Gastroenterology First-line Treatments PDF

Gastroenterology Dyspepsia For patients presenting with mild dyspepsia symptoms (not associated with heartburn): Antacids will work for most people presenting at the pharmacy with mild dyspeptic symptoms. They can be used as first-line therapy o Rutter p179 mentions about c...

Gastroenterology Dyspepsia For patients presenting with mild dyspepsia symptoms (not associated with heartburn): Antacids will work for most people presenting at the pharmacy with mild dyspeptic symptoms. They can be used as first-line therapy o Rutter p179 mentions about combination products to ensure the product has quick onset (sodium or calcium) and a long duration of action (aluminium or calcium) and to minimize side effects (e.g. aluminium and calcium can cause constipation whereas magnesium can cause diarrhoea) o Rutter p181: ideally, antacids should be given in the liquid form because the acid- neutralizing capacity and speed of onset is greater than that of tablet formulations H2 antagonists (i.e. ranitidine) appear to be equally as effective as antacids but are considerably more expensive. Since antacids can impair the absorption of other medicines, ranitidine could be a preferred option (potentially means a simpler regimen than having to leave a time interval between doses), provided it doesn’t interact with the patients’ existing medicines and all other product licence requirements were met. The main issue here is the lack of availability of ranitidine-containing products following the safety recall. PPIs (i.e. omeprazole, pantoprazole and esomeprazole) are the most effective and could be considered first-line, especially for those patients who suffer from moderate to severe or recurrent symptoms NB: OTC PPIs are typically licensed for the treatment of reflux symptoms (e.g. heartburn, acid regurgitation/reflux) rather than ‘indigestion’ or more general symptoms Where heartburn predominates: An alginate or alginate/antacid combination can be used. ‘Alginate-only’ products are not available in the UK Proton pump inhibitors (i.e. omeprazole, pantoprazole and esomeprazole) and H2 antagonists (i.e. ranitidine) are also options. Since antacids can impair the absorption of other medicines, a PPI or H2 antagonist could be a preferred alternative (potentially means a simpler regimen than having to leave a time interval between doses), provided it didn’t interact with the patients’ existing medicines and all other product licence requirements were met. See above - lack of availability of ranitidine-containing products following the safety recall. PPIs are the most effective and could be considered first-line, especially for those patients who suffer from moderate to severe or recurrent symptoms. They are typically licensed for the treatment of reflux symptoms (e.g. heartburn, acid regurgitation/reflux). However, they may be less suitable for discrete attacks requiring immediate relief as they take several days to reach maximum effect Individual products will specify how long the product can be used for prior to seeking medical advice. If the symptoms are linked to eating certain food (e.g. a spicy or fatty meal) or a large amount, they should be short-lived, and the product typically only required for a day or so. Rutter outlines various general measures that may be useful in the context of dyspepsia (see p178-9 and p181 Hints and Tips box 7.4) including dietary measures, portion sizes and frequency of eating, stopping smoking, reducing weight (if applicable), keeping alcohol intake to recommended levels and elevating the head of the bed. Pregnancy: Give lifestyle advice as first-line management i.e. eat smaller meals more frequently (every 3 hours), not eat late at night (or less than 3 hours before bedtime), and avoid known irritants (for example alcohol, caffeine, fruit juices and carbonated drinks, chocolate, and fatty and spicy foods). Keep a food diary to identify triggers. Try raising the head of their bed by 10–15 cm. Stop smoking (if applicable). Antacids and alginates are recommended as first-line treatments if symptoms are relatively mild and are NOT controlled adequately by lifestyle changes. Alginate products (for example Gaviscon Advance®) are particularly useful if symptoms of gastro-oesophageal reflux (heartburn) are dominant. Gaviscon Advance® is licensed for OTC use but the PIL mentions to take for the shortest duration possible. Calcium-containing products are recommended for short-term or occasional use (check product licence for OTC suitability first) but products containing sodium bicarbonate or magnesium trisilicate are not recommended in pregnancy. Diarrhoea As there are numerous causes of diarrhoea, it is difficult to have one overarching management strategy or safety net. Rutter (p182) states that acute gastroenteritis is the most common cause of diarrhoea in all age groups, so the below information relates to it primarily (although much of the information is relevant in a broad sense). Travellers’ diarrhoea will be covered in Travel Week. NB: Vomiting is encompassed in the essential reading resource ‘Diarrhoea and vomiting summary’ and is also mentioned in the preparation exercise. It will also be covered in Travel week (motion sickness) and Pain week (as a clinical feature of migraine). Hydration and oral rehydration salt solution (ORS) Children: Encourage adequate fluid intake (but discourage fruit juices and carbonated drinks). Advise continued breastfeeding (if applicable) and other milk feeds. NICE CKS states that ORS can be offered as supplemental fluid to children at increased risk of dehydration (NICE CKS outlines which children are at increased risk of dehydration - but you do not need to learn these for the class test). In an OTC product licence context, the age of the child (and product literature wording) may prevent the supply of ORS and necessitate referral. Adults: In most otherwise healthy adults, encouraging fluid intake (especially if supplemented with fruit juice and soups) will be sufficient. Consider supplementing fluid intake with oral rehydration solution in adults at increased risk of a poor outcome (see the other essential reading pdf for such adults). Anti-diarrhoeal medicines These not usually necessary for the management of gastroenteritis. However, they (with loperamide being the drug of choice) may be useful for symptomatic control in adults with mild-to-moderate diarrhoea, for example if quicker resolution of diarrhoea would enable the person to continue essential activities. [Never to be used if the person has: blood and/or mucus in the stools, or high fever (indicating dysentery); confirmed, probable, or suspected vero cytotoxin-producing Escherichia coli 0157 (VTEC) infection; shigellosis.] Amend Rutter’s maximum daily dose (p188) to 12 mg (6 capsules) for Imodium®, rather than 16 mg. Infection control measures See the other essential reading resource for details. This will include hand washing, cleaning of surfaces and clothing, not sharing towels and flannels, when children should return to school and when adults should return to work Follow up and safety net See the other essential reading resource for details Stool sample requirements and notification of infectious diseases: See the other resources for details, but you do not need to learn this information for the class test. Pregnancy: this is a risk factor for dehydration (and any signs or symptoms of dehydration will require referral). Otherwise, ensure adequate fluid intake and check individual ORS products prior to sale to ensure licensed for use. Infection control measures may also be relevant depending on the cause. Potentially stool sample and notification are relevant too, but this is beyond the remit of the module. Loperamide: The BNF states that ‘manufacturers advise avoid-no information available.’ Constipation (adults from age 18 onwards) Advise on lifestyle measures, such as increasing dietary fibre, having adequate fluid intake, and increasing activity and exercise levels if necessary. NICE CKS outlines helpful toileting routines too. Fibre intake should be increased gradually (to minimize flatulence and bloating), and adults should aim to consume 30 g of fibre per day. The beneficial effects of increasing dietary fibre may take several weeks. If these measures are ineffective, or symptoms do not respond adequately: offer a bulk-forming laxative first-line, such as ispaghula (see the GI preparation exercise for more guidance about this, including the importance of having an adequate fluid intake). NB: the management of opioid-induced constipation is very specific (NICE CKS states “do not prescribe bulk-forming laxatives. Offer an osmotic laxative and a stimulant laxative (or docusate is an alternative which also has stool-softening properties)” advise the person to gradually reduce and stop laxatives once the person is producing soft, formed stool without straining at least three times per week (but remember that the manufacturer may stipulate a duration for which their product should be used) Pregnancy: Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels, as appropriate. If these measures are ineffective, or symptoms do not respond adequately, offer short-term treatment with oral laxatives. Adjust the dose, choice, and combination of laxatives used, depending on the woman's symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference. Offer a bulk-forming laxative first-line, such as ispaghula (some ispaghula husk-containing OTC products are licensed for use in pregnancy, such as Fybogel Hi- Fibre® orange sachets). Irritable bowel syndrome (IBS) A Cochrane review by Ruepert (2011) concluded that antispasmodics as a class of medicines when compared to placebo provided a statistically significant benefit for abdominal pain, global assessment and IBS symptom score. However, as the authors acknowledge, antispasmodics are pharmacologically diverse and in their review it was not possible to include all compounds (due to limited number of studies) at sub-group analysis. Therefore, in this review, it was not possible to determine the individual effectiveness of certain OTC antispasmodics (…) The only OTC product which the review found evidence of efficacy was peppermint oil. For peppermint oil a statistically significant effect for improvement of global assessment and for improvement of IBS symptom score was found. OTC products containing peppermint oil and indicated for IBS