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Xyloproct
c
(AstraZeneca) A
Ointment
(water-miscible), aluminium acetate 3.5%,
hydrocortisone acetate 0.275%,
lidocaine 5%, zinc
oxide 18%,
net price 20 g (with applicator) = £2.26
Dose
apply several
times daily;
short-term use only
1.7.3
Rectal sclerosants
Oily phenol
injection is used to inject
haemorrhoids
particularly when unprolapsed.
PHENOL
Indications
see notes above
Side-effects
irritation,
tissue necrosis
Oily Phenol Injection, BP A
phenol 5% in a suitable fixed oil. Net price 5-mL amp
= £4.65
Dose
2–3 mL into the submucosal
layer at the base of the pile;
several injections may be given at different sites,
max.
total
injected 10 mL at any one time
1.7.4
Management of anal
fissures
The management
of
anal
fissures
requires stool
soft-
ening by increasing dietary fibre in the form of bran or
by using a bulk-forming laxative. Short-term use of local
anaesthetic preparations
may help (section 1.7.1).
If
these measures are inadequate,
the patient
should be
referred for specialist treatment in hospital. The use of a
topical
nitrate (e.g.
glyceryl
trinitrate 0.4% ointment)
may be considered.
Before considering surgery,
topical
diltiazem 2% may be used twice daily [unlicensed indi-
cation] in patients with chronic anal fissures unrespon-
sive to topical nitrates.
The
Scottish Medicines Consortium
(p.
4) has advised
(January 2008)
that
glyceryl
trinitrate 0.4% ointment
(
Rectogesic
c
) is not recommended for use within NHS
Scotland for the relief
of
pain associated with chronic
anal fissure.
GLYCERYL TRINITRATE
Indications
anal fissure; angina, left ventricular failure
(section 2.6.1);
extravasation (section 10.3)
Cautions
section 2.6.1
Contra-indications
section 2.6.1
Hepatic impairment
section 2.6.1
Renal impairment
section 2.6.1
Pregnancy
section 2.6.1
Breast-feeding
section 2.6.1
Side-effects
section 2.6.1;
also diarrhoea,
burning,
itching,
and rectal bleeding
Dose
. See preparations
Rectogesic
c
(ProStrakan) A
Rectal ointment
,
glyceryl trinitrate 0.4%,
net price
30 g = £34.80
Excipients
include lanolin,
propylene glycol
Dose
ADULT over 18 years, apply 2.5 cm of ointment to anal canal
every 12 hours until pain stops;
max.
duration of use 8 weeks
Note
2.5 cm of
ointment contains glyceryl
trinitrate 1.5 mg;
dis-
card tube 8 weeks after first opening
1.8
Stoma care
Prescribing for patients with stoma calls for special care.
The following is a brief
account
of
some of
the main
points to be borne in mind.
Enteric-coated
and
modified-release
preparations are
unsuitable,
particularly in patients with an ileostomy,
as there may not
be sufficient
release of
the active
ingredient.
Laxatives
Enemas and washouts should not be pre-
scribed for patients with an ileostomy as they may cause
rapid and severe loss of water and electrolytes.
Colostomy patients may suffer from constipation and
whenever possible should be treated by increasing fluid
intake or
dietary fibre.
Bulk-forming drugs (section
1.6.1) should be tried.
If
they are insufficient,
as small
a dose as possible of
senna (section 1.6.2)
should be
used.
Antidiarrhoeals
Drugs such as loperamide, codeine
phosphate,
or
co-phenotrope
(diphenoxylate
with
atropine)
are
effective.
Bulk-forming drugs
(section
1.6.1) may be tried but it is often difficult to adjust the
dose appropriately.
Antibacterials should not be given for an episode of
acute diarrhoea.
Antacids
The tendency to diarrhoea from magnesium
salts
or
constipation from aluminium salts
may be
increased in these patients.
Diuretics
Diuretics should be used with caution in
patients with an ileostomy as they may become exces-
sively dehydrated and potassium depletion may easily
occur.
It is usually advisable to use a potassium-spar-
ing diuretic (see section 2.2.3).
Digoxin
Patients with a stoma are particularly suscep-
tible to hypokalaemia if on digoxin therapy and potas-
sium supplements or a potassium-sparing diuretic may
be advisable (for comment see section 9.2.1.1).
Potassium supplements
Liquid formulations are
preferred to modified-release formulations (see above).
Analgesics
Opioid analgesics (see section 4.7.2) may
cause troublesome constipation in colostomy patients.
When a non-opioid analgesic is required paracetamol is
usually suitable but
anti-inflammatory analgesics may
cause gastric irritation and bleeding.
Iron preparations
Iron preparations may cause loose
stools and sore skin in these patients.
If this is trouble-
some and if iron is definitely indicated an intramuscular
iron preparation (see section 9.1.1.2)
should be used.
Modified-release preparations should be avoided for
the reasons given above.
Care of stoma
Patients are usually given advice about
the use of
cleansing agents
,
protective creams
,
lotions
,
deodorants
, or
sealants
whilst in hospital, either by the
surgeon or by stoma care nurses.
Voluntary organisa-
tions offer help and support to patients with stoma.
BNF 61
1.7.3 Rectal sclerosants
77
1
Gastro-intestinal system