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Diarrhea &

Constipation
CAPP IV: PYDI 5320
April 17, 2015

Janelle E. Hestin, PharmD


PGY-1 Ambulatory Care Pharmacy Resident

Objectives
In lab, P2 students should be able to do the following
without error:
Using QuEST/SCHOLAR-MAC techniques, eff ectively and
effi ciently interview a patient presenting with a diarrhea or
constipation complaint
Appropriately refer patients to a physician for follow-up care
based on patient-specifi c exclusions for self-care treatment of
diarrhea or constipation
Following the patient interview and assessment, select the
most appropriate product based on the patients specifi c
symptoms and treatment goals.

On a written exam and without class notes, P2 students


should be able to do the following without error:
Select an appropriate over-the-counter product for a patient
presenting with diarrhea/constipation or recognize when
medical referral is needed
Classify a patients level of dehydration based on symptoms

CONSTIPATION

What is Constipation?
Rome III Functional Constipation Criteria:
Two or more of the following symptoms for more than
25% of defecations in the past 3 months (with
symptom onset at least 6 months prior to diagnosis):

Straining
Lumpy or hard stools
Sensation of incomplete evacuation
Sensation of anorectal obstruction/blockage
Manual maneuvers to facilitate defecations
Less than 3 defecations per week

Additionally, loose stools are not present and there is


insuffi cient criteria for irritable bowel syndrome

Causes of Constipation
Lifestyle/Extrinsic
Factors
Low fi ber intake
Sedentary lifestyle
Low fl uid intake
Ignoring urge to
defecate

Structural issues
Colorectal injury, bowel
obstruction, etc.

Systemic issues
What are some
examples?

Neurologic issues
Autonomic neuropathy
MS
Parkinsons
Stroke
Dementia

Psychological issues
Depression
Eating disorders
Stress

MEDICATIONS

Medications & Constipation


Analgesics
Antacids
Anticholinergics
Anticonvulsants
Antidepressants
Antimuscarinics
Benzodiazepines
Calcium Channel
Blockers
Calcium
supplements

Clonidine
Diuretics
MAOIs
Muscle relaxants
OPIATES
Parkinsonism agents
Sedative hypnotics
Sucralfate
AND MORE
(see chapter for more
examples)

Constipation - Treatment Goals


1. Relieve symptoms and reestablish normal
bowel function
2. Establish lifestyle changes to prevent
reoccurrence
3. Emphasize safe/eff ective use of laxative
products

Constipation - Patient Assessment


Question the patient quickly and accurately
Using SCHOLAR-MAC

Establish that the patient is an appropriate


self-care candidate
Suggest appropriate self-care
strategies/treatments
Talk to the patient

Constipation - Patient Assessment


Symptoms
Characteristics/course
History of symptoms in
the past

Onset
Location
Aggravating factors
Relieving/Remitting
factors

Medications
Allergies

Constipation - Question
S Symptoms:
What symptoms are you having?
Ask about/recognize alarm symptoms

Blood/mucous/pus in stool
Nausea/vomiting
Fever
Pencil-thin stools
Irritable bowel disease
Severe abdominal pain

C Characteristics:
What types of bowel movements are you having?
How often are your BMs?
Describe your stool (hard and small, etc. ?)

Constipation - Question
H History:
Have you experienced these symptoms in the past?
How have you treated these symptoms in the past?
What treatments were eff ective in the past?

O Onset:
When did your symptoms start?
How long as it been since your last BM?

L Location:
Probably unnecessary to ask in this case

A Aggravating Factors:
What makes your symptoms worse?

Constipation - Question
R Relieving Factors:
What makes your symptoms better?

M Medications:
What medications are you taking?
OTC AND RX

A Allergies:
Do you have any drug allergies?

C Conditions (Medical Conditions):


What medical conditions/disease states do you have?

