Dyspepsia
Overview
Dyspepsia covers upper abdominal pain, fullness, early satiety, bloating, and nausea. It can occur with gastric and duodenal ulceration, gastro-oesophageal reflux disease, gastritis, and upper gastro-intestinal motility disorders, but most commonly it is of uncertain origin.
Patients with dyspepsia should be advised about lifestyle changes (avoidance of excess alcohol and of aggravating foods such as fats); other measures include weight reduction, smoking cessation, and raising the head of the bed. Some medications may cause dyspepsia—these should be stopped, if possible.
A compound alginate preparation may provide relief from dyspepsia; persistent dyspepsia requires investigation.
Treatment with a H2-receptor antagonist or a proton pump inhibitor should be initiated only on the advice of a hospital specialist.
Helicobacter pylorimay be present in children with dyspepsia.H. pylorieradication therapy should be considered for persistent dyspepsia if it is ulcer-like. However, most children with functional (investigated, non-ulcer) dyspepsia do not benefit symptomatically fromH. pylorieradication.
ANTACIDS
Antacids
Overview
Antacids (usually containing aluminium or magnesium compounds) can often relieve symptoms inulcer dyspepsia and innon-erosive gastro-oesophageal reflux; they are also sometimes used in functional (non-ulcer) dyspepsia but the evidence of benefit is uncertain.
Aluminium- andmagnesium-containing antacids, 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.
Complexes such ashydrotalciteconfer no special advantage.
Calcium-containingantacids can induce rebound acid secretion; with modest doses the clinical significance of this is doubtful, but prolonged high doses also cause
hypercalcaemia and alkalosis.
Simeticone
Simeticone (activated dimeticone p.48) is used to treat infantile colic, but the evidence of benefit is uncertain.
Simeticone is added to an antacid as an antifoaming agent to relieveflatulence. These preparations may be useful for the relief of hiccup in palliative care.
Alginates
Alginatestaken in combination with an antacid increases the viscosity of stomach contents and can protect the oesophageal mucosa from acid reflux. Some alginate-containing preparations form a viscous gel (‘raft’) thatfloats on the surface of the stomach contents, thereby reducing symptoms of reflux. Alginate-containing preparations are
used in the management of mild symptoms of dyspepsia and gastro-oesophageal reflux disease.
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
›
ALGINATEAlginic acid
lINDICATIONS AND DOSE GAVISCON INFANT®POWDER SACHETS
Management of gastro-oesophageal reflux disease
▶BY MOUTH
▶Neonate (body-weight up to 4.5 kg):1dose as required, to be mixed with feeds (or water, for breast-fed infants);
maximum6doses per day.
▶Neonate (body-weight 4.5 kg and above):2doses as required, to be mixed with feeds (or water, for breast-fed infants); maximum12doses per day.
▶Child 1–23 months (body-weight up to 4.5 kg): 1dose as required, to be mixed with feeds (or water, for breast-fed infants); maximum6doses per day
▶Child 1–23 months (body-weight 4.5 kg and above):2doses as required, to be mixed with feeds (or water, for breast-fed infants); maximum12doses per day lCONTRA-INDICATIONSIntestinal obstruction
.
pretermneonates
.
where excessive water loss likely (e.g. fever, diarrhoea, vomiting, high room temperature) lINTERACTIONS→Appendix1(antacids).Not to be used with other preparations containing thickening agents.
Antacids should preferably not be taken at the same time as other drugs since they may impair absorption.
Antacids may damage enteric coatings designed to prevent dissolution in the stomach.
lHEPATIC IMPAIRMENTIn patients withfluid retention, avoid antacids containing large amounts of sodium. Avoid antacids containing magnesium salts in hepatic coma if there is a risk of renal failure.
lRENAL IMPAIRMENTIn patients withfluid retention, avoid antacids containing large amounts of sodium.
lPRESCRIBING AND DISPENSING INFORMATIONEach half of the dual-sachet is identified as‘one dose’.
