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Clinical Pharmacy > Constipation > Flashcards

Constipation Flashcards

1
Q

What is the definition of constipation?

A
  • infrequent/unsatisfactory defecation fewer than 3x per week with patients describing
    1. straining/ pain
    2. passing dry, hard stool
    3. passing small stools
    4. feelings of incomplete bowel evacuation
    5. bloating or decreased stool frequency with distention
    6. feeling of rectal blockage and abdominal discomfort
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2
Q

What are the risk factors for constipation?

A
  • female
  • non white
  • living in rural areas of north america
  • over 65 years old
  • fewer years of formal eduction
  • low caloric intake
  • increased number of medications used
  • lower socioeconomic status
  • sedentary living
  • travelling
  • toilet training in children
  • ignoring the urge to defecate
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3
Q

What are some of the disease conditions that can cause constipation?

A
  • IBS
  • IBD
  • neurological conditions
  • diabetes
  • chronic renal failure
  • carcinoma
  • psychiatric conditions
  • anal fissures
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4
Q

What are some of the lifestyle causes of constipation?

A
  • decreased/inadequate dietary fibre
  • inadequate intake of fluids
  • lack of exercise/immobility
  • pregnancy or older age
  • ignoring and postponing the urge to defecate
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5
Q

What are some of the most common signs and symptoms of constipation? 1`

A

`- infrequent defecation

  • abdominal distention/discomfort
  • nausea
  • vomiting
  • anorexia
  • early satiety
  • stools that are small, hard and difficult to evacuate
  • incomplete rectal emptying
  • rectal bleeding due to a fissure or hemorrhoids
  • weight loss
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6
Q

What are the red flags necessary for a referral in constipation?

A
  • symptoms that persist to over 2 weeks (or has not has a BM for more than 7 days) with laxative use
  • blood in stool (dark and tarry), mucous, rectal bleeding, severe pain when defecating
  • persistent abdominal pain or severe pain when defecating, fever
  • persistent abdominal pain or severe pain when defecating
  • unexplained weight loss >5%
  • family history of colon cancer (esp is over 50 y/o)
  • anemia symptoms
  • vomiting
  • under 2 y/o
  • recent abdominal surgery
  • chronic illness associated with constipation
  • eating disorders
  • moderate to extreme thirst
  • diarrhea alternating with constipation(IBS)
  • rectal or abdominal mass
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7
Q

What are the goals of therapy of treating constipation?

A
  • relieve constipation, constipation symptoms, improve stool consistency and re-estabilish normal bowel function
  • establish dietary and exercise habits
  • promote safe and effective use of laxative products
  • increase stool frequency to at least 3x a week or more
  • improve quality of life and avoid complications due to constipation
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8
Q

What are some of the preventative measures to take for constipation?

A
  • high fibre diet with adequate fluid consumption (min. 1500 ml/day)
  • routine, private toilet regimen
  • defecating when feeling the urge
  • prophylactic laxative use -when taking a constipating medication or when a chronic condition associated with constipation
  • daily physical activity (moderate)
  • increase amount of fluid id patient only drinks a small amount or is dehydrated
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9
Q

What is the general treatment approach for constipation?

A
  • adjust the diet to nuclide high fibre content and increase fluid intake
  • include some form of exercise
  • pharmacological intervention should be used in conjunction with lifestyle modification- identify the cause to determine the most beneficial lifestyle modification
  • select laxative based on patient age
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10
Q

What are some of the non-pharms that can be used for constipation?

A
  • increase fibre in diet (should be added gradually)
  • increase calories if consuming a low amount of calories
  • adequate fluid intake
  • eat more fruit
  • exercise
  • have a regular bowel regimen
  • footstool
  • if chronic constipation and overweight, then weight loss might be helpful
  • biofeedback and relaxation training
  • toilet routine to try defecation 5-15 minutes after each meal until B< happens that day
  • biofeedback
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11
Q

What are some of the dietary sources of fibre?

A
  • popcorn, green peas, avocado, blackberries, raspberries, plums and cheerios
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12
Q

What agents cause the softening of feces in 12-72 hours

A

bulk forming agents (fibre supplements) and emollients

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13
Q

What are the agents that result in semisolid stool in 6-12 hours?

A

bisacodyl, senna/sennosides

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14
Q

What are the three products that are known to cause a watery evacuation in 0.5-3 hours?

