Steatorrhea medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
Depending upon the underlying etiology, management of steatorrhea include: | |||
=== '''Celiac disease''' === | |||
* '''<u>Refractory disease</u>''' | |||
** A minority of patients suffer from refractory disease, which means they do not improve on a [[gluten-free diet]]. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone or the patient is not adhering to the diet, or the patient is consuming foods that contain [[gluten]]. Pharmacotherapy is used if dietary modification is not effective.<ref name="pmid20332526">{{cite journal |vauthors=Rubio-Tapia A, Murray JA |title=Classification and management of refractory coeliac disease |journal=Gut |volume=59 |issue=4 |pages=547–57 |year=2010 |pmid=20332526 |pmc=2861306 |doi=10.1136/gut.2009.195131 |url=}}</ref> | |||
***1. '''Steroids''' | |||
****Preferred regimen(1): [[Prednisone]] 0.5–1 mg/kg q24h | |||
****Preferred regimen(2): [[Budesonide]] 9 mg q24h | |||
****Preferred regimen(3): [[Prednisone]] 0.5–1 mg/kg q24h and [[azathioprine]] 2 mg/kg q24h combination | |||
***2. '''Immunosuppressive drugs''' (Used in steroid dependent or steroid refractory disease) | |||
****2.1 '''Antiproliferative agents''' | |||
*****Preferred regimen(1): [[Azathioprine]] 2 mg/kg q24h | |||
****2.2 '''Calcineurin Inhibitors:''' | |||
*****Preferred regimen(1): [[Cyclosporine]] 5 mg/kg q24h PO | |||
****2.3 '''Monoclonal antibodies''' | |||
*****Preferred regimen(1): [[Infliximab]] 5 mg/kg q24h | |||
*****Preferred regimen(2): [[Alemtuzumab]] 30 mg twice a week per 12 weeks | |||
*'''<u>Dermatitis herpetiformis</u>''' | |||
**1. '''Life style modification'''<ref name="pmid12477369">{{cite journal |vauthors=Collin P, Reunala T |title=Recognition and management of the cutaneous manifestations of celiac disease: a guide for dermatologists |journal=Am J Clin Dermatol |volume=4 |issue=1 |pages=13–20 |year=2003 |pmid=12477369 |doi= |url=}}</ref> | |||
***1.1 '''Gluten-free diet (GFD)''' | |||
**2. '''Pharmocatherapy'''<ref name="pmid18360613">{{cite journal |vauthors=Mutasim DF |title=Therapy of autoimmune bullous diseases |journal=Ther Clin Risk Manag |volume=3 |issue=1 |pages=29–40 |year=2007 |pmid=18360613 |pmc=1936286 |doi= |url=}}</ref><ref name="pmid20729961">{{cite journal |vauthors=Han A |title=A practical approach to treating autoimmune bullous disorders with systemic medications |journal=J Clin Aesthet Dermatol |volume=2 |issue=5 |pages=19–28 |year=2009 |pmid=20729961 |pmc=2924135 |doi= |url=}}</ref> | |||
***2.1 '''Sulfones''' | |||
****Preferred treatment(1): [[Dapsone]] 50 mg q24h increased every week until clearance or tolerance | |||
***2.2 '''Suhphonamides''' | |||
****Alternative treatment (1): [[Sulfasalazine]] 500 mg q8h (maximum, 2g q8h) | |||
***2.3 '''Combination treatment'''<ref name="pmid28133723">{{cite journal |vauthors=Bevans SL, Sami N |title=Dapsone and sulfasalazine combination therapy in dermatitis herpetiformis |journal=Int. J. Dermatol. |volume=56 |issue=5 |pages=e90–e92 |year=2017 |pmid=28133723 |doi=10.1111/ijd.13542 |url=}}</ref> | |||
****Alternative treatment (1): [[Dapsone]] plus [[sulfasalazine]] | |||
***2.4 '''Other treatment''' (intolerance or allergies to dapsone and [[sulfasalazine]]) | |||
****Alternative treatment (1): [[Colchicine]]<ref name="pmid7458365">{{cite journal |vauthors=Silvers DN, Juhlin EA, Berczeller PH, McSorley J |title=Treatment of dermatitis herpetiformis with colchicine |journal=Arch Dermatol |volume=116 |issue=12 |pages=1373–84 |year=1980 |pmid=7458365 |doi= |url=}}</ref> | |||
****Alternative treatment (2): [[Cholestyramine]] | |||
****Alternative treatment (3): [[Tetracycline]]<ref name="pmid10844495">{{cite journal |vauthors=Shah SA, Ormerod AD |title=Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide |journal=Clin. Exp. Dermatol. |volume=25 |issue=3 |pages=204–5 |year=2000 |pmid=10844495 |doi= |url=}}</ref> | |||
****Alternative treatment (4): [[Nicotinamide|Niacinamide]]<ref name="pmid10844495" /> | |||
****Alternative treatment (5): [[Heparin]]<ref name="pmid10844495" /> | |||
****Alternative treatment (6): [[Cyclosporine|Cyclosporin]] | |||
***2.5 '''Monoclonal antibodies'''<ref name="pmid28030659">{{cite journal |vauthors=Albers LN, Zone JJ, Stoff BK, Feldman RJ |title=Rituximab Treatment for Recalcitrant Dermatitis Herpetiformis |journal=JAMA Dermatol |volume=153 |issue=3 |pages=315–318 |year=2017 |pmid=28030659 |doi=10.1001/jamadermatol.2016.4676 |url=}}</ref> | |||
****Preferred treatment(1): [[Rituximab]] | |||
****'''Note:''' Used is severe cases not improved by other medications. | |||
=== Choledocolithiasis === | |||
* '''<u>Gall stones</u>''' | |||
**'''1.1.1 Adult''' | |||
***'''1.1.1.1 Gall stone dissolution''' | |||
****Preferred regimen (1): [[Ursodiol]] PO 8-10 mg/kg q24h in 2-3 divided doses (Max up to 24 months) | |||
***'''1.1.1.2 Gall stone prevention''' | |||
****Preferred regimen (1): [[Ursodiol]] PO 300 mg q12h | |||
***'''Primary biliary cirrhosis''' | |||
****Preferred regimen (3): ([[Urso]], [[Urso forte]]): Oral: 13-15 mg/kg/day in 2-4 divided doses (with food) | |||
**'''1.1.2 Pediatric''' | |||
***'''1.1.2.1 Children < 8 years of age''' | |||
****Preferred regimen (1):In parenteral nutrition-induced cholestasis in neonates, some experts recommend: Oral: 30 mg/kg/day in 2- 3 divided doses | |||
***'''1.1.2.2 Children > 8 years of age''' | |||
***'''1.1.2.2.1 Gall stone dissolution''' | |||
****Preferred regimen (1): [[Ursodiol]] PO 25 mg/kg q24h (Max up to 13 months) | |||
* '''<u>Lipid lowering agents</u>''' | |||
**'''2.1.1 [[HMG-CoA reductase|HMG CoA reductase]] inhibitors<ref name="pmid84174842">{{cite journal |vauthors=Saunders KD, Cates JA, Abedin MZ, Roslyn JJ |title=Lovastatin and gallstone dissolution: a preliminary study |journal=Surgery |volume=113 |issue=1 |pages=28–35 |year=1993 |pmid=8417484 |doi= |url=}}</ref><ref name="pmid95121292">{{cite journal |vauthors=Chapman BA, Burt MJ, Chisholm RJ, Allan RB, Yeo KH, Ross AG |title=Dissolution of gallstones with simvastatin, an HMG CoA reductase inhibitor |journal=Dig. Dis. Sci. |volume=43 |issue=2 |pages=349–53 |year=1998 |pmid=9512129 |doi= |url=}}</ref><ref name="pmid253036822">{{cite journal |vauthors=de Bari O, Wang HH, Portincasa P, Paik CN, Liu M, Wang DQ |title=Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice |journal=Eur. J. Clin. Invest. |volume=44 |issue=12 |pages=1159–68 |year=2014 |pmid=25303682 |pmc=4659711 |doi=10.1111/eci.12350 |url=}}</ref><ref name="pmid4471122">{{cite journal |vauthors=Doran J, Keighley MR, Bell GD |title=Rowachol--a possible treatment for cholesterol gallstones |journal=Gut |volume=20 |issue=4 |pages=312–7 |year=1979 |pmid=447112 |pmc=1412390 |doi= |url=}}</ref><ref name="pmid64303902">{{cite journal |vauthors=Ellis WR, Somerville KW, Whitten BH, Bell GD |title=Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation |journal=Br Med J (Clin Res Ed) |volume=289 |issue=6438 |pages=153–6 |year=1984 |pmid=6430390 |pmc=1442019 |doi= |url=}}</ref>''' | |||
***Preferred regimen (1): [[Statins]] | |||
**:'''NOTE (1):''' [[Statins]]will reduce cholesterol secretion hence the rationale for their use. | |||
**2.1.2 '''Cholesterol absorption inhibitor''' | |||
***Preferred regimen (1): '''[[Ezetimibe]]''' | |||
**:'''NOTE (1):''' [[Ezetimibe]] is a hypocholesterolemic drug that acts by inhibiting [[intestinal]] [[cholesterol]] [[absorption]]. | |||
*'''<u>Dissolution agents</u>''' | |||
