Lansoprazole 01-Aug-2018 l INDICATIONS AND DOSE
9.2 Haemorrhoids
Haemorrhoids
01-Dec-2016Description 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
gStools should be kept soft and easy to pass (to minimise straining) by increasing dietaryfibre andfluid intake. Advice about perianal hygiene is helpful to aid healing and reduce irritation and itching.h
Drug treatment
gIf constipation is reported, it should be treated. A bulk-forming laxative can be prescribed (see Constipation p.53).
A simple analgesic such as paracetamol p.444can 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—seeRelated drugsbelow.gThey 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 beavoided.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.
gTopical corticosteroids are suitable for occasional short-term use (no more than7days) after exclusion of infections (such as perianal streptococcal infection,herpes simplexor 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.
gRecurrent symptoms, should be referred to secondary care for further investigation and management.
Treatments available fromspecialistsinclude rubber band ligation, injection sclerotherapy (using phenol p.95in oil), infrared coagulation/photocoagulation, bipolar diathermy and direct-current electrotherapy, haemorrhoidectomy, stapled haemorrhoidectomy, and haemorrhoidal artery ligation.h
Pregnancy
gBulk forming laxatives are not absorbed, and are therefore safe for use in pregnant women (see Pregnancy,
under Constipation p.53).hNo topical haemorrhoidal preparations are licensed for use during pregnancy.
gIf treatment with a topical haemorrhoidal preparation is required, a soothing preparation containing simple, soothing products (notlocal anaesthetics or corticosteroids) can be considered.h
Related drugs
Topical preparations used for haemorrhoids: lidocaine hydrochloride p.103, benzyl benzoate with bismuth oxide, bismuth subgallate, hydrocortisone acetate, peru balsam and zinc oxide below, cinchocaine hydrochloride with fluocortolone caproate andfluocortolone pivalate p.94, cinchocaine with hydrocortisone p.94, cinchocaine with prednisolone p.94.
CORTICOSTEROIDS
Benzyl benzoate with bismuth oxide, bismuth subgallate, hydrocortisone acetate, peru balsam and zinc oxide
21-Dec-2017
lINDICATIONS AND DOSE Haemorrhoids|Pruritus ani
▶BY RECTUM USING OINTMENT
▶Adult:Apply twice daily for no longer than7days, to be applied morning and night, an additional dose should be applied after a bowel movement
▶BY RECTUM USING SUPPOSITORIES
▶Adult:1suppository twice daily for no longer than 7days, to be inserted night and morning, additional dose after a bowel movement
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC ADMINISTRATION (AUGUST 2017)
See Corticosteroids, general use p.670.
lCAUTIONSLocal anaesthetic component can be absorbed through the rectal mucosa (avoid excessive application, particularly in children and infants)
.
local anaesthetic component may cause sensitisation (use for short periods only—no longer than a few days)lPRESCRIBING AND DISPENSING INFORMATIONA proprietary brandAnusol Plus HC®(ointment and suppositories) is on sale to the public.
lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug.
Ointment
▶Anusol-Hc(Church & Dwight UK Ltd)
Hydrocortisone acetate 2.5 mg per 1 gram, Bismuth oxide 8.75 mg per 1 gram, Benzyl benzoate 12.5 mg per 1 gram, Peru Balsam 18.75 mg per 1 gram, Bismuth subgallate 22.5 mg per 1 gram, Zinc oxide 107.5 mg per 1 gramAnusol HC ointment| 30gramP£2.49
Suppository
▶Anusol-Hc(Church & Dwight UK Ltd)
Hydrocortisone acetate 10 mg, Bismuth oxide 24 mg, Benzyl benzoate 33 mg, Peru Balsam 49 mg, Bismuth subgallate 59 mg, Zinc oxide 296 mgAnusol HC suppositories|12suppositoryP
£1.74
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Cinchocaine hydrochloride with fluocortolone caproate and
fluocortolone pivalate
21-Dec-2017 lINDICATIONS AND DOSEHaemorrhoids|Pruritus ani
▶BY RECTUM USING OINTMENT
▶Adult:Apply twice daily for5–7days, apply3–4times a day if required, on thefirst day of treatment, then apply once daily for a few days after symptoms have cleared
▶BY RECTUM USING SUPPOSITORIES
▶Adult:Initially1suppository daily for5–7days, to be inserted after a bowel movement, then1suppository once daily on alternate days for1week
Haemorrhoids (severe cases)|Pruritus ani (severe cases)
▶BY RECTUM USING SUPPOSITORIES
▶Adult:Initially1suppository2–3times a day for 5–7days, then1suppository once daily on alternate days for1week
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC ADMINISTRATION (AUGUST 2017)
See Corticosteroids, general use p.670.
lCAUTIONSLocal anaesthetic component can be absorbed through the rectal mucosa (avoid excessive application)
.
local anaesthetic component may cause sensitisation (use for short periods only—no longer than a few days) lMEDICINAL FORMSThere can be variation in the licensing of
different medicines containing the same drug.
