Gastrointestinal Disorders

Case 1—Nausea and Vomiting

DM is a 5-year-old boy brought into the pharmacy by his mother, who is seeking a recommendation for the prevention of motion sickness for her son. DM’s mother says that she and her family are planning to spend the weekend at their shore house on the bay, and each time she has taken her son out on the family’s boat previously, he has experienced episodes of nausea and occasional vomiting. His symptoms have always resolved upon returning the boat to dock, so she does not believe his symptoms to be related to other causes. He has no known allergies and takes no medications. What counseling points and treatments can you recommend to his mother at this time?

Answer

Motion sickness is a common cause of nausea and vomiting in both children and adults. This condition is thought to result from a mismatch of impulses among the vestibular receptors of the inner ear, visual input, and proprioceptive neurons.^1,2 Although the exact cause of motion sickness is unknown, it is thought that stimulation of certain neurons within the hypothalamus and cerebral cortex may elicit strong sensations of nausea in certain individuals in response to real or perceived movement.²

Motion sickness can be prevented with lifestyle and pharmacologic interventions. Although suggesting DM’s family avoid the precipitating factor may not be realistic, recommending that DM avoid excessive food intake prior to the trip and stay in a place on the vessel where the sensation of motion is reduced, such as in the center of the boat between the bow and stern, may help minimize symptoms.¹ Counsel his mother to try positioning him in a forward-facing position and instructing him to look toward the stationary horizon. Acupressure wrist bands can also be recommended as alternatives or adjuncts to medications for preventing motion sickness and have been used by children as young as age 2 years.

As motion sickness may be triggered by excessive histamine activity within the central nervous system, antihistamines are a key class of agents indicated for the prevention of motion sickness.

Given DM’s age, recommend a product containing either dimenhydrinate or diphenhydramine, as these agents are approved for the prevention of motionrelated emesis in children 2 years or older. Products containing cyclizine and meclizine should be reserved for use in older children or adults. Counsel DM’s mother to administer these agents at least 30 to 60 minutes prior to departure and to readminister as indicated, based on the selected product and duration of travel. Remind her that the most common side effect of these agents is drowsiness. If her son experiences excessive vomiting or signs of dehydration, she should seek medical attention.

Case 2—Hemorrhoids

JB is a 62-year-old businessman who is currently experiencing a flare-up of his hemorrhoids, a condition he has been evaluated for by his physician in the past. He will be leaving the next day for a business conference, and is looking for a product to soothe the pain and irritation so that he can endure his 6-hour flight without a problem. He reports he is allergic to penicillin and currently takes the combination hydrochlorothiazide 25 mg and lisinopril 20 mg once daily for hypertension, pravastatin 40 mg once daily for dyslipidemia, and aspirin 81 mg daily for heart attack prevention. Describe nonpharmacologic and pharmacologic recommendations to alleviate JB’s symptoms.

Answer

Symptomatic dilated hemorrhoidal veins, or hemorrhoids, are estimated to affect 4.4% of the general population and nearly 50% of adults older than 50 years. Hemorrhoids are thought to result from increasing age or aggravating factors (eg, straining on defecation, lifting heavy objects, constipation, diarrhea).³ Such factors are thought to contribute to the deterioration of the connective tissue that usually secures blood vessels and smooth muscle in the rectum, causing hemorrhoids to bulge, descend, and cause symptoms.^3,4

Nonpharmacologic interventions for treating hemorrhoids include increasing dietary fiber intake, maintaining good anal hygiene and toileting practices, and utilizing warm water soaks to soothe the affected area. In the case of JB, consider recommending OTC therapies to alleviate his symptoms, such as astringents, topical anesthetics, or protectants. Depending on the selected product, many of these agents can be applied as needed up to 6 times per day and have minimal side effects secondary to limited systemic absorption. JB’s hypertension would preclude him from using topical vasoconstrictors, such as phenylephrine, which may be systemically absorbed when administered rectally and could exacerbate his condition. Topical vasocontrictors should only be used under the advice of his physician. PT

Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.

References

1. Shane-McWhorter L, Oderda L. Nausea and vomiting. In: Berardi R, Ferreri S, Hume A, et al, eds. Handbook of Nonprescription Drugs. Washington DC: American Pharmacists Association; 2009:335-354.

2. Herron DG. The ups and downs of motion sickness. Am J Nursing. 2010;110:49-51.

3. Chan J, Berardi RR. Anorectal disorders. In: Berardi R, Ferreri S, Hume A, et al, eds. Handbook of Nonprescription Drugs. Washington DC: American Pharmacists Association; 2009:309-324.

4. Haas PA, Fox TA Jr, Haas GP. The pathogenesis of hemorrhoids. Dis Colon Rectum. 1984;27:442.