Community Pharmacy Lecture 2 PDF

Lecture 2 Dr.Sahar Badr Associate prof. of Clinical Pharmacy 1 GASTROINTESTINAL CONDITIONS 2 Mouth Ulcers 3 ▪ Mouth ulcers (aphthous ulcers) are common. ▪ They are classified as minor or major or herpetiform...

Lecture 2 Dr.Sahar Badr Associate prof. of Clinical Pharmacy 1 GASTROINTESTINAL CONDITIONS 2 Mouth Ulcers 3 ▪ Mouth ulcers (aphthous ulcers) are common. ▪ They are classified as minor or major or herpetiform ulcers. ▪ Most cases are minor aphthous ulcers, which are self- limiting; they are not associated with systemic diseases and their cause is unknown. ▪ Other types of ulcer may be due to a variety of causes including infection, trauma and drug allergy. ▪ However, occasionally mouth ulcers appear as a symptom of serious disease such as carcinoma. ▪ The pharmacist should be aware of the signs and characteristics that indicate more serious conditions. 4  Causes and Epidemiology ▪ The cause is unknown, but there may be a genetic predisposition, as about 40% of people with recurrent aphthous ulcers have a family history of oral ulceration. ▪ Mouth ulcers are relatively common, and common in females more than males. ▪ The condition is uncommon in children. 5 ▪ Drugs that have been reported to cause the problem include aspirin and other non-steroid alanti- inflammatory drugs (NSAIDs), cytotoxic drugs, beta-blockers and sulphasalazine (sulfasalazine). ▪ Radiotherapy may also induce mouth ulcers. ▪ It is worth asking about herbal medicines because feverfew (used for migraine) has been known to cause mouth ulcers. 6  Signs and Symptoms ▪ Minor aphthous ulcers are small ulcers (5–6 mm in diameter), round and regular in shape, with a clearly defined margin, a floor of yellowish-grey slough and an inflamed outer margin. ▪ They occur on the sides of the cheeks, the tongue and the inside of the lips. ▪ They occur singly or in groups of up to five. ▪ Some sufferers experience a localized burning sensation for up to 48 hours before ulcers appear. ▪ Mouth ulcers heal spontaneously and without scarring within about 7 days. ▪ There is usually a history of recurrence. 7 Types of Aphthous Ulcers 8 9  Differential Diagnosis ▪ Major aphthous ulcers: more than 1 cm diameter, in crops of 10 or more. They may coalesce into a single, very large ulcer. They heal spontaneously within 30 days (4-6 weeks). ▪ Herpetiform ulcers: pinpoint ulcers, in crops of up to 100. They usually occur at the rear of the mouth, and heal spontaneously within (1-2 weeks). ▪ Trauma: from biting the inside of the mouth or burning with hot food or drink. ▪ Oral thrush: creamy white plaques on the tongue and inside of cheeks. They can be scraped off to reveal raw red tissue beneath. ▪ Herpes simplex: a common cause of ulceration in children. It is difficult to distinguish from minor aphthous ulcers. ▪ Squamous cell carcinoma: initially painless, becoming painful over time, mainly on side of tongue, mouth and lower lip. ▪ Chickenpox: spots often occur inside the mouth. 10  What you need to know ▪ Age ▪ Nature of the ulcers (size, appearance, location, number) ▪ Duration ▪ Previous history ▪ Other symptoms ▪ Medications Symptoms and Circumstances for Referral ▪ children under 10 years ▪ duration more than 14 days ▪ painless ulcers ▪ fever or other signs of systemic illness ▪ ulcers more than 1 cm diameter ▪ crops of more than 5 ulcers. 11  Treatment ▪ Treatment for mouth ulcers includes:  Topical anti-inflammatory  Topical corticosteroids  Local analgesics  Local anaesthetics  Antimicrobials (Chlorhexidine Gluconate)  Preparations containing combinations of local anaesthetic, analgesic, antimicrobial and astringent ingredients. ▪ Gels and liquids may be more accurately applied using a cotton bud or cotton wool, provided the ulcer is readily accessible. ▪ Mouthwashes can be useful where ulcers are difficult to reach. 12  Topical anti-inflammatories Topical Corticosteroids ▪ Hydrocortisone sodium succinate 2.5 mg and triamcinolone acetonide 0.1% act locally on the ulcer to reduce inflammation and pain and to shorten healing time. ▪ The former is used as pellets, the latter as a protective paste (apply to the ulcer with a finger, at bedtime and two or three times a day for a maximum of 5 days). ▪ One pellet is used four times a day. The pharmacist should explain that the pellets should not be sucked, but dissolved in contact with the ulcer. ▪ These treatments are best used as early as possible. They have no effect on recurrence, but should be restarted at the first signs of a new outbreak. 