Constipation - Establish Self-Care


Determine whether or not the patient is an
appropriate candidate for self care
Exclusions for Self-Care:
Abdominal Pain
Nausea and/or Vomiting
Sudden change in bowel habits that persists for
at least 2 weeks
Laxative use >7days without relief (unless
directed by a physician)
Rectal bleeding/Lack of bowel movement at
anytime during treatment with a laxative

Constipation Suggest Therapy


Suggest appropriate self-care strategies
OTC medications
General care measures
Lifestyle changes

Constipation Talk to the Patient


Counsel patient on recommended treatment
options
Product description
Product use
Dose (treatment dose and maximum dose), route,
frequency, max duration

When to expect relief


Adverse reactions

Counsel patient on non-pharmacologic


recommendations
Exercise
Diet
Etc.

Counsel patient on when to contact physician

Constipation Treatment Options


Class
Bulk-forming
Hyperosmotic agents

Agents
Methylcellulose (Citrucel)
Calcium polycarbophil (FiberCon, Fiber-Lax)
Psyllium (Metamucil)
Polyethylene glycol (MiraLax, GlycoLax)
Glycerin

Emollient agent

Docusate (Colace, Stool Softener, Dulcolax Stool


Softener)

Lubricant agent

Mineral oil (Fleet Oil)

Saline laxative agents

Stimulant agents
Combination

Magnesium citrate (Citroma)


Magnesium hydroxide (Milk of Magnesia)
Magnesium sulfate (Epsom Salt)
Mono/di-basic sodium (Fleet Enema)
Senna (Ex-Lax, Senokot)
Bisacodyl (Dulcolax, Bisacodyl Laxative)
Castor oil
Docusate + senna (Senokot-S)

Bulk-Forming Agents
MOA: Increases bulk of stool in order to stimulate GI
motility; stimulates action that mimics normal
physiology
Not recommended for:
Patients with diffi culty swallowing
Patients requiring fl uid restriction
Patients who are immobile

Counseling Points:
Good choice if no immediate action is needed
Take with adequate fl uid (at least 8 oz per dose)

Side Eff ects:


Bloating
Cramping
Flatulence

Bulk-Forming Agents
Agent

Methylcellulose

Calcium
polycarbophil

Dosage Form

Adult Dosage

Caplet 500 mg

2 caplets PO up
to 6 times daily

Powder 2
mg/tablespoon

1 rounded
tablespoonful
PO up to TID
(Mixed in liquid)

Caplet 625 mg

2 caplets PO
daily up to QID

Capsule 520mg

Psyllium

Powder 3.4 g
per scoop or
packet

5 capsules PO
up to TID (Take
with 8 oz of
liquid)
1 rounded
tablespoonful
PO up to TID

Onset of
Action

12 to 24 hours
Up to 72 hours

Hyperosmotic Agents
MOA: Draws water into the colon/rectum; stimulates
bowel movement
Not recommended for:
Patients with intestinal obstruction

Counseling Points:
Polyethylene Glycol

Use measuring device supplied with the medication


Take with plenty of water (mixed in 4 to 8oz of liquid)
Do not use in IBS
Generally well-tolerated

Glycerin Suppository
Proper suppository administration (see counseling slide)

Side Eff ects:


Polyethylene Glycol Bloating, cramping, fl atulence,
diarrhea (high doses)
Glycerin Suppository Rectal irritation

Hyperosmotic Agents

Agent

Dosage Form

Adult Dosage

Onset of
Action

Polyethylene
glycol

Powder
17g/capful

17 grams mixed
into 4 to 8 oz
liquid daily

12 to 72 hours
Up to 96 hours

1 suppository

15 to 30 minutes

Rectal solid
suppository 2
gram
Glycerin

Rectal liquid
suppository 5.6
gram/5.5 mL

Emollient Agents
MOA: Increases wetting effi cacy of intestinal fl uid;
allows for improved interaction between water and
stool (stool softener )
Recommended for:
Patients who should refrain from straining post-surgery,
post-heart attack
Primary role in therapy Prevention

Counseling points:
Do NOT use with mineral oil
WHY?

