OTC medicines GI tract

Pharmacy Practice 301

OVERVIEW ONLY
NOT sufficiently detailed to allow you to make
informed choices about which OTC to recommend
You will be expected to cover this topic in far more
detail when preparing for the workshop and exam
Responding to symptoms (RTS) will NOT be covered
comprehensively in these lectures.
lectures They are covered
in workshops and workshop preparation.
For each RTS workshop you will need to review the
relevant chapter of:
Rutter, Paul Newby, David Community Pharmacy Symptoms,

(2008) outline
Diagnosis
See p10and
of Treatment
P301 course

Aim of session
To provide an OVERVIEW of OTC products used in
selected GI conditions
Diarrhoea, heartburn / indigestion, irritable bowel and constipation

To revise action, adverse effects & mode of use

To outline advice which might be given to patients
To provide information to help select appropriate
products

Diarrhoea
W

Young children & the elderly. At greater risk of dehydration.

Watery stools suggests acute diarrhoea.

Blood and mucous in stools requires referral
Look for signs of dehydration sunken eyes

Acute <7 days, persistent >14 days & chronic >1 month
Symptoms
S
t
can occur hours
h
to
t 3 days
d
after
ft ingesting
i
ti
contaminated food.
Diarrhoea longer than 2-3 days or repeat episodes
Recent travel?

Tried an anti-diarrhoeal?

Some medicines can cause diarrhoea Magnesium

containing antacids, broad spectrum antibiotics.

Tried self-care measures

Interpretation
Other causes to rule out:
Giardiasis watery, foul-smelling, bloating and epigastric pain.
Irritable bowel syndrome
Medicine induced (e.g.

Ulcerative collitis & Chrohns disease urgency, nocturnal or

early morning diarrhoea, blood can be present. Patient unwell.
Malabsorption (e.g. lactose intolerance, coeliac disease)
Faecal impaction regular poorly formed stools hard to pass
Colorectal cancer persistent diarrhoea, bowel doesnt feel
empty. Weight loss.

Interpretation
Hints for referral:
Change in bowel habit over 50 years
Changes medicines, eating patterns
Diarrhoea for longer than 2-3 days in children or the elderly

Signs
g of blood or mucous in the stools
Signs of dehydration
Severe abdominal pain
Frothy or floating stools
Possible faecal impaction - elderly

Management
Large proportion of cases can be managed
Relieve symptoms
Oral rehydration therapy (ORT)
Stop the diarrhoea anti-diarrhoeals, bulking agents

Both can be used together where appropriate

(ORT) Electrolyte replacement

Simple & highly effective
Dehydration can occur in adults, and is a high risk in
infants
Oral rehydration solutions as powders
powders, made up with
water to a specific volume
Important not to make too concentrated
Observe storage requirements for reconstituted products
1 reconstituted sachet per loose motion in babies <1 year,
2 for older children.

Electrolyte replacement products

e.g.Gastrolyte, Pedialyte, Enerlyte
Dissolve the contents of one sachet in 200ml of
water and take as required.
p unused p
portion in fridge,
g discard after 24 hours.
Keep
Can also be used after vigorous exercise
Different flavours may appeal more to children
Do not add juice or flavouring
Some are pre-made.
Ice-blocks available in some brands

Antidiarrhoeals
Older products contained opioids (e.g. codeine)
Newer opioids : slow down movement through gut
by increasing muscle tone & reducing motility.

o Loperamide
Side effects are rare.
Not for children.

o Diphenoxylate

Bulking agents
Examples include isphaghula, methylcellulose, sterculia
e.g. Isogel, Metamucil, Normacol
Work by absorbing fluid and bulking out the faeces

o More often used for chronic diarrhoea

(e.g. IBS)

Side effects bloating and abdominal discomfort

Drink plenty of fluids
Do not take immediately before going to bed.
Caution in: Elderly people
Avoid with: intestinal obstruction, faecal impaction;
difficulty in swallowing

Choosing a product

Avoid dehyrdation ORT

Loperamide

o Convenience
o Better than placebo
o Comparable to diphenoxylate

Informing the patient

Fluid replacement important
Continue breastfeeding
Can eat food bland food (e.g. rice, mashed potatoes)
Avoid:
Raw fruit and vegetables
Spicy food
Dairy

Medicines absorption can be affected - OC

Heartburn, indigestion and reflux

Unusual in children but abdominal pain is common.

