A Review of Inguinal and Hiatal Hernia Management

Colter G. Sheveland, PharmD; Caitlin N. Edwards, PharmD; Jeffrey A. Kyle, PharmD, BCPS

US Pharmacist. 2022;47(6):HS-2-HS-6.

The Pharmacist's Role

Because hernias are common, pharmacists should have a basic understanding of hernia care in order to better assist patients. Managing the various types of hernias requires an interprofessional team approach. Although surgery is the mainstay of hernia treatment, pharmacists can play a role in the management of hernias and support patients who have undergone treatment. Regardless of the setting, pharmacists can assist patients with managing pain medication and selecting appropriate self-care products. Pharmacists can also advise patients about postoperative care, such as wound care, and lifestyle modifications, such as smoking cessation (Table 2). A truss may be recommended for some patients, and pharmacists can counsel on their proper use. Above all, pharmacists can ensure that medications for hernia therapy are being used safely, effectively, and optimally.

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The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

Table 1. Nonpharmacologic Management of Inguinal Hernia
Diet	Support Device	Physical Activity
Consume fiber-rich foods such as whole grains, oats, almonds, chia seeds, avocado	A truss may be used to help retain viscera in patients with a low strangulation risk, but it does not treat the hernia Consultation with a provider for the appropriate indication and fit is crucial when a truss is being considered	Use proper technique when lifting heavy objects (i.e., bending down with the knees and lifting the object with the chest perpendicular to the floor) Maintain core strength to avoid excess strain on the abdominal musculature

Source: References 27, 28.

Table 2. Pharmacologic Management of Inguinal Hernia
Condition	Intervention	Additional Information
Chronic postoperative inguinal pain	NSAIDs (ibuprofen, naproxen)	Consult PCP if used for >10 days Consult PCP if pregnant or planning pregnancy Dosing: ibuprofen—200–400 mg po q4–6h; max 3,200 mg/day. Naproxen—200–400 mg po once, then 200 mg q8–12h prn; max dose: 400 mg in any 8–12-h period or 600 mg in a 24-h period
Chronic postoperative inguinal pain	Opioids, gabapentin, pregabalin, tricyclic antidepressants, SSRIs/SNRIs	Refer to PCP or a pain-management specialist
Smoking cessation	First-line: behavioral therapy plus varenicline (Chantix) or combination NRT: long-acting (e.g., patch) plus short-acting (e.g., gum, lozenge) or varenicline (Chantix) plus patch or bupropion SR	Interview patient using the 5A's of smoking cessation: Ask, Advise, Assess, Assist, Arrange If patient is hesitant or refuses intervention, provide smoking-cessation information: 1–800-QUIT-NOW; text "QUIT" to 47848; use mobile app quitSTART Do not use bupropion in seizure disorders
Superficial incision	I&D plus amoxicillin-clavulanate or levofloxacin or ciprofloxacin plus metronidazole	Duration: 10–14 days or until resolution of signs and symptoms of active infection Dosing: amoxicillin-clavulanate—875/125 mg po bid; levofloxacin—750 mg po daily; ciprofloxacin—500 mg po bid; metronidazole—500 mg tid

I&D: incision and drainage; max: maximum; NRT: nicotine replacement therapy; NSAID: nonsteroidal anti-inflammatory drug; PCP: primary care provider; SNRI: serotonin-norepinephrine reuptake inhibitor; SR: sustained-release; SSRI: selective serotonin reuptake inhibitor. Source: References 29–31.

Table 3. Lifestyle Modifications for Hiatal Hernia
Diet	Medication	Lifestyle
Avoid large meals and meals within 2–3 h of bedtime Remain upright during and after meals Avoid certain foods: alcohol, coffee, chocolate, carbonated beverages, onions, garlic, tomatoes, citrus, fatty foods, and spicy foods	Avoid medications that can potentiate symptoms: calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives (benzodiazepines) Take medications that can potentially irritate the esophagus with a full glass of water	Elevate head of the bed 6–8 inches or sleep on a foam wedge (pillows are not effective) Sleep on the left side Stop smoking or using tobacco products If overweight or obese, lose weight Keep a diary to track dietary, lifestyle, and medication triggers

Source: References 24, 26.

Table 4. Pharmacologic Management of Hiatal Hernia
Drug Class	Drug/Primary Ingredient	Additional Information
Proton pump inhibitor	Omeprazole (Prilosec) Lansoprazole (Prevacid) Esomeprazole (Nexium) Pantoprazole (Protonix) Dexlansoprazole (Dexilant) Rabeprazole (AcipHex)	Take 30–60 min before a meal Omeprazole, esomeprazole, lansoprazole inhibit CYP2C19 For patients aged ≥18 y
H₂ receptor antagonist	Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid AR)	Consult PCP if used >14 days May take before or after meals May reduce absorption of drugs requiring acidic environment CYP450 interactions For patients aged ≥12 y
Antacids	Magnesium hydroxide (carbonate or trisilicate) Aluminum hydroxide (phosphate) Calcium carbonate Sodium bicarbonate	For temporary relief of mild, infrequent heartburn and dyspepsia Do not take >4 times/day (or max daily dosage for specific product) Do not use regularly >14 days Take prn when symptoms start Caution: risk of bleeding with combination antacid-aspirin products May affect absorption of other medications For patients aged ≥12 y