Self-Care Constipation PDF

SELF-CARE CONSTIPATION Kelly Orr, PharmD Clinical Professor Constipation ◦ Defined as ¯ frequency of fecal elimination ◦ Providers consider < 3 BMs per week in adults ◦ Characterized by difficult passage of hard, dry stools ◦ Patients may describe: ◦ Straining to have a BM ◦ Passage...

SELF-CARE CONSTIPATION Kelly Orr, PharmD Clinical Professor Constipation ◦ Defined as ¯ frequency of fecal elimination ◦ Providers consider < 3 BMs per week in adults ◦ Characterized by difficult passage of hard, dry stools ◦ Patients may describe: ◦ Straining to have a BM ◦ Passage of hard, dry stool ◦ Passage of small stools ◦ Feelings of incomplete bowel elimination ◦ Decreased stool frequency Constipation Statistics ◦ Very common GI complaint ◦ 2 – 28% general population ◦ Older adults 5x’s more likely to develop ◦ Women 3x’s more likely than men ◦ Common reason for self-treatment ◦ 2.5 million physician visits per year Etiology (Table 1) Causes Examples Lifestyle or Extrinsic Low fiber diet, low fluid intake, sedentary or immobile, or Factors suppressing the urge Structural Colorectal or anorectal injury, inflammation, pelvic floor disorders, structural abnormalities Systemic Thyroid disorders, diabetes mellitus, IBS, neurological disorders, autonomic neuropathy, cerebrovascular accidents, multiple sclerosis, dementia, Parkinsonism, post-surgical causes Psychological Depression, eating disorders, and situational stress Medication Table 2; Ca or Al antacids, narcotic analgesics, anticholinergics Medications Causing Constipation (2) ◦ Analgesics ◦ Hematinics ◦ Antacids ◦ Hyperlipidemia agents ◦ Anticholinergics ◦ Hypotensives ◦ Anticonvulsants ◦ Antidepressants ◦ Muscle relaxers ◦ Antihistamines ◦ Opiates ◦ Antimotility ◦ Parkinsonism agents ◦ Antimuscarinics ◦ Polystyrene sodium sulfonate ◦ Benzodiazepines ◦ Calcium Channel Blockers ◦ Psychotherapeutic drugs ◦ Calcium supplements ◦ Sedative hypnotics ◦ Diuretics ◦ Serotonin agonists ◦ Sucralfate Treatment Goals ◦ Relieve constipation and reestablish normal bowel function ◦ Establish dietary and exercise habits that will aid in preventing recurrences ◦ Promote the safe and effective use of laxative products ◦ General Treatment Approach ◦ Figure 15 – 2 Exclusions to Self-Care ◦ Marked abdominal pain, significant distention or cramping ◦ Marked or unexplained flatulence ◦ Fever ◦ Nausea and/or vomiting ◦ Daily laxative use ◦ Excluding fiber-based therapies ◦ Unexplained change in bowel habits, especially if accompanied by weight loss ◦ Blood in stool or dark, tarry stool ◦ Presence of a chronic medical condition that may preclude self-care treatment (IBS, paraplegia/quadriplegia, colostomy) Exclusions to Self-Care continued ◦ Marked change in character of stool ◦ Ie: Becomes pencil thin ◦ A sudden change in bowel habits that persists for 2 weeks or recur over a period of at least 3 months ◦ Symptoms that recur after dietary or lifestyle changes, or laxative use ◦ Inflammatory bowel disease ◦ Anorexia ◦ Age < 2 years old Non-Pharmacological Measures ◦ Increased fruit, vegetables, & whole grains ◦ American Dietetic Association recommends 14 g/1000 kcal of fiber per day ◦ 25 g adult women and 38 g adult men per day ◦ Tables 15-3 and Chapter 24 ◦ Gradual increase over 1 – 2 weeks ◦ Limit foods lacking fiber ◦ Cheese, meat, processed foods, etc. ◦ Supplement with fiber if not achieved by diet (Table 15 - 3) ◦ Bulk forming laxatives: Methylcellulose, psyllium, calcium polycarbophil ◦ Dietary supplements: Inulin, powdered cellulose, wheat dextrin, partially hydrolyzed guar gum Non-Pharmacological Measures cont. ◦ In general, 2 L per day recommended ◦ 8 glasses of 8 oz fluids ◦ Pregnant & lactating women additional 300 mL