Duration of PPI in H Pylori Eradication

• Proton pump inhibitors have both direct and indirect effects on H. pylori eradication.
• The PPIs directly affect H. pylori by reducing its density and causing lysis of the H. pylori at neutral pH in the presence of urea.
• Indirectly, PPIs increase antibiotic concentration in gastric juice by reducing the volume of gastric-acid secretion.
• They increase the permeability of gastric juice by decreasing its viscosity, and they reduce the degradation of acid-labile antibiotics in the stomach by increasing intragastric pH

Shorter Duration

• Laine's study compared 7, 10, and 14 days of omeprazole, amoxicillin, clarithromycin (OAC) therapy and evaluated compliance and side effects. Compliance was perfect at 7 days but worsened at 10 and 14 days of therapy.
• Similarly, side effects did not occur at 7 days but were present both at 10 and 14 days of therapy
• Short-term H. pylori eradication therapy tends to improve compliance, reduce the incidence of side effects, and decrease the cost of therapy by up to 50%

Long Term Use : Against

• Recurrence of ulcers following  H. pylori eradication are uncommon. One prospective study which followed 141 duodenal ulcer and 45 gastric ulcer patients for 9.8 years found no ulcer recurrence after  H. pylori eradication in patients not taking ASA or NSAIDs. Thus, most patients do not require further acid suppression treatment following  H. pylori eradication. Addittional short term acid suppression with PPI or H2RA may be indicated in symptomatic patients.¹
• A 5-yr prospective, randomized, controlled study by Liu et al. in 82 Taiwanese patients with a history of ulcer bleeding demonstrated that maintenance acid suppression was not routinely necessary to prevent ulcer recurrence after successful H. pylori eradication and ulcer healing.²
• Rebound acid hypersecretion occurs in H. pylori-negative subjects after omeprazole treatment. Its severity is related to the degree of elevation of pH on treatment. Persisting suppression of acid secretion masks the phenomenon in H. pylori-positive subjects.³
•  Development of gastric erosions after H. pylori eradication may be controlled by acid suppression treatment. Less severe atrophy or more severe gastritis in oxyntic glands before eradication may be involved in the development of gastric erosions. These results support the idea that recovery of acid secretion may be one of factors for development of gastric mucosal erosions after successful eradication.⁴
• There is one study shows that one-week triple therapy alone is highly effective healing non-complicated H.Pylori associated duodenal ulcer without additional antisecretory treatment.⁵
• The use of proton pump inhibitors for a long periodand presence of H. pylori infection are risk factors for enterochromaffin-like cell hyperplasia
• For uncomplicated duodenal ulcers, once H. pylori has been eradicated, continued PPI use does not produce higher ulcer healing rates and is generally not indicated.

Long Term Use: Supporting

• PPI may be indicated for acute healing of gastric ulcer.

Recommendations

• Prolonged PPI therapy (e.g., for 4 to 8 weeks) after a course of eradication therapy is not routinely recommended for uncomplicated duodenal ulcers but has been recommended for gastric ulcers or complicated duodenal ulcers

References:

1. http://www.rxfiles.ca/rxfiles/uploads/documents/hpylori.pdf
2. http://gi.org/guideline/management-of-helicobacter-pylori-infection/
3. http://www.ncbi.nlm.nih.gov/pubmed/9922302/
4. http://www.ncbi.nlm.nih.gov/pubmed/11966544
5. http://www.ncbi.nlm.nih.gov/pubmed/10962387
6. http://www.aafp.org/afp/2002/0715/p273.html
7. Effects of Helicobacter pylori infection and long-term proton pump inhibitor use on enterochromaffin-like cells. Annals of Gastroenterology (2012) 25, 123-127
8. Test and Treat for Helicobacter pylori in Dyspepsia, British Infection Association
9.  MEDICAID DRUG USE REVIEW CRITERIA FOR OUTPATIENT USE, Drug Information Service, The University of Texas Health Science Center at San Antonio, and the College of Pharmacy, The University of Texas at Austin.
10. PPI DEPRESCRIBING Approaches for stopping or dose reduction of PPIs
    in those who may not need lifelong treatment, April 2015

