OTC L18 Gas, hemorrhoids, motion sickness, gastroenteritis

Causes of intestinal gas ^^

Swallowing food/air/saliva — smoking — gum chewing — sucking on hard candy — carbonated beverages — anxiety & hyperventilation — sugar alcohols in good — fiber in diet — genetics — altered gut bacteria — food intolerances (lactose, fructose, sucrose)

medical conditions associated with increased intestinal gas

irritable bowel syndrome

lactose intolerance/malabsorption

celiac disease

pancreatic insufficiency

medications that contribute to intestinal gas ^^

drugs/agents/meds that…

• affect gut biome (lactulose, antibiotics)

• affect metabolism of glucose and dietary substances (acarbose, metformin)

• affect gi motility (narcotics, anticholinergics, calcium channel blockers, psyllium, cholestryamine)

• contain or release gas (alka-seltzer)

symptoms of intestinal gas ^^

eructation (burping), bloating, indigestion, abdominal pain/cramping, borborygmi (bowel sounds), flatulence

when to refer for intestinal gas ^^

sx persist for more than few days or occur several times a month

sx are severe and debilitating

sudden change of abdominal pain, increase, severity of sx

new onset of sx in ppl 40+ due to risk of colon cancer

gas in conjunction with other symptoms

goals of therapy for intestinal gas ^^

reduce symptoms, minimize gas impact on lifestyle

DON’T eliminate gas, is normal function

non-pharm options for intestinal gas

probiotics - 14-day trial of trying things to cycle through body, could be from immune defense

fermented food products with live active cultures (kombucha tea)

herbal carminatives (fennel seed, japanese mint) - not good evidence, avoid w gerd since they lower LES pressure, avoid more than 1 tsp/day of fennel seed in preg/lact

otc options for intestinal gas

prevention - alpha-galactosidase, lactase enzyme

treatment - simethicone, activated charcoal

follow-up recommendations for intestinal gas

1 week

alpha-galactosidase info (MOA, indic, pd, se, di, avoid, preg/lact)

moa: hydrolyzes oligosaccharides into component parts

indic: prevention of intestinal gas

pd: starts within 30 mins of taking/eating, lasts 5 hrs

se: allergic reaction

di: none

avoid: ppl w galactosemia, mold allergies

preg/lact: likely okay, check w pcp

alpha-galactosidase dosing

adults & adolescents: 300-450 units per food serving

children ask hcp

lactase enzyme (moa, indic, pd, se, di, avoid, preg/lact)

moa: replacement enzyme that breaks down lactose into glucose + galactose

indic: dairy intolerance

pd: starts immediately, lasts while digesting dairy product

se: none, possible stomach pain

di: dunno

avoid: dunno

preg: likely okay but check

lact: no info but check

lactase enzyme dosing for all ages

og strength: 3 caplets

extra strength: 2 caplets

ultra strength: 1 caplet, 2 max

simethicone (moa, indic, pd, se, di, avoid, preg/lact)

moa: defoaming agent, reduces surface tension of gas bubbles in gi tract mucus, eliminates more easily

indic: intestinal gas

pd: starts within 30 mins, lasts up to 4 hrs

se, di, avoid: dunno

preg/lact: safe

simethicone dosing after meals + bedtime

adults + adolescents — 40-125 mg 4x daily prn

children 2-12 — 40-50 mg 4x daily prn

children -2 — 20 mg 4x daily prn

activated charcoal (moa, indic, pd, se, di, avoid, preg/lact)

moa: unknown, absorb gas given charcoal’s large surface area

indic: promoted for relief of intestinal gas (no evidence)

pd: dunno

se: poor palatability, constipation

di: may decrease drug absorption

avoid: taking charcoal within 1 hr after meds

preg/lact: likely safe for occasional use, check

activated charcoal dosing

adults: 500-520 mg after meals prn, may repeat hourly

adolescents, children: dunno

hemorrhoid definition

inflamed, swollen blood vessels in rectum and anus that protrude during bowel movements

