Gastrointestinal Illnesses CP161 Lecture 2 PDF

Gastrointestinal Illnesses Clin Pharm 161 Prepared by: Cecilio Angelo M. Hipolito. RPh...

Gastrointestinal Illnesses Clin Pharm 161 Prepared by: Cecilio Angelo M. Hipolito. RPh Adapted from: Charles Mandy G. Ayran, RPh, Pharm.D. (Melit.) September 5, 2024 This material has been reproduced and communicated to you by or on behalf of University of the Philippines pursuant to PART IV: The Law on Copyright of Republic Act (RA) 8293 or the “Intellectual Property Code of the Philippines”. The University does not authorize you to reproduce or communicate this material. The Material may contain works that are subject to copyright protection under RA 8293. Any reproduction and/or communication of the material by you may be subject to copyright infringement and the copyright owners have the right to take legal action against such infringement. Do not remove this notice. Learning Objectives: By the end of the lecture, you are expected to be able to: Describe the signs and symptoms of common gastrointestinal illnesses Analyze risk factors and appropriate prevention strategies for common gastrointestinal illnesses Identify red flags for referrals among patients in the community pharmacy presenting with signs and symptoms of common gastrointestinal illnesses Recommend appropriate non-pharmacologic and pharmacologic non-prescription therapies for common gastrointestinal illnesses 17 September 2024 2 Outline Day 1 Day 2 Indigestion Constipation Heartburn Diarrhea Hemorrhoids Irritable Bowel Syndrome (IBS) 17 September 2024 3  Indigestion 17 September 2024 4 Dyspepsia Umbrella term for upper abdominal symptoms, which include: Vague abdominal discomfort (aching) above the umbilicus associated with belching Bloating Flatulence A feeling of fullness Nausea and/or vomiting Heartburn 17 September 2024 5 Dyspepsia 90% of cases arising from the Incidence Cause following five major conditions: Most likely Non-ulcer dyspepsia/functional dyspepsia (indigestion) Non-ulcer dyspepsia/functional dyspepsia (indigestion) Unlikely Medicine-induced Gastro-esophageal reflux disease Peptic ulcers Irritable bowel syndrome (GERD, heartburn) Gastritis Very unlikely Gastric and esophageal cancers Duodenal ulcers Atypical angina Gastric ulcers 17 September 2024 6 Indigestion Also called functional dyspepsia or non- ulcer dyspepsia No specific cause can be found for patient’s symptoms Vs GERD Decreased muscle tone → lower esophageal sphincter incompetence Vs Gastritis, gastric and duodenal ulcers H. pylori infection or acute alcohol indigestion → stimulation of inflammatory cascade → increased acid production Vs Medicine-induced NSAIDs and aspirin 17 September 2024 7  Indigestion PQRST Likely Indigestion Likely Other Diagnosis Pain shortly after eating (1 to 3 hours) and relieved by Often brought on by certain types of food, for food or antacids P example caffeine-containing products, spicy or fatty Pain wakes patient at night food, chocolate, and alcohol Pain worse when stomach is empty Q Aching or discomfort pain Gnawing, sharp, or stabbing pain Pain below the umbilicus Pain above the umbilicus and centrally located Pain experienced behind the sternum (breastbone) R (epigastric area) If patient can point to a specific area of the abdomen Pain radiating to other areas S Pain described as debilitating or severe Bouts of excessive drinking T Eating food on the move or too quickly Persistent vomiting with or without blood Others Young adults Black and tarry stools 17 September 2024 8  Indigestion Red Flags for Referral Reason ALARM Anemia Loss of weight Symptoms requiring further investigation Anorexia Recent onset of progressive symptoms Melena, dysphagia Pain described as severe, debilitating or that wakes the patient in the night Suggests ulceration, or even cancer Persistent vomiting Referred pain Possible cardiovascular cause Age over 45 if symptoms develop for first time Possible gastric cancer Children Rare in children, and abdominal pain is common symptom associated