions represent 90% of dyspepsia cases presented to the GP. Prevalence and epidemiology: ✓ The exact prevalence of dyspepsia is unknown. ✓ This is largely because of the number of people who self-medicate or do not report mild symptoms to their GP. However, it is clear that dyspepsia is extremely common. ✓ The prevalence of dyspepsia is modestly higher in women than men. Etiology: The etiology of dyspepsia differs depending on its cause. 1. Decreased muscle tone leads to lower esophageal sphincter incompetence (often as a result of medicines or overeating) and is the principal cause of GORD. 2. Increased acid production results in inflammation of the stomach (gastritis) and is usually attributable to Helicobacter pylori infection, or acute alcohol indigestion. ✓ The presence of H. pylori is central to duodenal and gastric ulceration – H. pylori is present in 95% of duodenal ulcers and 80% of gastric ulcers. ✓ The exact mechanism by which it causes ulceration is still unclear, but the bacteria does produce toxins that stimulate the inflammatory cascade. 3. Increasingly common are medicine induced ulcers, most notably NSAIDs and low- dose aspirin. Finally, when no specific cause can be found for a patient’s symptoms the complaint is said to be non-ulcer dyspepsia. (Some authorities do not advocate the use of this term, preferring the term ‘functional dyspepsia’). Arriving at a differential diagnosis: ✓ medical and drug history should be taken to enable the community pharmacist to rule out serious pathology. ✓ A number of dyspepsia specific questions should always be asked of the patient to aid in diagnosis. 1 Community pharmacy DR/Sherin Lec 10 Clinical features of dyspepsia: Patients with dyspepsia present with a range of symptoms commonly involving: 1) Vague abdominal discomfort (aching) above the umbilicus associated with belching. 2) Bloating & Flatulence. 3) A feeling of fullness. 4) Nausea and/or vomiting. 5) Heartburn. Although, dyspeptic symptoms are a poor predictor of disease severity or underlying pathology, retrosternal heartburn is the classic symptom of GORD. Conditions to eliminate: Unlikely causes: 1. Peptic ulceration: ✓ Ruling out peptic ulceration is probably the main consideration for community pharmacists when assessing patients with symptoms of dyspepsia. ✓ Ulcers are classed as either gastric or duodenal. Typically, the patient will have well localized mid epigastric pain described as ‘constant’, ‘annoying’ or ‘gnawing/boring’. ✓ If ulcers are suspected referral to the GP is necessary as peptic ulcers can only be conclusively diagnosed by endoscopy. gastric ulcers Duodenal ulcers the pain comes on whenever eating, usually 30 tend to be more consistent minutes after eating, in symptom presentation. lasts from 30 minutes to 60 minutes. Pain occurs 2 to 3 hours relieved by antacids after eating. aggravated by food, alcohol and caffeine. pain that wakes a person at more commonly associated with night is highly suggestive of 1) weight loss Patients can experience weight loss of 5 duodenal ulcer. to 10 kg and although this could indicate carcinoma, The pain is relieved by food. especially in people aged over 40, on investigation a duodenal ulcer is usually benign gastric ulcer is found most of the time. associated with weight gain. NSAID use is associated with a three- to fourfold increase in gastric ulcers. 2) GI bleeds. 2 Community pharmacy DR/Sherin Lec 10 2. Medicine-induced dyspepsia: A number of medicines can cause gastric irritation leading to or provoking GI discomfort or they can decrease esophageal sphincter tone resulting in reflux. Aspirin and NSAIDs are very often associated with dyspepsia and can affect up to 25% of patients. 3. Irritable bowel syndrome: Patients younger than 45, who have uncomplicated dyspepsia and also lower abdominal pain and altered bowel habits are likely to have irritable bowel Very unlikely causes: 1. Gastric carcinoma: Gastric carcinoma is the third most common GI malignancy after colorectal and pancreatic cancer. However, only 2% of patients who are referred by their GP for an endoscopy have malignancy. It is therefore a rare condition and community pharmacists are extremely unlikely to encounter a patient with carcinoma. One or more ALARM symptoms should be present plus symptoms such as nausea and vomiting or other dyspepsia symptoms 2. Esophageal carcinoma: In its early stages, esophageal carcinoma might go unnoticed. Over time, however, as the esophagus becomes constricted, patients will complain of ✓ difficulty in swallowing ✓ experience a sensation of food sticking in the esophagus. ✓ As the disease progresses weight loss becomes prominent despite ✓ the patient maintaining a good appetite. 