Trimedat has become a popular drug among gastroenterologists and other specialists who prescribe it for the treatment of pancreatitis and pathologies of the abdominal organs, since its gentle and selective action can not only normalize the motor function of the entire gastrointestinal tract, but also regulate its work as needed.
The basis of this drug, which belongs to the group of myotropic antispasmodics, is the substance trimebutine. It selectively acts either on excitation receptors or on suppressing excitation of smooth muscles of the digestive tract, regulating its functioning. With spasms of smooth muscles, trimebutine relaxes them, and with hypotension, it stimulates them.
The gastrointestinal tract is the entry point for the virus.
The virus enters the body not only through the respiratory tract, but also through the cells of the gastrointestinal tract and liver, on the surface of which receptors (or entry gates) for the virus are also found. Therefore, a feature of COVID-19 is the high frequency of symptoms from the digestive system
.
Approximately 15% of patients with COVID-19 experience nausea and vomiting, loss of appetite, loose stools, and abdominal pain. Sometimes these symptoms turn out to be the first manifestations of the disease
, that is, they precede symptoms from the respiratory system, fever, etc. That is why experts around the world have concluded that
all patients with new gastrointestinal complaints should be tested for COVID-19
.
In addition, in approximately 1/3 of patients, especially with severe COVID-19, changes in the biochemical blood test are observed, indicating liver damage (increased AST, ALT, bilirubin, alkaline phosphatase, gamma-glutamyltransferase).
As a rule, all of the listed symptoms and abnormalities go away on their own during recovery. However, complications can also occur - the formation of erosions and ulcers, gastric bleeding and others.
The risk of contracting the virus, as well as complications of this infection, is higher in patients who had any chronic digestive disease before COVID-19. In addition, the complex treatment prescribed for COVID-19, in particular non-steroidal anti-inflammatory drugs (ibuprofen, etc.), antibiotics, antiviral drugs, etc., can have a negative effect on the digestive organs.
Undesirable side effects and contraindications
Trimedat is contraindicated for use in the following conditions:
- Individual hypersensitivity to the components of the drug;
- I trimester of pregnancy;
- Breastfeeding period;
- Age up to 3 years (for the drug in tablets).
If trimedat is used correctly and in compliance with all doctor’s recommendations, the drug rarely has side effects. When they occur, they are almost always mild and easily eliminated on their own.
Undesirable side effects of trimedat include allergic manifestations on the skin, which occur due to hypersensitivity to one of the components of the drug. They can be of varying degrees of intensity and appear as:
- Redness of the skin;
- hives or rash;
- Sensations of itching and burning of the skin.
If you do get sick with COVID-19
It is important to inform the doctor treating COVID-19 about the chronic disease you have and the medications you are taking.
.
This will allow the doctor to choose the safest treatment for you and avoid prescribing medications that may adversely interact with the medications you regularly take.
If you have chronic liver disease, when infected with COVID-19, you should avoid an overdose of paracetamol (no more than 2 grams per day), and also minimize the use of non-steroidal anti-inflammatory drugs. Do not cancel your ongoing treatment for liver disease; discuss with your doctor the addition of ursodeoxycholic acid for the prevention and treatment of drug-induced liver damage.
If you have an autoimmune liver or intestinal disease, doctors recommend continuing your ongoing therapy, but taking medications such as azathioprine and methotrexate may be temporarily suspended.
If you have GERD or a peptic ulcer, then among antisecretory drugs you should give preference to rabeprazole or pantoprozole - safer in terms of the risk of drug interactions. It is important to avoid or minimize the use of non-steroidal anti-inflammatory drugs. During the period of COVID-19 disease, to prevent complications, doctors recommend additionally taking drugs that have a protective effect on the mucous membrane of the esophagus and stomach (rebamipide, etc.).
Consequences of COVID-19 in patients with digestive diseases
A severe infection can lead to exacerbation and decompensation of chronic liver disease
, especially at the stage of liver cirrhosis.
It is rare to experience a severe reaction to drugs used to treat COVID-19 in the form of drug-induced hepatitis. This disease can also develop in patients with a previously healthy liver. Even more rarely, a virus and drugs can trigger the development of autoimmune liver disease
.
