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NAPLEX Review > Constipation & Diarrhea > Flashcards

Constipation & Diarrhea Flashcards

1
Q

What is constipation?

A

Constipation is defined as infrequent bowel movements (less than three per week) or difficulty in passing stools (e.g. straining, lumpy/hard stools, pushing for more than 10 minutes, stool requiring digital evacuation or the sensation of incomplete evacuation)

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2
Q

What are some causes of constipation?

A

Constipation can be caused by diet, lifestyle, drugs, pregnancy. GI disorders and other medical conditions

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3
Q

What are some medical conditions that can cause constipation?

A

Irritable bowel syndrome (constipation-predominant), anal disorders (fissures, fistulae, rectal prolapse), multiple sclerosis, cerebrovascular events, Parkinson disease, spinal cord tumors, diabetes, hypothyroidism

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4
Q

When does constipation become chronic idiopathic constipation?

A

When constipation persists for several weeks or longer, and the cause is unknown

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5
Q

What is IBS-C?

A

Idiopathic constipation associated with chronic or recurrent abdominal discomfort that is relieved by defecation is termed irritable bowel syndrome with constipation (IBS-C)

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6
Q

What are examples of preferred treatment of constipation?

A

Non-drug treatments are preferred for constipation. These include increasing fluid intake (64 oz daily recommended), limiting caffeine and alcohol intake (to avoid dehydration) and increasing physical activity. Replacing refined foods with whole grain products, bran, fruits, vegetables, beans and other food high in fiber is useful

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7
Q

What are examples of key drugs that cause constipation?

A

Antacids (aluminum- and calcium-containing), antidiarrheals, clonidine, colesevelam, drugs with anticholinergic effects, iron, non-DHP CCB, opioids, sucralfate

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8
Q

What should be done if constipation does not improve with lifestyle measures?

A

One or more drug treatments can be used. Most medications are available OTC and can be tried for the initial treatment of IBS-C, CIC or opioid-induced constipation

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9
Q

What should be done if constipation is not improved after seven days of OTC treatment?

A

A healthcare provider should be consulted for further evaluation and, if appropriate, prescription medication can be considered

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10
Q

What are the most common side effects of drug treatment of constipation?

A

Diarrhea and abdominal cramping

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11
Q

What are the common classes of drugs used for the treatment of constipation?

A

Bulk-forming drugs, osmotics, stimulants, stool softeners, lubricants

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12
Q

Which OTC should be recommended for most adults with constipation?

A

Fiber

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13
Q

Which OTC should be recommended in iron-induced or hard stool constipation?

A

Docusate (stool softener)

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14
Q

Which OTC should be recommended for opioid-induced constipation?

A

Senna or bisacodyl (stimulant)

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15
Q

Which OTC should be recommended for pregnant women with constipation?

A

Fiber

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16
Q

Which OTC should be recommended when fast relief of constipation is needed?

A
  • Adults: bisacodyl or glycerin suppository

- Children: glycerin suppository

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17
Q

How do bulk-forming drugs work?

A

Bulk-forming drugs and dietary fiber are the first-line treatments in most cases and the treatment of choice in pregnancy. They absorb water in the intestine, soaking up fluid and adding bulk to the stool which increases peristalsis and decreases stool transit time

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18
Q

How do osmotics work?

A

Osmotics contain large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis

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19
Q

How do stimulants work?

A

Stimulants directly stimulate neurons in the colon, causing peristaltic activity

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20
Q

Why do patients using chronic opioids require a stimulant laxative?

A

Opioids reduce peristalsis and prolong stool transit time

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21
Q

How do stool softeners work?

A

Stool softeners are emollients that reduce the surface tension of the stool oil-water interface, allowing more water and fat to mix with the stool which softens the fecal mass making defecation easier

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22
Q

How do lubricants work?

A

Lubricants coat the bowel and stool with a waterproof film which keeps moisture in the stool and makes defecation easier

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23
Q

What are some examples of bulk-forming drugs?

A

Psyllium (Metamucil), calcium polycarbophil, methylcellulose, wheat dextrin

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24
Q

What are some contraindications of Psyllium?

A

Fecal impaction and GI obstruction

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25
Q

What are some side effects of bulk-forming drugs?

A

Flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough liquid)

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26
Q

What are some notes about bulk-forming drugs?

