Constipation

1. Constipation Prepared by: Alison Deux, 4th year pharmacy student

3. Constipation affects more than 4.5 million Canadians! Constipation affects twice as many women as men Toilet Troubles

4. Constipation is generally defined as infrequent and/or unsatisfactory defecation fewer than 3 times per week. • Patients may define constipation as passing hard stools or straining, incomplete or painful defecation. • Constipation is a symptom, NOT a disease. • Constipation has many causes and may be a sign of undiagnosed disease. What is constipation?

5. The following factors can increase a person’s likelihood of becoming constipated; however, these do not need to be present for constipation to occur: • Female gender • Over 65 years of age • Low caloric intake (eating less food) • Greater number of medications used • Sedentary lifestyle (lack of exercise) • Ignoring the urge to defecate Risk factors for constipation

6. Diet Lack of exercise Age Nerves, stress Ignoring the urge Drug induced – pain medications, iron, calcium, blood pressure medications, etc Disease States/Conditions – Multiple Sclerosis, hypothyroidism, hemorrhoids, Parkinson’s, senility, Irritable Bowel Syndrome, pregnancy, diabetic neuropathy, etc. Causes of constipation

7. Infrequent defecation • Nausea • Vomiting • Anorexia • Feeling full quickly • Stools that are small, hard, and/or difficult to evacuate • Rectal bleeding • Weight loss (in chronic constipation) Signs and symptoms of constipation

8. When should I contact a health care provider? • Constipation for more than 2 weeks (or has not had a bowel movement for more than 7 days) despite use of laxatives; particularly in elderly and in those with chronic medical conditions such as diabetes or parkinson’sdisease • If medication is suspected to be the cause of constipation • Blood or mucus in stool or rectal bleeding, fever • Symptoms suggestive of anemia such as tiredness or lethargy • Family history of colon cancer (particularly if patient is >50 years old) • Persistent abdominal pain • Vomiting • Severe pain upon defecation • Diarrheaalternating with constipation • Recent abdominal surgery • Eating disorders • Moderate to extreme thirst • Unexplained weight loss of greater than 5% • Chronic illness associated with constipation • Rectal or abdominal mass

9. High fibre diet • Minimum fluid consumption of 1500mL daily • Regular, private toilet routine • Heed the urge to defecate • Use of a laxative if using constipating medication or in presence of diseases associated with constipation Prevention of constipation

10. Two approaches to consider: • Non-drug Approach • Drug Approach I’m constipated, now what?

11. Non-Drug Measures: • Increase calories in low calorie diets • Have a regular bowel regimen: patients should attempt to have a bowel movement at the same time each day especially after breakfast since colonic activity is highest at that time. Patients should not repress the urge to defecate or spend prolonged periods of time at the toilet. Placing a footstool in front of the toilet helps elevate the thighs, thus placing the pelvis in the optimum position for defecation. • Consume a high fibre diet: the target is 25-28g of fibre daily • Eat more fruits: apples, pears, and prunes contain the natural laxative sorbitol • Exercise: inactivity is associated with constipation • Weight loss: want BMI to be between 18.5-24.9 I’m constipated, now what?

12. Drug Measures: • There are many different types of drugs that can be used for constipation: • Bulk-forming Agents • Emollients/Stool Softeners • Osmotics • Hyper-osmotics • Stimulants I’m constipated, now what?

13. Bulk-Forming Agents: • Examples: Metamucil, Benefiber, FiberSure • Are considered the safest agents and are suitable for long-term use • Each dose of a bulk-forming laxative should be administered with a full glass of water or juice • Do not use if patient is dehydrated or fluid restricted • Are the drug of choice for prevention; not for immediate relief I’m constipated, now what?

14. Emollients/Stool Softeners • Example: Docusate • Used for prevention; not for immediate relief • Used very often but lack of data showing it actually works • Company says that this product “makes it easier to go” I’m constipated, now what?

15. Osmotics: • Examples: Milk of Magnesia • Limitations for use of this group of laxatives include frequent diarrhea, and multiple electrolyte abnormalities. • Should be administered with sufficient water to prevent dehydration. • Not used very often I’m constipated, now what?

16. Hyper-Osmotics: • Examples: Glycerin Suppositories, Lactulose Syrup, Lax-a-Day (PEG 3350) • PEG produces the loosest stool and overall greatest efficacy compared to other members in this class. It may have benefit in patients unresponsive to other treatments. Daily use of PEG is safe and does not have significant side effects and may facilitate the discontinuation of other laxatives. May take 2-4 days to see an effect. This is the drug of choice in almost all situations! • Lactulose is very safe to use long term. May see increase in gas and bloating compared to other options. Takes 1-2 days to work. • Glycerin suppositories have a quicker onset of action (usually 30-60 minutes). They are less effective if the stool is dry and hard. I’m constipated, now what?

17. Stimulants: • Examples: Senokot, Dulcolax (bisacodyl) • This group produces rhythmic muscle contractions in the intestines and may be recommended if osmotic laxatives fail or are not tolerated. • Are usually given at bedtime and they usually provide overnight relief (work within 8-12 hours). I’m constipated, now what?

18. Treatment is often complicated by chronic conditions, multiple drug use, and cognitive impairment. • Management should be tailored to each individuals needs and expectations regardless of age or place of residence. • The patients functional abilities related to mobility, following instructions, communicating needs, eating, drinking, and cognitive status must be assessed. • Fluid intake should target 1500-2000mL daily unless fluid restrictions are imposed as in those with heart failure. • Dietary fibre should be targeted at 25-30g daily. • Exercise to patients capacity. • Drug review is essential to rule out drug induced constipation. • Renal impairment must be monitored prior to using laxatives. • Don’t use laxatives for more than a week unless the doctor says it is ok. • Safest laxative to use is a bulk forming agent such as Metamucil. Special Considerations in the elderly

19. Many nursing homes have “bowel programs” for their residents. These include exercise, increasing the amount of fibre in the meals, and bowel retraining. • Oral agents are commonly used: • Senokot is common for quicker relief • Lax-a-Day or Metamucil very common for prevention • Lactulose is very useful for people who are bedridden Special Considerations in nursing home residents

21. Constipation is very common in the elderly and nursing home residents. There are many causes of constipation; it should be considered a symptom, not a disease. There are many options for prevention and treatment. The choice should be tailored to each individual person. Talk to your health care provider if you have any concerns or if constipation lasts for longer than one week. Summary

22. Thank-you