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OTC > Constipation > Flashcards

Constipation Flashcards

1
Q

healthcare definition

A

<3/week
straining associated with defecation
hard dry stool

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2
Q

patient perception of constipation

A

small stool
feeling of incomplete evacuation
decreased stool frequency

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3
Q

patho

A

slower than normal movement thru the gi tract. Tonic contractions (stomach), peristaltic waves (intestines)
internal anal spincter relaxation (rectum)

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4
Q

secondary causes:
systemic
neuro
pshychological

A
  1. systemic: electrolyte imbalances, thyroid disorders, IBS
  2. neurological: autonomic neuropathy, MS, parkinsons, cerebrovascular accidents, dementia
  3. psychological: depression, eating disorders, situational stress
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5
Q

contributing meds

A 
OPIATES *morphine and oxycodone*
antacids
anticholinergics 
antidepressents 
antihistamines 
benzodiazepines 
beta blockers 
calcium channel blockers 
diuretics
iron supplements 
muscle relaxants 
statins
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6
Q

risk factors

A

age > 65
female
pregnancy and post birth
secondary causes

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7
Q

clinical presentation

A

complains: reduced stool frequency, straining, hard/dry stools, feeling of incomplete evacuation

additional symptoms: anorexia, headache, low back pain, abdominal discomfort, bloating, flatulence

complications: hemorrhoids, bleeding, rectal ulcers, anal fissures

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8
Q

rome criteria

A

2 or more of the following:
- less than 3 bowel movements / week
- straining during > 25% of defecations
sensation of incomplete evacuation in >25%
-sensation of anorectal obstruction / blockage for >25
- manual maneuvers to facilitate >25%

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9
Q

exclusions to self care

A

severe ab pain, distention, cramping, or unexplained flatulence
concomitant fever, nauseu, and or vomiting
unexplained changes in bowel habits (esp if weight loss)
blood in the stool or dark tarry stool or changes in stool character
symtoms persisting >2 weeks or recur over a period of 3+ months, or after dietary/lifestyle changes
daily laxitive use (not including fiber based therapy)
Age <2 years
conditions precluding laxatve self treatment (paraplegiz/ quadriplegiz, colostomy)
history of inflammatory bowel disease, anorexia

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10
Q

nonpharmacologic

A

diet and excersize
- increase fluid 2L / day
increase fiber (25g in women 38 for men)
fruits (prunes) vegetables, whole grains.
limit foods with little fiber content
- meats cheese and processed foods
effects seen in 3-5 days

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11
Q

how should you increase fiber?

A

slowly over 1-2 weeks

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12
Q

what is bowel retraining

A

it is heed the urge, allow sufficent toilet time

attempt upon waking or 30 minutes post meal

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13
Q

what are some daily fiber supplements

A

Inulin (fiberchoice, metamucil, clear and natural)
partiallly hydrolyzed guar gum (sunfiber)
powdered cellulose (unifiber)
wheat dextrin (benefiber)

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14
Q

pharmacologic laxative types

A 
bulk forming
hyperosmotic 
emollient
lubricant
saline 
stimulant
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15
Q

Bulk forming laxatives indiciation

A

RECOMMENDED CHOICE for most instances of constipation
- useful for patients on low fiber diets, post partum, older adults, patients w colostomies, IBS
propylaxis for those who should refrain from straining

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16
Q

bulk forming - MOA

A

dissolves or swells in the intestinal fluid -> forms emollient gel -> stimulates peristalsis -> facilitates passage of intestinal contents

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17
Q

Bulk forming - SAFETY

A
  • CHOKING RISK - avoid if difficult studying, esopheal strictures, fluid restrictions ( heart failure)
  • OBSTRUCTION, fecal impaction - avoid if palliative care, OPIOID-INDUCED constipation, intestinal ulcerations
  • HYPERCALCEMIA – older adults, renal impairment
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18
Q

Bulk forming - TOLERABILITY

A

Abdominal cramping, flatulence

increased flatulence or risk of obstruction if recommended dose exceeded

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19
Q

Bulk forming - efficacy

A

Closely mimic the physiologic mechanism in promoting evacuation
Onset: 12-24 hours (may be delayed up to 72 hours)

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20
Q

Bulk forming - DI

A

Decreased absorption
- Physical binding of medications in GI tract
- Chelation with calcium-containing laxatives
- Oral tetracyclines,
quinolones
Separate administration by 2 HOURS

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21
Q

Hyperosmotic Laxatives - Indication

A

Polyethylene glycol (PEG) 3350 - short term treatment for occasional constipation for patiens 17+ years

Glycerin - lower bowel evacuation for patients of all ages

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22
Q

Hyperosmotic Laxatives - MOA

A

large, poorly absorbed ions that draw water into the colon or rectum via osmosis

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23
Q

Hyperosmotic Laxatives - Safety

A

PEG3350- consult pcp in renal disease and IBS

Glycerin: innappropriate for patients with rectal irritation
hypokalemia with chronic use

24
Q

Hyperosmotic Laxatives - Tolerability

A

Peg 3350: bloating, abdominal discomfort, cramping, flatulence
diarrhea/excessive stool frequency with higher doses

Glycerin: rectal irritation

25
Q

Hyperosmotic Laxatives - Efficacy

A

PEG 3350- onset 12-72 hours (up to 96 hours in some patients)

