PHARM 130 - Chapter 38 - Hemorrhoids

What is the recommended dose of phenylephrine?

0.25% gel May be applied every morning and evening and after each bowel movement

What is the recommended adult dose of hydrocortisone acetate for treating hemorrhoids?

0.5% ointment applied every morning and evening and after each bowel movement

What is the recommended adult dose of zinc sulfate?

0.5% ointment/cream; 10mg suppository May be applied up to 6 times daily after each bowel movement

What is the adult dose of dibucaine?

0.5-1% ointment/cream Administered each morning and evening and after each bowel movement Max: 30g ointment daily

Hydrocortisone acetate should not be taken for more than:

1 week

You should refer patients if their hemorrhoid problems persist for more the ____

1 week

Hydrocortisone-containing hemorrhoidal products should not be used for more than:

1 week (to reduce chances of side effects such as mucosal atrophy)

What is the recommended dose of yeast?

1% ointment/cream; 22mg suppository May be applied every morning and evening and after each bowel movement to improve wound healing

What is the recommended adult dose of pramoxine?

1% ointment; 20mg suppository Administered each morning and evening and after each bowel movement

What kinds of adverse effects are associated with local anesthetics?

1) CNS effects (restlessness, excitement, nervousness, paresthesias, dizziness, tinnitus, blurred vision, N/V, muscle twitching and tremors, convulsions) 2) Cardiovascular effects (hypotension, bradycardia)

Patients should be advised to not sit on the toilet for more than _____

1-2 minutes (it is KEY to avoid constipation)

What is the recommended adult dose of glycerin?

10% ointment Applied up to 4 times per day

Nonprescription hemorrhoidal products should not be given to patients under the age of ___ (unless assessed by physician)

12

You should refer a patient with hemorrhoids if they are under the age of ___

12 (possible birth abnormalities, pinworms, sexual abuse)

Which degree of hemorrhoid is the following: hemorrhoid swelling in the anal cushion due to straining and is usually painless

1st degree

Which degree of hemorrhoid is the following: small part of the anal mucosa or cushion may protrude at the anus during defecation, but spontaneously returns back to normal after

2nd degree

What is the recommended adult dose of shark liver oil as a protectant?

3% ointment/cream, 66mg suppository May be applied every morning and evening and after each bowel movement

Which degree or hemorrhoid is the following: hemorrhoid remains prolapsed after defecation but can be manually pushed back in

3rd degree

Hemorrhoids mostly affect people ages __ to __

45 to 65

Which degree of hemorrhoid is the following: hemorrhoids cannot be replaced after a bowel movement and thus create a permanent bulge at the anus (quite painful)

4th degree

What is the recommended adult dose of hamamelis water (witch hazel)?

50% gel; available as pads or wipes May be applied up to 6 times daily after each bowel movement

What is the onset time of phenylephrine 0.25% gel as a vasoconstictor?

A few seconds to 1min (duration of action is 2-3h)

Why dosage forms are hemorrhoidal preparations available in? Which is the most effective?

A variety of dosage forms: creams, ointments, suppositories, cleaning pads Suppositories are not really recommended because they can slip out and melt. Stick with creams/ointments.

What is a Sitz bath?

A warm tub of water (46 degrees Celsius) in which a patient sits in for 15min

Which class does hydrocortisone acetate belong to?

Anti-inflammatory

What is the recommended adult dose of white petrolatum?

Applied up to 4 times per day

Which class does hamamelis water (witch hazel) fall under?

Astringent

Which class does zinc sulfate fall under?

Astringent

How do astringents work?

By causing coagulation (clumping) of proteins in the cells of the perianal skin or the lining of the anal canal (promotes dryness of skin)

What do hemorrhoids consist of?

Connective tissue Arteriovenous plexus Suspensory smooth muscle

Internal hemorrhoids originate above the ____ line

Dentate/pectinate/anorectal

How are diarrhea and hemorrhoids related?