are: Colpermin IBS Relief® Capsules [peppermint Oil 0.2ml, excipient: arachis oil (peanut oil)] and Mintec® (peppermint oil 0.2ml). In terms of allergies, note that Colpermin IBS Relief® contains peanut oil. Colpermin IBS Relief® SmPC states: The patient should be advised to consult a doctor before use in the following circumstances: first presentation of these symptoms for confirmation of IBS. Mintec® SmPC states: If this is the first occurrence of these symptoms, a doctor should be consulted before self-medication begins, to confirm the appropriateness of the treatment. NB: NICE CKS does not state peppermint oil capsules must be recommended first line over other direct-acting smooth muscle relaxants such as mebeverine hydrochloride and alverine citrate. It also only mentions these in the context of ongoing symptoms of abdominal pain or spasm. NICE CKS states that all people with IBS should be given advice on diet, lifestyle and mental wellbeing - in the context of the open book scenario, such advice can be found within NICE CKS IBS management section. if there are predominant symptoms of constipation, advise the person to: try soluble fibre supplements (for example ispaghula) or foods high in soluble fibre (for example oats and linseed). Also, to gradually increase fibre intake to minimize flatulence and bloating and be aware that beneficial effects may be seen after several weeks. [NB: NICE CKS states that lactulose is not recommended for the treatment of constipation in IBS. NICE CKS states that if symptoms of constipation persist to consider prescribing a bulk-forming laxative] if there are predominant symptoms of diarrhoea and/or bloating, advise the person to: reduce their intake of insoluble fibre, such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice. Also, to consider reducing foods that may exacerbate symptoms, such as caffeine, alcohol, carbonated drinks, and gas-producing foods. NICE CKS also mentions that ‘loperamide may be a useful adjunct to other treatments for diarrhoea-predominant’, but it is mainly discussed under ‘ongoing management’, from a prescribing context. There are some OTC loperamide products licensed for diarrhoea associated with IBS but the age limit tends to be 18 years not 12 years and an initial IBS diagnosis from the doctor may be required when it is used for this indication e.g. Imodium IBS Relief capsules SmPC states they are “For the symptomatic treatment of acute episodes of diarrhoea associated with Irritable Bowel Syndrome in adults aged 18 years and over following initial diagnosis by a doctor.” See also Rutter p199 Hints and Tips Box 7.7 and p198-200 for information about alternative treatments such as probiotics, cognitive behavioural therapy and hypnotherapy. Pregnancy: provide non-pharmacological advice as outlined above. Care with pharmacological management. For example, the SmPC for Colpermin® IBS Relief states that there are no adequate and well-controlled studies in pregnant women. This product should not be used during pregnancy unless the potential benefit of treatment to the mother outweighs the possible risks to the developing foetus. Similar wording is used in various POM IBS products too. For example, Colofac® 135 mg tablets states that there are no or limited amounts of data from the use of mebeverine in pregnant women (…) Mebeverine is not recommended during pregnancy. Haemorrhoids NICE CKS discusses providing advice to minimize constipation and straining (see constipation management) and offering simple analgesia such as paracetamol. Advise the person about perianal hygiene as this may be helpful in symptomatic relief and prevention of perineal dermatitis. Recommend careful perianal cleansing with moistened towelettes or baby wipes, and to pat (rather than rub) the area dry. NICE CKS states that there is no evidence that any topical haemorrhoidal preparations is more effective than another. The choice of preparation should therefore be based on the risk of adverse effects and the person's symptoms and preference. Rutter (p205) reiterates this message (little data available on their effectiveness) and also states that it seems prudent to recommend products containing a local anaesthetic or hydrocortisone as they do have proven effectiveness in other similar conditions. If you wish to find such products, in addition to Counter Intelligence Plus Section b, you can go to eMC and search for ‘lidocaine’ and select ‘P’ and ‘GSL’ (and repeat for hydrocortisone). The product indication may be obvious from the name, otherwise click on the products to check that they are indicated for haemorrhoids. Explain how to insert suppository/internal ointment or cream. Pregnancy: provide non-pharmacological advice about perianal hygiene as outlined above. If constipation is present in addition to haemorrhoids, follow the constipation management strategy for pregnancy, as previously outlined. Many OTC haemorrhoid products state to seek medical advice prior to use (even those without hydrocortisone such as Anusol® cream) so referral may also be warranted, particularly if a haemorrhoid product or physical examination is deemed necessary or desired. Some OTC paracetamol products may be licensed for use in pregnancy for pain.