Constipation and Diarrhea

Constipation is infrequent bowel movements____ or difficulty passing stools

<3 a week

Chronic idiopathic constipation (CIC)

persistent constipation without an identifiable cause

IBS-C definition

Chronic idiopathic constipation causing abdominal discomfort that is RELIEVED BY DEFECATION

Medical conditions that can cause constipation

IBS (constipation-predominant)

anal disorders

MS

cerebrovascular events

Parkinson disease

DM

Hypothyroidism

Non drug treatment of constipation include

increasing fluid intake

physical activity

eating foods high in fiber

Drugs that are constipating

aluminum antacids,

anticholinergics,

non-dhp CCB (esp Verapamil)

TCAs

Incontinence drugs (oxybutynin)

Phenothiazines (prochlorperazine)

Antispasmodics (baclofen)

iron

opioids,

sucralfate

A healthcare provider should be consulted if constipation is not improved with OTC help after _____

7 days

Bulk-forming drugs include:

soluble fiber like psyllium

first line OTC for constipation

bulk-forming drugs (soluble fiber, such as psyllium and dietary fiber)

Treatment of choice in pregnancy constipation

bulk-forming drugs (dietary fiber, psyllium)

PEG polyethylene glycol is a ______ laxative that works by

osmotic

works by containing large molecules that are poorly absorbed, that draw fluid into bowel throug hosmosis, that distends colon and increases peristalsis

Stimulant laxatives include

senna, bisacodyl

Patients using chronic opioids (all of which are constipating) often require a _____ laxative

stimulant

______ can be given with a stimulant laxative if the stool is hard

stool softener like docusate

stool softeners like _____ are emollients that reduce surface tension of stool oil-water interface

docusate

mineral oil is a _____ laxative

lubricant - coats bowel and stool with waterproof film

Recommendation for iron-induced constipation

docusate stool softener

If fast relief is needed in constipation, recommend:

adults: bisacodyl or glycerin (more gently suppository)

children: glycerin suppository

Side effects of bulk-forming laxatives

flatulence, abdominal cramping, bloating

Notes about bulk-forming drugs

must take adequate fluids

calcium is a polyvalent cation, so calcium polycarbophil (Fibercon) must be separated from some drugs due to binding interaction

Laxative that contains cation that may require separation due to binding interaction

Calcium polycarbophil (Fibercon)

Wheat Dextrin is the brand name

Benefiber

Citrucel is generic

methylcellulose

Fleet enema contains

sodium phosphates

side effects of osmotics

eletrolyte imbalance, abdominal cramping

notes about osmotic laxatives

Mg products: caution with renal impairment, don't use if severe renal impairment

Lactulose: used commonly for hepatic encephalopathy

glycerin suppository: used commonly in children who need to defecate quickly

Ex-lax generic

Senna

SennS. and Senokot S. contain

Senna + docusate

Dulcolax generic

bisacodyl

Side effects of stimulant laxatives

abdominal crmaping

notes about stimulant laxatives

take oral products at bedtime

chronic opioid use often requires stimulant laxatives

Laxative preferred when straining should be avoided

docusate

(i.e. postpartum, post-MI, hemorrhoid)

Lubiprostone drug class

chloride channel activator

linaclotide drug class

guanylate cyclase C agonist

alvimopan drug class

PAMORA: peripherally-acting mu-opioid receptor antagonist in the GI tract, decreasing constipation

Amitiza generic

Lubiprostone

Lubiprostone is used for

CIC, OIC, IBS-C

Side effect of Amtizia

(Lubiprostone)

nausea

Linzess is used for

(linaclotide)

CIC, IBS-C

side effect of linaclotide

diarrhea

Entereg generic

Alvimopan

Entereg indication

(alvimopan) for hospitalized surgery patients to decrease risk of post-operative ileus

given to patients after surgery to decrease risk of post-operative ileus

Entereg (alvimopan)

