PHARM 345 - Other > Constipation > Flashcards

Constipation Flashcards

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1
Q

Where is Constipation most common in

A
  • Females
  • Elderly
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2
Q

Constipation
- Definition

A

Infrequent bowel movements of less than 3 stools per week
- Straining when passing stools
- Hard/lumpy stools

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3
Q

Constipation
- Other Symptoms

A
  • Sensation of incomplete evacuation
  • Bloating
  • Discomfort
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4
Q

Chronic Constipation
- ROME IV

A

Presence of 2 or more of the following lasting for longer than 3 months (Onset of 6 months before diagnostic)
- Straining
- Lumpy/hard stools
- Sensation of incomplete evacuation
- Sensation of anorectal obstruction
- Manual help to defecate
- Less than 3 spontaneous bowel movements per week

Loose stools not present
NO IBS symptoms

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5
Q

3 Types of Constipation

A
  1. Normal Transit Constipation
  2. Dys-synergic (Disordered) Defecation
  3. Slow Transit Constipation
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6
Q

Causes of Constipation

A

Primary Constipation
- No underlying cause

Secondary Constipation
- Low fiber, Low fluids, physical inactivity
- Medical conditions
- Medications

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7
Q

OTCs associated with Constipation

A
  • Calcium and Aluminium Antacids
  • Calcium supplements
  • Iron Supplements
  • Antihistamines
  • Dimenhydrinate
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8
Q

Rxs associated with Constipation

A
  • Opioids
  • Calcium Channel Blockers
  • Anticholinergics
  • Antidepressants
  • Antipsychotics
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9
Q

Constipation
- Complications

A
  • Hemmrrhoids
  • Fecal impaction
  • Malnutrition
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10
Q

Constipation
- Red flag questions

A
  • GI bleeding
  • Unintentional weight loss
  • Palpable abdominal mass
  • Unexplained anemia
  • Family history of colon cancer
  • Older than 50 years
  • Severe pain
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11
Q

Constipation
- Nonpharm

A

High fiber diet
- Increase gradually to prevent bloating, cramping
- Also increasing calories helps

Fluid intake
- To complement high fiber diet

Fruit in diet

High sorbitol foods
- Prunes, Figs, Pears, Apples

Lifestyle

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12
Q

Effect of Sorbitol on bowels

A

Draws water into large intestine
- Increases GI motility leading to laxative effects

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13
Q

Constipation
- Nonpharm (Lifestyle)

A
  • Regular exercise
  • Avoid suppressing urge to defecate
  • Regular scheduled time to defecate
  • Weight loss (Chronic Constipation)
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14
Q

Classes of Laxatives

A
  1. Bulk Forming Laxative
  2. Osmotic Laxative
  3. Stimulant Laxative
  4. Emollient/Stool Softner
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15
Q

Bulk Forming Laxatives
- Examples

A

Natural:
- Bran
- Soluble Fiber

Preferred:
- Psyllium

Alternative:
- Calcium Polycarbophil
- Methylcellulose

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16
Q

Bulk Forming Laxatives
- Mechanism of Action

A

Increases stool weight and consistency
- Decreases GI transit time
- Ensures easier peristalsis

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17
Q

Bulk Forming Laxatives
- Onset

A

1-3 days

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18
Q

Bulk Forming Laxatives
- Considerations

A
  • Take with water (250 mL minimum)
  • First line treatment, except constipation from poor GI motility or opioids
  • Avoid in patients who are dehydrated or fluid restricted
  • Dose other drugs after 2 hours of administration of laxative
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19
Q

Bulk Forming Laxatives
- Adverse Effects

A
  • Bloating
  • Flatulence
  • Diarrhea
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20
Q

Bulk Forming Laxatives
- Psyllium vs Methylcellulose vs Synthetic Fibers

A

Psyllium causes more flatulence

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21
Q

Osmotic Laxatives
- Examples

A

Saline Laxatives
- Magnesium Hydroxide
- Magnesium Citrate
- Sodium Phosphate

Hyperosmotic
- Glycerin Suppositories
- Polyethylene Glycol 3350
- Lactulose

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22
Q

Osmotic Laxatives
- Mechanism of Action

A

Water is retained in lumen through an osmotic gradient of poorly absorbed solutes/ions
- Stimulates peristalsis