**2.2.1 [[Monoterpenes]] | |||
***Preferred regimen (1): Rowachol | |||
**:'''NOTE (1):''' Rowachol, an orally administered mixture of cyclic [[monoterpenes]] is capable of dissolving radiolucent and some radio-opaque gallstones. | |||
**:'''NOTE (2):''' It also enhances the efficacy of [[Ursodiol|ursodeoxycholic acid]] or [[Lithotriptor|lithotripsy]] when used in combination. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Revision as of 16:40, 8 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]
Overview
Medical Therapy
Depending upon the underlying etiology, management of steatorrhea include:
Celiac disease
- Refractory disease
- A minority of patients suffer from refractory disease, which means they do not improve on a gluten-free diet. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone or the patient is not adhering to the diet, or the patient is consuming foods that contain gluten. Pharmacotherapy is used if dietary modification is not effective.[1]
- 1. Steroids
- Preferred regimen(1): Prednisone 0.5–1 mg/kg q24h
- Preferred regimen(2): Budesonide 9 mg q24h
- Preferred regimen(3): Prednisone 0.5–1 mg/kg q24h and azathioprine 2 mg/kg q24h combination
- 2. Immunosuppressive drugs (Used in steroid dependent or steroid refractory disease)
- 2.1 Antiproliferative agents
- Preferred regimen(1): Azathioprine 2 mg/kg q24h
- 2.2 Calcineurin Inhibitors:
- Preferred regimen(1): Cyclosporine 5 mg/kg q24h PO
- 2.3 Monoclonal antibodies
- Preferred regimen(1): Infliximab 5 mg/kg q24h
- Preferred regimen(2): Alemtuzumab 30 mg twice a week per 12 weeks
- 2.1 Antiproliferative agents
- 1. Steroids
- A minority of patients suffer from refractory disease, which means they do not improve on a gluten-free diet. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone or the patient is not adhering to the diet, or the patient is consuming foods that contain gluten. Pharmacotherapy is used if dietary modification is not effective.[1]
- Dermatitis herpetiformis
- 1. Life style modification[2]
- 1.1 Gluten-free diet (GFD)
- 2. Pharmocatherapy[3][4]
- 2.1 Sulfones
- Preferred treatment(1): Dapsone 50 mg q24h increased every week until clearance or tolerance
- 2.2 Suhphonamides
- Alternative treatment (1): Sulfasalazine 500 mg q8h (maximum, 2g q8h)
- 2.3 Combination treatment[5]
- Alternative treatment (1): Dapsone plus sulfasalazine
- 2.4 Other treatment (intolerance or allergies to dapsone and sulfasalazine)
- Alternative treatment (1): Colchicine[6]
- Alternative treatment (2): Cholestyramine
- Alternative treatment (3): Tetracycline[7]
- Alternative treatment (4): Niacinamide[7]
- Alternative treatment (5): Heparin[7]
- Alternative treatment (6): Cyclosporin
- 2.5 Monoclonal antibodies[8]
- Preferred treatment(1): Rituximab
- Note: Used is severe cases not improved by other medications.
- 2.1 Sulfones
- 1. Life style modification[2]
Choledocolithiasis
- Gall stones
- 1.1.1 Adult
- 1.1.1.1 Gall stone dissolution
- Preferred regimen (1): Ursodiol PO 8-10 mg/kg q24h in 2-3 divided doses (Max up to 24 months)
- 1.1.1.2 Gall stone prevention
- Preferred regimen (1): Ursodiol PO 300 mg q12h
- Primary biliary cirrhosis
- Preferred regimen (3): (Urso, Urso forte): Oral: 13-15 mg/kg/day in 2-4 divided doses (with food)
- 1.1.1.1 Gall stone dissolution
- 1.1.2 Pediatric
- 1.1.2.1 Children < 8 years of age
- Preferred regimen (1):In parenteral nutrition-induced cholestasis in neonates, some experts recommend: Oral: 30 mg/kg/day in 2- 3 divided doses
- 1.1.2.2 Children > 8 years of age
- 1.1.2.2.1 Gall stone dissolution
- Preferred regimen (1): Ursodiol PO 25 mg/kg q24h (Max up to 13 months)
- 1.1.2.1 Children < 8 years of age
- 1.1.1 Adult
- Lipid lowering agents
- 2.1.1 HMG CoA reductase inhibitors[9][10][11][12][13]
- Preferred regimen (1): Statins
- NOTE (1): Statinswill reduce cholesterol secretion hence the rationale for their use.
