Professional Documents
Culture Documents
Constipation
CAPP IV: PYDI 5320
April 17, 2015
Objectives
In lab, P2 students should be able to do the following
without error:
Using QuEST/SCHOLAR-MAC techniques, eff ectively and
effi ciently interview a patient presenting with a diarrhea or
constipation complaint
Appropriately refer patients to a physician for follow-up care
based on patient-specifi c exclusions for self-care treatment of
diarrhea or constipation
Following the patient interview and assessment, select the
most appropriate product based on the patients specifi c
symptoms and treatment goals.
CONSTIPATION
What is Constipation?
Rome III Functional Constipation Criteria:
Two or more of the following symptoms for more than
25% of defecations in the past 3 months (with
symptom onset at least 6 months prior to diagnosis):
Straining
Lumpy or hard stools
Sensation of incomplete evacuation
Sensation of anorectal obstruction/blockage
Manual maneuvers to facilitate defecations
Less than 3 defecations per week
Causes of Constipation
Lifestyle/Extrinsic
Factors
Low fi ber intake
Sedentary lifestyle
Low fl uid intake
Ignoring urge to
defecate
Structural issues
Colorectal injury, bowel
obstruction, etc.
Systemic issues
What are some
examples?
Neurologic issues
Autonomic neuropathy
MS
Parkinsons
Stroke
Dementia
Psychological issues
Depression
Eating disorders
Stress
MEDICATIONS
Clonidine
Diuretics
MAOIs
Muscle relaxants
OPIATES
Parkinsonism agents
Sedative hypnotics
Sucralfate
AND MORE
(see chapter for more
examples)
Onset
Location
Aggravating factors
Relieving/Remitting
factors
Medications
Allergies
Constipation - Question
S Symptoms:
What symptoms are you having?
Ask about/recognize alarm symptoms
Blood/mucous/pus in stool
Nausea/vomiting
Fever
Pencil-thin stools
Irritable bowel disease
Severe abdominal pain
C Characteristics:
What types of bowel movements are you having?
How often are your BMs?
Describe your stool (hard and small, etc. ?)
Constipation - Question
H History:
Have you experienced these symptoms in the past?
How have you treated these symptoms in the past?
What treatments were eff ective in the past?
O Onset:
When did your symptoms start?
How long as it been since your last BM?
L Location:
Probably unnecessary to ask in this case
A Aggravating Factors:
What makes your symptoms worse?
Constipation - Question
R Relieving Factors:
What makes your symptoms better?
M Medications:
What medications are you taking?
OTC AND RX
A Allergies:
Do you have any drug allergies?
Agents
Methylcellulose (Citrucel)
Calcium polycarbophil (FiberCon, Fiber-Lax)
Psyllium (Metamucil)
Polyethylene glycol (MiraLax, GlycoLax)
Glycerin
Emollient agent
Lubricant agent
Stimulant agents
Combination
Bulk-Forming Agents
MOA: Increases bulk of stool in order to stimulate GI
motility; stimulates action that mimics normal
physiology
Not recommended for:
Patients with diffi culty swallowing
Patients requiring fl uid restriction
Patients who are immobile
Counseling Points:
Good choice if no immediate action is needed
Take with adequate fl uid (at least 8 oz per dose)
Bulk-Forming Agents
Agent
Methylcellulose
Calcium
polycarbophil
Dosage Form
Adult Dosage
Caplet 500 mg
2 caplets PO up
to 6 times daily
Powder 2
mg/tablespoon
1 rounded
tablespoonful
PO up to TID
(Mixed in liquid)
Caplet 625 mg
2 caplets PO
daily up to QID
Capsule 520mg
Psyllium
Powder 3.4 g
per scoop or
packet
5 capsules PO
up to TID (Take
with 8 oz of
liquid)
1 rounded
tablespoonful
PO up to TID
Onset of
Action
12 to 24 hours
Up to 72 hours
Hyperosmotic Agents
MOA: Draws water into the colon/rectum; stimulates
bowel movement
Not recommended for:
Patients with intestinal obstruction
Counseling Points:
Polyethylene Glycol
Glycerin Suppository
Proper suppository administration (see counseling slide)
Hyperosmotic Agents
Agent
Dosage Form
Adult Dosage
Onset of
Action
Polyethylene
glycol
Powder
17g/capful
17 grams mixed
into 4 to 8 oz
liquid daily
12 to 72 hours
Up to 96 hours
1 suppository
15 to 30 minutes
Rectal solid
suppository 2
gram
Glycerin
Rectal liquid
suppository 5.6
gram/5.5 mL
Emollient Agents
MOA: Increases wetting effi cacy of intestinal fl uid;
allows for improved interaction between water and
stool (stool softener )
Recommended for:
Patients who should refrain from straining post-surgery,
post-heart attack
Primary role in therapy Prevention
Counseling points:
Do NOT use with mineral oil
WHY?