with infection 17 September 2024 9 17 September 2024 10 Indigestion Lifestyle Advice Eat small, frequent meals Smoking cessation Decrease weight, if overweight Reduce alcohol, fat, caffeine, and chocolate intake Raise the head of the bed when sleeping Avoid bending or stooping Do not eat a main meal directly before bedtime 17 September 2024 11 Treatment Options Antacids Works for majority with mild dyspeptic symptoms Can be used as first-line, unless heartburn predominates H2 Antagonists Equally effective (or more) to antacids, but more expensive vs antacids With OTC and Rx doses Proton Pump Inhibitors (PPIs) Most effective, but more expensive vs antacids Can be used as first-line, especially for moderate to severe symptoms Requires Rx 17 September 2024 12 Antacids Acid-neutralizing capacity (ANC) and solubility are dependent on metal used Affects onset and duration of action Sodium and Potassium salts Most highly soluble → quick-onset but short-acting Bismuth, Magnesium, and Aluminum salts Less soluble → slow-onset but longer-acting Magnesium causes diarrhea; Aluminum causes constipation Calcium salts Quick-onset and longer-acting Combination to ensure quick onset and prolonged action + minimize side effects (e.g. Maalox, Kremil-S) 17 September 2024 13 Antacids Affects absorption of other medications via chelation and adsorption Reduced absorption of tetracyclines, quinolones, phenytoin, penicillamine and bisphosphonates Reduced absorption of enteric-coated preparations Dose spacing of at least 2 to 4 hours when taking antacids Avoid sodium salt in patients with heart disease Not recommended in children under 12 y/o 17 September 2024 14  Antacids Pregnancy and Medicine Use in Children Likely S/E Drug Interactions Cautions Breastfeeding Sodium None None Heart disease Bicarbonate Potassium Hyperkalemia None Bicarbonate Magnesium Diarrhea Hydroxide >12 years Tetracyclines Ok Aluminum Constipation Quinolones Ok Hydroxide Phenytoin Bismuth Penicillamine Constipation Subsalicylate Bisphosphonates Calcium Constipation Carbonate 17 September 2024 15  Sodium Bicarbonate Cheap, fast-acting, and effective Side Effects and Cautions Carbon dioxide production → Highly soluble and absorbed eructation/belching → relieves systemically → prolonged use can distention of stomach cause sodium overload and alkalosis Antacid dose range: 1 to 5 g Regular use may cause: Should no longer be given alone for Excess sodium → water retention → relief of dyspepsia increase in BP and load in heart Avoid in patients with hypertension, renal disease, salt-restricted diet, and pregnancy Acid rebound 17 September 2024 16 Potassium Bicarbonate Alternative to Sodium Side Effects and Cautions Bicarbonate May cause hyperkalemia when taken together with potassium- sparing diuretics (spironolactone) or ACE inhibitors (perindopril, lisinopril, ramipril) 17 September 2024 17 Aluminum Hydroxide Reacts with acid to form insoluble Side Effects and Cautions colloid → minimal absorption, long- Has phosphate-binding action acting Interferes with phosphate and bone Acts as mechanical barrier against metabolism → bone and CNS problems acid in renally-impaired patients Antacid dose range: up to 1g Constipation Rarely used alone Combined with magnesium to negate effect 17 September 2024 18 Magnesium Hydroxide Similar properties with Aluminum Side Effects and Cautions salt, but more absorbed Hypermagnesemia Tend to increase tone of Cardiovascular and CNS problems in gastroesophageal sphincter → renally-impaired patients useful in gastric reflux Diarrhea Antacid dose range: 400 to 1200mg Combined with aluminum to negate Rarely used alone effect Example: Milk of Magnesia 17 September 2024 19 Bismuth Subsalicylate Similar properties with Magnesium Side Effects and Cautions and Aluminum salt Aspirin-sensitive individuals Acts as mechanical barrier against Blackening of feces and tongue acid Due to conversion to bismuth sulfide in Antacid dose range: 262mg the gut Example: Pepto-Bismol 17 September 2024 20 17 September 2024 21 17 