Table 4. Typical clinical scenarios of ostomy-related problems with pharmaceutical options and recommendations.

Clinical scenario	Ostomy-related problem/ORP	Options and recommendations
Pain management: Oxycodone extended-release, ER 58-year-old patient with a formation of a protective ileostomy treated postoperatively with a combination of immediate- and extended-release oxycodone and metamizole (dipyrone). Under current analgesia, the patient complains about pain and the oxycodone extended-release tablets appear in the ostomy bag.	Due to shortened intestine and reduced transit time, drug absorption in ileostomy patients can be reduced. The release of the drug varies depending on the drug formulation. The disintegration time for extended-release formulations is prolonged, so that the drug possibly is not or only partially released and absorbed.	• Before adapting the drug formulation, consider whether this patient needs an opioid therapy or whether an analgesic of WHO level 1 is sufficient. • For severe pain, it is recommended to switch to a transdermal fentanyl patch to achieve sufficient analgesia. Here, sufficient absorption is ensured by bypassing the gastrointestinal tract. Remember, in cachectic patients the absorption can be reduced. • Check critically in ileostomy patients with an opioid therapy if a constipation prophylaxis (e.g. macrogols) is indicated. It is often included in pain standards, but rather counterproductive in patients with high ostomy output.
Concomitant medication: Pantoprazole enteric-coated tablets 71-year-old ileostomy patient currently suffering from high output syndrome with more than 3000 mL/day of stomal effluent. Among other drugs, the patient is treated with a proton pump inhibitor, here pantoprazole (enteric-coated tablet) to reduce gastrointestinal fluid output.	The pantoprazole enteric-coated tablet repeatedly ends up in the ostomy bag. In the context of a HOS, the transit time is often too short for enteric-coated tablets to dissolve.	• Do not crush pantoprazole tablets, as the enteric coating will be destroyed and efficacy will be impaired. • Especially in the hypersecretory phase after new ostomy formation, proton pump inhibitors are indicated. • Recommended aut-simile exchange to esomeprazole tablets (Nexium® mups). Due to enteric coated micropellets, it is possible to suspend these tablets in water before administration. • For reasons of cost, pantoprazole tablets are often prescribed as standard.
Nausea and vomiting: Metoclopramide 42-year-old patient complains of persistent nausea and is treated with metoclopramide. The patient’s underlying disease is ulcerative colitis and several years ago an ileostomy was placed. Currently, the ostomy carries very thin effluent and high volume.	Metoclopramide has an antiemetic effect via blockage of dopamine receptors (mainly D2) and serotonin receptors (5-HT3). At the same time, it has a propulsive effect via an increasing muscle motility (5-HT4) and a decreasing tension of the pylorus. The propulsive effect increases ostomy output.	• Postoperative nausea and vomiting (PONV) is a common problem during hospitalization. • The side effects of drugs are often unknown or disregarded until a problem occurs. • Possible alternative for postoperative nausea is ondansetron - ideally in form of an orally disintegrating tablet (ODT). Here, the constipating adverse drug effect can be beneficial in the case of high stomal effluent.
Anti-motility measures: Loperamide 68 year old patient with an ileostomy and currently suffering from high output syndrome (HOS). Therapy is based on pectin powder (Aplona®) one sachet three times daily and loperamide as hard capsules with a dosage of 4 mg three times a day.	If the ostomy output is considerably increased, both thickening and motility-inhibiting measures are required. In general, better absorption is possible with liquid formulations, as the active drug is already present in solution. Thus the absorption process can start immediately without the need for release from the dosage form (so called "liberation").	• Loperamide is available in the form of hard capsules, ODT, drops and oral solution. The switch to a liquid loperamide form is preferable. • For liquid formulations, the concentration and volume must be critically examined. Especially with oral solution approved for children, high volumes and additives such as propylene glycol and sweeteners can cause laxative effects. • ODTs are also possible, but more expensive than oral solutions or hard capsules. After liberation Loperamide is absorbed via small intestine and not via the oral mucosa. • Alternatively hard capsules can be opened and stirred into water (off-label use). • Check critically concomitant medication e.g. diuretics or propulsive agents.
Summary of medication management in ostomy patients: • Consider the type of ostomy ileo- vs. colostomy and the duration since ostomy surgery (new vs. existing ostomy). • Avoid modified release drug formulations in ileostomy patients (extended release tablets/capsules, enteric-coated tablets/capsules, matrix tablets). • Prefer immediate release drug formulations (drops, sublingual tablets, effervescent tablets) or parenteral drug formulations (transdermal patches, injections/infusions). • Consider concomitant drug therapy and take into account the main and the adverse drug effects (e.g. metoclopramide vs. ondansetron against PONV). • Think of ostomy-related problems, ORPs (e.g. HOS, constipation, hypersecretion, nausea and vomiting).