Gastrointestinal Illnesses (Year 2 Sem 1, AY 2024-2025) PDF

GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 VI. IRRITABLE BOWEL SYNDROME OUTLINE...

GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 VI. IRRITABLE BOWEL SYNDROME OUTLINE A. PQRST OF IBS I. INDIGESTION/DYSPEPSIA B. RED FLAGS FOR IBS A. PQRST OF INDIGESTION C. IBS LIFESTYLE ADVICE i. OTHER TOPICS D. IBS TREATMENT OPTIONS ii. OTHER TOPICS E. ANTISPASMODICS B. RED FLAGS FOR REFERRAL F. IBS-CLINICAL PEARLS C. LIFESTYLE ADVICE D. TREATMENT OPTIONS I. INDIGESTION/DYSPEPSIA i. ANTACIDS Umbrella term for upper abdominal symptoms, which includes: II. HEARTBURN ○ Vague abdominal discomfort (aching) A. PQRST OF HEARTBURN above umbilicus associated with belching B. RED FLAGS FOR REFERRAL (burping) C. LIFESTYLE ADVICE ○ Bloating D. TREATMENT OPTIONS ○ Flatulence i. ALGINATES ○ Feeling of fullness E. CASE 2 ○ Nausea or vomiting ○ Heartburn III. HEMORRHOIDS 90% of cases arise from 5 major conditions: A. PQRST OF HEMORRHOIDS ○ Non-ulcer dyspepsia/functional dyspepsia B. RED FLAGS FOR REFERRAL (Indigestion) C. LIFESTYLE ADVICE ○ Gastro-Esophageal Reflux Disease (GERD, D. TREATMENT OPTIONS Heartburn) i. LOCAL ANESTHETICS ○ Gastritis - Inflammation ii. ASTRINGENTS ○ Duodenal Ulcers iii. ANTI-INFLAMAMATORIES ○ Gastric Ulcers iv. PROTECTORANTS v. SCLEROSING AGENTS vi. COUNTER-IRRITANTS Duodenal Ulcers and Gastric Ulcers NOTE vii. FLAVONOIDS require prescription (Rx) medicines IV. CONSTIPATION A. PQRST OF CONSTIPATION B. RED FLAGS FOR REFERRAL C. LIFESTYLE ADVICE D. TREATMENT OPTIONS i. LAXATIVES V. DIARRHEA A. PQRST OF DIARRHEA B. RED FLAGS FOR REFERRAL C. HOW TO APPROACH PATIENT WITH DIARRHEA D. LIFESTYLE ADVICE Dyspepsia is often self-diagnosed (Pain in E. MEDICINE INDUCED DIARRHEA the upper chest to the lower abdominal F. TREATMENT OPTIONS symptoms) i. ORS Also called functional dyspepsia or non-ulcer ii. LOPERAMIDE dyspepsia iii. BISMUTH SUBSALICYLATE No specific cause can be found for patient’s G. CLINICAL PEARLS symptoms COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 1 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ Vs. GERD Decreased muscle tone to lower esophageal sphincter incompetence (Sphincter is relaxed, food is refluxed) ○ Vs. Gastrititis, gastric and duodenal ulcers H. pylori infection or acute alcohol indigestion stimulates inflammatory cascade that causes immune system to increase acid production ○ Vs Medicine-induced NSAIDS - Non-steroidal Anti-inflammatory Aspirin C. LIFESTYLE ADVICE A. PQRST OF INDIGESTION Non-pharmacologic Treatment to reduce indigestion: ○ 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 Medicines that cause dyspepsia D. TREATMENT OPTIONS ○ Antibiotics (Macrolytes and Tetracycline) ○ Anticoagulants (Warfarin) Antacids ○ ACE Inhibitors (Hypertension) ○ Works for majority of mild dyspeptic ○ Alcohol symptoms ○ Metformin ○ Can be used as first-line, unless heartburn ○ Metronidazole (For worms) predominates ○ Hormones (Estrogens) ○ Steroids, Potassium Supplements H2 Antagonists ○ SSRIs (Selective Serotonin Reuptake ○ Equally effective or more to antacids, but Inhibitors) more expensive ○ Available for OTC and Rx Doses B. RED FLAGS FOR REFERRAL Proton Pump Inhibitors (PPIs) ○ Most effective, but more expensive vs antacids ○ Can be used as first-line for moderate to severe symptoms ○ Requires Rx i. ANTACIDS Acid-neutralizing capacity (ANC) and solubility are dependent on metal used ○ Sodium and Potassium Salts COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 2 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Most highly soluble, quick on-set but short-acting ○ Bismuth, Magnesium, and Aluminum ○ ➡️ Highly soluble and absorbed systemically prolonged use can cause sodium overload and alkalosis Salts Less soluble, slow on-set but longer-acting ○ Excess