Phillips Pt Case Pres Chronic Diarrhea


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  • In the early 18th century Jakob Le Mort (1650–1718),[1] a professor of chemistry at Leiden University, prepared an elixir for asthma and called it "paregoric".[2] The word "paregoric" comes from the Greek word "paregoricon" which was originally applied to oratory and to a particular form of oratory in which distraction of attention was the predominant feature. It then passed through various shades of meaning from "consoling" to "soothing" and finally came to have the same significance as "anodyne".[3] Le Mort's elixir, consisting of "honey, licorice, flowers of Benjamin, and opium, camphor, oil of aniseed, salt of tartar and spirit of wine," became official as "Elixir Asthmaticum" in the London Pharmacopoeia of 1721.
  • Use of paregoric dates back to the 1970s.
  • In usual antidiarrheal doses, opium does not result in analgesia or euphoria; therefore paregoric may be used in the treatment of diarrhea with little risk of development of psychological dependence. Prolonged use of paregoric may result in physical dependence.
  • Morphine readily crosses the placenta and should be used cautiously during pregnancy or obstetric delivery. Use with caution while breastfeeding because it has been detected in breast milk.
  • Important for pharmacy to not be limited to what drug manufactures have to offer. We have access to a plethora of chemicals that can be compounded to fit patient specific needs (dosage form, availability etc…)
  • Phillips Pt Case Pres Chronic Diarrhea

    1. 1. Chronic Diarrhea: Working with older patients to meet patient specific needs <br />Presented By: Cory Phillips<br />March 24, 2011<br />
    2. 2. Case summary<br />JS is an 82 yo WF whose husband presented to the compounding pharmacy looking for paregoric. JS had chronic, severe diarrhea and possibly IBS. The patient had used paregoric in the past, but was unable to find it because the manufacturers stopped supplying the medication. The husband stated that “She had tried everything!” She was set on getting paregoric because she had used this medication for years and it had worked well for her. In her opinion this was the only medication that helped. <br />
    3. 3. Patient history <br />82 yo WF<br />Average height<br />Average weight<br />NKDA<br />KNA<br />No nicotine, alcohol, or recreational drug use<br />Overall good health for an 82 yo woman<br />ROS: chronic diarrhea<br />
    4. 4. Primary problem <br />The patient had chronic diarrhea with possible IBS.<br />The manufacturer of paregoric no longer supplies the drug.<br />The patient’s husband presented to the compounding pharmacy in hopes of being able to have paregoric compounded.<br />
    5. 5. Background on disease state (IBS) <br />Chronic, episodic GI disorder<br />Affects gut motility<br />Characterized by<br />Abdominal pain<br />Discomfort<br />Defecation disturbances<br />Bloating <br />~ 10-15% of adult population has symptoms consistent with IBS<br />Prevalence of IBS 2x higher in females than males<br />Symptoms present by age 35<br />
    6. 6. Background on disease state (IBS) <br />Causes unknown<br />Alteration in <br />Intestinal motility<br />Visceral hypersensitivity<br />Brain response to visceral stimuli<br />May follow bacterial gastroenteritis in 7-30% of cases<br />
    7. 7. paregoric<br /><ul><li>Paregoric, or camphorated opium tincture, is a schedule C-III controlled substance
    8. 8. When compounded it becomes a C-II substance</li></li></ul><li>History of Paregoric<br />Camphorated opium tincture or tincture of paregoric<br />Oral alcoholic solution containing morphine<br />Opium obtained from Papaver somniferum Linne or album De Candolle<br />Contains several alkaloids not less than 9.5% anhydrous morphine<br />Small amounts of codeine, noscapine, papaverine, and thebaine<br />Paregoric 25x less potent than opium tincture<br />
    9. 9. Older Generation Uses<br />One of the first agents used for teething in babies<br />Use declined due to known and potential toxic effects of ingredients<br />Used to treat diarrhea or severe withdrawal in neonates born to women addicted to opiates<br />More effective and/or safer agents for the treatment of diarrhea have largely replaced paregoric <br />