3. Atypical angina: Not all cases of angina have classical textbook presentation of pain in the retrosternal area with radiation to the neck, back or left shoulder that is precipitated by temperature changes or exercise. Patients can complain of dyspepsia-like symptoms and feel generally unwell. These symptoms might be brought on by a heavy meal. In such cases antacids will fail to relieve symptoms and referral is needed. 3 Community pharmacy DR/Sherin Lec 10 Evidence bases for over-the-counter medication: The group of patients that should be treated by pharmacists are classed as having ‘uninvestigated dyspepsia’ (i.e., Those that have not had endoscopic investigation). OTC treatment options consist of antacids, H2 antagonists and proton pump inhibitors (PPIs). Before treatment is instigated lifestyle advice should be given where appropriate. The patient should be assessed in terms of diet and physical activity: 1. Move to a lower fat diet. 2. Smoking cessation. 3. Decrease weight. 4. Reduce caffeine intake. 5. Alcohol intake to recommended levels. It might also be possible to identify factors that precipitate or worsen symptoms. Commonly implicated foods that precipitate dyspepsia are spicy or fatty food, caffeine, chocolate, and alcohol. Bending is also said to worsen symptoms. 1) Antacids: ✓ Antacids have been used for many decades to treat dyspepsia and have proven efficacy in neutralizing stomach acid. However, the neutralizing capacity of each antacid varies dependent on the metal salt used. In addition, the solubility of each metal salt differs, which affects their onset and duration of action. 1. Sodium and potassium salts are the most highly soluble, which makes them quick but short acting. 2. Magnesium and aluminum salts are less soluble so have a slower onset but greater duration of action. 3. Calcium salts have the advantage of being quick acting yet have a prolonged action. It is therefore commonplace for manufacturers to combine two or more antacid ingredients together to ensure a quick onset (generally sodium salts e.g. Sodium bicarbonate) and prolonged action (aluminum, magnesium or calcium salts). ✓ The majority of marketed antacids are combination products containing two, three or even four constituents. The rationale for combining different salts together appears to be two-fold. 1. First, to ensure the product has quick onset (containing sodium or calcium) and a long duration of action (containing magnesium, aluminum, or calcium). 2. Second, to minimize any side effects that might be experienced from the product. For example, magnesium salts tend to cause diarrhea and aluminum salts constipation, however, if both are combined in the same product then neither side effect is noticed. 4 Community pharmacy DR/Sherin Lec 10 ✓ Antacids can affect the absorption of a number of medications via chelation and adsorption. Commonly affected medicines include tetracyclines, quinolones, imidazoles, phenytoin, penicillamine and bisphosphonates. ✓ In addition, the absorption of enteric-coated preparations can be affected due to antacids increasing the stomach ph. ✓ The majority of these interactions are easily overcome by leaving a minimum gap of 1 hour between the respective doses of each medicine. ✓ Most patient groups can take antacids, although patients on salt-restricted diets (e.g. Patients with coronary heart disease) should ideally avoid sodium-containing antacids. ✓ In addition, antacids should not be recommended in children because dyspepsia is unusual in children under 12. Indeed, most products are licensed for use only for children aged 12 and over. However, there are a few exceptions which have product licenses for use in children. Examples of antacids include: 1. Aluminum hydroxide gel (Alternagel, Amphojel) 2. Calcium carbonate (Alka-Seltzer, Tums) 3. Magnesium hydroxide (Milk of Magnesia) 4. Gaviscon, Gelusil, Maalox, Mylanta, Rolaids. 5. Pepto-Bismol. 