sodium ➡️ Regular use may cause: ➡️ water retention increase in BP and load in heart Magnesium causes diarrhea [MAG Avoid in patients with TAE]; Aluminum causes constipation hypertension, renal disease, [ALA TAE] salt-restricted diet, and pregnancy ○ Calcium Salts (gestational hypertension) Quick on-set and longer-acting ○ Acid rebound (increase in stomach acid Salts can be combined to ensure quick onset, production) prolonged action, and minimized side effects ○ Usually paired with other antacids Affects absorption of other medications via chelation and adsorption POTASSIUM BICARBONATE ○ Can increase Gastric pH, causing premature release of the drug Alternative to Sodium Bicarbonate ○ Reduced absorption of tetracyclines, Side effects and cautions: quinolones, phenytoin, penicillamine, and ○ May cause hyperkalemia when taken biphosphonates together with potassium-sparing diuretics ○ Reduced absorption of enteric-coated (spironolactone) or ACE inhibitors preparations (perindopril, lisinopril, rampiril) ○ Dose spacing of at least 2 to 4 hours when Other name of bicarbonate (in Gaviscon taking antacids Advanced) = Potassium Hydrogen Carbonate) ○ Avoid sodium salt in patients with heart ○ Usual dosage range (as a liquid dosage disease form) = 200 mg/ 10 mL ○ Not recommended in children under 12 ➡️ ALUMINUM HYDROXIDE y/o Reacts with acid to form insoluble colloid Dyspepsia is unusual for children minimal absorption, long-acting under 12, most likely their GI Acts as mechanical barrier against acid symptoms is caused by an infection Antacid dose range: up to 1 g ○ Rarely used alone (due to side effect of constipation) Side effects and cautions: ○ Has phosphate-binding action metabolism ➡️ Interfered with phosphate and bone bone and CNS problems in renally-impaired patients ○ Constipation Combined with magnesium to negate effect MAGNESIUM HYDROXIDE SODIUM BICARBONATE Similar properties with Aluminum salt, but more absorbed ➡️ ➡️ Cheap, fast-acting, and effective Carbon dioxide production eructation/belching relieves distention of sphincter ➡️ Tend to increase tone of gastroesophageal useful in gastric reflux Antacid dose range: 400-1200 mg stomach Antacid dose range: 1-5 g ○ Rarely used alone ○ Should no longer be given alone for relief ○ Example: Milk of Magnesia of dyspepsia Side effects and cautions: Side effects and cautions: ○ Hypermagnesemia COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 3 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Cardiovascular and CNS problems in Reduces surface tension and renally-impaired patients allows easier elimination of gas ○ Diarrhea from gut by eructation Combined with aluminum to negate Example: Aluminum Hydroxide + effect Magnesium Hydroxide + Simethicone ANTACIDS - CLINICAL PEARLS BISMUTH SUBSALICYLATE Liquid formulation preferred Similar properties with Magnesium and ○ Better ANC and onset of action vs tablet Aluminum salt formulations (but more convenient & Acts as mechanical barrier against acid cost-effective) Antacid dose range: 262 mg Misuse and chronic use ○ Example: Pepto-Bismol ○ Should not be used for longer than 2 Side effects and cautions: weeks ○ Aspirin-sensitive individuals Best taken 1 hour after eating Long term use may cause absorption and neurological damage. Salicylate is absorbed following the administration presence of food ➡️ ○ Gastric emptying is delayed in the antacids may exert effect for up to 3 hours of bismuth subsalicylate, and may ○ Dose-spacing for at least 2 to 4 hours if cause the same adverse effect as there is interacting drug aspirin. Use of constipating antacids ○ Blackening of feces and tongue ○ Avoid in elderly as they are more prone to Due to conversion to bismuth sulfide constipation as it is metabolized in the body. May contain large amounts of sugar ○ Caution in DM