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Pharm II > Constipation and Diarrhea > Flashcards

Constipation and Diarrhea Flashcards

1
Q

Definition of constipation

A

Infrequent passage of stool or passage with difficulty

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2
Q

When is constipation more common?

A

Elderly
Women
Pts of low SES

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3
Q

Rome Criteria for constipation

A

Two or more of the following sx for at least 3 mos

  • Hard stools at least 25% of the time
  • Two or fewer BMs per week
  • Difficulty passing (straining) at least 25% of the time
  • Incomplete evacuation at a minimum of 25% of the time
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4
Q

What to ask the pt about constipation

A 
Current bowel movements and consistency
Usual bowel movements and consistency
Associated sx
Medical conditions
Dietary habits
Meds
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5
Q

Sx of constipation

A 
Nausea
-Can be present with or without vomiting
Abdominal pain
-Often described as "colicky"
Urinary incontinence
Diarrhea
-Fecal matter higher in the colon is broken down and moves past the hard impacted fecal mass
-Ask them when they had a meaningful BM
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6
Q

Alarming sx-constipation

A 
Severe abd pain
N/V
Blood in stool
A change in bowel habits >2 wks
Worsening of constipation despite tx
Tx >7 days unless directed by a PCP
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7
Q

Common reversible causes of constipation

A 
Meds
Reduced physical activity
Reduced fluid intake
-Dehydration
Reduced food intake
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8
Q

Other common causes of constipation

A 
Ileus
Malignancy
Autonomic dysfunction
Mechanical obstruction
Metabolic abnormalities
Spinal cord compression
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9
Q

Meds that can cause c onstipation

A 
Iron
NSAIDs
Opioids
Diuretics
Anticholinergics
CCBs, esp. nondihydropyradine
Calcium-containing antacids
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10
Q

Tx for constipation- goals

A

Prevention easier than tx
-Increase exercise, dietary intake fiber, fluid intake
Identify reversible causes and correct if possible
-Diet and meds commonly
Goal is two or three nl BMs per week with pt comfort being a goal as well.

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11
Q

Non-pharmacological tx options for constipation

A 
Encourage fluids
Activity as tolerated
Encourage fiber in diet as tolerated
-25-30 g per day
-Whole veggies and fruit
Avoid constipating meds if possible
Provide a comfortable and private environment for defecation
Educate about appropriate use of laxatives to minimize laxative abuse syndrome
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12
Q

Selection of tx for constipation

A

Minimal evidence to select one agent over another
Selection of a specific agent should depend on several factors such as cause, associated sx, medical hx, pt preference (administration), and cost

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13
Q

Laxative classifications

A 
Lubricants
Surfactants
Prokinetic agents
Osmotic laxatives
Stimulant laxatives
Bulk-forming agents
Opioid receptor antagonists
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14
Q

Examples of bulk-forming agents

A

Psyllium
Methylcellulose
Polycarbophil

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15
Q

Advantages of bulk-forming agents

A

Natural
Cheaper
Well-tolerated

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16
Q

Onset of action of bulk-forming agents

A

12-72 hrs

More preventative than acute

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17
Q

SEs of bulk-forming agents

A

Bloating
Cramping
Flatulence

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18
Q

Clinical pearls of bulk-forming agents

A

Often considered first-line therapy
Requires adequate hydration, at least 8 oz of water per dose
Caution in debilitated pts

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19
Q

Example of chloride channel activator

A

Lubiprostone (Amitiza)

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20
Q

Use for chloride channel activator

A

Reserved for chronic idiopathic constipation: failed other therapies
More appropriate niche is IBS
Very expensive

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21
Q

What do the lubricants do for constipation?

A

Mineral oil inhibits water reabsorption in the colon

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22
Q

SEs of mineral oil

A

Depletion of fat-soluble vitamins

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23
Q

Clinical pearls of mineral oil

A

Reserved- last line

Oral formulation not recommended in debilitated pts- risk of aspiration

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24
Q

Examples of osmotic constipation meds

A

Lactulose or sorbitol
Polyethylene glycol- OTC
-Also comes in PEG-ES for bowel evacuation
Used more in hepatic encephalopathy (lactulose)

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25
Q

Use for osmotic constipation meds

A

2nd line

26
Q

Onset of action of polyethylene glycol

A

24-96 hrs

27
Q

Examples of osmotic/saline meds for constipation

A

Magnesium citrate or hydroxide

28
Q

Use for magnesium citrate or hydroxide

A

Reserved- can cause electrolyte disturbances

Avoid in renal insufficiency and CHF

29
Q

What are examples of opioid antagonists for constipation?

A

Methylnaltrexone

Alvimopan- hospital use only

30
Q

Use of methylnaltrexone

A

For chronic opioid therapy

Does not cross blood-brain barrier, only acts on GI tract

31
Q

Use of alvimopan

A

To prevent bowel obstruction after bowel resection surgery- reserved

32
Q

What is an example of a prokinetic agent for constipation?