13 ▪ Corticosteroids are thought to exert their anti- inflammatory action through two mechanisms:  stabilization of lysosomal membranes, reducing the release of inflammatory hydrolytic enzymes.  inhibition of phospholipase A, which reduces the release of arachidonic acid from phospholipids in cell membranes, inhibiting prostaglandin synthesis. 14  Chlorhexidine Gluconate ▪ Chlorhexidine mouthwash reduces the pain, duration and severity of ulceration. The rationale for the use of antibacterial agents in the treatment of mouth ulcers is that secondary bacterial infection frequently occurs. ▪ Chlorhexidine helps to prevent secondary bacterial infection but it does not prevent recurrence. ▪ Regular use can stain teeth brown – an effect that is not usually permanent. Advising the patient to brush the teeth before using the mouthwash can reduce staining. The mouth should then be well rinsed with water as chlorhexidine can be inactivated by some toothpaste ingredients. 15 ▪ It has a bitter taste and is available in peppermint as well as standard flavour. ▪ An antiseptic mouthwash containing chlorhexidine gluconate 0.2% is available. It is used undiluted twice daily, rinsing 10 mL in the mouth for 1 min and continued for 48 h after symptoms have gone. 16  Local Analgesics ▪ Local analgesics products are available in the form of gels, paints, pastilles and mouthwashes to reduce pain and discomfort. ▪ Benzydamine hydrochloride (0.15%) mouthwash or spray and choline salicylate dental gel are short acting but can be useful in very painful major ulcers. ▪ The mouthwash is used by rinsing 15 mL in the mouth three times a day. Numbness, tingling and stinging can occur with benzydamine. Diluting the mouthwash with the same amount of water before use can reduce stinging. ▪ The mouthwash is not licensed for use in children under 12. ▪ Benzydamine spray is used as four sprays onto the affected area three times a day. 17 18  Local Anaesthetics ▪ Local anaesthetics (lidocaine and benzocaine) gels. ▪ They are effective in producing temporary pain relief but maintenance of gels in contact with the ulcer surface is difficult. Reapplication of the preparation may be done when necessary. ▪ Tablets and pastilles can be kept in contact with the ulcer by the tongue and can be of value when just one or two ulcers are present. They placed close up against lesions and allowed to dissolve slowly, may produce a more prolonged effect. 19 20 21  Heartburn ▪ Heartburn is a form of indigestion (medical term is dyspepsia), which is also more formally known as gastro-oesophageal reflux disease (GORD/GERD). ▪ Heartburn are caused when there is reflux of gastric contents, particularly acid, into the esophagus (GERD), which irritate the sensitive mucosal surface (esophagitis). 22 ▪ Gastro-esophageal reflux disease (GERD) is reflux of the gastric contents into the esophagus, which leads to erosion (reflux esophagitis), pain, experienced as ‘heartburn’, although sometimes there may be back or shoulder pain. ▪ GERD may be caused or exacerbated by an increase in abdominal pressure (due to overeating, obesity or pregnancy) or incompetence (i.e. ineffectiveness) of the gastro- esophageal sphincter as a result of a hiatus hernia or drugs (nitrates, antimuscarinic agents, theophylline, opioids and calcium channel blockers). 23 ▪ Patients will often describe the symptoms of heartburn typically a burning discomfort/pain felt in the stomach passing upwards behind the breastbone. 24 25 Age ▪ The symptoms of reflux and esophagitis occur more commonly in patients aged over 55 years. ▪ Heartburn is not a condition normally experienced in childhood, although symptoms can occur in young adults and particularly in pregnant women. ▪ Children with symptoms of heartburn should be referred to their doctor. ▪ Males are more likely to experience GERD. 26  Symptoms/associated factors ▪ A burning discomfort is experienced in the upper part of the stomach (epigastrium) and the burning feeling tends to move upwards behind the breastbone. ▪ It is occur in those who are overweight and can be aggravated by a recent increase in weight. ▪ It is also more likely to occur after a large meal. 1- Severe pain ▪ Sometimes the pain can come on suddenly and severely and even radiate to the back and arms. ▪ In this situation differentiation of symptoms is difficult as the pain can mimic a heart attack and an urgent medical referral is essential. 