Gastroenterology Case No 4.case of IBS Antidepressants-1.

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Gastroenterology Case No 4.case of IBS Antidepressants-1.

IBS এর মুল কারন হচ্ছে Stress!! তাই Stress এর জন্য Antidepressant দেয়া হয়IBS যেহেতু Stress এর জন্য হয়ে থাকে ,তাই কাদের কোন Antidepressants দেয়া যেতে পারে চলুন যেনে নেই,

IBS কে আমরা ৩ ভাবে ভাগ করতে পারি…

IBS- type C ( Constipation)

lBS-Type D (Diarrhoea)

IBS mixed( Type C & D ) both!!

তবে 1&2 ই বেশি দেখা যায়!!

Depression এ constipation থাকতে পারে; আর Anxiety তে Diarrhoea হতে পারে!

IBS নিয়ে গ্রুপে Informative Article লিখা আছে; তাই আজকে শুধু কথা বলবো Role of Antidepressant in IBS &

Choice_of_Antidepressants_In_IBS

So trtmnt

প্রথমত Discipline

2…Diet

3. Drug

1st ২ টা (Discipline & diet) এতেই Patient অনেকটা সুস্থ হয়ে যায় ,অনেক Patient!! Triggering food must b avoid.

IBS-C তে হিসেবে Antidepressant হিসেবে আমরা SSRI Clomipramine hydrochloride // Duloxetine**দিতে পারি! কারন এর Anticholinergic Effect কম যার ফলে আলাদা Constipation বাড়ানোর chance থাকে না!!

Tablet 1:-Diliner DR 60Mg AS A Duloxetine Hydrochloride Serotonin-norepinephrine reuptake inhibitor (SNRI) (1+0+0)—

Indications of Tablet :-Diliner DR 60Mg AS A Duloxetine Hydrochloride Serotonin-norepinephrine reuptake inhibitor (SNRI):-

Diliner DR is a serotonin and norepinephrine reuptake inhibitor (SNRI) indicated for-

Major Depressive Disorder (MDD)
Generalized Anxiety Disorder (GAD)
Diabetic Peripheral Neuropathic Pain (DPNP)
Fibromyalgia and
Chronic Musculoskeletal Pain.

Pharmacology of Tablet :-Diliner DR 60Mg AS A Duloxetine Hydrochloride Serotonin-norepinephrine reuptake inhibitor (SNRI):-

Duloxetine Hydrochloride is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) for oral administration. Duloxetine is a less potent inhibitor of dopamine reuptake. Duloxetine has no significant affinity for dopaminergic, adrenergic, cholinergic, histaminergic, opioid, glutamate, and GABA receptors in vitro. Duloxetine does not inhibit monoamine oxidase (MAO). Orally administered Duloxetine hydrochloride is well absorbed. Elimination of Duloxetine is mainly through hepatic metabolism.

Dosage & Administration of Tablet :-Diliner DR 60Mg AS A Duloxetine Hydrochloride Serotonin-norepinephrine reuptake inhibitor (SNRI):-

Major Depressive Disorder (MDD)-

Starting Dose: 40 mg/day to 60 mg/day
Target Dose: Acute: 40 mg/day (20 mg twice daily) to 60 mg/day (once daily or as 30 mg twice daily); Maintenance: 60 mg/day
Maximum Dose: 120 mg/day

Generalized Anxiety Disorder (GAD)-

Starting Dose: 60 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 120 mg/day

Diabetic Peripheral Neuropathic Pain (DPNP)-

Starting Dose: 60 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 60 mg/day

Fibromyalgia-

Starting Dose: 30 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 60 mg/day

Chronic Musculoskeletal Pain-

Starting Dose: 30 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 60 mg/day

Some patients may benefit from starting at 30 mg once daily. There is no evidence that doses greater than 60 mg/day confers an additional benefit, while some adverse reactions were observed to be dose-dependent. A gradual dose reduction is recommended to avoid discontinuation symptoms.

Side Effects of Tablet :-Diliner DR 60Mg AS A Duloxetine Hydrochloride Serotonin-norepinephrine reuptake inhibitor (SNRI):-

The most commonly observed adverse events in Diliner DR treated patients were nausea, dizziness, dry mouth, constipation, decreased appetite, fatigue, somnolence, increased sweating, hyperhidrosis and asthenia. It may slightly increase blood pressure. No clinically significant differences were observed for QT, PR, and QRS intervals between Diliner DR-treated and placebo-treated patients.

Month or Timex * OR

Tablet 2. Timex 25 mg (As a Clomipramine Hydrochloride Tricyclic & related anti-depressant drugs).