Emollient Agents
Agent
Docusate
sodium
Docusate
calcium
Dosage Form
Adult Dosage
Capsules 50 mg
and 100 mg
50 to 300 mg PO
daily in single or
divided doses
Syrup 60
mg/15mL
1 to 6
tablespoonsful
daily in single or
divided doses
Capsule 250 mg
1 capsule PO
daily for several
days or until
BMs normalize
Onset of
Action
48 to 72 hours
Lubricating Agents
MOA: Coats fecal matter/decreases intestinal
absorption of water, softens/lubricates to ease
passage of stool
Recommended for:
No one
Avoid recommending General safety concerns
Counseling points:
Do not use with docusate; may increase absorption of
mineral oil
Take on an empty stomach
Lubricating Agent
Agent
Dosage Form
Adult Dosage
Onset of
Action
1 to 3
tablespoonsful
Oral liquid
Mineral oil
Max:
3 tablespoonsful
in 24 hours
Oral liquid
emulsion (2.5
mL/5 mL)
6-15
tablespoonsful
per day
Rectal liquid
enema (118 mL)
1 bottle as
directed
6 to 8 hours
5 to 15 minutes
Recommended for:
Patients looking for quick relief
Electrolyte imbalances
Diarrhea
Dehydration Take with 8 ounces of fl uid to avoid this
Abdominal cramping
Nausea/vomiting
Agent
Dosage Form
Adult Dosage
Onset of
Action
Magnesium
citrate
Liquid 10 oz
to 1 bottle
to 3 hours
Mono-/dibasic
sodium
phosphate
Rectal liquid
enema 118 ml
1 bottle
2 to 15 minutes
Chewable tablet
311 mg/tablet
2 to 4
tablespoonsful
daily in single or
divided doses
8 tabs in a single
dose or in
divided doses
per 24 hours
to 6 hours
Stimulant Agents
MOA: Increases intestinal motility by irritating the local
mucosa; increases secretions of water/electrolytes into
the intestines
Recommended for:
Patients using opioid therapy (used with or without docusate)
Counseling points:
Do not take bisacodyl within 1 hour of milk, milk products,
antacids or H2-blockers (cimetidine, famotidine, ranitidine,
etc.)
