Retention enema

ASA appears to be the active component of sulfasalazine without the sulfa component, and is free of the serious side effects seen with sulfasalazine. It is used orally, in a delay-release formulation, as a retention enema, and as a suppository. It is well tolerated in most patients. 

It is critically important to recognize that the treatments of hyperkalemia discussed thus far are transient, temporizing measures. They are intended to provide time to institute definitive therapy aimed at removing excess potassium from the body. Agents that increase potassium excretion from the body include sodium polystyrene sulfonate, loop diuretics, and hemodialysis or hemofiltration (used only in patients with renal failure). Sodium polystyrene sulfonate (Kayexalate , various manufacturers) can be given orally, via NG tube, or as a rectal retention enema and is dosed at 15 to 60 grams in four divided doses per day. 

In circumstances where oral therapy cannot be given, intravenous metronidazole (500 mg every 6-8 hours), vancomycin retention enemas (500 mg every 4-8 hours), or vancomycin via colonic catheter should be considered.38 Antiperistaltic agents should not be given because the use of these agents is associated with the development of toxic megacolon. 

In episodic HE, lactulose is initiated at 45 mL every hour (or 300 mL lactulose syrup with 700 mL water given as a retention enema) until catharsis begins. The dose is then decreased to 15 to 30 mL orally every 8 to 12 hours and titrated to produce two to three soft, acidic stools per day. 

Lactulose may be given as a retention enema via a rectal balloon catheter. Do not use cleansing enemas containing soap suds or other alkaline agents. 

Portal-systemic encephalopathy PO Initially, 30-45 ml every hr. Then, 30-45 ml (20-30 g) 3-4 times a day. Adjust dose q 1-2 days to produce 2-3 soft stools a day. Rectal (as retention enema) 300 ml with 700 ml water or saline solution patient should retain 30-60 min. Repeat q4-6h. If evacuation occurs too promptly, repeat immediately. 

Distal ulcerative colitis, proctosigmoiditis, proctitis Rectal (retention enema) 60 mi (4 g) at bedtime retained overnight for approximately 8 hr for 3-6 wk. Rectal (500-mg suppository) Twice a day. May increase to 3 times a day. Rectal (1,000-mg suppository) Once daily at bedtime. Continue therapy for 3-6 wk. 

Rectal 100 mg/60 mL unit retention enema 90 mg/applicatorful intrarectal foam Mesalamine (5-ASA)... 

Rectal 40 mg/bottle retention enema Olsalazine (Dipentum)... 

A 48-year-old woman developed avascular necrosis 9 months after she had completed a 3-month course of hydrocortisone 100 mg retention enemas once or twice daily for ulcerative proctitis (470). An MRI scan showed multiple bony infarcts in her distal femora, proximal tibiae, and posterior proximal right fibular head, extending from the diaphysis to the epiphysis, consistent with avascular necrosis. 

Table 10.1 Dog colon tissue biopsy concentrations of intact ISIS 2302 oligonucleotide at 3 and 24 h after single-dose retention enema (10 mg/kg) or intravenous (dosage indicated) administrations.

Purvis J (1988) Enemas in ulcerative colitis. Pharmaceutical Journal 13 August 208. Predsol Retention Enema, Summary of Product Characteristics. Available at http //emc. medicines.org.uk/ [Accessed 7 July 2008],... 

Treatment and prophylaxis of hepatic encephalopathy Start with 30-45 ml (20 gm/30 ml) p.o. 3-4 times daily, then adjusted to achieve 2-3 soft formed stools/day or 300 ml (200 g) mixed with 700 ml of water or saline rectally as a retention enema (retain for 30-60 min) every 4-6 h. as needed... 

In hyperkalaemia, oral administration or retention enemas of a polystyrene sulphonate resin may be used. A sodium phase resin (Resonium A) should obviously not be used in patients with renal or cardiac failure as sodium overload may result. A calcium phase resin (Calcium Resonium) may cause hypercalcaemia and should be avoided in predisposed patients, e.g. those with multiple myeloma, metastatic carcinoma, hyperparathyroidism and sarcoidosis. Enemas should be retained for as long as possible, although patients rarely manage for... 

Sulfasalazine is also used as a disease-modifying agent in rheumatoid arthritis (see p. 292), the condition for which it was originally introduced in the 1930s. It is available as a tablet, retention enema or suppository. 

Solutions, suspensions, or retention enemas represent rectal dosage forms with very limited application. 

Administer diuretics and ion-exchange resins (Kayexalate [retention enema]) to increase the excretion of potassium. 

In acute HE, lactulose is initiated at a dose of 45 mL orally every hour (or by retention enema, 300 mL lactulose symp in 700 mL water, held for 30 to 60 minutes) until catharsis begins. The dose is then decreased to 15 to 45 mL orally every 8 to 12 horns (enemas every 6 to 8 horns) and titrated to produce two to fom soffi acidic stools per day. In patients with chronic HE, lactulose may be initiated at a dose of 30 to 60 mL/day with titration to the same endpoint. Monitor electrolytes periodically, follow patients for changes in mental status, and titrate to the number of stools as above. 

Glucocorticoid enemas are useful in patients whose disease is limited to the rectum (proctitis) and left colon. Hydrocortisone is available as a retention enema (100 mg/60 mL), and the usual dose is one 60-mL enema per night for 2 or 3 weeks. When administered optimally, the drug can reach up to or beyond the descending colon. Patients with distal disease usually respond within 3—7 days. Hydrocortisone also can be given once or twice daily as a 10% foam suspension (CORTIFOAM) that delivers 80 mg hydrocortisone per application this formulation can be useful in patients with very short areas of distal proctitis and difficulty in retaining fluid. 

See Table 10.6. PR. Administered as retention enema. Corticosteroids discussed in Tables 10.6. 

Lima JJ, Jusko WJ. Bioavailability of hydrocortisone retention enemas in relation to absorption kinetics. Clin Pharmacol Ther 1980 28 262-269. 

Powell Tuck, J., Lennard Jones, J.E., May C. S., Wilson, C. G. and Paterson, J. W. (1976) Plasma prednisolone levels after administration of prednisolone-2I-phosphate as a retention enema in colitis. Brit. med. J., 1, 193. 

Plasma prednisolone levels comparable to those obtained after peroral administration were observed after prednisolone-21-phosphate retention enema in ulcerative colitis (115 ). Eight cases with appearance of uterine bleeding in relation to initiation of steroid therapy have been reported (10 ). 

Plasma prednisolone levels after administration of prednisolone-21-phosphate as a retention enema in colitis. Brit. med. J., 1, 193. 

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