Drug Action
Orlistat, a lipase inhibitor, reduces the absorption of dietary fat.
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Drug reference
Orlistat, a lipase inhibitor, reduces the absorption of dietary fat.
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Adjunct in obesity (in conjunction with a mildly hypocaloric diet in individuals with a body mass index (BMI) of 30 kg/m2 or more or in individuals with a BMI of 28 kg/m2 or more in the presence of other risk factors such as type 2 diabetes, hypertension, or hypercholesterolaemia) ▶BY MOUTH ▶Adult: 120 mg up to 3 times a day, dose to be taken immediately before, during, or up to 1 hour after each main meal, continue treatment beyond 12 weeks only if weight loss since start of treatment exceeds 5% (target for initial weight loss may be lower in patients with type 2 diabetes), if a meal is missed or contains no fat, the dose of orlistat should be omitted
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Cholestasis. chronic malabsorption syndrome
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Chronic kidney disease. may impair absorption of fat-soluble vitamins. volume depletion CAUTIONS, FURTHER INFORMATION Vitamin supplementation (especially of vitamin D) may be considered if there is concern about deficiency of fat- Gastro-intestinal system soluble vitamins.
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→Appendix 1: orlistat
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▶Common or very common Abdominal pain (may be minimised by reduced fat intake). anxiety. diarrhoea. gastrointestinal disorders ▶Frequency not known Anorectal haemorrhage. bullous dermatitis. cholelithiasis. diverticulitis. hepatitis. oxalate nephropathy. pancreatitis. renal failure
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Use with caution.
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Avoid—no information available.
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There can be variation in the licensing of different medicines containing the same drug. Capsule ▶Orlistat (Non-proprietary) Orlistat 120 mg Orlistat 120mg capsules | 84 capsule P £35.43 DT = £27.30 ▶Alli (GlaxoSmithKline Consumer Healthcare) Orlistat 60 mg Alli 60mg capsules | 84 capsule p £30.70 DT = £30.70 ▶Beacita (Actavis UK Ltd) Orlistat 120 mg Beacita 120mg capsules | 84 capsule P £21.95 DT = £27.30 ▶Orlos (Crescent Pharma Ltd) Orlistat 60 mg Orlos 60mg capsules | 84 capsule p £16.95 DT = £30.70 ▶Xenical (Cheplapharm Arzneimittel GmbH) Orlistat 120 mg Xenical 120mg capsules | 84 capsule P £31.63 DT = £27.30 Rectal and anal disorders Other drugs used for Rectal and anal disorders Diltiazem hydrochloride, p. 169 9.1 Anal fissures Anal fissure Description of condition An anal fissure is a tear or ulcer in the lining of the anal canal, immediately within the anal margin. Clinical features of anal fissure include bleeding and persistent pain on defecation, and a linear split in the anal mucosa. Aims of treatment The aim of treatment is to relieve pain and promote healing of the fissure. Drug treatment Acute anal fissure g Initial management of acute anal fissures (present for less than 6 weeks) should focus on ensuring that stools are soft and easily passed. Bulk-forming laxatives (such as ispaghula husk p. 58) are recommended and an osmotic laxative (such as lactulose p. 60) can be considered as an alternative—see also Constipation p. 57, for further information about these laxatives. Short-term use of a topical preparation containing a local anaesthetic (such as lidocaine hydrochloride p. 1422) or a simple analgesic (such as paracetamol p. 465 or ibuprofen p. 1203) may be offered for prolonged burning pain following defecation. If these measures are inadequate, the patient should be referred for specialist treatment in hospital. h Chronic anal fissure g Chronic anal fissures (present for 6 weeks or longer), and associated pain, may be treated with glyceryl trinitrate Gastro-intestinal system rectal ointment 0.4% or 0.2% p. 232 [unlicensed] (available from Special-order manufacturers p. 1710 or specialist importing companies). Limited evidence suggests that the strength used does not influence the effectiveness, but that the higher strength potentially increases the incidence of side-effects. Healing rates with topical glyceryl trinitrate are marginally superior to placebo, but the incidence of headache as an adverse effect is quite high (about 20-30% of patients). Recurrence of the fissure after treatment is common. As an alternative to glyceryl trinitrate rectal ointment, chronic anal fissure may also be treated with topical diltiazem hydrochloride 2% p. 169 [unlicensed] or nifedipine 