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PHRM 504 > Lecture 14: Constipation > Flashcards

Lecture 14: Constipation Flashcards

1
Q

Constipation

A

Defined as three or less bowel movements per week that are also accompanied
by straining and difficulty with passage of hard, dry stools

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2
Q

Normal gastric motility

A
  1. Ingested food sits in stomach/small intestine for ~ 3 hours
  2. Food then moves along toward the duodenum
  3. non-digestable food moves from the small intestine to the large intestine
  4. fecal matter is stored in the sigmoid colon until defecation
  5. once fecal mater is in the colon it triggers involuntary
    movement that moves the fecal matter into the rectum
  6. once in the rectum
    the abdominal wall muscles tighten and the external sphincter relax than
    allows the stool to pass
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3
Q

Primary Constipation

A
  1. Irritable bowel syndrome
  2. Slow-transit constipation
  3. Functional defaction disorders
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4
Q

Secondary Constipation

A

Metabolic
Medications
Neurologic disorders
Primary Colonic disorders

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5
Q

Metabolic

A

Hypercalcemia

Hypothyrodism

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6
Q

Medications

A

Opiates
Calcium channel blockers
Antipsychotics

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7
Q

Neurologic disorders

A

Parkisons Disease
Spinal Cord Injury
DM

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8
Q

Primary Colonic Disorders

A

Stricture
Cancer
Anal Fissure
Proctitis

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9
Q

DRUGS THAT CAUSE CONSTIPATION

A
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Antacids
  • Anticholinergics (benztropine, glycopyrrolate)
  • Iron tablets
  • Calcium channel blockers (diltiazem, verapamil)
  • Anithistamines (loratadine)
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10
Q

DRUGS THAT CAUSE CONSTIPATION

A

Opioids (morphine, codeine)

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11
Q

WHO IS MOST AT RISK FOR CONSTIPATION?

A
  • Women
  • Non-white ancestry
  • Children
  • Older adults (>65 years and older)
  • Pregnancy (later in the trimester)
  • Post childbirth
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12
Q

Hemorrhoids:

A

blood vessels around your anus that are dilated and

inflamed

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13
Q

Anal fissures

A

tear in the inner lining of the anal mucosa

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14
Q

Fecal impaction

A

feces stays in the rectum/ large intestine for so long it
sticks to the lining and is
hard to detach

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15
Q

SIGN AND

SYMPTOMS

A 
Decreased frequency of passing stool
Difficulty passing stool
Abdominal discomfort
Bloating
Flatulence
Anorexia
Dull headache
Physical/mental weakness
Lower back pain
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16
Q

TREATMENT GOALS

A
  1. Relieve constipation
  2. Reestablish normal bowel function
  3. Establish dietary and exercise habits
  4. Promote safe and effective use of laxative products if needed
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17
Q

NON-PHARMACOLOGICAL OPTIONS

A

Increase daily fiber intake to 25 g for adult women and 38 g for adult men

  • Encourage diet change over a period of 1-2 weeks
  • Whole grains, wheat bran, fruits and veggies
  • Can take up to 3-5 days after changing your diet or taking fiber supplements to see effect in bowel movement

Bowel training: the gastrocolic reflex is strongest in the AM and ~30 minutes post
meal. Trying to have a bowel movement at these times can help promote defecation
as it is consistent with the body’s natural physiologic response

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18
Q

Pharmacological options

A 
Bulk-forming agents
Osmotic agents
Stool softener/emollients
Lubricant
Stimulant
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19
Q

Bulk-forming agents

A

Methylcellulose
Polycarbophil
Psyllium

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20
Q

Bulk-forming agents MOA

A

increases the mass of stool which causes distension and activates enteric reflexes. This increases GI motility and decreases the amount of time it takes the stool to travel down the colon

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21
Q

Bulk-forming agents PK

A

Onset: constipation relief can be seen 12-72 hours

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22
Q

Bulk-forming agents Adverse

A

abdominal cramping, gas, possible intestinal obstruction

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23
Q

Bulk-forming agents

Do not use:

A

Do not use:

  • if enteric reflexes are not functional
  • if the cause of constipation is unknown
  • patients with intestinal ulcerations, stenosis, or disabling adhesions
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24
Q

WHEN TO SUGGEST USING A BULK FORMING AGENT

A

Use for short term therapy in the follow situations:
¡ Patients on low-fiber diets
¡ Postpartum period
¡ Geriatric patients
¡ Prophylactically in patients who should avoid straining during a bowel movement