2) Alginates: For patients suffering from GORD an alginate product should be first-line treatment. When in contact with gastric acid the alginate precipitates out, forming a sponge-like matrix that floats on top of the stomach contents. Alginate preparations are also commonly combined with antacids to help neutralize stomach acid. Products containing alginates are combination preparations that contain an alginate with antacids. They are best given after each main meal and before bedtime, although they can be taken on a when-needed basis. They can be given during pregnancy and breastfeeding and to most patient groups but, as with antacids, patients on salt-restricted diets should ideally avoid sodium- containing alginate preparations. They are reported not to have any side effects or interactions with other medicines. 5 Community pharmacy DR/Sherin Lec 10 3) H2 antagonists: (Ranitidine, nizatidine and Famotidine): Trials showed conclusively that ranitidine, and its comparator drug famotidine, did significantly raise intragastric pH compared to placebo. Famotidine: ✓ The dose for famotidine is 10 mg (one tablet) at the onset of symptoms; however, if symptoms persist an additional dose can be repeated after 1 hour. ✓ The maximum dose is 20 mg (two tablets) in 24 hours. A dose can be taken 1 hour prior to consuming food or drink that are known to bring on symptoms. Ranitidine: ✓ Dosing for ranitidine (Zantac 75) is similar to famotidine in that one tablet should be taken straight away but if symptoms persist then a further tablet should be taken 1 hour later. ✓ The maximum dose is 300 mg (four tablets) in 24 hours. 4) Proton pump inhibitors: PPIs are generally superior to H2 antagonists in treating dyspeptic symptoms Omeprazole: is licensed for the relief of reflux-like symptoms (e.g., heartburn) associated with acid-related dyspepsia in patients aged over 18 years of age. The initial dose is two 10 mg tablets once daily. Once symptoms improve the dose can be reduced to one tablet (10 mg). If symptoms return, then the dose can be stepped back up to 20 mg. Patients should be referred to their GP if symptoms do not resolve in 2 weeks or they need to use omeprazole for more than 4 weeks continuously. common side effects (>1 in 100), which include headache, diarrhea, constipation, abdominal pain, nausea and vomiting and flatulence. Drug interactions with omeprazole are possible because it is metabolized in the liver by cytochrome P450 isoenzymes. These include ‘azole’ antifungals (decrease in azole bioavailability), diazepam (enhanced diazepam side effects), fluvoxamine (increased omeprazole levels), cilostazol (increased cilostazol levels) and clopidogrel (reduced clopidogrel levels). Other interactions listed in the manufacturer’s literature include phenytoin and warfarin, but their clinical significance appears low. It appears to be safe in pregnancy and excreted in only small amounts of breast milk and is not contraindicated. 6 Community pharmacy DR/Sherin Lec 10 Rabeprazole Its product license is very similar to that of omeprazole: it has a license for the short- term symptomatic treatment of GORD-like symptoms (e.g. heartburn) in adults aged 18 and over; if symptoms have not been controlled within 2 weeks or if continuous treatment for more than 4 weeks is required, then the patient should be referred to their doctor; and it should be avoided in pregnant and breastfeeding women. The dose is one 10 mg tablet each day. Side effects commonly seen include insomnia, headaches, dizziness, cough, diarrhea, vomiting, nausea, abdominal pain, and constipation. It interacts with oral ‘azole’ medicines and on theoretical grounds should not be co administered with atazanavir. The currently available PPIs include: omeprazole (Prilosec, Prilosec OTC, Zegerid) lansoprazole (Prevacid) pantoprazole (Protonix) rabeprazole (Aciphex) esomeprazole (Nexium) dexlansoprazole (Dexilant) Summary: 1) Antacids will work for the majority of people presenting at the pharmacy with mild dyspeptic symptoms. They can be used as first-line therapy unless heartburn predominates then an alginate or alginate/antacid combination can be used. 2) H2 antagonists appear to be equally effective to antacids but are considerably more expensive. 3) Proton pump inhibitors are the most effective and could be considered firstline, especially for those patients that suffer from moderate to severe or recurrent symptoms. Like H2 antagonists they are expensive in comparison to simple antacids and might influence patient choice or pharmacist recommendation. Diarrhea ✓ defined as an increase in frequency of the passage of soft or watery stools relative to the usual bowel habit for that individual. ✓ It is not a disease but a sign of an underlying problem such as an infection or gastrointestinal disorder. ✓ It can be classed as a) acute (less than 7 days) b) persistent (more than 14 days) c) chronic (lasting longer than a month). 