Drug treatments in BAM

Anti-diarrhoea medicines such as codeine phosphate or loperamide (Imodium). Anti-diarrhoea drugs are usually much more effective if taken 30-60 minutes before main meals. They are most helpful in people with mild bile salt malabsorption. Taking a regular dose at the same time(s) every day seems to give the most benefit. However, most people find that they still get unpredictable episodes of diarrhoea even when taking the anti-diarrhoea drugs regularly. Anti-diarrhoea drugs are least likely to help those people with bile salt malabsorption that have frequent greasy, pale stools.

Bile acid sequestrants: These are a very specific treatment for bile acid malabsorption. Currently, there are two different types of bile acid sequestrant available in powder and tablet forms.

Powders: There are two similar types of powders, colestyramine (Questran) and colestipol (Colestid). These have been available for years. Very occasionally, a dose on alternate days is enough. Most people, however, need to take them regularly once, twice or even three times every day depending on the severity of their symptoms. About one in four people cannot take them because they cannot tolerate the taste or because the powders make diarrhoea worse or cause intolerable nausea, heartburn, wind or bloating.

Tablets: Colesevelam- dose can be between two and seven tablets a day in two or three doses, usually after food.

Colesevelam -is only licensed in the UK to treat high cholesterol. It does this by binding bile salts in the bowel. It can also be used for other reasons such as bile salt malabsorption but this does mean that if a patient in the UK developed some sort of serious problems as a result of taking this drug for bile salt malabsorption, it might limit the drug manufacturer’s liability. Also, most general practitioners in the UK are unlikely to be prepared to write out repeat prescriptions because it is not licensed for bile salt malabsorption,

Colesevelam can potentially cause the same side effects as the powders Though it tolerated much better and easier to take

Powders are normally the first medication to be tried.

Possible side effects of the medication

If the patient can tolerate them, the powders are safe drugs. As the tablet is quite a new drug, we have less information about its long term safety. However, as it works in a similar way to the powders and is not absorbed from the bowel, it seems likely it will have a similar safety record to the powders. So far, there are no concerns at all about the long-term safety of the tablet.

All forms of bile acid sequestrants may lower cholesterol levels when taken for a long time. There are however, three possible problems with them: 

• they can, with time, lead to low levels of fat soluble vitamins because they can interfere with the way these vitamins get into the body. Therefore, anyone taking bile acid sequestrants should have a blood test after three months to look at their blood levels of vitamin A, D, E and K and have a repeat blood test yearly. If their vitamin levels fall, this can be corrected with a vitamin supplement prescribed by the doctor. Vitamin B12 levels should also be checked yearly.
   
• Though good for cholesterol, these medicines can occasionally lead to increases in a different sort of fat in the blood (triglycerides). Very high levels of triglycerides may be harmful. Triglyceride levels should also be checked with an annual blood test if someone is taking one of these drugs long term.
   
• They may interfere with the absorption of other drugs patients might have to take. This is not usually a problem as the drugs can be spaced out at different times through the day. However, whenever you are prescribed new medicines for whatever reason, you need to tell your doctor and the pharmacist that you take a bile acid sequestrant.

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