[Binding of antacids to bile acids (author's transl)]

Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting

BACKGROUND

Gastro-oesophageal reflux disease (GERD) and constipation have a major impact on public health; however, the wide variety of treatment options presents difficulties for recommending therapy. Lack of definitive guidelines in pharmacy and general practice medicine further exacerbates the decision dilemma.

AIMS

To address these issues, a panel of experts discussed the principles and practice of treating GERD and constipation in the general population and in pregnancy, with the aim of developing respective treatment guidelines.

RESULTS

The panel recommended antacids 'on-demand' as the first-line over-the-counter treatment in reflux, and as rescue medication for immediate relief when reflux breaks through with proton pump inhibitors. Calcium/magnesium-based antacids were recommended as the treatment of choice for pregnant women because of their good safety profile. In constipation, current data do not distinguish a hierarchy between polyethylene glycol (PEG)-based laxatives and other first-line treatments, although limitations are associated with stimulant- and bulk-forming laxatives. Where data are available, PEG is superior to lactulose in terms of efficacy. In pregnancy, PEG-based laxatives meet the criteria for the ideal treatment.

CONCLUSIONS

The experts developed algorithms that present healthcare professionals with clear treatment options and management strategies for GERD and constipation in pharmacy and general practice medicine.

Diarrhoea and constipation

Drug-induced constipation is mostly caused by changes in gut motility, whilst diarrhoea is more frequently caused by an increase in intestinal fluid secretion. In both instances the drug has to reach the enteric nervous system or the enterocyte, either via the blood or from the lumen, in sufficient concentrations to affect the mediators that regulate motility and fluid transport. Diarrhoea and constipation are frequently mentioned as side-effects of drugs, and therapeutic agents for almost all organ systems have been implicated. However, both these side-effects are usually mild or moderate, and rarely necessitate interruption of drug treatment. An exception to this rule is the antibiotic-associated colitis seen in patients treated with antibiotics such as lincomycin or clindamycin; in principle almost all antibiotics may cause this severe and potentially life-threatening complication. Other rare forms of severe, drug-induced colitis and diarrhoea result from toxic or anaphylactic reactions against gold preparations, cytostatic agents and sulphonamides. Ischaemic colitis due to vascular complications has been described in some women taking oral contraceptives, and in patients treated with vasopressin or digitalis.