amber m. hutchison, pharmd, bcps assistant clinical professor auburn university harrison school of...

Going or Stopping:Picking the Right Product for

Constipation & Diarrhea

Amber M. Hutchison, PharmD, BCPSAssistant Clinical ProfessorAuburn University Harrison School of Pharmacy

Harrison School of PharmacySpring CE 2013

Disclosures

Programming offered by Auburn University Harrison School of Pharmacy shall exhibit balance, providing the audience information of different perspectives from which to develop an informed professional decision.I, Amber Hutchison, have no actual or potential conflict of interest in relation to this program.

Objectives

List three common causes of constipation and diarrhea in the communityRecognize patient-specific exclusions for self-treatment of constipation or diarrhea Effectively counsel patients seeking self-treatment for constipation or diarrhea

Constipation

ConstipationIs a symptom, not a diseaseRome III criteria:

Two or more of the following symptoms for >6 months for more than 25% of defecations in the past 3 months:

StrainingLumpy or hard stoolsSensation of incomplete evacuationSensation of anorectal obstruction/blockageManual maneuvers to facilitate defecations; <3 defecations per weekLoose stools are not present with insufficient criteria for irritable bowel syndrome

Bharucha AE. Gastroentrol 2013; 144(1):218-238.

ConstipationCauses

Lifestyle or extrinsic factors

Structural issues

Systemic

Neurologic

Psychological

Weitzel KW and Goode JVR. Constipation. In: Krinsky DL, Berardi RR, Ferreri SP, Hume AL, Newton GD, Rollins CJ, Tietze KJ, editors. Handbook of Nonprescription Drugs. Washington, DC: American Pharmacist Association; 2012. p 253-278.

Constipation—QuEST

Question the patient quickly and accuratelyUtilize SCHOLAR-MAC

Establish that the patient is an appropriate self-care candidateSuggest appropriate self-care strategiesTalk to the patient

Constipation—Question

S- Symptoms: What types of symptoms have you been having?

C- Characteristics/Course: Describe the types of bowel movements (BMs) you have been having?How often are you having BMs?Is it hard and small?

H- History of symptoms in past: Has this happened previously?How have you treated these symptoms in the past?


O- Onset: When did the symptoms start?When was your last BM?

L- Location: Likely to be obvious

A- Aggravating Factors: What makes your symptoms worse?

R- Relieving Factors: What makes your symptoms better?


M- Medications: What medications do you currently take?

A-Allergies: What allergies do you have?

C- Medical Conditions:What other disease states or illnesses do you have?

Constipation—Establish self-carePatient is not an appropriate candidate if any of the following are present:

Abdominal painNauseaVomitingSudden change in bowel habits that persists for two weeksUse of a laxative product for more than seven days unless directed by primary care providerOccurrence of rectal bleeding or lack of BM after laxative use at any time during treatment


Constipation—Suggest therapy

Suggest appropriate self-care strategiesMedicationsAlternative care measuresGeneral care measures

Class AgentsBulk-forming Methylcellulose

Calcium polycarbophilPsyllium

Hyperosmotic agents Polyethylene glycolGlycerin

Emollient agent Docusate

Lubricant agent Mineral oil

Saline laxative agents Magnesium citrateMagnesium hydroxideMagnesium sulfateMono/di-basic sodium

Stimulant agents SennaBisacodylCastor oil


Constipation—SuggestBulk forming agentsAgent Dosage Form Adult Dosage Onset of Action

Methylcellulose Caplet 500 mg

Powder 2 mg/tbsp

2 caplets up to 6 times daily1 rounded tbsp up to TID

12-24 hoursUp to 72 hours

Calcium polycarbophil

Caplet 625 mg 2 caplets daily Up to QID

Psyllium Capsule 0.52 g

Powder 3.4 g per scoop or packet

5 capsules w/8 oz of liquid up to TID1 rounded tbsp in 8 ounces of liquid up to TID


tbsp=tablespoon

Constipation—SuggestHyperosmotic agents

Agent Dosage Form Adult Dosage Onset of Action

Polyethylene glycol Powder 17 gm/capful

17 gm in 4-8 oz liquid daily

12-72 hoursUp to 96 hours

Glycerin Rectal solid suppository 2gmRectal liquid suplpository 5.6 gm/5.5 mL

1 suppository

1 suppository

15-30 minutes


tbsp=tablespoon

Constipation—SuggestEmollient agents


Docusate sodium Capsules 50 mg and 100 mg

Syrup 60 mg/15mL

50-300 mg PO daily in single or divided doses1-6 tbsp daily in single or divided doses

