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Chapter: Modern Medical Toxicology: Miscellaneous Drugs and Poisons: Gastrointestinal and Endocrinal Drugs

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Bile Acids and Pancreatic Enzymes - Antiemetics and Prokinetic Drug

Bile acids are constituents of bile and are synthesised from cholesterol.

Bile Acids and Pancreatic Enzymes

Bile Acids

Bile acids are constituents of bile and are synthesised from cholesterol. After being secreted, they are largely reabsorbed in the ileum and recycled via an enterohepatic cycle. Examples include cholic acid, deoxycholic acid, chenodeoxycholic acid, ursodeoxycholic acid. They are used in the treatment of gall-stones and primary biliary cirrhosis.

Adverse effects include diarrhoea, pruritis, dry skin, sweating, hair thinning, nausea, dyspepsia, myalgia, rhinitis, insomnia.

Pancreatic Enzymes

Pancreatic enzymes are standardised preparations of pancreas which contain protease, amylase, and lipase. They are used in cases of pancreatic enzyme insufficiency, such as that found in cystic fibrosis. Examples include pancreatin and pancreli-pase, which contain amylase, lipase, and protease. They are used in the treatment of chronic pancreatitis and pancreatic insufficiency. Adverse effects include nausea, diarrhoea, and hyperuricaemia. Perianal irritation, particularly in infants, has been reported with therapeutic use. Many of these prod-ucts are made from hog pancrease, and hence, individuals sensitive to pork protein may experience allergic reactions. Pancreatic alpha amylase and trypsin have been determined to be two of the causative allergens. There have been several cases of these enzymes being contaminated by Salmonella. Folate absorption is inhibited by use of pancreatic extracts. These extracts form complexes with folates which reduce absorption. Patients on chronic therapy should have folate monitored.

Toxicity is uncommon, but there have been cases of hyper-sensitivity after inhalation, anal irritation, and oral irritation when the tablets are held in the mouth. Asthma, bronchial hypersensitivity, and pulmonary hypersensitivity have been reported after exposure to the powder in both home and occu-pational settings. These symptoms may occur in parents of children with cystic fibrosis. Fibrosing colonopathy have been reported in children with cystic fibrosis following long-term pancreatin therapy, with the majority of patients receiving high-dose preparations. It has been theorised that delayed gastrointestinal transit time and prolonged exposure of the colon to high-strength pancreatic enzymes in cystic fibrosis patients may be associated with the development of fibrosing colonopathy in these patients.

In general, pancreatic enzyme tablets are low in toxicity and are not expected to produce serious overdose effects. Treatment should be symptomatic and supportive. Patients should be monitored for irritation of the gastrointestinal tract, possible hypersensitivity reactions, and increased uric acid in the blood and urine. Dilution may be indicated following inges-tion of large amounts in order to reduce irritation. Immediately dilute with 4 to 8 ounces (120 to 240 ml) of water or milk (not to exceed 4 ounces or 120 ml in a child). Activated charcoal is generally not indicated because of low toxicity. Mild to moderate allergic reactions may be treated with antihistamines with or without inhaled beta agonists, corticosteroids or adrena-line. Treatment of severe anaphylaxis also includes oxygen supplementation, aggressive airway management, adrenaline, ECG monitoring and IV fluids.


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