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PHARM 345 GI/NUTRITION > Lecture 4 And 5 Constipation > Flashcards

Lecture 4 And 5 Constipation Flashcards

1
Q

Incidence of constipation in female > male (__ fold)

A

2.5

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2
Q

Definition of constipation

A

Unsatisfactory defacation - infrequent stools, difficulty passing stools or both

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3
Q

Diagnostic criteria for chronic constipation

A

Prescence of greater than or equal to 2 of the following for last 3 months

  • straining
  • lumpy hard stool
    -incomplete evacuation
  • sensation of anorectal obstruction
    -manual help to defacation
  • <3 spontaneous bowel movement per week
  • loose stools not present
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4
Q

Causes of constipation

A

No identifiable underlying cause

Bloating or straining, difficulty with defecation, linked with bad diet

3 types:

Normal transit constipation
Days-synergic
Slow transit constipation

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5
Q

Drugs commonly associated with constipation

A

OTC: calcium supplements, antacids, aluminum containing iron supplements, antihistamines, anti diarrheal agents, Dimenhydrinate

Rx medication: opioids, anticholinergic, CCB, tricyclic antidepressants, diuretics, antispasmodics, antipsychotics, antiseizure meds

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6
Q

Complications of constipation

A

Hemorrhoids
Fissures
Fecal impaction
Megacolon
Malnutrition
Rare : pelvi organ prolapse in women
Very rare - intestinal perforation

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7
Q

Red flags for constipation

A

GI bleeding
Unexplained iron deficiency anemia
Unintentional weight loss
Palpable abdominal mass
Family hx
Sudden acute onset
Symptom onset >50 yrs of age
Abdominal pain

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8
Q

Non pharmacological treatment approaches to constipation (diet)

A
  • High fibre diet ( 28-38gm per day). Ex. Lentils, chickpeas, kidney beans, prunes, plumes, raspberries
  • fluid intake 2-3L
  • fruit in diet

High sorbitol foods - Priunes, prune juice

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9
Q

Non pharmacological treatment approaches to constipation (lifestyle)

A

Regular excercise

Regular scheduled time for toilet use

Avoid suppressing urge to defecate

Weight loss

Increase calories if on low cal diet

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10
Q

Four general classes of Laxatives sold as OTC

A

Bulk forming laxatives

Osmotic laxatives

Stimulant laxatives

Emollient/stool softener

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11
Q

Bulk forming laxatives

A

Soluble / insoluble fibers

Preferred : Psyllium ( eg. Metamucil) - natural fiber from husks of plant seeds, another name is isaghula

Alternates: calcium polycarbophil (fibrecon), methyl cellulose (citrucel)

Others: all natural

Guar gum
Sterculia gum
Inulin

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12
Q

Bulk forming laxatives

MOA
Onset
Adverse affects
Drug interaction

A

MOA: increase stool weight and constituency, decreases GI transit time

Onset : 12-72 hours ( usually 1-3 days)

** Often first line treatment except constipation from poor GI motility or opioids **

Adverse affects: bloating, flatulence, diarrhea

Drug interactions: avoid use within 2 hours of administration of medication

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13
Q

What are the types of osmotic laxatives and their MOA

A

MOA : poorly absorbed solutes or ions act by exerting an osmotic gradient and retain water in lumen

Types: saline laxatives, hyperosmotic

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14
Q

Osmotic laxatives : Saline

Onset

Caution

A

0.5-3hrs

Caution: in chronic constipation due to risk of electrolyte disturbances, avoid in renal impairment (can cause Hypermagnesemia)

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15
Q

Osmotic laxatives : Hyperosmotic ( glycerin suppository)

Onset
Adverse effects
Use in children
Instructions

A

Quick (15-30 mins)

Well tolerated but can cause local irritant effect

2-6 yrs - 1 supp daily prn
<2 yr- limited data, use 1 ever 3 days prn

Moisten in lukewarm water, then insert and retain for about 15 mins if possible

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16
Q

Osmotic laxatives: Hyperosmotic (PEG)

Onset
Adverse effects
Drug interactions
Dose

A

48-96 hours

Adverse effects: bloating, flatulence, diarrhea

Avoid use within 2 hours of administration

Dose: add 17g powder to 250ml water, juice, coffee or tea and stir until dissolved

Use in acute or chronic constipation

17
Q

PEG + electrolyte solution

A

Colyte, golytely

Complete bowel evacuation before surgery or diagnostic procedures or for refractory constipation