Indications of Tablet:-Timex 25 mg (As a Clomipramine Hydrochloride Tricyclic & related anti-depressant drugs):-

Timex is used to treat-

Obsessive Compulsive Disorder (OCD)
Major Depressive Disorder (MDD)
Depression.

Pharmacology Tablet :- Timex 25 mg (As a Clomipramine Hydrochloride Tricyclic & related anti-depressant drugs).

Clomipramine Hydrochloride is an original tricyclic antidepressant, a member of the dibenzazepine group of compounds. It is presumed to influence obsessive and compulsive behaviors through it’s effects on serotonergic neuronal transmission. The actual neurochemical mechanism is unknown but it has the capacity to inhibit the reuptake of serotonin (5-HT) which is thought to be important (like obsessions, compulsion) thus hampers social acquaintance.

Side Effects of Tablet :- Timex 25 mg (As a Clomipramine Hydrochloride Tricyclic & related anti-depressant drugs):-

The most frequent side effects are gastrointestinal disturbances, Headache, dizziness, nausea, constipation, dry mouth, increased sweating, shaking hands, tremor, difficulty in passing urine, problems with their eyes, feeling tired or sleepy, sexual disturbance, restlessness

Therapeutic Class of Tablet :- Timex 25 mg (As a Clomipramine Hydrochloride Tricyclic & related anti-depressant drugs):-

Tricyclic & related anti-depressant drugs

Pain থাকলে Meverine hydrochloride (Rostil) & Alverine (Alve) দিতে পারি!!!(Both IBs-c&D)For prevent Constipation আমরা laxative দিতে পারি

Tablet 3:-Rostil 135 mg (Mebeverine Hydrochloride AS A Anticholinergics).

Indications of Tablet :-Rostil 135 mg (Mebeverine Hydrochloride AS A Anticholinergics).

Rostil is indicated for the:

Symptomatic treatment of irritable bowel syndrome (IBS)
Chronic irritable colon
Spastic constipation
Mucous colitis
Colicky abdominal pain
Persistent non-specific diarrhoea

Description of Tablet :-Rostil 135 mg (Mebeverine Hydrochloride AS A Anticholinergics).

Rostil is a musculotropic antispasmodic agent used to relieve cramps or spasms of the stomach and intestine (gut). It is particularly useful in treating irritable bowel syndrome (IBS) and similar conditions. It works by relaxing the muscles and helping restore the normal movement of the gut.

Dosage & Administration of Tablet :-Rostil 135 mg (Mebeverine Hydrochloride AS A Anticholinergics).

For adults, elderly and children over 10 years:

Mebeverine Hydrochloride 135 mg tablet: 1 tablet 03 times daily.
Mebeverine Hydrochloride 200 mg capsule: 1 capsule 02 times daily.

This is most effective when taken 20 minutes before meals. After several weeks when the desired effect has been obtained, the dosage may be gradually reduced.

Missed dose: If a dose of this medicine is missed, that should be taken as soon as possible. However, if it is almost time for the next dose, then skip the missed dose and the regular dosing schedule should be maintained. Dose should not be doubled at the same time to compensate the missed dose.

Use in children: Mebeverine is not recommended for children under 10 years.

Side Effects of Tablet :-Rostil 135 mg (Mebeverine Hydrochloride AS A Anticholinergics).

Generally Rostil is well tolerated. However, few side-effects like skin rash, urticaria and angioedema may appear

Tablet 3:-Alve 60 mg (As a Alverine Citrate As a Anticholinergics).

Indications of Tablet :-Alve 60 mg (As a Alverine Citrate As a Anticholinergics).

Alve is indicated in-

Irritable Bowel Syndrome
Bowel movement disturbances caused by small sacs or pouches in the wall of the gut (diverticular disease)
Abdominal pain associated with menstrual periods (Primary dysmenorrhea)
Relief of other conditions associated with spasm of involuntary muscle

Pharmacology of Tablet :-Alve 60 mg (As a Alverine Citrate As a Anticholinergics).

Alverine Citrate is a smooth muscle relaxant. Smooth muscle is a type of muscle that is not under voluntary control; it is the muscle present in places such as the gut and uterus. Alverine Citrate acts directly on the muscle in the gut, causing it to relax. This prevents the muscle spasm which occur in the gut in conditions such as irritable bowel syndrome and diverticular disease. Alverine Citrate also relaxes the smooth muscle in the uterus. It is therefore also used to treat painful menstruation, which is caused by muscle spasm in the uterus (dysmenorrhea).

Side Effects of Tablet :-Alve 60 mg (As a Alverine Citrate As a Anticholinergics).

