Constipation

Question 1

What are the cautions of constipation?

Answer 1

• Inadequate fibre:
  Fibre adds bulks to stools and improves bowel function. Fibre includes fruit, vegetables, cereals and whole bread.
• Medications:
  Such as painkillers like codeine and morphine, some antacids (aluminium), some antidepressants, and iron tablets.
• Medical conditions:
  Such as IBS, underactive thyroid and some bowel disorders.
• Pregnancy: Due to hormonal change, bowel movements are slowed.

Question 2

What are red flags for constipation?

Answer 2

• New onset of constipation when 50 years and over.
• Anaemia
• Abdo pain
• Unexplained weight loss
• Blood in stool (black & mixed in stool - could mean cancer or G.I bleed)

Question 3

What are the different types of Laxatives?

Answer 3

BOSS

B - Bulk
O - Osmotic
S - Stimulant
S - Softeners

& Linaclotide & Prucalopride (5-HT4 receptor agonist)

Question 4

What are examples of Bulk laxatives?

Answer 4

• Bran
• Ispaghula husk
• Sterculia
• Methyl cellulose

Question 5

What are examples of osmotic laxatives?

Answer 5

• Macrogols (laxido)
• Lactulose
• Magnesium salts (MgO)

Question 6

What are examples of Stimulants laxatives?

Answer 6

• Bisacodyl
• Senna
• Sodium picosulfate
• Glycerol
• Co-danthramer
• Docusate sodium (stimulant & softner)

Question 7

What are examples of softeners laxatives?

Answer 7

• Liquid paraffin
• Docusate sodium (stimulant & softner)
• Arachis (peanut) enemas (also lubricates faeces)

Question 8

What do Bulk forming laxatives do and when is it normally used?

Answer 8

It increases bulk in the stool like fibre does. and has an onset action up to 72 hours.

Used in:
- colostomy
- ileostomy
- haemorrhoids
- anal fissure
- IBS
- Diverticular disease
- Ulcerative colitis

Question 9

What should patients do when taking bulk forming laxatives and why?

Answer 9

Maintain adequate fluid intake to prevent intestinal obstruction.

Question 10

What can be a side effect of bulk forming laxatives?

Answer 10

• Bloating
• Cramping
• Flatulence

Question 11

What do stimulant laxatives do and what is their onset time?

Answer 11

Increases intestinal motility.
Onset is 8-12hrs, therefore bedtime dose is recommended.

But stimulant laxative suppositories act quicker within 20-60 mins.

Question 12

What are the side effects of stimulant laxatives?

Answer 12

• Abdominal cramps

And there is an abuse risk which can also cause hypokalaemia.

Question 13

When should stimulant laxatives be avoided?

Answer 13

Avoid in intestinal obstruction.

Question 14

Which stimulant laxatives are only reserved for terminally ill patients?

Answer 14

Co-danthramer & Co-danthrusate

Question 15

What is the MHRA updates for stimulant laxatives?

Answer 15

Pack size restrictions:
- Products available for general sale is limited to a pack size of two short treatment courses (up to 20 standard-strength tablets, 10 maximum-strength tablets or 100ml solution/syrup.

Recommended ages:
- Recommended for use in people 18 years and older. No longer used in children under 12 years without advice from prescriber.
Products for ages 12-17 years can be supplied under supervision of a pharmacist.

If used regularly for long-term use in chronic constipation or inappropriate for self-care (such as for bowel clearance before surgery), should only be given on prescription only products.

Question 16

What do faecal softeners do?

Answer 16

They decrease surface tension and increase penetration of liquid into faecal mass

Question 17

What is a side effect of liquid paraffin?

Answer 17

Can cause malabsorption of fat soluble vitamins

Question 18

What do osmotic laxatives do?

Answer 18

Increase the amount of water in large bowel by drawing fluid from the body into bowel or maintaining fluid in the bowel.

Question 19

Which osmotic laxative acts faster?

Answer 19

Macrogols

Lactulose takes up to 2 days for max effect - not suitable for immediate relief.

Question 20

What is the side effect of lactulose?

Answer 20

• Abdo pain
• Bloating
• Electrolyte imbalance

Question 21

What condition is lactulose normally used for?

Answer 21

Hepatic encephalopathy

Question 22

Which laxatives clear the bowel quickly?

Answer 22

• Phosphate enemas (saline laxatives)
• Magnesium salts (osmotic laxatives)

Question 23

What can laxative abuse lead to?

Answer 23

Hypokalaemia

Question 24

Which drugs cause constipation?

Answer 24

VEry Old Antis get Constipations

Verapamil
Opiates
Antimuscarinics
Antihistamines
Anti-epileptics
Antispasmodics
Antipsychotics
Antidepressants
Antacids (aluminium)

Question 25

What is the order in which laxatives are used?

Answer 25

Bulk forming laxatives are normally used first.
Then osmotic
Then stimulant if others are ineffective.

(BOS - Bulk, osmotic, then stimulant)

Use one at a time, not together.

Question 26

Explain the management of constipation in different conditions?

Answer 26

• Short duration constipation (BOS)

-Pregnancy/Breastfeeding (BOS)

• Chronic constipation (BOS)

^ SPC is BOS ^

• Faecal impaction (OS)
• Children (OS) o = macrogol
• Opioid induced constipation (OS / Naloxegol/methylnaltrexone)

Question 27

What is the patient and carer advice for bulk forming laxative?

Answer 27

Preparations that cause swelling when in contact with liquid, should be carefully swallowed with water and should not be taken immediately before going to bed. The full effect may take a few days to develop.

So takes hours before going to bed and drink A LOT of water.