September 2024 22 Calcium Bicarbonate Has the greatest ANC of all antacids Side Effects and Cautions Cheap, long-acting Hypercalcemia Antacid dose range: 500mg to 1g Because of formation of calcium chloride upon neutralization May be used alone or in combination with other salts Milk Alkali Syndrome Example: Rennie, Tums When used long-term, and with large quantities of milk and sodium bicarbonate → nausea, headache, possibly renal damage Acid rebound Constipation 17 September 2024 23 Additional Ingredients Antiflatulent Dimethicone and Simethicone Surfactant/ anti-foaming agent/ carminative Reduces surface tension and allows easier elimination of gas from gut by eructation Example: Aluminum Hydroxide + Magnesium Hydroxide + Simethicone 17 September 2024 24 Antacids – Clinical Pearls Liquid formulation preferred Better ANC and onset of action vs tablet formulations (but more convenient) Misuse and chronic use Should not be used for longer than 2 weeks Best taken 1 hour after eating Gastric emptying is delayed in the presence of food → antacids may exert effect for up to 3 hours Dose-spacing for at least 2 to 4 hours if there is interacting drug Use of constipating antacids Avoid in elderly as they are more prone to constipation May contain large amounts of sugar Caution in DM patients 17 September 2024 25 H2 Antagonists Histamine Most important mediator of gastric acid secretion Stimulates protein kinase → activates parietal cell H+/K+ ATPase → hydrogen ion secretion into the stomach 17 September 2024 27 H2 Antagonists No clinically important drug interactions, with rare side effects Abdominal pain, diarrhea, constipation, headache Recent evidence shows safety in pregnant and breastfeeding women Compared to antacids Longer duration, up to 9 hours Slower-onset, up to 2 hours, hence combined with antacids for rapid and extended relief (e.g. Kremil-S Advance) May be used for prevention of indigestion (Famotidine) Can be taken 1 hour before consuming food or drink that is known to provoke dyspepsia Not recommended in children 3 weeks weeks With associated symptoms such as N/V, loss of appetite, Others Lack of dietary fiber and altered bowel habit 17 September 2024 43  Hemorrhoids (Piles) Red Flags for Referral Reason Persistent change in bowel habit in patients over 40 y/o May be sinister pathology Unexplained rectal bleeding Patients who have to reduce their hemorrhoids manually OTC treatment will not help Severe pain associated with defecation May be anal fissure Blood mixed in the stool Fever Suspect GI bleeds or inflammatory bowel disease Symptoms not improving after 1 week of treatment May have underlying reason 17 September 2024 44 17 September 2024 45 Hemorrhoids (Piles) Lifestyle Advice Address constipation Increase fiber and fluid intake If diet modification not applicable, fiber supplementation with bulk-forming laxative Takes 2 – 3 days to relieve constipation May use short-term stimulant laxative initially for rapid-onset of action (6 to 12 hours) Examples: Bisacodyl, Senna Takes up to 6 weeks to improve symptoms of hemorrhoids Examples: Ispaghula/Psyllium (Rx/OTC), Methylcellulose Good anal hygiene Wash with warm water and mild soap Use soft tissue in a patting manner (vs rubbing motion) Warm bath may soothe discomfort 17 September 2024 46 Treatment Options Usually combination products, and with little data on effectiveness, but with apparent satisfaction Local anesthetics, Anti-inflammatories, and Sclerosing Agents May consider as first-line due to proven effectiveness in other conditions if patient can access GP Requires Rx Astringents, Protectorants, Counter-irritants, and Flavonoids Can be given OTC Prolapsing hemorrhoids may need non-surgical intervention with sclerotherapy or rubber band ligation, or surgical hemorrhoidectomy 17 September 2024 47 Treatment Options Local Anesthetics Astringents Short-acting temporary relief for Precipitates surface proteins → coating perianal itching and pain over the hemorrhoids Requires frequent application → skin Must be at