Possible side effects may include nausea, headache, dizziness, itching, rash and allergic reactions.

Dosage & Administration of Tablet :-Alve 60 mg (As a Alverine Citrate As a Anticholinergics).

Adult: Orally: 60-120 mg 1-3 times daily.

Laxative hisebe amra dite pari

Tablet 4:-Ezylife 10 mg (As a Sodium Picosulfate Stimulant Laxative).

Indications of Tablet :-Ezylife 10 mg (As a Sodium Picosulfate Stimulant Laxative).

Ezylife is indicated in the following conditions-

Constipation of any etiology
Relief from prolonged & recurrent constipation
Bowel clearance before surgery, childbirth or radiological investigations.

Pharmacology of Tablet :-Ezylife 10 mg (As a Sodium Picosulfate Stimulant Laxative).

Sodium Picosulfate is a triarylmethane group derivative stimulant laxative. After oral administration it is activated by the colonic bacteria and acts locally in the colon. The active form then stimulates the nerve endings of the intestinal wall and results in colonic peristalsis with promotion of accumulation of water and electrolytes in the colonic lumen. This results in stimulation of defecation, reduction of transit time and softening of the stool. Stimulation of the rectum causes increased motility and a feeling of rectal fullness. The rectal effect may help to restore the “call to stool”.

Dosage & Administration of Tablet :-Ezylife 10 mg (As a Sodium Picosulfate Stimulant Laxative).

For oral administration. The following dosages are recommended to be taken at night to produce evacuation the following morning. It is recommended to start with the lowest dose. The dose may be adjusted up to the maximum recommended dose to produce regular stools. The maximum recommended daily dose should not be exceeded:

10 mg tablet dose:

Adults and children over 10 years of age: 5-10 mg per day.
Children aged 4-10 years: 2.5-5 mg per day.

Oral Solution (5 mg/5 ml) dose:

Adults and children over 10 years of age: 5-10 ml or one to two teaspoonful per day.
Children aged 4-10 years: 2.5-5 ml or half to one teaspoonful per day.
Children from One month to 4 years of age: 0.25 ml/kg body weight per day.

Concentrated Oral Solution (7.5 mg/ml) dose:

Adults and children over 10 years of age: 0.67-1.33 ml per day.
Children aged 4-10 years: 0.33-0.67 ml per day.

Side Effects of Tablet :-Ezylife 10 mg (As a Sodium Picosulfate Stimulant Laxative).

Hypersensitivity, dizziness, syncope, vasovagal response, gastrointestinal disorders, diarrhea, abdominal pain and abdominal cramps, nausea, vomiting.

IBS type D te antidepressants হিসেবে TCA (Amitriptylin) দিতে পারি.. কারন এর AntiCholinergic Effect আছে ;;যার জন্য Constipation করতে পারে;;এতে Diarrhoea এর frequency কমবে!!!

Amitriptyline (0+0+1)—3 month(evening)

Tablet 5:-Amilin 25 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant.)

Indications of Tablet :-Amilin 25 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant.)

Indications

Amilin is indicated in-

Depressive Illness: particularly where sedation is required.
Nocturnal Enuresis in children.
Prophylaxis of Migraine.
Tension Headache.
Chronic Pain.

Pharmacology of Tablet :-Amilin 25 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant.)

The mechanism of action of this drug is not fully elucidated. It is suggested that amitriptyline inhibits the membrane pump mechanism responsible for the re-uptake of transmitter amines, such as norepinephrine and serotonin, thereby increasing their concentration at the synaptic clefts of the brain. These amines are important in regulating mood. The monoamine hypothesis in depression, one of the oldest hypotheses, postulates that deficiencies of serotonin (5-HT) and/or norepinephrine (NE) neurotransmission in the brain lead to depressive effects. This drug counteracts these mechanisms, and this may be the mechanism of amitriptyline in improving depressive symptoms. Whether its analgesic effects are related to its mood-altering activities or attributable to a different, less obvious pharmacological action (or a combination of both) is unknown.

Dosage & Administration of Tablet :-Amilin 25 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant.)

Depression: Initially 75 mg (Elderly and Adolescents 30-75 mg) daily in divided doses or as a single dose at bedtime increased gradually as necessary to 150-200 mg; Child under 16 years not recommended for depression.

Nocturnal Enuresis: Child 7-10 years: 10-20 mg, 11-16 years: 25-50 mg at night; max. period of treatment (including gradual withdrawal) 3 months-full physical examination before the further course.

Prophylaxis of Migraine: 100 mg daily.