A
  • Onset of action: 12-72 hours
  • Adequate fluids are required; use caution if fluid restricted, if difficulty swallowing or if at risk for fecal impaction
  • Calcium is a polyvalent cation; separate calcium polycarbophil from select drugs due to binding interaction
  • Sugar-free options available
  • Psyllium modestly improves cholesterol and blood glucose levels
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27
Q

What are some examples of osmotics?

A

Magnesium hydroxide (Milk of Magnesia), Miralax, Glycerin, Lactulose, Sodium phosphates (Fleet Enema), Sorbitolq

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28
Q

What are some contraindications of osmotics?

A

Anuria (sorbitol), low galactose diet (lactulose), GI obstruction (Miralax), galactosemia (lactitol)

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29
Q

What are some side effects of osmotics?

A

Electrolyte imbalance, abdominal cramping, abdominal distention, flatulence, dehydration, rectal irritation (suppository)

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30
Q

What are some side effects specific to Lactitol?

A

Upper respiratory tract infections, increased blood pressure, increased blood creatinine phosphokinase

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31
Q

What are some notes associated with all osmotics?

A

Onset of action is 30 min to 96 hours (oral), 5-30 min (rectal)

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32
Q

What are some notes about magnesium-containing osmotics?

A

Caution with renal impairment and do not use if severe renal impairment

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33
Q

What are some notes about Lactulose?

A

Used commonly for hepatic encephalopathy

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34
Q

What are some notes about glycerin suppositories?

A

Glycerin suppository used commonly in children who need to defecate quickly

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35
Q

What are some examples of stimulants?

A

Senna, Bisacodyl

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36
Q

What are some warnings associated with stimulants?

A

Avoid use with stomach pain, N/V or a sudden change in bowel movements that lasts > 2 weeks

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37
Q

What are some side effects of stimulants?

A

Abdominal cramping, electrolyte imbalance, rectal irritation (suppository)

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38
Q

What are some notes about stimulants?

A
  • Onset of action 6-12 hours (oral), 15-60 mins (rectal)
  • Take oral products at bedtime to induce a bowl movement the following morning; can give 30 mins after a meal to enhance peristalsis
  • Chronic opioid use often requires a stimulant laxative
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39
Q

What is an example of an emollient?

A

Docusate sodium

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40
Q

What are some contraindications of emollients?

A

Abdominal pain, N/V, use with mineral oil, OTC use > 1 week

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41
Q

What are some side effects of emollients?

A

Abdominal cramping, throat irritation

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42
Q

What are some notes about emollients?

A
  • Onset of action: 12 -72 hours (oral), 2-15 mins (rectal)
  • Preferred when straining should be avoided (e.g. postpartum, post-MI, anal fissures, hemorrhoids)
  • Use when stool is hard or dry
  • Do not take docusate and mineral oil together (it increases the absorption of mineral oil)
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43
Q

What is an example of a lubricant?

A

Mineral oil

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44
Q

What are contraindications of lubricants?

A

Age < 6 years, pregnancy, bedridden patients, elderly, use > 1 week, difficulty swallowing

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45
Q

What are some side effects of lubricants?

A

Abdominal cramping, nausea, incontinence, rectal discharge

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46
Q

What are some notes about lubricants?

A
  • Onset of action 6-8 hours (oral), 2-15 mins (rectal)
  • Oral formulation generally not recommended due to safety concerns (e.g. risk of aspiration and lipid pneumonitis)
  • Take a multivitamin at a different time due to malabsorption of fat-soluble vitamins
  • Do not take docusate and mineral oil together (it increases the absorption of mineral oil)
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47
Q

What are prescription medications that can be used to treat constipation?

A

Lubiprostone, Guanylate cyclase C agonists, peripherally-acting, mu-opioid receptor antagonists, serotonin 5HT-4 receptor agonists

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48
Q

How does lubiprostone work?

A

The chloride channel activator lubiprostone acts on chloride channels in the gut, leading to increased fluid and peristalsis

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49
Q

How do guanylate cyclase C agonists work?

A

Guanylate cyclase C agonists increase chloride and bicarbonate secretion in to the lumen of the intestines, increasing the speed of GI transit and reducing abdominal pain

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50
Q

How do peripherally-acting, mu-opioid receptor antagonists work?

A

Peripherally-acting, mu-opioid receptor antagonists act on mu-opioid receptors in the GI tract, decreasing constipation

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51
Q

How do serotonin 5HT-4 receptor agonists work?

A

Serotonin 5HT-4 receptor agonists release acetylcholine which causes muscle contractions and increases gastrointestinal motility

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52
Q

What is Lubiprostone indicated for?