Good description of the pain will aid decision to treat or refer

Persistent or recurrent indigestion can suggest a more

serious cause.

Caution in older patients with first time symptoms.

What are the symptoms associated with?

What about possible triggers? Diet? alcohol?

Indigestion that has not responded to treatment

Some medicines can cause indigestion e.g. NSAIDs, iron

Interpretation
Other causes to rule out:
Peptic ulceration - localised pain described as constant, gnawing
Medicine related (e.g. NSAIDs)
Irritable bowel syndrome
Gastric carcinoma- very rare, accompanied by nausea & vomiting.
Oesophageal carcinoma difficulty swallowing, food sticking,
ultimately weight loss even with good appetite.

Interpretation
Hints for referral:
Severe pain (e.g. wakes patient up)
No improvement in 5 days
Ongoing change in bowel habit (> 1 week)
Vomiting
V iti ffor > 1-2
12d
days
Unexplained weight loss
Referred pain (e.g. arm)
Blood in stools or vomit
Failed treatment
Food sticking in throat

Management
Increasing stomach pH relieves symptoms
Treatments include:
Acid neutralisers - antacids
Alginates
Al i t form
f
raft
ft on top
t off stomach
t
h contents
t t
H2 receptor antagonists reduce acid secretion
Dimethicone / simethicone for flatulence
Omeprazole

Restricted

(http://www.medsafe.govt.nz/profs/class/classification.asp)

Omeprazole in tablets or capsules containing

10 milligrams or less and when sold in packs
approved by the Minister or the DirectorGeneral for distribution as restricted medicines

Acid neutralisers
Combination products different duration & onset of action
May interfere with absorption of other medications (e.g. tetracyclines)
May affect absorption of enteric coated tablets
Liquid form has quicker onset of action
Sodium content of some products caution
Side effects:
Calcium and aluminium can cause constipation.
Magnesium can cause diarrhoea

Alginates
Forms sponge-like matrix (raft) in contact with gastric
acid & floats on stomach contents
Evidence better than placebo; as effective as
antacids in reducing heartburn
py (e.g. PPIs, H2 antagonists)
Can be used with antacid therapy
Can be used during pregnancy
Care with sodium and potassium content
e.g. Gaviscon Double Strength sodium alginate,
potassium bicarbonate, calcium carbonate

H2 receptor antagonists
Ranitidine (Zantac) & Famotidine (Pepcid AC)
Reversible inhibitors of action of histamine at H2-receptors,

Inhibits histamine action at parietal cell H2 receptor

Decreases basal and food stimulated acid secretion
Inhibits 50-80% of daily gastric acid secretion
The incidence of adverse effects is relatively low
Can be used with antacids
Longer acting than antacids

Caution:

o Not in pregnancy or breastfeeding

o Middle aged patients with new undiagnosed symptoms
o NSAID use
Short term symptomatic relief of indigestion and heartburn

Choosing a product
Antacids effective for most people
With heartburn alginate / antacid
H2 antagonists are longer acting and can give
cover if symptoms appear after meals
meals.
Liquids act more quickly, tablets more portable
Other conditions CVD
Some preparations contain sugar

Informing the patient

Medicines:
o Antacids more effective if taken 1 hour after food
o Chew tablets to facilitate disintegration
o Separate doses with medicines that interact (e.g. Doxycycline)

Self care:
o Avoid triggers (e.g. smoking, caffeine, spicy or fatty food)
o Small, regular meals. Do not rush meals.
o Lose weight if applicable & wear loose fitting clothes.
o Raise the bed nocturnal heartburn

Irritable bowel Syndrome

W

More common in women

Generally affects people less than 40 years.
People 40 or older with first time symptoms may have more
serious underlying cause

Characterised by abdominal pain (lower left quadrant but can be

upper abdominal)

Can be sharp, local pain or more generalised aching

Pain may be relieved by passage of wind / stool
Change in bowel habit increased frequency normal stools
Diarrhoea on waking or shortly after food (can be with mucous)

H
A
M

Chronic medical disorder that occurs as episodes can have

months of being well.
Tried self-care measures
Some medicines can cause diarrhoea or constipation.