internal - inside rectum, can’t see or feel, rare discomfort

external - under skin around anus, usually have symptoms

presenting symptoms of internal and external hemorrhoids

internal - rare discomfort, stool passage may cause painless bleeding

external - itching, discomfort/irritation, burning, inflammation, swelling

when to refer for hemorrhoids

younger than 12

ulcerative colitis or crohn’s disease

family history colon cancer

anorectal disorder

acute onset severe pain, bleeding, black tarry stools, severe symptoms

minor symptoms not responding to 7 days of self care

goals of therapy for hemorrhoids ^^

resolve symptoms, keep stool soft, maintain remission of symptoms, prevent complications

non-pharm options for hemorrhoids

dietary modification - avoid alcohol, caffeine, citrus, fatty foods; get adequate fiber

avoid lifting heavy objects

proper bowel habits - defecation, toilet sitting time 2-5 minutes, avoid excessive cleaning, avoid commercial wipes/pads

sitz baths - sit in few mins, pat dry, 2-4x day

bidet

otc treatment options for hemorrhoids

local anesthetics, vasoconstrictors, protectants, astringents, keratolytics, analgesics/anesthetics/antiprutitics, corticosteroids

follow up recommendation for hemorrhoids

1 week

local anesthetics (ex, moa, indic, pd, se, di, avoid, preg/lact, dosing)

benzocaine, benzyl alcohol, dibucaine, dyclonine, lidocaine

moa: block transmission of nerve impulses

indic: temporary relief of external anal symptoms

pd: starts within mins, duration depends on agent, most 4 hrs

se: allergic reaction, dermatitis

di: none

avoid: more severe anorectal disorders, open lesions

preg/lact: likely okay, check

dosing: apply 3-6x/day, check label

vasoconstrictors (ex, moa, indic, pd, se, di, avoid, preg/lact, dosing)

ephedrine, epinephrine, phenylephrine

moa: stimulation of alpha-receptors to constrict arterioles and decrease swelling

indic: relief of discomfort, itching, reduce swelling (ephedrine, phenylephedrine: internal, external; epinephrine: external)

pd: starts 5-10 mins, lasts 6 hrs

se: mild pain, stinging if raw/bleeding skin

di: dunno

avoid: cardiac history, diabetes, bph, thyroid conditions, check first

preg/lact: likely okay, check

dosing: apply 4x/day, check label

protectants (ex, moa, indic, pd, se, di, avoid, preg/lact, dosing)

alum hydroxide gel, cocoa butter, glycerin, lanolin, mineral oil, zinc oxide

moa: provide physical protective barrier

indic: temporary relief of discomfort, irritation, burning (glycerin: external, other: internal or external)

pd: dunno start but works quickly, lasts 4 hours or longer

se: uncommon, lanolin caution (itchiness from sheep’s wool, avoid)

di: dunno

avoid: applying other meds after protectants

preg/lact: likely okay, check

dosing: petroleum as needed, others up to 6x/day or after each bowel movement

astringents (ex, moa, indication, pd, se, di, avoid, preg/lact, dosing)

calamine, zinc oxide, witch hazel

moa: help coagulate surface proteins to protect lower tissue, decrease cell volume, provide thin protective layer

indic: temporary relief of itching, burning, irritation of anorectal do (witch hazel: external, calamine, zinc oxide: internal or external)

pd: dunno, but lats up to 4 hrs

se: slight stinging witch hazel

di, avoid: dunno

preg/lact: likely okay, check

dosing: apply up to 6x/day

keratolytics (ex, moa, indic, pd, se, di, avoid, preg/lact, dosing)

alcloxa, resorcinol

moa: cause sloughing of epidermal surface cells - helps skin renew itself

indic: treat pain and itching caused by minor skin irritations

pd: dunno but lasts up to 4 hrs

se: allergy to resorcinol

di: dunno

avoid: using with harsh soaps, irritates skin

preg/lact: likely okay, check

dosing: apply up to 6x/day

analgesics/anesthetics/antipruritics (ex, indic, pd, se, di, avoid, preg/lact, dosing)

