Transcript LITERATURE REVIEW: IMPAIRED DRUG

LITERATURE REVIEW: IMPAIRED DRUG ABSORPTION IN
PATIENTS WITH SHORTENED BOWEL
Atalie Ferring, Lindsay Snodgrass, Dr. Nita Pandit (Mentor)
Drake University College of Pharmacy and Health Sciences, Department of Pharmaceutical Sciences
Background
Drug absorption may be a problem in patients
with shortened bowel due to:
Less surface area
Less residence time
pH dependent drugs
Loss of bile salt reabsorption [small intestine]
Clinicians are often unaware of this when creating
dosing regimens. There is insufficient literature on
this topic.
Normal Small Intestine (Small
1,2
Bowel)
Total length: 10.0-20.0 feet
Duodenum: <1.0 foot
Jejunum: 3.0-6.0 feet
Ileum: 6.0-12.0 feet
Intestine3,4
Normal Large
(Large Bowel/Colon)
Total length: 5.0-5.5 feet
Shortened Intestines
Small intestine: short bowel syndrome (SBS)
Large intestine: no medical diagnosis
Reasons for
Name
Objectives
1. Review published evidence of impaired drug
absorption in patients with shortened small
intestine or large intestine
2. Make recommendations to clinicians for
appropriate drug therapy in these patients
3. Use ostomy patients as a resource for
identifying drug absorption problems
Hypothesis: Drugs that will be a problem
Shortened small intestine
Poorly dissolving/poorly absorbing
Poor bioavailability
Problem in SBS/SC Patients
6,7
cimetidine
↓ absorption, ↓ efficacy
Absorption in ile
8,9.10
digoxin
↓ dissolution/absorption, ↓ F
↓ absorption, ↓ F
Poorly dissolved
duodenum/ jejun
↓ absorption
Absorption in col
12
nifedipine
↓ absorption
Absorption in col
diclofenac sodium12
↓ absorption
Absorption in col
cefaclor13,10
↓ absorption, ↓ efficacy
?
Rapidly absorbed
↓ absorption
?
Rapidly absorbed
15,10
cyclosporin
↓ absorption, ↓ F
Poorly absorbed
acetaminophen16,10
↓ absorption, ↓ F
Absorption in jej
amoxicillin17
↓ absorption, ↓ F
Rapidly absorbed
↓ absorption
Rapidly absorbed
↓ absorption
Absorption in en
intestine
↓ absorption
Absorbed in entir
intestine, poor F
hydrochlorothiazide11
isosorbide
12
dinitrate
erythromycin
14
stearate
Shortened small intestine or large intestine
Sustained-release or extended-release
Drugs given in large doses
Methods
Studies obtained through literature searches of
MEDLINE, SCOPUS, SciFinder Scholar, and
SuperSearch databases
Keywords: drug malabsorption, absorption,
bioavailability, ostomy, ileostomy, short bowel,
drug monitoring.
Proposed R
oral
18
contraceptives
phenytoin19
morphine
20
sulfate
5
shortening
Inflammatory bowel disease
Intestinal cancer
Intestinal obstruction
Results
15 papers found; discuss drug malabsorption
Problems reported with 14 drug products
Reliability of papers
Ostomy
Drug easily identified
in stool [bag]
Use as resource
Sample size, variability, peer-reviewed
Difficult to assess
Conclusions
Lack of published literature
Options for patients with shortened b
Drug malabsorption in patients with
shortened bowel
Drug products in ostomy bags
Clinicians unaware of problem
Individual dose-adjustment
Selection of a different route
Therapeutic monitoring of blood levels
Crushing