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Therapeutics II > Block 1: Constipation > Flashcards

Block 1: Constipation Flashcards

1
Q

What is constipation?

A

Occurrence of fewer than 3 bowel movements/week associated with strainign and difficult passage of hard, dry stools

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2
Q

Untreated constipation can lead to ?

A
  1. Hemorrhoids
  2. Anal fissures
  3. Rectal prolapse
  4. Fecal impaction
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3
Q

Causes of constipation?

A
  1. Med problems and meds
  2. Psychological and physiological conditions
  3. Lifestyle, inadequate fluid and fiber
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4
Q

Meds that can cause constipation?

A
  1. Opiates
  2. Anticholinergics
  3. Iron
  4. NSAID
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5
Q

What is normal stool according to Bristol?

A

3-4

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6
Q

What are exclusions of constipation self-care?

A
  1. Abdominal pain or distenstion
  2. Fever, N/V
  3. Use of laxatives
  4. Blood in stool
  5. Over 2 weeks sx, recurrance within 3 months
  6. Anorexia
  7. <2 YO
  8. Excessive flatulence
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7
Q

What are alarm sx of constipation?

A
  1. Hematochezia
  2. Melena
  3. Hx of colon cancer or IBD
  4. Anemia
  5. Weight loss
  6. ANorexia
  7. N/V
  8. Severe or persistnat
  9. New or worsening
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8
Q

What are non-pharm of constipation?

A
  1. Adequate fiber intake (25g women, 38g for men) (fiber supplement)
  2. Increase fluid intake
  3. Behavior mod (bowel training)
  4. Increase PE
  5. 1 month trial
  6. Squatty potty
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9
Q

Classes of laxatives

A
  1. Softening of feces in 1-3 days
  2. Soft or semifluid stool in 6-12 hr
  3. Watery evacuation in 1-6 hr
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10
Q

Types of stool softners 1-3 days?

A
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11
Q

Type of semifluid laxatives 6-12hr?

A
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12
Q

Type of fluid laxatives 1-6hr?

A
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13
Q

What are your bulk forming agents? MOA?

A

methylcellulose, polycarbophil, and psyllium

Absorb fluid from the intestines, swell to form soft, bulky stool

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14
Q

Counseling points bulk forming agents?

A
  1. Onset 12-24hr, delay up to 72 hr
  2. Adequate fluids
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15
Q

ADRs of bulk forming agents?

A
  1. Cramping, farts
  2. Avoid in patient who have difficulty swallowing
  3. Avoid patients on fluid restriction
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16
Q

Types of hyperosmotics? MOA?

A
  1. PEG3350
  2. Glycerin
  3. Lactulose

Draw water into the colon or rectum through osmosis to stimulate a bowel movement

Onset of effect: 12-72 hours, can take up to 96 hours

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17
Q

What are the ADRs of hyperosmotic?

A
  1. Bloating
  2. Abdominal discomfort
  3. Cramping
  4. Fart

No DDI

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18
Q

What hyperosmotic is a suppositories? Indications?

A

Glycerin (15-30 min) aprroved for all ages

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19
Q

What are the emollients? MOA?

A

Docusate

Act in the small and large intestine to increase the wetting efficiency of intestinal fluid

Facilitates mixture of aqueous and fatty substances to soften the fecal mass

Combo with stimulants to help with evac

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20
Q

ADRs of docusate

A

Limited

Onset: 12-72 hr up to 3-5 days

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21
Q

What are lubricants? MOA?

A

Mineral oil

Softens fecal content by coating stool and preventing colonic absorption of fecal water

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22
Q

Indications for mineral oil?

A

Formulation: liquid (onset 6-8 hours) or rectal (5-15 minutes)

Should not be used in children < 6 years, pregnant women, bedridden or older adults, and individuals with difficulty swallowing

Should be avoided

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23
Q

What ar the types of saline laxatives? MOA?

A

Magnesium citrate, magnesium hydroxide, dibasic sodium phosphate, monobasic sodium phosphate, magnesium sulfate

  • Draw water into the small and large intestine or colon by osmosis
  • Increase intraluminal pressure and promote GI motility
  • Available as oral (onset 30 mins – 3 hours) or rectal (2-15 mins)
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24
Q

ADRs and DDIs of saline laxatives?