menthol, juniper tar, camphor

indic: temporary relief of burning, pain, itching, external

pd: dunno but lasts up to 4 hrs

se: allergic reactions

di: dunno

avoid: use on irritated or damaged skin

preg/lact: likely okay, check

dosing: up to 6x/day

corticosteroid (ex, moa, indic, pd, se, di, avoid, preg/lact, dosing)

hydrocortisone 0.25-1%

moa: lysosomal membrane stabilization + antimitotic activity

indic: temp relief of minor external anal itching

pd: dunno but lasts up to 6-8 hrs

se: skin atrophy

di: dunno

avoid: prolonged use, max 7 days or will begin to thin the skin

preg/lact: likely okay, check

dosing: apply up to 3-4x/day

motion sickness

carsick, seasick, airsick

caused by brain disconnect of what we see vs movement the inner ear senses

highest risk is women and children 2-12 yrs

factors increasing risk of motion sickness ^^

family history — hormonal birth control — inner ear conditions — menstrual periods — migraines — parkinson’s disease — pregnancy

presenting symptoms of motion sickness ^^

cold sweats, dizziness, headache, inability to concentrate, increased salivation, nausea, vomiting, rapid breathing

when to refer for motion sickness

a person who feels “motion sickness” but isn’t traveling

goals of therapy for motion sickness ^^

provide symptom relief, prevent episodes/recurrence

non-pharm options for motion sickness (travel by… sit…)

boat: in middle on upper deck

bus: window seat

car: front passenger seat/be the driver

plane: wing section

train: forward-facing seat

non-pharm options to prevent and/or treat motion sickness ^^

look at horizon, avoid phone/tablet, lay back + close eyes, drink water, eat low-fat food before travel, avoid alcohol, fresh air/air vents to you

complementary therapies for motion sickness

ginger (250mg-2g daily in 3-4 doses, fewer adverse effects than dimenhydrinate, possible anticoagulant/hypotensive effect, very little ginger in drinks)

pyridoxine (vitamin b6, 10-25 mg tid, >200 mg/day x > 2 months = peripheral neuropathy, weakness, lethargy)

acupuncture (p6 point on wrists)

cannabidiol oil

preg: don’t use cannabidiol oil, others okay

lact: avoid cbd oil and higher doses of pyridoxine (suppresses milk production)

otc treatment options for motion sickness

1st gen antihistamines (dimenhydrinate, diphenhydramine, meclizine)

follow up recommendations for motion sickness

if nondrug and drug therapies not helpful, referral

antihistamines (ex, moa, indic, pd, se, di, avoid, preg/lact)

fda approved: meclizine, dimenhydrinate, diphenhydramine, others not approved

moa: blockage of histamine 1 receptors

indic: prevention of nausea, vomitting, dizziness

pd: starts 30-60 mins, duration depends

se: drowsiness, dry mouth, confusion, dizziness, constipation

di: cns depressants, opioids, diazo'

avoid: glaucoma, bph, alcohol

preg/lact: check

antihistamines dosing (ages + max, taking before travel, sedation)

dimenhydrinate

• 12+ — 50-100 mg every 4-6 hrs (400mg)

• 6-12 — 25-50 mg every 6-8 hrs (150mg)

• 2-6 — 12.5-25 mg every 6-8 hrs (75mg)

diphenhydramine

• 12+ — 25-50 mg every 6-8 hrs (300mg)

• 6-12 — 12.5-25 mg every 6-8 (150mg)

• 2-6 — not recommended

meclizine

• 12+ — 25-50 mg 1 hr before travel (50mg)

