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Pharm II > Constipation and Diarrhea > Flashcards

Constipation and Diarrhea Flashcards

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1
Q

Definition of constipation

A

Infrequent passage of stool or passage with difficulty

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2
Q

When is constipation more common?

A

Elderly
Women
Pts of low SES

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3
Q

Rome Criteria for constipation

A

Two or more of the following sx for at least 3 mos

  • Hard stools at least 25% of the time
  • Two or fewer BMs per week
  • Difficulty passing (straining) at least 25% of the time
  • Incomplete evacuation at a minimum of 25% of the time
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4
Q

What to ask the pt about constipation

A 
Current bowel movements and consistency
Usual bowel movements and consistency
Associated sx
Medical conditions
Dietary habits
Meds
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5
Q

Sx of constipation

A 
Nausea
-Can be present with or without vomiting
Abdominal pain
-Often described as "colicky"
Urinary incontinence
Diarrhea
-Fecal matter higher in the colon is broken down and moves past the hard impacted fecal mass
-Ask them when they had a meaningful BM
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6
Q

Alarming sx-constipation

A 
Severe abd pain
N/V
Blood in stool
A change in bowel habits >2 wks
Worsening of constipation despite tx
Tx >7 days unless directed by a PCP
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7
Q

Common reversible causes of constipation

A 
Meds
Reduced physical activity
Reduced fluid intake
-Dehydration
Reduced food intake
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8
Q

Other common causes of constipation

A 
Ileus
Malignancy
Autonomic dysfunction
Mechanical obstruction
Metabolic abnormalities
Spinal cord compression
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9
Q

Meds that can cause c onstipation

A 
Iron
NSAIDs
Opioids
Diuretics
Anticholinergics
CCBs, esp. nondihydropyradine
Calcium-containing antacids
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10
Q

Tx for constipation- goals

A

Prevention easier than tx
-Increase exercise, dietary intake fiber, fluid intake
Identify reversible causes and correct if possible
-Diet and meds commonly
Goal is two or three nl BMs per week with pt comfort being a goal as well.

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11
Q

Non-pharmacological tx options for constipation

A 
Encourage fluids
Activity as tolerated
Encourage fiber in diet as tolerated
-25-30 g per day
-Whole veggies and fruit
Avoid constipating meds if possible
Provide a comfortable and private environment for defecation
Educate about appropriate use of laxatives to minimize laxative abuse syndrome
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12
Q

Selection of tx for constipation

A

Minimal evidence to select one agent over another
Selection of a specific agent should depend on several factors such as cause, associated sx, medical hx, pt preference (administration), and cost

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13
Q

Laxative classifications

A 
Lubricants
Surfactants
Prokinetic agents
Osmotic laxatives
Stimulant laxatives
Bulk-forming agents
Opioid receptor antagonists
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14
Q

Examples of bulk-forming agents

A

Psyllium
Methylcellulose
Polycarbophil

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15
Q

Advantages of bulk-forming agents

A

Natural
Cheaper
Well-tolerated

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16
Q

Onset of action of bulk-forming agents

A

12-72 hrs

More preventative than acute

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17
Q

SEs of bulk-forming agents

A

Bloating
Cramping
Flatulence

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18
Q

Clinical pearls of bulk-forming agents

A

Often considered first-line therapy
Requires adequate hydration, at least 8 oz of water per dose
Caution in debilitated pts

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19
Q

Example of chloride channel activator

A

Lubiprostone (Amitiza)

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20
Q

Use for chloride channel activator

A

Reserved for chronic idiopathic constipation: failed other therapies
More appropriate niche is IBS
Very expensive

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21
Q

What do the lubricants do for constipation?

A

Mineral oil inhibits water reabsorption in the colon

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22
Q

SEs of mineral oil

A

Depletion of fat-soluble vitamins

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23
Q

Clinical pearls of mineral oil

A

Reserved- last line

Oral formulation not recommended in debilitated pts- risk of aspiration

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24
Q

Examples of osmotic constipation meds

A

Lactulose or sorbitol
Polyethylene glycol- OTC
-Also comes in PEG-ES for bowel evacuation
Used more in hepatic encephalopathy (lactulose)