7 Community pharmacy DR/Sherin Lec 10 ✓ Most patients will present to the pharmacy with a self-diagnosis of acute diarrhea. It is necessary to confirm this self-diagnosis because patients’ interpretations of their symptoms might not match up with the medical definition of diarrhea. Prevalence and epidemiology: The exact prevalence and epidemiology of diarrhea is not well known. This is probably due to the number of patients who do not seek care or who self- medicate. However, acute diarrhea does generate high GP consultation rates. It has been reported that children under the age of 5 years have between one and three bouts of diarrhea per year and adults, on average, just under one episode of diarrhea per year. Many of these cases are thought to be food related. Etiology: ✓ The etiology of diarrhea depends on its cause. ✓ Acute gastroenteritis, the most common cause of diarrhea in all age groups, is usually viral in origin. Other pathogens identified include Escherichia coli, Salmonella, Shigella; viruses such as adenovirus; and the protozoa Cryptosporidium and Giardia. Viral causes tend to cause diarrhea by blunting of the villi of the upper small intestine decreasing the absorptive surface. ✓ Bacterial causes of diarrhea are normally a result of eating contaminated food or drink and cause diarrhea by a number of mechanisms. For example: a) enterotoxigenic E. coli: produce enterotoxins that affect gut function with secretion and loss of fluids. b) enteropathogenic E. coli: interferes with normal mucosal function. c) enteroinvasive E. coli, Shigella and Salmonella species: cause injury to the mucosa of the small intestine and deeper tissues. d) Other organisms, for example Staphylococcus aureus and Bacillus cereus, produce preformed enterotoxins which on ingestion stimulate the active secretion of electrolytes into the intestinal lumen. Arriving at a differential diagnosis: The most common causes of diarrhea are viral or bacterial infection, and the community pharmacist can appropriately manage the vast majority of cases. The main priority is identifying those patients that need referral and how quickly they need to be referred. Dehydration is the main complicating factor, especially in the very young and very old. A number of diarrhea specific questions should always be asked of the patient to aid in diagnosis. 8 Community pharmacy DR/Sherin Lec 10 Clinical features of acute diarrhea: 1. Symptoms are normally rapid in onset, with the patient having a history of prior good health. 2. Nausea and vomiting might be present prior to or during the bout of acute diarrhea. 3. Abdominal cramping 4. flatulence tenderness is also often present. If rotavirus is the cause the patient might also experience viral prodromal symptoms such as cough and cold. Acute infective diarrhea is usually watery in nature with no blood present. Complete resolution of symptoms should be observed in 2 to 4 days. However, diarrhea caused by the rotavirus can persist for longer. Conditions to eliminate: Likely causes Medicine-induced diarrhea: Many medicines (both POM and OTC) can induce diarrhea. If medication is suspected as the cause of the diarrhea the GP should be contacted and an alternative suggested Unlikely causes: 1. irritable bowel syndrome: Patients younger than 45 with lower abdominal pain and a history of alternating diarrhea and constipation are likely to have IBS. 2. Giardiasis: Giardiasis, a protozoan infection of the small intestine, is contracted through drinking contaminated drinking water. It is an uncommon cause of diarrhea in Western society. However, with more people taking exotic foreign holidays, enquiry about recent travel should be made. The patient will present with watery and foul-smelling diarrhea accompanied with symptoms of bloating, flatulence, and epigastric pain. If giardiasis is suspected the patient must be referred to the GP quickly for confirmation and appropriate antibiotic treatment. 3. Fecal impaction: ✓ Fecal impaction is most commonly seen in the elderly and those with poor mobility. 