Therapeutics Weeks 12-15

Causes of intestinal gas

• Excessive aerophagia (air swallowing)

• Eructation (belching of swallowed air)

• Bloating (excessive gas, especially after eating)

• Flatulence (excessive passage of air from stomach/intestines)

• IBS

• Medical conditions (lactase deficiency)

• Medications (antibiotics, GI motility, GI lipase inhibitors)

Presentation of intestinal gas

• Patient may complain of stomach pain, being bloated, or may admit they’re gassy

• If IBS - recurrent gas pains (3 days/month in last 3 months) associated with either diarrhea or constipation

• If celiac disease - intolerance to gluten

How much do we ‘pass gas’ per day?

~10-20 times

How many times do we ‘belch’ per day?

~20-30 times

Nonpharmacologic treatment for managing intestinal gas

• Modify eating habits and diet

• Reduce lifestyle consequences

• Reduce consumption of gas-producing foods

• Reduce amount of lactose in diet if lactose intolerant

Exclusions to self-treatment of intestinal gas

• Sxs that persist for more than several days or occurs more often than occasionally (e.g., several times/month)

• Severe debilitating sxs

• Sudden change in location of abdominal pain, significant increase in the frequency or severity of sxs, or onset of sxs in patients 40 years of age

• Sxs accompanied by significant abdominal discomfort or a sudden change in bowel function (diarrhea or constipation)

• Presence of accompanying signs and sxs such as severe or persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, or frequent nocturnal sxs

Simethicone as pharm option for intestinal gas

• Adults: 40-125mg orally after meals and at bedtime, as needed

• Children >12: 40-125mg four times daily

• Children 2-12 years: 40-50mg four times daily

• Children <2: 20-40mg four times daily, as needed

Activated charcoal as pharm option for intestinal gas

• Adults: 500-520mg orally after meals, as needed; may repeat hourly

• Children >12/Children 2-12/Children <2: Guidelines unavailable

A-galactosidase inhibitor as pharm option for intestinal gas

• Adults: 300-450 units orally per serving of food

• Children >12/Children 2-12/Children <2: Guidelines unavailable

Lactase enzyme as pharm option for intestinal gas

• Adults: 1,800-3,000 units orally at first bite of food or drink containing lactose

• Children >12: 1,800-3,000 units orally at first bite of food or drink containing lactose

• Children 2-12/Children <2: Guidelines unavailable

Probiotics as pharm option for intestinal gas

Guidelines unavailable for all ages

Causes of constipation

• Lack of exercise

• Dehydration

• Lack of fiber in diet

• Lifestyle changes (i.e., travelling, pregnancy, young children, old age)

Presentation of constipation

• Less than 3 bowel movements per week

• Straining, difficulty passing, dry stools

• Abdominal pain

Nonpharmacologic treatment for managing constipation

• Dietary changes (e.g., increase in fiber, increase water intake)

• Exercise regularly

• Good bowel habits (e.g., not ignoring urge to defecate)

6 pharmacologic agents for managing constipation

1. Bulk Forming

2. Hyperosmotic

3. Emollient

4. Lubricant

5. Saline Laxative

6. Stimulant

Bulk Forming agent (ex: Metamucil)

Dissolve/swell in intestinal fluid, stimulating peristalsis

Not absorbed systemically, does NOT interfere with absorption of nutrients

Helps colon recognize contractions to go to bathroom

• Safe to take all the time

• Take up to 3 times daily

• Promotes/maintain digestive health

Hyperosmotic agent (ex: MiraLAX, Glycerin)

First line option!