Therefore, all patients who have had COVID-19 should monitor a biochemical blood test after the infection resolves and, if abnormalities in biochemical parameters persist, contact a hepatologist
.
Previous COVID-19 and drug exposure can lead to exacerbation and complications (for example, bleeding, diarrhea) of other digestive diseases. Taking antibacterial drugs can lead to disruption of intestinal microflora
with the development of loose stools (so-called antibiotic-induced diarrhea).
This diarrhea goes away on its own and with the use of medications - probiotics, adsorbents. However, in some cases, if a special bacterium (clostridium) is present in the intestines, a severe and dangerous form of diarrhea can develop, which is called pseudomembranous colitis
.
Therefore, in all cases of abdominal pain, heartburn, nausea, diarrhea and bloating after COVID-19, you should consult a gastroenterologist and conduct a full examination to clarify the cause and carry out appropriate treatment
.
New opportunities in pain and replacement therapy for chronic pancreatitis.
Elena Aleksandrovna Poluektova , doctor, candidate of medical sciences:
– We are returning to gastroenterology, and the message will be given by Doctor of Medical Sciences, Professor Oleg Samuilovich Shifrin “New opportunities in pain and replacement therapy for chronic pancreatitis.”
Oleg Samuilovich Shifrin , professor, doctor of medical sciences:
– Dear colleagues, the working group of the Russian Gastroenterological Association has developed recommendations for the management of patients with chronic pancreatitis. Please note that very important fundamental principles that a doctor should take into account in the management of this type of patient are indicated in red. This is the determination of the cause of pain, abdominal pain in chronic pancreatitis and its treatment. The second important area is the treatment of exocrine pancreatic insufficiency. These are the questions that form the basis of my message.
So, at the onset of chronic pancreatitis, abdominal pain occupies a very important place, this is a cardinal sign. It occurs much more often than manifestations of exocrine insufficiency, symptoms of pancreatogenic diabetes, jaundice, etc. In almost 90% of patients with various forms of pancreatitis, regardless of etiology, pain occupies a central leading place at the onset of the disease. At an advanced stage of the disease, exocrine insufficiency may come to the fore, and this is important to take into account.
Clinical example. A 54-year-old man came to our clinic with a complaint of severe abdominal pain in the upper abdomen of a semi-girdling nature, most often occurring about 30-40 minutes after eating, severe painful bloating and diarrhea (unformed stool about 2 -3 times a day). It should be noted that the patient abused alcohol for 2-3 decades, drank about 2-3 bottles of strong alcoholic drinks a week, and smoked a lot. Smoker's index 240 points. We will dwell a little later on the interaction of these two extremely important pancreatotoxic factors: alcohol and smoking.
So, urine tests revealed that the patient had a 2-3-fold level of hyperamylasuria. Therapy with drotaverine, secretion blockers, and festal was ineffective.
What questions should you ask when undertaking to treat this patient? First, the diagnosis should be clarified: is it pancreatitis? It is no secret that pancreatitis, unfortunately, is very often both underdiagnosed and overdiagnosed. Next, when confirming the diagnosis, the question must be asked: what kind of pancreatitis is this? It is very important to determine the etiology and morphological form of the disease. It is necessary to identify and highlight the main clinical syndromes of the disease. And finally, if there is abdominal pain, and our patient has severe abdominal pain, its nature should be determined. This is fundamentally important in the future when prescribing optimal therapy.
It should be said that according to the Heidelberg classification, the so-called M-ANNHEIM classification, German colleagues identify the polyetiological cause of the development of pancreatitis. That is, various factors are combined in different proportions, and very rarely we are faced with a monoetiological form of the disease.
In our patient, two pancreatotoxic factors are clearly identified (even when questioning him): alcohol abuse and smoking. When interacting, these factors mutually reinforce each other, causing rapid development and progression of the disease.
Objectively, pain in the projection of the pancreas and bloating were noted. Otherwise, no significant changes were found. The analyzes showed a twofold increase in urine amylase levels. Please note that, despite obvious manifestations of exocrine insufficiency, fecal elastase is within normal limits.
Computed tomography shows the heterogeneous structure of the pancreas, but no pronounced local changes such as pseudocysts were identified.