Interpretation
Hints for referral:
Children <16
Adults >40 with recent change to bowel habit
No previous history
Blood in stools
Change in symptom presentation in IBS sufferers

Management
Relieve symptoms
Abdominal pain & bloating
Diarrhoea
Constipation

Tailor to the patient presentation

Little evidence for efficacy for some treatments
Treatments for individual symptoms no one
treatment to manage this symptom complex

OTC management of IBS

Constipation:
o Bulking agents (can also help with diarrhoea)

Diarrhoea
o Loperamide

Abdominal pain
o Mintec peppermint oil (antispasmodic)
o Buscopan - Hyoscine butylbromide

Bloating
o Simethicone/dimethicone little evidence

Constipation
W

More common in the elderly and in women.

Change in individuals normal bowel habit

Constipation can occur in pregnancy especially 3rd trimester

Children - functional
Stools hard to pass / patient reports straining to pass stools
Abdominal bloating & discomfort
Pain when going to toilet can be local rectal problem
Presence of blood (bright red vs dark stools)

Often precipitated by a cause (i.e. social or behavioural)

A
M

Tried bulk laxatives

Chronic more than 6 weeks

Some medicines can cause constipation (e.g.opiates, iron)

Interpretation
Other causes to rule out:
Medicine induced constipation
Irritable bowel syndrome
Functional constipation in children
Medical conditions (e.g. hypothyroidism)
Colorectal cancer

Interpretation
Hints for referral:
Longer than 7 days with no identifiable cause
Pain which causes patients to suppress urge
No
N previous
i
hi
history
t
> 40 years.
Blood in stools
Suspected medical condition

Management
Promote return to normal bowel habit
Dietary and lifestyle modification can be enough
Increased fibre
Increased
I
d fluid
fl id
People dont appreciate this takes time
Laxatives can provide more short-term relief

OTC treatments include:

Bulking agents, faecal softeners, osmotic laxatives, stimulant
laxatives, lubricants and enemas

10

Bulking agents
Mimic increased fibre consumption
1st line Tx, but patients often dont like them
Take 2-3 days to reach full effect
Side effects bloating,
bloating discomfort
Increase fluid intake, do not take at bedtime
Side effects:
Abdominal distension
Flatulence
May cause discomfort in late pregnancy

Faecal/lubricants softeners
Glycerin suppositories
Docusate sodium
Softening agent & stimulant
Childrens products

Liquid paraffin no longer used

Osmotic laxatives
Draw water into the lumen stimulate peristalsis
Magnesium hydroxide
o occasional use where rapid bowel evacuation is required
o need to drink plenty of fluids. Care in renal impairment
Phosphate enemas are useful in bowel clearance before
radiology,
di l
endoscopy,
d
and
d surgery.
Lactulose - a semi-synthetic disaccharide which is not absorbed
from the GI tract. Very sweet.
Can take up to 3 days to take full effect
Need to increase fluid intake
Side effects:
Flatulence, abdominal pain and colic

11

Stimulant laxatives
Increase intestinal motility
Often cause abdominal cramp
Long term can lead to atonic colon and hypokaleamia
Caution in pregnancy, bowel obstruction, acute abdominal pain
Includes:
o Senna
S
(S
(Senokot)
k t) care in
i b
breastt ffeeding
di
o Bisacodyl (Dulcolax)
o Docusate sodium (may also act as softener) (Coloxyl)
Orally: usually taken at night as take around 6-12 hours to work
Suppositories work in around 20 -30 minutes

Choosing a product
Ideally recommend increased fibre and fluid
Bulk-forming laxatives 1st choice
Not absorbed and can be used long-term

Stimulant
Sti l t laxatives
l
ti
can b
be used
d tto re-establish
t bli h
bowel habit if dietary measures insufficient
Lactulose not always well tolerated
Includes some lactose

Informing the patient Self Care

Discuss what is normal bowel habit for them
Lifestyle modification
Increase fruit and vegetables
Increase fluid
Increase exercise (e.g. regular walking)
Increase whole grain cereals, breads, brown rice,
wholemeal pasta, nuts, bran.
Increase fibre slowly over a few weeks to avoid wind

Dont ignore the need to go to the toilet

12