Drug reference
Acute diarrhoea with abdominal colic ▶BY MOUTH ▶Child 12–17 years: Initially 1 tablet, then 1 tablet, after each loose stool, for up to 2 days; maximum 4 tablets per day ▶Adult: Initially 2 tablets, then 1 tablet, after each loose stool, for up to 2 days; maximum 4 tablets per day
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→Appendix 1: loperamide
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There can be variation in the licensing of different medicines containing the same drug. Tablet ▶Imodium Plus (McNeil Products Ltd) Loperamide hydrochloride 2 mg, Dimeticone (as Simeticone) 125 mg Imodium Plus caplets | 12 tablet p £4.21 DT = £4.21 Disorders of gastric acid and ulceration 4.1 Dyspepsia Dyspepsia Description of condition Dyspepsia describes a range of upper gastro-intestinal symptoms, which are typically present for 4 or more weeks. Symptoms include but are not limited to upper abdominal pain or discomfort, heartburn, gastric reflux, bloating, nausea and/or vomiting. Symptoms can be attributed to an underlying cause (e.g. Gastro-oesophageal reflux disease p. 88, Peptic ulcer disease p. 76, gastro-oesophageal malignancy, or side effects from drugs), but the majority of patients are likely to have functional dyspepsia, where an underlying cause cannot be identified and endoscopy findings are normal. Uninvestigated dyspepsia describes symptoms in patients who have not had an endoscopy. Dyspepsia symptoms in pregnancy are commonly due to gastro-oesophageal reflux disease (GORD), for management see GORD in pregnancy in Gastro-oesophageal reflux disease p. 88. Aims of treatment The aim of treatment is to manage symptoms, and where possible, to treat the underlying cause of dyspepsia. Non-drug treatment g Lifestyle measures, such as healthy eating, weight loss (if obese), avoiding any trigger foods, eating smaller meals, eating the evening meal 3–4 hours before going to bed, raising the head of the bed, Smoking cessation p. 520, and reducing alcohol consumption may improve symptoms. Assess the patient for stress, anxiety, or depression, as these conditions may exacerbate symptoms. Urgent endoscopic investigation is required for patients with dysphagia, significant acute gastrointestinal bleeding, or in those aged 55 years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia. h Drug treatment g Drugs that may cause dyspepsia, such as alpha- blockers, antimuscarinics, aspirin, benzodiazepines, beta- blockers, bisphosphonates, calcium-channel blockers, corticosteroids, nitrates, non-steroidal anti-inflammatory drugs (NSAIDs), theophyllines, and tricyclic antidepressants, should be reviewed. The lowest effective dose should be used and if possible, stopped. Antacids and/or alginates may be used for short-term symptom control, but long-term, continuous use is not recommended. h Initial management Uninvestigated dyspepsia g A proton pump inhibitor should be taken for 4 weeks. Patients with dyspepsia should be tested for Helicobacter pylori (H. pylori) infection, and treated if positive. h Public Health England recommends that patients who are at high risk for H. pylori infection should be tested for H. pylori first, or in parallel with a course of proton pump inhibitor. For treatment regimens, see Helicobacter pylori infection p. 89. Functional dyspepsia g Patients should be tested for H. pylori infection and treated if positive. See Helicobacter pylori infection p. 89 for testing and management of H. pylori infection. In patients not infected with H. pylori, a proton pump inhibitor or a histamine2-receptor antagonist (H2-receptor antagonist) should be taken for 4 weeks. h Follow up management Uninvestigated and functional dyspepsia g For patients with refractory dyspepsia symptoms, new alarm symptoms should be assessed and alternative diagnoses should be considered. The patient’s adherence to initial management should be checked and lifestyle advice reinforced. If symptoms persist or recur following initial management, a proton pump inhibitor or H2-receptor antagonist therapy should be used at the lowest dose needed to control symptoms. The patient may use the treatment on an ’as- needed’ basis. In patients with uninvestigated dyspepsia taking an NSAID and unable to stop the drug, consider reducing the NSAID dose and using long-term gastro-protection with acid suppression therapy, or switching to an alternative to the NSAID, such as paracetamol p. 465 or a selective