Side eff ects:


Bad taste (liquid docusate)
Diarrhea
Cramps

Emollient Agents

Agent

Docusate
sodium

Docusate
calcium

Dosage Form

Adult Dosage

Capsules 50 mg
and 100 mg

50 to 300 mg PO
daily in single or
divided doses

Syrup 60
mg/15mL

1 to 6
tablespoonsful
daily in single or
divided doses

Capsule 250 mg

1 capsule PO
daily for several
days or until
BMs normalize

Onset of
Action

48 to 72 hours

Lubricating Agents
MOA: Coats fecal matter/decreases intestinal
absorption of water, softens/lubricates to ease
passage of stool
Recommended for:
No one
Avoid recommending General safety concerns

Counseling points:
Do not use with docusate; may increase absorption of
mineral oil
Take on an empty stomach

Side Eff ects:


Lipoid pneumonia
Oily anal discharge

Lubricating Agent

Agent

Dosage Form

Adult Dosage

Onset of
Action

1 to 3
tablespoonsful
Oral liquid
Mineral oil

Max:
3 tablespoonsful
in 24 hours

Oral liquid
emulsion (2.5
mL/5 mL)

6-15
tablespoonsful
per day

Rectal liquid
enema (118 mL)

1 bottle as
directed

6 to 8 hours

5 to 15 minutes

Saline Laxative Agents


MOA:
Creates an osmotic gradient, pulls fl uid into intestinal tract
to soften stool; decreases transit time through the colon

Recommended for:
Patients looking for quick relief

NOT recommended for:


Patients at risk for electrolyte imbalances (sodium
restricted diet, etc.)
Avoid in elderly

Side eff ects:

Electrolyte imbalances
Diarrhea
Dehydration Take with 8 ounces of fl uid to avoid this
Abdominal cramping
Nausea/vomiting

Saline Laxative Agents

Agent

Dosage Form

Adult Dosage

Onset of
Action

Magnesium
citrate

Liquid 10 oz

to 1 bottle

to 3 hours

Mono-/dibasic
sodium
phosphate

Rectal liquid
enema 118 ml

1 bottle

2 to 15 minutes

Liquid 400 mg/5


mL
Magnesium
hydroxide

Chewable tablet
311 mg/tablet

2 to 4
tablespoonsful
daily in single or
divided doses
8 tabs in a single
dose or in
divided doses
per 24 hours

to 6 hours

Stimulant Agents
MOA: Increases intestinal motility by irritating the local
mucosa; increases secretions of water/electrolytes into
the intestines
Recommended for:
Patients using opioid therapy (used with or without docusate)

Counseling points:
Do not take bisacodyl within 1 hour of milk, milk products,
antacids or H2-blockers (cimetidine, famotidine, ranitidine,
etc.)
Do not crush or chew bisacodyl
Not for long term use (>7 days) unless clinically indicated

Side eff ects:

Severe cramping
Electrolyte and fl uid defi ciencies
Enteric loss of protein, malabsorption
Hypokalemia

Stimulant Agents

Agent

Senna

Bisacodyl

Castor oil

Dosage Form

Adult Dosage

Tablet 8.6 mg
sennosides

2 tabs PO daily
Max: 4 tabs PO
BID

Pills or chocolate
pieces 15 mg
sennosides

2 pills or
chocolate
pieces daily or
BID

Tablet 5 mg

1 to 3 tablets
daily

Rectal suppository
10 mg

1 suppository
daily

Liquid

1 to 4
tablespoonsful

Onset of
Action

6-10 hours after


PO
15-60 minutes
after suppository
(bisacodyl)

Do not

Combination Product

Agent

Dosage Form

Tablet 8.6 mg
Senna/docusa sennosides /
te
docusate sodium
50 mg

Adult Dosage

Onset of
Action

2 tabs PO daily
Max: 4 tabs PO
BID

6 to 10 hours
after PO

Counseling Rectal Administration


Enema
Recommended position: On left side with knees bent (other
positions depicted below)
Dilute product per package instructions
Lubricate enema tip and anal area
Gently insert tip 2 to 3 inches into the rectum
Allow solution to fl ow slowly
Retain until cramping sensation begins

