2024 Oct 1 CSD2 Constipation Diarrhea by Gerber PDF

Self Care: Gastrointestinal (GI) Disorders Constipation/Diarrhea Dr. Gerber, PharmD, BCGP, FASCP, FAzPA Office: 201-15 Please use Canvas Inbox for “email” course communication to Dr. Gerber, instead of MWU email. A succinct subject line is appreciated. Example subject line: ADEs. This will help Dr....

Self Care: Gastrointestinal (GI) Disorders Constipation/Diarrhea Dr. Gerber, PharmD, BCGP, FASCP, FAzPA Office: 201-15 Please use Canvas Inbox for “email” course communication to Dr. Gerber, instead of MWU email. A succinct subject line is appreciated. Example subject line: ADEs. This will help Dr. Gerber respond to communication more efficiently and quickly. Every effort is made to respond to Canvas Inbox messages within 48 hours. 2  1. Classify the severity of a patient’s GI complaints. 2. Describe diet, pharmacologic agents, and other After attending issues that can exacerbate constipation or diarrhea. these lectures, 3. Compare and contrast the mechanism of action, indications, onset, and duration of action, and completing the adverse effects of OTC medications used to treat constipation or diarrhea. required reading 4. Assess the advantages and disadvantages of OTC medications used to treat constipation or diarrhea. and studying 5. Recommend an appropriate drug treatment these handouts, selection for a patient with constipation or diarrhea. the pharmacy 6. Formulate appropriate counseling information to be provided a patient on a given treatment regimen for student should constipation or diarrhea. be able to: Required Reading: Handbook of Nonprescription Drugs: Constipation & Diarrhea chapter CONSTIPATION 4  What is constipation? YOUR description: Classmate’s description: 1. 1. 2. 2. 3. 3. 5  Prevalence in United States estimated to be between 2-28% Women are more than 3x as likely as men to experience constipation Older adults (>65 years) are 5x more likely to be affected Fast Facts Consequences: – Accounts for at least 2.5 million physician visits/year – Sales of enemas and laxatives combined reached $1.4 billion 6  Symptoms Straining to have a Hard, dry stools Small stools bowel movement Feeling as though bowel evacuation is Decreased stool incomplete frequency (tenesmus) 7 Causes of Constipation 8  Medication Causes of Constipation Antihistamines (e.g. diphenhydramine) Anticholinergic drugs Antidepressants Calcium channel blockers Calcium supplements and antacids Diuretics Iron supplements Opioids 9  Opioid Induced Constipation First-line therapy: – Stimulant laxative (senna/bisacodyl) ± docusate – Polyethylene glycol (PEG) 3350 scheduled daily Bulk-forming laxatives are NOT used for this indication – Risk of fecal impaction 10  Conditions Dementia Depression Diabetes Irritable bowel syndrome Multiple sclerosis Neurologic disorders Parkinsonism Stroke Thyroid disorders 11  Lifestyle Low calorie or low fiber diet Dehydration Inactivity Urge avoidance 12  Complications Hemorrhoids Anal fissures Rectal Fecal prolapse impaction 13  Exclusion of self-treatment CONDITIONS SPECIAL POPULATIONS Prolonged Diabetics Marked abdominal pain, distention, cramping, or flatulence Fever, nausea/vomiting Children Blood in stool or dark, tarry stool Pregnancy Sudden change in character of stool Weight loss 14  SCHOLAR-MAC Symptoms Characteristics History Onset Location Aggravating factors Remitting factors Medications Allergies Conditions 15  What questions do you need to ask? What could be the cause? If not excluded for self-treated, which medication is best? Treatment or prevention? What other disease states are present? What has happened in the past couple What other medications are present? of day? What education needs to be provided Past medical history? for best medication outcome? Current disease states? Medications? 