Draw water into colon/rectum via osmosis to stimulate bowel movements

• MiraLAX: 17 yo and older unless prescribed; 17g in 4-8 oz water for relief within 12-72 hours up to 96 hours

• Glycerin: Safe for all ages; relief in 15-30 min; minimal side effects

Emollient agent (ex: Colace)

Very safe to use; 12 yo and older (1-3 caps daily)

• Stool softener - acts in intestines to increase wetting efficacy of intestinal fluid, and facilitates mix of aqueous and fatty substances to soften fecal matter (slippery)

• Prevents straining and painful defecation

• Relief within 12-72 hours up to 3-5 days

Lubricant agent (ex: mineral oil)

Soften fecal contents in colon by coating stool and preventing colonic absorption of fecal water

• Can cause anal leakage of oil and lipid pneumonia

• NOT recommended

Saline Laxative agent (ex: Mg citrate, Mg hydroxide, Mg sulfate)

Draw water in by osmosis to increase intraluminal pressure and intestinal motility

• May lead to electrolyte imbalance

• Relief in 30 min to 3-6 hours (for oral); 2-15 min (for rectal)

• Only use if someone is being tested; easily overused in older population

Stimulant agent (ex: Dulcolax, Bisacodyl, Senna)

Increases intestinal motility in colon by local irritation of mucosa or intestinal smooth muscle, and increases secretion of water and electrolytes in intestine

• Second line option!

• Overnight relief (6-10 hours up to 24 hours)

Exclusions to self-treatment of constipation

• Unintentional weight loss

• Rectal bleeding

• If sxs persist despite lifestyle changes or OTC treatment

• <17 years of age

Acute Diarrhea vs. Persistent Diarrhea vs. Chronic Diarrhea

Acute: Abrupt, <2 weeks, abdominal pain, malaise, flatulence, generally resolves in 3 days

Persistent: 2-4 weeks; refer!

Chronic: Frequent passage >4 weeks, difficult to diagnose; refer!

Traveler’s vs. Food-Induced Diarrhea

Traveler’s:

• 3-8 watery stools per day with nausea, abdominal cramps, ± vomiting, fever

• Subsides over 3-5 days

• Usually bacterial

Food-Induced:

• Due to an allergy, fatty or spicy food, fiber, seeds, or lactose intolerance

Presentation of diarrhea

• Abnormal frequency or volume of semi-liquid or fluid fecal matter

• >3 times daily

• Self-limiting

• Black, tarry stool (upper GI bleed)

• Red stool (lower bowel, hemorrhoids, red foods, drugs)

• High sodium-secretory diarrhea

• Yellowish-bilirubin-liver diagnosis; Whitish-fat-malabsorption diagnosis

Nonpharmacologic treatment for diarrhea

• Dietary changes

• Hydration (water and ORS) - prevent and correct fluid & electrolyte loss and acid-base disturbance

• Manage symptoms

• Prevent acute morbidity

Dietary management related to the management of diarrhea

• Early refeeding and ORS

• Breast and cow milk easily tolerable

• BRAT diet - bananas, rice, applesauce, toast (not for long-term)

• Avoid fatty and spicy foods, simple sugars, caffeine, and alcohol

Exclusions to self-treatment of diarrhea

• <6 months of age

• Severe dehydration

• >/ 6 months with high fever (>102.2 F)

• Blood, mucus, pus in stool

• Protracted vomiting

• Severe abdominal pain/distress

• Risk for significant complications

• Pregnancy

• Chronic/persistent diarrhea

• Suboptimal response to ORS

Internal vs. External Hemorrhoids

Internal: Inside the rectum

• Often painless and may not be visible

• Possible bleeding (bright red)

External: Under the skin around the anus

• Small, painful lumps

• May cause itching, pain, and swelling

• Bleeding during BM

Presentation of anorectal disorders

• Large, bulging, symptomatic conglomerates of hemorrhoidal vessels, supporting tissues, overlying mucous membranes in anorectal region

• Itching, discomfort, irritation, burning, inflammation, swelling

Nonpharmacologic treatment for anorectal disorders

• Avoid lifting heavy objects

• D/C foods that irritate or aggravate sxs (caffeine, citrus, spicy)

• Increase fiber

• Avoid NSAIDs and ASA which may promote bleeding

• Listen to body

• Good hygiene

• Sitz bath 2-4 times per day x10-20 min

Pharmacological agents for anorectal disorders

• Local Anesthetics

• Vasoconstrictors

• Protectants

• Astringents

• Keratolytics

• Analgesic/Anesthetics, Antipruritics

• Corticosteroids

Local Anesthetics for treatment of anorectal disorders (ex: Tucks)

