LIVOLUK FIBRE

Indications

• Chronic constipation
• Portal-systemic encephalopathy

Dosage

Children: Child 1-11 months: 2.5 mL twice daily, adjusted according to response. Child 1-4 years: 5 mL twice daily, adjusted according to response. Child 5-10 years: 10 mL twice daily, adjusted according to response. Child 5-17 years: 5-20 mL twice daily, adjusted according

Adults: Initially 15 mL twice daily, adjusted according to response. For hepatic encephalopathy, doses can be 30-50 mL three times a day, adjusted to produce 2-3 soft stools per day.

Mechanism of action

Lactulose is broken down by saccharolytic bacteria in the large intestine into organic acids, such as lactic acid, which increases intraluminal gas formation and enhances peristaltic gut motility. This osmotic effect increases water content in stool, facilitating bowel movements. Additionally, it acidifies the colonic contents, helping to treat portal-systemic encephalopathy by promoting the conversion of ammonia to ammonium ions, which are less absorbable.

Pharmacodynamics

Lactulose has minimal systemic absorption, exerting its effects predominantly within the gastrointestinal tract. It enhances stool volume and softens stool, which may lead to increased bowel sounds, feelings of bloating, belching, flatus, and diarrhea. These effects contribute to its laxative properties and its role in treating hepatic encephalopathy.

Pharmacokinetics

Lactulose is poorly absorbed from the gastrointestinal tract and exerts its action locally. It typically takes 24 to 48 hours to manifest its laxative effect. The substance is not metabolized before reaching the colon, where it is fermented by gut bacteria, resulting in the production of short-chain fatty acids and gases.

Contra-indications

• Galactosaemia
• Gastrointestinal obstruction
• Gastrointestinal perforation
• Risk of gastrointestinal perforation
• Lactose intolerance

Adverse effects

• Diarrhoea
• Gastrointestinal discomfort
• Nausea
• Abdominal pain
• Flatulence
• Vomiting
• Electrolyte imbalance

Precautions

• Caution in patients with a history of gastrointestinal disorders
• Monitor for electrolyte imbalance in prolonged use

Pregnancy

Not known to be harmful, but manufacturer advises to avoid.

Breast-feeding

Manufacturer advises to avoid.

Storage

Store in a cool, dry place away from direct sunlight. Keep out of reach of children.

Formulations

• Lactulose 10g/15ml oral solution
• Lactulose 680 mg per 1 ml
• Lactulose granules

Indications

• Constipation
• Irritable bowel syndrome (IBS)
• Diverticular disease
• Cholesterol management
• Blood sugar control in diabetes

Dosage

Children: For children, it is recommended to consult a healthcare provider for appropriate dosing based on age and weight, as specific pediatric dosing

Adults: For adults, the typical dosage is 1 to 2 teaspoons (5 to 10 grams) of psyllium husk taken 1 to 3 times daily, mixed with at least 8 ounces of water or other liquid.

Mechanism of action

Psyllium husk acts as a bulk-forming laxative. It is not digested by the body, but when mixed with water, it expands and forms a viscous gel. This gel increases the bulk of the stool and triggers peristalsis, enhancing bowel movements. Additionally, it may slow down the absorption of carbohydrates and fats, contributing to its cholesterol-lowering and blood sugar-regulating effects.

Pharmacodynamics

The primary pharmacodynamic effect of husk is its ability to increase stool bulk and water content, which facilitates easier passage of stool through the intestines. This leads to improved bowel regularity and relief from constipation. Furthermore, psyllium husk has been shown to have a mild effect on lowering serum cholesterol levels, particularly low-density lipoprotein (LDL) cholesterol, and may improve glycemic control in patients with type 2 diabetes.

Pharmacokinetics

Psyllium husk is not absorbed systemically; it remains in the gastrointestinal tract, where it exerts its effects. The onset of action for bowel regulation typically occurs within 12 to 72 hours after ingestion, depending on the individual's digestive transit time and fluid intake. Adequate hydration is essential to maximize its efficacy and prevent potential gastrointestinal obstruction.

Adverse effects

• Bloating
• Abdominal cramping
• Diarrhea
• Nausea

Precautions

• Ensure adequate fluid intake when using husk to prevent gastrointestinal obstruction
• Monitor for allergic reactions in sensitive individuals

Pregnancy

Generally considered safe to use during pregnancy, but always consult a healthcare provider.

Breast-feeding

Considered safe while breastfeeding, but consult a healthcare provider for personalized advice.

