Gastroenterology Case No 5.case of IBS-Antidepressents-2

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Gastroenterology Case No 5.case of IBS-Antidepressents-2

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!!

Duloxetine (1+0+0)–2 Month or Timex *

Tablet 1.Duloxen 60mg AS A Duloxetine Hydrochloride AS A Serotonin-norepinephrine reuptake inhibitor (SNRI).

Indications of Tablet:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A Serotonin-norepinephrine reuptake inhibitor (SNRI).

Duloxen 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:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A 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:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A 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.

Interaction of Tablet:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A Serotonin-norepinephrine reuptake inhibitor (SNRI).

Both CYP1A2 and CYP2D6 isozymes are responsible for Duloxen metabolism. When Duloxen was co-administered with fluvoxamine, a potent CYP1A2 inhibitor, the AUC, Cmax and t of Duloxen was increased. Other drugs that inhibit CYP1A2 metabolism include cimetidine and quinolone antimicrobials such as ciprofloxacin and enoxacin would be expected to have similar effects and these combinations should be avoided. Because CYP2D6 is involved in Duloxen metabolism, concomitant use of Duloxen with potent inhibitors of CYP2D6 may result in higher concentrations of Duloxen.

Side Effects of Tablet:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A Serotonin-norepinephrine reuptake inhibitor (SNRI).

The most commonly observed adverse events in Duloxen 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 Duloxen-treated and placebo-treated patients.

Pregnancy & Lactation of Tablet:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A Serotonin-norepinephrine reuptake inhibitor (SNRI).

Pregnancy: Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women; therefore, Duloxetine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Labor and Delivery: The effect of Duloxetine on labor and delivery in humans is unknown. Duloxetine should be used during labor and delivery only if the potential benefit justifies the potential risk to the fetus.

Lactation: It is unknown whether or not Duloxetine and/or it’s metabolites are excreted into human milk, but nursing while on Duloxetine is not recommended

Therapeutic Class of Tablet:-Duloxen 60mg AS A Duloxetine Hydrochloride AS A Serotonin-norepinephrine reuptake inhibitor (SNRI).

Serotonin-norepinephrine reuptake inhibitor (SNRI)

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

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 2:-Tryptin 25mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

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

Tryptin is indicated in-

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

Pharmacology of Tablet :-Tryptin 25mg (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 :-Tryptin 25mg (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.

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

TCA enhances the sedative effect of alcohol and opioid analgesics. When TCA is used with Moxifloxacin or Terfenadine, it increases the risk of ventricular arrhythmias. Disulfirum and Cimetidine inhibit the metabolism of Tryptin. When TCA is used with diuretics, it enhances the risk of postural hypotension.

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

Amitriptyline is contraindicated in myocardial infarction, arrythmias, particularly heart block of any degree, mania and severe liver disease. Initially, sedation may affect the ability to drive or operate machinery.

Side Effects of Tablet :-Tryptin 25mg (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.

Pregnancy & Lactation of Tablet :-Tryptin 25mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Pregnancy Category C. Amitriptyline has been shown to cross the placenta. Amitriptyline should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus. Amitriptyline is excreted into breast milk. Because of the potential for serious adverse reactions in nursing infants from Amitriptyline, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Therapeutic Class of Tablet :-Tryptin 25mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Tricyclic Anti-depressant

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

কষ্ট করে পড়ার জন্য ধন্যবাদ

Tablet 3.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.

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.

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

Emistat does not itself appear to induce or inhibit the cytochrome P-450 drug-metabolizing enzyme system of the liver. Because Emistat is metabolized by hepatic cytochrome P-450 drug-metabolizing enzymes, inducers or inhibitors of these enzymes may change the clearance and hence, the half-life of Emistat. On the basis of available data, no dosage adjustment of Ondasetron is recommended for patients on these drugs.

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

Contraindicated in patients known to have hypersensitivity to the drug or any of its components. Concomitant use of apomorphine.

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.

Pregnancy & Lactation of Tablet:-Emistat 8mg (As a Ondansetron As a Anti-emetic drugs).

Carcinogenic effects were not seen in 2-year studies in rats and mice with oral Ondansetron doses up to 10 and 30 mg/kg per day, respectively. Ondansetron was not mutagenic in standard tests for mutagenicity. Oral administration of Ondansetron up to 15 mg/kg per day did not affect fertility or general reproduction performance of male and female rats.

Reproduction studies have been performed in pregnant rats and rabbits at daily oral doses up to 15 and 30 mg/kg per day, respectively, and have revealed no evidence of impaired fertility or harm to the fetus due to Ondansetron. There are, however, no adequate and well-controlled studies in pregnant women. Ondansetron is excreted in the breast milk of rats. So caution should be exercised when Ondansetron is administered to a nursing women.

Therapeutic Class of Tablet:-Emistat 8mg (As a Ondansetron As a Anti-emetic drugs).

Anti-emetic drugs

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:-20-01-2025 Monday Time:-10-06-45 Pm

Raiyyan Tahsan

Raiyyan Tahsan