Reversibly blocks transmission of nerve impulses to provide temporary relief of itching, irritation, burning, discomfort, and pain

• For external anal symptoms

• Not to use on open sores

Vasoconstrictors for treatment of anorectal disorders (ex: Ephedrine)

Constricts arterioles; increases cardiac contractility and heart rate

• For external and intrarectal use

• Minimal CNS effect

Protectants for treatment of anorectal disorders (ex: Petrolatum, mineral oil)

Prevent fecal matter from causing perianal irritation by forming physical protective barrier over skin

• Soften dry anal canal by decreasing water loss

• For external and intrarectal use

Astringents for treatment of anorectal disorders (ex: witch hazel; calamine, zinc oxide)

Promote coagulation of skin cells (protect underlying tissue)

• Witch hazel - for external use

• Calamine, Zinc Oxide - for external and intrarectal use

Keratolytics for treatment of anorectal disorders

Desquamation & debridement of epidermal surface cells

• NOT recommended

Analgesic/Anesthetics/Antipruritics for treatment of anorectal disorders (ex: menthol, juniper tar, camphor)

Relieves pain, itching, burning, and discomfort by producing local sensation that distracts

• For external use

Corticosteroids for treatment of anorectal disorders (ex: Cortizone)

Vasoconstrictor & Antipruritic

• For minor external anal itching

• Onset may take 12 hours, but long effect

• First pick!

Exclusions to self-treatment of anorectal disorders

• Severe pain, bleeding, or sxs like rectal prolapse

• Incontinence (difficulty controlling BM)

• Underlying medical conditions (e.g., IBD)

• Development of a fever and/or chills

• Signs of infection

• <12 years of age

What benefits are there to home pregnancy tests?

• Early consult with physician

• Early warning to stop drugs that might negatively affect fetus and initiate prenatal vitamins

• Allows for early termination of pregnancy (decreases risks of complications)

When is the best time to take a home pregnancy test in order to obtain the most accurate results?

Right after the first missed period

At what point(s) would you counsel your home pregnancy test patient to seek professional care?

• If the second test is negative and menstruation has not begun

• If test is positive

False negative

Indicates testing being done too early or drinking large amounts of fluid before testing

False positive

Indicates miscarriage or birth within past 8 weeks or if she is using fertility medications that contain hCG

4 items which may affect sperm count

• Heavy alcohol use

• Smoking cigarettes

• Type 1 diabetes

• Medicines (Rx, non-Rx, herbal)

How to counsel a patient to take accurate blood pressure measurements at home

• Rest in chair for at least 15 minutes

• With your left arm resting comfortably on a flat surface at heart level, sit calmly and avoid talking

• Do not smoke, exercise, drink caffeinated or alcoholic beverages 30 minutes before

• Take at least 2 readings 1 min apart (in the morning before taking any meds and evening before dinner)

• Use calibrated and validated instrument; check cuff size and fit

• Place bottom of the cuff above bend of the elbow

• Sit still and relaxed with your feet flat on the floor and back straight & supported

If 180/120 = seek emergency care

If 140/90 = make PCP aware

If 120/80 = normal

Typical sleep cycle

Alternating pattern of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep - takes place over 90-110 minutes with about 3-7 cycles per night.

• Wake stage: Alpha waves become more predominant than beta

• Non-REM sleep:

  • N1 (light sleep) - muscle tone present and respiratory rate is stable

  • N2 (deep sleep) - heart rate + body temperature decreases

  • N3 (deep sleep) - regrowth and repair of tissue, building of muscle & bone, and strengthening of immune system

• REM sleep: High brain metabolism and oxygen-use

How does sleep change with age?

Quality of sleep decreases

Primary insomnia vs. Secondary insomnia

Primary → Not due to any underlying condition(s) and is considered its own sleep disorder

Secondary → Caused by another condition(s)

Diphenhydramine (Benadryl) in treatment of insomnia

Recommended as an OTC sleep-aid for intermittent use (not for chronic conditions)

• Dose: 25-50mg caplet per night

• Side effects: Dry mouth, next day sedation, drowsiness, difficulty urinating, morning grogginess

• Counseling Points:

  • Takes about 1 hour to be in effect

  • Recommend taking at least 30 minutes prior to bedtime

  • Lasts ~4-6 hours

How are insomnia, drowsiness, and fatigue related to each other?

