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PHARM 130 - Exam > Constipation > Flashcards

Constipation Flashcards

1
Q

What is the ROME IV criteria for functional/chronic constipation?

A
  1. Must include 2 or more of the following for at least 3 months with an onset of at least 6 months prior to diagnosis:
    - straining
    - lumpy or hard stools (Bristol 1-2)
    - sensation of incomplete evacuation
    - sensation of anorectal obstruction
    - <3 movements/week
    - manual maneuvers to facilitate more than 25% of defacations
  2. Loose stools are rarely present without use of laxatives
  3. Insuficient criteria for IBS

***discomfort and not PAIN

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2
Q

What are some presenting symptoms of IBS-C that will distinguish it from constipation?

A
  • bloating and pain

- painful constipation may be identifying feature occurring 1 day/week over the past 3 months

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3
Q

What is fecal impaction and what are some of the symptoms of it?

A

Fecal impaction = inability to pass a hard collection of stool

Symptoms:

  • rectal discomfort
  • anorexia
  • nausea
  • vomiting
  • abdominal pain
  • urinary frequency

***physically or mentally incapacitated persons and the elderly are at particular risk of impaction

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4
Q

What are some of the medications that could contribute to chronic constipation?

A
  • anticholinergics
  • antidepressants
  • antiepileptics (gabapentin, pregabalin)
  • antiplatelets
  • antipsychotics
  • Diuretics
  • NSAIDs
  • Vinca alkaloids
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5
Q

What are the goals of therapy for constipation? (7)

A

1) treat or correct cause of constipation
2) return frequency of stool to normal or minimum >3/week
3) eliminate symptoms of straining, incomplete emptying, bloating, pain and obstruction
3) improve stool consistency
4) avoid complications (hemorrhoids, anal fissure, rectal prolapse, impaction)
5) treat fecal impaction or obstruction
6) use laxatives appropriately and AVOID DEPENDENCY
7) improve quality of life

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6
Q

What are the s/s of constipation?

A
  • infrequent defecation
  • abdominal distention
  • N/V
  • anorexia
  • small stools that are hard and difficult to evacuate
  • incomplete rectal emptying
  • weight loss (in chronic constipation)
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7
Q

What are the red flag s/s requiring further assessment of a patient presenting with constipation?

A
  • children <2 years
  • constipation lasts >2 weeks or no bowel movement for 7 days despite use of laxatives
  • blood or mucus in stool, rectal bleeding, fever
  • family history of colon cancer (esp if patient is >50)
  • persistent abdominal pain
  • vomiting
  • severe pain upon defecation
  • unremitting nocturnal symptoms
  • diarrhea alternating with constipation
  • recent abdominal surgery
  • moderate to extreme thirst
  • unexplained weight loss >5%
  • rectal or abdominal mass
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8
Q

What are some strategies to prevent constipation?

A
  • consume high fiber diet with ~1500mL of fluid/day
  • regular, private toilet routine
  • heed urge to defecate
  • take prophylactic medication if using constipating medication or if patient has disease associated with constipation
  • moderate daily physical activity, particularly with the elderly
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9
Q

What is the dietary fiber intake recommended for adult females, adult males, pregnant females, and children?

A

Female = 25g

Male = 38g

Pregnant/breastfeeding = 28/28g

Children = >10g for 3-7, >15 for 8-14

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10
Q

List some vegetables that are high in fiber

A
  • artichoke hearts
  • beans (pinto and red kidney)
  • chickpeas
  • lentils
  • green peas
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11
Q

List some fruits that are high in fiber

A
  • avocado
  • blackberries
  • plum
  • prune
  • raspberries
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12
Q

What are some non-pharmacological options for the management of constipation for adults? (7)

A
  • increase calories if low caloric intake; improves colonic transit
  • have a regular bowel regimen; same time very day, especially after breakfast, heed the urge to defecate, avoid prolonged periods on the toilet
  • consume high fiber diet 25-38g; soluble fiber is better
  • eat more fruits; contain natural laxative sorbitol
  • exercise
  • lose weight in overweight patients; statistical benefit not shoen but still recommend
  • biofeedback and relaxation
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13
Q

What are some non-pharmacologic options in the management of constipation in children?

