Lec 7

Definition
• Bowel symptoms (difficult or infrequent passage of stool,

hardness of stool, or a feeling of incomplete evacuation).
• Normal stool frequency ranges from three times daily to
three times per week.
• It is considered chronic if it is present for at least 12 weeks (in
total, not necessarily consecutively) during the previous year.
• Constipation is common in all age groups, however; there
is a higher prevalence in people > 65 years of age & Women
suffer from constipation more often than men.
Common causes include:
 Nutritional (e.g., reduced fiber and water intake)

 Medications: Antacids, Iron, BZDs, Opioids, TCA,
 Disorders (e.g., hypothyroidism, diabetes)
 Pregnancy
 Structural obstruction
Complications
 Difficulty in defecation may cause substantial discomfort, abdominal
cramping, and a general feeling of malaise.
 Constipation typically results in self-medicating with various laxatives.
Although laxatives may correct the acute problem, chronic use of these
agents leads to habituation, necessitating ever-increasing doses that
result in drug dependency and, ultimately, a hypotonic laxative colon.
 Acute or chronic episodes of straining may cause acute or chronic
hemorrhoidal disease (characterized by pain, itching, or bleeding) that
occur secondary to an increase in colonic luminal pressure and
intravascular pressure
Treatment Strategies
1. Removal or treatment of underlying cause(s), if possible
2. Nonpharmacologic interventions:
 Increase fluid intake to 6–8 glasses of water per day
 Increase dietary fiber intake: Dietary fiber is available in diverse
natural sources, such as fruits, vegetables, and cereals.
 Incorporate or increase exercise to 3–5 days/week.
 Bowel training to increase regularity (i.e., allowing regular and
adequate time for defecation).

 Milk and milk products should be minimized if these prove
constipating.
 In some patient populations, coffee, tea, and alcohol account for
the majority of the fluid volume consumed. Patients should be
made to understand that because of the diuretic effects of these
products. It is usually recommended that patients decrease their
consumption of coffee, tea, and alcohol as much as possible

3-Drug therapy
• Choose drug therapy on the basis of desired onset of action,
patient preference, presence of potential contraindications, and
use in special populations.
• Recommendations for simple constipation should begin as a
step-wise approach with bulk-forming laxatives as first line,
hyperosmotic laxatives as second line, and then stimulant
laxatives
Bulk-forming laxatives:
Fiber is arguably the best and least expensive medication for long-term
treatment. It is important to convey to patients that bulk-forming agents
generally do not work rapidly and must be used on a long-term basis.
Drug: Psyllium, Inulin, Wheat dextrin, Methylcellulose
Role:
Intermittent or chronic constipation
Comments:
Onset 12–72 hours, requires adequate water intake to be effective
Safe in renal and hepatic disease, pregnancy, geriatrics
May cause gas/bloating
Osmotic laxatives
Drug: Glycerin
Role:
Management of acute or intermittent constipation
Used in pediatric patients
Comments:
Suppository
Fast onset (within 1 hour)
Osmotic laxatives
Drug: Lactulose
Role:
Management of acute, intermittent, or chronic
constipation, preferred in chronic liver disease
Comments:
Onset 1–2 days (may require multiple doses)
Associated with gas/bloating
Syrup
Osmotic laxatives
Drug: Sorbitol
• irrigation solution: 3g/100mL (3%)
• oral solution: 70%

Osmotic laxatives
Drug: Polyethylene glycol (PEG)
Role:
The use of PEG as first-line therapy in chronic
constipation is increasing
Preoperative/colon preparation
Comments:
Safe in renal and hepatic disease and pregnancy
Overall, well tolerated; may be used long term
Stimulant laxatives
Drug: Senna
Role:
Short-term relief of acute or intermittent constipation
Comments:
Tablets and liquid
Onset 6–12 hours
May cause abdominal cramping, electrolyte disturbances, melanosis coli
Stimulant laxatives
Drug: Bisacodyl
Role:
Short-term relief of acute or intermittent constipation
or as part of preoperative/ colonoscopy bowel preparation
Comments:
Oral onset 6–12 hours, suppository within 1 hour
Oral tablets are enteric coated
Stimulant laxatives
Drug: Sodium picosulfate
Sodium picosulfate is a prodrug.
Stimulant laxatives
Drug: Castor oil
Role:
Castor oil is reduced to ricinoleic acid. It decreases net
absorption of fluid and electrolytes and stimulates peristalsis.
Emollient laxatives
Drug: Docusate sodium, Docusate potassium
Role:
Emollient laxatives, also known as surfactants, work by allowing
water to move more easily into the stool. This creates a softer stool,
which is easier to pass. Thus, these agents are particularly useful in
those who must avoid straining to pass hard stools (e.g., recent
myocardial infarction, rectal surgery)
Comments:
Requires adequate water intake to be effective
Saline laxatives
Drug: Magnesium citrate, Magnesium hydroxide, Sodium phosphate
Role:
Acute or intermittent constipation
Preoperative or preprocedure bowel preparation
Comments:
Fast onset (15 minutes to 3 hours)
Avoid in renal impairment, HF
Lubricant laxatives
Drug: Mineral oil
Role:
They lubricate the intestine and facilitate passage of stool
by decreasing water absorption from the intestine.
Comments:
Mineral oil should be taken on an empty stomach.
Because of possible aspiration of mineral oil into the
lungs (lipid pneumonitis)
Drug: Lubiprostone
Dose is 24 mcg twice daily for constipation
Need negative pregnancy test before use

Prokinetic Agents
Drug: Prucalopride
Role: a selective 5-hydroxytryptamine type 4 receptor (5-
HT4) agonist, is a gastrointestinal (GI) prokinetic agent that
stimulates colonic peristalsis, thus increasing bowel motility.
It is indicated for chronic idiopathic constipation.

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Definition

• Bowel symptoms (difficult or infrequent passage of stool,

 Nutritional (e.g., reduced fiber and water intake)

 Disorders (e.g., hypothyroidism, diabetes)

 Increase fluid intake to 6–8 glasses of water per day

 Increase dietary fiber intake: Dietary fiber is available in diverse

natural sources, such as fruits, vegetables, and cereals.

 Incorporate or increase exercise to 3–5 days/week.

 Bowel training to increase regularity (i.e., allowing regular and

adequate time for defecation).

 In some patient populations, coffee, tea, and alcohol account for

the majority of the fluid volume consumed. Patients should be

made to understand that because of the diuretic effects of these

products. It is usually recommended that patients decrease their

consumption of coffee, tea, and alcohol as much as possible

• Choose drug therapy on the basis of desired onset of action,

patient preference, presence of potential contraindications, and

use in special populations.

• Recommendations for simple constipation should begin as a

step-wise approach with bulk-forming laxatives as first line,

hyperosmotic laxatives as second line, and then stimulant

• irrigation solution: 3g/100mL (3%)

• oral solution: 70%

Dose is 24 mcg twice daily for constipation

Need negative pregnancy test before use

Role: a selective 5-hydroxytryptamine type 4 receptor (5-

HT4) agonist, is a gastrointestinal (GI) prokinetic agent that

stimulates colonic peristalsis, thus increasing bowel motility.

It is indicated for chronic idiopathic constipation.

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