Constipation & Diarrhea Flashcards
What is constipation?
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)
What are some causes of constipation?
Constipation can be caused by diet, lifestyle, drugs, pregnancy. GI disorders and other medical conditions
What are some medical conditions that can cause constipation?
Irritable bowel syndrome (constipation-predominant), anal disorders (fissures, fistulae, rectal prolapse), multiple sclerosis, cerebrovascular events, Parkinson disease, spinal cord tumors, diabetes, hypothyroidism
When does constipation become chronic idiopathic constipation?
When constipation persists for several weeks or longer, and the cause is unknown
What is IBS-C?
Idiopathic constipation associated with chronic or recurrent abdominal discomfort that is relieved by defecation is termed irritable bowel syndrome with constipation (IBS-C)
What are examples of preferred treatment of constipation?
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
What are examples of key drugs that cause constipation?
Antacids (aluminum- and calcium-containing), antidiarrheals, clonidine, colesevelam, drugs with anticholinergic effects, iron, non-DHP CCB, opioids, sucralfate
What should be done if constipation does not improve with lifestyle measures?
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
What should be done if constipation is not improved after seven days of OTC treatment?
A healthcare provider should be consulted for further evaluation and, if appropriate, prescription medication can be considered
What are the most common side effects of drug treatment of constipation?
Diarrhea and abdominal cramping
What are the common classes of drugs used for the treatment of constipation?
Bulk-forming drugs, osmotics, stimulants, stool softeners, lubricants
Which OTC should be recommended for most adults with constipation?
Fiber
Which OTC should be recommended in iron-induced or hard stool constipation?
Docusate (stool softener)
Which OTC should be recommended for opioid-induced constipation?
Senna or bisacodyl (stimulant)
Which OTC should be recommended for pregnant women with constipation?
Fiber
Which OTC should be recommended when fast relief of constipation is needed?
- Adults: bisacodyl or glycerin suppository
- Children: glycerin suppository
How do bulk-forming drugs work?
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
How do osmotics work?
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
How do stimulants work?
Stimulants directly stimulate neurons in the colon, causing peristaltic activity
Why do patients using chronic opioids require a stimulant laxative?
Opioids reduce peristalsis and prolong stool transit time
How do stool softeners work?
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
How do lubricants work?
Lubricants coat the bowel and stool with a waterproof film which keeps moisture in the stool and makes defecation easier
What are some examples of bulk-forming drugs?
Psyllium (Metamucil), calcium polycarbophil, methylcellulose, wheat dextrin
What are some contraindications of Psyllium?
Fecal impaction and GI obstruction
What are some side effects of bulk-forming drugs?
Flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough liquid)
What are some notes about bulk-forming drugs?
- 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
What are some examples of osmotics?
Magnesium hydroxide (Milk of Magnesia), Miralax, Glycerin, Lactulose, Sodium phosphates (Fleet Enema), Sorbitolq
What are some contraindications of osmotics?
Anuria (sorbitol), low galactose diet (lactulose), GI obstruction (Miralax), galactosemia (lactitol)
What are some side effects of osmotics?
Electrolyte imbalance, abdominal cramping, abdominal distention, flatulence, dehydration, rectal irritation (suppository)
What are some side effects specific to Lactitol?
Upper respiratory tract infections, increased blood pressure, increased blood creatinine phosphokinase
What are some notes associated with all osmotics?
Onset of action is 30 min to 96 hours (oral), 5-30 min (rectal)
What are some notes about magnesium-containing osmotics?
Caution with renal impairment and do not use if severe renal impairment
What are some notes about Lactulose?
Used commonly for hepatic encephalopathy
What are some notes about glycerin suppositories?
Glycerin suppository used commonly in children who need to defecate quickly
What are some examples of stimulants?
Senna, Bisacodyl
What are some warnings associated with stimulants?
Avoid use with stomach pain, N/V or a sudden change in bowel movements that lasts > 2 weeks
What are some side effects of stimulants?
Abdominal cramping, electrolyte imbalance, rectal irritation (suppository)
What are some notes about stimulants?
- 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
What is an example of an emollient?
Docusate sodium
What are some contraindications of emollients?
Abdominal pain, N/V, use with mineral oil, OTC use > 1 week
What are some side effects of emollients?
Abdominal cramping, throat irritation
What are some notes about emollients?
- 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)
What is an example of a lubricant?
Mineral oil
What are contraindications of lubricants?
Age < 6 years, pregnancy, bedridden patients, elderly, use > 1 week, difficulty swallowing
What are some side effects of lubricants?