9 Community pharmacy DR/Sherin Lec 10 ✓ Patients might present with continuous soiling as a result of liquid passing around hard stools and mistakenly believe they have diarrhea. ✓ On questioning, the patient might describe the passage of regular poorly formed hard stools that are difficult to pass. ✓ Referral is needed as manual removal of the faeces is often needed. Very unlikely causes: 1) Ulcerative colitis and Crohn’s disease: Both conditions are characterized by chronic inflammation at various sites in the GI tract and follow periods of remission and relapse. They can affect any age group, although peak incidence is between 20 and 30 years of age. In mild cases of both conditions, diarrhea is one of the major presenting symptoms, although blood in the stool is usually present. Patients might also find that they have urgency, nocturnal diarrhea, and early morning rushes. In the acute phase patients will appear unwell and have malaise. 2) Malabsorption syndromes: a) Lactose intolerance is often diagnosed in infants under 1 year old. In addition to more frequent loose bowel movements symptoms such as fever, vomiting, perianal excoriation and a failure to gain weight might occur. b) Coeliac disease has a bimodal incidence. first, in early infancy when cereals become a major constituent of the diet. second, during the fourth and fifth decades. c) Steatorrhoea (Fatty stools) is common and might be observed by the patient as frothy or floating stools in the toilet pan. Bloating and weight loss in the presence of a normal appetite might also be observed. 3) Colorectal cancer: Any middle-aged patient presenting with a longstanding change of bowel habit must be viewed with suspicion. Persistent diarrhea accompanied by a feeling that the bowel has not really been emptied is suggestive of neoplasm. This is especially true if weight loss is also present. 10 Community pharmacy DR/Sherin Lec 10 Evidence bases for over-the-counter medication: Goals of OTC treatment are therefore concentrated on relief of symptoms. Before considering treatment, it is important to stress to patients the importance of hand washing. Interventions that promote hand washing can reduce diarrhea episodes by about one-third. Antidiarrheal medicines include: Loperamide (1 brand name: Imodium). Bismuth subsalicylate (2 brand names: Kaopectate, Pepto-Bismol). 1) Oral rehydration solution (ORS). ✓ Loperamide is a synthetic opioid analogue. ✓ It is thought to exert its action via opiate receptors slowing intestinal tract time and increasing the capacity of the gut. 2) Loperamide ✓ Loperamide is also available compounded with simethicone. However, there is little evidence of better efficacy in terms of diarrheal symptoms with the combination. 3) Bismuth ✓ Bismuth-containing products have been used for many decades. subsalicylate: ✓ Its use has declined over time as other products have become more popular. However, bismuth subsalicylate has been shown to be effective in treating traveler’s diarrhea 4) Kaolin and morphine 5) Rotavirus In 2006, two new oral vaccines (Rotarix, and RotaTeq) were licensed vaccine: by the European Medicines Agency and the US Food and Drug Administration. From 2013, the rotavirus vaccine will be added to the routine UK childhood vaccination schedule. Here are five of the most popular options. 1. Loperamide. Loperamide is one of the bestknown anti-diarrheal medicines. 2. Diphenoxylate. Diphenoxylate is similar to loperamide. 3. Cholestyramine. 4. Codeine sulfate. 5. Pepto-Bismol. Antidiarrheals Pepto Bismol or Kaopectate (bismuth subsalicylate)—available over the counter Imodium AD (loperamide)—available over the counter Lomotil (diphenoxylate/atropine)—available by prescription only, used to treat serious diarrhea. Mytesi (crofelemer)—available by prescription only, used to treat diarrhea associated with HIV/AIDS 11 Community pharmacy DR/Sherin Lec 10 Constipation Background Constipation arises when the patient experiences a reduction in their normal bowel habit accompanied with more difficult defecation and/or hard stools. Prevalence and epidemiology: ✓ Constipation is very common. It occurs in all age groups but is especially common in the elderly. It has been estimated that 25 to 40% of all people over the age of 65 have constipation. ✓ The majority of the elderly have normal frequency of bowel movements but strain at stool. ✓ This is probably a result of sedentary lifestyle, a decreased fluid intake, poor nutrition, avoidance of fibrous foods and chronic illness. ✓ Women are two to three times more likely to suffer from constipation than men and 40% of women in late pregnancy experience constipation. Etiology: a) The normal function of the large intestine is to remove water and various salts from the colon, drying and expulsion of the faeces. b) Any process that facilitates water reabsorption will generally lead to