Glycerin - onset 15-30 minutes

26
Q

Hyperosmotic Laxatives - DI

A

minimally absorbed - none sig

27
Q

Emollient laxatives - stool softeners indication

A

prevention of straining and painful defecation

patients with anorectal disorders, severe hypertension, cardiovascular disease, recent surgery, postpartum women

prevention of opioid induced constipation in combination with a stimulant laxative

treatment of occasional constipation `

28
Q

Emollient laxatives - MOA

A

anionic surfactant that softens fecal mass

- increases the wetting efficiency of intestinal fluid -> mixture of aq and fatty substances

29
Q

Emollient laxatives - safety

A

weakness, sweating, muscle cramps, irregular heartbeat with excessive doses

30
Q

Emollient laxatives - tolerability

A

diarrhea, mild cramping

31
Q

Emollient laxatives - efficacy

A

onset 12 - 72 hours (up to 3-5 days in some patients)

32
Q

Emollient laxatives - DI

A

minimally absorbed

increased systemic absorption of mineral oil - avoid combination

33
Q

Emollient laxatives - examples of meds

A

docusate sodium

docusate calcium

34
Q

Lubricant Laxatives - indication

A

prevention of straiing or painful defecation

USE IN SELF CARE STRONGLY DISCOURAGED DUE TO SAFER ALTERNATIVES

35
Q

Lubricant Laxatives - MOA

A

softens fecal contents by coating stool and preventing colonic absorption of fecal water

36
Q

Lubricant Laxatives - Safety

A

lipid pneumonia - avoid in patients < 6 years, older adults, pregnant, bedridden, difficulty swallowing

37
Q

Lubricant Laxatives - Tolerability

A

abdominal cramps, diarrhea, nausea, vomiting, anal leakage with larger doses

38
Q

Lubricant Laxatives - efficacy

A

onset 6-8 hours (oral) 5-15 minutes (rectal)

use is similar to emollient laxatives

39
Q

Lubricant Laxatives - DI

A

Increased systemic absorption
- avoid combination with docusate products
decreased absorption of vitamins
- increased bleeding risk in patients taking warfarin

40
Q

Lubricant Laxatives - product

A

Mineral oil - oral liquid or enema

41
Q

Saline Laxatives - indication

A

Treatment of occasional constipation

Pre-operative bowel evacuation (e.g. colonoscopy)

42
Q

Saline Laxatives - MOA

A

Ions that are retained in the intestinal wall

Draw in water via osmosis -> increased intraluminal pressure and intestinal motility

43
Q

Saline Laxatives - Safety

A

Dehydration – avoid in patients who cannot tolerate fluid loss

Magnesium products – avoid in newborns, older adults, renal impairment

Sodium phosphate products – avoid in congestive heart failure, caution in renal impairment

44
Q

Saline Laxatives - tolerability

A

Cramping, nausea, vomiting

Dehydration – consume 8 oz. water following administration of magnesium products

45
Q

Saline Laxatives - Efficacy

A

Onset 30 min. – 6 hours (oral magnesium hydroxide)
Onset 30 min. – 3 hours (oral magnesium citrate, sodium phosphate)
Onset 2-15 min. (rectal magnesium citrate, sodium phosphate)

46
Q

Saline Laxatives - DI

A

Oral anticoagulants, digoxin, chlorpromazine
Decreased absorption
Chelation with magnesium-containing laxatives
Oral tetracyclines, quinolones

47
Q

Saline Laxatives - products

A

Magnesium citrate
magnesium hydroxide
sodium phosphate
magnesium sulfate

48
Q

Stimulant Laxatives - indication

A

Pre-operative bowel evacuation (e.g. colonoscopy)

Prevention or treatment of opioid-induced constipation in combination with docusate

49
Q

Stimulant Laxatives - MOA

A

Increase intestinal motility by local irritation of the mucosa or action on the intramural nerve plexus of intestinal smooth muscle
Increase secretion of water and electrolytes into the intestine

50
Q

Stimulant Laxatives - safety

A

Severe cramping, electrolyte and fluid deficiencies, protein loss, malabsorption, hypokalemia, excessive loss of fluid during evacuation

Subject to overuse (patients with disordered eating, elderly, misconceptions about normal BM frequency)

51
Q

Stimulant Laxatives - tolerability

A

Vomiting, nausea, diarrhea, severe cramping with excessive doses; 
red/violet/brown-colored urine (senna)

52
Q

Stimulant Laxatives - efficacy

A

Onset 6-10 hours (up to 24 hours in some patients)

Onset 15-60 minutes (rectal bisacodyl)

53
Q

Stimulant Laxatives - DI

A

Rapid erosion of enteric coating (bisacodyl)
Antacids, histamine2-receptor antagonists, proton pump inhibitors, milk
Separate administration by 1 hour

54
Q

Stimulant Laxatives - products

A

senna
bisacodyl
castor oil

55
Q 
Special Populations
Children
Advanced Age
Pregnancy
Lactation
A

Children
Difficulty/delay in BMs 2+ weeks
See previous slides
< 2 years = direction of medical provider

Advanced Age
Avoid/use caution with mineral oil, saline and stimulant laxatives

Pregnancy
Bulk-forming laxatives, docusate, short-term senna or bisacodyl use
Avoid castor oil, mineral oil, saline laxatives

Lactation
Senna, bisacodyl, PEG 3550, docusate
Avoid castor oil, mineral oil

56
Q

5 major counseling points

A
  1. Dietary, fluid, exercise changes effective for most
  2. Bulk-forming, PEG 3350 laxatives 1st line for most
  3. Self-treatment limited to 7 days
  4. Stop use and contact MD if rectal bleeding occurs
  5. Separate most laxatives from other meds by 2 hours

OTC (2 decks)

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