A
  • magnesium citrate and magnesium oxide (purgative)
  • magnesium hydroxide
  • oral sodium phosphates (fleet) - for laxative use only
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15
Q

What is the timeframe that should be expected for lactulose?

A

24 to 48 hours

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16
Q

What is the timeframe for glycerin suppositories?

A

15-30 minutes to an hour

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17
Q

What is the timeframe for PEG 3350 action?

A

2 to 4 days

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18
Q

What is the timeframe for bisacodyl suppositories?

A

30 minutes

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19
Q

What is the timeframe for using enemas?

A
  • 5-15 minutes
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20
Q

What is the timeframe for using mineral oil/lansoyl?

A

6-8 hours

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21
Q

What is the mechanism of action of bulk forming agents?

A

dissolve or swell in fluids of digestive tract by attracting water to hydrophilic sites forming gels that promote a bowel movement

  • increase stool weight/volume and frequently
  • often first line in most cases
  • require administration with water or juice, avoid in dehydration or fluid restricted patients
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22
Q

When are bulk forming agents indicated for prophylactic use?

A
  • in patients who should refrain from straining during BM and non-pharm methods are not enough
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23
Q

What are the examples of emollients?

A

docusate sodium/calcium

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24
Q

How many days does it typically take for bulk forming agents to take effect?

A

1-3 days

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25
Q

When are bulk forming agents generally not recommended?

A
  • not useful in those that are on opioids (they decrease the peristalsis of the intestine)
  • not good agent in patients that have throat problems
  • not appropriate in those that are fluid restricted
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26
Q

What is the MOA of emollients?

A
  • surfactants that help water in the bowel mix with the focal mass, causing softening
  • these agents can be used for prevention only - evidence for efficacy is lacking
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27
Q

Emollients are highly ____ in preventing chronic opiate induced constipation or if inadequate dietary intake

A

ineffective

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28
Q

In what cases may emollients be useful?

A
  • in patients who should not strain, have fissures or hemorrhoids
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29
Q

Emollients are generally combined with ______ as long term treatment in cases like opiate-induced constipation

A

sennosides/bisacodyl

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30
Q

What is the MOA of lubricants (heavy mineral oil)

A
  • mineral oil acts as a laxative by lubricating fecal material and the intestinal mucosa. They also reduce reabsorption of water from the GI tract, thereby increasing fecal bulk and decreasing intestinal transit time
31
Q

What are the potential risks associated with oral administration of heavy mineral oil?

A
  • to avoid aspiration, orally administered mineral oil preps should not be attempted when there is an increased risk of vomiting, regurgitation or other preexisting swallowing difficulty or patients are bedridden
  • higher risk in children and the elderly
32
Q

Heavy mineral oil can block the absorption of what?

A
  • vitamin A, D, E and K - this is not a first line medication, other options should be used that are safer
33
Q

Heavy mineral oil blocks the ______ - it is an oil that coats the throat and stops the cough reflex that you would have when something goes down the wrong tube

A

cough reflex

34
Q

Should not use mineral oil for longer than _______

A

1 week

35
Q

What is the MOA of a stimulant laxative?

A
  • increase the propulsive peristaltic activity of the intestine
36
Q

What are the 2 types of stimulant laxatives?

A
  1. anthraquionones (senna, cascara)

2. diphenylmethane (bisacodyl)

37
Q

When are stimulant laxatives most useful?

A
  • acceptable to treat constipation for short periods of time (acute), recommended when osmotic laxatives fail or are not tolerated
38
Q

What is the first line treatment for constipation induced by opiates?

A

stimulant laxatives

39
Q

Bisacodyl should not be taken with what?

A
  • milk, antacids, or PPIs
40
Q

What is the MOA of osmotic laxatives?

A
  • presence of ions draws water into the intestine, thereby increasing the intraluminal pressure, which applies a mechanical stimulus that increases intestinal motility
41
Q

What are the examples of osmotic laxatives?

A
  • polyethylene glycol
  • lactulose
  • glycerin
  • milk of magnesia/ magnesium citrate
  • oral sodium phosphate
42
Q

What are the issues associated with using an osmotic laxative?

A

electrolyte imbalances

43
Q

What products are PEG 3350 used in?

A

LaxADay, RestoraLAX, Relaxa, PegaLAX

44
Q

What is PEG 3350 indicated for?

A
  • indicated for short term use in patients with constipation and may be used long term as well (6 months). May be used for opiate induced constipation
45
Q

What is the efficacy of PEG 3350 compared to lactulose?