Diarrhea can cause hemorrhoids due to futile and protracted straining

Bioflavonoids, particularly _____ and _____ have demonstrated efficacy in the treatment of hemorrhoids

Diosmin Hesperidin

When is horse chestnut contraindicated?

During pregnancy/breastfeeding, in patients with bleeding disorders, and it may interact with ASA/thrombotics

Which are well innervated, internal or external hemorrhoids?

External

True or false: fibre and hemorrhoids are associated

False

True or false: spicy foods can worsen hemorrhoids

False

True or false: heredity is an important factor for hemorrhoids

False (the only connection between heredity and hemorrhoids is the diet of the family)

True or false: external hemorrhoids lack nerves and are painless

False, INTERNAL hemorrhoids lack nerves and are painless

True or false: prolapsed hemorrhoids should be replaced using a clean, dry hand.

False, a moistened tissue should be used (After wiping the area with soap and water)

True or false: hemorrhoids affect males more

False, it affects males and females equally

True or false: there is a lot of evidence to support the use of local anesthetics in hemorrhoidal preparations

False, lacks evidence

True or false: many hemorrhoidal products reduce bleeding or prolapse.

False, no good evidence.

True or false: pharmacologic treatments are directed both towards symptom management and curing.

False, only symptom management (none are curative)

When might thrombosed hemorrhoids be accompanied by a sudden relief of pain?

Following rupture of the skin overlying the thrombus and bleeding

What is the purpose of applying yeast thought to be?

Improves wound healing (but there is insufficient evidence to confirm efficacy)

When should you check up with a patients with hemorrhoids after giving them treatment?

In 1 week

How are sitting on the toilet for a prolonged period of time and hemorrhoids related?

In this position, the perineum is relaxed and the anal cushions are unsupported - this can lead to hemorrhoids

What can you recommend to a pregnant patient with hemorrhoids?

Increasing fibre content in diet, administering stool softeners, increasing liquid intake, training in toilet habits, Sitz bath

How can hemorrhoids be classified?

Internal External Mixed

How is constipation associated with hemorrhoids?

It can cause hemorrhoids due to excessive straining

How can fibre supplementation help with hemorrhoids?

It can relieve constipation It can relieve pruritus associated with fecal soilage

How is prolapse of hemorrhoids associated with rectal mucus production?

It causes an increase in rectal mucus production

Why should hemorrhoidal products with local anesthetics not be used for more than 1 week?

It increases the chances of contact dermatitis

What will a Sitz bath help to relieve?

Itching and irritation (relaxes the internal anal sphincter)

Is there evidence to support the use of horse chestnut?

Little evidence to support use, but appears to reduce swelling and inflammation.

Which class does dibucaine fall under?

Local anesthetics

Which class does pramoxine fall under?

Local anesthetics

Are astringents good for minor or severe symptoms?

Minor only. If there is severe itching and discharge, hydrocortisone preparation should be recommended

What are some adverse effects associated with hydrocortisone cream?

Mucosal atrophy (more common with prolonged use)

Which patients would surgical hemorrhoidectomy be recommended for?

Only a minority of patients since it is risky (ex. for treatment failures, third and fourth degree hemorrhoids, acute thrombosed hemorrhoids)

What are some symptoms of thrombosed hemorroids?

Pain, itching, swelling, burning

What are some adverse effects of phenylephrine?

Possible systemic absorption if applied to abraded skin (increased BP, CNS disturbances, cardiac arrhythmia, aggravation of symptoms of hyperthyroidism)

Which has lower incidence of sensitization, dibucaine or pramoxine?

Pramoxine because it does not have the usual amide or ester structure, while dibucaine is amide-type

How are pregnancy and hemorrhoids related?

Pregnancy can cause hemorrhoids due to an increase in abdominal pressure (also, the women may be more constipated = increased straining)

Which class does glycerin fall under?

Protectant

Which class does petrolatum fall under?

Protectant

Which class does shark liver oil fall under?

Protectant

What effect does aescin (a saponin from horse chestnut) appear to have on hemorrhoidal symptoms?

