Self-Care for Constipation

Self-Care Constipation

• Defined as a frequency of fecal elimination less than 3 bowel movements per week in adults.
• Characterized by difficult passage of hard, dry stools.
• Patients may report straining, hard/dry stool passage, small stools, feelings of incomplete bowel elimination, and decreased stool frequency.

Constipation Statistics

• Very common gastrointestinal (GI) complaint (2-28% of the general population).
• Older adults are 5 times more likely to develop constipation, and women are 3 times more likely than men.
• Common reason for self-treatment; 2.5 million physician visits per year.

Etiology of Constipation

• Lifestyle/Extrinsic factors: Low fiber diet, low fluid intake, sedentary lifestyle, or suppressing the urge to defecate.
• Structural factors: Colorectal or anorectal injury, inflammation, pelvic floor disorders, or structural abnormalities.
• Systemic factors: Thyroid disorders, diabetes mellitus, irritable bowel syndrome (IBS), neurological disorders, autonomic neuropathy, cerebrovascular accidents, multiple sclerosis, dementia, Parkinsonism, or post-surgical causes.
• Psychological factors: Depression, eating disorders, and situational stress.
• Medications: Calcium or aluminum antacids, narcotic analgesics, and anticholinergics.

Medications Causing Constipation

• Analgesics
• Antacids
• Anticholinergics
• Anticonvulsants
• Antidepressants
• Antihistamines
• Antimotility
• Antimuscarinics
• Benzodiazepines
• Calcium Channel Blockers
• Calcium supplements
• Diuretics
• Hematinics
• Hyperlipidemia agents
• Hypotensives
• Muscle relaxers
• Opiates
• Parkinsonism agents
• Polystyrene sodium sulfonate
• Psychotherapeutic drugs
• Sedative hypnotics
• Serotonin agonists
• Sucralfate

Treatment Goals

• Relieve constipation and reestablish normal bowel function.
• Establish dietary and exercise habits to prevent future constipation.
• Promote safe and effective use of laxative products.

Exclusions to Self-Care

• Marked abdominal pain, significant distention, or cramping.
• Unexplained flatulence or fever.
• Nausea, vomiting
• Daily laxative use.
• Excluded fiber-based therapies.
• Unexplained change in bowel habits, especially with weight loss.
• Blood in stool or dark, tarry stools.
• Presence of chronic medical conditions (IBS, paraplegia/quadriplegia, colostomy).
• Marked change in stool character (e.g., pencil thin).
• A sudden change in bowel habits lasting 2 weeks or recurring over 3 months.
• Inflammatory bowel disease.
• Anorexia.
• Age less than 2 years old.

Non-Pharmacological Measures

• Increased fruit, vegetables, and whole grains (14 g/1000 kcal fiber per day; 25 g/day for women and 38 g/day for men).
• Gradual increase in fiber (1-2 weeks).
• Limit foods lacking fiber (e.g., cheese, meat, processed foods).
• Supplement with fiber if diet is insufficient.
• Bulk-forming laxatives (methylcellulose, polycarbophil, psyllium).
• Dietary supplements (inulin, powdered cellulose, wheat dextrin, partially hydrolyzed guar gum).
• 2 liters of water per day, or increased fluids for pregnant or lactating women.
• Establish regular bowel habits, ideally after eating or upon rising.
• Encourage physical activity.

Goals of Pharmacologic Therapy

• Nonirritating and nontoxic action.
• Act only on the descending and sigmoid colon.
• Produce a normally formed stool within a few hours.
• FDA mandates labeling for short-term use (<1 week) without healthcare provider oversight.

Types of Laxative Agents

• Bulk-forming
• Emollient
• Lubricant
• Saline
• Hyperosmotic
• Stimulants

Bulk-Forming Laxatives

• Methylcellulose, polycarbophil, and psyllium (e.g., Citrucel®, FiberCon®, or Metamucil®).
• Most recommended for constipation.
• Mechanism involves dissolving or swelling in the intestinal fluid, facilitating passage of intestinal contents.
• Not absorbed systemically.
• Take with 8 ounces of water, 12-24 hours onset, up to 72 hours.