27 2- Difficulty in swallowing (dysphagia) ▪ Difficulty in swallowing must be regarded as serious symptom. The difficulty may be either discomfort as food or drink is swallowed or a sensation of food or liquids sticking in the gullet. Both require referral. ▪ It is possible that the swallowing discomfort may be secondary to inflammation of the esophagus due to acid reflux, especially when it occurs while swallowing hot drinks or irritant fluids (e.g. alcohol or fruit juice). 28 3- Regurgitation ▪ Regurgitation (the action of bringing swallowed food up again to the mouth) occurs due to mechanical blockage in the esophagus which requires immediate referral. 4- Pregnancy ▪ It has been estimated that half of all pregnant women suffer from heartburn. ▪ Pregnant women aged over 30 years are more likely to suffer from the problem. ▪ The symptoms are caused by an increase in intra-abdominal pressure and incompetence of the lower esophageal sphincter. ▪ It is thought that hormonal influences, particularly progesterone, are important in the lowering of sphincter pressure. 29 5- Medication ▪ Any medication that has been tried to treat the symptoms should be established. ▪ Any other medication being taken by the patient should also be identified to ascertain drugs that cause or aggravate the symptoms of heartburn e.g. those with anticholinergic actions, such as tricyclic antidepressants, calcium channel blockers, theophylline, nitrates, and caffeine in compound analgesics or when taken as a stimulant. ▪ NSAIDs, such as ibuprofen or aspirin, and oral corticosteroids, such as prednisolone, will aggravate heartburn/indigestion and any esophagitis caused by acid reflux. 30  When we refer to GP ▪ Failure to respond to antacids or OTC H2 antagonist within 2 weeks or recurring after stopping. ▪ Pain radiating to arms. ▪ Difficulty or pain on swallowing. ▪ Regurgitation. ▪ Long duration. ▪ Increasing severity. ▪ Children below 12 years of age. ▪ Severe abdominal or back pain. ▪ Unexplained weight loss. ▪ Chest pain that is indistinguishable from ischemic heart pain. ▪ Presence or history of vomiting blood. ▪ Black or tarry bowel movements. ▪ Possibility of being pregnant. 31  Management ▪ The symptoms of heartburn respond well to treatments that are available over the counter (OTC).  Antacids  Alginates  H2 antagonists  Proton pump inhibitor (PPI) 32  Antacids ▪ Antacids can be effective, more so in combination with an alginate, in controlling the symptoms of heartburn and reflux. ▪ Preparations that are high in sodium should be avoided by anyone on a sodium-restricted diet (hypertension or heart failure or kidney or liver problems). ▪ Liquids are more effective antacids than are solids; they are easier to take, work quicker and have a greater neutralizing capacity. Their small particle size allows a large surface area to be in contact with the gastric contents. 33 ▪ Some patients find tablets more convenient and these should be well chewed before swallowing for the best effect. ▪ Antacids are best taken about 1 h after a meal because the rate of gastric emptying has then slowed and the antacid will therefore remain in the stomach for longer. ▪ Taken at this time antacids may act for up to 3 h compared with only 30 min–1 h if taken before meals. 34  Sodium bicarbonate ▪ Sodium bicarbonate is an absorbable antacid that is useful in practice. ▪ It is water soluble, acts quickly, is an effective neutralizer of acid and has a short duration of action. ▪ It is often included in OTC formulations in order to give a fast-acting effect, in combination with longer acting agents. ▪ However, antacids containing sodium bicarbonate should be avoided in patients if sodium intake should be restricted (e.g. in patients with congestive heart failure). ▪ Sodium bicarbonate increases excretion of lithium, leading to reduced plasma levels. ▪ In addition, long-term use of sodium bicarbonate may lead to systemic alkalosis and renal damage. 