To avoid errors prescribe with directions in terms of
‘dose’. lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Powder
ELECTROLYTES:May contain Sodium
▶Gaviscon Infant(Forum Health Products Ltd)
Magnesium alginate 87.5 mg, Sodium alginate 225 mgGaviscon Infant oral powder sachets sugar-free|15dual dose sachetG
£4.39
Gastro-intestinalsystem
1
Sodium alginate with potassium bicarbonate
The properties listed below are those particular to the combination only. For the properties of the components please consider, alginic acid p.46.
lINDICATIONS AND DOSE
Management of mild symptoms of dyspepsia and gastro-oesophageal reflux disease
▶BY MOUTH USING CHEWABLE TABLETS
▶Child 6–11 years (under medical advice only):1tablet, to be chewed after meals and at bedtime
▶Child 12–17 years:1–2tablets, to be chewed after meals and at bedtime
▶BY MOUTH USING ORAL SUSPENSION
▶Child 2–11 years (under medical advice only):2.5–5mL, to be taken after meals and at bedtime
▶Child 12–17 years:5–10mL, to be taken after meals and at bedtime
lPRESCRIBING AND DISPENSING INFORMATIONFlavours of oral liquid formulations may include aniseed or peppermint.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Chewable tablet
EXCIPIENTS:May contain Aspartame ELECTROLYTES:May contain Potassium, sodium
▶Sodium alginate with potassium bicarbonate (Non-proprietary) Potassium bicarbonate 100 mg, Sodium alginate 500 mgSodium alginate500mg / Potassium bicarbonate100mg chewable tablets sugar free sugar-free|60tabletG no price available DT price =
£3.07
▶Brands may include Gaviscon Advance Oral suspension
ELECTROLYTES:May contain Potassium, sodium
▶Gaviscon Advance(Reckitt Benckiser Healthcare (UK) Ltd) Potassium bicarbonate 20 mg per 1 ml, Sodium alginate 100 mg per 1 mlGaviscon Advance oral suspension aniseed sugar-free| 150mlp £3.23sugar-free|300mlp £5.82
Gaviscon Advance oral suspension peppermint sugar-free|300mlp
£5.82
ANTACIDS
›
ALUMINIUM AND MAGNESIUMCo-magaldrox
The properties listed below are those particular to the combination only. For the properties of the components please consider, aluminium hydroxide p.558, magnesium hydroxide p.39.
lINDICATIONS AND DOSE MAALOX®
Dyspepsia
▶BY MOUTH
▶Child 14–17 years:10–20mL, to be taken20–60minutes after meals, and at bedtime or when required MUCOGEL®
Dyspepsia
▶BY MOUTH
▶Child 12–17 years:10–20mL3times a day, to be taken 20–60minutes after meals, and at bedtime, or when required
lPRESCRIBING AND DISPENSING INFORMATION Co-magaldrox is a mixture of aluminium hydroxide and magnesium hydroxide; the proportions are expressed in the form x/y where x and y are the strengths in milligrams per unit dose of magnesium hydroxide and aluminium hydroxide respectively.
MUCOGEL®Mucogel®suspension is low in sodium.
MAALOX®Maalox®suspension is low in sodium.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Maalox(Sanofi)
Magnesium hydroxide 39 mg per 1 ml, Aluminium hydroxide gel dried 44 mg per 1 mlMaalox oral suspension sugar-free| 500mlG£3.35
▶Mucogel(Chemidex Pharma Ltd)
Magnesium hydroxide 39 mg per 1 ml, Aluminium hydroxide gel dried 44 mg per 1 mlMucogel oral suspension sugar-free| 500mlG£2.99
Co-simalcite
lINDICATIONS AND DOSE Dyspepsia
▶BY MOUTH
▶Child 8–11 years:5mL4times a day as required, to be taken between meals and at bedtime
▶Child 12–17 years:10mL4times a day as required, to be taken between meals and at bedtime
lCONTRA-INDICATIONSHypophosphataemia
.
infants.
neonates
CONTRA-INDICATIONS, FURTHER INFORMATION
▶Aluminium-containing antacidsAluminium-containing antacids should not be used in neonates and infants because accumulation may lead to increased plasma-aluminium concentrations.
lINTERACTIONS→Appendix1(antacids).
Antacids should preferably not be taken at the same time as other drugs since they may impair absorption.
Antacids may damage enteric coatings designed to prevent dissolution in the stomach.
lSIDE-EFFECTS
SIDE-EFFECTS, FURTHER INFORMATION
▶Constipation and diarrhoeaMagnesium-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.
lHEPATIC IMPAIRMENTAvoid; can cause constipation which can precipitate coma. Avoid in hepatic coma; risk of renal failure.
lRENAL IMPAIRMENTAntacids containing magnesium salts should be avoided or used at a reduced dose because there is an increased risk of toxicity. Aluminium-containing antacids should not be used in children with renal impairment, because accumulation may lead to increased plasma-aluminium concentrations.
