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NAPLEX 25 > Chapter 72: Constipation & Diarrhea > Flashcards

Chapter 72: Constipation & Diarrhea Flashcards

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1
Q

What is constipation defined as?

A

Infrequent bowel movements (less than three per week) or difficulty passing stools.

Symptoms include straining, lumpy/hard stools, prolonged pushing, requiring digital evacuation, or feeling of incomplete evacuation.

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2
Q

What are common causes of constipation?

A
  • Diet
  • Lifestyle
  • Drugs
  • Pregnancy
  • GI disorders
  • Other medical conditions

See Key Drugs Guy for specific medications that may cause constipation.

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3
Q

What is chronic idiopathic constipation (CIC)?

A

Constipation that persists for several weeks or longer with an unknown cause.

Patients with CIC should be screened for alarm symptoms before treatment.

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4
Q

What should be done if alarm symptoms are present in CIC patients?

A

Diagnostic testing should occur.

Alarm symptoms include weight loss or gastrointestinal bleeding.

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5
Q

What is irritable bowel syndrome with constipation (IBS-C)?

A

Idiopathic constipation associated with chronic or recurrent abdominal discomfort relieved by defecation.

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6
Q

List some medical conditions that can cause constipation.

A
  • Irritable bowel syndrome
  • Parkinson disease (constipation-predominant)
  • Anal disorders (fissures, fistulae, rectal prolapse)
  • Multiple sclerosis
  • Pregnancy
  • Spinal cord tumors
  • Diabetes
  • Hypothyroidism
  • Cerebrovascular events
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7
Q

What are preferred non-drug treatments for constipation?

A
  • Increasing fluid intake (64 oz daily recommended)
  • Limiting caffeine and alcohol intake
  • Increasing physical activity
  • Replacing refined foods with whole grain products, bran, fruits, vegetables, beans, and other high-fiber foods.
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8
Q

Fill in the blank: Constipation can be caused by _______.

A

[diet, lifestyle, drugs, pregnancy, GI disorders, other medical conditions]

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9
Q

What should be done to prevent constipation?

A

Drugs that are constipating should be discontinued, if possible. Use the bathroom as soon as the urge to defecate arises. For young children, a scheduled bathroom time may be needed.

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10
Q

What is the first-line treatment for constipation?

A

Bulk-forming drugs (e.g., soluble fiber such as psyllium) and dietary fiber.

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11
Q

What are the primary actions of most drug treatments for constipation?

A

They stimulate the muscles of the digestive tract or soften the stool, resulting in quicker bowel movements.

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12
Q

What should be done if constipation does not improve after seven days of OTC treatment?

A

Consult a healthcare provider for further evaluation and possible prescription medication.

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13
Q

What is the mechanism of action of osmotic laxatives?

A

They draw fluid into the bowel lumen through osmosis, distending the colon and increasing peristalsis.

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14
Q

Fill in the blank: _______ are emollients that reduce the surface tension of the stool.

A

Stool softeners

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15
Q

What type of laxative is often required for patients using chronic opioids?

A

Stimulant laxative

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16
Q

What role do lubricants (e.g., mineral oil) play in constipation treatment?

A

They coat the bowel and stool with a waterproof film, keeping moisture in the stool.

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17
Q

Name two stimulant laxatives.

A
  • Senna
  • Bisacodyl
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18
Q

What are common side effects of drug treatments for constipation?

A
  • Diarrhea
  • Abdominal cramping
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19
Q

List two bulk-forming drugs.

A
  • Psyllium
  • Dietary fiber
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20
Q

What is the treatment of choice for constipation during pregnancy?

A

Bulk-forming drugs and dietary fiber.

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21
Q

True or False: Antihistamines can contribute to constipation.

A

True

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22
Q

What are cation-containing drugs that may cause constipation?

A
  • Antacids with aluminum or calcium
  • Iron
  • Sucralfate
  • Colesevelam
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23
Q

What is a common OTC recommendation for fiber-induced or hard stool?

A

Stool softener (e.g., docusate) or bulk-forming drug.

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24
Q

What laxative is recommended for fast relief in adults?

A

Bisacodyl or glycerin suppository.