A

CIC, IBS-C, OIC

53
Q

What is Linaclotide, Plecanatide indicated for?

A

CIC, IBS-C

54
Q

What is Alvimopan indicated for?

A

Surgery induced constipation

55
Q

What is methylnaltrexone, naloxegel, naldemedine indicated for?

A

OIC

56
Q

What is Prucalopride indicated for?

A

CIC

57
Q

What is Tegaserod indicated for?

A

IBS-C

58
Q

What is an example of a chloride channel activator?

A

Lubiprostone

59
Q

What are contraindications of Lubiprostone?

A

Mechanical bowel obstruction

60
Q

What are some side effects of Lubiprostone?

A

Nausea, diarrhea, abdominal pain, abdominal distension, headache

61
Q

What are some notes about Lubiprostone?

A
  • Take with food and water to decrease nausea

- Consider alternative treatment with methadone (decreased lubiprostone effects)

62
Q

What are some examples of guanylate cylcase C agonists?

A

Linaclotide, Plecanatide

63
Q

What is a boxed warning of guanylate cyclase c agonists?

A

Do not use in pediatric patients; high risk of dehydration that can cause death

64
Q

What are contraindications of guanylate cyclase C agonists?

A

Age < 6 years, mechanical GI obstruction

65
Q

What are some side effects of guanylate cyclase C agonists?

A

Diarrhea, abdominal pain, flatulence

66
Q

What are some notes about Linzess?

A
  • Swallow Linzess capsules whole; if needed, the capsule can be opened and the contents mixed with 1 teaspoonful of applesauce or 30 mL of room temperature water; the mixture must be swallowed immediately
  • Protect from moisture; original container has a desiccant
67
Q

What is a note about Trulance?

A

Trulance tablets can be crushed

68
Q

What are some examples of peripherally acting mu opioid receptor antagonists?

A

Alvimopan (Entereg), Methylnaltrexone (Relistor), Naloxegol (Movantik), Naldemedine (Symproic)

69
Q

What are the boxed warnings of peripherally acting mu opioid receptor antagonists?

A
  • Potential risk of MI with long term use

- Available only for short-term inpatient use through a REMS program

70
Q

What are contraindications of peripherally-acting mu-opioid receptor antagonists?

A

Therapeutic doses of opioids for > 7 consecutive days immediately prior to use =

71
Q

What are side effects of peripherally acting mu opioid receptor antagonists?

A

Dyspepsia

72
Q

What are some notes about peripherally acting mu opioid receptor antagonists?

A

Only used in patients taking opioids who have OIC

73
Q

What are some examples of Serotonin 5HT-4 receptors agonists?

A

Prucalopride (Motegrity), Tegaserod (Zelnorm)

74
Q

What are contraindications of serotonin 5HT-4 receptor agonists?

A

Gastrointestinal obstruction

75
Q

What are contraindications of Prucalopride?

A

Bowel perforation, ileus, severe inflammatory conditions of the GI tract (Crohn’s disease, ulcerative colitis, toxic megacolon)

76
Q

What are contraindications of Tegaserod?

A

Intestinal ischemia (e.g. ischemic colitis), history of cardiovascular events (e.g. MI, stroke or TIA, angina), severe renal impairment or ESRD, hepatic impairment (Child-Pugh class B or C), gallbladder disease, sphincter of Oddi dysfunction, abdominal adhesions

77
Q

What are some warnings about serotonin 5HT-4 Receptor Agonists?

A

Suicidal ideation

78
Q

What are some side effects of serotonin 5HT-4 receptor agonists?

A

Diarrhea, headache, nausea, abdominal pain

79
Q

What are some monitoring parameters of serotonin 5HT-4 receptor agonists?

A

Worsening of depression or emergence of suicidal thoughts; rectal bleeding, blood in stool, severe abdominal pain

80
Q

What are potential complications of laxatives for whole bowel irrigation?

A

Although usually safe and well-tolerated, laxatives for whole bowel irrigation can cause fluid and electrolyte loss

81
Q

When is extra caution necessary for laxatives for whole bowel irrigation?

A

Use extra caution in patients with cardiovascular disease, renal insufficiency or if taking loop diuretics (due to additional fluid loss) or NSAIDs

82
Q

What are some examples of laxatives used for whole bowel irrigation?