patients CALCIUM BICARBONATE CASE 1 Has the greatest ANC (acid-neutralizing What would be your recommend antacids or capacity) of all antacids interventions for the following patients if Cheap, long-acting applicable: Antacid dose range: 500 mg to 1 g ○ If patient comes in with hypertension ○ May be used alone or in combination with Avoid sodium bicarbonate/potassium other salts bicarbonate due to possible side ○ Example: Rennie, Tums effects Side effects and cautions: ○ A patient requesting for a convenient way ○ Hypercalcemia of taking antacids Because of formation of calcium Antacids that are available as tablets chloride upon neutralization (chewable tablets) ○ Milk Alkali Syndrome ○ A patient who has been taking antacids When used long-term, and with large for 3 weeks for her dyspepsia bicarbonate ➡️ quantities of milk and sodium nausea, headache, possibly renal damage Referral - if more than 2 weeks taking antacids and no improvement of symptoms might be the cause of ○ Acid rebound another problem in the body. ○ Constipation ○ An 8 year old patient complaining of dyspepsia ADDITIONAL INGREDIENTS Referral - children that are below 12 Antiflatulent years old, most likely have an infection. ○ Dimethicone and Simethicone (Activated ○ A renally impaired patient dimethicone) Avoid aluminum , sodium, potassium, Surfactant/Anti-foaming magnesium containing antacids agent/carminative COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 4 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ A patient who is concurrently tetracycline 10 mg for symptomatic relief or 1 hour antibiotics every 8 am and 8 pm before consuming food or drink that Dose spacing causes symptoms ○ A patient who has aspirin allergy ○ Maximum dose: n of calciu20mg/24 hours Avoid bismuth subsalicylate antacids Ranitidine ○ OTC dose: 75mg ii. H2 ANTAGONISTS ○ Rx dose: 150mg 75 mg for symptomatic relief, followed Most important mediator of gastric acid by 75mg 1 hour later if symptoms secretion persist Stimulates protein kinase → activates parietal Maximum dose: 300mg/24hours cell H+/K+ ATPase → hydrogen ion secretion ○ *Not licensed for prevention into the stomach II. HEARTBURN Caused by reflux of gastric contents into the esophagus → esophagitis Gastroesophageal reflux disease H2 Antagonist prevents Histamine from binding to your receptor. ○ It will inhibit Hydrogen-Potassium ATPase pump. No clinically important drug interactions, with A. PQRST FOR HEARTBURN rare side effects ○ Common side effects: Abdominal pain, diarrhea, constipation, headache Recent evidence shows Gastruc esafety 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 B. RED FLAGS FOR REFERRAL FOR (Famotidine) HEARTBURN Can be taken 1 hour before consuming food or drink that is known to provoke dyspepsia Not recommended in children Lactulose and bulk-forming ○ Dehydration is a common sign (hours to days) > stool softeners (days) ○ Vary from one person to another Use in pregnancy: ○ May be associated with N/V, ○ Fiber supplementation and bulk-forming abdominal cramping, flatulence, and > stimulant and macrogols tenderness resolving in 2 to 4 days Use of laxative in children usually needs ○ May be classified as medical supervision Acute - less than 7 days ○ If dietary modification fails, may Persistent - more than 14 days recommend single glycerol suppository Chronic - more than 1 month 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 I. HOW TO USE CLINICAL PEARLS Remove foil wrapper Moisten the suppository with water or A. PQRST FOR DIARRHEA water-based lubricating jelly COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 14 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 Avoid hypertonic fruit juice, milk, apple juice, powdered drink mixes, gelatin water, carbonated and caffeinated drinks ○ These can cause further