Counseling Rectal Administration


Suppository
Do not handle excessively prior
to administration (may melt)
If too soft, may need to chill

REMOVE WRAPPING
Recommended position: On left
side with knees bent (other
positions depicted on previous
slide)
Relax the buttock before
inserting
Insert tapered end fi rst
Insert completely (past the
anal sphincter)
Continue to lie down to allow
dissolving

Non-Pharmacologic Treatment
Diet
FIBER
25-35 grams per day
Whole grains, oats,
fruits, vegetables

Avoidance of
constipating foods
Processed cheese,
concentrated sweets,
etc.

Adequate fl uid intake


At least eight 8 ounce
glasses of water per day

Physical activity
Increase
exercise/activity level

Bowel Habits
Do not ignore the urge
to defecate

General emotional
well-being and
avoidance of
stressful situations

Self-Assessment
A 45 yo WM reports to your community pharmacy with
complaints of constipation. He has been self-treating with a
combination product called Senna-S (sennosides/docusate)
regularly for the past week and a half, but has not had any
relief. He wants to know what other products might help. He
denies any other medical conditions or medications. What
would you recommend next for this patient?
A. Mineral oil, 3 tablespoons PO daily
B. Bisacodyl 10 mg rectal suppository, 1 suppository daily
C. PEG 3350, 17 grams mixed into 4 to 8 oz liquid PO daily
D. Nothing--Refer to medical care for further assessment

Self Assessment
AB, a 35 yo AAM, is looking for a product that
will relieve his constipation as quickly as
possible.
What questions would you like to ask AB?

Self Assessment
S: Unable to produce regular BMs, feelings of
incomplete evacuation. No alarm s/s.
C: Hard, very small BMs
H: Does not happen often, but has happened in the
past. Symptoms previously resolved w/o treatment
O: Symptoms started 4 days ago
L:
A: Nothing
R: Nothing
M: Amlodipine 10 mg po daily
A: Penicillin (rash, hives)
C: Hypertension

What would you recommend for AB?


A. PEG 3350 powder
B. Bisacodyl 10 mg suppository
C. Docusate sodium 100 mg capsules
D. Senna 8.6 mg tablets
E. Mineral oil oral liquid

Self Assessment

Product
PEG 3350 powder
Bisacodyl suppository
Docusate sodium
capsules
Senna tablets
Mineral oil oral liquid

Onset of Action
12 to 72 hours
Up to 96 hours
15 to 60 minutes
48 to 72 hours
6 to 10 hours
6 to 8 hours

DIARRHEA

Diarrhea
An abnormal increase in the frequency,
liquidity, or weight of stool
More than 3 BMs per day is considered
abnormal
Most prevalent in children younger than 5 years
old
Least prevalent in
Types
of Diarrhea
older
adults
Acute

Symptoms for < 14


days

Persistent

Symptoms for 2 to 4
weeks

Chronic

Symptoms for > 4


weeks

Causes of Diarrhea
Viral gastroenteritis
Noroviruses
Rotavirus
Adenoviruses
Astroviruses
Hepatitis A

Bacterial gastroenteritis
Campyllobacter spp.
Salmonella spp,
Shigella spp.
Escherichia coli
Staphylococcus spp.
Clostridium spp.
Yersinia entercolitica
Bacillus cereus

Food-borne
gastroenteritis
Bacterial, protozoal, or
viral
Travelers diarrhea

Food intolerances
Medications
Antibiotics
Antacids containing
magnesium
Chemotherapy agents
PPIs
Etc.