Do not crush or chew bisacodyl
Not for long term use (>7 days) unless clinically indicated
Severe cramping
Electrolyte and fl uid defi ciencies
Enteric loss of protein, malabsorption
Hypokalemia
Stimulant Agents
Agent
Senna
Bisacodyl
Castor oil
Dosage Form
Adult Dosage
Tablet 8.6 mg
sennosides
2 tabs PO daily
Max: 4 tabs PO
BID
Pills or chocolate
pieces 15 mg
sennosides
2 pills or
chocolate
pieces daily or
BID
Tablet 5 mg
1 to 3 tablets
daily
Rectal suppository
10 mg
1 suppository
daily
Liquid
1 to 4
tablespoonsful
Onset of
Action
Do not
Combination Product
Agent
Dosage Form
Tablet 8.6 mg
Senna/docusa sennosides /
te
docusate sodium
50 mg
Adult Dosage
Onset of
Action
2 tabs PO daily
Max: 4 tabs PO
BID
6 to 10 hours
after PO
REMOVE WRAPPING
Recommended position: On left
side with knees bent (other
positions depicted on previous
slide)
Relax the buttock before
inserting
Insert tapered end fi rst
Insert completely (past the
anal sphincter)
Continue to lie down to allow
dissolving
Non-Pharmacologic Treatment
Diet
FIBER
25-35 grams per day
Whole grains, oats,
fruits, vegetables
Avoidance of
constipating foods
Processed cheese,
concentrated sweets,
etc.
Physical activity
Increase
exercise/activity level
Bowel Habits
Do not ignore the urge
to defecate
General emotional
well-being and
avoidance of
stressful situations
Self-Assessment
A 45 yo WM reports to your community pharmacy with
complaints of constipation. He has been self-treating with a
combination product called Senna-S (sennosides/docusate)
regularly for the past week and a half, but has not had any
relief. He wants to know what other products might help. He
denies any other medical conditions or medications. What
would you recommend next for this patient?
A. Mineral oil, 3 tablespoons PO daily
B. Bisacodyl 10 mg rectal suppository, 1 suppository daily
C. PEG 3350, 17 grams mixed into 4 to 8 oz liquid PO daily
D. Nothing--Refer to medical care for further assessment
Self Assessment
AB, a 35 yo AAM, is looking for a product that
will relieve his constipation as quickly as
possible.
What questions would you like to ask AB?
Self Assessment
S: Unable to produce regular BMs, feelings of
incomplete evacuation. No alarm s/s.
C: Hard, very small BMs
H: Does not happen often, but has happened in the
past. Symptoms previously resolved w/o treatment
O: Symptoms started 4 days ago
L:
A: Nothing
R: Nothing
M: Amlodipine 10 mg po daily
A: Penicillin (rash, hives)
C: Hypertension
Self Assessment
Product
PEG 3350 powder
Bisacodyl suppository
Docusate sodium
capsules
Senna tablets
Mineral oil oral liquid
Onset of Action
12 to 72 hours
Up to 96 hours
15 to 60 minutes
48 to 72 hours
6 to 10 hours
6 to 8 hours
DIARRHEA
Diarrhea
An abnormal increase in the frequency,
liquidity, or weight of stool
More than 3 BMs per day is considered
abnormal
Most prevalent in children younger than 5 years
old
Least prevalent in
Types
of Diarrhea
older
adults
Acute
Persistent
Symptoms for 2 to 4
weeks
Chronic
Causes of Diarrhea
Viral gastroenteritis
Noroviruses
Rotavirus
Adenoviruses
Astroviruses
Hepatitis A
Bacterial gastroenteritis
Campyllobacter spp.
Salmonella spp,
Shigella spp.
Escherichia coli
Staphylococcus spp.
Clostridium spp.
Yersinia entercolitica
Bacillus cereus
Food-borne
gastroenteritis
Bacterial, protozoal, or
viral
Travelers diarrhea
Food intolerances
Medications
Antibiotics
Antacids containing
magnesium
Chemotherapy agents
PPIs
Etc.
Mild-toModerate
Dehydration
Severe
Dehydration
<3%
3 to 9%
>9%
Mental status
Good, alert
Normal, fatigued
or restless,
irritable
Apathetic,
lethargic
unconscious
Thirst
Drinks
Thirsty, eager to
normally, might
drink
refuse liquids
Degree of
dehydration
Drinks poorly,
unable to drink
Tachycardia,
bradycardia if
severe
Heart rate
Normal
Normal to
increased
Extremities
Warm
Cool
Cold, motteled
cyanotic
Blood
pressure
Normal, no
orthostatic
changes
Normal, mild
orthostatic
changes
Low blood
pressure,
dizziness
Onset
Location
Aggravating factors
Relieving/Remitting
factors
Medications
Allergies
Diarrhea- Question
S Symptoms:
What symptoms are you having?