A

Polyethylene glycol (Colyte, Golytely, Nulytely, GaviLyte), Osmoprep, Suprep, Clenpiq

83
Q

What is a boxed warning of Osmoprep?

A

Nephropathy

84
Q

What are contraindications for the laxatives used for whole bowel irrigation?

A

Ileus, gastrointestinal obstruction, gastric retention, bowel perforation, toxic colitis, toxic megacolon

85
Q

What are contraindications of OsmoPrep?

A

Acute phosphate nephropathy, gastric bypass or stapling surgery

86
Q

What are contraindications of Clenpiq?

A

Severe renal impairment

87
Q

What are some warnings associated with laxatives used for whole bowel irrigation?

A

Arrhythmias, electrolyte abnormalities, seizures

88
Q

What are some side effects associated with laxatives used for whole bowel irrigation?

A

Abdominal discomfort, bloating, N/V

89
Q

What are some notes about laxatives used for whole bowel irrigation?

A
  • Onset of action: 1-6 hours
  • Bowel prep regimens typically require doses the evening before colonoscopy and the morning of colonoscopy to completely evacuate the bowel
  • A clear liquid diet is required the day prior to colonoscopy and can include: water, clear broth (beef or chicken)m juices without pulp (apple, white, cranberry, white grape, lemonade), soda, coffee or tea (without milk or cream), clear gelatin (without fruit pieces), popsicles (without fruit pieces or cream)
  • do not consume the following: solid or semi-solid foods, anything with red or blue/purple food coloring (including gelatin and popsicles), milk, cream, tomato, orange or grapefruit juice, alcoholic beverages, cream soups
90
Q

What is diarrhea?

A

Diarrhea is an increase in the number of bowel movements or stools that are more watery and loose than normal. When the intestines push stools through the bowel before the water in the stool can be reabsorbed, diarrhea occurs

91
Q

What is the most common bacterial cause of diarrhea?

A

E. coli

92
Q

What is recurrent idiopathic diarrhea associated with?

A

Recurrent idiopathic diarrhea associated with chronic or reoccuring abdominal discomfort that is relieved by defecation is termed irritable bowel syndrome with diarrhea (IBS-D)

93
Q

What does management of diarrhea include?

A

Management of diarrhea includes fluid and electrolyte replacement, especially in moderate-severe cases and in the elderly, children or adults with chronic medical conditions

94
Q

How do you replace fluid and electrolytes in dehydration from diarrhea?

A

Replace fluids and electrolytes with oral rehydration solutions (ORS), such as Pedialyte or Enfamil Enfalyte, which are available over the counter. Gatorade or similar products can be used as alternatives

95
Q

What are drugs that can cause diarrhea?

A

Acetylcholinesterase inhibitors, antacids containing magnesium, antibiotics (especially broad-spectrum), antidiabetics, antineoplastics, colchicine, drugs used for constipation, misoprostol, mycophenolate, prokinetic drugs, protease inhibitors, quinidine, roflumilast

96
Q

What should be recommended for most patients with non-infectious diarrhea who require symptomatic relief?

A

Most patients with non-infectious diarrhea who require symptomatic relief can use short-term bismuth subsalicylate (Pepto-Bismol) or loperamide as needed

97
Q

What are some examples of antidiarrheals?

A

Bismuth subsalicylate, loperamide, diphenoxylate/atropine

98
Q

What is the MOA of Loperamide and diphenoxylate?

A

Antimotility drugs that slow intestinal motility, prolonging the time for water absorption

99
Q

What is an example of antispasmodic?

A

Dicyclomine

100
Q

What is an example of a peripherally acting mixed mu opioid receptor agonist?

A

Eluxadoline (Viberzi)

101
Q

What is the MOA of Eluxadoline?

A

Eluxadoline binds to the opioid receptors as an agonist to treat diarrhea and is indicated for IBS-D when diarrhea is difficult to treat with usual measures

102
Q

What are some contraindications of Pepto-Bismol?

A

Salicylate allergy, taking other salicylates (e.g. aspirin), GI ulcer, bleeding problems, black/bloody stool

103
Q

What are some warnings of Pepto-Bismol?

A

Children and teenagers who are recovering from the flu, chickenpox or other viral infections should not use this drug due to the risk of Reye’s syndrome

104
Q

What are some side effects associated with Pepto-Bismol?

A

Black tongue/stool (temporary and harmless), salicylate toxicity if used excessively (tinnitus, metabolic acidosis), nausea, abdominal pain

105
Q

What are some notes associated with Pepto-Bismol?