0.2-0.5% p. 174 [unlicensed] (available from Special-order manufacturers p. 1710 or specialist importing companies), which have a lower incidence of adverse effects than topical glyceryl trinitrate. Oral nifedipine [unlicensed indication] and oral diltiazem hydrochloride [unlicensed indication] may be as effective as topical treatment, but the incidence of adverse effects are likely to be higher and topical preparations are preferred. Patients who do not respond to first-line treatment may be referred to a specialist for local injection of botulinum toxin type A [unlicensed indication]. h Non-drug treatment g Surgery is an effective option for the management of chronic anal fissure in adults but is generally reserved for those who do not respond to drug treatment. h 9.2 Haemorrhoids Haemorrhoids Description of condition Haemorrhoids, or piles, are abnormal swellings of the vascular mucosal anal cushions around the anus. Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated. External haemorrhoids originate below the dentate line and can be itchy or painful. Women are predisposed to developing haemorrhoids during pregnancy. Aims of treatment The aims of treatment are to reduce the symptoms (pain, bleeding and swelling), promote healing, and prevent recurrence. Non-drug treatment g Stools should be kept soft and easy to pass (to minimise straining) by increasing dietary fibre and fluid intake. Advice about perianal hygiene is helpful to aid healing and reduce irritation and itching. h Drug treatment g If constipation is reported, it should be treated. A bulk- forming laxative can be prescribed (see Constipation p. 57) A simple analgesic such as paracetamol p. 465 can be used for pain relief. Opioid analgesics should be avoided as they can cause constipation, and NSAIDs should be avoided if rectal bleeding is present. h Topical preparations that contain a combination of local anaesthetics, corticosteroids, astringents, lubricants, and antiseptics are available—see Related drugs below. g They can offer symptomatic relief of local pain and itching but evidence does not suggest that any preparation is more effective than any other. Topical preparations containing local anaesthetics (lidocaine, benzocaine, cinchocaine and pramocaine) should only be used for a few days as they may cause sensitisation of the anal skin. Local anaesthetics can be absorbed through the rectal mucosa (with a theoretical risk of systemic side effects) and very rarely may cause increased irritation; therefore excessive application should be avoided. h Topical preparations combining corticosteroids with local anaesthetics and soothing agents are available for the management of haemorrhoids. They may ameliorate local perianal inflammation, but no data suggest that they actually reduce haemorrhoidal swelling, bleeding, or protrusion. g Topical corticosteroids are suitable for occasional short-term use (no more than 7 days) after exclusion of infections (such as perianal streptococcal infection, herpes simplex or perianal thrush). Long-term use of corticosteroid creams can cause ulceration or permanent damage due to thinning of the perianal skin and should be avoided. h Continuous or excessive use carries a risk of adrenal suppression and systemic corticosteroid effects. g Recurrent symptoms, should be referred to secondary care for further investigation and management. Treatments available from specialists include rubber band ligation, injection sclerotherapy (using phenol in oil p. 102), infrared coagulation/photocoagulation, bipolar diathermy and direct-current electrotherapy, haemorrhoidectomy, stapled haemorrhoidectomy, and haemorrhoidal artery ligation. h Pregnancy g Bulk forming laxatives are not absorbed, and are therefore safe for use in pregnant women (see Pregnancy, under Constipation p. 57). h No topical haemorrhoidal preparations are licensed for use during pregnancy. g If treatment with a topical haemorrhoidal preparation is required, a soothing preparation containing simple, soothing products (not local anaesthetics or corticosteroids) can be considered. h Related drugs Topical preparations used for haemorrhoids: lidocaine hydrochloride p. 1422, benzyl benzoate with bismuth oxide, bismuth subgallate, hydrocortisone acetate, peru balsam and zinc oxide below, cinchocaine hydrochloride with fluocortolone caproate and fluocortolone pivalate p. 101, cinchocaine with hydrocortisone p. 101, cinchocaine with prednisolone p. 102. CORTICOSTEROIDS
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120 mg up to 3 times a day, dose to be taken
First-line fragment. Read the complete Indications and Dose section above.
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