Constipation Flashcards
What age range is a RED FLAG?
children less than 2 years
What are red flag symptoms that require referral?
-no BM for 7 days
-constipation > 2 weeks
-systemic sx: vomiting, fever, rash, extreme thirst
-abd pain, nocturnal sx
-anemia, severe pain during defecation
-impaction
-fam hx of colon cancer (esp if pt is > 50 yo)
-abdominal or rectal mass
-blood or mucous in stool
-both constipation AND diarrhea (IBS)
-eating disorder or wt loss > 5%
How much dietary fibre should be taken?
Slowly increase to 25-38 g daily
How much fluid intake is recommended as a non-pharm?
2.2-3 L daily
Why should mineral oil be avoided? What class of drug is this?
Stool softener.
Avoid due to limited efficacy data, risk of aspiration, can bind fat-soluble drugs
What are 1st line OTC options?
Psyllium (bulk forming)
PEG (Osmotic)
Glycerin (Osmotic)
If osmotic laxatives are not tolerated/failed, what is the next best option OTC?
stimulants - bisacodyl or senokot
Effective OTC drug for opioid-induced constipation?
osmotics (peg or lactulose), glycerin, senokot (less abdominal discomfort than bisacodyl)
Onset of action for bulk-forming psyllium?
1-3 days
Onset of action of osmotic laxatives?
lactulose: 1-2 days
PEG: 2-4 days
glycerin PR: 15-60 min
how long should glycerin suppository be retained?
if possible, 15 mins
which osmotic laxative is a concern for bowel necrosis?
sorbitol 70% solution (altho, its as effective as lactulose)
Can lactulose be used in diabetics?
yes, monitor for hyperglycemia still
which laxatives are safe for long term use?
psyllium, PEG
Examples of osmotic saline laxatives?
Mg citrate
MgOH
NaPO4 enema
Onset: <30 min to 6 hrs. If enema, its onset is < 15 min
Caution in saline laxatives (i.e. fleet enema)?
-avoid in renal failure/cardiac disease, causes electrolyte imbalances
-used for bowel cleansing
Prescribed Meds
- 5HT4R agonist: prucalopride
- u-Opioid R Antaognist: methylnaltrexone, naloxegol
- Guanylate Cyclase-C R agonist: linaclotide
Key points about Prucalopride?
indication: women with chronic idiopathic constipation
-GI prokinetic activities
-use for upto 4 wks, stop if ineffective after 4 wks.
Key points about methylnaltrexone or naloxegol
M: palliative care, SC injection, adjunct to other laxatives
N: opioid-induced, non-cancer pts who dont respond to others; C/I in strong 3a4 inhibitors
Both $$$$$$ and used in refractory cases
Key points about linaclotide
-SE: diarrhea
-2nd line when OTC laxatives are ineffective
-chronic idiopathic constipation
Opioids should always be paired with ___ or ____?
stimulant or osmotic laxative
which class of drugs can patients become dependent on?
stimulant laxatives
Which laxatives are contraindicated in fecal impaction?
bulk-forming
Red flag symptoms in children?
< 2 y/o
organic cause suspected,
medication induced,
bleeding,
signs of infection,
distention/abd pain,
intermittent loose stools,
lethargy/vomiting/fever,
weight loss,
fecal impaction,
poor growth