The inability to get proper sleep (insomnia) can result in daytime drowsiness and fatigue. When you feel sleepy (drowsiness), you will also naturally feel tired (fatigue)

Insomnia

Having trouble falling or staying asleep, waking up too early and not being able to return to sleep, or not feeling refreshed after sleeping

Drowsiness

The feeling of being sleepy and lethargic

Fatigue

The subjective feeling of tiredness, which is distinct from weakness, and has a gradual onset

Presentation of insomnia

• Difficulty falling asleep

• Anxiety and/or irritability

• Waking up too early

• Night-time wakefulness

• Daytime sleepiness

• Not feeling well-rested

• Inability to focus

• Difficulty recollecting memories

• Lack of motivation

Exclusions to self-treatment of insomnia

• < 12 years old

• >/ 65 years old

• Pregnant or breastfeeding/chest-feeding

• Frequent nocturnal awakenings or early morning awakenings

• Chronic insomnia (>/ 3 months)

• Sleep disorder secondary to psychiatric or general medical disorders

Goal of insomnia treatment

To improve the patient’s presenting symptoms, quality of life, and functioning

Nonpharmacologic options for insomnia

• Use bed for sleeping/intimacy only

• Avoid electronic devices within a few hours of bedtime (turn down brightness if using)

• Exercise regularly, but avoid doing so within a few hours of bedtime

• Eat a light snack; no heavy meals at least 2 hours prior to bedtime

• Avoid caffeine, alcohol, and nicotine within several hours of bedtime

• Limit excessive fluids before bedtime

• Try not to take naps during the day - limit to 20-30 min if you do

What should a patient do if they are unable to fall back asleep and are lying in bed for more than 20 min?

Do not try to continue sleeping - get out of bed and do a relaxing activity until you feel tired

Note: Watching the clock can be detrimental and make it more difficult to fall back to or stay asleep

Cognitive Behavioral Therapy for Insomnia (CBTI)

A nonpharmacological option that includes cognitive therapy, behavioral interventions (e.g., sleep restrictions, relaxation, stimulus control), and educational interventions (e.g., sleep hygiene)

• Regular (weekly) visits to clinician who gives patient a series of sleep assessments (e.g., sleep diary)

• First line treatment - should be done along with 1 or 2 other measures

Which pharmacological option is the only FDA approved to be safe/efficacious for self-treatment of insomnia?

Diphenhydramine

Alcohol as a pharmacological treatment for insomnia

Very commonly used in those with insomnia, but has a short DOA and several adverse effects such as:

• CNS depression

• Misuse

• Dependence

• Decreased REM sleep time

• Decreased sleep quality

Not recommending

Doxylamine as pharmacological treatment for insomnia

This and diphenhydramine affect sleep in the same way (competitively block H1 receptors)

• Safety/efficacy is not fully established; not recommending

Benadryl as treatment for insomnia

OTC sleep-aid for intermittent use only (7-10 days)

• Dose: 25-50mg per night

• Onset: 1 hour post administration; take 30 minutes before bed

• DOA: 4-6 hours on average

• Recommendations: If you are getting good sleep with use for 2-3 night in a row, try skipping for a night to see if insomnia has resolved

• Side effects: Drowsiness, sedation, morning grogginess (“hangover effect”), dry mouth, constipation, blurred vision

AdvilPM as treatment for insomnia

Combination product - not recommending

Complementary therapies for insomnia

Melatonin, valerian root, chamomile, mindfulness meditation

Melatonin as complementary therapy for insomnia

Conflicting evidence of efficacy (depends on dose/timing of administration)

• Contact PCP if insomnia has not resolved after 10 days of use

Valerian root as complementary therapy for insomnia

Not recommending - lack of benefit

Chamomile as complementary treatment for insomnia

Calming/relaxing effect, but there’s no statistically significant difference in severity of insomnia, sleep onset latency, and sleep duration while taking

What to recommend for complementary therapy for insomnia

Mindfulness meditation → Helps with attention regulation, body awareness, emotional regulation, and self-awareness

