pharmacological aspects of if – key tips
TRANSCRIPT
Pharmacological Aspects
of IF – Key Tips Gavin Leahy
Senior Pharmacist
Salford Royal NHS Foundation Trust
Overview
General considerations
MDT approach
Medicines Optimisation
Drug treatment of high output stomas
Drug absorption issues
Specific medication
Drug Treatment of High Output Stomas
Maximise gastrointestinal function
Use a combination of drugs
Antimotility drugs
Antisecretory drugs
Glucose/Saline solution
Response affected by whether patient is a “secretor” or “absorber”
Antimotility Drugs
Act on local opiate receptors in gut wall
Reduce intestinal motility so increase GI transit time
Benefit seen in secretors but particularly effective in absorbers
Take 30-60min before meals
Loperamide used as first line
Codeine can be added
Evidence to suggest beneficial to use in combination
Antimotility Drugs - Considerations
High dose Loperamide
64mg daily
Concordance
High tablet burden
Care with hypertonic syrups
Crush tablets/open capsules
Self administration?
Antisecretory Drugs
Proton Pump Inhibitors
Reduce gastric acid secretion to reduce sodium and water excretion
Greatest benefit seen in net secretors
Omeprazole
Good dose/ response curve
Well absorbed in the duodenum and upper small bowel
Dose/route titrated according to stoma pH (homecare considerations)
Use of MUPS formulation?
Antisecretory Drugs
H2 Antagonists
2nd line agent to proton pump inhibitors
Greatest benefit seen in net secretors
Ranitidine
Evidence based dose of 300mg bd
Useful in patients who can’t tolerate PPIs (allergy, hypomagnesaemia, altered
LFTs)
Antisecretory Drugs
Octreotide
Reduces salivary, gastric, pancreatico-biliary secretions
Increase bowel transit time
Greatest reduction in output seen in secretors
2nd line agent
Equivalent effect to proton pump inhibitors
Unlicensed indication – cost/administration implications
Glucose/Saline Solutions
Avoid drinking hypotonic fluids
Glucose/Saline solutions reduce sodium and fluid loss
Concentration of sodium at least 90mmol/L
Various solutions available
Double Strength Dioralyte(120mmol Na/L) - 10sachets in 1L
Considerations
Adherence
Education of HCPs
Palatability of Glucose/Saline Solutions
Switch to Dioralyte Relief?
Importance of Citrate
Add flavouring and keep chilled
to improve palatability
Drug Absorption
Very difficult to predict – significant interpatient variability
BPNG Handbook of drug administration
Drug companies have very little data on file
“well absorbed throughout GI tract”
Look at time to peak concentration
Reduce the output as much as possible to improve absorption
Drug Absorption
How much and what type of
bowel remaining
Use other routes if possible:
transdermal, parenteral, rectal
Give more often or increase dose
Can you measure drug levels?
Use of liquids, syrups?
Crush tablets, open capsules
Avoid use of M/R preparations
Consider the distal route if
available
Distal Route of Drug Administration
Need at least 75-100cm
Caution with choice of drugs
Loperamide to aid distal feeding
Look at time to peak - want 3-4 hours
Success Stories-
Pt needed 450microgram orally of levothyroxine
Swapped to distal route - now on 125microgram via distal feeding tube
Specific Medication Issues
Magnesium Supplementation
Magnesium deficiency is common
Various preparations available
Magnesium Aspartate (10mmol/sachet)
Magnesium Glycerophosphate (4mmol/tablet)
Magnesium Oxide (4mmol/capsule)
Side effects/fluid considerations
S/C infusions?
Check Vitamin D levels
Cost implications?
Vitamin D supplementation
Commonly deficient in short bowel/PN patients
In PN bags only 200 units/day
Recent studies show oral preferable to IM injections
Colecalciferol capsules 20,000 units
Dose - 40,000 units od for 10 days then 20,000 units once a week
Ergocalciferol injection 300,000 units every 3-6 months IM
Recheck levels after 8 weeks
Questions?