A
  • increase fiber in diet
  • prune, apple and pear juice 1-3mL/day in children 6-12 months
  • restrict dairy intake, suggest soy milk
  • normal level of physical activity
  • behavioural therapy; encourage to attempt defecation 5-10 minutes after each meal until a bowel movement happens that day
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14
Q

what is the cycle of constipation?

A

constipation –> accumulation of feces –> increased diameter of Gi tract –> effectively reduces function of GI tract –> time taken to pass increases –> constipation

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15
Q

What are the categories of laxatives? (5)

A
  • bulk-forming
  • emollient/stool softeners
  • osmotic
  • stimulant
  • saline laxatives
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16
Q

Bulk-forming laxatives - list examples, brand names, MOA, safety, efficacy, instructions for use

A

Examples:
Psyllium/Metamucil
Wheat Dextran, Inulin/Benefiber

MOA: increases stool volume and stimulates motility

Instructions: take with AT LEAST 250mL of water/juice

Safety/Efficacy: safest agents suitable for long term use, not enough evidence for calcium polycarbophil and methylcellulose although still recommended if patient cannot tolerate other bulk-forming laxatives

17
Q

Emollients/stool softeners - list an example, proposed MOA and efficacy/safety.

A

Example: docusate sodium

MOA: act as a surfactant to soften the stool by allowing the mixing of aqueous and fatty substances

Efficacy/safety: weak anecdotal evidence, does not improve symptoms of chronic constipation, heavy mineral oil is not generally recommended although studies in pediatric patients have shown superiority to senna-based laxatives but inferior still to osmotic agents

18
Q

Osmotic laxatives - list examples, MOA, safety/efficacy and dosage forms

A

Examples: PEG and Lactulose

MOA: create an osmotic gradient and retain water in the intestinal lumen, increased pressure on lumen wall induces gastric motility

Efficacy/safety: effective and well tolerated (PEG>lactulose), daily use of PEG is safe and effective for up to 6 months, possible to experience diarrhea, best used regularly rather than as needed (require 24-72 hours for onset)
- safe for use in diabetics

Glycerin suppositories act osmotically and have a fast onset of action 15-30 minutes, less effective if stool is dry/hard or high in colon

19
Q

What is the second line osmotic laxative and why?

A

Milk of magnesia –> frequent diarrhea, electrolyte abnormalities, must be administered with sufficient water to avoid dehydration

Lower level of evidence

Should only be used in patients with normal renal function

20
Q

Purgatives - what is safe and effective, what isn’t?

A

High volume PEG with electrolytes or low volume PEG without electrolytes = safe and effective when used at high doses for purging

  • **repeated or prolonged use may result in electrolyte imbalance
  • *Caution in patients with renal impairment, taking diuretics and pediatric or geriatric patients

UNSAFE FOR PURGING = oral sodium phosphate

21
Q

Stimulant laxatives - list some examples, MOA, efficacy/safety, AEs and onset of action

A

Examples: Bisacodyl, senna, sodium picosulfate

MOA: increases colonic peristalsis by producing rhythmic muscle contractions in the intestines

Efficacy: may be recommended if osmotic laxatives fail or are not tolerated, bisacodyl has moderate evidence, low quality evidence supports senna, treatment of choice for opioid induced constipation

Safety: likely safe in chronic constipation

AE: abdominal cramping; higher with bisacodyl

Onset: take at bedtime due to 6-12 hour delay in onset

22
Q

Can castor oil be recommended as an alternative stimulant laxative?