    10. 10. Mechanism of Action <br />Activity due to opiate agonist morphine<br />Increase smooth muscle tone <br />Antral portion of stomach<br />Small intestine (especially the duodenum)<br />Large intestine<br />Sphincters<br />Decrease secretions<br />Stomach<br />Pancreas<br />Biliary tract<br />Results in constipation and delayed digestion <br />
    11. 11. Contraindications/Precautions<br />Sedation<br />Use caution when driving or operating machinery<br />CI<br />Patients with diarrhea secondary to poisoning <br />Infectious diarrhea<br />Use cautiously in pts with GI disease<br />Obstruction<br />Ulcerative colitis<br />Pre-existing constipation<br />Biliary spasms<br />Avoid in pts with severe pulmonary disease<br />Acute or chronic asthma<br />COPD<br />
    12. 12. Side Effects (cholinergic)<br />Bradycardia<br />Peripheral vasodilation<br />Problematic in pts with cardiac disease<br />Urinary retention<br />Oliguria<br />Pregnancy Category C<br />
    13. 13. Drug Interactions<br />Adverse Reactions<br />Lightheadedness<br />Dizziness<br />Sedation<br />N/V<br />Constipation<br />Ileus<br />GI obstruction<br />Dry mouth <br />Blurred vision<br />Miosis<br />Respiratory depression/arrest<br />Apnea<br />Circulatory depression<br />Coma <br />Shock<br />Cardiac arrest<br />Physical dependence following prolonged use<br />CNS depressants<br />Mixed opiate agonists/antagonists<br />Opiate antagonists<br />
    14. 14. Compounding of paregoric <br />
    15. 15. Other Options for Diarrhea<br />Individualized treatment <br />Lifestyle changes<br />Dietary changes<br />Cognitive-behavioral therapies<br />Complementary therapies in ajunct to drug therapy<br />Atropine; Difenoxin<br />Atropine; Diphenoxylate<br />Attapulgite<br />Bismuth Subsalicylate<br />Kaolin; Pectin<br />Loperamide<br />Loperamide; Simethicone<br />Opium Tincture<br />Nonpharmacological <br />Pharmacological <br />
    16. 16. Summary of Primary Literature<br />No recent literature due to paregoric being an older drug<br />Some early 2000s studies on paregoric in neonatal withdrawal syndrome<br />2008 Brazilian phase I study investigated the safety of Elixir paregoric®<br />Investigated whether administration causes any noticable toxic effects in healthy volunteers<br />No serious adverse reactions were reported following administration<br />Mild adverse effects resolved themselves<br />
    17. 17. Recommendations/Solution <br />The solution was to compound the drug<br />Compounded as a CII prescription<br />The dosage given was 5—10 ml PO 1—4 times per day<br />Recommend the patient see her physician if problem persists<br />Might have IBS which is treated differently than diarrhea alone<br />
    18. 18. Conclusion/Follow-up<br />The patient is satisfied with the paregoric which is working well for her.<br />
    19. 19. Application <br />Pearls of Wisdom<br />Pharmacists need to be able to work with a variety of patients, including older patients, to meet patient specific needs.<br />It is important for pharmacists to have knowledge of older generation drugs and what they are indicated for. <br />Critical pharmacy problems can be solved when the pharmacist has a strong knowledge of the patient population and drugs associated with this population. <br />Pharmacy should not be limited to what drug manufacturers have to offer. We have access to a plethora of chemicals that can be compounded to fit patient specific needs. <br />
    20. 20. References <br />Patient and Preceptor (Dr. Randall Allen) <br />Gold Standard, Inc. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2011. Available at Accessed March 19, 2011. <br />Irritable Bowel Syndrome. DISEASEDEX. [database online]. Available at New York: Thomson Reuters; 2011. Accessed March 19, 2011. <br />MEA de Moraes, Bezerra MM, Bezerra FAF, et al. Safety evaluation of Elixir paregorico® in healthy volunteers: a phase I study. Human & Experimental Toxicity. 2008; 27(10): 751-756. <br />