A
  1. Abdominal cramping
  2. N/V
  3. Dehydration

Cation in renal impairment, newborns, older adults

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25
What are examples of stimulants used with docusate? MOA?
1. Senna 2. Bisacodyl 3. Castor-oil Increases intestinal motility, increases secretion of water and electrolytes in the intestines Onset 6-10 hours for oral, bisacodyl supp 15-60 mins
26
What are the ADRs of stimulants?
1. Severe cramping 2. Electrolyte and fluid deficiencies 3. Hypokalemia
27
Counseling points for bisacodyl?
Enteric coated should not be crushed or chewed or giving with agents that increase gastric pH
28
Emollients counseling points?
Preferred post-op
29
Counseling point with hyperosmotics?
Sticky
30
PEG counceling point?
Smooth and easy best for chronic
31
Counseling points for saline laxatives?
electrolyte disturbances in CHF, renal disease - not for chronic use
32
Counseling point for glycerin?
Supportitories preferred in infants
33
Counseling point with stimulants?
With docusate not for prevention or chronic use
34
Rank the following laxatives in order of onset of action from fastest to slowest. PEG powder Magnesium citrate enema Docusate sodium chewable gummy Bisacodyl oral tablets
Mag citrate >> Bisacodyl >> PEG powder >> Docusate
35
Rank the speed of agents?
Enemas--------Fastest Suppositories Lubricants Salines Stimulants Osmotics Stool softeners Bulk---------Slowest
36
Rank the comfort of agents?
Stool softeners-----Most comfortable Bulk forming Osmotic Stimulants Salines Lubricants Suppositories Enemas -----Least comfortable
37
What is the treatment algorithm for constipation?
38
What is chronic constipation?
Duration >6 months Intestinal Secretagogues
39
What is the tx for chronic constipation? MOA?
1. Lubiprostone 2. Linaclotide 3. Plecanatide
40
MOA of Lubiprostone?
Lubiprostone for idiopathic and opoiod induced Chloride channel activator that works in the gut- stimulates chloride-rich fluid secretion into the intestinal lumen
41
ADR of Lubiprostone?
N/HA/diarrhea
42
Dosing of lubiprostone?
Taken as 24 mcg capsule BID with food Costly
43
INdication and MOA of linaclotide?
Chronic and IBS-C Increases intestinal fluid secretion and quickens intestinal motility
44
How should linaclotide be given?
1. Doses are 72 mcg or 145 mcg daily to be taken on empty stomach at least 30 minutes before first meal 2. Do not use in patients under the age of 18
45
ADR of linaclotide?
1. Diarrhea 2. Fart 3. Abdominal pain
46
MOA of plecanatide? Dosing?
Increases intestinal fluid secretion and quickens intestinal motility Dosed daily 3mg without regard to food
47
CI for Plecanatide?
1. Less than 6 YO with GI mechanical obstruction 2. Should not be used in patient under 18
48
Exampls of opioid receptor antagonists?
1. Methylnaltrexone 2. Naloxegol
49
Indications of methylnaltrexone?
1. mu-receptor antagonist approved for OIC in patients with advanced disease receiving palliative care 2. patients with noncancer chronic pain with insufficient results with laxatives Does not cross BBB or antagonize analgesia
50
Dosing? CI with methylnaltrexone?
Given as subq injection daily CI: GI obstruction Reduce dose for hepatic and renal insufficinecy
51
Indications of naloxegol?
OIC in adults with noncancer pain
52
Dosing? ADRs of naloxegol?
25 mg po once daily, 1 hour before or 2 hours after a meal Dose adjustment for renal dysfunction ADR: Diarrhea/abdominal pain/N
53
Treatment for pediatrics primary?
diet and lifestyle modifications
54
Treatment options 2-6YO?
1. PO docusate 2. Mag hydroxide 3. Senna
55
Treatment options 6-12YO?
Oral products: methylcellulose, psyllium powder, docusate, mineral oil , bisacodyl, senna, mag citrate, mag hydroxide, mag sulfate Rectal: glycerin suppositories, mineral oil, sodium phosphate, and bisacodyl
56
Tx for geriatric?
1. review of medication and history needed 2. Lifestyle mod 3. Bulk-forming laxatives or PEG 3350 appropriate 4. Stool softeners may also be appropriate
57
What causes constipation in pregnancy?
1.Prenatal supplement 2.Growing uterus 3. Hormones
58
Tx of pregnancy constipation?
1. Lifestyle mod 2. Bulk-forming recommended initially with increase in fluids 3. Short term senna or bisacodyl 4. Avoid castor oil, mineral oil, saline laxatives
59
Tx of lactation constipation?
1. Senna, bisacodyl, PEG 3350, and docusate 2. Avoid castor, mineral oil
60
What is the commonly diagnosed GI condition? Sx?
IBS 1. Chronic abdominal pain 2. Altered habits in absence of organic cause 3. Diarrhea or constipation Women and younger patients
61
Tx of IBS?
62
Tx of IBS-C?
1. Increase dietary fiber and fluids 2. Bulk forming laxatives Consider: 1. Serotonin-4 agonist (tegaserod)- requires REMS 2. Serotonin-4 agonists (prucalopride)- Europe only **3. Guanylate cyclase C receptor agonist (linaclotide, Linzess®) 4. Chloride channel activator (lubiprostone, Amitiza®)**
63
Tx for IBS-D?
1. Avoid food triggers (caffeine, alcohol, artificial sweeteners) Consider: **1. Opioid agonists (Loperamide (for episodic management, not chronic daily use)** (Eluxadoline (Viberzi®) 2. Serotonin antagonist (alosetron, Lotronex®) - REMS program 3. Antibiotic- Rifaximin (Xifaxan®) 2-week regimen

Therapeutics II (30 decks)

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