Magnesium Trisilicate: Children & Pregnancy

Syrup Magnesium Trisilicate: 

• Mg Carbonate Light / Mg Trisilicate / Sodium Hydrogen Carbonate – all at 250mg/5ml

Tablet Magnesium Trisilicate: 

• Mg Trisilicate 250mg, Dried Aluminium Hydroxide 120mg

Children 

• Antacids are appropriate for short-term relief of heartburn in older children, adolescents, or adults with infrequent symptoms (less than once a week). 
• The efficacy and safety of antacids have not been well-studied, and chronic use is generally not recommended, especially in infants due to potential complications such as hypophosphatemic rickets

o    5-12 years: 5-10ml with water, TDS or as required

o    12-18 years: 10-20ml with water, TDS or as required

o    CHILD over 6 years: 1 tablet to be taken 3-4 times a day

Pregnancy & Lactation 

• Only limited data exist concerning the effects of antacids on the fetus with no controlled trials of efficacy. 
• Magnesium-, aluminium-, or calcium-containing antacids are not teratogeneic in animal studies although 15-30% of magnesium and a smaller percentage of aluminium preparations are absorbed after reacting with hydrochloric acid. 
• analysis of individual antacids (aluminium hydroxide, sodium bicarbonate, magnesium trisilicate and calcium carbonate) found no association with increased congenital anomalies. 
•  A recent European consensus conference recommended calcium/magnesium-based antacids for pregnant women because of their safety profile 
• Antacids should be taken at a different time than supplemental iron, because normal gastric acid facilitates the absorption of iron.

References:

1.      www.uptodate.com

2.      http://online1.mimsgateway.com.my/

3.      https://www.medicines.org.uk/emc/medicine/25289

Cordyceps: Interactions

• Cordyceps is a fungus that lives on certain caterpillars in the high mountain regions of China

Rationale For Use

• More evidence is needed to rate the effectiveness of cordyceps for these uses
• Cordyceps MIGHT improve immunity by stimulating cells and specific chemicals in the immune system
• coughs, chronic bronchitis, respiratory disorders, kidney disorders, nighttime urination, male sexual problems, anemia, irregular heartbeat, high cholesterol, liver disorders, dizziness, weakness, ringing in the ears, unwanted weight loss, and opiumaddiction. 
• It is also used for strengthening the immune system, improving athletic performance, reducing the effects of aging, promoting longer life, and improving liver function in people with hepatitis B. 
• Some people use cordyceps as a stimulant, a tonic, and an “adaptogen,” which is used to increase energy, enhance stamina, and reduce fatigue.

Safety

• Cordyceps is POSSIBLY SAFE for most people when taken appropriately by mouth, short-term

Pregnancy and breast-feeding:

• There is not enough reliable information about the safety of taking cordyceps if 
• Stay on the safe side and avoid use

Interactions

Cyclophosphamide

• might decrease the effectiveness of cyclophosphamide

Immunosuppressants

• Cordyceps might increase the immune system.
• Decrease the effectiveness of medications that decrease the immune system.
  Some medications that decrease the immune system include azathioprine (Imuran), basiliximab (Simulect), cyclosporine (Neoral, Sandimmune), daclizumab (Zenapax), muromonab-CD3 (OKT3, Orthoclone OKT3), mycophenolate (CellCept), tacrolimus (FK506, Prograf), sirolimus (Rapamune), prednisone (Deltasone, Orasone), corticosteroids (glucocorticoids), and others.

Prednisolone

• Prednisolone is sometimes used to decrease the immune system.
• Taking cordyceps might make prednisolone less effective for decreasing the immune system.

Drugs that increase the risk of bleeding

• aspirin, anticoagulants (blood thinners) such as warfarin (Coumadin®) or heparin, antiplatelet drugs such as clopidogrel (Plavix®), and nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®).
• Multiple cases of bleeding have been reported with the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto

Antidiabetic Medications

• Cordyceps may lower blood sugar levels.
• Caution is advised in people with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar.
• Blood glucose levels may need to be monitored

Antihypertensives

• Cordyceps may cause low blood pressure.
• Caution is advised in people taking drugs or herbs and supplements that lower blood pressure.