least 50% of dosage unit sensitization Examples: Limit use to two weeks Zinc oxide, hamamelis (witch hazel), Examples: allantoin, aesculin, Peru Balsam Lidocaine, Prilocaine, Benzocaine, Anucare® Ointment (Zinc oxide + Cinchocaine Cream and Ointment Peru Balsam + Benzyl Benzoate) Bismuth salts also have mild antiseptic action Rowatanal® Cream (Zinc oxide + Calcium carbonate + Bismuth subgallate + Menthol) 17 September 2024 48 Treatment Options Anti-inflammatories Protectorants Reduces inflammation and swelling to With protective and emollient properties relieve itching and pain → forms a barrier on skin surface → Treatment should be used each morning prevents irritation and loss of moisture and at night after bowel movement Examples: Limit use to 18 y/o Zinc oxide, kaolin Cannot be used in pregnant or Shark liver oil breastfeeding women Said to promote healing and tissue repair Examples: Ethical issues Hydrocortisone Ointment and Suppository Proctosedyl® Ointment (Framycetin sulfate + Aesculin + Cinchocaine hydrochloride + Hydrocortisone) Kortos® Cream (Hydrocortisone acetate + Benzocaine + Benzalkonium Chloride (1% Solution) + Bismuth subgallate) 17 September 2024 49 Treatment Options Sclerosing Agents Counter-irritants Results to scarring reaction → gradual Stimulates nerve endings → cooling shrinking of hemorrhoids and tingling sensation → distracts from Examples: sensation of pain Lauromacrogol Examples: Korto-S® Rectal Suppository Menthol, phenol (Lauromacrogol 400 + Hydrocortisone Acetate) 17 September 2024 50 Treatment Options Flavonoids Used as adjunct to reduce acute symptoms and secondary hemorrhage after hemorrhoidectomy Examples: Daflon® 500mg or 1000mg Tablet (Diosmin + Hesperidin) Day 1 to 4: 1g-1g-1g Day 5 to 7: 1g-0-1g Score line is to facilitate breaking for ease of swallowing, and not to divide into equal doses 17 September 2024 51 Hemorrhoids (Piles) – Clinical Pearls Creams and ointments preferred vs suppositories Creams and ointment for both internal and external piles Applied in the morning, at night, and after each bowel movement Use applicator to avoid further damage in perianal skin Suppositories for internal piles Inserted in the morning, at night, and after each bowel movement Depending on severity Mild cases: local anesthetic, astringent, or protectorant With inflammation and irritation: may add hydrocortisone With underlying constipation: initially short-term stimulant laxative → increased fiber and fluid intake + regular use bulk-laxative May use flavonoids as adjunct If symptoms have not improved after 1 week, patients should see their doctor 17 September 2024 52  Constipation 17 September 2024 54 Constipation Characterized by less frequent passage Incidence Cause of hard and dry stools as compared to a Eating habits/lifestyle Most likely person’s normal patterns Likely Medication Vary from one person to another Irritable bowel syndrome May be accompanied by feeling of Pregnancy incomplete defecation, abdominal pain, and Unlikely Depression bloating Functional Disorders (children) More common in the elderly, women, and during pregnancy Colorectal cancer Very unlikely Hypothyroidism Symptom, and not a disease 17 September 2024 55  LAXATIVES 17 September 2024 56  Constipation PQRST Likely Constipation Likely Other Diagnosis Change of diet or routine P Lifestyle changes such as changes in job or marital status Pain on defecation Associated with persistent low mood and loss of interest in most activities Q Passage of dry and hard stools Associated with weight loss, especially in >40 y/o Associated with weight gain, lethargy, cold intolerance, coarse hair and dry skin Lower abdominal pain and a history of alternating R diarrhea and constipation S If lasting for more than 2 weeks with no identifiable T Chronic if lasting 6 weeks cause Taking medicine causing constipation Bright red specks in toilet Others Pregnancy Melena and hematochezia 17 September 2024 57  Constipation Red Flags for Referral Reason Pain on defecation causing patient to suppress