constipation. c) The commonest cause of constipation is an increase in intestinal tract transit time of food which allows greater water reabsorption from the large bowel leading to harder stools that are more difficult to pass. d) This is most frequently caused by a deficiency in dietary fiber, a change in lifestyle and/or environment and medication. e) Occasionally, patients ignore the defecatory reflex as it may be inconvenient for them to defecate. ‫النوع الوحيد اللي بنعالجه‬ acute uncomplicated Arriving at a differential diagnosis: ‫الباقي بنعمل ريفير‬ ✓ The first thing a pharmacist should do is to establish the patient’s current bowel habit compared to normal. This should establish if the patient is suffering from constipation. Questioning should then concentrate on determining the cause because constipation is a symptom and not a disease and can be caused by many different conditions. ✓ Constipation does not usually have sinister pathology and the commonest cause in the vast majority of non-elderly adults will be a lack of dietary fiber. 12 Community pharmacy DR/Sherin Lec 10 ✓ However, constipation can be caused by medication and many disease states including: a) neurological disorders (e.g., multiple sclerosis, Parkinson’s disease), b) metabolic and endocrine conditions (diabetes, hypothyroidism) c) neoplasm. ✓ A number of constipation-specific questions should always be asked of the patient to aid in diagnosis. Clinical features of constipation: ✓ Besides the inability to defecate, patients might also have: 1. Abdominal discomfort and bloating. 2. In children, parents might also notice the child is more irritable and have a decreased appetite. 3. Specks of blood in the toilet pan might be present and are usually due to straining at stool. In the vast majority of cases blood in the stool does not indicate sinister pathology. ✓ Those patients presenting with acute constipation with no other symptoms apart from very small amounts of bright red blood can be managed in the pharmacy, ✓ however, if blood loss is substantial (stools appear tarry, red, or black) or the patient has other associated symptoms such as malaise, abdominal distension and is over 40 years old then referral is needed. Conditions to eliminate: Likely causes: 1. Medicine-induced constipation: Many medicines are known to cause constipation. Most exert their action by decreasing gut motility, opioids, and their analogues. Unlikely causes: 1. Irritable bowel syndrome: Patients younger than 45 with lower abdominal pain and a history of alternating diarrhea and constipation are likely to have IBS. 2. Pregnancy: ✓ Constipation is common in pregnancy, especially in the third trimester. ✓ A combination of increased circulating progesterone, displacement of the uterus against the colon by the fetus, decreased mobility and iron supplementation all contribute to an increased incidence of constipation whilst pregnant. Most patients complain of hard stools rather than a decrease in bowel movements. ✓ If a laxative is used a bulk-forming laxative should be recommended. 13 Community pharmacy DR/Sherin Lec 10 3. Depression: Upwards of 20% of the population will suffer from depression at some time. Many will present with physical as well as emotional symptoms. It has been reported that a third of all patients suffering from depression present with gastrointestinal complaints in a primary care setting. Core symptoms of persistent low mood and loss of interest in most activities should trigger referral. 4. Functional causes in children: Constipation in children is common and the cause can be varied. Constipation is not normally a result of organic disease but stems from poor diet or a traumatic experience associated with defecation, for example, unwillingness to defecate due to association of prior pain on defecation. Very unlikely causes: 1. Colorectal cancer: ✓ Colorectal carcinomas are rare in patients under the age of 40. However, the incidence of carcinoma increases with increasing age and any patient over the age of 40 presenting for the first time with a marked change in bowel habit should be referred. Sexes appear to be equally affected. ✓ The patient might complain of abdominal pain, rectal bleeding, and tenesmus. Weight loss – a classical textbook sign of colon cancer – is common but observed only in the latter stages of the disease. ✓ Therefore, a patient is unlikely to have noticed marked weight loss when visiting a pharmacy early in disease progression. 