LARGE volume

18
Q

Osmotic laxatives : Hyperosmotic (Lactulose)

Onset

Acute or chronic

Adverse effects

A

Non absorbable disaccharide (fructose, galactose)

Onset: 24-48 hours

Acute or chronic

Adverse effects: flatulence, bloating, nausea, diarrhea

19
Q

Lactulose downsides and drug interactions

A

Downsides: sweet taste, can be masked by diluting in water, juice, or milk, less effective than PEG 3350

Drug interactions: avoid use within 2 hours of administration

20
Q

Stimulant Laxatives ( Anthranoid laxatives)

A

Sennosides ( anthraquinones, ie senokot, ex-lax)
Cascara
Onset 8-10ths

Bisacodyl.diphenylmethane (Dulcolax)
Oral 6-8h, supp 0.5-1hr
Large interpatient variability with dose

21
Q

Stimulant laxatives adverse effects

A

Abdominal cramps, diarrhea ; others: hypokalemia ; suppositories irritation

Senna discolour urine

Bisacodyl oral are enteric coated - caution with use of PPI or H2blockers

Usually short term

22
Q

Emollient/ stool softeners (docusate)

Onset
Effectiveness

A

12-72 hours

Not been found effective for constipation

23
Q

Enemas

A

Stretches colon to produce urge to defecate

Faster onset

Examples:
- mineral oil retention enemas
- phosphate enemas
- Tap water enemas

24
Q

Administering enema

A

Lubricate nozzle
Lie on left side with knees bent
Insert nozzle in rectum
Gently squeeze container
Retain the solution until cramping is felt

25
Q

Mu receptor antagonists

Medication
Use
Onset
Adverse effects

A

Methyl naltrexone bromide (relistor)
Naloxegol (Movantik)

Use for opioid induced constipation

Averse effects: diarrhea, abdominal pain, flatulence, nausea, dizziness, hyperhidrosis

Typical second line. Discountinue other laxatives when initiating

26
Q

Prucalopride (Restoran)

Dose
Acts within ….
Use
Adverse effects

A

2mg daily

Acts within 2-3 hours

Indicated for female patients with severe constipation who have not responded to other laxatives

Adverse effects : nausea, diarrhea, cramping

27
Q

What is the indication for Linaclotide ( Constella)

A

RX

Indication: chronic idiopathic constipation and IBS with constipation

28
Q

Therapeutic approach to acute constipation

A

Mild : Bulk forming laxatives

Moderate to severe or wants rapid response: glycerin or Bisacodyl supp, magnesium hydroxide/citrate, stimulant laxatives

If rapid not required : PEG or Lactulose can be considered

29
Q

Agents with an onset of action of 15-60 minutes

A

Glycerin supp
Bisacodyl supp
Enemas

30
Q

Onset of action of 0.5-3 hrs

A

Saline laxatives (Magnesium products)

31
Q

Onset of action 6-12 hours

A

Stimulant laxatives ( senna, Bisacodyl oral)

32
Q

Onset of action 1-4 days

A

Bulk forming laxatives ( 12-72hr)
Emollient/ stool softeners ( 12-72hrs)
Lactulose ( 24-48hr)
PEG 3350( 48-96hr)

33
Q

Opioid induced constipation (palliative care patients)

A

Consider regular laxative use if on chronic opioids

Avoid bulk forming laxatives - impaction

Methylnatrxone or naloxegol - if constipation is severe and not responded to other laxatives

34
Q

Constipation in elderly

First line
Options
Avoid ….

A

First line : fluid and fibre

Options ; PEG, Lactulose - evidence to support elderly

Consider glycerin supp for quick action

Avoid magnesium laxatives if renal impairment

35
Q

Constipation in pediatrics

First line Options
Avoid….
Second line

A

Glycerin supp, PEG, Lactulose
Avoid mineral oil, stimulants and enemas
Magnesium laxatives

36
Q

Constipation in pregnancy

First line
Not recommended

A

Fiber - diet or bulk forming laxatives considered first line
Magnesium laxatives

Glycerin or Bisacodyl for quick action Avoid

PEG and Lactulose are option if fiber not effective

Linaclotide and prucalopride not recommended during pregnancy

37
Q

LOOK AT CHART ON PAGE 60

A

PHARM 345 GI/NUTRITION (7 decks)

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