Constipation - Med/High Priority Flashcards by Jordan Cyr

What is constipation?

the definition of constipation varies among individuals and includes (not limited to the following):
-infrequent defecation (< 3 x/week) along with other sx
-straining or painful defecation, hard/lumpy stools, incomplete evacuation, bloating and abdominal discomfort, a sense of rectal blockage

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What are the classifications of primary constipation?

normal colonic transit:
-normal bowel motility rate + feeling of incomplete evacuation
slow transit constipation:
-delay in stool transit + infrequent defecation
pelvic floor dysfunction:
-ineffective defecation due to pelvic floor muscular dysfunction and/or coordinated issues

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What is the Rome IV criteria?

a tool used to diagnose chronic constipation
-symptoms must be present for >=3 months with an onset of >=6 months before diagnosis

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What are the risk factors for constipation?

female
pregnancy
> 65 yrs of age
lower education or socioeconomic status
changes in diet or eating disorders
low caloric, fiber and/or fluid intake
living conditions
sedentary lifestyle
ignoring the urge to defecate

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Which medical conditions can cause constipation?

CV disease: stroke
GI: IBS, hemorrhoids
neurologic: Parkinsons, spinal cord injuries
metabolic: diabetes, thyroid, low Mg, low/high Ca, low K
psychiatric: depression, anxiety

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What are some medication causes of constipation?

anticholinergics
antidepressants
antidiarrheals
antiepileptics
antihistamines
antihypertensives
antinauseants
anti-Parkinsons
diuretics
cation-containing agents (iron, calcium, aluminum)
antispasmodics
antipsychotics
NSAIDs
opioids
vinca alkaloids
5-HT3 antagonists

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What are the red flags for constipation?

new onset in children < 2 yrs or adults > 50 yrs
family history of colon cancer
recent abdominal surgery
unexplained wt loss > 5%
diagnosed IBS-C or IBD
eating disorders
GI bleeds
vomiting, rash, fever, or extreme thirst
persistent abdominal pain or unremitting nocturnal sx
abdominal or rectal mass
unexpected acute changes in bowel behavior
symptoms of iron deficiency with or w/o anemia
severe pain during defecation
impaction

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What are the goals of therapy for constipation?

identify and treat underlying cause(s)
educate pts on appropriate laxative use
alleviate discomfort
establish normal bowel routine
prevent complications

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What are the non-pharmacological measures for constipation?

dietary modifications:
-encourage sufficient daily fiber intake (25-35g)
-promote adequate fluid intake (2.2-3L)
behavioral changes:
-avoid straining
-establish a normal bowel routine
-eliminate the urge to avoid defecation
-encourage regular physical activity

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What are examples of bulk-forming agents?

psyllium

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What is the onset of psyllium?

1-3 days

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What are the adverse effects of psyllium?

bloating
flatulence
abdominal discomfort (start low dose)

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How is psyllium taken?

take one dose with at least 8 oz of water to prevent fecal impaction

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What is the role for psyllium in chronic constipation?

safe for chronic use

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What is a contraindication of psyllium?

fecal impaction

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What are the 1st line options for constipation?

bulk-forming (psyllium)
osmotic (PEG)

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What are examples of osmotic laxatives?

PEG 3350
lactulose
sorbitol 70% solution
glycerin suppositories
magnesium citrate/hydroxide
sodium phosphate enema

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What is the onset of PEG 3350?

2-4 days

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What is the efficacy of PEG 3350?

more effective than lactulose
effective in opioid-induced constipation

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What is the role for PEG 3350 in chronic constipation?

safe for long-term use

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How should PEG 3350 be administered?

separate from other medications by at least 2 hours

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What is the onset of lactulose?

1-2 days

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Can lactulose be used in diabetes?

can be used, although still monitor for hyperglycemia

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What is the efficacy of lactulose?

effective in opioid-induced constipation

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How should lactulose be administered?

separate from other medications by at least 2 hours

What is the efficacy of sorbitol 70% solution?

equally as effective as lactulose (onset 1-2 days) effective in opioid-induced constipation

What is the concern with sorbitol 70% solution?

concern for bowel necrosis

What is the onset of glycerin suppositories?

quick onset -15 min to 1hr

How long should glycerin suppositories be retained for?

15 min

What is the efficacy of glycerin suppositories?

effective in opioid-induced constipation

What is the onset of saline laxatives?

rapid onset - < 30 minutes - 6 hours -enemas have an onset of < 15 min

What are the risks with saline laxatives?

contain electrolytes: avoid in renal failure/cardiac disease can cause electrolyte imbalances

What is the role for saline laxatives?

bowel cleansing

What are examples of stimulant laxatives?

senna bisacodyl

What is the onset of stimulant laxatives?

po 6-12 hr bisacodyl PR: 0.5-1 hr

When are stimulant laxatives used?

an option if osmotic laxatives are not tolerated/fail effective in opioid-induced constipation

Which stimulant laxative causes less abdominal discomfort?

senna

What is the risk with stimulant laxatives?

potential for dependence

What are examples of stool softeners?

docusate mineral oil

What is the onset of stool softeners?

