A person with a stoma requires a variety of medications and products for stoma care, as well as guidance to manage any complications. Living with a stoma also comes with an array of psychological consequences and needs, meaning a person's mental health and quality of life will also need to be considered.
Therefore, from a pharmaceutical perspective, a patient's needs are potentially vast. Giving the patient an understanding of stoma care and their choices in terms of their appliances and medications can empower the patient to not only feel more independent but also hopeful about finding the product that best suits their needs. It also helps them to feel confident in their health professionals and prescribers when they are informed when it comes to what products and medications are required for managing their stoma.
About 100 000 people in the UK are currently living with an intestinal stoma, often formed following cancer surgery or surgery for inflammatory bowel disease (Strong et al, 2021). The stoma can be temporary or permanent, and is formed from the small or large bowel. There are many different types of stoma, and the type of stoma can affect how common particular complications are and the indicators of those complications.
Common complications
A high output can put a patient at risk of dehydration, making advice such as drinking oral rehydration solutions rather than plain water important, as water can make the problem worse. Modified release medications should be avoided where patients have a high output, as the drug will be expelled before it has been absorbed (Strong et al, 2021). Therefore, a faster-release product would be required, which the pharmacist or stoma specialist can advise on (Strong et al, 2021).
Other complications such as skin irritations and stoma prolapse can be managed in the primary care setting. Barrier creams are essential for keeping skin in good condition and medications will be covered in the latter part of this article.
A common concern for a person with a high-output stoma is that of an incomplete obstruction.
Colostomy appliances
A colostomy bag requires changing 1–3 times a day, when full (NHS, 2017). However, other bags, known as ‘drainable bags’ can be used, which can be replaced every 1–2 days and are more suitable for people with very loose stools (NHS, 2017). The stoma care nurse usually sees the patient before and after the colostomy operation and helps the patient choose their preferred equipment.
For example, there is a one-piece pouch, where the bag and flange (the part that attaches to the skin) are joined together, where the appliance is removed when full and disposed of. There is also a two-piece pouch, where the bag and flange are separate but can be connected, and the flange can remain attached to the skin for several days, and the bag can be removed and disposed of several times a day (NHS, 2017). The appliances used for stomas are made from hypoallergenic material to reduce chances of irritation and contain filters to avoid unpleasant odours coming from the bag.
Some patients may be so used to their stoma and their bowel habits that they may choose not to wear a bag but instead should be advised to wear a cap because of the risk of leakages, which may occasionally happen. The patient's mental state and any neurological deficits should be considered in case they are less aware about their stoma care management. For instance, they may forget to change the bag and therefore it is important they have the right care package or a relative, friend or carer to assist with the management of their stoma.
Other appliances or aids used for colostomy patients include: support belts and girdles, deodorisers (charcoal) that are inserted into the appliance, protective skin wipes, sprays for adhesive removal, protective stoma rings and underwear and swimwear specifically designed to help a stoma patient feel comfortable, supported and confident. The stoma care nurse is the point of contact for such aids or appliances (NHS, 2017).
Colostomy irrigation
Some patients may choose to irrigate their colon with water every day or every other day, as an alternative to wearing an appliance around the stoma site. To do this, a small device is inserted into the stoma with a bag full of water attached. The water is then slowly squeezed into the colon to irrigate it, with a cap covering the stoma between irrigations. This may be a good thing in terms of the patient being able to choose when to perform the irrigation, and that an appliance is not required except for a cap, a more varied diet can be enjoyed and flatulence is less common (NHS, 2017). However, a limitation to this method is that it takes 45–60 minutes a day to complete. It should also be carried out at the same time every day, which may be difficult for someone to commit to with work, personal or social. It must be noted however that this technique is not suitable for people with Crohn's disease or those with diverticulitis, or for someone who is having radiotherapy or chemotherapy (NHS, 2017).
Modifying medications
The National Institute for Health and Care Excellence (NICE, 2020) has issued British National Formulary (BNF) guidance with regards to stoma care options when considering treatments.
Enteric-coated and modified-release medicines are unsuitable for stoma patients, especially in those with an ileostomy, as there is insufficient release of release active ingredients. Soluble tablets, liquids, capsules or uncoated tablets are more suitable for such patients as they dissolve more quickly, but where solid dose forms have been given, the ostomy bag contents should be checked for any remnants (NICE, 2020). The BNF guidance issued by NICE (2020) also states that sorbitol preparations should be avoided as they has laxative side effects.
It is important to be aware that opioids may be unsuitable because of the troublesome side effect of constipation, and that paracetamol is more suitable. NSAIDs may not be useful as a result of their side effects in irritating the gut lining and causing bleeding, and if these have been taken by the patient then the faecal output should be monitored for signs of any blood (NICE, 2020). Magnesium salts may cause diarrhoea and aluminium or calcium salts may cause constipation in stoma patients. Proton pump inhibitors and somatostatin analogues, such as octreotide and lanreotide, can be given to reduce the risk of gastric acid secretion in increasing stomal output. For decreasing the risk of diarrhoea, the patient may be taking loperamide or codeine phosphate.
The patient may become hypokalaemic if taking digoxin, as a result of fluid and sodium depletion, and thus a potassium supplement or potassium-sparing diuretic such as spironolactone may be given, but the patient should be monitored for early signs of toxicity(NICE, 2020). Diuretics should be used with caution, as they may cause excessive dehydration, leading to potassium depletion. This is another reason to give a potassium-sparing diuretic (NICE, 2020). Iron preparations can loosen the stool and make the skin sore, so it is important if the patient requires iron, they should ideally be taking an intramuscular iron preparation, and modified-release preparations should be avoided (NICE, 2020).
For clear reasons, laxatives should not be used in patients who have an ileostomy, as they may cause a rapid and severe loss of water and electrolytes (NICE, 2020). Constipation may occur in people who have a colostomy but wherever possible it is crucial this is treated with an increase in fluid intake or dietary fibre as opposed to using laxatives. However, for colostomy patients, bulk-forming drugs can be tried where necessary. If these do not work, a small dose of a stimulant laxative such as senna could be used with caution (NICE, 2020). Forf potassium, supplements in liquid form are preferred over modified-release preparations with a daily dose split to avoid osmotic diarrhoea.
Mental health
It is important to recognise that stoma patients often have additional mental health needs due to the stoma being potentially a life-changing surgery for them. As a nurse, there is a duty of care to the patient to ensure their psychological needs are met through the right support and referral to therapy services where indicated.
Polidano et al (2018) reported that yyoung adults in particular can have mental health needs, as a result of the impact the stoma may have on sexual relationships and body image. It is important to take the time to discuss with the patient how they are feeling, taking a gentle approach to sensitive topics. Open questions will allow the patient to fully explain, if they want to, how they are feeling. Asking how they feel they are managing and what their moods have been like, as well how the stoma has caused a change in their life and how they are managing the psychological impact can help to support patients living with a stoma. Another question to ask may be how they feel about accessing talking therapy.
Conclusion
The range of appliances, medications and referrals relating to a person with a colostomy is vast. A person will have multifactorial needs, including choice of appliance and ensuring it suits them, medications and products for stoma care and complication management and intervention for the related psychological effects. With correct care and early intervention, access to choice and information, the person can have access to the tools needed to live with the highest quality of life possible.