cyclo- oxygenase (COX)-2 inhibitor (but see Cardiovascular Events under Non-steroidal anti-inflammatory drugs p. 1193). In patients with uninvestigated dyspepsia taking aspirin and unable to stop the drug, consider switching from aspirin to an alternative antiplatelet drug. Patients treated with H. pylori eradication therapy do not require routine retesting. h There are specific situations where retesting may be appropriate, see Retesting for Helicobacter pylori, under Helicobacter pylori infection p. 89. g If retesting is positive, second-line eradication therapy should be prescribed. An annual review should be performed for patients with dyspepsia to assess their symptoms and treatment. A ’step down’ approach, or stopping treatment, should be encouraged if possible and clinically appropriate. A return to self-treatment with antacid and/or alginate therapy may be Gastro-intestinal system appropriate. Referral to a specialist for further investigations should occur in patients of any age with gastro-oesophageal symptoms that are unexplained or non-responsive to treatment, or in patients with H. pylori infection that has not responded to second-line eradication therapy—see Helicobacter pylori infection p. 89. h Useful Resources Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. National Institute for Health and Care Excellence. NICE guideline 184. September 2014, reviewed October 2019. www.nice.org.uk/guidance/cg184 ANTACIDS Antacids Overview Antacids (usually containing aluminium or magnesium compounds) can often relieve symptoms in ulcer dyspepsia and in non-erosive gastro-oesophageal reflux ; they are also sometimes used in functional (non-ulcer) dyspepsia but the evidence of benefit is uncertain. Antacids are best given when symptoms occur or are expected, usually between meals and at bedtime, although additional doses may be required. Conventional doses of liquid magnesium– aluminium antacids promote ulcer healing, but less well than antisecretory drugs; proof of a relationship between healing and neutralising capacity is lacking. Liquid preparations are more effective than tablet preparations. Aluminium- and magnesium-containing antacids (e.g. aluminium hydroxide, magnesium carbonate p. 75, co- magaldrox p. 74 and magnesium trisilicate p. 75), being relatively insoluble in water, are long-acting if retained in the stomach. They are suitable for most antacid purposes. Magnesium-containing antacids tend to be laxative whereas aluminium-containing antacids may be constipating; antacids containing both magnesium and aluminium may reduce these colonic side-effects. Aluminium accumulation does not appear to be a risk if renal function is normal. The acid-neutralising capacity of preparations that contain more than one antacid may be the same as simpler preparations. Complexes such as hydrotalcite confer no special advantage. Sodium bicarbonate p. 1099 should no longer be prescribed alone for the relief of dyspepsia but it is present as an ingredient in many indigestion remedies. However, it retains a place in the management of urinary-tract disorders and acidosis. Bismuth-containing antacids (unless chelates) are not recommended because absorbed bismuth can be neurotoxic, causing encephalopathy; they tend to be constipating. Calcium-containing antacids can induce rebound acid secretion: with modest doses the clinical significance is doubtful, but prolonged high doses also cause hypercalcaemia and alkalosis, and can precipitate the milk- alkali syndrome. Simeticone Simeticone p. 76 (activated dimeticone) is added to an antacid as an antifoaming agent to relieve flatulence. These preparations may be useful for the relief of hiccup in palliative care. Alginates Alginates taken in combination with an antacid increases Gastro-intestinal system the viscosity of stomach contents and can protect the oesophageal mucosa from acid reflux. Some alginate- containing preparations form a viscous gel (‘raft’) that floats on the surface of the stomach contents, thereby reducing symptoms of reflux. The amount of additional ingredient or antacid in individual preparations varies widely, as does their sodium content, so that preparations may not be freely interchangeable. ANTACIDS › ALGINATE
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Initially 1 tablet, then 1 tablet, after
First-line fragment. Read the complete Indications and Dose section above.
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