and 750 – 1000 mL of fluid ◦ “Bowel Training”: Regular pattern of bathroom visits ◦ Gastrocolic reflexes strongest in am & 30 minutes after eating ◦ Encourage physical activity Goals of Pharmacologic Therapy ◦ Be nonirritating and nontoxic ◦ Act only on the descending and sigmoid colon ◦ Produce a normally formed stool within a few hours, after which action will cease and normal bowel activity would resume ◦ FDA has mandated labeling of laxatives to stress only short term (< 1 week) without health care practitioner oversight Types of Agents ◦ Bulk Forming ◦ Emollient ◦ Lubricant ◦ Saline ◦ Hyperosmotic ◦ Stimulants See Table 15 - 4 for classification and properties Bulk Forming ◦ Methylcellulose, polycarbophil, and psyllium ◦ Ex: Citrucel®, FiberCon®, or Metamucil® ◦ Most recommended for constipation, due to mechanism ◦ Most like physiologic mechanism ◦ Facilitate passage of intestinal contents by dissolving or swelling in the intestinal fluid ◦ Not absorbed systemically ◦ Take with 8 oz. of water ◦ Onset: 12-24 hours, up to 72 h Indications for Bulk Forming Laxatives ◦ Indicated for short term relief and may be indicated for: ◦ Low residue (low fiber) diets ◦ Women during post-partum ◦ Patients of advanced age ◦ Patients w/ colostomies, IBS, or diverticular disease ◦ Also used prophylactically to avoid straining ◦ Potential benefit in lowering cholesterol Safety Considerations w/ Bulk Forming Laxatives ◦ Common adverse effects are abdominal cramping and flatulence, especially with not enough fluid ◦ Choking also a concern on labeling w/out water ◦ Will bind or hinder absorption of drugs (space 2 h) ◦ Warfarin, digoxin, salicylates, and other oral drugs ◦ Not appropriate for fluid restricted diets ◦ Such as renal failure or Congestive Heart Failure ◦ May cause esophageal or intestinal obstruction ◦ Children < 6 and patients on opioids at increased risk ◦ Calcium polycarbophil limited to 150 mg patient susceptible to hypercalcemia (ie: renal disease) ◦ Avoid in patients with hypersensitivity Fluids and Bulk Forming Laxatives ◦ Choking may occur with lack of fluids ◦ FDA Labeling ◦ "Taking this product without adequate fluid may cause it to swell and block your throat or esophagus and may cause choking. Do not take this product if you have difficulty in swallowing. If you experience chest pain, vomiting, or difficulty in swallowing or breathing after taking this product, seek immediate medical attention." Hyperosmotic ◦ Glycerin or Polyethylene Glycol (PEG)- 3350 ◦ Ex: Fleet Glycerin Suppository®, Fleet Babylax®, MiraLAX® ◦ Large ions/ molecules provide an osmotic effect that draws water into rectum facilitating bowel movement ◦ Not systemically absorbed w/ little side effects ◦ Useful in treatment of occasional simple constipation ◦ PEG – 3350 has become a 1st line option in adults since OTC switch in 2006 ◦ Onset: ◦ Glycerin 15-30 minutes rectally ◦ PEG – 3350 12-72 hours orally (up to 96 h) Safety Considerations with Hyperosmotics ◦ Poorly absorbed, little drug interactions ◦ MiraLAX® ◦ Dosing: 1 capful/packet (17 g) of powder dissolved in 4-8 oz of any beverage ◦ Only adults and children ≥ 17 years old ◦ Bloating, discomfort, cramping, and flatulence may occur ◦ Suppositories ◦ Dosing: ◦ 1-2.8 g in children < 6 years old ◦ 2-5.6 g in children and adults ≥ 6 years old ◦ Don’t use w/ rectal irritation PEG 3350 – Only Available OTC Use beyond the nonprescription approved labeling should only be in conjunction with a healthcare provider recommendation Ex: Children < 17 years old or beyond 7 days Emollient Laxatives ◦ Docusate sodium (50 – 100 mg) & calcium (240 mg) ◦ Examples: Colace®, Correctol Stool Softener®, or Ex-Lax Stool Softener® ◦ Anionic surfactant = softening ◦ Wetting