defecatory reflex Check for local anorectal issue such as anal fissure Patients aged over 40 y/o with sudden change in bowel habits with no obvious cause Danger symptom for rectal carcinoma Greater than 14 days duration with no identifiable Suspect underlying cause that requires fuller GP cause (adults), or >7 days (children) investigation Tiredness Check for anemia or thyroid dysfunction Melena and hematochezia ? Associated with persistent low mood and loss of May be depressive illness interest in most activities Children 6 years None None Ok Methycellulose bloating Stimulant Senna >2 years Ok, but consider other Glycerol Infant upwards laxatives first Abdominal pain None None Na Picosulfate >10 years Senna excreted via Bisacodyl >4 years milk Osmotic Lactulose Infant upwards Flatulence, abdominal None None Ok Mg(OH)2 Not recommended bloating, colic Stool Softener Docusate >6 months None reported None None Ok 17 September 2024 64 Bulk-forming Laxatives Mechanism Products Mimics increased fiber consumption → swells Ispaghula/Psyllium Husk in the bowel → increases fecal mass As powder or granules for suspension, up to 1 to 6 sachets/day Rx in PH (Mucillin®, Mucofalk®) Onset of Action OTC in EU (Fybogel®) 12 to 36 hours, but may take up to 72 hours As husk and capsule, marketed as fiber supplement, once daily OTC: C-lium Fiber® Counseling Points Increase fluid intake while taking bulk-forming Others laxatives OTC in other countries: Polycarbophil Vitamin and mineral supplements taken 2-3 (FiberCon), Methylcellulose (Citrucel), hours before or after psyllium Sterculia (Normacol) Once psyllium granules are mixed with water, drink as soon as effervescence subsides Consider palatability Do not take before bed → esophageal blockage 17 September 2024 65 Stimulant Laxatives Mechanism Counseling Points Stimulates colonic nerves → increase Main side effect is griping, abdominal GI motility pain Long term use may cause possible nerve damage → loss of colonic Onset of Action smooth muscle tone → larger dose of PO: 6 to 12 hours laxative → permanent constipation Rectal Suppository: 15 to 30 minutes Safe in pregnancy But might stimulate uterine contractions Might be excreted via milk → diarrhea in infants May color urine yellowish brown to red color Use of castor oil as stimulant laxative → obsolete 17 September 2024 66 Stimulant Laxatives Products Senna As teabag, OD before HS OTC: Biofitea®, Biguerlai® As standardized concentrate in tablet (374mg), max 2 tablets BID OTC: Senokot® Glycerol Rectal Suppository Mild irritant, with osmotic properties; may have some lubricating and softening actions OTC: 1g for infant, 2g for children, 4g for adult 17 September 2024 67 Stimulant Laxatives Products Sodium Picosulfate As 5mg/5mL syrup, 5 to 10mL HS OTC: Dulcolax SP® Bisacodyl As EC tablet, 5 to 10mg HS As rectal suppository, 5 to 10mg OTC: Dulcolax® 17 September 2024 68 Osmotic Laxatives Mechanism of Action Products Retains fluid in the bowel by osmosis or by Lactulose changing water distribution in the feces As 3.3g/5mL syrup, BD for all ages Adults: 15mL Onset of Action Children 5 to 18 y/o: 5 to 15mL Children 1 to 5 y/o: 2.5 to 10mL 3 to 8 hours for inorganic salts Children 12y/o: up to 500mg Onset of Action Children 2 to 12 y/o: 12.5 to 25mg TID 24 to 72 hours, or more Children Stimulants (hours) > Lactulose and bulk-forming (hours to days) > stool softeners (days) Use in pregnancy: Fiber supplementation and bulk-forming > stimulant and macrogols Use of laxative in children usually needs medical supervision If dietary modification fails, may recommend single glycerol suppository Dose spacing with EC tablets and antacids and milk Avoid drinks with caffeine (Why?) Little evidence on combining classes of laxatives, but might be justifiable in refractory cases Be observant with laxative abuse, intentional or unintentional, especially in slim people who frequently buy these products as slimming aid Know how to insert rectal suppository Refer patient if constipation not resolved within a week 17 