PF1011 Pharmacy Practice I Gastrointestinal Tract – Part 1 PDF

PF1011: Pharmacy Practice I Gastrointestinal Tract – Part 1 Dr. Harriet Bennett-Lenane [email protected]  Aims and Objectives By the end of this lecture series you should be able to: Understand the various considerations which should be taken into account when dealing with patient quer...

PF1011: Pharmacy Practice I Gastrointestinal Tract – Part 1 Dr. Harriet Bennett-Lenane [email protected]  Aims and Objectives By the end of this lecture series you should be able to: Understand the various considerations which should be taken into account when dealing with patient queries regarding the gastro-intestinal system. Appreciate the various types of these symptoms and their aetiologies. Be aware of the various treatment options for patients with these symptoms and have an appreciation of their safe and effective use. Understand when referral for further medical attention is required. Lecture Layout Gastrointestinal Tract - Part 1 Dyspepsia Symptoms ALARM/Red Flag symptoms Treatment Non-Pharmacological Advice Antacids Alginates H2 Antagonists Proton Pump Inhibitors Gastrointestinal Tract Anatomy Oesophagus Lower oesophageal sphincter (LOS) - regulates the movement of food from oesophagus to the stomach.  Gastrointestinal Tract Anatomy & Physiology Stomach Parietal cells secrete ~2L of hydrochloric acid (HCl) per day. Acid in the stomach: 1. Kills bacteria. 2. Aids digestion. 3. Establish the optimal pH for digestive enzyme, pepsin. Dyspepsia ‘Bad digestion’ No universally accepted definition. Umbrella term to describe a range of symptoms associated with the upper gastro-intestinal tract. A complex group of symptoms rather than a diagnosis itself. Symptoms Upper abdominal pain or discomfort Heartburn, gastric acid reflux Heaviness or ache Fullness, abdominal bloating, belching Flatulence Nausea, vomiting, early satiety May be associated with eating Dyspepsia Causes: 80% functional dyspepsia (unknown origin) Gastro-oesophageal reflux disease (GORD) 20% peptic ulcer, duodenal ulcer or erosive oesophagitis Very rare to have oesophageal or gastric cancers ( 55 years. Patients on long term PPI therapy (need to see specialist). Patients on medications that may worsen symptoms or cause bleeding (NSAIDs?) Refer if severe, frequent symptoms (not controlled by OTC products). Dyspepsia Treatment – Non-Pharmacological Advice Lifestyle advice can be helpful to reduce symptoms: Weight, Exercise Poor posture, tight fitting clothes Smoking Alcohol Raising head of bed (not extra pillows) Avoiding triggers like coffee, chocolate, fatty or spicy food, or eating too late at night. Smaller more frequent meals. Identifying and Managing Risk Factors. Getting adequate sleep and reducing stress factors my improve digestive symptoms. Identify potential medications which may be exacerbating symptoms. OTC Medications Treatment – Pharmacological Advice OTC Medications Antacids and Alginates H2 Antagonists Proton Pump Inhibitors (PPIs) Dyspepsia Antacids Aluminium hydroxide, magnesium carbonate, magnesium trisilicate, calcium carbonate, sodium bicarbonate etc. Aluminium or magnesium salts preferred (e.g. aluminium hydroxide, magnesium carbonate, magnesium hydroxide, magnesium trisilicate) Neutralise stomach acid (H+ and OH-) Symptomatic relief Neutralises acid in stomach Taken when required (prn ‘pro re nata) or when symptoms are expected to occur. i.e. 1 hr after a meal and/or prior to bedtime. 12 years plus only - Max. 2 weeks use – if symptoms persist after 7 days, medical advice. Dyspepsia Antacids Main adverse effects are diarrhoea (Mg), constipation (Al or Ca) or belching. Consider the sodium content of various products. Safe in Pregnancy and Breastfeeding. Counselling Advice: 1-2 hours - Avoid taking at the same time as some other medications, as the absorption of these meds would be impaired: Iron supplements Digoxin Calcium supplements Aspirin Antibiotics (tetracyclines, Thiazide diuretics quinolones, azithromycin) Bisphosphonates Levothyroxine Tuberculosis therapy Phenytoin HIV therapy Dyspepsia Simeticone Antifoaming agent – relief of trapped wind. Causes gas bubbles to coalesce and disperse, liberating any trapped wind Added to antacid to relieve flatulence. Rennie Deflatine: Adults: One or two tablets to be sucked or chewed as required, to a maximum of eleven tablets a day. Should not be taken continuously for longer than 2 weeks. If symptoms persist after 7 days, further medical advice should be sought. Okay in Pregnancy and Breastfeeding. Alginates Sodium Alginate e.g. Gaviscon Forms a protective layer on walls of stomach & oesophagus – ‘raft forming’. Given in combination with Antacids. Forms a protective layer - Creating a mechanical barrier. Increases viscosity of stomach contents. Safe in Pregnancy and Breastfeeding if clinically needed. If symptoms do not improve after seven days, the clinical situation should be reviewed. Adults and Children over 12. Given after meals and at bedtime. Dyspepsia H2 (Histamine Receptor 2) Antagonists H2 antagonists act by competitively inhibiting the H2 receptor on the parietal cells. This reduces the production of acid.  Dyspepsia H2 Receptor Antagonists Short-term relief of heartburn, indigestion (dyspepsia) and excess acid. Prevention of symptoms associated with meals including nocturnal symptoms (license). Counselling Points: Twice daily dosing – before meals or bedtime. Treatment for maximum of 2 weeks OTC. Avoid in children < 16 years. Avoid in pregnancy and breast-feeding unless prescribed by doctor. May interact with other medications (WWHAM) – also in Pepcid Duo consider antacid interactions. Dyspepsia Proton Pump Inhibitors (PPIs) e.g. Esomeprazole, Omeprazole, Pantoprazole. Used to be prescription only, now available OTC Work by blocking the “proton pump”, which suppresses acid secretion, irrespective of the stimulus for acid secretion Produce prolonged acid suppression – dosing is generally once daily. Should be taken at least half an hour before food, ideally before breakfast. Acid-labile, thus are enteric coated. What does this mean for instructions to patients? Most OTC products state for >18 years of age only (Exception: Losec control does not have an age limit “ADULTS”) Dyspepsia Proton Pump Inhibitors (PPIs) Takes up to three days for maximum relief What to do in the meantime? Refer to GP if symptoms not relieved or continue past the duration on the licence Interactions include clopidogrel, some Hep C/HIV antivirals. Also, drugs who have pH dependent absorption. OTC PPIs in Pregnancy and BF Pregnancy and Breastfeeding – Antacids and Alginates can be provided OTC, while H2 antagonists and PPIs under medical advice from doctor. Esomeprazole and Pantoprazole, not to be provided to anyone who is pregnant or breastfeeding. Omeprazole (Losec Control) states the following: Antacids and Alginates can provide short-term relief of symptoms. Proton Pump Inhibitors Duration of Treatment OTC: Esomeprazole and Omeprazole - maximum use OTC is 20mg for two weeks, refer to GP after that period has elapsed. Pantoprazole - maximum use OTC is 20mg daily for four weeks, provided that it’s working. Two weeks use without symptom relief – refer to doctor.