Reduce swelling and inflammation

The active ingredients in horse chestnut (which is used for symptomatic relief of hemorrhoids) appear to be _____

Saponins (aescin is the most important)

How should the patient apply a hemorrhoidal product with local anesthetics?

Should be used only in the perianal region or in the lower anal canal to reduce systemic absorption (advise patient to not insert suppositories too far up and to lie does for a few minutes after)

If fibre supplementation does not relieve hemorrhoids, another nonpharm methods that you can recommend to patients is a:

Sitz bath, 3-4 times per day

What is the most effective treatment for hemorrhoids?

Surgical hemorrhoidectomy (but it is also associated with the highest complication hates and postoperative disability)

In thrombosed hemorrhoids, ______ is probably the main cause of pruritus

Swelling

Which symptoms will astringents temporarily relieve?

Their action promotes dryness of skin, so they will relieve burning, itching, an pain (good for MILD symptoms)

Are diosmin and hesperidin effective in the treatment of hemorrhoids? By which mechanism do they work?

They have demonstrated efficacy They work on venous capillary walls (also considered safe)

How are heavy lifting and prolonged sitting/standing related to hemorrhoids?

They may cause hemorrhoids due to an increase in abdominal pressure

By which mechanism do protectants work?

They prevent irritation of the perianal area by forming a physical barrier on the skin (reduces irritation, itching, pain, and burning by preventing contact of the irritated skin with aggravating liquid or stool)

If a patient is experiencing a painful mass at the anus that lasting for several days to week, they are experiencing a ______ hemorrhoid

Thrombosed

What purpose do local anesthetics serve in hemorrhoidal products?

To relieve pain

What purpose does hydrocortisone serve in hemorrhoidal products?

To temporarily relieve itchy anal areas

True or false: dibucaine is an amide-type local anesthetic

True

True or false: hemorrhoids are a normal anatomic feature of the anal canal

True

True or false: medical treatment, rubber banding, and infrared coagulation cause much less discomfort have have a faster recovery time than surgery

True

True or false: more than half of people will have hemorrhoids at some point in their life

True

True or false: oral analgesics, such as acetaminophen, may provide relief for mild discomfort or pain

True

True or false: you should refer a patient with hemorrhoids who has dark coloured blood

True

True or false: zinc sulfate is a common ingredient in hemorrhoidal products

True

True or false: the incidence of hemorrhoids may be overestimated

True (only 50% of patients who complain of hemorrhoids actually have simple hemorrhoids)

True or false: anesthetics are included in some topical hemorrhoidal preparations

True, to relieve pain

True or false: penetration of intact skin by local anesthetics is generally poor

True. But with excessive application to the rectal mucosa, absorption can occur.

When does a patient with damaged hemorrhoids usually bleed?

Usually only during defecation

Which class does phenylephrine fall under?

Vasoconstrictor

People consuming a _____ diet are most likely to get hemorrhoids

Western (high in white flour, sugar, and fibre-depleted carbohydrate foods)

Are non-surgical treatments for hemorrhoids (ex. rubber-banding or infrared coagulation) effective?

Widely used but no placebo-controlled studies to prove their efficacy

Is fecal soiling of underwear common with hemorrhoids?

Yes

Should you refer a patient if they have prolapsed hemorrhoids that they must manually reinsert?

Yes

Can external medications for hemorrhoids be given to pregnant patients with hemorrhoids?

Yes and they are preferred over drugs that are inserted into the rectum

Is horse chestnut associated with any adverse effects?

Yes, pruritus, nausea, stomach complaints, bleeding, nephropathy, and allergic reactions

Is topical bovine cartilage effective in the treatment of hemorrhoids?

Yes, the 5% cream relieves itching and the 2% suppository works like a stool softener

Can local anesthetics and corticosteroids be given to a pregnant patients with hemorrhoids?

Yes, with medical supervision (watch out for systemic absorption of corticosteroids = intrauterine growth retardation)