September 2024 72 Laxative – Clinical Pearls 17 September 2024 73  Diarrhea 17 September 2024 75  Diarrhea Characterized by more frequent Incidence Cause passage of soft and watery stool as compared to a person’s normal Most likely Viral and bacterial infection patterns Likely Medication Vary from one person to another Irritable bowel syndrome May be associated with N/V, abdominal Unlikely Giardiasis cramping, flatulence, and tenderness Fecal impaction resolving in 2 to 4 days May be classified as: Inflammatory bowel disease (Ulcerative colitis, Crohn’s disease) Acute: < 7 days Very unlikely Colorectal cancer Persistent: > 14 days Malabsorption syndromes Chronic: > 1 month Symptom, and not a disease 17 September 2024 76  Diarrhea PQRST Likely Diarrhea Likely Other Diagnosis Ingestion of contaminated food P Changes in diet History of travel Associated with blood and mucus (dysentery) Q Passage of watery stools more frequently than normal Associated with watery and foul-smelling diarrhea Associated with weight loss Lower abdominal pain and a history of alternating diarrhea and R constipation Mild (12 years None None Ok N/V, tiredness Tetracyclines Quinolones Black stools or Ok, but avoid if Bismuth >16 years Phenytoin None tongue possible Penicillamine Bisphosphonates Morphine salts >12 years None None None Ok 17 September 2024 84 Oral Rehydration Salts (ORS) Mechanism Products Replenishes water and electrolyte loss → prevention of dehydration until diarrhea resolves Hydrite® Granules for suspension Counseling Points Pedialyte® 45 Maintenance Oral Recommended, even if referral is solution necessary 2 L of ORS should be given in the first 24 hours, followed by unrestricted normal fluids with 200 mL of rehydration solution per loose stool or vomit Solution is best sipped every 5–10 min rather than drunk in large quantities less frequently NOT INTENDED TO STOP diarrhea 17 September 2024 85 Loperamide Mechanism Products Synthetic opioid analogue → Imodium®, Diatabs®, Lomotil® 2mg capsule/tablet acts on opiate receptors → Given 2 capsules immediately, then 1 slows intestinal tract time and capsule after each further bout of increases capacity of gut diarrhea Max dose: 16mg/day (8 capsules) Due to CNS and respiratory Counseling Points depressant effects at high doses Not advisable for 3 days ORS is a staple recommendation, even if other antidiarrheal is recommended or if referral is needed Ensure proper volume for dilution, usually diluted with ~200mL of water Use ASAP upon mixing, maximum of 1 hour unrefrigerated, or up to 24 hours refrigerated Consider flavor preference Consider alternative to ORS if cost is a problem For adults who want to curtail diarrhea, may add loperamide Consider avoiding cow’s milk during diarrhea → inactivation of lactase → temporary lactose intolerance 17 September 2024 88  Irritable Bowel Syndrome (IBS) 17 September 2024 89  Irritable Bowel Syndrome (IBS) Functional bowel disorder (i.e. absence of abnormality) in which abdominal pain and bloating is associated with a change in bowel habit (constipation and diarrhea) Usually affects people aged 20 to 30 y/o May be due to hyperactivity of the small intestine and colon in response to food and drugs May be exacerbated by stressful situations 17 September 2024 90  Irritable Bowel Syndrome (IBS) PQRST Likely IBS Likely Other Diagnosis P Precipitated by food or stress Varied, ranging from localized and sharp to diffuse and Change in nature and severity of pain Q aching, but similar nature in the past Associated with fever or N/V R Normally located in the left lower quadrant Patient has had any of the following symptoms for 6 months: Abdominal pain or discomfort S Bloating Severe abdominal pain Change in bowel habit Episodic History of chronic diarrhea, but may be IBD or colon cancer History of recurrent diarrhea with no identifiable cause T too Nocturnal diarrhea Diarrhea first thing in the morning Bloody stools Others Age under 45 y/o Elderly with poor mobility 17 September 2024 91  Irritable Bowel Syndrome (IBS) Red