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Diverticular disease
Diverticular
disease is treated with a high-fibre diet,
bran supplements,
and bulk-forming drugs (section
1.6.1). Antispasmodics may provide symptomatic relief
when colic is a problem (section 1.2). Antibacterials are
used only when the diverticula in the intestinal
wall
become infected.
Antimotility drugs which slow intes-
tinal
motility,
e.g.
codeine,
diphenoxylate,
and loper-
amide
could possibly exacerbate
the
symptoms
of
diverticular disease and are contra-indicated.
Irritable bowel syndrome
Irritable bowel
syndrome can present
with pain,
con-
stipation,
or diarrhoea.
In some patients there may be
important
psychological
aggravating
factors
which
respond to reassurance and possibly specific treatment
e.g.
with an antidepressant.
The
fibre
intake
of
patients
with
irritable
bowel
syndrome should be reviewed.
If an increase in dietary
fibre is
required,
soluble fibre (e.g.
ispaghula husk,
sterculia,
or oats) is recommended;
insoluble fibre (e.g.
bran) may exacerbate symptoms and its use should be
discouraged.
A laxative (section 1.6)
can be used to
treat
constipation.
An osmotic
laxative,
such as
a
macrogol,
is preferred;
lactulose may cause bloating.
Stimulant
laxatives
should be avoided or
used only
occasionally.
Loperamide (section 1.4.2)
may relieve
diarrhoea and antispasmodic drugs (section 1.2) may
relieve pain.
Opioids
with a central
action,
such as
codeine,
are better avoided because of the risk of dep-
endence.
A tricyclic antidepressant (section 4.3.1) can be used
for abdominal pain or discomfort [unlicensed indication]
in patients who have not responded to laxatives,
loper-
amide, or antispasmodics. Low doses of a tricyclic anti-
depressant are used (e.g. amitriptyline, initially 5–10 mg
each night,
increased if necessary in steps of 10 mg at
intervals of at least 2 weeks to max. 30 mg each night). A
selective serotonin reuptake inhibitor (section 4.3.3)
may be considered in those who do not respond to a
tricyclic antidepressant [unlicensed indication].
Malabsorption syndromes
Individual
conditions need specific management
and
also general
nutritional
consideration.
Coeliac disease
(gluten enteropathy) usually needs a gluten-free diet and
pancreatic insufficiency needs pancreatin supplements
(section 1.9.4)
For
further
information on foods
for
special
diets
(ACBS), see Appendix 7.
1.5.1
Aminosalicylates
Sulfasalazine is a combination of 5-aminosalicylic acid
(‘5-ASA’) and sulfapyridine;
sulfapyridine acts only as a
carrier to the colonic site of action but still causes side-
effects.
In the newer aminosalicylates,
mesalazine (5-
aminosalicylic acid), balsalazide (a prodrug of 5-amino-
salicylic acid) and olsalazine (a dimer of
5-aminosali-
cylic acid which cleaves in the lower bowel),
the sul-
phonamide-related
side-effects
of
sulfasalazine
are
avoided, but 5-aminosalicylic acid alone can still cause
side-effects including blood disorders (see recommen-
dation below) and lupus-like syndrome also seen with
sulfasalazine.
Cautions
Renal
function should be monitored before
starting an oral
aminosalicylate,
at
3 months of
treat-
ment,
and then annually during treatment
(more fre-
quently in renal impairment). Blood disorders can occur
with aminosalicylates (see recommendation below).
Blood disorders
Patients
receiving
aminosalicylates
should
be
advised to report
any unexplained bleeding,
bruis-
ing,
purpura,
sore throat,
fever
or
malaise that
occurs during treatment.
A blood count
should be
performed and the drug stopped immediately if
there is suspicion of a blood dyscrasia.
Contra-indications
Aminosalicylates
should
be
avoided in salicylate hypersensitivity.
Side-effects
Side-effects
of
the
aminosalicylates
include diarrhoea,
nausea,
vomiting,
abdominal
pain,
exacerbation of
symptoms of
colitis,
headache,
hyper-
sensitivity reactions (including rash and urticaria); side-
effects
that
occur
rarely include acute pancreatitis,
hepatitis,
myocarditis,
pericarditis,
lung
disorders
(including eosinophilia and fibrosing alveolitis),
periph-
eral
neuropathy,
blood disorders (including agranulo-
cytosis, aplastic anaemia, leucopenia, methaemoglobin-
aemia,
neutropenia,
and thrombocytopenia—see also
recommendation above),
renal
dysfunction (interstitial
nephritis, nephrotic syndrome), myalgia, arthralgia, skin
reactions
(including
lupus
erythematosus-like
syndrome,
Stevens-Johnson syndrome), alopecia.
BALSALAZIDE SODIUM
Indications
treatment of mild to moderate ulcerative
colitis and maintenance of remission
Cautions
see notes above; also history of asthma;
interactions: Appendix 1 (aminosalicylates)
Blood disorders
See recommendation above
Contra-indications
see notes above
Hepatic impairment
avoid in severe impairment
Renal impairment
manufacturer advises avoid in
moderate to severe impairment
Pregnancy
manufacturer advises avoid
Breast-feeding
monitor infant for diarrhoea
Side-effects
see notes above;
also cholelithiasis
Dose
. Acute attack,
2.25 g 3 times daily until remission
occurs or for up to max.
12 weeks
. Maintenance,
1.5 g twice daily,
adjusted according to
response (max.
6 g daily)
.
CHILD
under 18 years see
BNF for Children
Colazide
c
(Almirall) A
Capsules
,
beige,
balsalazide sodium 750 mg.
Net
price 130-cap pack = £30.42.
Label:
21,
25, counsel-
ling,
blood disorder symptoms (see recommendation
above)
BNF 61
1.5.1 Aminosalicylates
61
1
Gastro-intestinal system