35 36  Aluminium and magnesium salts (Aluminium hydroxide and Magnesium trisilicate) ▪ Aluminium-based antacids are effective; they tend to be constipating and this can be a useful effect in patients if there is slight diarrhea. ▪ Conversely, the use of aluminium antacids is best avoided in anyone who is constipated and in elderly patients who have a tendency to be so. ▪ Magnesium salts are more potent acid neutralizers than are aluminium salts. ▪ They tend to cause osmotic diarrhea as a result of the formation of insoluble magnesium salts and are therefore useful in patients who are slightly constipated. ▪ Combination products containing aluminium and magnesium salts cause minimum bowel disturbance and are valuable preparations for recommendation by the pharmacist. 37  Calcium carbonate ▪ Calcium carbonate is commonly included in OTC formulations. ▪ It acts quickly, has a prolonged action and is a potent neutralizer of acid. ▪ It can cause acid rebound and, if taken over long periods at high doses, can cause hypercalcaemia and so should not be recommended for long term use. ▪ Calcium carbonate and sodium bicarbonate can, if taken in large quantities with a high intake of milk, result in the milk–alkali syndrome. ▪ Milk–alkali syndrome involves hypercalcaemia, metabolic alkalosis and renal insufficiency; its symptoms are nausea, vomiting, anorexia, headache and mental confusion. 38 39  Dimeticone (Simeticone) ▪ Dimeticone is sometimes added to antacid formulations for its defoaming properties (antiflatulent). ▪ Theoretically, it reduces surface tension and allows easier elimination of gas from the gut. 40 41  Interactions with antacids ▪ Because they raise the gastric pH, antacids can interfere with enteric coatings on tablets that are intended to release their contents further along the GI tract; adverse effects may occur if the drug is in contact with the stomach. ▪ Taking the doses of antacids and other drugs at least 1 h apart should minimize the interaction. ▪ Antacids may reduce the absorption of tetracyclines, itraconazole, ketoconazole, azithromycin, ciprofloxacin, norfloxacin and rifampicin. ▪ The changes in pH that occur after antacid administration can result in a decrease in iron absorption if iron is taken at the same time. 42  Alginates ▪ Alginates are muco-polysaccharides and may be combined with antacids (Gaviscon preparations). ▪ Alginates form a raft (i.e. float) that sits on the surface of the stomach contents and prevents reflux. ▪ Some alginate-based products contain sodium bicarbonate, which, in addition to its antacid action, causes the release of carbon dioxide in the stomach, enabling the raft to float on top of the stomach contents. ▪ Alginate products with low sodium content are useful for the treatment of heartburn in patients on a restricted sodium diet. ▪ If a preparation low in sodium is required, the pharmacist can recommend one containing potassium bicarbonate instead. 43 44  H2 -Antagonists ▪ H2-receptor antagonists (Cimetidine, Famotidine, Ranitidine) ▪ These are competitive antagonists at the histamine H2- receptor and inhibit histamine-induced gastric acid secretion. ▪ Famotidine and ranitidine can be used for the short-term treatment of dyspepsia, hyperacidity and heartburn in adults and children over 16. ▪ The H2 antagonists have both a longer duration of action (up to 8–9 h) and a longer onset of action than do antacids. ▪ Where food is known to precipitate symptoms, the H2 antagonist should be taken an hour before food. ▪ Headache, dizziness, diarrhea and skin rashes have been reported as adverse effects. ▪ Patients should not take OTC famotidine or ranitidine without checking with their doctor if they are taking other prescribed medicines. 45  Proton Pump Inhibitors (PPIs) ▪ Omeprazole can be used for the relief of heartburn symptoms associated with reflux in adults. ▪ It may take a day or so for them to start being fully effective. ▪ During this period a patient with ongoing symptoms may need to take a concomitant antacid. ▪ Omeprazole works by suppressing gastric acid secretion in the stomach. inhibits the final stage of gastric hydrochloric acid production by blocking the hydrogen–potassium ATPase enzyme in the parietal cells of the stomach wall. ▪ Two 10-mg tablets once daily is the initial starting dose. Subsequently, symptomatic relief from heartburn can be achieved in some subjects by taking 10 mg once daily, increasing to 20 mg if symptoms return. 