• 2-12 — not recommended

doxylamine

• in pregnancy, 10-12.5 mg w/wo pyridoxine every 8 hrs

• 2-12 — not recommended

take at least 30-60 mins before travel then regularly for duration of travel

more sedation for all

gastroenteritis definition

inflammation of stomach and intestines due to viral infection or bacterial/protozoal toxins, causing vomiting and diarrhea

causes of gastroenteritis

viral → nonvirus (year-round, peak during winter, transmitted via contaminated food/water, environmental surfaces), rotavirus (seasonal nov, feb, transmitted fecal-oral), other virus

bacterial → mainly due to campylobacter spp, salmonella, others, transmitted by food, food/water associated with travel

protozoal → least common, no nonrx therapy, self-management inappropriate

presenting symptoms of gastroenteritis

viral rotavirus - nausea, vomiting, fever, acute and watery diarrhea

viral norovirus - nausea, vomiting, fever, watery diarrhea

bacterial - nausea, vomiting, fever, diarrhea

when to refer for gastroenteritis

age < 6 months or weight < 17.5 lbs

risk for important complications (diabetes, severe cvd, kidney disease, immunocompromised)

persistent fever, visible blood, pus, mucus in stool, persistent vomiting, signs of severe dehydration (no urination after 8 hrs), severe abdominal pain, pregnancy, chronic diarrhea, no improvement after 48 hrs of self-care

goals of therapy for gastroenteritis ^^

prevent or correct fluid and electrolyte loss and acid-base disturbance

control symptoms

identify and treat cause

prevent acute morbidity and mortality

general treatment approach for gastroenteritis

fluid and electrolyte replacement via ORS (oral rehydration solution)

antidiarrheal drugs in selected individuals

self-limiting condition

improvement 24-48 hrs, normal bowel function 24-72 hrs

non-pharm options for gastroenteritis

fluid, electrolyte management - rehydration + maintenance (children)

• self care algorithms

• commercial products

• household products (apple juice, chicken broth, colas, avveptable is mild, self-limiting diarrhea, avoid dehydration symptoms or mod to severe diarrhea in children -5)

adults

• ORS recommended, little evidence if healthy person maintains adequate fluid intake

dietary management for gastroenteritis ^^

avoid fatty foods, simple sugars, spicy foods, caffeine. can tolerate breastmilk and cow milk. brat (bananas, rice, applesauce, toast) diet, not recommended = insufficient calories, protein, fat

otc treatment options for gastroenteritis

loperamide, bismuth subsalicylate

follow up recommendations for gastroenteritis

no improvement after 48 hrs of drug therapy

loperamide (moa, indic, pd, se, di, avoid)

moa: stimulates peripheral micro-opioid receptors in intestinal circular muscles to slow motility so water and electrolytes can be absorbed

indic: symptomatic relief of acute, nonspecific diarrhea

pd: starts within 1 hr, lasts up to 3 days

se: occassional dizzines,s constipation, euphoria if abused

di: quinidine, ketoconazole, ritonavir, protease inhibitors, cyclosporine

avoid: high fever or blood/mucus in stool

loperamide dosing

adults (2mg caplets, 1 mg/7.5 mL liquid)

• 4 (30mL) mg initially, then 2 mg after each loose stool, max 8mg/24 hrs

children

• -6: seek medical advice

• 6-8 yrs (48-59 lbs) - 2 mg initially, then 1 mg after each loose stool, max 4 mg//24 hrs

• 9-11 yrs (60-95 lbs) - 2 mg initially, then 1 mg after each loose stool, max 6 mg//24 hrs

bismuth subsalicylate (moa, indic, pd, se, di, avoid)

moa: inhibition of prostaglandin synthesis, stimulation of sodium and potassium reabsorption

indic: management of acute diarrhea in ppl 12+

pd: starts 30 mins to 4 hrs, dunno last

se: mild tinnitus, black tongue, stool

di: warfarin, valproic acid, methotrexate, tetracycline, fluoroquinoilone antibiotics

avoid: gout, asthma-associated bronchospasm, if recovering from chickenpox/influenza, within 6 weeks of live vaxx

bismuth subsalicylate dosing

max 48 hrs of use

adults - 262/525 mg

• tablets: 525 mg every 30-60 mins up to 4200 mg/day (8 doses in 24 hrs)

• liquid 262, 525 mg (30 mL) every 60 mins up to 240 ml/day (8 doses in 24 hrs)

• liquid 525, double liquid 262, half doses

children not recommended