2. Hypothyroidism ✓ The signs and symptoms of hypothyroidism are often subtle and insidious in onset. Patients might experience weight gain, lethargy, cold intolerance, coarse hair and dry skin as well as constipation. ✓ Hypothyroidism affects ten times more women than men and peak incidence is in the fifth or sixth decade. ✓ Constipation is often less pronounced than lethargy and cold intolerance Evidence bases for over-the-counter medication: For uncomplicated constipation, non-drug treatment is advocated as first-line treatment for all patient groups a simple dietary and lifestyle modifications (increasing exercise) will relieve the majority of acute cases of constipation. Advice includes. 14 Community pharmacy DR/Sherin Lec 10 a) increasing fluid and fiber intake. b) Dietary fiber increases stool bulk, stool water content and colonic bacterial load. c) Fiber intake should be increased to approximately 30 g day in the form of fruit, vegetables, cereals, grain foods and whole meal bread. d) It is important to remind patients that adequate fluid intake (2 L per day) is needed when following a high-fiber diet and patients might experience excessive gas production, colicky abdominal pain and bloating. Effects of a high-fiber diet are usually seen in 3 to 5 days. If medication is required, four classes of OTC laxatives are available: bulk-forming agents, stimulants, osmotic and stool softeners. Summary: It appears from the evidence that laxatives do work, but deciding on which laxative to give a patient cannot be made on an evidence-based approach. Other factors will need to be considered such as the patients’ status, side-effect profile of the medicine and its cost. Practical prescribing and product selection: ✓ Prescribing laxatives in children should ideally be left to those healthcare professionals experienced in managing childhood constipation. ✓ OTC products are licensed for use in young children but in accordance with good practice those children younger than 6 years old who have failed to respond to dietary intervention should be referred to their GP. 1) Bulk-forming laxatives (methylcellulose): Bulk-forming laxatives exert their effect by a) mimicking increased fiber consumption, swelling in the bowel and increasing faecal mass. b) In addition, they also encourage the proliferation of colonic bacteria, and this helps further increase faecal bulk and stool softness. Patients should be advised to increase their fluid intake whilst taking bulk forming medicines. Their effect is usually seen in 12 to 36 hours but can take as long as 72 hours. Side effects commonly experienced include flatulence and abdominal distension. They are well tolerated in pregnancy and breastfeeding and have no teratogenic effects. They appear to have no drug interactions of any note. Bulk-forming laxatives psyllium (Metamucil, Konsyl) calcium polycarbophil (FiberCon) methylcellulose fiber (Citrucel) 15 Community pharmacy DR/Sherin Lec 10 2) Stimulant laxatives (e.g. bisacodyl, glycerol, senna, sodium picosulfate): ✓ Stimulant laxatives increase GI motility by directly stimulating colonic nerves. ✓ the main side effect associated with stimulant laxatives. a) abdominal pain b) the possibility of nerve damage in long-term use and are the most commonly abused laxatives. ✓ Their onset in action is quicker than other laxative classes, with patients experiencing a bowel movement in 6 to 12 hours when taken orally. ✓ They can be taken by all patient groups, have no drug interactions and are safe in breastfeeding. However, because of their stimulant effect on uterine contractions they are best avoided in pregnancy if possible. 3) Osmotic laxatives (e.g., lactulose, macrogols and magnesium salts) ✓ These act by retaining fluid in the bowel by osmosis or by changing the pattern of water distribution in the faeces. ✓ Flatulence, abdominal pain, and colic are frequently reported. They can be taken by all patient groups, have no drug interactions and safely used in pregnancy and breastfeeding. ✓ Osmotic laxatives include: 1. magnesium hydroxide (Phillips Milk of Magnesia) 2. magnesium citrate (Citroma) 3. polyethylene glycol (MiraLAX) 4. sodium phosphate (Fleet Saline Enema) 5. glycerin (Fleet Glycerin Suppository) 4) Stool softeners (Liquid paraffin and docusate sodium): Liquid paraffin has been traditionally used to treat constipation. However, the adverse side-effect profile of liquid paraffin now means it should never be recommended because other, safer and more effective medications are available 16