Gastroenterology COMMUNITY PHARMACY LECTURE NO.16

PART 1 ORAL THRUSH

BACKGROUND Oropharyngeal candidiasis (oral thrush) is an opportunistic mucosal infection and is unusual in healthy adults. A healthy adult with no risk factors generally requires referral to the GP.

PREVALENCE AND EPIDEMIOLOGY Most cases are associated with underlying pathology such as: Diabetes. Xerostomia (dry mouth). Patients who are immunocompromised. Identifiable risk factors such as recent antibiotic therapy, inhaled corticosteroids, and ill-fitting dentures.

AETIOLOGY Candida albicans is the main cause (30-60% of healthy people in the developing countries). Denture wearers are with a higher prevalence than mentioned earlier. Changes to the normal environment in the oral cavity will allow C. albicans to proliferate. It is transmitted directly between infected people or via objects that can hold the organism.

ARRIVING AT A DIFFERENTIAL DIAGNOSIS

CLINICAL FEATURES OF ORAL THRUSH The classical presentation of oral thrush is of creamy-white soft elevated patches that can be wiped off revealing underlying erythematous mucosa. Pain, soreness, altered taste and a burning tongue can be present.

CLINICAL FEATURES OF ORAL THRUSH (continued) Lesions can occur anywhere in the oral cavity but usually affect the tongue, palate, lips and cheeks. Patients sometimes complain of malaise and loss of appetite. In neonates, spontaneous resolution usually occurs but can take a few weeks.

CONDITIONS TO ELIMINATE LIKELY CAUSES Minor aphthous ulcers. Medicine-induced thrush. Denture wearers.

1- Minor aphthous ulcers Superficial painful oral lesions. MAU are roundish, grey-white in colour and painful.

2- Medicine-induced thrush Inhaled corticosteroids and antibiotics are often associated with causing thrush. Medicines that cause dryness of the mouth can also predispose people to thrush.

3- Denture wearers Wearing dentures, especially if they are not taken out at night, not kept clean, or do not fit well can predispose people to thrush.

UNLIKELY CAUSES 1- Lichen planus  similar in appearance to plaque psoriasis(dermatological condition with lesions occours without skin rash). 2- Underlying medical disorders (diabetes, xerostomia (dry mouth) or are immunocompromised). 3- Other forms of ulceration (e.g. major and herpetiform ulcers, herpes simplex

VERY UNLIKELY CAUSES 1- Leukoplakia 2- Squamous cell carcinoma

1- Leukoplakia White lesion of the oral mucosa. It is often associated with smoking and is a precancerous lesion. Patients present with a symptomless white patch that develops over a period of weeks on the tongue or cheek. The lesion cannot be wiped off, unlike oral thrush. Suspected cases require referral.

EVIDENCE BASE FOR OVER-THE-COUNTER MEDICATION Only MICONAZOLE oral gel (Daktarin®) is available OTC to treat oral thrush. The gel should be applied directly to the area with a clean finger. Co-administration of warfarin with miconazole increases warfarin levels markedly and the patient's International normalized ratio (INR) should be monitored closely.

CHLORHEXIDINE GLUCONATE Has an effective ANTIBACTERIAL effect in reducing plaque formation and gingivitis Although it is free from side effects, patients should be warned that prolonged use may stain the tongue and teeth brown.

BETADINE GARGLE AND MOUTHWASH Povidone iodine is an antiseptic. It is a complex of iodine, which kills micro-organisms such as bacteria, fungi, viruses, protozoa and bacterial spores. It can therefore be used to treat infections with these micro-organisms. Povidone iodine gargle and mouthwash is used to treat infections of the mouth and throat, such as gingivitis (inflammation of the gums) and mouth ulcers. It is also used for oral hygiene, to kill micro-organisms before, during and after dental and oral surgery and hence prevent infections.

GASTROENTEROLOGY DYSPEPSIA COMMUNITY PHARMACY LECTURE NO.17 22 22

Background Refer to a group of upper abdominal symptoms that arise from five main conditions: Non-ulcer dyspepsia/functional dyspepsia (indigestion) Gastro-oesophageal reflux disease (GORD, heartburn) Gastritis Duodenal ulcers Gastric ulcers.

Aetiology Decreased muscle tone leads to lower oesophageal sphincter incompetence (often as a result of medicines or overeating) and is the principal cause of GORD. Increased acid production results in inflammation of the stomach (gastritis) and is usually attributable to Helicobacter pylori infection (produce toxins that stimulate the inflammatory cascade) or acute alcohol indigestion. Medicine induced ulcers, most notably NSAIDs and low-dose aspirin.

Clinical features of dyspepsia Vague abdominal discomfort (aching) above the umbilicus associated with belching Bloating Flatulence Feeling of fullness Nausea and/or vomiting Heartburn.