Diarrhea Treatment Goals


1. To prevent/correct fl uid and electrolyte loss
2. To control symptoms
3. To identify/treat the cause
4. To prevent acute morbidity and mortality

Assessing Dehydration Status


Minimal to No
Dehydration

Mild-toModerate
Dehydration

Severe
Dehydration

<3%

3 to 9%

>9%

Mental status

Good, alert

Normal, fatigued
or restless,
irritable

Apathetic,
lethargic
unconscious

Thirst

Drinks
Thirsty, eager to
normally, might
drink
refuse liquids

Degree of
dehydration

Drinks poorly,
unable to drink
Tachycardia,
bradycardia if
severe

Heart rate

Normal

Normal to
increased

Extremities

Warm

Cool

Cold, motteled
cyanotic

Blood
pressure

Normal, no
orthostatic
changes

Normal, mild
orthostatic
changes

Low blood
pressure,
dizziness

Diarrhea- Patient Assessment


Question the patient quickly and
accurately
Using SCHOLAR-MAC

Establish that the patient is an


appropriate self-care candidate
Suggest appropriate self-care
strategies/treatments
Talk to the patient

Diarrhea- Patient Assessment


Symptoms
Characteristics/course
History of symptoms in
the past

Onset
Location
Aggravating factors
Relieving/Remitting
factors

Medications
Allergies

Diarrhea- Question
S Symptoms:
What symptoms are you having?

C Characteristics:
What types of bowel movements are you having?
How often are your BMs?

H History:
Have you experienced these symptoms in the past?
How have you treated these symptoms in the past?
What treatments were eff ective in the past?

O Onset:
When did your symptoms start?
How long as it been since your last BM?
Have you traveled recently

Diarrhea- Question
L Location:
Probably unnecessary to ask in this case

A Aggravating Factors:
What makes your symptoms worse?

R Relieving Factors:
What makes your symptoms better?

Diarrhea- Question
M Medications:
What medications are you taking?
OTC AND RX
Watch for antibiotic use!!

A Allergies:
Do you have any drug allergies?

C Conditions (Medical Conditions):


What medical conditions/disease states do you have?

Diarrhea Establish Self Care


Exclusions for Self Care
Younger than 6 months

Chronic or persistent diarrhea

>6 months of age with persistent


high fever (>102.2F)

Pregnancy

Moderate to severe diarrhea in


children age 2 and younger

Suboptimal response to oral


replacement solution

Severe dehydration

Severe abdominal pain/distress

Blood, mucous, or pus in stool

Protracted vomiting

Patients risk for significant complications:


-DM, severe CVD, renal disease
-Multiple chronic medical conditions
-Immunosuppressed patients

Diarrhea Suggest Therapy


Suggest appropriate self-care strategies
OTC medications
General care measures
Fluid replacement

Lifestyle changes
Avoidance of irritating foods

Managing Fluids and Electrolytes


Oral replacement solutions (ORS)
Treatment of choice for mild to moderate dehydration,
secondary to diarrhea
Recommended phases of treatment
Rehydration Given over 3 to 4 hours
Maintenance Given until normal dietary intake is
reestablished

Recommended sodium content


75 mEq/L (according to the World Health Organization)
Commercial available products in the U.S. contain 75 to 90
mEq/L (rehydration) and 40 to 50 mEq/L (maintenance)

Some liquids may worsen diarrhea and contribute to


low sodium levels
ORS in powder form - Counsel on appropriate mixing

Managing Fluid and Electrolytes


Osmolarity
(mOsm/L)

Carbohydra
te (gram/L)

Potassium
(mEq/L)

Sodium
(mEq/L)

245

13.5
(glucose)

20

75

249

20
(dextrose), 5
(fructose)

20

45

Cola**

550

50 to 150
(fructose
and
dextrose)

0.1

Chicken
Broth**

450

250

Product
WHO-ORS
Pedialyte

45
Gatorade
(dextrose,
330
3
** Not recommended for use as ORS
in children < 5 years old
**
other
sugars)

20

Treatment of Dehydration Secondary to Acute Diarrhea in


Pediatric Patients (Age 6 months to 5 years)
Severe Dehydration

Seek immediate medical attention

Mild to Moderate
Dehydration

1. ORS: 50 to 100 mL/kg over 3 to 4 hours;


follow with 10 mL/kg for each subsequent
loose stool
2. Continue for 4 to 6 hours or until hydrated
3. Resume regular diet as soon as able
4. If not resolved after 48 hours from start of
ORS, seek medical attention