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25
Q

Methylcellulose Dose and Dosing

A

500mg Caplet

1-2 caplets up to 6 times daily

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26
Q

Methylcellulose Comments

A

Not recommended in
children < 6 except under
PCP

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27
Q

Calcium Polycarbophil Dose and Dosing

A

625mg caplet

1-2 caplets up to 4 times daily

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28
Q

Calcium Polycarbophil comments

A

Not recommended in
children < 6 except under
PCP

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29
Q

Psyllium Dose and Dosing

A

Powder 3.4g/scoop or
package

1 package or scoop in
8oz of liquid( full glass of water) up to 3 times
daily

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30
Q

Psyllium Comments

A

Not recommended in
children < 12 except under
PCP

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31
Q

Osmotic agents

A
  1. Polyethylene glycol (PEG)
  2. Magnesium hydroxide
  3. Glycerin suppository
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32
Q

Osmotic Agents MOA

A 
non-absorbable salts that
draw water into the small and
large intestine (oral products) or colon (rectal products) though osmosis to stimulate bowel movement
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33
Q

Osmotic Agents- PEG

Onset

A

Onset: 12-72 hours

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34
Q

Osmotic Agents- PEG

Use

A
  • short term constipation

- Use with caution in patients with renal impairment, use for ages 17+ only

35
Q

Osmotic Agents- PEG

Adverse effects

A

electrolyte imbalances and flatulence

36
Q

Osmotic Agents Dose and directions of use

A

mix 17-gram packet in 8 oz of liquid once daily

37
Q

Magnesium Hydroxide Onset

A

30 mins to 5 hours

38
Q

Magnesium Hydroxide Dose

A

400mg/5mL: 30-60 mL

its a suspension

39
Q

Magnesium Hydroxide Use

A

short term laxative also used as an antacid

40
Q

Magnesium Hydroxide Cautions

A
  • Use with caution in patients with renal impairment
  • not recommended < 2
    years of age
41
Q

Magnesium Hydroxide Adverse effects

A

bloating, abdominal discomfort, cramping, and flatulence

42
Q

Magnesium Hydroxide FYI

A

prevents the absorption of some antibiotics (specifically tetracyclines) must be spaced appropriately

43
Q

Stool softener agents

A

Docusate

44
Q

Stool softener agents MOA

A

softens fecal mass by incorporation of water and fat to allow easy passage

45
Q

Stool softener agents Onset

A

12-72 hours

46
Q

Stool softener agents Drug Interactions

A

Mineral oil

  • Do not used in combination with mineral oil because it leads to the absorption of mineral oil
  • can lead to toxicity, hepatic and mesenteric lymphoid tissues
47
Q

Stool softener agents Adverse effects

A

Generally well tolerated

48
Q

When to use a stool softener agent

A
  • Prophylaxis to prevent straining
  • Prophylaxis to prevent painful defecation or when stool is hard
  • Used in combination with stimulant laxatives for opioid induced constipation* (referral to PCP)
49
Q

Difference between Docusate sodium and Docusate calcium

A
  • Clinically there is no difference as far as efficacy but Docusate sodium is cheaper and more frequently used and available
  • Docusate sodium has multiple dosage forms
50
Q

Docusate sodium Dose and Dosing

A

Capsules 50mg ; 100mg

50-300mg daily in single
or divided doses typically twice daily

51
Q

Docusate sodium

A

Dose of 50-150mg
capsules daily can be
used in children 2-12

52
Q

Lubricating agents

A

Mineral Oil

53
Q

Lubricating agents MOA

A

Softens fecal contents by coating stool and preventing colonic absorption of
fecal water and lubricates the intestine

54
Q

Lubricating agents Onset

A

6-8 hours (oral)

2-15 minutes (rectal)

55
Q

Lubricating agents Exclusions to self-care

A

Do not use:

  • in children less than 6 years old
  • pregnant women
  • immobile adults
  • patients with difficulty swallowing
56
Q

Lubricating agents Warnings/Precautions

A

Risk of lipid pneumonia due to aspiration into the lungs.

To avoid this, advise the patient not to lay down after taking this medication for 30 minutes to an hour

57
Q

Lubricating agents Drug interactions

A

Vitamins A, D, E and K
- Impairs the absorption of fat soluble vitamins

  • Also docusate
58
Q

WHEN TO SUGGEST USING LUBRICANT AGENT

A

Not typically recommended as first line therapy (unless recommended by PCP) as there are better alternatives for constipation available over the counter

59
Q

Mineral Oil Formulation

A

Liquid (Oral formulation)

60
Q

Mineral Oil Adult dosing

A

1-3 tbsp (15-45 mL)

MDD: 3 tbsp (45 mL)

61
Q

Mineral Oil CHildren 6-12 dosing

A

1-3 tsps (5-15mL)

MDD: 3 tsps (15mL)

62
Q

Mineral Oil Children 2-6 dosing

A

Not recommended for children under 6 except under advice of PCP

63
Q

Stimulating Agents

A

Senna

Bisacodyl

64
Q

Stimulating Agents-Senna MOA

A

works in the colon to increase intestinal motility and increase the
secretion of water and electrolytes in the intestine