~48 hoursUp to 3-5 days

Docusate calcium Capsule 250 mg 1 capsule PO daily for several days or until BM normal


tbsp=tablespoon

Constipation—SuggestLubricant agents


Mineral oil Oral liquid

Oral liquid emulsion (2.5 mL/5 mL)

Rectal liquid enema (118 mL)

1-3 tbsp, max 3 tbsp/24 hours6-15 tbsp per day

1 bottle as directed

6-8 hours after PO5-15 minutes after enema


tbsp=tablespoon

Constipation—SuggestSaline laxative agentsAgent Dosage Form Adult Dosage Onset of Action

Magnesium citrate Liquid 10 oz ½-1 bottle ½-3 hours after PO2-15 minutes after rectal

Mono-/dibasic sodium phosphate

Rectal liquid enema 118 ml

1 bottle

Magnesium hydroxide

Liquid 400 mg/5 mL

Chewable tablet 311 mg/tablet

2-4 tbsp daily single or divided doses8 tabs once in a 24 hour period

½-6 hours

Magnesium sulfate (Epsom salt)

Solid—generally not recommended

2-6 teaspoons daily Do not recommend!


tbsp=tablespoon

Constipation—SuggestStimulant agentsAgent Dosage Form Adult Dosage Onset of Action

Senna Tablet 8.6 mg sennosides

Pills or chocolate pieces 15 mg sennosides

2 tabs PO daily up to 4 tabs PO BID

2 pills or pieces daily or BID

6-10 hours after PO15-60 minutes after suppository

Bisacodyl Tablet 5 mgRectal suppository 10 mg

1-3 tablets daily1 suppository daily

Castor oil(generally not recommended)

Liquid 1-4 tbsp PO daily Do not recommend!


tbsp=tablespoon

Constipation—SuggestCombination Product


Senna/docusate Tablet 8.6 mg sennosides and docusate sodium 50 mg

2 tabs PO daily up to 4 tabs PO BID 6-10 hours after PO


Constipation—Talk to patient Medication counseling

Bulk forming agentsMUST take with adequate fluidSide effects: abdominal cramping and flatulence

Hyperosmotic laxativesUse measuring devices which come with the medicationPolyethylene glycol side effects: bloating, abdominal discomfort, cramping, flatulenceGlycerin side effects: rectal irritation

Emollient laxativesDo not take mineral oil with docusate


Constipation—Talk to patient Medication counseling

Lubricant laxativesMineral oil side effects: possible lipoid pneumonia

Saline laxativesOlder adults may be at increase risk of electrolyte disturbancesSide effects: abdominal cramping, nausea, vomiting, dehydration

Stimulant laxativesSide effects: severe cramping, electrolyte and fluid deficiencies, enteric loss of protein, malabsorption, hypokalemia


Constipation—Talk to patient ROUTE of administration of product

EnemaLie on left side with knees bent or other position recommended by productMay need to dilute per package instructionsLubricate enema tip and anal areaGently insert tip 2-3 inches into the rectumAllow solution to flow slowlyRetain until cramping is felt

SuppositoryGently squeeze to determine firmness

May need to chillREMOVE WRAPPINGLie on left side with knees bent or other position recommended by productRelax the buttock before insertingInsert tapered end firstNeed to insert past the anal sphincterContinue to lie down to allow dissolving


Constipation—Talk to patient

Discuss diet25-35 gm of dietary fiber per day

Will need to titrate up to goalAvoid constipating foodsDrink plenty of fluids

Increase exerciseDo not take other medications within 2 hours of a laxativeTake most laxatives at bedtime


Constipation—Talk to patient

Good bowel habitsEstablish a regular pattern

Urge is strongest in the morning and 30 minutes after a meal

Do not delay responding to urge to defecateAllow adequate time for toileting

When to follow up with physician No relief after 7 days of laxative treatmentIf rectal bleeding occurs


Diarrhea

DiarrheaDefined as:

Abnormal increase in stool frequency, liquidity, or weightLength of symptoms:

Acute is < 14 daysPersistent is 14 days to 4 weeksChronic is > 4 weeks

Walker PC. Diarrhea. In: Krinsky DL, Berardi RR, Ferreri SP, Hume AL, Newton GD, Rollins CJ, Tietze KJ, editors. Handbook of Nonprescription Drugs. Washington, DC: American Pharmacist Association; 2012. p 279-298.

