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)