65
Q

Stimulating Agents-Senna

Onset

A

6-10 hours

66
Q

Stimulating Agents-Senna

Adverse Effects

A
  • can cause discoloration of urine (pink/red/violet/brown)
  • abdominal
    cramps
  • diarrhea
  • nausea
  • vomiting
67
Q

Stimulating Agents- Bisacodyl MOA

A

works directly on the smooth muscle in the colon to increase intestinal
motility and increase the secretion of water and electrolytes in the intestine

68
Q

Stimulating Agents- Bisacodyl Onset

A

6-10 hours (oral)

15-60 minutes (rectal)

69
Q

Stimulating Agents-Bisacodyl Adverse effects

A

abdominal cramps

atonic/Lazy colon (colonstasis) -( w prolonged use)-when there is a lack of normal muscle tone or strength in the colon

vertigo (sensation that everything around you is moving or spinning)

70
Q

Stimulating Agents-Bisacodyl

Patient Education

A
  • Do not crush break or chew
  • Space out from medications that increase gastric pH (H2RA blockers, PPIs,
    etc. )
71
Q

When to suggest using stimulating agents

A
  1. Prophylaxis to prevent straining

2. Prophylaxis to prevent painful defecation or when stool is hard

72
Q

Senna dose and dosing- Adults

A

Tablets: 8.6 mg sennosides

Starting dose: 2 tablets once daily
MDD: 4 tablets twice daily

73
Q

Bisacodyl Oral Dose and dosing- Adults

A

Tablets: 5 mg
Dosing: 1-3 tablets(usually 2) once daily

74
Q

Bisacodyl Rectal Dose and dosing- Adults

A

Rectal solid suppository: 10 mg

1 suppository in a single daily dose

75
Q

Patient Education for Bisacodyl

A

Avoid using Bisacodyl suppository frequently because it can make the colon lazy and the muscle tone to help push it out is going to be lost

76
Q

Drug-Drug Interactions

A

Docusate salts-Mineral Oil

Magnesium hydroxide - Tetracylcine antibiotics: Wait at least 1 hour before administration

Bisacodyl-Drugs that raise gastric pH (ex. PPIs)

77
Q

Exclusions to Self-Care

A
  • Marked abdominal pain pr significant distention or cramping
  • Marked or unexplained flatulence
  • Fever
  • Nausea/Vomiting
  • Paraplegia or Quadriplegia
  • Daily laxative use
  • Unexplained changes in bowel habits, if accompanied by weight loss
  • Blood in stool, or dark or tarry stool
  • Any bowel symptoms that persist for 2 weeks or recur over period of at least 3 mths
  • Any symptoms that recur after dietary/lifestyle changes, or laxative use
  • History of IBD
  • Anorexia
78
Q

Clinical presentation: CHildren

A
  • Defined as difficulty or delay in having a bowel movement over a period of 2
    weeks+
  • Caused by many different factors such as emotional distress, febrile(symptoms of fever), chronic
    medical conditions, family conflict, diet changes, etc.
  • Mild constipation is usually relieved with diet or behavioral changes alone
79
Q

SPecial Ops- Children

A
  • 2-6 years old: oral docusate, magnesium hydroxide, senna; rectal glycerin, or
    sodium phosphate products
  • 6-12 years old: methylcellulose, docusate, mineral oil, magnesium hydroxide,
    senna, bisacodyl or castor oil; rectal glycerin, or sodium phosphate products
  • PEG is not approved for children <17 years of age
80
Q

SPECIAL POPULATIONS: OLDER ADULTS

A
  • At greater risk of constipation due to age related dietary changes such as reduced fiber and fluid intake, decreased physical activity, polypharmacy and
    presence of comorbidities
  • Preform a medication history and recommend lifestyle changes first
  • First line: bulk forming agents or PEG (for faster onset)
81
Q

For older adults Patient Education

A
  • Stool softeners are helpful in older adults with annal fissures or hemorrhoids
    ¡ Avoid: mineral oil due to risk of aspiration and use osmotic agents with
    caution due to risk of fluid and electrolyte depletion and drug drug
    interactions
82
Q

SPECIAL POPULATIONS: PREGNANCY

A

Effects up to 1/3 of pregnant women during and post pregnancy
-Due to compression of the colon, increased progesterone levels, low fluid/fiber intake
and constipating effects of iron and calcium in prenatal vitamins
- Recommend lifestyle changes first
- First line: bulk forming agents, stimulating agents, docusate, PEG
- Avoid lubricating agents like mineral and castor oil

83
Q

FYI abt mineral oil

A

castor oil has been associated with uterine contraction and rupture, DO NOT USE and mineral oil may be associated with decreased maternal absorption of fat soluble vitamins which may cause adverse maternal and neonatal effects

PHRM 504 (22 decks)

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