DiarrheaCauses

Viral gastroenteritisNoroviruses and rotavirus

Bacterial gastroenteritisFood-borne gastroenteritis

Bacterial, protozoal, or viralTraveler’s diarrhea

Food intolerancesMedications


Diarrhea—Dehydration SeverityMinimal-No Dehydration

Mild-to-moderate Dehydration

Severe Dehydration

Degree of dehydration

<3% 3-9% >9%

Mental status Good, alert Normal, fatigued or restless, irritable

Apathetic, lethargic unconscious

Thirst Drinks normally, might refuse liquids

Thirsty, eager to drink Drinks poorly, unable to drink

Heart rate Normal Normal to increased Tachycardia, bradycardia if severe

Extremities Warm Cool Cold, mottled cyanotic

Blood pressure Normal, no orthostatic changes

Normal, mild orthostatic changes

Low blood pressure, dizziness

# unformed stools

<3 3-5 6-9


Diarrhea—Question

S- Symptoms: What types of symptoms have you been having?

C- Characteristics/Course: Describe the types of bowel movements (BMs) you have been having?How often are you having BMs?

H- History of symptoms in past: Has this happened previously?How have you treated these symptoms in the past?

Diarrhea—Question

O- Onset: When did the symptoms start?When was your last BM?

L- Location: Likely to be obvious

A- Aggravating Factors: What makes your symptoms worse?

R- Relieving Factors: What makes your symptoms better?

Diarrhea—Question

M- Medications: What medications do you currently take?

A-Allergies: What allergies do you have?

C- Medical Conditions:What other disease states or illnesses do you have?

Patient is not an appropriate candidate if any of the following are present:

< 6 months of ageSevere dehydration>6 months of age with persistent high fever (>102.2F)Blood, mucus, or pus in the stoolProtracted vomitingSevere abdominal pain/distressPregnancy

Risk for significant complications

DM, severe CVD, renal diseaseMultiple chronic medical conditionsImmunosuppressed patients

Chronic or persistent diarrheaInability of the caregiver to administer oral replacement solution (ORS)Suboptimal response to ORS

Diarrhea—Establish self-care


Diarrhea—Suggest

Medication Dosage Forms Directions Length of Treatment

Loperamide Caplets—2 mgLiquid—2 mg/15 mL

4 mg initially, then 2 mg after each loose stoolMax=8 mg/day

48 hours

Bismuth subsalicylate

Tablets—262 mgCaplets—262 mgLiquid—262 mg/15 mL and 525 mg/15 mL

525 mg every 30-60 minutesMax=4200 mg/day or 8 doses/day

48 hours

Digestive enzymes

Chewable tablets, caplets, liquids

Package directions with first bite of dairy product

With each dairy product


Diarrhea—Suggest Manage fluid and electrolytes

Oral replacement solution (ORS)Some common liquids may worsen diarrhea and contribute to low sodium levelsFor patients >5 years of age, sports drinks with added sodium source may be sufficient

Product Dextrose g/L

Sodiummeq/L

Potassiummeq/L

OsmolaritymOsm/L

WHO-ORS 13.5 75 20 245

Pedialyte® 25 45 20 249

Gatorade® 45 20 3 330

Chicken broth 0 250 5 450

Ginger ale 50-150 3 1 540


Diarrhea—Suggest Manage fluid and electrolytes

Oral replacement solution (ORS) recommended for mild-moderate dehydration

Severe dehydration requires immediate medical attentionMild to moderate dehydration:

Drink 2-4 liters of ORS over 4 hoursReplace ongoing losses

Minimal to no dehydration: Drink 0.5-1 cup of ORS per loose stool

Probiotics?Not recognized by the FDA


Diarrhea—Talk with patientCounsel on medication recommended

LoperamideOnly use in patients >6 years of ageSide effects: occasional dizziness, constipation

Bismuth subsalicylateOnly use in patients >12 years of ageUse caution if patient is concurrently using aspirinSide effects:

Harmless black staining of stool or darkening of tongueDiscontinue if patient experiences mild tinnitus or signs of neurotoxicity


Diarrhea—Talk with patientIllness should be self-limitingDo not withhold food for > 24 hours

May start with a bland dietBRAT diet is inappropriate

Bananas, Rice, Applesauce, Toast

Hygiene measures may be warrantedORS in powder form

Counsel on appropriate mixing


Diarrhea—Talk with patientWhen to follow up with primary care provider

If diarrhea has not resolved after 48-72 hours of initial treatmentNumber of BMs increasesSigns of dehydrationHigh feverBlood in the stool


Going or Stopping:Picking the Right Product for

Constipation & Diarrhea

Amber M. Hutchison, PharmD, BCPSAssistant Clinical ProfessorAuburn University Harrison School of Pharmacy

Harrison School of PharmacySpring CE 2013

amber m. hutchison, pharmd, bcps assistant clinical professor auburn university harrison school of...

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