Speaking about the causes of pain in a patient, we should highlight the pain associated with the actual inflammation of the pancreatic tissue, no matter whether exudation processes predominate, when inflammatory edema compresses the nerve ganglia, or when alterative processes predominate in the inflammatory substrate, when biologically active substances act on the membrane of the nerve ganglia and destroy it. In these cases, inflammation itself plays a leading role in the genesis of pain. This is type A pain, which we will discuss a little later.
In the case of complications of the actual inflammation of the pancreatic tissue with the development of pseudocysts, in which aggressive pancreatic juice affects the exposed nerve endings, with compression of the bile ducts or duodenum enlarged due to inflammation by the head of the pancreas, or due to compression of the Wirsung duct by areas of fibrosis, pain occurs B -type.
What is their difference? Type A pain, that is, pain caused by inflammation of the pancreatic tissue itself, is distinguished by a relatively short duration, usually somewhere less than two weeks, with long light intervals of several months. And the effect comes from conservative therapy, no matter whether it is the prescription of several paracetamol tablets or hospitalization of the patient in the intensive care unit with a set of measures to treat severe exacerbation of pancreatitis. But healing and improvement in this case are brought about by conservative tactics, that is, such patients are under the care of gastroenterologists and therapists.
B-type pain. Clinically, it is distinguished by a long period of exacerbation, usually at least two months, short clear intervals and the effect occurs either from surgical or endoscopic treatment methods.
Another mechanism of abdominal pain in chronic pancreatitis. Already at the relatively early stages of the disease, the production of bicarbonate solution by the pancreas (the pancreas, let me remind you, weighs only 60-80 grams) decreases. A healthy pancreas produces one and a half to two liters of bicarbonate solution per day. Due to a decrease in the production of bicarbonate solution, acidification of the initial parts of the duodenum occurs, due to acidification of the environment in the intestine, enzymes are inactivated, and manifestations of exocrine insufficiency occur. And all this is accompanied by severe motor impairment and the development of flatulence, which sometimes patients cannot distinguish from a feeling of abdominal pain. Let me remind you that our patient has severe flatulence, which sharply reduces his quality of life.
So, what are the main directions of pain treatment, conservative directions? I emphasize that this is a treatment for type A pain. Quitting smoking and drinking alcohol for any form of pancreatitis, not necessarily for toxic forms, both for biliary and hereditary; for any pancreatitis, additional pancreatotoxic factors should be abandoned and removed. The first step is to prescribe mild analgesics, then “light” opioids such as tramadol may be prescribed, but this rarely happens, and even less often, in exceptional cases with pancreatitis, unlike pancreatic cancer, classical narcotic drugs are prescribed. This is a last resort; each time this approach requires a very careful discussion and assessment of the full depth of the situation in relation to a particular patient. Tricyclic antidepressants - the so-called drug denervation of the pancreas - are an effective method of treating type A abdominal pain.
Please note that secretion inhibitors, which we very often use in the treatment of abdominal pain in chronic pancreatitis, as well as sandostatin, do not show their effectiveness in the treatment of painful pancreatitis in controlled studies. Obviously, this is due to the fact that the study group includes patients with both A-pain and B-pain, that is, there is a mixture of different types of pain. And accordingly, when processing statistical data, it is not possible to obtain reliable results. Although all of us clinicians know very well that we begin to treat abdominal pain, first of all, with a combination of enzyme preparations and secretion inhibitors.
So, let's focus on enzyme preparations. Classic studies from the end of the last century showed that traditional pancreatin tablets are more effective in the treatment of A-type abdominal pain in chronic pancreatitis, and they also significantly reduce pressure in the pancreatic ducts. At the same time, encapsulated, microgranulated pancreatin preparations do not significantly reduce the level of A-type abdominal pain and do not significantly reduce elevated pressure in the pancreas ductal system.
Due to lack of time, I will not dwell on the pathogenesis of the action of tablet and microgranular drugs. But the point is that tablet drugs use the releasing system, a feedback mechanism, to a greater extent, because pancreatin, which is contained in tablets, proteases begin to act earlier in the initial parts of the duodenum, where, in fact, the feedback mechanism is carried out , where the releasing system operates.
Let's return to our patient. Chronic pancreatitis in the acute stage, caused by toxic factors (alcohol and smoking), first stage according to the Cambridge classification. Small intestinal microbial overgrowth syndrome. Exogenous-constitutional obesity of the first degree, this is also often found with pancreatitis. One should not necessarily think that all these patients must necessarily be extremely emaciated.
