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Clinical - Winter > 14 - Constipation > Flashcards

14 - Constipation Flashcards

1
Q

What is constipation?

A

Infrequent and/or unsatisfactory defecation fewer than 3 times per week

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2
Q

What are common symptoms that px complain of w/ constipation?

A
  • Straining and/or pain
  • Passing dry, hard stool
  • Passing small stools
  • Feelings of incomplete bowel evacuation
  • Bloating or decreased stool frequency w/ distention
  • Feeling of rectal blockage and abdominal discomfort
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3
Q

What is considered normal bowel habits?

A

Can range from 3 BM/day to 1 BM every 3 days

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4
Q

What is functional constipation?

A

Chronic constipation not caused by a drug, anatomic, or physiologic abnormality

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5
Q

What are some risk factors for constipation?

A
  • Female
  • Non-white
  • Living in rural, northern, or mountainous areas in North America
  • Over 65 y/o
  • Fewer years of formal education
  • Low caloric intake
  • Increased number of medications
  • Lower socioeconomic status
  • Sedentary lifestyle
  • Travelling
  • Ignoring urge to defecate
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6
Q

What are some diseases that cause constipation?

A
  • IBS, IBD
  • Neurological (stroke, MS, Parkinson’s)
  • Diabetes
  • Chronic renal failure
  • Carcinoma
  • Psychiatric
  • Anal fissures
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7
Q

What are some medications that can cause constipation?

A
  • Antacids (aluminum and calcium)
  • Anticholinergics
  • Iron supplements
  • Analgesics
  • Antihypertensive agents
  • Anticonvulsants
  • Antipsychotics
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8
Q

What are some lifestyle factors that can cause constipation?

A
  • Decreased/inadequate dietary fibre
  • Inadequate intake of fluids
  • Lack of exercise
  • Travel
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9
Q

What are red flags for constipation?

A
  • Sx lasting longer than 2 weeks (or no BM for 7 days) w/ laxative use
  • Blood in stool (dark, tarry); mucous; rectal bleeding; severe pain w/ defecating; fever
  • Persistent abdominal pain or severe pain when defecating
  • Unexplained weight loss of over 5%
  • Family history of colon cancer (esp. if px over 50 y/o)
  • Anemia sx (fatigue, lethargy)
  • Vomiting
  • Under 2 y/o
  • Unremitting nocturnal sx
  • Recent abdominal surgery
  • Chronic illness associated w constipation
  • Eating disorder
  • Moderate to extreme thirst
  • Diarrhea alternating w/ constipation
  • Rectal or abdominal mass
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10
Q

What can be done to prevent constipation?

A
  • High fibre diet w/ adequate fluid consumption (min. 1.5 L/day)
  • Routine, private toilet regimen
  • Defecating when feeling urge
  • Prophylactic laxative use (when taking a constipating medication or have chronic condition associated w/ constipation)
  • Daily physical activity (moderate)
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11
Q

What is the general tx approach for constipation?

A
  • Adjust diet to increase fibre and fluid intake
  • Include some form of aerobic exercise
  • Pharm intervention used in conjunction w/ lifestyle modification
  • Select laxative based on px age, health status, and MOA of product
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12
Q

What are some fruits that can be recommended for constipation?

A

Apples, pears, prunes

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13
Q

___ can be recommended to children to help w/ constipation because it _____

A

Unbuttered popcorn; builds bulk in the stool

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14
Q

What are some non-pharms for constipation in children?

A
  • Increase daily dietary fibre (popcorn, green peas, avocado, plums)
  • Juice that contains sorbitol
  • Toilet routine to try defecation 5-15 mins after each meal
  • Biofeedback
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15
Q

What is the timeframe to effectiveness for OTC products for constipation?

A
  • Agents that soften feces (bulk forming agents, emollients) = 12-72 hours
  • Agents that result in soft or semisolid stool (stimulant laxatives) = 6-12 h
  • Agents that cause watery evacuation (magnesium citrate, magnesium hydroxide, oral sodium phosphates) = 0.5-3 h
  • Enemas = 5-15 mins
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16
Q

What is the MOA of bulk forming agents?