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25
What should be done if a patient does not improve after using OTC treatments for constipation?
Refer the patient to a healthcare provider.
26
What are the forms of Psyllium used for constipation?
Capsule, powder ## Footnote Commonly known as Metamucil and others
27
What is the typical dosing range for Psyllium?
2.5-30 g/day in divided doses
28
What are the forms of Calcium polycarbophil?
Caplet, chewable tablet ## Footnote Commonly known as FiberCon and others
29
What is the dosing for Calcium polycarbophil?
1,250 mg 1-4 times/day
30
What are the forms of Methylcellulose?
Caplet, powder ## Footnote Commonly known as Citrucel and others
31
What is the dosing for Methylcellulose?
1-6 g/day
32
What are the forms of Wheat dextrin?
Tablet, chewable tablet, powder ## Footnote Commonly known as Benefiber
33
What is the dosing for Wheat dextrin?
4 g (2 teaspoons) in 4-8 oz of liquid or soft food TID
34
What are the forms of Magnesium hydroxide?
Chewable tablet, suspension ## Footnote Commonly known as Milk of Magnesia and others
35
What is the dosing for Magnesium hydroxide?
2.4-4.8 g QHS or in divided doses
36
What is the dosing for Polyethylene glycol 3350?
17 g in 4-8 oz of water daily ## Footnote Commonly known as MiraLax, GaviLax, GlycoLax, others
37
What are the forms of Glycerin?
Suppository: adult & pediatric sizes ## Footnote Commonly known as Fleet Liquid Glycerin Supp and others
38
What is the dosing for Lactulose?
PO: 10-20 g daily ## Footnote Commonly known as Constulose, Enulose, Generlac, Kristalose
39
What are the contraindications for Psyllium?
Fecal impaction and GI obstruction
40
What are common side effects of bulk-forming drugs?
* Flatulence * Abdominal cramping * Bloating * Bowel obstruction (if strictures present) * Choking (if powder forms are not taken with enough liquid)
41
What is the onset of action for bulk-forming drugs?
12-72 hrs
42
What precautions should be taken with bulk-forming drugs?
* Adequate fluids are required * Use caution if fluid restricted * Difficulty swallowing * At risk for fecal impaction
43
What are contraindications for Sorbitol?
Anuria
44
What are common side effects of osmotic drugs?
* Electrolyte imbalance * Abdominal cramping * Abdominal distention * Flatulence * Dehydration * Rectal irritation (suppository)
45
What is the onset of action for osmotic drugs?
30 mins to 96 hrs (oral), 5-30 mins (rectal)
46
What caution is advised with magnesium-containing products?
Caution with renal impairment and do not use if severe renal impairment
47
What is Lactulose commonly used for?
Hepatic encephalopathy
48
What is the common use of Glycerin suppository?
Used commonly in children who need to defecate quickly
49
What are examples of stimulants used as laxatives?
Senna (Ex-Lax, Senokot, others) ## Footnote Stimulants are used to promote bowel movements.
50
What forms does Senna come in?
Tablet, chewable tablet, liquid, syrup ## Footnote Senna is available over-the-counter (OTC).
51
What is the dosing range for Senna?
17.2-50 mg daily-BID ## Footnote PO: 5-15 mg daily, do not take within 1 hr of dairy products or antacids.
52
What should be avoided when using laxatives?
Stomach pain, N/V, sudden change in bowel movements that lasts > 2 weeks ## Footnote These are warnings for the use of stimulant laxatives.
53
What are common side effects of stimulant laxatives?
Abdominal cramping, electrolyte imbalance, rectal irritation (suppository) ## Footnote Monitoring for these side effects is important.
54
What is the onset of action for oral stimulant laxatives?
6-12 hours ## Footnote Rectal administration has a faster onset of 15-60 minutes.
55
What are emollients (stool softeners)?
Docusate sodium (Colace, others), docusate calcium, docusate potassium ## Footnote They are available in capsule, tablet, enema, liquid, syrup forms and are OTC.
56
What is the dosing for docusate sodium?
PO: 50-360 mg daily or in divided doses ## Footnote PR (enema): 283 g/5 mL daily-TID.
57
What is an important note regarding the use of docusate?
Do not take docusate and mineral oil together ## Footnote It increases the absorption of mineral oil.
58
What are the contraindications for stimulant laxatives?
Abdominal pain, N/V, use with mineral oil, OTC use > 1 week ## Footnote These contraindications help prevent complications.
59
What are the side effects of docusate?