How to treat a child <12 years old for insomnia

Refer

How to treat adolescents for insomnia

Ask about their intake of caffeine, nicotine, alcohol, and any illicit substances

• Recommend behavioral therapy / good sleep hygiene (first line)

How to treat pregnant/breastfeeding/chest-feeding women for insomnia

Safety is not established; refer unless PCP approves

• Diphenhydramine can slow milk production as well as pass into breast/chest milk and harm the baby

How to treat an older adult for insomnia

Behavioral therapy or pharmacotherapy with approved agents

• DON’T recommend 1st gen antihistamines because of anticholinergic effects (falls, delirium, blurred vision, etc.)

Patient counseling for insomnia

• Keep a sleep diary

• If symptoms worsen or do not improve after 7-10 days, they should contact their healthcare provider

• Advise patients to utilize good sleep hygiene on top of OTC tx

Independent risk factors for drowsiness & fatigue

• Depression

• Insomnia

• Chronic pain

• Smoking

• Male sex

• Poor sleep quality

• Moderate to severe sleep apnea

Exclusions to self-treatment of drowsiness & fatigue

• < 12 years old

• Pregnancy

• Breastfeeding/chest-feeding

• Cardiac conditions

• Anxiety disorders

• Medication-induced drowsiness (refer to HCP for dose adjustment)

• Chronic fatigue defined as >/ 6 months of fatigue (refer to HCP to rule out hypothyroidism, sleep apnea, and other medical conditons)

Goal of treatment for drowsiness & fatigue

To identify and eliminate the underlying cause to improve mental alertness and productivity

What is the only FDA approved non-prescription stimulant for treatment of drowsiness & fatigue?

Caffeine

Caffeine as treatment for drowsiness & fatigue

• Dose: 200mg every 3-4 hours, as needed

• Peak concentration: 30-60 minutes

• Elimination half-life: ~5 hours in all ages (can be increased with pregnancy or cirrhosis)

• Recommendations: Do not exceed 200mg dose; only for short-term, occasional use

• Side effects: Increased alertness, increased productivity, peak performance

How to treat children < 12 years old for drowsiness & fatigue (with caffeine tx)

Do not recommend; they are more susceptible to cardiovascular and CNS adverse effects due to lower body weight

How to treat pregnant/breastfeeding women for drowsiness & fatigue (with caffeine tx)

Caffeine freely crosses placenta and passes through breast/chest milk

• Recommended dose: < 200mg every 3-4 hours OR no more than 300mg daily

• If breastfeeding, consume caffeine right after feeding to avoid adverse effects in baby

How to treat older adults for drowsiness & fatigue (with caffeine tx)

Normally not an issue, but possible drug-drug interactions if on multiple medications

Patient counseling on drowsiness & fatigue

• Focus on good sleep hygiene

• If a caffeine product is indicated, review:

  • Dosage guidelines

  • Adverse effects

  • Drug interactions

• Sxs of excessive caffeine ingestion: Irritability, tremor, dizziness, heart palpitations

• Withdrawal sxs: HA, anxiety

• Successful outcomes: Daytime alertness, increased productivity, and peak performance

• When to seek medical evaluation:

  • If experiencing caffeine toxicity sxs such as: increased HR, increased bp, HA, anxiety/insomnia, increased hand tremor

  • > 7-10 days of self-treatment with no improvement

Who regulates the supplement industry?

FDA

What does the FDA do in regard to supplement industry?

Prohibits adulteration and misbranding of dietary supplements and natural products; Is responsible for taking action against adulterated or misbranded products once they reach the market (e.g., send warning letters, issue recalls, legal action, product seizure)

Reasons for adulteration of supplements

1. Economically Motivated Adulteration: Suppliers/manufacturers substitute the product with something cheaper or more widely available

2. Mistaken Identity

3. Inadequate Quality Control Practices or Negligence: Noncompliance with cGMPs

Simple Heartburn

Burning sensation behind the breast bone that may radiate toward the neck, throat, and occasionally the back