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25
Use for osmotic constipation meds
2nd line
26
Onset of action of polyethylene glycol
24-96 hrs
27
Examples of osmotic/saline meds for constipation
Magnesium citrate or hydroxide
28
Use for magnesium citrate or hydroxide
Reserved- can cause electrolyte disturbances | Avoid in renal insufficiency and CHF
29
What are examples of opioid antagonists for constipation?
Methylnaltrexone | Alvimopan- hospital use only
30
Use of methylnaltrexone
For chronic opioid therapy | Does not cross blood-brain barrier, only acts on GI tract
31
Use of alvimopan
To prevent bowel obstruction after bowel resection surgery- reserved
32
What is an example of a prokinetic agent for constipation?
Metoclopramide
33
Use for metoclopramide
Reserved, think concomitant n/v | Often requires high doses
34
Examples of stimulants for constipation
Senna Bisacodyl Sodium phosphate
35
Onset of action for stimulants for constipation
6-12 hrs
36
SEs of stimulants for constipation
Nausea Cramping Electrolyte disturbance
37
Clinical pearls of stimulants for constipation
2nd or 3rd line Possible dependence with long-term use Sodium phosphate is last line agent Use no longer than 7 days- exception might be opioid use Senna and bisacodyl come in many different forms
38
What is a miscellaneous agent for constipation?
Linaclotide (Linzess)
39
Use of linaclotide
Chronic idiopathic constipation or IBS with constipation
40
What is an example of a surfactant for constipation?
Docusate sodium
41
Use of docusate sodium
Increases mixing of fatty materials in stool, 2nd or 3rd line Requires adequate hydration
42
What is the indication for rectal drugs for constipation?
Institutionalized, one week of constipation, quick tx
43
Definition of diarrhea
Greater than or equal 3 unformed stools in 24 hrs The passage of frequent, loose stools with urgency Considered chronic if lasting longer than 30 days
44
4 broad categories of diarrhea
Secretory Osmotic Exudative Altered intestinal transit
45
Common causes of diarrhea
``` AIDS Infection -Common in daycares and nursing homes Obstruction Meds Radiation therapy to bowel Malabsorption from cancers or resection ```
46
Meds associated with causing diarrhea
``` Abx Laxatives Cholinergics Mg antacids Chemo ```
47
Questions to ask for diarrhea
``` Diet -Changes in fiber, fat intake Appearance -Frequency, vol, consistency, and color Recent travel Med use Source of water Onset of sx and duration ```
48
Exclusions for self-tx of diarrhea
High-grade fever Recent abx use Severe abd pain Pregnancy or child <6 mos Pt is or is at risk for severe dehydration Immunocompromised or severe chronic illness If persists longer than 72 hrs or if gross blood or pus is present in stool
49
Tx principles of diarrhea
``` Dietary concerns Relieve sx Treat curable causes Treat any secondary d/os Prevent dehyrdation and electrolyte loss ```
50
Supportive care for diarrhea
Assess need for hydration and electrolytes -Rarely needed in short-term -Oral >IV Clear liquids and simple carbs Caution milk products to minimize risk of transient lactose intolerance May d/c solid foods and dairy products x 24 hrs in adults -Osmotic diarrhea -Secretory: diarrhea persists -Continue feeding children with acute bacterial diarrhea: BRAT diet: decreased morbidity and mortality
51
What are the general pharmacological classes for diarrhea?
``` Opioid agonists Anticholinergics Absorben (psyllium) Absorbent (attapulgite) Somatostatin analogues Mucosal prostaglandin inhibitors (bismuth subsalicylate) ```
52
What are the most effective oral agents for diarrhea?
Opioids
53
Loperamide facts
Often considered a drug of choice bc of efficacy, potency, and not crossing the blood brain barrier Shown to inhibit peristalsis, prolong transit time, reduce fecal volume, and increase anal sphincter tone Well tolerated with some peripheral opioid side effects -Can still cause drowsiness
54
Loperamide dosing
4 mg PO initially, then 2 mg after each loose stool up to a max of 16 mg/day
55
Indications for loperamide
Traveler's diarrhea Nonspecific acute diarrhea When pt has low grade fever no bloody stools
56
Codeine facts
DOES cross the blood brain barrier and can cause CNS depression Effective but has many SEs Other opioid antagonists are theoretically effective Caution co-administration with other CNS depressants
57
Diphenoxylate with atropine facts
Prescription DOES cross the blood brain barrier and can cause CNS depression Little to no analgesic properties Do not exceed 20 mg/day in adults Combined with atropine to reduce abuse potential
58
MOA of anticholinergics for diarrhea
Work by decreasing secretions into the GI tract and possibly altering gut motility SEs are numerous and efficacy is questionable Do NOT recommend use for tx
59
Examples of anticholinergics for diarrhea
Atropine Dicyclomine Hyoscyamine
60
Lactobacillus preparations facts
Replace colonic microflora Supposedly restores nl intestinal fxn and suppresses growth of pathogenic microorganisms Use caution in IC pts Wide range of cost
61
Lactase enzyme
For lactose intolerance | Directions specific to product selected
62
Monitoring for diarrhea
``` Viral infectious diarrhea is often self-limiting Monitoring should include: -Med adverse effects -S/sx of dehydration -Improvement in diarrhea within 48 hrs ```

Pharm II (8 decks)

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