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Therapeutics II > Block 1: Constipation > Flashcards

Block 1: Constipation Flashcards

1
Q

What is constipation?

A

Occurrence of fewer than 3 bowel movements/week associated with strainign and difficult passage of hard, dry stools

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2
Q

Untreated constipation can lead to ?

A
  1. Hemorrhoids
  2. Anal fissures
  3. Rectal prolapse
  4. Fecal impaction
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3
Q

Causes of constipation?

A
  1. Med problems and meds
  2. Psychological and physiological conditions
  3. Lifestyle, inadequate fluid and fiber
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4
Q

Meds that can cause constipation?

A
  1. Opiates
  2. Anticholinergics
  3. Iron
  4. NSAID
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5
Q

What is normal stool according to Bristol?

A

3-4

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6
Q

What are exclusions of constipation self-care?

A
  1. Abdominal pain or distenstion
  2. Fever, N/V
  3. Use of laxatives
  4. Blood in stool
  5. Over 2 weeks sx, recurrance within 3 months
  6. Anorexia
  7. <2 YO
  8. Excessive flatulence
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7
Q

What are alarm sx of constipation?

A
  1. Hematochezia
  2. Melena
  3. Hx of colon cancer or IBD
  4. Anemia
  5. Weight loss
  6. ANorexia
  7. N/V
  8. Severe or persistnat
  9. New or worsening
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8
Q

What are non-pharm of constipation?

A
  1. Adequate fiber intake (25g women, 38g for men) (fiber supplement)
  2. Increase fluid intake
  3. Behavior mod (bowel training)
  4. Increase PE
  5. 1 month trial
  6. Squatty potty
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9
Q

Classes of laxatives

A
  1. Softening of feces in 1-3 days
  2. Soft or semifluid stool in 6-12 hr
  3. Watery evacuation in 1-6 hr
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10
Q

Types of stool softners 1-3 days?

A
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11
Q

Type of semifluid laxatives 6-12hr?

A
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12
Q

Type of fluid laxatives 1-6hr?

A
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13
Q

What are your bulk forming agents? MOA?

A

methylcellulose, polycarbophil, and psyllium

Absorb fluid from the intestines, swell to form soft, bulky stool

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14
Q

Counseling points bulk forming agents?

A
  1. Onset 12-24hr, delay up to 72 hr
  2. Adequate fluids
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15
Q

ADRs of bulk forming agents?

A
  1. Cramping, farts
  2. Avoid in patient who have difficulty swallowing
  3. Avoid patients on fluid restriction
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16
Q

Types of hyperosmotics? MOA?

A
  1. PEG3350
  2. Glycerin
  3. Lactulose

Draw water into the colon or rectum through osmosis to stimulate a bowel movement

Onset of effect: 12-72 hours, can take up to 96 hours

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17
Q

What are the ADRs of hyperosmotic?

A
  1. Bloating
  2. Abdominal discomfort
  3. Cramping
  4. Fart

No DDI

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18
Q

What hyperosmotic is a suppositories? Indications?

A

Glycerin (15-30 min) aprroved for all ages

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19
Q

What are the emollients? MOA?

A

Docusate

Act in the small and large intestine to increase the wetting efficiency of intestinal fluid

Facilitates mixture of aqueous and fatty substances to soften the fecal mass

Combo with stimulants to help with evac

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20
Q

ADRs of docusate

A

Limited

Onset: 12-72 hr up to 3-5 days

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21
Q

What are lubricants? MOA?

A

Mineral oil

Softens fecal content by coating stool and preventing colonic absorption of fecal water

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22
Q

Indications for mineral oil?

A

Formulation: liquid (onset 6-8 hours) or rectal (5-15 minutes)

Should not be used in children < 6 years, pregnant women, bedridden or older adults, and individuals with difficulty swallowing

Should be avoided

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23
Q

What ar the types of saline laxatives? MOA?

A

Magnesium citrate, magnesium hydroxide, dibasic sodium phosphate, monobasic sodium phosphate, magnesium sulfate

  • Draw water into the small and large intestine or colon by osmosis
  • Increase intraluminal pressure and promote GI motility
  • Available as oral (onset 30 mins – 3 hours) or rectal (2-15 mins)
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24
Q

ADRs and DDIs of saline laxatives?

A
  1. Abdominal cramping
  2. N/V
  3. Dehydration

Cation in renal impairment, newborns, older adults

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25
Q

What are examples of stimulants used with docusate? MOA?

A
  1. Senna
  2. Bisacodyl
  3. Castor-oil

Increases intestinal motility, increases secretion of water and electrolytes in the intestines

Onset 6-10 hours for oral, bisacodyl supp 15-60 mins

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26
Q

What are the ADRs of stimulants?

A
  1. Severe cramping
  2. Electrolyte and fluid deficiencies
  3. Hypokalemia
27
Q

Counseling points for bisacodyl?

A

Enteric coated should not be crushed or chewed or giving with agents that increase gastric pH

28
Q

Emollients counseling points?

A

Preferred post-op

29
Q

Counseling point with hyperosmotics?

A

Sticky

30
Q

PEG counceling point?

A

Smooth and easy best for chronic

31
Q

Counseling points for saline laxatives?

A

electrolyte disturbances in CHF, renal disease - not for chronic use

32
Q

Counseling point for glycerin?

A

Supportitories preferred in infants

33
Q

Counseling point with stimulants?