Bleeding disorders

• Cordyceps might slow blood clotting.
• might increase the risk of bleeding in people with bleeding disorders.

Surgery

• might increase the risk of bleeding during surgery.
• Stop taking cordyceps 2 weeks before surgery

References:

1. http://www.webmd.com/vitamins-supplements/ingredientmono-602-cordyceps.aspx?activeingredientid=602
2. http://www.wellness.com/reference/herb/cordyceps-cordyceps-sinensis/dosing-and-safety
3. https://www.drugs.com/npp/cordyceps.html
4. http://www.rxlist.com/cordyceps-page3/supplements.htm#Interactions

Alfacalcidol : Via Ryles Tube

Availability:

• Soft gel capsule or 250mcg and 500mcg

Administration

• Manufacturer do not recommend opening the capsules owing to the risk of administering an incomplete dose

Administration Capsule

• With capsules, the gelatin is usually a binding agent in the capsule rather than in the medicine itself.
• A simple alternative can be to to pierce liquid-containing capsules and squeeze the liquid onto a spoon
• No information available on stability of solution with food or milk, thus advice for direction administration into mouth of infants

Recommendations:

• Use of oral drops (2mcg/drop)
• A prolonged break in the feed in not required
• Several references also uses One-Alpha injection orally or via feeding tube

References:

1. https://www.medicines.org.uk/emc/medicine/1030
2. stockportccg.org/wp-content/uploads/2012/01/34838_Med_Admin_Dysphagia.pdf
3. NEEMMC GUIDELINES FOR TABLET CRUSHING AND ADMINISTRATION VIA ENTERAL FEEDING TUBES
4. Handbook of Drug Administration via Enteral Feeding Tubes

Moringa: Drug Interactions

• Moringa oleifera is a tree that is sometimes called the Tree of Life or a Miracle Tree. It is a plant that is native to the sub-Himalayan areas of India, Pakistan, Bangladesh, and Afghanistan. The leaves, bark, flowers, fruit, and seeds are used to make medicine.¹
• The leaves, fruit, and seeds of Moringa might be safe when eaten as food. However, it's important to avoid eating the root and its extracts. These parts of the plant may contain a toxic substance that can cause paralysis and death.¹
• Moringa has been used safely in doses up to 6 grams daily for up to 3 weeks.¹

Interaction 

• evidences of actual case reports or on established findings are still lacking

Levothyroxine²

• Taking moringa along with levothyroxine might decrease the effectiveness of levothyroxine because it will decrease the absorption of levothyroxine in the body.

Medications changed by the liver (cytochrome P450 (CYP3A4) substrates)²

• Moringa might decrease how quickly the liver breaks down some medications.  Thus by taking moringa along with some medications that are broken down by the liver can increase the effects and side effects of that medications.
• Example of drugs that are broken down by the liver:
• Lovastatin
• Ketoconazole
• Itraconazole
• Fexofenadine
• Triazolam and etc.

Medications for Diabetes (Antidiabetic)²

• Moringa might lower the blood sugar level. For diabetes patient who are taking the medications with this supplement, they need to monitor closely their blood sugar.
• Example of medications:
• Insulin
• Gliclazide
• Glimeperide
• Glyburide
• Rosiglitazone and etc.

Medications for Hypertension (Antihypertensive)²

• Moringa might lower blood pressure. For hypertension patient who are taking the antihypertensives medications with this supplement, they need to monitor closely their blood pressure.
• Example of medications :
• Captopril
• Enalapril
• Losartan
• Valsartan
• Diltiazem
• Amlodipine
• Hydrochlorothiazide and etc.

Anticoagulant medications³

• Moringa has anticoagulant properties. For patients who are taking the anticoagulant medications with this supplement, they have high risk of bleeding and they need to monitor closely the sign and symptom of bleeding.
• Example of drugs :
• Warfarin
• Heparin
• Clopidogrel and etc.

Reference

1. http://www.webmd.com/vitamins-supplements/ingredientmono-1242-moringa.aspx?activeingredientid=1242
2. http://www.rxlist.com/drumstick_tree-page3/supplements.htm#Interactions
3. https://naturalmedicines.therapeuticresearch.com/