Indications for Bulk-Forming Laxatives

• Short-term relief.
• Low-residue (low-fiber) diets.
• Women during postpartum.
• Advanced age.
• Patients with colostomies, IBS, or diverticular disease.
• Prevention of straining.
• Potential benefit in lowering cholesterol.

Safety Considerations for Bulk-Forming Laxatives

• Common adverse effects: abdominal cramping and flatulence.
• Choking is a risk without adequate fluid intake.
• May bind or hinder drug absorption (separate by 2 hours).
• Not appropriate for fluid-restricted diets (e.g., renal failure, congestive heart failure).
• May cause esophageal or intestinal obstruction.
• Children <6 years and patients on opioids at increased risk.
• Calcium polycarbophil limited to 150 mg in patients susceptible to hypercalcemia (renal disease).
• Avoid in patients with hypersensitivity.

Fluids and Bulk-Forming Laxatives

• Choking may occur with insufficient fluids.
• FDA labeling emphasizes the need for adequate fluid intake to avoid product swelling and blockage of the esophagus.

Hyperosmotic Laxatives

• Glycerin or polyethylene glycol (PEG) 3350 (e.g., Fleet, Babylax, MiraLAX).
• Large ions/molecules draw water into the rectum to facilitate movement.
• Not systemically absorbed.
• Useful for occasional simple constipation.
• PEG 3350 became an OTC option in 2006.
• Glycerin onset: 15-30 minutes rectally.
• PEG 3350 onset: 12-72 hours orally, up to 96 hours.

Safety Considerations for Hyperosmotics

• Poorly absorbed, little drug interactions.
• Bloating, discomfort, cramping, and flatulence may occur in some individuals.
• Dosing:
  • Glycerin: 1-2.8 grams in children younger than 6 years old and 2-5.6 grams in children and adults age 6 years or older.
  • PEG-3350: 1 capsule/packet mixed in water
• Avoid in patients with rectal irritation.

Emollient Laxatives

• Docusate sodium and calcium (e.g., Colace, Correctol).
• Anionic surfactant that acts as a wetting agent to soften stool.
• Helps prevents straining.
• Onset: 12-72 hours.
• May take up to 3-5 days.

Indications for Emollients

• Occasional constipation.
• Straining/painful defecation.
• Anorectal disorders or conditions where straining is undesired.
• Post-abdominal/rectal surgery or postpartum.
• Opioid-induced constipation (in conjunction with stimulants).
• Avoid co-administration with mineral oil.

Lubricant Laxatives

• Mineral oil (liquid petrolatum) (e.g., Fleet Mineral Oil Enema, Kondremul Emulsion).
• Coats the intestines decreasing fecal H2O absorption.
• Onset: 6-8 hours by mouth, 5-15 minutes rectally.
• Judicious use to maintain soft stool to prevent straining/painfu defecation.
• Routine use not preferred, docusate is a better option.

Safety Considerations for Lubricants

• Drug interactions (ADEK vitamins, avoid co-administration with docusate)
• Do not take within 2 hours of eating
• Lipid pneumonia (esp. in dysphagia patients)
• Pruritis ani, cryptitis, or perianal conditions (DC use)
• Contraindicated in bedridden patients, or in situations with limited mobility.
• Avoid in young children, pregnant women, older, or immobile patients.
• Don't use in children younger than 6 unless prescribed

Saline Laxatives

• Magnesium Citrate, Magnesium Hydroxide, Dibasic sodium phosphate and monobasic sodium phosphate, Magnesium Sulfate (e.g., Fleet Ready-to-Use, Phillips, Epsom).
• Ions draw water into intestines/colon via osmosis increasing intraluminal pressure & motility.
• Take on an empty stomach.
• Onset: 30 minutes - 6 hours rectally, 0.5-3 hours orally.

Indications for Saline Laxatives

• Occasional constipation relief
• Bowel preparation for colonoscopy.
• Not for long-term constipation management.

Safety Considerations for Saline Laxatives

• Abdominal cramping, nausea/vomiting, or dehydration.
• Electrolyte imbalance (fluid loss).
• Label warnings to avoid in patients on restricted diets (Mg, PO4, Na).
• Up to 20% of magnesium salts may be absorbed leading to hypermagnesemia.
• Not recommended in patients with renal impairment, newborns, or older adults.
• Most do not use in children younger than 6 years old.