A

No longer recommended

Contraindicated in pregnant and elderly patients, produces abdominal cramping and pain, can be aspirated and stimulates uterine contractions during pregnancy

23
Q

Enemas - List the type of constipation used for, onset, safety/efficacy and instructions for use

A

Useful and effective for the treatment of acute constipation and as means for cleansing distal colon for endoscopic/surgical procedures

Onset: faster than suppositories, <15-30 minutes and produce cleansing within 1 hour of administration

Safety: associated with increased mortality in the elderly

Instructions:

  • lubricate enema nozzle if not already pre-lubricated
  • lie on left side with knees bent
  • insert enema nozzle into rectum with nozzle pointing towards navel
  • gently squeeze container until dose is expelled
  • if discomfort is felt, flow is too fast
  • retain solution until definite abdominal cramping is felt
24
Q

What is the efficacy of using probiotics in the management of constipation?

A

Meta-analysis showed mean increase in stool frequency and reduction of intestinal transit time

Lack of heterogeneity in products makes it difficult to determine most beneficial strains, dosage, frequency and duration of treatment

25
Q

How is treatment for acute constipation managed?

A

According to the patient’s level of discomfort

Usually start with an agent with relatively onset of action like glycerin or bisacodyl suppositories. Saline laxatives can be used as well if there is no indication of bowel obstruction

If not relieved in 48 hours, enema or oral milk of magnesia should be used

26
Q

Who should bulk laxatives be avoided in?

A

Patients with fecal impaction

Patients who do not have adequate fluid intake

27
Q

What are the best treatment options for chronic constipation?

A

PEG and lactulose (osmotic laxatives) –> highest level of evidence

Bisacodyl (stimulant laxative) –> efficacious with moderate evidence

28
Q

What is the stepwise approach for the management of chronic constipation?

A
  1. Unless modifiable cause is identified, initial management is patient education, lifestyle modification, dietary changes (increasing fiber every 7-10 days), stimulant laxatives, glycerin suppositories and/or enemas can be used as rescue treatment if no BM has occurred for 2 consecutive days
  2. If problem persists after 4-6 wks, second line agents like osmotic laxatives may be added
  3. Third line agents like emollients and stimulants should be limited to short-term use as rescue therapy or if other agents have failed (high incidence of SE from these classes)
  4. Prosecretory or prokinetic agents may be tried for chronic idiopathic constipation for 8-12 wk trial prior to specialist referral
29
Q

If a patient with opioid induced constipation is non-responsive to osmotic or stimulant laxatives, what can be given?

A

Methylnaltrextone, naloxegol –> my-opioid receptor antagonists

**SECOND LINE although significant evidence to support

Methylnaltrexone requires subcutaneous administration

30
Q

What are the recommendations for infants with constipation?

A
  • use of enema NOT recommended, only if >2 years
  • rectal disimpaction can be achieved with pediatric glycerin suppositories
  • barely malt extract, corn syrup or sorbitol can be used as stool softeners
  • heavy mineral oil and stimulant laxatives NOT recommended
31
Q

What are the first line agents for children >1 year with constipation? What is second line? Third?

A

1st –> PEG, lactulose and sorbitol

  • PEG is preferred over lactulose for most patients
  • SE: flatulence, abdominal pain, nausea, diarrhea, headache
  • PEG without electrolytes > PEG with electrolytes

2nd –> magnesium hydroxide

3rd –> stimulant laxatives (rescue medication when others have failed)

32
Q

What is the preferred treatment for pregnant women with constipation? Second line?

A

Psyllium, dietary bran or wheat fiber are preferred as initial treatment.

Lack of reliable data studying safety of laxatives in pregnant women.

2nd–> if stools remain hard, consider adding or switching to lactulose or PEG: both safe and effective (NOT milk of magnesia)

3rd –> stimulant laxatives have been shown to be more effective than dietary/medicinal fiber but cause more AEs

33
Q

When are saline laxatives contraindicated?

A

renal and heart failure

PHARM 130 - Exam (10 decks)

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