Max dose of almivopan

max of 15 doses

Boxed warning on Entereg

(almivopan)

risk of MI with long-term use

contraindications for Entereg

(almivopan)

therapeutic doses of opioids for >7 consecute days immediately prior

Almivopan is only to be used by

patients taking opioids who have OIC

Tegaserod is a serotonin 5-HT-4 agonist that is contraindicated in

intestinal ischemia, history of cardiovascular events

Serotonin 5HT-4 receptor agonists like Prucalopride have warnings for ___ and side effects of:

warnings: suicidal ideation

side effects: diarrhea

Brand name used for colonprep

GoLytely

Side effect of all colon prep laxatives and caution/warnings

fluid and electrolyte losses

can be critical in some patients wand with products with oral sodium phosphates like OsmoPrep

use caution in pt with cardiovascular disease, renal insufficiency, and those on loop diuretics due to additional fluid loss, NSAIDS

GoLytely is a brand of _____ used for ____

polyethylene glycol used for colon prep/bowel irrigation

OsmoPrep has a BOXED WARNING for ___________

nephropathy

osmoprep is contraindicated in

acute phosphate nephropathy, gastric bypass or stapling surgery

counseling notes for whole bowel irrigation/bowel prep products

require doses night before and morning of colonoscopy

clear liquid diet is required day prior

don't consume solid/semi-solid foods, anything with red/blue/purple food coloring

Sodium phosphates brand name for whole bowel irrigation

osmoprep

Sodium sulfate, potassium sulfate, and magnesium sulfate brand name

Suprep Bowel prep kit

Most common bacterial cause of diarrhea

e. coli

most causes of diarrhea are:

viral

IBS-D

idiopathic diarrhea associated w/ chronic abdominal discomfort relieved by defecation

Diarrhea occuring after consuming milk products can be due to

lactose intolerance

T/F: Gatorade can be used as an alternative to Pedialyte or oral rehydration solutions (ORS)

true

Oral rehydration solutions for managing fluid and electrolytes after diarrhea include

enfamil enfalyte and pedialyte

antimotility drugs used in diarrhea include

loperamide and diphenoxylate

Patients with non-infectious diarrhea can often be treated with symptomatic relief short-term with:

bismuth subsalicylate (pepto-bismol) or

loperamide

Eluxadoline drug class

mixed mu-opioid receptor agonist

PAMORAs are mu ____ used to treat _____

while eluxadine is a mu____ used to treat ____

PAMORA (alvimopan) mu antagonist used to treat constipation

Eluxadine: mixed mu agonist used to treat diarrhea

Max dose of loperamide (Imodium A-D)

8mg OTC

16mg Rx

Loperamide dosing

4mg initially, then 2mg after each loose stool (up to max doses)

In addition to black tonuge/stool, side effects of pepto-bismol include

tinnitus and nausea if used in excess

Loperamide has boxed warning for

cardiac arrest and sudden death with doses higher than recommended. do NOT exceed recommended dose

Notes regarding loperamide

don't use >48H

Diphenoxylate/atropine brand name

lomotil

Lomotil generic

Diphenoxylate/atropine

Lomotil is a schedule _____ drug

C-V drug

contraindications of lomotil

risk of CNS depression (do not use if <2 years of age or <6 for tablets!)

Notes regarding lomotil

liquid formulation is recommended in children <13

anticholinergic effects due to atropine

The anticholinergic effects of lomotil are due to the ____ component

atropine

Dicyclomine has the brand name _____ and the is of the drug class _____

brand: bentyl

class: antispasmodic

Warnings with Bentyl

(dicyclomine)

anticholinergic (caution in pt 65+) BEERS

can cause toxic megacolon or paralytic ileus

side effects of Bentyl

dizziness, dry mouth, nausea, blurred vision

Eluxadoline is a schedule _____

C-IV

Contraindications to Eluxadoline

patients without a gallbladder

Alosetron is a 5HT-3 antagonist approved only for _____ not used often due to risk of _____

approved for women only

risk of ischemic colitis

T/F: Rifaximin is not used often for diarrhea since there is risk of relapse often

true