Abdominal cramping, throat irritation (liquid) ## Footnote Monitoring for these side effects is essential.
60
What is the onset of action for oral emollients?
6-8 hours ## Footnote Rectal administration has a faster onset of 2-15 minutes.
61
True or False: Oral formulations of mineral oil are generally recommended due to safety concerns.
False ## Footnote Risks include aspiration and lipid pneumonitis.
62
Fill in the blank: Chronic opioid use often requires a _______.
stimulant laxative ## Footnote This is due to the constipating effects of opioids.
63
What should be taken at a different time due to malabsorption issues?
Multivitamin ## Footnote This is particularly important when taking mineral oil.
64
What is the preferred use of stimulant laxatives?
When straining should be avoided (e.g., postpartum, post-MI, anal fissures, hemorrhoids) ## Footnote Stimulants are favored in these conditions.
65
What is the mechanism of action of lubiprostone?
Acts on chloride channels in the gut, leading to increased fluid secretion and peristalsis ## Footnote Lubiprostone is used for chronic idiopathic constipation (CIC), opioid-induced constipation (OIC), and IBS-C in adult women.
66
What do guanylate cyclase C agonists do?
Increase chloride and bicarbonate secretion into the lumen of the intestines, increasing the speed of GI transit and reducing abdominal pain ## Footnote Examples include linaclotide and plecanatide.
67
What are PAMORAs and their function?
Peripherally-acting mu-opioid receptor antagonists that act on mu-opioid receptors in the GI tract, decreasing constipation ## Footnote An example is alvimopan.
68
What is the effect of serotonin 5-HT4 receptor agonists?
Release acetylcholine which causes muscle contractions and increases gastrointestinal motility ## Footnote An example is prucalopride.
69
List the prescription drugs indicated for CIC.
* Lubiprostone * Linaclotide * Plecanatide * Alvimopan * Methylnaltrexone * Naloxegol * Naldemedine * Prucalopride ## Footnote CIC stands for chronic idiopathic constipation.
70
What is the dosing for lubiprostone in CIC and OIC?
24 mcg BID ## Footnote For IBS-C, the dose is 8 mcg BID.
71
What are the contraindications for lubiprostone?
* Mechanical bowel obstruction ## Footnote Common side effects include nausea and diarrhea.
72
What is the dosing for linaclotide in CIC?
145 mcg daily ## Footnote For IBS-C, the dose is 290 mcg daily.
73
What are the boxed warnings for linaclotide?
Do not use in pediatric patients due to high risk of dehydration that can cause death ## Footnote Contraindications include age < 6 years and mechanical bowel obstruction.
74
What is the dosing and administration advice for plecanatide?
3 mg daily; can be crushed ## Footnote It is used for CIC and IBS-C.
75
What is the dosing for alvimopan?
12 mg, 30 min-5 hrs prior to surgery, then 12 mg BID for up to 7 days total ## Footnote Maximum of 15 doses.
76
What is the boxed warning for alvimopan?
Potential risk of MI with long-term use; available only for short-term inpatient use through a REMS program ## Footnote It is contraindicated in patients taking therapeutic doses of opioids for more than 7 consecutive days.
77
What are the common side effects of alvimopan?
Dyspepsia ## Footnote It is primarily used to decrease the risk of post-operative ileus.
78
What is the indication for methylnaltrexone?
Used for opioid-induced constipation (OIC) in patients taking opioids ## Footnote It is a PAMORA.
79
What is the indication for naloxegol?
Used for opioid-induced constipation (OIC) ## Footnote Naloxegol is a PAMORA.
80
What is naldemedine used for?
Opioid-induced constipation (OIC) ## Footnote Naldemedine is also a PAMORA.
81
What should be considered when taking lubiprostone?
Take with food and water to decrease nausea ## Footnote Alternative treatment with methadone may be considered.
82
What is the drug name of the Serotonin 5-HT4 Receptor Agonist?
Prucalopride (Motegrity) ## Footnote Used for Chronic Idiopathic Constipation (CIC) and off-label for Opioid-Induced Constipation (OIC)
83
What is the dosing recommendation for Prucalopride in patients with CrCl < 30 mL/min?
1 mg daily ## Footnote Standard dosing is 2 mg daily for other patients
84
List the contraindications for Prucalopride.
* Gastrointestinal obstruction * Bowel perforation * Ileus * Severe inflammatory conditions of the GI tract (e.g., Crohn's disease, ulcerative colitis, toxic megacolon) * Avoid use in ESRD with HD ## Footnote ESRD: End Stage Renal Disease; HD: Hemodialysis