- 2.1.2 Cholesterol absorption inhibitor
- Preferred regimen (1): Ezetimibe
- NOTE (1): Ezetimibe is a hypocholesterolemic drug that acts by inhibiting intestinal cholesterol absorption.
- 2.1.1 HMG CoA reductase inhibitors[9][10][11][12][13]
- Dissolution agents
- 2.2.1 Monoterpenes
- Preferred regimen (1): Rowachol
- NOTE (1): Rowachol, an orally administered mixture of cyclic monoterpenes is capable of dissolving radiolucent and some radio-opaque gallstones.
- NOTE (2): It also enhances the efficacy of ursodeoxycholic acid or lithotripsy when used in combination.
- 2.2.1 Monoterpenes
References
- ↑ Rubio-Tapia A, Murray JA (2010). "Classification and management of refractory coeliac disease". Gut. 59 (4): 547–57. doi:10.1136/gut.2009.195131. PMC 2861306. PMID 20332526.
- ↑ Collin P, Reunala T (2003). "Recognition and management of the cutaneous manifestations of celiac disease: a guide for dermatologists". Am J Clin Dermatol. 4 (1): 13–20. PMID 12477369.
- ↑ Mutasim DF (2007). "Therapy of autoimmune bullous diseases". Ther Clin Risk Manag. 3 (1): 29–40. PMC 1936286. PMID 18360613.
- ↑ Han A (2009). "A practical approach to treating autoimmune bullous disorders with systemic medications". J Clin Aesthet Dermatol. 2 (5): 19–28. PMC 2924135. PMID 20729961.
- ↑ Bevans SL, Sami N (2017). "Dapsone and sulfasalazine combination therapy in dermatitis herpetiformis". Int. J. Dermatol. 56 (5): e90–e92. doi:10.1111/ijd.13542. PMID 28133723.
- ↑ Silvers DN, Juhlin EA, Berczeller PH, McSorley J (1980). "Treatment of dermatitis herpetiformis with colchicine". Arch Dermatol. 116 (12): 1373–84. PMID 7458365.
- ↑ 7.0 7.1 7.2 Shah SA, Ormerod AD (2000). "Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide". Clin. Exp. Dermatol. 25 (3): 204–5. PMID 10844495.
- ↑ Albers LN, Zone JJ, Stoff BK, Feldman RJ (2017). "Rituximab Treatment for Recalcitrant Dermatitis Herpetiformis". JAMA Dermatol. 153 (3): 315–318. doi:10.1001/jamadermatol.2016.4676. PMID 28030659.
- ↑ Saunders KD, Cates JA, Abedin MZ, Roslyn JJ (1993). "Lovastatin and gallstone dissolution: a preliminary study". Surgery. 113 (1): 28–35. PMID 8417484.
- ↑ Chapman BA, Burt MJ, Chisholm RJ, Allan RB, Yeo KH, Ross AG (1998). "Dissolution of gallstones with simvastatin, an HMG CoA reductase inhibitor". Dig. Dis. Sci. 43 (2): 349–53. PMID 9512129.
- ↑ de Bari O, Wang HH, Portincasa P, Paik CN, Liu M, Wang DQ (2014). "Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice". Eur. J. Clin. Invest. 44 (12): 1159–68. doi:10.1111/eci.12350. PMC 4659711. PMID 25303682.
- ↑ Doran J, Keighley MR, Bell GD (1979). "Rowachol--a possible treatment for cholesterol gallstones". Gut. 20 (4): 312–7. PMC 1412390. PMID 447112.
- ↑ Ellis WR, Somerville KW, Whitten BH, Bell GD (1984). "Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation". Br Med J (Clin Res Ed). 289 (6438): 153–6. PMC 1442019. PMID 6430390.