Conditions To Eliminate UNLIKELY CAUSES Peptic ulceration Medicine-induced dyspepsia Irritable bowel syndrome

1. Peptic ulceration Ulcers are classed as either gastric or duodenal. Typically the patient will have well localized mid- epigastric pain described as 'constant', 'annoying' or 'gnawing/boring'. In gastric ulcers the pain comes on whenever the stomach is empty, usually 30 minutes after eating and is generally relieved by antacids or food and aggravated by alcohol and caffeine.

Peptic ulceration (continued) Gastric ulcers are also more commonly associated with weight loss and GI bleeds than duodenal ulcers. In duodenal ulcers, pain occurs 2 to 3 hours after eating and pain that wakes a person at night is highly suggestive of duodenal ulcer. If ulcers are suspected referral to the GP is necessary

2. Medicine-induced dyspepsia A number of medicines can cause gastric irritation leading to provoking GI discomfort or they can decrease oesophageal sphincter tone resulting in reflux. Aspirin and NSAIDs are very often associated with dyspepsia

3. Irritable Bowel Syndrome Patients younger than 45, who have uncomplicated dyspepsia and also lower abdominal pain and altered bowel habits are likely to have irritable bowel syndrome (IBS).

Oesophageal carcinoma Atypical angina VERY UNLIKELY CAUSES Gastric carcinoma Oesophageal carcinoma Atypical angina

1. Gastric Carcinoma Gastric carcinoma is the third most common GI malignancy after colorectal and pancreatic cancer.

2. Oesophageal Carcinoma In its early stages, oesophageal carcinoma might go unnoticed. Over time, as the oesophagus becomes constricted, patients will complain of difficulty in swallowing and experience a sensation of food sticking in the oesophagus. As the disease progresses weight loss becomes prominent despite the patient maintaining a good appetite.

3. Atypical Angina Not all cases of angina have classical textbook presentation of pain in the retrosternal area with radiation to the neck, back or left shoulder that is precipitated by temperature changes or exercise. Patients can complain of dyspepsia-like symptoms and feel generally unwell. These symptoms might be brought on by a heavy meal. In such cases antacids will fail to relieve symptoms and referral is needed.

Evidence Base For Over-the-counter Medication The patient should be assessed in terms of diet and physical activity: I. Move to a lower fat diet 2. Decrease alcohol intake 3. Smoking cessation 4. Decrease weight 5. Reduce caffeine intake Commonly implicated foods that precipitate dyspepsia are spicy or fatty food, caffeine, chocolate and alcohol. Bending is also said to worsen symptoms.

MEDICATIONS Alginates Antacids H2 antagonists PPI

1. Alginates {e.g. the Gaviscon range) For patients suffering from GORD an alginate product should be first-line treatment. When in contact with gastric acid the alginate precipitates out, forming a sponge-like matrix that floats on top of the stomach contents. Alginate preparations are also commonly combined with antacids to help neutralize stomach acid. PPIs and H2 antagonists do have superior efficacy to alginates.

2. Antacids The majority of marketed antacids are combination products containing two, three or even four constituents. The rationale for combining different salts together appears to be twofold. First, to ensure the product has quick onset (containing sodium or calcium) and a long duration of action (containing magnesium, aluminium or calcium). Second, to minimize any side effects that might be experienced from the product.

2. Antacids (continued) For example, magnesium salts tend to cause diarrhea and aluminium salts constipation, if both are combined in the same product then neither side effect is noticed. Antacids can affect the absorption of a number of medications via chelation and adsorption. Commonly affected medicines include tetracyclines, quinolones, imidazoles, phenytoin, penicillamine and bisphosphonates. The absorption of enteric-coated preparations can be affected due to antacids increasing the stomach pH.

3. H2 Antagonists Ranitidine, famotidine, cimetidine and nizatidine They possess no clinically important drug interactions and side effects are rare.

4. Proton Pump Inhibitors (PPI) A number of trials have compared PPis with H2 antagonists for non-ulcer dyspepsia and GORD-like symptoms. Results indicate that PPis, even at half the standard POM dose, are generally superior to H2 antagonists in treating dyspeptic symptoms.

Summary Antacids will work for the majority of people presenting at the pharmacy with mild dyspeptic symptoms. They can be used as first-line therapy unless heartburn predominates then an alginate or alginate/antacid combination can be used. H2 antagonists appear to be equally effective to antacids but are considerably more expensive. Proton pump inhibitors are the most effective and could be considered first-line, especially for those patients that suffer from moderate to severe or recurrent symptoms. Like H2 antagonists they are expensive in comparison to simple antacids and might influence patient choice or pharmacist recommendation.