Storage

Store in a cool, dry place, away from direct sunlight and moisture.

Formulations

• Psyllium husk powder
• Psyllium husk capsules
• Psyllium husk granules

Indications

• Constipation
• Irritable bowel syndrome
• Diverticular disease
• Hyperlipidemia

Dosage

Children: Refer to the BNF for Children for appropriate dosing guidelines in children.

Adults: Refer to the BNF for specific dosing recommendations, typically starting with a standard dose that can be adjusted based on individual response.

Mechanism of action

Ispaghula acts as a soluble fiber that increases the water content and bulk of the stool. This action stimulates peristalsis (the wave-like muscle contractions of the intestines) and facilitates easier passage of stool through the gastrointestinal tract. It may also contribute to the modulation of intestinal microbiota and has prebiotic effects, promoting the growth of beneficial gut bacteria.

Pharmacodynamics

Ispaghula exhibits its pharmacodynamic effects through its ability to absorb water and swell in the gastrointestinal tract, which increases stool mass and triggers bowel movements. This bulk-forming property helps alleviate constipation and maintains bowel health. Additionally, the gel-like substance formed can slow down the absorption of glucose and cholesterol, providing further metabolic benefits.

Pharmacokinetics

Ispaghula is not absorbed in the gastrointestinal tract, which means it does not have systemic effects. It passes through the digestive system and is excreted unchanged. The onset of action typically occurs within 12 to 72 hours after ingestion, depending on the individual and the volume of fluid consumed with the fiber. Adequate hydration is necessary for optimal efficacy.

Contra-indications

• Intestinal obstruction
• Severe dehydration
• Dysphagia

Adverse effects

• Abdominal bloating
• Flatulence
• Diarrhea
• Constipation
• Esophageal obstruction

Interactions

• May reduce the absorption of concomitantly administered oral medications due to its bulk-forming properties
• Caution should be exercised when taken with anticoagulants as it may affect their absorption

Precautions

• Adequate fluid intake should be ensured to prevent esophageal obstruction
• Caution in patients with a history of gastrointestinal disorders

Pregnancy

Generally considered safe for use during pregnancy, but it is advisable to consult a healthcare provider.

Breast-feeding

Considered safe during breastfeeding; however, maternal hydration should be maintained.

Storage

Store in a cool, dry place, away from direct sunlight.

Formulations

• Powder for oral suspension
• Granules for oral intake
• Tablets

Mechanism of action

Lactulose is a synthetic disaccharide derivative of lactose that consists of one molecule of galactose and one molecule of fructose. Saccharolytic bacteria present in the large intestine subsequently break the substance down into organic acids like lactic acid and small amounts of formic and acetic acids. Such resultant volatile fatty acid metabolites, in combination with hydrogen and methane that is also generated consequently enhance intraluminal gas formation, peristaltic gut motility, and elicit an osmotic effect that facilitates an increase in the water content of stool as well as associated stool softening. All of these actions ultimately assist in facilitating and increasing the frequency of bowel movements in patients experiencing constipation, although it may take 24 to 48 hours after using the medication for this laxative effect to become evident. At the same time, the formation of such acids via the metabolism of lactulose by colonic bacteria also acidifies the contents of the colon, thereby contributing to the treatment of portal-systemic encephalopathy (PSE). As one of the principal features of PSE involves the accumulation of nitrogenous waste products like ammonia in the systemic circulation, a state in which the colonic contents become more acidic than blood allows ammonia in the circulation to diffuse into the colon.. Furthermore, ammonia that diffuses into the acidic colon is ionized to ammonium ions that are incapable of being absorbed back into the blood. These effects, combined with the laxative action of lactulose facilitates the excretion of excess ammonia. And finally, it is also believed that an acidic colonic environment results in the elimination of urease-producing bacteria that contribute to the formation of ammonia while surviving colonic bacteria use up any trapped ammonia in the colon as a source of nitrogen for protein synthesis.

Pharmacodynamics

Lactulose formulations are most commonly administered via the oral route or the rectal route. Consequently, because the substance experiences minimal absorption by the gut it typically remains localized in the gastrointestinal tract environment and ultimately demonstrates almost all of its pharmacologic effects within the gut. In particular, as lactulose elicits its laxative effects in enhancing stool amounts and softening stool, such biochemical and physiologic activities can cause increased bowel sounds (borborygmi), a feeling of bloatedness, belching, frequent flatus, and diarrhea.