46 ▪ The lowest effective dose should always be used and the maximum daily dose is two tablets. ▪ Patients taking omeprazole should be advised not to take H2 antagonists at the same time. ▪ The tablets should be swallowed whole with plenty of liquid prior to a meal. ▪ Alcohol and food do not affect the absorption of omeprazole. ▪ If no relief is obtained within 2 weeks, the patient should be referred to the doctor. ▪ Omeprazole should not be taken during pregnancy or whilst breastfeeding. 47  Types of PPIs ▪ There are many names of PPIs, most work equally as well and side effects may vary from drug to drug. ▪ Omeprazole (Prilosec), available over-the-counter (without a prescription) ▪ Esomeprazole (Nexium), available over-the-counter (without a prescription) ▪ Lansoprazole (Prevacid), available over-the-counter (without a prescription) ▪ Omeprazole with sodium bicarbonate (Zegerid), available over- the-counter (without a prescription) 48  Prostaglandin Analogues (Misoprostol) ▪ This is a stable prostaglandin analogue E1, which inhibits the release of acid and is also cytoprotective by stimulating the release of mucus and bicarbonate. 49  Prokinetic Drugs (Domperidone, Metoclopramide) ▪ These agents facilitate the movement of gastric contents from the stomach to the duodenum. ▪ Domperidone closes the gastro-esophageal sphincter and promotes gastric emptying, and this is of benefit in reflux esophagitis. ▪ Metoclopramide acts locally to increase gastric motility and promote emptying. ▪ Both agents will provide symptomatic relief of ‘bloating’. 50  Lifestyle Modifications ▪ Elevate head of bed 4-6 inches. ▪ Avoid eating within 2-3 hours of bedtime. ▪ Lose weight if overweight. ▪ Stop smoking. ▪ Modify diet ▪ Eat more frequent but smaller meals. ▪ Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea. ▪ Elimination of medications that are mucosal irritants or that lower esophageal pressure. ▪ Avoidance of chocolate, peppermint, coffee, tea, cola beverages, tomato juice, citrus fruit juices. ▪ Avoidance of supine position for 2 hours after meal. ▪ Avoidance of tight fitting clothes. 51 ▪ If lifestyle changes are inadequate, antacids and then antacids plus alginates will provide rapid relief but limited healing. ▪ H2- receptor antagonists may be used to provide relief in mild- to-moderate disease but are much less effective than PPIs. ▪ If symptoms persist, then PPIs are the most effective agents; they remove symptoms and allow healing. ▪ They may initially be used for 4–8 weeks, after which a lower maintenance dose should be tried. ▪ Prokinetic drugs may also be used, especially when the symptoms include postprandial bloating, nausea and belching. 52  Indigestion (Dyspepsia) ▪ Indigestion (dyspepsia) is defined as a persistent or recurrent pain or discomfort in the upper abdomen. ▪ Dyspepsia describes upper gastrointestinal symptoms, including heartburn, acidity, nausea, discomfort, and may be referred to as ‘indigestion’ by the patient. ▪ Many patients use the terms indigestion and heartburn interchangeably. 53 ▪ A patient presenting with symptoms of dyspepsia (indigestion), which may include upper abdominal or epigastric pain, requires differential diagnosis from cardiac problems. Symptoms ▪ The symptoms of typical indigestion include poorly localized upper abdominal (the area between the belly button and the breastbone) discomfort, which may be brought on by particular foods, excess food, alcohol or medication (aspirin). The symptoms of indigestion include: ▪ Burning in the stomach or upper abdomen. ▪ Abdominal pain. ▪ Bloating (full feeling). ▪ Belching and gases. ▪ Nausea and vomiting. 54  Medical Conditions that may present as indigestion and require referral Ulcer ▪ Ulcers may occur in the stomach (gastric ulcer) or in the first part of the small intestine (duodenal ulcer). Duodenal Ulcer ▪ Duodenal ulcers are more common and have different symptoms from gastric ulcers. ▪ Typically the pain of a duodenal ulcer is localized to the upper abdomen, slightly to the right of the midline. ▪ It is often possible to point to the site of pain with a single finger. ▪ The pain is dull and is most likely to occur when the stomach is empty, especially at night. ▪ It is relieved by food (although it may be aggravated by fatty foods) and antacids. ▪ Nausea and, less frequently, vomiting. 