Tension Headache: 10-25 mg three times daily.

Side Effects of Tablet :-Amilin 25 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant.)

Anticholinergic: Excessive perspiration, dry mouth, blurred vision, hyperpyrexia, urinary retention and urinary tract dilatation.
Cardiovascular reactions: Hypotension, syncope, postural hypotension, hypertension, tachycardia, palpitations, myocardial infarction, etc.
CNS and Neuromuscular: Confusional states, disturbed concentration, disorientation, delusions, etc.
Allergic: Skin rash, urticaria, photosensitization, etc.
Haematological: Bone-marrow depression.
Gastrointestinal: Nausea, epigastric distress, vomiting, anorexia, stomatitis, unpleasant taste, weight loss, diarrhoea, constipation, etc.
Endocrine: Testicular swelling, gynaecomastia, breast enlargement, galactorrhoea, etc.

এছাড়া IBS-D te Ondasatron (Emistat) ম্যাজিক এর মতো Diarrhoea কে কমিয়ে দেয়!!

কষ্ট করে পড়ার জন্য ধন্যবাদ

Tablet 6. Emistat 8mg (As a Ondansetron AS A Anti-emetic drugs).

Indications of Tablet:-Emistat 8mg (As a Ondansetron AS A Anti-emetic drugs).

Emistat is a serotonin subtype 3 (5-HT3) receptor antagonist indicated:

Prevention of nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy.
Prevention and treatment of post-operative nausea and vomiting.
Prevention of radiotherapy-induced nausea and vomiting.

Description of Tablet:-Emistat 8mg (As a Ondansetron AS A Anti-emetic drugs).

Emistat oral soluble film is a orally dissolving film designed to be applied on top of the tongue where it will dissolve within 20 seconds and then is swallowed with saliva. Oral soluble film does not require water to aid dissolution or swallowing. The active ingredient in Emistat is Emistat base, the racemic form of Emistat, and a selective blocking agent of the serotonin 5-HT3 receptor type. The empirical formula is C₁₈H₁₉N₃O representing a molecular weight of 293.3.

Pharmacology of Tablet:-Emistat 8mg (As a Ondansetron AS A Anti-emetic drugs).

Ondansetron is a potent, highly selective 5HT₃ receptor-antagonist. Its precise mode of action in the control of nausea and vomiting is not known. Chemotherapeutic agents and radiotherapy may cause release of 5HT in the small intestine initiating a vomiting reflex by activating vagal afferents via 5HT₃ receptors. Ondansetron blocks the initiation of this reflex. Activation of vagal afferents may also cause a release of 5HT in the area postrema, located on the floor of the fourth ventricle, and this may also promote emesis through a central mechanism. Thus, the effect of ondansetron in the management of the nausea and vomiting induced by cytotoxic chemotherapy and radiotherapy is probably due to antagonism of 5HT₃ receptors on neurons located both in the peripheral and central nervous system. The mechanisms of action in post-operative nausea and vomiting are not known but there may be common pathways with cytotoxic induced nausea and vomiting.

Dosage of Tablet:-Emistat 8mg (As a Ondansetron AS A Anti-emetic drugs).

Chemotherapy-Induced Nausea and Vomiting-
Adults, Pediatric patients (6 months to 18 years):

8 mg tablet/orodispersible tablet: Three 0.15 mg/kg doses, up to a maximum of 16 mg per dose.
4 mg orodispersible tablet: Three 0.15 mg/kg doses, up to a maximum of 16 mg per dose.
Injection: Three 0.15 mg/kg doses, up to a maximum of 16 mg per dose, infused intravenously over 15 minutes.

Radiotherapy-Induced Nausea and Vomiting-
Adults:

8 mg tablet/orodispersible tablet: Initial Dose: 8 mg orally 1 to 2 hours before radiotherapy. Post Radiotherapy: 8 mg orally every 8 hours for up to 5 days after a course of treatment.
4 mg orodispersible tablet: Three 0.15 mg/kg doses, up to a maximum of 16 mg per dose.
Injection: Three 0.15 mg/kg doses, up to a maximum of 16 mg per dose, infused intravenously over 15 minutes.