85
What are the warnings associated with Prucalopride?
Suicidal ideation ## Footnote Important to monitor for changes in mental health
86
What are common side effects of Prucalopride?
* Diarrhea * Headache * Nausea * Abdominal pain
87
What should be monitored in patients taking Prucalopride?
* Worsening of depression * Emergence of suicidal thoughts * Rectal bleeding * Blood in stool * Severe abdominal pain
88
Which laxatives are typically used for whole bowel irrigation?
* Polyethylene glycol-electrolyte solution * Sodium phosphates (OsmoPrep) * Sodium sulfate, potassium sulfate, and magnesium sulfate (Suprep Bowel Prep Kit) * Sodium picosulfate, magnesium oxide, and citric acid (Clenpiq)
89
What is the dosing for Polyethylene glycol-electrolyte solution?
Drink 240 mL every 10 mins until 4 liters are consumed ## Footnote Variations exist for specific products like MoviPrep and Plenvu
90
What is a boxed warning for OsmoPrep?
Nephropathy ## Footnote Particularly important in patients with renal issues
91
What are the contraindications for Sodium phosphates (OsmoPrep)?
* Ileus * Gastrointestinal obstruction * Gastric retention * Bowel perforation * Toxic colitis * Toxic megacolon
92
What are the common side effects of Sodium phosphates (OsmoPrep)?
* Abdominal discomfort * Bloating * Nausea/Vomiting
93
What is the onset of action for bowel prep laxatives?
1-6 hours
94
What dietary restrictions are recommended the day prior to colonoscopy?
* Water * Clear broth (beef or chicken) * Juices without pulp (apple, white cranberry, white grape, lemonade) * Soda * Coffee or tea (without milk or cream) * Clear gelatin (without fruit pieces) * Popsicles (without fruit pieces or cream)
95
Fill in the blank: Patients should not consume solid or semi-solid foods, anything with red or blue/purple food coloring, milk, cream, tomato, orange or grapefruit juice, alcoholic beverages, or _______.
cream soups
96
What is the dosing for Sodium sulfate, potassium sulfate, and magnesium sulfate (Suprep Bowel Prep Kit)?
Evening before: drink 480 mL followed by 960 mL clear liquid over 1 hr; repeat in the morning
97
What is the dosing for Sodium picosulfate, magnesium oxide, and citric acid (Clenpiq)?
Evening before: drink 160 mL; repeat 5 hrs before the procedure
98
What is diarrhea?
An increase in the number of bowel movements or stools that are more watery and loose than normal.
99
What can cause diarrhea after consuming milk or milk products?
Lactose intolerance.
100
How can lactose intolerance be confirmed?
Through testing or eliminating dairy intake to see if diarrhea resolves.
101
What symptoms can accompany diarrhea?
* Abdominal cramps * Nausea * Vomiting * Fever
102
What are common causes of diarrhea?
* Idiopathic * Diseases * Drugs * Contaminated food/water
103
What is the most common bacterial cause of diarrhea?
E. coli.
104
What is irritable bowel syndrome with diarrhea (IBS-D)?
Recurrent idiopathic diarrhea associated with chronic abdominal discomfort relieved by defecation.
105
What is the primary management strategy for diarrhea?
Fluid and electrolyte replacement.
106
Why is dehydration from diarrhea in infants dangerous?
It should be overseen by a healthcare provider.
107
What are examples of oral rehydration solutions (ORS)?
* Pedialyte * Enfamil Enfalyte
108
Name some drugs that can cause diarrhea.
* Acetylcholinesterase inhibitors (e.g., donepezil) * Antacids containing magnesium * Antibiotics * Antidiabetics (e.g., metformin) * Antineoplastics (e.g., irinotecan) * Colchicine * Laxatives * Misoprostol * Mycophenolate * Prokinetic drugs (e.g., metoclopramide) * Protease inhibitors (e.g., nelfinavir) * Quinidine * Roflumilast
109
What is a common non-infectious drug treatment for diarrhea?
Short-term bismuth subsalicylate (Pepto-Bismol) or loperamide.
110
What are the effects of bismuth subsalicylate?
It has both antisecretory and antimicrobial effects.
111
What do loperamide and diphenoxylate do?
They are antidiarrheal drugs that slow intestinal motility.
112
How can pain and abdominal discomfort associated with IBS-D be managed?
* Antispasmodics (e.g., dicyclomine) * Antidepressants in select cases
113
What is eluxadoline (Viberzi) indicated for?
IBS-D when other treatments have failed.
114
What type of receptor does eluxadoline act on?
Mixed mu-opioid receptor agonist.
115
True or False: PAMORAs are mu-receptor antagonists.
True.
116