55  Gastric Ulcer ▪ The pain of a gastric ulcer is in the same area but less well localized. ▪ It is often aggravated by food and may be associated with nausea and vomiting. ▪ Appetite is usually reduced and the symptoms are persistent and severe. ▪ Both types of ulcers are associated with Helicobacter pylori infection and may be exacerbated or precipitated by smoking and NSAIDs. 56 Gallstones ▪ Single or multiple stones can form in the gall bladder. ▪ The gall bladder stores bile. ▪ It periodically contracts to transmit bile through a narrow tube (bile duct) into the duodenum to aid the digestion of food, especially fat. ▪ Stones can become temporarily stuck in the opening to the bile duct as the gall bladder contracts. ▪ This causes severe pain (biliary colic) in the upper abdomen below the right rib margin. ▪ Sometimes this pain can be confused with that of a duodenal ulcer. ▪ Biliary colic may be precipitated by a fatty meal. 57 Irritable bowel syndrome ▪ Irritable bowel syndrome (IBS) is a common, non-serious, condition in which symptoms are caused by colon spasm. ▪ There is usually an alteration in bowel habit, often with alternating constipation and diarrhoea. ▪ The diarrhoea is typically worse first thing in the morning. ▪ Pain is usually present. ▪ It is often lower abdominal (below and to the right or left of the belly button) but it may be upper abdominal and therefore confused with indigestion. ▪ Any persistent alteration in normal bowel habit is an indication for referral. 58  Atypical Angina ▪ Angina is usually experienced as a tight, painful constricting band across the middle of the chest. ▪ Atypical angina pain may be felt in the lower chest or upper abdomen. ▪ It is likely to be precipitated by exercise or exertion. ▪ If this occurs, referral is necessary. 59  Aggravating Factors Diet ▪ Fatty foods and alcohol can cause indigestion, aggravate ulcers and precipitate biliary colic. Smoking habit ▪ Smoking predisposes to indigestion and ulcers. ▪ Ulcers heal more slowly and relapse more often during treatment in smokers. Medication ▪ NSAIDs have been implicated in the causation of ulcers and bleeding ulcers. ▪ Sometimes these drugs cause indigestion. ▪ Elderly patients are particularly prone to such problems. ▪ Severe or prolonged indigestion in any patient taking an NSAID is an indication for referral. ▪ OTC medicines also require consideration; aspirin and iron are among those that may produce symptoms of indigestion 60 ▪ NSAIDs use are the next most common cause of ulceration. ▪ Gastric damage due to NSAIDs is highest in older patients and is more often associated with certain NSAIDs, such as, aspirin, naproxen and piroxicam, whereas ibuprofen, etodolac and nabumetone appear to cause fewer gastric side effects. ▪ It should be recognized that low-dose aspirin (75 mg) for antiplatelet therapy is also associated with a significant incidence of gastric side effects. ▪ For NSAID-induced damage, the initial approach is to stop the NSAID if this is possible and switch to paracetamol for pain relief if this is required. Treatment timescale If symptoms have not improved within 5 days, the patient should see the doctor. 61  When Refer to GP ▪ Symptoms are persistent (longer than 5 days) or recurrent. ▪ Severe pain. ▪ Anemia. ▪ Blood in vomit hematemesis or stool melena. ▪ Pain worsens on effort. ▪ Persistent vomiting. ▪ Treatment has failed. ▪ Weight loss. ▪ Children. ▪ Older people 62  Goals of Treatment ▪ The general goals are symptomatic relief or cure. ▪ Symptomatic relief may involve lifestyle changes, avoidance of causative drugs, suppression of acid release and mucosal protection. ▪ The logical approach to dyspepsia, due to gastritis or ulceration, is a stepped approach, stepping up or down as appropriate:  Step 1: antacid or alginate and antacid  Step 2: H2-receptor antagonist  Step 3: PPI ▪ PPIs are the most effective agents should be used empirically in uninvestigated dyspepsia. 63 64