Ointment
▶Ultraproct(Meadow Laboratories Ltd)
Fluocortolone pivalate 920 microgram per 1 gram, Fluocortolone caproate 950 microgram per 1 gram, Cinchocaine hydrochloride 5 mg per 1 gramUltraproct ointment|30gramP £8.27 Suppository
▶Ultraproct(Meadow Laboratories Ltd)
Fluocortolone pivalate 610 microgram, Fluocortolone caproate 630 microgram, Cinchocaine hydrochloride 1 mgUltraproct suppositories|12suppositoryP £4.06
Cinchocaine with hydrocortisone
21-Dec-2017
lINDICATIONS AND DOSE PROCTOSEDYL®OINTMENT Haemorrhoids|Pruritus ani
▶TO THE SKIN, OR BY RECTUM
▶Child:Apply twice daily, to be administered morning and night and after a bowel movement. Apply externally or by rectum. Do not use for longer than 7days
▶Adult:Apply twice daily, to be administered morning and night and after a bowel movement. Apply externally or by rectum. Do not use for longer than 7days
PROCTOSEDYL®SUPPOSITORIES Haemorrhoids|Pruritus ani
▶BY RECTUM
▶Child 12–17 years:1suppository, insert suppository night and morning and after a bowel movement. Do not use for longer than7days
▶Adult:1suppository, insert suppository night and morning and after a bowel movement. Do not use for longer than7days
UNIROID-HC®OINTMENT Haemorrhoids|Pruritus ani
▶TO THE SKIN, OR BY RECTUM
▶Child 12–17 years:Apply twice daily, and apply after a bowel movement, apply externally or by rectum, do not use for longer than7days
▶Adult:Apply twice daily, and apply after a bowel movement, apply externally or by rectum, do not use for longer than7days
UNIROID-HC®SUPPOSITORIES Haemorrhoids|Pruritus ani
▶BY RECTUM
▶Child 12–17 years:1suppository, insert twice daily and after a bowel movement. Do not use for longer than 7days
▶Adult:1suppository, insert twice daily and after a bowel movement. Do not use for longer than7days
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC ADMINISTRATION (AUGUST 2017)
See Corticosteroids, general use p.670.
lCAUTIONSLocal anaesthetic component can be absorbed through the rectal mucosa (avoid excessive application, particularly in children and infants)
.
local anaesthetic component may cause sensitisation (use for short periods only—no longer than a few days)lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug.
Ointment
▶Proctosedyl(Sanofi)
Cinchocaine hydrochloride 5 mg per 1 gram, Hydrocortisone 5 mg per 1 gramProctosedyl ointment|30gramP£10.34DT =
£10.34
▶Uniroid HC(Chemidex Pharma Ltd)
Cinchocaine hydrochloride 5 mg per 1 gram, Hydrocortisone 5 mg per 1 gramUniroid HC ointment|30gramP £4.23DT = £10.34 Suppository
▶Proctosedyl(Sanofi)
Cinchocaine hydrochloride 5 mg, Hydrocortisone 5 mgProctosedyl suppositories|12suppositoryP£5.08DT =
£5.08
▶Uniroid HC(Chemidex Pharma Ltd)
Cinchocaine hydrochloride 5 mg, Hydrocortisone 5 mgUniroid HC suppositories|12suppositoryP£1.91DT = £5.08
Cinchocaine with prednisolone
21-Dec-2017 lINDICATIONS AND DOSEHaemorrhoids|Pruritus ani
▶BY RECTUM USING OINTMENT
▶Adult:Apply twice daily for5–7days, apply3–4times a day on thefirst day if necessary, then apply once daily for a few days after symptoms have cleared
▶BY RECTUM USING SUPPOSITORIES
▶Adult:1suppository daily for5–7days, to be inserted after a bowel movement
94 Rectal and anal disorders
BNF78Gastro-intestinalsystem
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Haemorrhoids (severe cases)|Pruritus ani (severe cases)
▶BY RECTUM USING SUPPOSITORIES
▶Adult:Initially1suppository2–3times a day, then 1suppository daily for a total of5–7days, to be inserted after a bowel movement
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC ADMINISTRATION (AUGUST 2017)
See Corticosteroids, general use p.670.
lCAUTIONSLocal anaesthetic component can be absorbed through the rectal mucosa (avoid excessive application)
.
local anaesthetic component may cause sensitisation (use for short periods only—no longer than a few days) lMEDICINAL FORMSThere can be variation in the licensing of
different medicines containing the same drug.
