Constipation & Diarrhea Flashcards
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Constipation:
infrequent stool passage (less than 3 bowel movements per week) or difficulty in passing stools.
- straining
- lumpy/hard stools, pushing for > 10 minutes
- requiring digital evacuation of stool
- sensation of incomplete evacuation
” is the most common digestive complaint in the U.S”
When should a patient be referred to see a medical provider if they have been using OTC medications to treat constipation but still having problems?
If no improvement in 7 days with OTC Tx, patient should go see provider.
When constipation persists for several weeks or longer, and the cause is unknown, it is termed ______________
chronic idiopathic constipation (CIC)
idiopathic constipation associated with chronic or recurrent abdominal discomfort that is relieved by defecation is termed ______________
irritable bowel syndrome with constipation (IBS-C)
Medical Conditions that can cause Constipation:
- IBS (irritable bowel syndrome)- constipation predominant
- anal disorders (fissures, fistulae, rectal prolapse)
- multiple sclerosis
- cerebrovascular events
- Parkinson disease (*remember dopamine controls movement through many mechanisms throughout body)
- hypothyroidism
- diabetes
- spinal cord tumors
Non-Drug Treatment:
Non drug treatments are preferred for _________
These would include:
constipation
- increasing fluid intake (64 oz daily recommended)
- limiting caffeine
- limiting alcohol (to avoid dehydration
- increasing physical activity
- replacing refined foods with whole grains, bran, fruits and vegetables, beans and other foods high in fiber
If constipation does not improve with lifestyle measures, or if a constipating drug cannot be stopped, 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 (OIC).
If constipation is NOT improved after _________________ a healthcare provider should be consulted for further evaluation and, if appropriate, prescription medication can be considered.
7 days of OTC treatment
Drug Tx Classes: OTC to Tx constipation
remember “ Large & Small Bulls Shit Often”- LSBSO
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2
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Most drug treatments act to stimulate the muscles of the digestive tract or soften the stool, often speeding up the time for bowel movements; thus the most common side effects are _________ and __________
1) Bulk Forming
2) Osmotics
3) Stimulants
4) Stool Softeners
5) Lubricants
diarrhea & abdominal cramping
Bulk-forming drugs:
How do they work?
(soluble fiber such as psyllium) 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. This increases peristalsis and decreases stool transit time.
—– use in pregnancy AND most adults
Osmotics:
How do they work?
[polyethylene glycol (PEG)] 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.
Examples of Osmotics:
Which Osmotics require a prescription?
Stimulants:
How do they work?
- directly stimulate neurons in the colon, causing peristaltic activity.
[patients using chronic opioids, all of which are constipating, often require a stimulant laxative, because opioids reduce peristalsis and prolong stool transit time]
—- use for opioid induced constipation
Stool Softeners:
How do they work?
- are emollients that reduce the surface tension of the stool oil-water interface, allowing more water and fat to mix with the stool. This softens the fecal mass making defecation easier.
- These can be used by patients using iron supplements, which often make the stool hard and compact.
- the stool softener docusate can be given with stimulant laxative if the stool is hard. (If the stool is NOT hard, but the patient cannot push it out “mush with no push”, a stimulant alone is the usual treatment.
- – use for iron induced or hard stools
For Fast relief needed:
Adults: Use stimulant bisacodyl suppository or Glycerin suppository
Children: glycerin suppository
Lubricants:
How do they work?
- (mineral oil) coat the bowel and stool with a waterproof film. This keeps moisture in the stool and makes defecation easier.
Which Bulk forming drugs OTC come as an chewable tablet?
calcium polycarbophil (Fibercon)
wheat dextrin (Benefiber)
Key Drugs that are Constipating:
- Antacids (aluminum and calcium containing)
- Antidiarrheals
- Clonidine
- Colesevelam
- Iron
- Non-DHP CCBs (diltiazem & verapamil)
- opioids
- Sucralfate
- [drugs with anticholinergic effects]:
antihistamines (diphenhydramine)
antispasmodics (baclofen)
phenothiazines (prochlorperazine)
TCAs (amitriptyline)
urge incontinence drugs (oxybutynin)
Metamucil
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psyllium
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: capsule, powder
Dosing: 2.5-30g/day in divided doses
Max dose:
Contraindications:
*Fecal impaction and GI obstruction (psyllium)
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
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- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
- psyllium modestly improves cholesterol and blood glucose
Onset: 12-72 hours
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FiberCon
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calcium polycarbophil
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: chewable tablet, caplet
Dosing: 1250mg 1-4 times/ day
Max dose:
Contraindications:
*Fecal impaction
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
Pearls/Notes:
- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
- Calcium is a polyvalent cation; *separate calcium polycarbophil from select drugs due to a binding interaction
Onset: 12-72 hours
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Citrucel
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methylcellulose
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: powder, caplet
Dosing: 1-6 grams/day
Max dose:
Contraindications:
*Fecal impaction
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
Pearls/Notes:
- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
Onset: 12-72 hours
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Benefiber
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Wheat dextrin
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: chewable tablet, powder, tablet
Dosing: 4 grams (2 teaspoonfuls) in 4-8 oz of liquid or soft food TID
Max dose:
Contraindications:
*Fecal impaction
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
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- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
Onset: 12-72 hours
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Milk of Magnesia
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magnesium hydroxide
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: chewable tablet, suspension
Dosing:
OTC- magnesium hydroxide: 2.4-4.8g QDHS or in divided doses
Max dose:
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
*Magnesium-containing products: Caution with renal impairment and DO NOT USE if severe renal impairment.
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Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
magnesium citrate/magnesium sulfate
MiraLax
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polyethylene glycol 3350
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: powder
Dosing:
OTC- 17g in 4-8 oz of water daily
Contraindications:
GI obstruction
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
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Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
