Lecture 9 - Diarrhea, constipation, IBS Flashcards
Constipation definition
Less than 3-5 bowel movements/week or > 3 days with no bowel movement
hard or lumpy stool
straining, incomplete pooping
Non-pharm tx for constipation
increase fiber intake to 20-35g/day..fruits/veggies/grains
maintain adequate fluid intake
exercise
correct underlying disease
Agents that cause softening of feces in 1-3 days
Bulk forming agents + osmotic agents:
Methylcellulose**, Polycarbophil, psyllium, polyethylene 3350
Emollients:
Docusate, Lactulose, Sorbitol
Agents that result in soft or semifluid stool in 6-12hrs
Bisacodyl
Senna
Magnesium sulfate = low dose
Agents that cause watery evacuation in 1-6hrs
used for extreme constipation, bowel prep. draw electrolytes into colon lumen..water follows…
Mag citrate Mag hydroxide (milk of magnesia) Mag sulfate = high dose Sodium phosphates Bisacodyl Gavilyte= polyethylene glycol electrolyte prep
Lubiprostone (Amitiza) MOA
activates chloride channels in GI tract to increase intestinal fluid secretions
Lubiprostone (Amitiza) ADE + usages
Diarrhea
nausea
used for chronic constipation
IBS w/ constipation in females > 18yrs old
Linaclotide (Linzess) ADE + indications
Diarrhea
Abdominal pain
chronic constipation
Linaclotide taken on full or empty stomach?
empty stomach
Plecanatide (trulance) ADE + uses
diarrhea way less
some other like URI, farting, AST/ALT elev, sinusitis
Used for chronic constipation
Prucalopride (Motegrity) MOA
5-HT4 receptor agonist…stimulates peristalsis, increases colonic motility
Prucalopride (Motegrity) ADE
Most common: HA/N/D/abdominal pain
Less common: warning/precaution suicidal behavior
Prucalopride (Motegrity) Indications
chronic constipation
Prucalopride Dosing
w/ or w/o food
2mg/day, dose adjust for renal
Managing opioid induced constipation (> 4 wks)
Osmotic or stimulant laxative
Lubiprostone or opioid receptor antagonist
Managing acute constipation (< 3-6months)
add osmotic laxative if no relief trial 2-4weeks
Add stimulate laxative if no BM in 2 days or no relief
Managing chronic constipation ( > 6 months)
Trial of intestinal secretagogue
Acute Diarrhea
less than 14 days
Persistent Diarrhea
More than 14 days
Chronic Diarrhea
over 30 days
causes of Diarrhea
Bacteria
Viruses
Parasites
Medications - abx, laxatives, antacids, colchicine
Self-care exclusion criteria
Signs of systemic illness = fever, chills, anorexia
Signs of moderate/severe dehydration
chronic diarrhea
Diarrhea w/ blood or mucus in stool
non-pharm diarrhea treatment
Typically self limiting
water and electrolytes
bland diet as diarrhea decreases
Absorbants MOA
non-specific, absorbs nutrients/toxins/drugs and digestive juices
Well-tolerated
Questionable efficacy
1st line diarrhea
Peptobismol or Bismut subsalicylate
precaution: interaction w/ anticoagulants, salicylic, reye syndrome
ADE: darkening of stool + tongue
Loperamide (Anti-peristalsis agent) info (Immodium)
indicated: diarrhea + travelers Diarrhea
Well tolerated
Precaution: Beers Criteria, Dementia, Cognitive impairment.
Loperamide OTC dosing
4mg then 2 mg after each loose stool
max: 16mg per day
Probiotics info
MOA: replace colonic microflora, restores normal function
Dosage depend on formulation
Monitoring and follow-up for diarrhea
typically resolves in < 72hrs
full resolution of symptoms in 3-7 days
Medical referral is appropriate for signs and symptoms that are persistent or worsen
IBS characterized by….
Chronic abdominal pain
Abdominal bloating/distension
Change in bowel habits = constipation, diarrhea, mixed features
Potential IBS Risk factors
Gastroenteritis Psychosocial Factors Genetics Fibromyalgia, migraine Asthma
Signs and Symptoms of IBS
Abdominal pain
Changes in bowel movements
Upper GI symptoms
Abdominal Distension
ALARM symptoms IBS
FEver GI/rectal bleeding Anemia Family history of IBD onset after age 50 unexplained weightloss Pain that is progressive/ sleep preventive Unrelenting diarrhea
IBS-C
IBS w/ predominant constipation
IBS-D
IBS w. predominant diarrhea
IBS-M
IBS with mixed bowel habits
IBS-U
IBS with unclassified bowel habits
Rome IV Diagnostic Criteria
Recurrent abdominal pain, atleast 1 day per week in the last 3 months associated with 2 or more of the following….
- Related to defecation
- Associated w/ a change in stool frequency
- Associated w/ change in stool form/appearance
must be fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis
Goals of IBS treatment
improve specific symptoms
improve quality of life
prevent complications
non-pharm tx of IBS
1st line = Diet and Modification
FODAMP diet
exercise
for IBS-C use….
Bulk forming agents Osmotic Laxatives Plecanatide Lubiprostone = strong recommendation Linaclotide Tenapanor Tegaserod
Tenapanor (Ibsrela) MOA
acts locally = poor GI absorption
Inhibits Na-H exchanger
reduces Na absorption, increase lumen water secretion
Tenapanor (Ibsrela) ADE + dosing
diarrhea - 15/16%
Severe in 2.5%
take immediate before breakfast and dinner
Tegaserod (Zelnorm) MOA
5-HT4 receptor partial agonist the inc peristalsis and intestinal secretion
Tegaserod (Zelnorm) ADE
HA
Diarrhea
Chest pain, Heart attack and stroke*****
Tegaserod (Zelnorm) dosing
Females only…before meals for 4-6weeks
ppl < 65 females without history of MI, CVA, TIA or angina
IBS-D drugs
Eluxadoline (Viberzi)
Rifaximin (Xifaxan)** recommended for pretreatment
Alosetron (Lotronex)
Eluxadoline (Viberzi) MOA
Mixed Mu and Kappa opioid receptor agonist, delta-opioid receptor antagonist
Locally reduces abdominal pain and diarrhea
Eluxadoline (Viberzi) ADE
Constipation
Abdominal pain
Pancreatitis = rare
Eluxadoline (Viberzi) doses
D/c if constipation persist > 4 days
Rifaximin dosing
14 days, retreat up to 2 times
Alosetrone (Lotronex) info
approved w/ severe diarrhea in females refractory to conventional therapy.
only available through MD Lotronex Prescribing program
Peppermint Oil
For global IBS symptoms
limited commercial preparations
generally well tolerated
Gut-directed psychotherapies
CBT
CDH
targets accompanying depression, anxiety, chronic pain
Probiotics for IBS
not recommended by AGA, low lvl of evidence supporting
Antiplasmatics…
thought to be somewhat beneficial
IBS-C treatment algo
- osmotic laxatives = constipation
- antispasmodics = abdominal pain
- Secretagogues = 2nd line, Tegaserod = 3rd line
- add low dose TCA, SNRI, CBT if no response
IBS-D treatment algo
- Loperamide = diarrhea
- antispasmodics = abdominal pain
- Rifaximin = 2nd line, Alosetron = 3rd line
- add low dose TCA, SNRI, CBT if no response