A
  • Dissolve or swell in fluids of digestive tract by attracting water to hydrophilic sites
  • Increase stool weight/volume and frequency
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17
Q

What is the first line agent for constipation in most cases?

A

Bulk forming agents b/c are considered dietary supplements instead of laxatives

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18
Q

Which px should avoid bulk forming agents?

A

Px w/ dehydration or that are fluid restricted

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19
Q

What is the recommended length of tx for bulk forming agents? Onset?

A
  • Recommended for short-term use, but can be used long-term for prevention (if non-pharms aren’t enough)
  • Onset = 1-3 days
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20
Q

What product is a stool softener?

A

Docusate sodium/calcium

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21
Q

What is the MOA of stool softeners? Onset?

A
  • Helps water in bowel mix w/ fecal mass, causing softening

- Onset = 12-72 hours

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22
Q

Are stool softeners used for prevention or tx of constipation?

A

Only prevention

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23
Q

When are stool softeners highly ineffective?

A
  • Preventing chronic opiate-induced constipation

- If inadequate dietary intake

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24
Q

When are stool softeners helpful?

A

Px who should not strain, and those w/ fissures or hemorrhoids

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25
Q

What are stool softeners often combined w/ for long term tx of opiate-induced constipation?

A

Sennosides/bisacodyl

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26
Q

How does mineral oil act as a laxative?

A
  • Lubricates fecal material and intestinal mucosa

- Reduces reabsorption of water from GI tract, increasing fecal bulk

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27
Q

What is laxative jelly used for? How long can it be used? What is the dosage?

A
  • For tx of occasional constipation
  • Used for max. 1 week
  • Dosage = single dose at bedtime
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28
Q

What is the difference between lubricants and stimulant laxatives?

A
  • Same onset of action

- Stimulant laxatives have less side effects, so typically recommended over lubricants

29
Q

When are stimulant laxatives used?

A
  • Acute constipation for short periods of time

- First line for opiate-induced constipation

30
Q

What is the onset of action for stimulant laxatives? When should they be taken?

A
  • Onset = 6-12 hours

- Taken at bedtime

31
Q

What are counselling notes about bisacodyl products?

A
  • Enteric coated so shouldn’t be crushed or chewed

- Not to be taken w/ milk, antacids, or PPI’s

32
Q

What is the MOA of osmotic laxatives?

A

Presence of ions draws water into intestine, increasing intraluminal pressure, which applies mechanical stimulus that increases intestinal motility

33
Q

When is PEG 3350 used? For how long? What is the dosing? Onset of action?

A
  • Indicated for short term use in px w/ constipation
  • May be used long term as well (6 months)
  • May be used for opioid-induced constipation
  • Dosing = once daily
  • Onset = 48-96 hours
34
Q

What are common side effects of PEG 3350?

A
  • Gas
  • Cramping
  • Bloating
  • Diarrhea
35
Q

What are some counselling tips regarding PEG 3350?

A
  • Avoid other medications w/in 2 hours of use

- Indicated for adults 18+ only, unless recommended by physician for use in children (commonly recommended in children)

36
Q

What is the safest and most effective product for constipation? Why?

A
  • Glycerin suppository

- Minimal SE (rectal irritation) and no drug interactions

37
Q

What is the MOA of glycerin suppositories? Onset?

A
  • Osmotic effect and local irritation effect leads to drawing of water into rectum to stimulate BM
  • Onset = 15-30 mins
38
Q

What is a counselling tip for glycerin suppositories?

A
  • Moisten w/ warm water before insertion

- Try to retain as long as possible

39
Q

When can magnesium osmotic products be used? Why?

A

If px has normal renal function b/c frequently cause diarrhea and electrolyte imbalances

40
Q

Magnesium products should be taken w/ ____ to prevent ______

A

Water; dehydration

41
Q

When should enemas not be used?

A

Elderly

42
Q

What should be done if constipation is not relieved w/in 48 hours of treatment?

A

Try another agent w/ a faster onset of action

43
Q

What is the maximum length of treatment for acute constipation?

A

1 week

44
Q

When should px be referred after attempting tx for constipation?

A
  • No BM w/in 7 days
  • Severe abdominal cramps and/or pain, N/V, rectal bleeding, rectal pain, anal fissures
  • Dehydration (if diarrhea occurs)
  • If sx last longer than 1 month (chronic)
45
Q

What is the recommended tx for constipation in infants under 1 y/o?