Abdominal cramping, nausea, incontinence, rectal discharge
What are some notes about lubricants?
- 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)
What are prescription medications that can be used to treat constipation?
Lubiprostone, Guanylate cyclase C agonists, peripherally-acting, mu-opioid receptor antagonists, serotonin 5HT-4 receptor agonists
How does lubiprostone work?
The chloride channel activator lubiprostone acts on chloride channels in the gut, leading to increased fluid and peristalsis
How do guanylate cyclase C agonists work?
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
How do peripherally-acting, mu-opioid receptor antagonists work?
Peripherally-acting, mu-opioid receptor antagonists act on mu-opioid receptors in the GI tract, decreasing constipation
How do serotonin 5HT-4 receptor agonists work?
Serotonin 5HT-4 receptor agonists release acetylcholine which causes muscle contractions and increases gastrointestinal motility
What is Lubiprostone indicated for?
CIC, IBS-C, OIC
What is Linaclotide, Plecanatide indicated for?
CIC, IBS-C
What is Alvimopan indicated for?
Surgery induced constipation
What is methylnaltrexone, naloxegel, naldemedine indicated for?
OIC
What is Prucalopride indicated for?
CIC
What is Tegaserod indicated for?
IBS-C
What is an example of a chloride channel activator?
Lubiprostone
What are contraindications of Lubiprostone?
Mechanical bowel obstruction
What are some side effects of Lubiprostone?
Nausea, diarrhea, abdominal pain, abdominal distension, headache
What are some notes about Lubiprostone?
- Take with food and water to decrease nausea
- Consider alternative treatment with methadone (decreased lubiprostone effects)
What are some examples of guanylate cylcase C agonists?
Linaclotide, Plecanatide
What is a boxed warning of guanylate cyclase c agonists?
Do not use in pediatric patients; high risk of dehydration that can cause death
What are contraindications of guanylate cyclase C agonists?
Age < 6 years, mechanical GI obstruction
What are some side effects of guanylate cyclase C agonists?
Diarrhea, abdominal pain, flatulence
What are some notes about Linzess?
- 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
What is a note about Trulance?
Trulance tablets can be crushed
What are some examples of peripherally acting mu opioid receptor antagonists?
Alvimopan (Entereg), Methylnaltrexone (Relistor), Naloxegol (Movantik), Naldemedine (Symproic)
What are the boxed warnings of peripherally acting mu opioid receptor antagonists?
- Potential risk of MI with long term use
- Available only for short-term inpatient use through a REMS program
What are contraindications of peripherally-acting mu-opioid receptor antagonists?
Therapeutic doses of opioids for > 7 consecutive days immediately prior to use =
What are side effects of peripherally acting mu opioid receptor antagonists?
Dyspepsia
What are some notes about peripherally acting mu opioid receptor antagonists?
Only used in patients taking opioids who have OIC
What are some examples of Serotonin 5HT-4 receptors agonists?
Prucalopride (Motegrity), Tegaserod (Zelnorm)
What are contraindications of serotonin 5HT-4 receptor agonists?
Gastrointestinal obstruction
What are contraindications of Prucalopride?
Bowel perforation, ileus, severe inflammatory conditions of the GI tract (Crohn’s disease, ulcerative colitis, toxic megacolon)
What are contraindications of Tegaserod?
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
What are some warnings about serotonin 5HT-4 Receptor Agonists?
Suicidal ideation
What are some side effects of serotonin 5HT-4 receptor agonists?
Diarrhea, headache, nausea, abdominal pain
What are some monitoring parameters of serotonin 5HT-4 receptor agonists?
Worsening of depression or emergence of suicidal thoughts; rectal bleeding, blood in stool, severe abdominal pain
What are potential complications of laxatives for whole bowel irrigation?
Although usually safe and well-tolerated, laxatives for whole bowel irrigation can cause fluid and electrolyte loss
When is extra caution necessary for laxatives for whole bowel irrigation?
Use extra caution in patients with cardiovascular disease, renal insufficiency or if taking loop diuretics (due to additional fluid loss) or NSAIDs
What are some examples of laxatives used for whole bowel irrigation?
Polyethylene glycol (Colyte, Golytely, Nulytely, GaviLyte), Osmoprep, Suprep, Clenpiq
What is a boxed warning of Osmoprep?
Nephropathy
What are contraindications for the laxatives used for whole bowel irrigation?
Ileus, gastrointestinal obstruction, gastric retention, bowel perforation, toxic colitis, toxic megacolon
What are contraindications of OsmoPrep?
Acute phosphate nephropathy, gastric bypass or stapling surgery
What are contraindications of Clenpiq?
