Constipation_Singh Handout 2SPP 2024-1.pdf

1/22/2024 Constipation DR. SINGH, RPh, PHARMD, CDCES ASSOCIATE PROFESSOR, PHARMACY PRACTICE [email protected] 1 Guidance on material for in-class exams and quizzes 1. Please study information on slides with  2. Please go through all slides to see which ones have  Guidance on material for online assig...

1/22/2024 Constipation DR. SINGH, RPh, PHARMD, CDCES ASSOCIATE PROFESSOR, PHARMACY PRACTICE [email protected] 1 Guidance on material for in-class exams and quizzes 1. Please study information on slides with  2. Please go through all slides to see which ones have  Guidance on material for online assignments and quizzes Please review and use ALL slides to complete online assignments or online quizzes 3. Please only know generic names 2 1 1/22/2024 Objectives 1. Recognize clinical presentation 2. Identify the most appropriate agent to use based on patient-specific variables 3. Formulate appropriate counseling information about lifestyle changes and pharmacotherapy Lippincott's Illustrated Reviews: Physiology, 1e, 2012 3 With chronic idiopathic constipation (CIC), we do not have an identifiable underlying cause for constipation CIC diagnosis: Symptoms for ≥ 6 months and ≥ 2 of the following symptoms for > 25% of defecations during the past 3 months Straining Lumpy/hard stools Sensation of incomplete evacuation Sensation of anorectal obstruction/blockage Manual maneuvers to facilitate Less than 3 spontaneous BM/week Several factors may contribute to chronic idiopathic constipation https://www.linzess.com/types-of-constipation/cic-symptoms 4 2 1/22/2024 Treatment Options  Previously covered in OTC Covered in this lecture Initial Management: Increase fiber, fluids, physical activity Agents that cause softening of feces in 1-3 days  Methylcellulose, Polycarbophil, Psyllium, Docusate, Polyethylene glycol  Lactulose  Agents that result in soft or semi-fluid stool in 6-12 h  Bisacodyl, Senna, Magnesium sulfate (low dose)  Agents that cause watery evacuation in 1-6 h  Magnesium citrate, hydroxide, sulfate (high dose), Sodium phosphates, Bisacodyl  Intestinal secretagogues  Lubiprostone  Linaclotide  Plecanatide  Prokinetic agent: Prucalopride 5 PRESCRIPTION: Osmotic Laxative: Lactulose  Non-absorbable disaccharide that reaches the large bowel  colonic bacteria metabolizes it to monosaccharides  laxative effect Increase stool frequency Administration  Oral solution: Mix with fruit juice, water, or milk.  Crystals for oral solution: Dissolve contents of packet in 120 mL water.  Typically administered once daily Can be used if fiber, senna, or bisacodyl Side effects 1. Abdominal cramps, bloating, are ineffective; If Miralax does not work, then lactulose may not work either flatulence 2. Dehydration Monitor periodically for electrolyte imbalance if used >6 months or in patients predisposed to electrolyte abnormalities (elderly) 6 3 1/22/2024 Treatment Pearls  1. Goals: relieve symptoms and re-establish normal bowel habits 2. Fiber is great and is often used first-line for mild CIC; treat for 2-4 weeks  Remember to avoid bulk laxatives if the patient cannot move, cannot drink plenty of fluids, or has difficulty swallowing 3. If fiber is partially effective or not effective at all, switch or add an osmotic laxative (Miralax, lactulose, magnesium oxide) for 2-4 weeks 4. Stimulant laxatives, such as bisacodyl or senna, are good for occasional use or rescue therapy in combination with other pharmacological medications for CIC  Can be used long term if the regimen is effective 5. If nothing else works, let’s go to the agents approved for chronic idiopathic constipation (CIC)…probably will be treated with one of these for at least 12 weeks 7 Patient presents to clinic with a chief complaint of constipation. Over the past 8 months, she has had 1-2 bowel movements per week. Stools are hard. She has to strain and feels like the movement is incomplete. OTC options for CIC 1. Fiber 2. Miralax 3. Bisacodyl Patient is started on fiber and uses bisacodyl as rescue as needed. However, after 2 months of this, her symptoms have not improved. She adds Miralax to her regimen and continues with this for another 6 months. Unfortunately, her symptoms have now returned, and the medications are not working. Her GI has decided to add a prescription medication. 8 4 1/22/2024 Prokinetic: Prucalopride (Motegrity) for CIC MOA/Efficacy Notes A selective serotonin type 4 receptor agonist; it is a GI prokinetic agent that stimulates colonic peristalsis  increased bowel motility During 12-week studies, patients will have ≥ 3 BMs per week, on average  Administration: Orally once daily, with or without food  Use a lower dose if CrCL < 30 mL/min  Side effects: headache, abdominal pain, nausea, diarrhea  Contraindications: tear in the stomach or intestinal wall; bowel obstruction; Crohn’s disease; ulcerative colitis  Safety/efficacy in those