Flags for Referral Reason Blood in the stool The presence of blood in the stool is not usual in IBS and can suggest inflammatory bowel disease Fever Nausea and/or vomiting Not usually associated with IBS. Suggests origin of Severe abdominal pain symptoms from other abdominal causes Children under 16 y/o or patients over 45 y/o with IBS unusual in these age groups. Refer for further recent change to bowel habit investigation. Presence of blood or mucus in the stool Suspected fecal impaction in the elderly Outside scope of community pharmacist Severe abdominal pain Steatorrhea Malabsorption syndromes? 17 September 2024 92 17 September 2024 93 Rutter, Community Pharmacy Symptoms, Diagnosis, and Treatment, 3rd edition (2013) Irritable Bowel Syndrome (IBS) Lifestyle Advice Discuss if stress is a factor, and consider addressing it Dietary modification Have regular meals and avoid missing meals Drink at least eight cups of fluid per day, especially non-caffeinated drinks Reduce intake of alcohol and fizzy drinks Consider limiting intake of high-fiber food Reduce intake of ‘resistant starch’ often found in processed or re-cooked foods Limit fresh fruit to three portions per day Suspected foods must be excluded from diet for a minimum of 2 weeks → gradually reintroduce to determine if food triggers symptoms May consider taking probiotics May consider undergoing hypnotherapy 17 September 2024 94 Treatment Options Antispasmodics First-line pharmacological treatment Provided a statistically significant benefit for abdominal pain, global assessment and IBS symptom score vs placebo (but as a class) Rx: Hyoscine N-Butylbromide (Buscopan®), Mebeverine (Duspatalin®), Alverine (Profenil®) OTC: Hyoscine N-Butylbromide + Paracetamol (Buscopan Plus®/Venus®) OTC in other countries: Peppermint Oil Capsule (not available in PH) Bulk-forming and Stimulant Laxatives For constipation-predominant IBS Can be taken on a regular basis, at the lowest dose Loperamide For diarrhea-predominant IBS Can be taken on a occasional short-term basis, at the lowest dose 17 September 2024 95  Antispasmodics Pregnancy and Medicine Use in Children Likely S/E Drug Interactions Cautions Breastfeeding Glaucoma, Constipation and dry TCAs, neuroleptics, myasthenia gravis, HNBB >12 years Avoid if possible mouth antihistamine and prostate enlargement Mebeverine >10 years None None None Ok Ok in pregnancy, but Alverine >12 years Rash None None try to avoid in breastfeeding Peppermint Oil >15 years Heartburn None None Ok 17 September 2024 96 Antispasmodics Mechanism Products Acts on the smooth muscle of Hyoscine N-Butylbromide (Buscopan®) the gut → relaxation and reduce 10mg tablet OD to TID, and may abdominal pain be increased to 2x tablet up to 4x/day Dicycloverine (Zyclodex®) Counseling Points 10mg tablet (or two tablets) TID Patient should see improvement within days, and must come Mebeverine (Duspatalin®) back after 1 week for monitoring 100mg tablet TID, 20 minutes of progress before meals May try other antispasmodic if Alverine (Profenil®) treatment fails 60mg tablet (or two tablets) TID, 20 minutes before meals 17 September 2024 97 IBS – Clinical Pearls All drug choices have long history of use for IBS Evidence of efficacy from RCTs still lacking No treatment can be recommended above any other Placebo effect may play a role in perceived effectiveness of any treatment due to psychological factor contributing to IBS in many cases Successful treatment may be found by trial and error Before making any recommendation, the pharmacist should ensure that the patient has been diagnosed by a doctor as having IBS 17 September 2024 98 Summary Day 1 Day 2 Indigestion Constipation Antacids, H2 Antagonists, PPIs Laxatives Heartburn Antacids, Alginates, H2 Antagonists, Diarrhea PPIs ORS, Loperamide, Adsorbents Hemorrhoids Irritable Bowel Syndrome (IBS) Local anesthetics, Anti-inflammatories, Antispasmodics, Laxatives, and Sclerosing Agents Loperamide Astringents, Protectorants, Counter- irritants, and Flavonoids 17 September 2024 99