Severe renal impairment
What are some warnings associated with laxatives used for whole bowel irrigation?
Arrhythmias, electrolyte abnormalities, seizures
What are some side effects associated with laxatives used for whole bowel irrigation?
Abdominal discomfort, bloating, N/V
What are some notes about laxatives used for whole bowel irrigation?
- 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
What is diarrhea?
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
What is the most common bacterial cause of diarrhea?
E. coli
What is recurrent idiopathic diarrhea associated with?
Recurrent idiopathic diarrhea associated with chronic or reoccuring abdominal discomfort that is relieved by defecation is termed irritable bowel syndrome with diarrhea (IBS-D)
What does management of diarrhea include?
Management of diarrhea includes fluid and electrolyte replacement, especially in moderate-severe cases and in the elderly, children or adults with chronic medical conditions
How do you replace fluid and electrolytes in dehydration from diarrhea?
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
What are drugs that can cause diarrhea?
Acetylcholinesterase inhibitors, antacids containing magnesium, antibiotics (especially broad-spectrum), antidiabetics, antineoplastics, colchicine, drugs used for constipation, misoprostol, mycophenolate, prokinetic drugs, protease inhibitors, quinidine, roflumilast
What should be recommended for most patients with non-infectious diarrhea who require symptomatic relief?
Most patients with non-infectious diarrhea who require symptomatic relief can use short-term bismuth subsalicylate (Pepto-Bismol) or loperamide as needed
What are some examples of antidiarrheals?
Bismuth subsalicylate, loperamide, diphenoxylate/atropine
What is the MOA of Loperamide and diphenoxylate?
Antimotility drugs that slow intestinal motility, prolonging the time for water absorption
What is an example of antispasmodic?
Dicyclomine
What is an example of a peripherally acting mixed mu opioid receptor agonist?
Eluxadoline (Viberzi)
What is the MOA of Eluxadoline?
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
What are some contraindications of Pepto-Bismol?
Salicylate allergy, taking other salicylates (e.g. aspirin), GI ulcer, bleeding problems, black/bloody stool
What are some warnings of Pepto-Bismol?
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
What are some side effects associated with Pepto-Bismol?
Black tongue/stool (temporary and harmless), salicylate toxicity if used excessively (tinnitus, metabolic acidosis), nausea, abdominal pain
What are some notes associated with Pepto-Bismol?
- 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
What is a boxed warning of loperamide?
- 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
What are contraindications of Loperamide?
Acute dysentery (bloody diarrhea and high fever), pseudomembranous colitis (C. difficile), bacterial enterocolitis caused by invasive organisms, abdominal pain without diarrhea, acute ulcerative colitis
What are some side effects of Loperamide?
Constipation, abdominal cramping, nausea, QT prolongation
What are some notes about Loperamide?
- 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)
What are contraindications of Lomotil?
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
What are some side effects of Lomotil?
Mild euphoria due to diphenoxylate, possible anticholinergic effects
What are some notes about Lomotil?
- 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
What are contraindications of Dicyclomine?
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
What are some warnings of Dicyclomine?
Anticholinergics (caution in patients > 65 years), caution in mild-moderate ulcerative colitis (can cause toxic megacolon or paralytic ileus)
What are some side effects of Dicyclomine?
Dizziness, dry mouth, nausea, blurred vision, somnolence, weakness, nervousness
What are some contraindications of Viberzi?
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
What are some warnings of Viberzi?
CNS depression
What are some side effects of Viberzi?
Constipation, nausea, abdominal pain
What are some monitoring parameters of Viberzi?
S/sx of pancreatitis or sphincter of Oddi spasm (e.g. abdominal pain that radiates to the back or shoulder, nausea and vomiting), LFTs
What are other oral medications less commonly used for diarrhea?
Xifaxan, Lotronex
What are some notes about Xifaxan?
Costly, and relapse often occurs within several months of treatment
What are some notes about Lotronex?
Approved for women only, but has restricted use due to risk of ischemic colitis
What are counseling points of all constipation products?
- Can cause diarrhea and/or abdominal cramping
- If no improvement after one week of OTC treatment, contact a healthcare provider
What is a counseling points of bulk-forming drugs?
Drug interactions due to binding
What are counseling points for all diarrhea products?
- 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
What are some counseling points of Pepto-Bismol?
- Do not take for longer than two days without the approval of your healthcare provider
- Can cause bleeding/bruising, dark tongue and stool
What is a counseling point of Loperamide?
Do not take for longer than two days without the approval of your healthcare provider
What is a counseling point of Lomotil and Dicyclomine?
Can cause anticholinergic effects