A

-there is a higher efficacy in PEG 3350

46
Q

What are the side effects that can be caused by PEG 3350?

A
  • gas, cramping, bloating but with less incidence compared to other osmotic agents. May cause diarrhea
47
Q

Other medications should be avoided within _____ of using PEG 3350

A

2 hours

48
Q

What is the onset of action of PEG 3350?

A

48 to 96 hours

49
Q

What is the age in which PEG 3350 can be used?

A
  • 48-96 hours
50
Q

What is the MOA of glycerin suppositories?

A
  • osmotic effect and local irritation effect of sodium street leads to the drawing of water into the rectum to stimulate a bowel movement
51
Q

What is the onset of action of glycerin suppositories?

A

15 to 30 minutes

52
Q

What is the major contraindication of use of magnesium products?

A

MgOH can be used as a laxative if patient has normal renal function

53
Q

What are the main effects of using MgOH as a laxative?

A
  • frequent diarrhea, abnormalities with electrolytes and hypovolemia
54
Q

What is the main use of magensium citrate?

A
  • bowel cleansing
55
Q

Oral sodium phosphate should NEVER be used as a purgative why?

A
  • due to serious electrolyte, kidney, cardiovascular and neurological problems
56
Q

What are some of the important lifestyle things that is important to consider when assessing constipation?

A
  • diet
  • medications (current, new mediations - laxative use)
  • medical conditions (surgery, pregnant, vitamins, any travel)
57
Q

What are the max number of days to treat acute constipation?

A

1 week

58
Q

What symptoms should a person be referred for for constipation treatment?

A
  • severe abdominal cramping/pain, N/V, rectal bleeding, rectal pain, dehydration
59
Q

What is the main treatment for constipation in infants under 1 year?

A
  • increase the amount of fluid (juices with sorbitol, for example), best to discuss with a dietician
  • do not use enemas, mineral oil and stimulant laxatives
  • pediatric glycerin suppositories may be used to receive rectal disimpaction
60
Q

What is the main treatment for constipation in infants over 1 year?

A
  • increase dietary intake and fluid (milk should not be considered a substitute of water)
  • non pharm approach is better
  • first tine tx option: PEG, lactulose, sorbital
  • second line: MgOH, heavy mineral oil
  • senna and bisacodyl are considered rescue medications
61
Q

What is the age restriction for using bulk forming laxatives and mineral oil?

A

6 years and up

62
Q

What is the age restrictions for using glycerin suppositories, lactulose and sorbitol, MgOH, senna liquid?

A

2 years and up

63
Q

What is the age restriction for using bisacodyl?

A

12 years and up

64
Q

What is the age restriction for using PEG 3350?

A

18 years and up

65
Q

What are the typical causes of constipation in pregnancy?

A
  • elevations in progesterone including muscle relaxation in the intestinal tract
  • reduction in motion levels
  • intestinal pressure
  • decreased exercise ability
  • iron and calcium supplements in prenatal vitamins
66
Q

What are the treatment options for constipation in pregnancy?

A
  • non pharms is the the treatment of choice (increase fluid intake, increase dietary fibre, try to time BMs after meals)
  • 1st line therapy: bulk forming agents
  • 2nd line: glycerin or bisacodyl suppositories can be used for occasional short term use
  • lactulose can be used in pregnancy with a doctors advise
67
Q

What are typically used for pharmacological therapy of choice to treat constipation in the elderly?

A
  • bulk forming agents (need to recommend that the patient increases their fluid)
  • glycerin, PEG are safe for use in the elderly as well
68
Q

Saline laxatives are contraindicated in the elderly that also have what conditions?

A
  • renal and heart failure, limited use due to potential for electrolyte imbalances
69
Q

What is typically used as a treatment option in patients that have cancer?

A
  • stimulant laxatives (PEG and lactulose are also alternatives)
70
Q

Why should bulk forming agents not be used in patients that have cancer?

A

they have an increased risk of impaction due to being bedridden

71
Q

In cancer patients, how long should we wait to refer?

A
  • 3 days
72
Q

What is laxative abuse?

A
  • routine, chronic use of most laxatives (many people believe that a daily BM is necessary)
73
Q

What is the treatment of laxative abuse?

A
  • requires the referral to a physician for further evaluations
  • generally required gradually withdrawing laxatives while adding a high fibre diet and supplementing with bulk forming laxative (longer term management)
  • encourage exercise, increase fluid intake

Clinical Pharmacy (24 decks)

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