dehydration BRAT Diet ○ Banana, Rice, Applesauce, Toast Rotavirus Vaccination during childhood ○ Per orem (Oral suspension or solution) ○ Minimum age: 6 weeks with minimum 4 weeks between doses Most frequent causes of Chronic Diarrhea ○ Latest dose must be administered not ○ Irritable Bowel Syndrome (IBS) later than 32 weeks of age ○ Colon Cancer ○ Available as 2-dose or 3-dose series B. RED FLAGS FOR REFERRAL E. MEDICINE INDUCED DIARRHEA Caused by consumption of: ○ Antacids Magnesium-containing antacids ○ Antidiabetics Metformin ○ Antibiotics All classes of Antibiotics ○ Cytotoxic agents Agents used to treat Cancer C. HOW TO APPROACH PATIENT WITH All classes of Cytotoxic agents DIARRHEA ○ NSAIDs Non-steroidal Anti-inflammatory Drugs ○ Ulcer-healing agents Proton pump inhibitors ○ Antidepressants, antipsychotics, anti-epileptics F. TREATMENT OPTIONS Oral Rehydration Salts (ORS) ○ First-line treatment for all age groups ○ Simple and highly effective with reduced morbidity and mortality Loperamide D. LIFESTYLE ADVICE ○ Clinically superior vs placebo Importance of handwashing ○ Useful as adjunct and reserved for Adequate fluid intake patients who find it inconvenient to go ○ Glucose to toilet ○ Sodium Bismuth sabsalicylate ○ Potassium ○ Clinically superior vs placebo, but ○ Chloride slower resolution vs Loperamide ○ Citrate ○ Treatment for different conditions as Homemade, 1 tsp + 4 tsp sugar well (Heartburn and Dyspepsia) +1L ○ Available over the counter Gatorade, Dilute in water Kaolin and Morphine COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 15 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 ○ No evidence of efficacy There are no contraindications for ORS ○ Dangerous drugs (Requires unless the patient is frequently Prescriptions) NOTE vomiting. If the patient has diarrhea with vomiting, it is preferred to give it intravenously. ii. LOPERAMIDE Mechanism ○ Synthetic opioid analogue → acts on opiate receptors → slows intestinal tract time and increases capacity of gut I. MAIN TOPIC Acts as an opioid agonist i. ORAL REHYDRATION SALTS (ORS) Antidiarrheal Counseling Points Mechanism ○ 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, IBS is different from IBD (Inflammatory usually diluted with ~200mL of water Bowel Disease) ○ Use ASAP upon mixing, maximum of 1 IBD = disease hour unrefrigerated, or up to 24 hours NOTE IBS = group of symptoms refrigerated ○ No abnormalities when you ○ Consider flavor preference perform colon exam ○ Consider alternative to ORS if cost is a ○ No increased risk for colon problem cancer For adults who want to curtail diarrhea, may add loperamide A. PQRST FOR IRRITABLE BOWEL SYNDROME Consider avoiding cow’s milk during diarrhea → inactivation of lactase → temporary lactose intolerance VI. 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 B. RED FLAGS FOR REFFERAL FOR IBS ○ May be due to hyperactivity of the small intestine and colon in response to food and drugs ○ May be exacerbated by stressful situations COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 17 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 quality of life, abdominal pain, constipation, diarrhea, and bloating ○ Patient is aware of what happens both during and after the hypnotic session ○ Help improves primary symptoms of IBS, can help with nausea, back ache, fatigue, urinary problems ○ Hypnosis should not be regarded as a cure all. Statistically, up to 25% of patients failed to respond to hypnotherapy. It is still important to This flowchart shows how to discern if it is an consider lifestyle factors such as diet. IBS, how it can be treated, and the IBS TREATMENT OPTIONS recommended lifestyle modification or pharmacologic prescription treatments. Antispasmodics IBS LIFESTYLE ADVICE ○ First-line pharmacological treatment Provided a statistically