Fill in the blank: Eluxadoline binds to opioid receptors as a _______.
[agonist]
117
What is Bismuth subsalicylate commonly known as?
Pepto-Bismol and others
118
What are the available forms of Bismuth subsalicylate?
* Suspension (262 mg/15 mL) * Chewable tablet (262 mg)
119
What is the maximum daily dosage of Bismuth subsalicylate?
4,200 mg/day for up to 2 days
120
What is the recommended dosing for Bismuth subsalicylate?
* 524 mg (30 mL or 2 tablets) every 30-60 mins PRN * 1,050 mg (60 mL or 4 tablets) every 60 mins PRN
121
What is Loperamide commonly marketed as?
Imodium A-D, Anti-Diarrheal, Diamode
122
What is the maximum dosage for self-care with Loperamide?
8 mg/day
123
What is the initial dosing for Loperamide after the first loose stool?
4 mg PO after the first loose stool, then 2 mg after each subsequent loose stool
124
What is the classification of Diphenoxylate/atropine?
C-V
125
What is the maximum daily dosage for Diphenoxylate?
20 mg/day
126
What are the contraindications for Bismuth subsalicylate?
* Salicylate allergy * Taking other salicylates (e.g., aspirin) * GI ulcer * Bleeding problems * Black/bloody stool
127
What serious condition can occur in children using Bismuth subsalicylate?
Reye's syndrome
128
What are common side effects of Bismuth subsalicylate?
* Black tongue/stool * Salicylate toxicity * Nausea * Abdominal pain
129
What warning is associated with Bismuth subsalicylate regarding dosage?
Do not exceed the recommended dose to avoid torsades de pointes, cardiac arrest, and sudden death
130
What conditions contraindicate the use of Loperamide?
* Acute dysentery * Pseudomembranous colitis * Bacterial enterocolitis caused by invasive organisms * Abdominal pain without diarrhea * Acute ulcerative colitis
131
What are potential side effects of Loperamide?
* Constipation * Abdominal cramping * Nausea * QT prolongation
132
What is the recommendation for self-treatment duration with Loperamide?
Do not use > 48 hrs
133
What is the maximum dose of Loperamide per package as required by the FDA?
48 mg (24 tablets/capsules)
134
What are the contraindications for Diphenoxylate/atropine?
* Gastrointestinal obstruction * Severe ulcerative colitis * Reflux esophagitis * Acute hemorrhage with cardiovascular instability * Obstructive uropathy * Narrow-angle glaucoma * Myasthenia gravis * Breastfeeding women * Infants < 6 months of age
135
What are common side effects of Diphenoxylate/atropine?
* Mild euphoria * Anticholinergic effects
136
What is the recommended dosage for Dicyclomine?
20 mg QID
137
What is the maximum dosage of Dicyclomine per day?
80 mg/day for < 2 weeks
138
What are the potential side effects of Dicyclomine?
* Dizziness * Dry mouth * Nausea * Blurred vision * Somnolence * Weakness
139
What should be considered when using Dicyclomine in patients aged ≥ 65 years?
Caution due to anticholinergic effects
140
What is the significance of the liquid formulation of Diphenoxylate/atropine?
Recommended in children ≤ 13 years
141
What is the purpose of atropine in Diphenoxylate/atropine?
Used to discourage abuse
142
What is the drug Eluxadoline (Viberzi) classified as?
Peripherally-Acting Mixed Mu-Opioid Receptor Agonist
143
What is the dosing for Eluxadoline (Viberzi)?
100 mg PO BID, decrease to 75 mg BID if unable to tolerate 100 mg dose
144
When should Eluxadoline be taken?
Take with food
145
What is the schedule classification of Eluxadoline (Viberzi)?
C-IV
146
What condition is Eluxadoline (Viberzi) used to treat?
IBS-D
147
Name a contraindication for Eluxadoline (Viberzi).
Patients without a gallbladder
148
List three contraindications for Eluxadoline (Viberzi).
* Biliary duct obstruction * Sphincter of Oddi dysfunction/disease * Severe hepatic impairment (Child-Pugh class C)
149
What are two side effects of Eluxadoline (Viberzi)?
* Constipation * Nausea
150
What should be monitored while a patient is taking Eluxadoline (Viberzi)?
S/sx of pancreatitis or sphincter of Oddi spasm, LFTs
151
True or False: Eluxadoline (Viberzi) can be used in patients with a history of pancreatitis.
False
152
What warning is associated with Eluxadoline (Viberzi)?
CNS depression
153
What is the recommended action if a patient is unable to tolerate the 100 mg dose of Eluxadoline?
Decrease to 75 mg BID
154
What is a common monitoring symptom for Eluxadoline (Viberzi)?
Abdominal pain that radiates to the back or shoulder

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