agent, mixture of aqueous & fatty substances to soften ◦ Preventing painful defecation and straining ◦ Onset: 12-72 hours ◦ May take up to 3 – 5 days  Indications for Emollients ◦ Can be used for occasional constipation ◦ Best suited to prevent straining or painful defecation in patients with: ◦ Anorectal disorders ◦ Conditions avoiding straining ◦ Post abdominal or rectal surgery ◦ Immediately postpartum ◦ Useful in opioid-induced constipation use w/ stimulant ◦ Avoid co-administration w/ mineral oil ◦ Docusate calcium not recommended in children < 12 years old unless prescribed Lubricant ◦ Mineral oil (liquid petrolatum) ◦ Ex: Fleet Mineral Oil Enema®, Kondremul Emulsion® ◦ Coats intestines = ¯ absorption fecal H20 ◦ Onset: 6-8 hours by mouth; 5 -15 minutes rectally administered ◦ Indications: ◦ Judicious use in maintenance of soft stool to avoid straining and painful defecation (same indications as docusate) ◦ Routine use not indicated, docusate preferred Safety Considerations with Lubricants ◦ Drug interactions ◦ ADEK vitamins ◦ Do not co-administer with docusate ◦ Do not take within 2 hours of eating ◦ Adverse Effects ◦ Lipid pneumonia (esp. in patients with dysphagia) ◦ Pruritis ani, cryptitis, or perianal conditions (DC use) ◦ Contraindicated in bedridden patients ◦ Avoid in young children, pregnant women, older patients, immobile patients, and dysphagia ◦ Don’t give to children < 6 years old unless prescribed Saline ◦ Magnesium citrate, magnesium hydroxide, dibasic sodium phosphate/ monobasic sodium phosphate, or magnesium sulfate ◦ Ex: Fleet Ready-to-Use Enema®, Phillips MOM®, Epsom salt ◦ Ions draw water into intestines or colon by osmosis = ­ intraluminal pressure & motility ◦ Take on an empty stomach ◦ Onset: ½-3 hours by mouth; 2-15 minutes rectally ◦ Magnesium Hydroxide: 30 minutes – 6 hours Indications for Saline Laxatives ◦ Occasional relief of constipation ◦ Magnesium hydroxide ◦ Acute evacuation of bowel for preparing for colonoscopy exam ◦ Magnesium citrate ◦ Sodium phosphate preps ◦ Magnesium sulfate (Epsom salt) not recommended ◦ Not for long-term management of constipation Safety Considerations with Saline Laxatives ◦ Abdominal cramping, n/v, or dehydration ◦ All saline laxatives can result in electrolyte imbalance and fluid loss ◦ Labeling to avoid in Mg, PO4, and Na restricted diets ◦ Up to 20% of magnesium salts may be absorbed resulting in hypermagnesia ◦ Avoid Mg in renal impairment, newborns, and older adults ◦ Most do not use in children < 6 years old, some have labeling for ages 2 – 5 yrs. old Safety Saline Laxatives continued ◦ Sodium phosphate can cause hyperphosphatemia, hypocalcemia, & hypernatremia ◦ Use cautiously in renal impairment, cardiac, sodium/fluid restricted diets, or with meds that will effect electrolytes (ie:diuretics) ◦ Contraindicated in Congestive Heart Failure patients ◦ Avoid rectally in patients with megacolon, gastrointestinal obstruction, imperforate anus, or colostomy ◦ Counseling ◦ Take on an empty stomach with full 8 oz. glass of water to avoid dehydration, if not fluid restrictive ◦ Drug Interactions ◦ Table 15 – 5 or next slide Laxative Drugs Drug-Interaction Management Magnesium citrate Fluoroquinolone and Decreased drug Avoid oral magnesium tetracycline antibiotics absorption citrate 1-3 hours Magnesium Captopril, cefdinir, some oral Decreased Separate dosing by at hydroxide bisphosphonates, bioavailability, and/or least 2 hours for most gabapentin, iron salts, rate or extent of drug agents phenytoin, nitrofurantoin, absorption phenothiazines, rosuvastatin Magnesium Ketoconazole, itraconazole, Decreased drug Avoid for at least 4 hours hydroxide fluoroquinolone and absorption before or up to 3 hours tetracycline