What are the directions of treatment tactics? We convinced the patient, including his relatives, that he completely needed to give up alcohol and smoking. The patient received sufficient detoxification therapy. We prescribed him the drug Mezim 20,000, two tablets 3 times a day until his condition improved, then we slightly reduced this dosage, and omeprazole. I will add that, taking into account the microbial overgrowth syndrome, a short course of seven-day treatment with rifaximin, an antibacterial drug, was also prescribed.
In our clinic, a study was conducted to compare the analgesic effect of classic pancreatin mezim 10,000 tablets and encapsulated pancreatin in the form of microspheres containing the same amount of lipase - 10,000 in one capsule. It was noted that Mezim 10,000 more often effectively reduced the level of pain and even stopped it completely, Mezim 10,000 less often caused the development of constipation, and Mezim 10,000 quite effectively reduced the level of flatulence, which often bothers our patients. Thus, Mezim 10000 and Mezim 20000, which reappeared on the market about a year ago, can effectively relieve type A abdominal pain, and they provide its effective leveling in case of moderate exocrine insufficiency. In addition, it should be noted that against the background of tablet preparations of pancreatin in the form of Mezim 10000 and Mezim 20000, such a complication of enzymatic therapy as constipation occurs less frequently.
Let us return once again to the main directions of treatment of chronic pancreatitis. In addition to eliminating toxic factors, we must prescribe enzyme preparations in an adequate dose, this is when treating abdominal pain, primarily with tablet preparations. If abdominal pain is combined with a severe degree of exocrine insufficiency, already encapsulated drugs are added.
I want to say that now a new pancreatin drug is appearing on our market - pancreatin microtablets enclosed in capsules - pangrol drug. It will be represented by 10,000 pancreatin capsules in terms of lipase content and, accordingly, pangrol 25,000 units, which contain 2.5 times more lipase. We will look at this drug in more detail a little later.
In addition, proton pump blockers are required. It should be borne in mind here that in the presence of, say, biliary pancreatitis, octreotide, which causes thickening of bile, should be used with caution, but nevertheless it has a good antisecretory effect in terms of the pancreas itself.
When treating spastic disorders (they most often occur with pancreatitis), it is certainly necessary to use antispasmodics, drug denervation of the pancreas, and prescribe tricyclic antidepressants. And mandatory treatment of trophological deficiency, microbial overgrowth syndrome, which is very often combined with chronic pancreatitis, and, finally, antioxidant therapy.
What is the advantage of the drug Mezim 20000? It contains a more effective enzymatic complex compared to Mezim 10000, which allows us to reduce the number of tablets that we prescribe to the patient, and this is very important, since in this case the patient’s desire to follow the doctor’s instructions increases. Patients do not like to take a large number of pills, patient compliance and their mood for treatment increases.
The drug Pangrol is, as I already said, capsules filled with mini-tablets. Each mini-tablet contains 500 units of lipase. Two forms of release are capsules of 10,000 units and capsules of 25,000 units. It is very important that the minitablets are coated not only with an enteric coating that is resistant to acidic gastric juice, but also with a functional membrane. This functional membrane, made on the basis of methacrylic acid derivatives, allows the drug to be released evenly in the small intestine. That is, you see, a comparison was made of how enzymes, in particular lipase, are released from mini-tablets and from mini-microspheres. It turned out that enzymes are released more evenly from minitablets, which is very important in relation to the treatment of exocrine pancreatic insufficiency.
In addition, mini-tablets ensure uniform mixing with food, and optimal activation of enzymes occurs in different parts of the small intestine.
It turned out that pangrol significantly reduces steatorrhea already on the 5th day of treatment, and in patients with severe exocrine pancreatic insufficiency.
It is very important that during therapy, in most patients, by the sixth month of treatment, body weight is normalized and serum albumin levels are normalized.
And I wanted to conclude my speech by saying that, despite the fact that new modern drugs have appeared in the treatment of chronic pancreatitis, in particular enzymatic drugs, the work of a gastroenterologist, the work of a therapist has not become less difficult. But the fact that new effective drugs have appeared makes it possible to make it more effective, that is, to help more of our patients.