Safety Considerations for Saline Laxatives (continued)

• Sodium phosphate can cause hyperphosphatemia, hypocalcemia, and hypernatremia.
• Use cautiously in renal impairment, or with other medications that affect electrolytes (e.g., diuretics) and/or cardiac conditions.
• Contraindicated in congestive heart failure.
• Avoid rectal administration in cases of megacolon, gastrointestinal obstruction, imperforate anus or colostomy.
• Take on an empty stomach with full 8 oz glass of water.
• Avoid dehydration
• Drug interactions vary depending on the specific medication, and require counseling.

FDA Actions for Oral Sodium Phosphate Products

• Acute phosphate nephropathy linked to oral sodium phosphate products used for bowel cleansing.
• In 2008, the FDA issued a boxed warning regarding the use of sodium phosphate-containing laxatives, along with additional recommendations for product labeling and usage instructions.
• Oral non-prescription products are not intended for bowel cleansing.
• Use is restricted in high risk patients (e.g., renal disease or those >55 years of age).
• Should not exceed one dose per 24-hr period.

Stimulant Laxatives

• Bisacodyl and senna (e.g., Correctol®, Dulcolax®, Ex-Lax®, Senokot®).
• Increase peristaltic activity.
• Local irritation of intestinal mucosa.
• Increase water & electrolyte secretions.
• Onset: 6-10 hours orally, 15-60 minutes rectally.

Indications for Stimulant Laxatives

• Components for endoscopic examinations
• Prevent/treat opioid-induced constipation.
• Second-line agent, after bulk-forming and hyperosmotics, in occasional constipation cases.

Safety Considerations for Stimulant Laxatives

• Adverse effects: cramping, electrolyte/fluid deficiencies.
• Enteric loss of protein or hypermobility.
• Laxative abuse consequences.
• Use cautiously due to mucous/fluid loss
• Take 1 hour before antacids or milk to avoid reduced enteric coating.
• Do not crush or break enteric-coated pills.
• Senna may discolor urine.

Laxative Overuse

• Misconceptions about bowel movements (fear of constipation, co-morbid conditions).
• Clinical features: diarrhea, vomiting, fluid & electrolyte imbalance, and dehydration.
• Wean off laxatives gradually, increasing fiber and fluid intake, and encouraging physical activity.

Opioid-Induced Constipation

• Stimulant laxatives with or without docusate are commonly recommended.
• PEG-3350 can prevent and/or treat opioid-induced constipation, whereas bulk-forming solutions/agents are not appropriate for these individuals
• Saline laxatives can be useful for acute cases when necessary.

Selecting Laxatives

• Review Figure 2.
• Lifestyle management, especially in cases of simple constipation.
• Bulk forming or PEG-3350 recommended as initial choice in simple cases.
• Consider co-existing conditions.
• Avoid mineral oil if possible

Pediatric Approach to Constipation

• Dietary and behavioral modification first for children.
• Consult healthcare provider for children under 2; for children aged two to six, docusate or magnesium hydroxide are viable options.
• Senna, or other rectal glycerin agents are viable choices for children ages 6 to 12 years.
• Methylcellulose, calcium polycarbophil, psyllium powder, magnesium hydroxide, or docusate sodium are viable options for children ages 6-12.

Older Adult Approach to Constipation

• Dietary and behavior modification first for older adults.
• Educate on normal bowel habits.
• Medication adjustments may be necessary.
• Bulk-forming laxatives are a good starting point, but account for any fluid restrictions and co-morbid conditions.
• PEG-3350 is another good initial option.
• Docusate useful in cases of hemorrhoids.
• Avoid mineral oil and watch for concerns about saline laxatives.

Counseling Issues for Laxative Use

• Lifestyle modifications always needed
• Do not use laxatives for more than one week without a healthcare provider's supervision.
• Be aware of potential co-morbid conditions and drug interactions.
• Onset varies based on the laxative type.
• Consider prevention strategies versus treatment solutions for long term care.