A

With docusate not for prevention or chronic use

34
Q

Rank the following laxatives in order of onset of action from fastest to slowest.

PEG powder
Magnesium citrate enema
Docusate sodium chewable gummy
Bisacodyl oral tablets

A

Mag citrate&raquo_space; Bisacodyl&raquo_space; PEG powder&raquo_space; Docusate

35
Q

Rank the speed of agents?

A

Enemas——–Fastest
Suppositories
Lubricants
Salines
Stimulants
Osmotics
Stool softeners
Bulk———Slowest

36
Q

Rank the comfort of agents?

A

Stool softeners—–Most comfortable
Bulk forming
Osmotic
Stimulants
Salines
Lubricants
Suppositories
Enemas —–Least comfortable

37
Q

What is the treatment algorithm for constipation?

A
38
Q

What is chronic constipation?

A

Duration >6 months

Intestinal Secretagogues

39
Q

What is the tx for chronic constipation? MOA?

A
  1. Lubiprostone
  2. Linaclotide
  3. Plecanatide
40
Q

MOA of Lubiprostone?

A

Lubiprostone for idiopathic and opoiod induced

Chloride channel activator that works in the gut- stimulates chloride-rich fluid secretion into the intestinal lumen

41
Q

ADR of Lubiprostone?

A

N/HA/diarrhea

42
Q

Dosing of lubiprostone?

A

Taken as 24 mcg capsule BID with food

Costly

43
Q

INdication and MOA of linaclotide?

A

Chronic and IBS-C

Increases intestinal fluid secretion and quickens intestinal motility

44
Q

How should linaclotide be given?

A
  1. Doses are 72 mcg or 145 mcg daily to be taken on empty stomach at least 30 minutes before first meal
  2. Do not use in patients under the age of 18
45
Q

ADR of linaclotide?

A
  1. Diarrhea
  2. Fart
  3. Abdominal pain
46
Q

MOA of plecanatide? Dosing?

A

Increases intestinal fluid secretion and quickens intestinal motility

Dosed daily 3mg without regard to food

47
Q

CI for Plecanatide?

A
  1. Less than 6 YO with GI mechanical obstruction
  2. Should not be used in patient under 18
48
Q

Exampls of opioid receptor antagonists?

A
  1. Methylnaltrexone
  2. Naloxegol
49
Q

Indications of methylnaltrexone?

A
  1. mu-receptor antagonist approved for OIC in patients with advanced disease receiving palliative care
  2. patients with noncancer chronic pain with insufficient results with laxatives

Does not cross BBB or antagonize analgesia

50
Q

Dosing? CI with methylnaltrexone?

A

Given as subq injection daily

CI: GI obstruction
Reduce dose for hepatic and renal insufficinecy

51
Q

Indications of naloxegol?

A

OIC in adults with noncancer pain

52
Q

Dosing? ADRs of naloxegol?

A

25 mg po once daily, 1 hour before or 2 hours after a meal

Dose adjustment for renal dysfunction

ADR: Diarrhea/abdominal pain/N

53
Q

Treatment for pediatrics primary?

A

diet and lifestyle modifications

54
Q

Treatment options 2-6YO?

A
  1. PO docusate
  2. Mag hydroxide
  3. Senna
55
Q

Treatment options 6-12YO?

A

Oral products: methylcellulose, psyllium powder, docusate, mineral oil , bisacodyl, senna, mag citrate, mag hydroxide, mag sulfate

Rectal: glycerin suppositories, mineral oil, sodium phosphate, and bisacodyl

56
Q

Tx for geriatric?

A
  1. review of medication and history needed
  2. Lifestyle mod
  3. Bulk-forming laxatives or PEG 3350 appropriate
  4. Stool softeners may also be appropriate
57
Q

What causes constipation in pregnancy?

A

1.Prenatal supplement
2.Growing uterus
3. Hormones

58
Q

Tx of pregnancy constipation?

A
  1. Lifestyle mod
  2. Bulk-forming recommended initially with increase in fluids
  3. Short term senna or bisacodyl
  4. Avoid castor oil, mineral oil, saline laxatives
59
Q

Tx of lactation constipation?

A
  1. Senna, bisacodyl, PEG 3350, and docusate
  2. Avoid castor, mineral oil
60
Q

What is the commonly diagnosed GI condition? Sx?

A

IBS

  1. Chronic abdominal pain
  2. Altered habits in absence of organic cause
  3. Diarrhea or constipation

Women and younger patients

61
Q

Tx of IBS?

A
62
Q

Tx of IBS-C?

A
  1. Increase dietary fiber and fluids
  2. Bulk forming laxatives

Consider:
1. Serotonin-4 agonist (tegaserod)- requires REMS
2. Serotonin-4 agonists (prucalopride)- Europe only
3. Guanylate cyclase C receptor agonist (linaclotide, Linzess®)
4. Chloride channel activator (lubiprostone, Amitiza®)

63
Q

Tx for IBS-D?

A
  1. Avoid food triggers (caffeine, alcohol, artificial sweeteners)

Consider:
1. Opioid agonists (Loperamide (for episodic management, not chronic daily use) (Eluxadoline (Viberzi®)
2. Serotonin antagonist (alosetron, Lotronex®) - REMS program
3. Antibiotic- Rifaximin (Xifaxan®) 2-week regimen

Therapeutics II (30 decks)

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