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23
Q

Osmotic Laxatives (Saline)
- Onset

A

0.5 - 3 hours
- Used when quick response is required

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24
Q

Osmotic Laxatives (Saline)
- Types

A

Occasional Constipation
- Magnesium Hydroxide

Bowel Prep
- Magnesium Citrate
- Sodium Phosphate

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25
Osmotic Laxatives (Saline) - Considerations
- Requires adequate fluid intake - Avoid in renal impairment or heart disease
26
Osmotic Laxatives (Saline) - Adverse Effects
- Hypermagnesemia (Especially in renal impairment) - Other electrolyte abnormalities - Dehydration - Diarrhea
27
Osmotic Laxatives (Glycerin Suppositories) - Mechanism of Action
Retain water in rectum - Stimulates peristalsis
28
Osmotic Laxatives (Glycerin Suppositories) - Onset
15 - 30 minutes - Very quick response
29
Osmotic Laxatives (Glycerin Suppositories) - Adverse Effects
- Generally well tolerated - Can cause local irritation
30
Osmotic Laxatives (Glycerin Suppositories) - Considerations
Useful for children - 2 to 6 years = 1 supp daily prn - <2 years = limited data, may use 1 every 3 days prn
31
Osmotic Laxatives (PEG 3350) - Mechanism of Action
Binds to water molecules
32
Osmotic Laxatives (PEG 3350) - Onset
48 - 96 hours
33
Osmotic Laxatives (PEG 3350) - Adverse Effects
- Bloating - Flatulence (Less compared to other osmotic agents) - Diarrhea
34
Osmotic Laxatives (PEG 3350) - Considerations
- Use for Acute or Chronic constipation - Use other drugs 2 hours after laxative
35
Osmotic Laxatives (PEG 3350) - Dose
Add 17 g of powder to 250 mL of water, juice, coffee, or tea - Stir until dissolved
36
PEG + Electrolyte Solution - What is it?
Used for complete bowel evacuation - Patient takes a large amount of PEG - Needs the electrolytes to replenish what is lost
37
Osmotic Laxatives (Lactulose) - Mechanism of Action
Non absorbable disaccharide (fructose, galactose) - Is then metabolized by bacteria in colon into low molecular weight fatty acids --> These fatty acids cause an osmotic effect
38
Osmotic Laxatives (Lactulose) - Onset
24 - 48 hours
39
Osmotic Laxatives (Lactulose) - Considerations
- Use for Acute or Chronic constipation - Less effective than PEG - Avoid using other drugs within 2 hours of administration
40
Osmotic Laxatives (Lactulose) - Adverse Effects
- Flatulence - Bloating - Nausea - Diarrhea
41
Stimulant Laxatives - Mechanism of Action
Stimulates peristalsis
42
Stimulant Laxatives - Examples
- Anthranoid Laxative (Senna or Cascara) - Bisacodyl/Diphenylmethane
43
Stimulant Laxatives - Onset
Anthranoid - 8 to 10 hours Bisacodyl/Diphenylmethane - Oral: 6 to 8 hours - Suppository: 0.5 to 1 hour Usually meant to be used short term - Can be used long term for special cases (Opioid Induced)
44
Stimulant Laxatives - Adverse Effect
Common: - Abdominal Cramps - Diarrhea Other: - Hypokalemia - Anthranoid (Senna) can discolour feces/urine, is harmless --> Excessive use can lead to melanosis coli (Inner lining of colon darkens) Suppositories: - Local Irritation
45
Stimulant Laxatives - Considerations
- Bisacodyl is stronger than senna or cascara --> Can cause bowel dependence on laxative - Elderly and children are at greater risks of adverse effects - Avoid use in GI impaction
46
Emollient/Stool Softener - Examples
- Docusate - Mineral Oil Have been found to be not effective for constipation - No longer recommended
47
Enemas - Mechanism of Action
Stretches colon to create urge to defecate
48
Enemas - Onset
Within 1 hour - Fast onset
49
Enemas - Examples
- Mineral Oil Retention Enemas - Phosphate Enemas - Tap water Enemas
50
Enemas - Consideration
Use in Acute or Chronic constipation
51