A
  • Increase amount of fluid (best to discuss w/ doctor)
  • Pediatric glycerin suppositories to relieve rectal disimpaction (if under 2, then only under pediatrician recommendation)
46
Q

What is the recommended tx for constipation in children 1 year or older?

A
  • Increase dietary intake and fluids (sorbitol)
  • First line = PEG, lactulose, sorbital
  • Second line = MgOH, heavy mineral oil
47
Q

Is pregnancy an automatic referral for constipation?

A

No b/c fairly common

48
Q

What is the recommended tx for constipation in pregnancy and breastfeeding?

A

Non-pharms

  • Increase fluid intake
  • Increase dietary intake of fibre
  • Try to time BM after meals

Can use pharm options to help in the meantime

  • First line = bulk forming agent
  • If stools remain hard, PEG
  • Glycerin suppositories can be used occassionally
49
Q

What is the recommended tx for constipation in the elderly?

A
  • Increase dietary and fluid intake (unless fluid restricted, like heart failure or renal problems)
  • Encourage px to establish routine time for BM (5-10 mins after meals)
  • Can recommend bulk forming agents if not CI’d (must increase fluid as well)
  • Can recommend glycerin suppositories, PEG, or stimulant laxatives (only for infrequent use)
50
Q

What is the first line product for constipation in cancer and palliative px?

A

Stimulant laxatives

51
Q

When should you refer cancer and palliative px w/ constipation?

A

No BM in 3 days

52
Q

What is the recommendation for laxative use w/ other medications?

A

Wait 2 hours before and after taking laxatives to take other medications

53
Q

What are common symptoms of laxative abuse?

A
  • Diarrhea (severe, chronic, watery, frequently at night)
  • Abdominal pain, N/V
  • Weight loss, muscle weakness
  • Electrolyte imbalance
54
Q

What is the tx for laxative abuse?

A
  • Referral

- If returning to pharmacy after being stabilized, recommend fibre or osmotic laxatives to establish normal BM

55
Q

What are contraindications for bulk forming agents?

A
  • Partial bowel obstruction
  • Fluid restricted px
  • Suspected fecal impaction
  • Dysphagia
  • GI strictures
  • Throat problems
56
Q

What are common side effects of bulk forming agents?

A
  • Flatulence
  • Bloating
  • Cramping
  • Psyllium = bronchospasm, anaphylaxis
  • Polycarbophil = esophageal obstruction, fecal impaction
57
Q

What are contraindications for stool softeners?

A
  • Intestinal obstruction
  • Acute abdominal pain
  • N/V
58
Q

What are common SE of stool softeners?

A
  • Mild transient nausea
  • GI cramps
  • Occasional rash
59
Q

What is a contraindication for lactulose use?

A

Galactose restricted px

60
Q

What are common SE of lactulose, sorbitol, and PEG?

A
  • Flatulence
  • Abdominal cramps
  • Nausea
61
Q

What is a contraindication for sorbitol use?

A

Severe cardiopulmonary or renal impairment

62
Q

What is a contraindication for PEG?

A

Renal disease

63
Q

What is a contraindication for MgOH, Mg citrate, and sodium phosphate?

A
  • Cardiac or renal disease

- Caution w/ dehydration

64
Q

What are drug interactions w/ MgOH and Mg citrate?

A

Digoxin and tetracyclines

65
Q

What are common SE for MgOH, Mg citrate, and sodium phosphate?

A
  • Hypokalemia
  • Abdominal cramps/pain
  • N/V
  • Dehydration w/ MgOH
66
Q

What are contraindications for senna and bisacodyl?

A
  • Undiagnosed rectal bleeding
  • Signs of intestinal obstruction
  • Appendicitis
67
Q

What does bisacodyl interact w/?

A

Milk, antacids, and PPI’s

68
Q

What are common SE for senna and bisacodyl?

A
  • Abdominal pain
  • Hypokalemia
  • Diarrhea
  • Dehydration
69
Q

What is a counselling tip for senna?

A

May discolour urine red to pink or brown to black

Clinical - Winter (24 decks)

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