Discuss if stress is a factor, and consider significant benefit for addressing it abdominal pain, global Dietary modification assessment and IBS symptom ○ Have regular ,wala and avoid missing score vs placebo (but as a class) meals ○ Rx: Hyoscine N-Butylbromide ○ Drink at least eight cups of fluid per (Buscopan®), Mebeverine (Duspatalin®), Alverine (Profenil®) day, especially non-caffeinated drinks OTC: Hyoscine N-Butylbromide Caffenation can cause diuresis + Paracetamol (Buscopan Plus and may exacerbate diarrhea ®/Venus®) ○ Reduce intake of alcohol and fizzy ○ OTC in other countries: Peppermint drinks Oil Capsule (not available in PH) ○ Consider limiting intake of high-fiber Bulk-forming and Stimulant Laxatives food ○ For constipation-predominant IBS ○ Reduce intake of ‘resistant starch’ ○ Can be taken on a regular basis, at the often found in processed or re-cooked lowest dose foods ○ When recommending bulk-forming ○ Limit fresh fruit to three portions per laxatives, remind them to increase day fluid intake, to take into account the Suspected foods must be additional fiber. excluded from diet for a Loperamide ➡️ minimum of 2 weeks gradually reintroduce to determine if food triggers ○ For diarrhea predominant IBS ○ Can be taken on a occasional short-term basis, at the lowest dose symptoms ○ A study showed that Loperamide May consider taking probiotics improved diarrhea, including ○ Lactobacillus and bifidobacterium improvement of bowel movement but ○ The size of effect and effectiveness of not abdominal pain and dyspepsia individual probiotics is yet to be established. ANTISPASMODICS May consider undergoing hypnotherapy ○ Progressive relaxation, suggestions of soothing imagery and sensations focused on the individual symptoms, improvements in overall wellbeing, COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 18 of 19 GASTROINTESTINAL ILLNESSES Clin Pharm 161 (PHARMACY WELLNESS AND PROMOTION) Professor Cecilio Angelo M. Hipolito | HYNITH: BSP 2023 | YEAR 2 SEM 1 | AY 2024-2025 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 HNBB= Hyoscine N-Butylbromide treatment due to psychological factor TCAs = Tricyclic antidepressants contributing to IBS in many cases Stress can induce IBS Mechanism Successful treatment may be found by trial ➡️ ○ Acts on the smooth muscle of the gut relaxation and reduce abdominal pain and error Before making any recommendation, the pharmacist should ensure that the patient Counseling Points has been diagnosed by a doctor as having IBS ○ Patient should see improvement within days, and must come back after SUMMARY OF GASTROINTESTINAL ILLNESSES 1 week for monitoring of progress Day 1 May try other antispasmodic if ○ Indigestion treatment fails Antacids, H2 Antagonists, PPIs Products ○ Heartburn ○ Hyoscine N-Butylbromide Antacids, Alginates, H2 (Buscopan®) Antagonists, PPIs 10 mg tablet OD to TID, and ○ Hemorrhoids may be increased to 2x tablet Local anesthetics, up to 4x/day (if necessary) Anti-inflammatories, and Does not readily cross the Sclerosing Agents blood brain barrier (BBB), Astringents, Protectants, sedation is not normally Counter-irritants, and encountered. Flavonoids May cause dry mouth and Day 2 constipation ○ Constipation ○ Dicycloverine (Zyclodex®) Laxatives 10mg tablet (or two tablets) TID ○ Diarrhea ○ Mebeverine (Duspatalin®) ORS, Loperamide, Adsorbents 100mg tablet TID, 20 minutes ○ Irritable Bowel Syndrome (IBS) before meals Antispasmodics, Laxatives, ○ Alverine (Profenil®) Loperamide 60mg tablet (or two tablets) TID, 20 minutes before meals ○ Peppermint oil (Colpermin IBS Relief) For adults and children (15 yrs and up) Daily dose is 1 capsule, 3 times a day, before meals, can be increased to 2 capsules, 3 times a day if the symptoms are severe. COURSE CODE (COURSE TITLE) Input Name of Editor/s Page 19 of 19