16  Treatment Goals Relieve Establish Promote Relieve symptoms Establish dietary and Promote safe and and reestablish exercise habits to effective use of normal bowel prevent recurrence laxatives if indicated function 17 TREATMENT & PREVENTION  Non-Pharmacologic Therapy Hydrate! – 64 fl oz ~ 1.9 liters per day Increase fiber intake – Recommendations: females 25 g, males 38 g – Gradually increase over 1-2 weeks to avoid abdominal discomfort Increase physical activity Behavioral modifications – Bowel training – Toileting positioning 19  Non-Pharmacologic Therapy: Juice Popular among older adults Plum vs prune juice – 3-4 gm fiber per serving Sorbitol-containing juices – Prune, apple, and pear 20 PHARMACOTHERAPY  Product Selection Approach Bulking agent is first-line (most physiological) If ineffective or faster onset desired, consider PEG 3350 If ineffective, add stimulant laxative If no improvement after 7 days of self-treatment → REFERRAL 22  Medication Classes Bulk-forming Laxatives Hyperosmotic Laxatives Mineral Oil Stimulant Laxatives Stool Softeners 23  Medication Classes Bulk-forming Hyperosmotic Mineral Laxatives Laxatives Oil Stimulant Laxatives Stool Softeners 24  Lubricants Mineral oil Mechanism of action – softens fecal contents Not recommended – Potential for aspiration pneumonia and adverse events – Safer first-line options 25  Medication Classes Bulk-forming Hyperosmotic Mineral Oil Laxatives Laxatives Stimulant Stool Softeners Laxatives 26  Bulk-Forming Agents Considered first-line for many patients– effects are most closely approximate physiological process Mechanism of action – swell in the presence of intestinal fluid to facilitate defecation Options: – Methylcellulose (Citrucel®) – Calcium polycarbophil (Fibercon®) – Psyllium (Metamucil®, Konsyl®) – Wheat dextrin (Benefiber®) 27  Bulk-forming Laxatives MOA – INCREASES stool bulk by swelling in water to form an emollient gel or viscous solution – Resulting bulk in the feces promotes peristalsis Dosing: – Follow label – Start low, Go slow Side Effects – Abdominal cramping, flatulence – Warning: bulk-forming laxatives may swell in the throat or esophagus (choking hazard) – take with plenty of water! Avoid if constipation caused by – Opioids – Gastroparesis Patient Education – Follow package instructions 28 Myths and Misconceptions About Constipation: A New View for the 2020s. Am J Gastroenterol. 2020; 115 (11): 1741-1745. nonfermentable, soluble fiber seems to be the more appropriate initial choice based on comparative studies in patients with CIC. Finely ground what bran has minimal mechanical effects on the colon and can actually result in harder stool with decreased water content (13). Other forms of fiber (soluble, highly fermentable nonstarch polysaccharide fiber and insoluble, nonfermentable fiber) have not shown meaningful improvement in CIC symptoms 29 Myths and Misconceptions About Constipation: A New View for the 2020s. Am J Gastroenterol. 30 2020; 115 (11): 1741-1745.  Useful in Bulk-Forming Agents – Postpartum patients – Older adults – Patients with colostomies, irritable bowel syndrome, or diverticular disease Onset – Usually 12-24 hours, may take up to 72 hours 31 Bulk-Forming Agents Counseling Points – Take with 8 fl oz water or other fluids – Separate from other medications by at least 2 hours  Self-assessment Learning objective: Describe diet, pharmacologic agents, and other issues that can exacerbate constipation Dawn is a 26-year-old female with a chief complaint of constipation. She is a marathon runner and recently started taking OTC diphenhydramine (Benadryl®) to prevent postnasal drip during her morning runs. She has no other medical conditions except for mild asthma. Which of the following factors is most likely contributing to Dawn’s constipation? A. Age B. Comorbid asthma C. Diphenhydramine use D. Inactivity 33  Medication Classes Bulk-forming Laxatives Hyperosmotic Mineral Oil Laxatives Stimulant Laxatives Stool Softeners 34  Hyperosmotic Agents Mechanism of action: pull water into colon or rectum through osmosis Examples: – Polyethylene glycol 3350 (MiraLax®) – Glycerin suppository 35  Hyperosmolar Agents Polyethylene glycol 3350 Not indicated for self-care among patients