Ointment
▶Scheriproct(Bayer Plc)
Prednisolone hexanoate 1.9 mg per 1 gram, Cinchocaine hydrochloride 5 mg per 1 gramScheriproct ointment| 30gramP £3.23DT = £3.23
Suppository
▶Scheriproct(Bayer Plc)
Cinchocaine hydrochloride 1 mg, Prednisolone hexanoate 1.3 mgScheriproct suppositories|12suppositoryP £1.52DT =
£1.52
Hydrocortisone with lidocaine
21-Dec-2017 lINDICATIONS AND DOSEHaemorrhoids|Pruritus ani
▶BY RECTUM USING AEROSOL SPRAY
▶Adult:1spray up to3times a day for no longer than 7days without medical advice, spray once over the affected area
▶BY RECTUM USING OINTMENT
▶Adult:Apply several times daily, for short term use only
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC ADMINISTRATION (AUGUST 2017)
See Corticosteroids, general use p.670.
lCAUTIONSLocal anaesthetic component can be absorbed through the rectal mucosa (avoid excessive application)
.
local anaesthetic component may cause sensitisation (use for short periods only—no longer than a few days) lMEDICINAL FORMSThere can be variation in the licensing of
different medicines containing the same drug.
Ointment
▶Xyloproct(Aspen Pharma Trading Ltd)
Hydrocortisone acetate 2.75 mg per 1 gram, Lidocaine 50 mg per 1 gramXyloproct5%/0.275% ointment|20gramP £4.19DT =
£4.19 Spray
▶Perinal(Dermal Laboratories Ltd)
Hydrocortisone 2 mg per 1 gram, Lidocaine hydrochloride 10 mg per 1 gramPerinal spray|30mlp £6.11
Hydrocortisone with pramocaine
21-Dec-2017
lINDICATIONS AND DOSE Haemorrhoids|Proctitis
▶BY RECTUM
▶Adult:1applicatorful2–3times a day and
1applicatorful, after a bowel movement, do not use for longer than7days; maximum4applicatorfuls per day
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC ADMINISTRATION (AUGUST 2017)
See Corticosteroids, general use p.670.
lCAUTIONSLocal anaesthetic component can be absorbed through the rectal mucosa (avoid excessive application)
.
local anaesthetic component may cause sensitisation (use for short periods only—no longer than a few days) lMEDICINAL FORMSNo licensed medicines listed.
SCLEROSANTS
Phenol
lINDICATIONS AND DOSE
Haemorrhoids (particularly when unprolapsed)
▶BY SUBMUCOSAL INJECTION
▶Adult:2–3mL, dose (using phenol5%) to be injected into the submucosal layer at the base of the pile;
several injections may be given at different sites, max.
total injected10mL at any one time
lSIDE-EFFECTSAbdominal sepsis
.
abscess.
dizziness.
erectile dysfunction
.
fever.
hepatitis.
increased risk of infection.
injection site necrosis.
ulcer.
urinary disorders lPRESCRIBING AND DISPENSING INFORMATIONWhenprepared extemporaneously, the BP states Oily Phenol Injection, BP consists of phenol5% in a suitablefixed oil.
lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: solution for injection
Solution for injection
▶Phenol (Non-proprietary)
Phenol 50 mg per 1 mlOily phenol5% solution for injection5ml ampoules|10ampouleP £70.31DT = £70.31
10 Reduced exocrine secretions
Exocrine pancreatic insufficiency
14-Dec-2016
Description of condition
Exocrine pancreatic insufficiency is characterised by reduced secretion of pancreatic enzymes into the duodenum.
The main clinical manifestations are maldigestion and malnutrition, associated with low circulating levels of micronutrients, fat-soluble vitamins and lipoproteins.
Patients also present with gastro-intestinal symptoms such as diarrhoea, abdominal cramps and steatorrhoea.
Exocrine pancreatic insufficiency can result from chronic pancreatitis, cysticfibrosis, obstructive pancreatic tumours,
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coeliac disease, Zollinger-Ellison syndrome, and gastro-intestinal or pancreatic surgical resection.
Aims of treatment
The aim of treatment is to relieve gastro-intestinal symptoms and to achieve a normal nutritional status.
Drug treatment
Pancreatic enzyme replacement therapy with pancreatin below is the mainstay of treatment for exocrine pancreatic insufficiency.