lPRESCRIBING AND DISPENSING INFORMATIONAltacite Plus®is low in Na+.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Altacite Plus(Peckforton Pharmaceuticals Ltd)
Simeticone 25 mg per 1 ml, Hydrotalcite 100 mg per 1 mlAltacite Plus oral suspension sugar-free|100mlp£4.00sugar-free| 500mlp£5.20DT price = £5.20
BNFC2016–2017
Dyspepsia 47
Gastro-intestinalsystem
1
Simeticone with aluminium hydroxide and magnesium hydroxide
The properties listed below are those particular to the combination only. For the properties of the components please consider, simeticone below, aluminium hydroxide p.558.
lINDICATIONS AND DOSE Dyspepsia
▶BY MOUTH
▶Child 2–4 years:5mL3times a day
▶Child 5–11 years:5–10mL3–4times a day
▶Child 12–17 years:5–10mL4times a day, to be taken after meals and at bedtime, or when required
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Maalox Plus(Sanofi)
Simeticone 5 mg per 1 ml, Magnesium hydroxide 39 mg per 1 ml, Aluminium hydroxide gel dried 44 mg per 1 mlMaalox Plus oral suspension sugar-free|500mlG £3.90
ANTACIDS
›
MAGNESIUMMagnesium trisilicate with magnesium carbonate and sodium bicarbonate
The properties listed below are those particular to the combination only. For the properties of the components please consider, sodium bicarbonate p.544.
lINDICATIONS AND DOSE Dyspepsia
▶BY MOUTH
▶Child 5–11 years:5–10mL3times a day, alternatively as required, dose to be made up with water
▶Child 12–17 years:10–20mL3times a day, alternatively as required, dose to be made up with water
lCONTRA-INDICATIONSHypophosphataemia
.
Severe renal failurelCAUTIONSHeart failure
.
hypermagnesaemia.
hypertension
.
metabolic alkalosis.
respiratory alkalosis lINTERACTIONS→Appendix1(antacids).Antacids should preferably not be taken at the same time as other drugs since they may impair absorption.
Antacids may damage enteric coatings designed to prevent dissolution in the stomach.
lSIDE-EFFECTSBelching due to liberated carbon dioxide
.
diarrhoea
lHEPATIC IMPAIRMENTIn patients withfluid retention avoid antacids containing large amounts of sodium. Avoid antacids containing magnesium salts in hepatic coma if there is a risk of renal failure.
lRENAL IMPAIRMENT Magnesium trisilicate and
magnesium carbonate mixtures have high sodium content;
avoid in patients withfluid retention.
lPRESCRIBING AND DISPENSING INFORMATIONWhen prepared extemporaneously, the BP states Magnesium Trisilicate Mixture, BP consists of5% each of magnesium trisilicate, light magnesium carbonate, and sodium bicarbonate in a suitable vehicle with a peppermint flavour.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Magnesium trisilicate with magnesium carbonate and sodium bicarbonate (Non-proprietary)
Magnesium carbonate light 50 mg per 1 ml, Magnesium trisilicate 50 mg per 1 ml, Sodium bicarbonate 50 mg per 1 mlMagnesium trisilicate oral suspension|200mlG£1.50DT price = £1.50 ANTIFOAMING DRUGS
Simeticone
(Activated dimeticone)
lDRUG ACTIONSimeticone (activated dimeticone) is an antifoaming agent.
lINDICATIONS AND DOSE DENTINOX®
Colic|Wind pains
▶BY MOUTH
▶Neonate:2.5mL, to be taken with or after each feed; may be added to bottle feed; maximum6doses per day.
▶Child 1 month–1 year:2.5mL, to be taken with or after each feed; may be added to bottle feed; maximum 6doses per day
INFACOL® Colic|Wind pains
▶BY MOUTH
▶Neonate:0.5–1mL, to be taken before feeds.
▶Child 1 month–1 year:0.5–1mL, to be taken before feeds lPRESCRIBING AND DISPENSING INFORMATION
DENTINOX®The brand nameDentinox®is also used for other preparations including teething gel.
lPATIENT AND CARER ADVICE
INFACOL® Patients or carers should be given advice on use of theInfacol®dropper.
lLESS SUITABLE FOR PRESCRIBING
INFACOL® Infacol®is less suitable for prescribing (evidence of benefit in infantile colic uncertain).
DENTINOX®Dentinox®colic drops are less suitable for prescribing (evidence of benefit in infantile colic uncertain).
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Infacol(Forest Laboratories UK Ltd)
Simeticone 40 mg per 1 mlInfacol40mg/ml oral suspension sugar-free|50mlG£2.71DT price = £2.71
Oral drops
▶Dentinox Infant(Dendron Ltd)
Simeticone 8.4 mg per 1 mlDentinox Infant colic drops| 100mlG£1.73
Combinations available:Simeticone with aluminium hydroxide and magnesium hydroxide,above
Gastro-intestinalsystem