Enemas - How to administer
1. Lubcricate nozzle 2. Lie on left side, knees bent 3. Insert nozzle in the recturm, while pointing towards navel 4. Gently squeeze container, discomfort means too fast 5. Retain solution until you feel cramping
52
Mu Receptor Antagonist - Mechanism of Action
Blocks mu opioid receptors directly in GI tract
53
Mu Receptor Antagonist - Examples
Methylnaltrexone Bromide Naloxegol
54
Mu Receptor Antagonist - Considerations
- Use in Opioid Induced Constipation where other laxatives give insufficient response - Second line, Discontinue other laxatives - Given subcutaneous every other day - Naloxegol has strong interactions with CYP3A4
55
Mu Receptor Antagonist - Onset
30 - 60 min
56
Mu Receptor Antagonist - Adverse Effects
- Abdominal Pain - Flatulence - Nausea - Dizziness - Hyperhidrosis - Diarrhea
57
5-HT4 Receptor Agonist - Examples
Prucalopride
58
5-HT4 Receptor Agonist - Mechanism of Action
Increases GI peristalsis
59
5-HT4 Receptor Agonist - Onset
Acts within 2-3 hours
60
5-HT4 Receptor Agonist - Consideration
- Use for female patients with severe constipation who have seen no improvement with other laxatives - Discontinue if inadequate response within 4 weeks
61
5-HT4 Receptor Agonist - Adverse Effects
- Cramping - Nausea - Diarrhea
62
Guanylate Cyclase-C Agonist - Examples
Linaclotide
63
Guanylate Cyclase-C Agonist - Consideration
- Use in patients with IBS with Constipation - Use in patients with Chronic Idiopathic Constipation
64
Mild Acute Constipation - Recommendations
Lifestyle Advice + Bulk Forming Laxative - Psyllium
65
Moderate to Severe or wants rapid response Acute Constipation - Recommendations
Glycerin or Bisacodyl Suppositories or Magnesium Hydroxide/Citrate or Stimulant Laxatives - PEG or Lactulose can be used if patient does not care about rapid action - Use Sodium Phosphate Enema if still not working
66
Laxatives - Onset 15-60 mins
Glycerin Supp Bisacodyl Supp Enemas
67
Laxatives - Onset 0.5-3 hours
Saline Laxatives (Magnesium Products)
68
Laxatives - Onset 6-12 hours
Stimulant Laxatives (Senna, Oral Bisacodyl)
69
Laxatives - Onset 1-4 days
- Bulk Forming (12-72h) - Emollient/Stool Softeners (12-72h) - Lactulose (24-48h) - PEG 3350 (48-96h)
70
Laxatives role in Palliative Care Patients
Regular laxative use if patient is on chronic opioids
71
Laxative choice in Palliative Care Patients
- Can use Stimulant Laxatives or Osmotic Laxatives (PEG, Lactulose) - Avoid Bulk Forming Laxative (Impaction) If constipation is severe and patient is not responding to laxatives - Methylnaltrexone or Naloxegol
72
Constipation treatment in Elderly
First Line: - Fluid and Fiber (Diet of Bulk Forming Laxative) Options: - PEG, Lactulose - For quick action: Glycerin Supp If above options fail: - Stimulant laxatives (Watch for side effects of bloating, flatulence, diarrhea)
73
What laxatives to avoid in elderly
Avoid Magnesium Laxatives if patient is renally impaired
74
Laxatives in Pediatrics
First Line - Fluid/Fiber - Fruit with sorbitol (Pears, Prunes, Apples) Options: - PEG, Lactulose - For quick action: Glycerin Supp Second Line: - Magnesium Laxatives If above options fail: - Stimulant laxatives
75
Laxatives in Pregnancy
First Line - Fiber (Diet or Bulk Forming) Options - Magnesium Laxatives - For quick action: Glycerin or Bisacodyl Supp - Stimulant Laxatives (Short Term) If Fiber not effective: - PEG, Lactulose
76
What laxatives to avoid in pregnancy
- Linaclotide (Guanylate Cyclase-C Agonist) - - Prucalopride (5-HT4 Receptor Agonist) - Castor Oil (Premature uterine contractions)
77
Laxatives in breastfeeding
Senna is okay even though some is excreted into breast milk
PHARM 345 - Other
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