A
  • Can cause an increased risk of bleeding when used with anticoagulants, antiplatelets (e.g. asprin) or NSAIDs
  • Use caution in those with renal insufficiency or in combination with other nephrotoxic drugs
106
Q

What is a boxed warning of loperamide?

A
  • Torsades de pointes, cardiac arrest and sudden death with doses higher than recommended; do not exceed the recommended dose
  • Do not use in children < 2 years
107
Q

What are contraindications of Loperamide?

A

Acute dysentery (bloody diarrhea and high fever), pseudomembranous colitis (C. difficile), bacterial enterocolitis caused by invasive organisms, abdominal pain without diarrhea, acute ulcerative colitis

108
Q

What are some side effects of Loperamide?

A

Constipation, abdominal cramping, nausea, QT prolongation

109
Q

What are some notes about Loperamide?

A
  • Self treatment: do not use > 48 hours
  • Loperamide can be abused, as it causes a mild opioid-like “high” in large quantities
  • To encourage safe use, the FDA requires use of blister packs or other single dose packaging for tablets and capsules, and the number of doses per package is limited to no more than 48 mg (24 tablets/capsules)
110
Q

What are contraindications of Lomotil?

A

Risk of respiratory and CNS depression in children (do not use if < 2 years of age (or < 6 years of age for tablets)], diarrhea caused by enterotoxin-producing bacteria or pseudomembranous colitis, obstructive jaundice

111
Q

What are some side effects of Lomotil?

A

Mild euphoria due to diphenoxylate, possible anticholinergic effects

112
Q

What are some notes about Lomotil?

A
  • Liquid formulation is recommended in children < 13 years
  • Anticholinergic effects due to atropine (e.g. constipation, dry mouth, sedation, tachycardia, flushing, urinary retention, blurred vision)l these are mild at recommended doses
113
Q

What are contraindications of Dicyclomine?

A

Gastrointestinal obstruction, severe ulcerative colitis, reflux esophagitis, acute hemorrhage with cardiovascular instability, obstructive uropathy, narrow-angle glaucoma, myasthenia gravis, breastfeeding women, infants < 6 months of age

114
Q

What are some warnings of Dicyclomine?

A

Anticholinergics (caution in patients > 65 years), caution in mild-moderate ulcerative colitis (can cause toxic megacolon or paralytic ileus)

115
Q

What are some side effects of Dicyclomine?

A

Dizziness, dry mouth, nausea, blurred vision, somnolence, weakness, nervousness

116
Q

What are some contraindications of Viberzi?

A

Patients without a gallbladder, biliary duct obstruction, sphincter of Oddi dysfunction/disease, pancreatic disease (including history of pancreatitis), alcoholism or > 3 alcoholic drinks/day, severe hepatic impairment, history of severe constipation, gastrointestinal obstruction

117
Q

What are some warnings of Viberzi?

A

CNS depression

118
Q

What are some side effects of Viberzi?

A

Constipation, nausea, abdominal pain

119
Q

What are some monitoring parameters of Viberzi?

A

S/sx of pancreatitis or sphincter of Oddi spasm (e.g. abdominal pain that radiates to the back or shoulder, nausea and vomiting), LFTs

120
Q

What are other oral medications less commonly used for diarrhea?

A

Xifaxan, Lotronex

121
Q

What are some notes about Xifaxan?

A

Costly, and relapse often occurs within several months of treatment

122
Q

What are some notes about Lotronex?

A

Approved for women only, but has restricted use due to risk of ischemic colitis

123
Q

What are counseling points of all constipation products?

A
  • Can cause diarrhea and/or abdominal cramping

- If no improvement after one week of OTC treatment, contact a healthcare provider

124
Q

What is a counseling points of bulk-forming drugs?

A

Drug interactions due to binding

125
Q

What are counseling points for all diarrhea products?

A
  • Contact a healthcare provider for any of the following: age < 6 months, pregnant, high fever (> 101 F), severe abdominal pain or blood in the stool
  • Can cause constipation
126
Q

What are some counseling points of Pepto-Bismol?

A
  • Do not take for longer than two days without the approval of your healthcare provider
  • Can cause bleeding/bruising, dark tongue and stool
127
Q

What is a counseling point of Loperamide?

A

Do not take for longer than two days without the approval of your healthcare provider

128
Q

What is a counseling point of Lomotil and Dicyclomine?

A

Can cause anticholinergic effects

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