antibiotics, after interacting agent levothyroxine Magnesium citrate Fluoroquinolone and Decreased drug Avoid 1-3 hours of tetracycline antibiotics absorption tetracyclines or fluoroquinolones FDA Actions for Oral Sodium Phosphate Products ◦ Acute phosphate nephropathy linked to oral sodium phosphate products used for bowel cleansing ◦ In 2008, boxed warning to all Rx sodium phosphate products and med guides ◦ Oral nonprescription products NOT be used for bowel cleansing ◦ In 2014, FDA safety communication reiterated appropriate use of nonprescription products ◦ Not to exceed 1 dose in 24 hour period ◦ Avoid in high risk patients (ie:renal disease, > 55 years old, etc) Stimulants ◦ Bisacodyl and senna ◦ Ex: Correctol®, Dulcolax®, Ex-Lax®, Senokot® ◦ Increases peristaltic activity ◦ By local irritation of mucosa OR ◦ Action on intramural nerve plexus of intestines smooth muscle ◦ They increase water and electrolyte secretion ◦ Onset ◦ Oral 6-10 hours, up to 24 hrs ◦ Rectal 15-60 minutes (bisacodyl) Indications for Stimulants ◦ A component for prior to endoscopic examinations (bisacodyl) resulting in complete bowel evacuation ◦ To prevent or treat opioid-induced constipation in use w/docusate ◦ 2nd line in simple occasional constipation after bulk forming & hyperosmotics, however more likely to have adverse effects Safety Considerations for Stimulants ◦ Adverse effects ◦ Can cause severe cramping, electrolyte/fluid deficiencies, enteric loss of protein, or hypermobility ◦ Consequences of laxative abuse (box description) ◦ Use cautiously in patients ◦ Due to mucous and fluid loses ◦ Drug interactions/Test interference ◦ Take bisacodyl 1 hour prior to antacids or milk due to ¯ enteric coating (EC), avoid with H2RA and PPIs ◦ Do not crush or break bisacodyl with EC ◦ Senna may color urine pink, red, violet, or brown Laxative Overuse ◦ Misconceptions about BMs, fear of constipation, co-morbid conditions (ie: anorexia nervosa) ◦ Clinical features: ◦ Diarrhea and vomiting ◦ Fluid & electrolyte imbalance ◦ Dehydration ◦ Wean patient off and increase fiber ◦ Encourage physical activity, fluid/fiber intake Opioid-Induced Constipation ◦ Stimulant laxatives commonly recommended ◦ With or without docusate ◦ Docusate alone is not effective ◦ PEG-3350 may be used for prevention or treatment ◦ Saline laxatives may be used periodically for acute evacuation if needed ◦ Bulk-forming not appropriate Selecting Laxatives ◦ Review Figure 2 ◦ Recommend lifestyle management ◦ Simple constipation, generally bulk forming or PEG - 3350 initial choice ◦ Consider side effects ◦ Avoid mineral oil if possible ◦ Consider coexisting conditions Pediatric Approach ◦ Dietary and behavior modification first ◦ Under 2, use with healthcare provider ◦ Ages 2 – 6 years old: ◦ Docusate sodium or magnesium hydroxide first ◦ Senna – also rectal glycerin, mineral oil, or sodium phosphate ◦ Ages 6 – 12 years old: ◦ Methylcellulose, calcium polycarbophil, psyllium powder, magnesium hydroxide, or docusate sodium first ◦ Mineral oil, magnesium citrate, magnesium sulfate, senna, and bisacodyl Older Adult Approach ◦ Dietary and behavior modification first ◦ Plus education on normal bowel habits ◦ Medication adjustments if possible ◦ Bulk forming first, however be aware of fluid restrictions and other co-morbid conditions ◦ PEG 3350 also first line ◦ Docusate helpful with hemorrhoids ◦ Avoid mineral oil, watch for concerns with saline laxatives Counseling Issues ◦ Lifestyle considerations always included ◦ Don’t take laxatives > 1 week without HCP monitoring ◦ Only exception is fiber/functional fiber ◦ Be aware of co-morbid conditions and potential drug interactions ◦ Onset varies upon agent ◦ Consider prevention vs. treatment