1-3 days

What is the efficacy of stool softeners?

limited efficacy data, generally NOT recommended

Why should mineral oil be avoided?

risk of aspiration can also bind to fat-soluble drugs

What are example of lavage laxatives?

picosulfate sodium magnesium oxide/citric acid electrolyte solutions

What is the role for laxage laxatives?

used before a colonoscopy or medical procedure

What are examples of prescription products for constipation?

prucalopride methylnaltrexone naloxegol linaclotide

What is the MOA of prucalopride?

5-HT4 receptor agonist -GI prokinetic activity

What is the onset of prucalopride?

24-48 hrs

What is the role for prucalopride in constipation?

adult female pts (> 18) with chronic idiopathic constipation who have not responded to two previous classes of laxatives

When should prucalopride be discontinued for constipation?

if ineffective after 4 weeks of treatment

What is the MOA of methylnatrexone and naloxegol?

u-opioid receptor antagonist

What is the onset of methylnaltrexone and naloxegol?

methylnaltrexone: 30 min - 4h naloxegol: 6h

What is the role for methylnaltrexone in constipation?

opioid-induced constipation in palliative care pts -SC injection -adjunctive therapy to laxatives

What is the role for naloxegol in constipation?

treatment of opioid-induced constipation in adults with non-cancer pain who has not responded adequately to laxatives

What are the contraindications to naloxegol and methylnaltrexone?

strong CYP 3A4 inhibitors

What is the MOA of linaclotide?

guanlyate cyclase-C receptor agonist -increases intestinal fluid and GI transit time but can cause diarrhea

What is the onset of linaclotide?

24-48 h

What is the indication for linaclotide in constipation?

chronic idiopathic constipation and IBS-C in adults when traditional therapies are ineffective

How is constipation managed in pregnancy?

encourage non-pharm options first bulk-forming agents with adequate hydration are 1st line -lack of systemic absorption if no improvement can add or switch to PEG or lactulose -for short duration glycerin suppositories or bisacodyl suppositories can be used for short-term

How is constipation managed in breastfeeding?

encourage non-pharm first bulk-forming agents with adequate hydration are 1st line -lack of systemic absorption magnesium hydroxide considered 2nd line bisacodyl & senna may be used for short-term

Which agents should not be used in breastfeeding?

docusate linaclotide prucalopride other laxatives

What should opioids always be paired with?

stimulant or osmotic laxative

Describe the step-wise approach to chronic constipation.

1. initiate non-pharm methods, if inadequate fiber consider bulk-forming agents 2. if no relief in 4-6 wks: consider osmotic agents along with fiber supplementation 3. if no relief in 4-8 wks: stimulant (short duration) 4. if no relief: prescription therapy

What is a colonscopy?

examination of the rectum and colon using a colonscope

What is required for a colonoscopy?

bowel preparation -clear liquid diet starting 1 day before procedure -stop certain drugs: iron, codeine, loperamide -take medication to empty colon

What are some tips when using PEG for colonoscopy prep?

refrigerate the night before to improve taste drink ~ 1 cup/hour if experiencing nausea, wait 20-30 min then try again

Which pts should use bowel preps for colonoscopy with caution?

heart failure or renal disease due to risk of electrolyte imbalances -PEG formulas: considered safer option -saline based formulas: risk of elyte imbalance & mineral overdose

What are the phases of increased risk for constipation in children?

introduction of solid food or cows milk inadequate fiber and fluid intake; excess milk consumption toilet training (stool withholding) beginning school or daycare

What are the two categories of constipation in children?

functional: -most common; no organic etiology -normal difficulty passing stool or infrequent stools that feel incomplete without underlying autonomic or neurologic cause organic: -seen in < 5% of children -potential causes include anatomical abnormalities, medical conditions -requires referral

What are the goals of therapy for constipation in children?

alleviate signs and symptoms of discomfort establish normal bowel routine prevent complications

What are the red flags for constipation in children?

inability to pass meconium within first 48 hrs suspected or diagnosed organic constipation medication-induced rectal bleeding or blood in stool signs of infection vomiting, fever significant abdominal distention with pain intermittent loose stools, ribbon stools symptoms of nutritional deficiencies fecal impaction suspected or explosive stool after DRE failure to thrive or developmental delays

What are the non-pharmacological measures for constipation in children?

encourage adequate fluid intake per weight recommended adequate fiber intake - ~5 g/day in children <=2 promote physical activity develop and optimize bowel routine by using a low stool or a trip 30 min after a meal avoid straining or sitting on toilet for more than 5 min keep a bowel movement diary lookout for signs of withholding

What is the key thing to understand with the pharmacological measures for constipation in children?

recommendations are not evidence-based

What is 1st line for constipation in children?

PEG 3350 -safe and commonly used

What is 2nd line for constipation in children?

lactulose -less effective than PEG 3350 -causes more bloating and abdominal pain

What is the role for mineral oil for constipation in children?

not recommended -increased risk of aspiration -less effective than PEG 3350

What is the role for glycerin suppositories in children?

safe and effective -good option if po route refused/for immediate relief -particularly in infants

What is the role for stimulant laxatives in children?

refractory cases -used when osmotic laxatives fail -contraindicated in infants

Constipation - Med/High Priority Flashcards

(77 cards)