GERD

Heartburn, acid regurgitation

Dyspepsia

Primary → Postprandial fullness, early satiation, epigastric pain and burning

“Other”→ Belching, bloating, nausea, vomiting

PUD

Gnawing or burning epigastric pain, occurring during the day and frequently at night; may be accompanied by heartburn and dyspepsia

Clinical presentation of heartburn & dyspepsia

Heartburn:

• Alone or with dyspepsia, GERD, PUD

• Within 1 hour of eating

• Lying down or bending over worsens

• Regurgitation

• Water brash - sudden filling in the mouth with clear, salty fluid secreted from salivary glands

Dyspepsia:

• Belching, bloating, N/V

• Postprandial fullness

• Early satiation

• Epigastric pain

• Epigastric burning

Nonpharmacologic options to manage heartburn

• Diary to track dietary, lifestyle, medication triggers and environmental triggers

• Weight loss

• Raise the head of the bed

• Smoking cessation (normal weight)

• Mediterranean diet

• Reduce intake of red or processed meat

Antacids as a pharmacological option for heartburn & dyspepsia

MOA: Neutralize stomach acid - cations react with chloride, anion reacts with H to form water (increased gastric pH)

Onset of relief: <5 minutes

Duration of relief: 20-30 minutes

Examples + dosing:

• Tums (PRN after meals)

• Alka-Seltzer (2 tabs every 4 hr PRN)

• Gaviscon (2-4 tsp 4x daily after meals and at bedtime)

• Mylanta (10-20 ml PRN)

H2RAs as a pharmacological option for heartburn & dyspepsia

MOA: Reduce acid secretion by inhibiting histamine on the H2 receptor of the parietal cell

Onset of relief: 30-45 minutes

Duration of relief: 4-10 hrs

Examples + dosing:

• Famotidine → Zantac 360 (1 tab with glass of water, 15-60 min before meal)

PPIs as a pharmacological option for heartburn & dyspepsia

MOA: Inhibit hydrogen potassium ATPase (proton pump) irreversibly blocking final step in gastric acid secretion

Onset of relief: 2-3 hrs

Duration of relief: 12-24 hrs

Examples + dosing:

• Nexium 24hr (20 mg once daily for 14 days)

• Prevacid 24hr (15 mg once daily for 14 days)

• Prilosec OTC (20 mg once daily for 14 days)

Exclusions for self-treatment of heartburn & dyspepsia

• Frequent heartburn for more than 3 months

• Heartburn while taking recommended dosages of nonRx H2RA or PPI

• Heartburn that continues after 2 weeks of tx with a nonRx H2RA or PPI

• Heartburn & dyspepsia that occur when taking a prescription H2RA or PPI

• Severe heartburn and dyspepsia

• Nocturnal heartburn

• Difficulty or pain in swallowing solid foods

• Unexplained weight loss

• Continuous nausea, vomiting, or diarrhea

• Vomiting blood or black material or passing black tarry stool

• Chronic hoarseness, wheezing, coughing, or choking

• Chest pain accompanied by sweating, pain radiating to shoulder, arm neck, or jaw, and shortness of breath

• Children <2 yr (for antacids), <12 yr (for H2RAs), or <18 yr (for PPIs)

• Adults >45 yr with new-onset dyspepsia

Clinical presentation of N/V

• Restlessness/irritability

• Rapid or deep breathing

• Tachycardia

• Dry mouth and tongue

• Sunken and/or dry eyes

• Sunken fontanelle

• Decreased urine output

• Dark urine

• Thirst (drinks eagerly)

• Absence of tears when crying

• Decreased skin turgor

• Prolonged capillary refill in the fingertip after release of a gentle squeeze

• Weight loss

  • Noticeable decrease in abdominal size

  • Loose fit clothing or diaper

  • <3% body weight loss, indicating minimal or no dehydration

  • 3%-9% body weight loss, indicating mild to moderate dehydration

  • >9% body weight loss, indicating severe dehydration

Nonpharmacologic options to treat N/V

• Acupuncture wristbands (chi energy)

• Acustimulation band (P6 point)

To prevent motion sickness:

• Avoid reading while traveling

• Focus vision straight ahead

• Stay where motion least expected

• Avoid strong odors

• Be in control of vehicle if possible