Pancreatin contains the three main groups of digestive enzymes: lipase, amylase and protease. These enzymes respectively digest fats, carbohydrates and proteins into their basic components so that they can be absorbed and utilised by the body.gPancreatin should be administered with meals and snacks. The dose should be adjusted, as necessary, to the lowest effective dose according to the symptoms of maldigestion and malabsorption.h
Fibrosing colonopathy has been reported in patients with cysticfibrosis taking high dose pancreatic enzyme replacement therapy (in excess of10 000units/kg/day of lipase). Possible risk factors are gender (in children, boys are at greater risk than girls), more severe cysticfibrosis, and concomitant use of laxatives. The peak age for developing fibrosing colonopathy is between2and8years.
Manufacturers ofPancrease HL®andNutrizym22® recommend that the total dose of pancreatin used in patients with cysticfibrosis should not usually exceed 10 000units/kg/day of lipase. Manufacturers of pancreatin recommend that if a patient taking pancreatin develops new abdominal symptoms (or any change in existing abdominal symptoms) the patient should be reviewed to exclude the possibility of colonic damage.
There is limited evidence that acid suppression may improve the effectiveness of pancreatin.g Acid-suppressing drugs (proton pump inhibitors or H2-receptor antagonists) may be trialled in patients who continue to experience symptoms despite high doses of pancreatin.
Levels of fat-soluble vitamins and micronutrients (such as zinc and selenium) should be routinely assessed and supplementation advised whenever necessary.h
Pancreatin preparations
Preparation Protease
units
Amylase units
Lipase units Creon®10 000capsule, e/c
granules 600 8000 10 000
Creon®Micro e/c granules (per
100mg) 200 3600 5000
Pancrex®granules (per gram) 300 4000 5000 Pancrex V®capsule, powder 430 9000 8000 Pancrex V‘125’®capsule, powder 160 3300 2950
Pancrex V®e/c tablet 110 1700 1900
Pancrex V®Forte e/c tablet 330 5000 5600 Pancrex V®powder (per gram) 1400 30 000 25 000
Higher-strength pancreatin preparations
Preparation Protease
units
Amylase units
Lipase units Creon®25 000capsule, e/c pellets 1000 18 000 25 000 Creon®40000capsule, e/c granules1600 25 000 40 000 Nutrizym22®capsule, e/c
minitablets 1100 19 800 22 000
Pancrease HL®capsule, e/c
minitablets 1250 22 500 25 000
Non-drug treatment
gDietary advice should be provided. Food intake should be distributed between three main meals per day, and two or three snacks. Food that is difficult to digest should be avoided, such as legumes (peas, beans, lentils) and high-fibre foods. Alcohol should be avoided completely. Reduced fat diets are not recommended.h
Medium-chain triglycerides (see MCT oil, inBorderline substances), which are directly absorbed by the intestinal mucosa, were thought to be useful in some patients.
However evidence has shown that MCT-enriched preparations offer no advantage over a normal balanced diet.
PANCREATIC ENZYMES
Pancreatin
08-Mar-2017lDRUG ACTIONSupplements of pancreatin are given to compensate for reduced or absent exocrine secretion. They assist the digestion of starch, fat, and protein.
lINDICATIONS AND DOSE CREON®10000 Pancreatic insufficiency
▶BY MOUTH
▶Child:Initially1–2capsules, dose to be taken with each meal either taken whole or contents mixed with acidic fluid or soft food (then swallowed immediately without chewing)
▶Adult:Initially1–2capsules, dose to be taken with each meal either taken whole or contents mixed with acidicfluid or soft food (then swallowed immediately without chewing)
CREON®25000 Pancreatic insufficiency
▶BY MOUTH
▶Child 2–17 years:Initially1–2capsules, dose to be taken with each meal either taken whole or contents mixed with acidicfluid or soft food (then swallowed immediately without chewing)
▶Adult:Initially1–2capsules, dose to be taken with each meal either taken whole or contents mixed with acidicfluid or soft food (then swallowed immediately without chewing)
CREON®40000 Pancreatic insufficiency
▶BY MOUTH
▶Child 2–17 years:Initially1–2capsules, dose to be taken with each meal either taken whole or contents mixed with acidicfluid or soft food (then swallowed immediately without chewing)
▶Adult:Initially1–2capsules, dose to be taken with each meal either taken whole or contents mixed with acidicfluid or soft food (then swallowed immediately without chewing)
CREON®MICRO Pancreatic insufficiency
▶BY MOUTH
▶Child:Initially100mg, for administration advice, see Directions for administration
▶Adult:Initially100mg, for administration advice, see Directions for administration
DOSE EQUIVALENCE AND CONVERSION
▶ForCreon®Micro:100mg granules = one measured scoopful (scoop supplied with product).
96 Reduced exocrine secretions
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NUTRIZYM 22®GASTRO-RESISTANT CAPSULES