A

Metoclopramide

33
Q

Use for metoclopramide

A

Reserved, think concomitant n/v

Often requires high doses

34
Q

Examples of stimulants for constipation

A

Senna
Bisacodyl
Sodium phosphate

35
Q

Onset of action for stimulants for constipation

A

6-12 hrs

36
Q

SEs of stimulants for constipation

A

Nausea
Cramping
Electrolyte disturbance

37
Q

Clinical pearls of stimulants for constipation

A

2nd or 3rd line
Possible dependence with long-term use
Sodium phosphate is last line agent
Use no longer than 7 days- exception might be opioid use
Senna and bisacodyl come in many different forms

38
Q

What is a miscellaneous agent for constipation?

A

Linaclotide (Linzess)

39
Q

Use of linaclotide

A

Chronic idiopathic constipation or IBS with constipation

40
Q

What is an example of a surfactant for constipation?

A

Docusate sodium

41
Q

Use of docusate sodium

A

Increases mixing of fatty materials in stool, 2nd or 3rd line
Requires adequate hydration

42
Q

What is the indication for rectal drugs for constipation?

A

Institutionalized, one week of constipation, quick tx

43
Q

Definition of diarrhea

A

Greater than or equal 3 unformed stools in 24 hrs
The passage of frequent, loose stools with urgency
Considered chronic if lasting longer than 30 days

44
Q

4 broad categories of diarrhea

A

Secretory
Osmotic
Exudative
Altered intestinal transit

45
Q

Common causes of diarrhea

A 
AIDS
Infection
-Common in daycares and nursing homes
Obstruction
Meds
Radiation therapy to bowel
Malabsorption from cancers or resection
46
Q

Meds associated with causing diarrhea

A 
Abx
Laxatives
Cholinergics
Mg antacids
Chemo
47
Q

Questions to ask for diarrhea

A 
Diet
-Changes in fiber, fat intake
Appearance
-Frequency, vol, consistency, and color
Recent travel
Med use
Source of water
Onset of sx and duration
48
Q

Exclusions for self-tx of diarrhea

A

High-grade fever
Recent abx use
Severe abd pain
Pregnancy or child <6 mos
Pt is or is at risk for severe dehydration
Immunocompromised or severe chronic illness
If persists longer than 72 hrs or if gross blood or pus is present in stool

49
Q

Tx principles of diarrhea

A 
Dietary concerns
Relieve sx
Treat curable causes
Treat any secondary d/os
Prevent dehyrdation and electrolyte loss
50
Q

Supportive care for diarrhea

A

Assess need for hydration and electrolytes
-Rarely needed in short-term
-Oral >IV
Clear liquids and simple carbs
Caution milk products to minimize risk of transient lactose intolerance
May d/c solid foods and dairy products x 24 hrs in adults
-Osmotic diarrhea
-Secretory: diarrhea persists
-Continue feeding children with acute bacterial diarrhea: BRAT diet: decreased morbidity and mortality

51
Q

What are the general pharmacological classes for diarrhea?

A 
Opioid agonists
Anticholinergics
Absorben (psyllium)
Absorbent (attapulgite)
Somatostatin analogues
Mucosal prostaglandin inhibitors (bismuth subsalicylate)
52
Q

What are the most effective oral agents for diarrhea?

A

Opioids

53
Q

Loperamide facts

A

Often considered a drug of choice bc of efficacy, potency, and not crossing the blood brain barrier
Shown to inhibit peristalsis, prolong transit time, reduce fecal volume, and increase anal sphincter tone
Well tolerated with some peripheral opioid side effects
-Can still cause drowsiness

54
Q

Loperamide dosing

A

4 mg PO initially, then 2 mg after each loose stool up to a max of 16 mg/day

55
Q

Indications for loperamide

A

Traveler’s diarrhea
Nonspecific acute diarrhea
When pt has low grade fever no bloody stools

56
Q

Codeine facts

A

DOES cross the blood brain barrier and can cause CNS depression
Effective but has many SEs
Other opioid antagonists are theoretically effective
Caution co-administration with other CNS depressants

57
Q

Diphenoxylate with atropine facts

A

Prescription
DOES cross the blood brain barrier and can cause CNS depression
Little to no analgesic properties
Do not exceed 20 mg/day in adults
Combined with atropine to reduce abuse potential

58
Q

MOA of anticholinergics for diarrhea

A

Work by decreasing secretions into the GI tract and possibly altering gut motility
SEs are numerous and efficacy is questionable
Do NOT recommend use for tx

59
Q

Examples of anticholinergics for diarrhea

A

Atropine
Dicyclomine
Hyoscyamine

60
Q

Lactobacillus preparations facts

A

Replace colonic microflora
Supposedly restores nl intestinal fxn and suppresses growth of pathogenic microorganisms
Use caution in IC pts
Wide range of cost

61
Q

Lactase enzyme

A

For lactose intolerance

Directions specific to product selected

62
Q

Monitoring for diarrhea

A 
Viral infectious diarrhea is often self-limiting
Monitoring should include:
-Med adverse effects
-S/sx of dehydration
-Improvement in diarrhea within 48 hrs

Pharm II (8 decks)

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