C Characteristics:
What types of bowel movements are you having?
How often are your BMs?
H History:
Have you experienced these symptoms in the past?
How have you treated these symptoms in the past?
What treatments were eff ective in the past?
O Onset:
When did your symptoms start?
How long as it been since your last BM?
Have you traveled recently
Diarrhea- Question
L Location:
Probably unnecessary to ask in this case
A Aggravating Factors:
What makes your symptoms worse?
R Relieving Factors:
What makes your symptoms better?
Diarrhea- Question
M Medications:
What medications are you taking?
OTC AND RX
Watch for antibiotic use!!
A Allergies:
Do you have any drug allergies?
Pregnancy
Severe dehydration
Protracted vomiting
Lifestyle changes
Avoidance of irritating foods
Carbohydra
te (gram/L)
Potassium
(mEq/L)
Sodium
(mEq/L)
245
13.5
(glucose)
20
75
249
20
(dextrose), 5
(fructose)
20
45
Cola**
550
50 to 150
(fructose
and
dextrose)
0.1
Chicken
Broth**
450
250
Product
WHO-ORS
Pedialyte
45
Gatorade
(dextrose,
330
3
** Not recommended for use as ORS
in children < 5 years old
**
other
sugars)
20
Mild to Moderate
Dehydration
Minimal to No
Dehydration
Mild to Moderate
Dehydration
Minimal to No
Dehydration
Self-Assessment
Which of the following oral replacement
solutions is the best choice for a 25 year old
female patient presenting with severe
dehydration?
A. Pedialyte
B. WHO-ORS
C. Gatorade
D. None of the above
Loperamide
(Imodium
AD)
Liquid: 2 mg/15
mL
4 mg initially, then
2 mg after each
subsequent loose
stool
48 hours
Tablets262 mg
Caplets262 mg
525 mg every 30
to 60 minutes
Liquid262 mg/15
mL and 525 mg/15 Max: 4200 mg/day
or 8 doses/day
mL
48 hours
Dosage
Forms
Chewable
tablets,
caplets, liquid
Directions
Follow package
directions with
first bite of dairy
product
Length of
Treatment
With each dairy
product
Adverse reactions
Diarrhea Non-Pharmacologic
Treatment
Illness should be self-limiting Around 48
hours
Diet
Do not withhold food for >24 hours
Resume diet as soon as rehydrated/tolerated
BRAT diet is inappropriate
Bananas, rice, applesauce, toast
Prevention
Avoidance of irritating foods
Proper hygiene, handwashing when handling food
LAB
For Lab
Before Lab:
Read over chapters 15 and 16 in the
Handbook of Nonprescription Drugs
Bring to Lab:
Pre-lab slides
PRINTED and completed drug product table
During Lab:
Be prepared to counsel a patient on any one
of the following products: Pepto-Bismol,
loperamide, Sennakot-S, bisacodyl
References
Weitzel KW, Goode JR. Constipation. In: Krinsky DL, Berardi
RR, Ferreri SP, Hume AL, Newton GD, Rollins CJ, Tietze KJ,
editors. Handbook of Nonprescription Drugs . Washington,
DC: American Pharmacist Association; 2012. p 253-278.
Walker PC. Diarrhea. In: Krinsky DL, Berardi RR, Ferreri SP,
Hume AL, Newton GD, Rollins CJ, Tietze KJ, editors. Handbook
of Nonprescription Drugs . Washington, DC: American
Pharmacist Association; 2012. p 279-298.
PL Detail-Document, Treatment of Constipation in Adults.
Pharmacists Letter/Prescribers Letter. April 2013.
PL Detail-Document, Medications for Constipation.
Pharmacist's Letter/Prescriber's Letter. May 2007.