Postoperative Nausea and Vomiting-
Adults:

8 mg tablet/orodispersible tablet: 16 mg given as two 8 mg tablets
4 mg orodispersible tablet: 16 mg
Injection: 4 mg

Pediatrics (>40 kg): Injection: 4 mg
Pediatrics (40 kg): Injection: 0.1 mg/kg

Chemotherapy-induced Nausea and Vomiting-
Adults/Geriatric/Child of 12 years or over:

Highly emetogenic cancer chemotherapy: 30 ml (24 mg) Ondansetron Oral Solution administered 30 minutes before start of emetogenic chemotherapy.
Moderate emetogenic cancer chemotherapy: 10 ml (8 mg) Ondansetron Oral Solution administered 30 minutes before start of emetogenic chemotherapy. A further 10 ml dose should be administered after 8 hours of the first dose. One 10 ml dose should be administered twice a day (every 12 hours) for 1-2 days after completion of chemotherapy.

Pediatric (4-11 years): 5 ml (4 mg) Ondansetron Oral Solution should be taken 30 minutes before the start of chemotherapy. The other 2 doses should be taken 4 and 8 hours after the first dose. Then 5 ml oral solution should be administered 3 times a day (every 8 hours) for 1-2 days after completion of chemotherapy.

Oral solution:

Radiotherapy induced Nausea and Vomiting (Adults/Geriatric/Child of 12 years or over):

The recommended oral dosage: 10 ml (8 mg) Ondansetron Oral Solution 3 times daily.
For total body irradiation: 10 ml (8-mg) Ondansetron Oral Solution should be administered 1 to 2 hours before each fraction of radiotherapy administered each day.
For single high-dose fraction radiotherapy to the abdomen: one 10 ml Ondansetron Oral Solution should be administered 1 to 2 hours before radiotherapy, with subsequent doses every 8 hours after the first dose for 1 to 2 days after completion of radiotherapy.
For daily fractionated radiotherapy to the abdomen: 10 ml (8-mg) Ondansetron Oral Solution should be administered 1 to 2 hours before radiotherapy, with subsequent doses every 8 hours after the first dose for each day radiotherapy is given.

Postoperative Nausea and Vomiting (Adults/Geriatric/Child of 12 years or over):

20 ml (16 mg) Ondansetron Oral Solution 1 hour before induction of anesthesia

Oral Soluble Film:

Prevention of nausea and vomiting associated with highly emetogenic cancer chemotherapy:

Adult oral dose: 24 mg given successively as three 8 mg films 30 minutes before the start of chemotherapy.

Prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy:

Adults and pediatric patients 12 years of age and older: One 8 mg film 30 minutes before chemotherapy followed by an 8 mg dose 8 hours later. Administer one 8 mg film twice a day (every 12 hours) for 1 to 2 days after completion of chemotherapy.
Pediatric patients 4 through 11 years of age: One 4 mg film three times a day. Administer the first dose 30 minutes before chemotherapy, with subsequent doses 4 and 8 hours later. Administer one 4 mg film three times a day (every 8 hours) for 1 to 2 days after completion of chemotherapy.
Prevention of nausea and vomiting associated with radiotherapy: The adult dosage is one 8 mg film three times a day.
Postoperative nausea and vomiting: The adult dose is 16 mg given successively as two 8 mg films 1 hour before anesthesia.

Side Effects of Tablet:-Emistat 8mg (As a Ondansetron AS A Anti-emetic drugs).

Frequently reported adverse events were headache, constipation and diarrhea, but the majority have been mild or moderate in nature. In chemotherapy-induced nausea and vomiting, rash has occurred in approximately 1% of patients receiving Emistat. There also have been reports to a sensation of flushing or warmth, hiccups and liver enzyme abnormalities. Rare cases of anaphylaxis, brochospasm, tachycardia, angina (chest pain), hypokalemia, shortness of breath have also been reported, except for bronchospasm and anaphylaxis, the relationship to Emistat is unclear. There have been no evidence to extrapyramidal reactions, in rare case oculogyric crisis appearing alone, as well as with other dystonic reactions without definitive clinical evidence. In case of PONV, with the exception of headache, rates of these events were not significantly different in the Emistat and placebo groups.

General Queries 1:

How emistat reduce diarrhoea in ibs D?

Answer is: iBS -D তে Serotonin receptr Stimulate হয় যার জন্য,,Diarrhoea এর ফ্রিকোয়েন্সী বেড়ে যায়

আর Emistat হলো 5HT receptor antagonist__Receptor কে ব্লক করে দিয়ে,Stimulte হতে দেয় না,ultimately Diarrhoea এর Frequency কমে

Git এর Ovar motility ও কমিয়ে দেয়

এভাবে IBS-D তে কাজ করে.

2.Ondansetron এর ডোজ কেমন হবে?

Answer is:TDS (three times a day).

Hopefully bojate peresi.

Raiyyan Tahsan.Date:-28-12-2024 Friday Time:-12-48-39 AM.

Raiyyan Tahsan

Raiyyan Tahsan