Minimal to No
Dehydration

1. Continue regular diet


2. May consider addition of a
dextrose/electrolyte solution if loose stool
is ongoing ( to 1 cup per loose stool)
3. May consider increasing normal dietary
intake of fluid

Treatment of Dehydration Secondary to Acute Diarrhea in


Patients > 5 years
Severe Dehydration

Seek immediate medical attention

Mild to Moderate
Dehydration

1. ORS: 2 to 4 liters over 3 hours; follow


with additional ORS to replace ongoing
fluid loss as needed
2. Resume normal diet as tolerated
3. Initiate symptomatic drug therapy if
needed
4. If not resolved after 48 hours from start of
ORS, seek medical attention

Minimal to No
Dehydration

1. Continue regular diet


2. May consider addition of a
dextrose/electrolyte solution if loose
stools are ongoing ( to 1 cup per loose
stool)
3. May consider increasing normal dietary
intake of fluid
4. Initiate symptomatic drug therapy if
needed
5. If no improvement, seek medical
attention

Self-Assessment
Which of the following oral replacement
solutions is the best choice for a 25 year old
female patient presenting with severe
dehydration?
A. Pedialyte
B. WHO-ORS
C. Gatorade
D. None of the above

Diarrhea Treatment Options


Loperamide
MOA: Synthetic opioid agonist; slows intestinal
motility, allows absorption of fl uid and electrolytes;
lacks CNS eff ects
Indications:
Treatment of acute, non-specifi c diarrhea in afebrile
patients (or patients with low-grade fever) age 6 or older;
travelers diarrhea
Not for use in patients < 6 years old, patients with bloody
stool, or patients meeting other exclusions for selfLength of
treatment (see earlier slide)
Medication Dosage Forms
Directions
Treatment
Side eff ects: Dizziness, constipation
Caplets: 2 mg

Loperamide
(Imodium
AD)

Liquid: 2 mg/15
mL

4 mg initially, then
2 mg after each
subsequent loose
stool

48 hours

Diarrhea Treatment Options


Bismuth Subsalicylate
MOA: Exact mechanism unknown
Indications:
Acute diarrhea in adults and children 12 years and older

Cautions: Check drug-drug interactions/concurrent


aspirin use
Side eff ects:
Harmless black staining of the tongue
Mild tinnitus or signs of neurotoxicity DISCONTINUE USE
Medicatio
Length of
Dosage Forms
Directions
n
Treatment
Bismuth
subsalicylat
e
(PeptoBismol)

Tablets262 mg
Caplets262 mg

525 mg every 30
to 60 minutes

Liquid262 mg/15
mL and 525 mg/15 Max: 4200 mg/day
or 8 doses/day
mL

48 hours

Diarrhea Treatment Options


Digestive Enzymes
MOA: Replaces lactase enzymes in patients with
lactase defi ciency
Indications:
Patients with lactase defi ciency/lactose intolerance

Counseling: Take with fi rst bite of milk or dairy


product
Medication
Digestive
enzymes

Dosage
Forms
Chewable
tablets,
caplets, liquid

Directions
Follow package
directions with
first bite of dairy
product

Length of
Treatment
With each dairy
product

Diarrhea Talk to Patient


Counsel patient on recommended treatment
options
Product description
Product use
Dose (treatment dose and maximum dose), route,
frequency, max duration

Adverse reactions

Counsel patient on non-pharmacologic


recommendations
Fluids, etc.

Diarrhea Talk to Patient


Counsel patient on when to contact
physician
Unresolved diarrhea 48 hours after initial
treatment
OTC or ORS

Increase in number of BMs


Signs of severe dehydration
High fever
Blood present in stool

Diarrhea Non-Pharmacologic
Treatment
Illness should be self-limiting Around 48
hours
Diet
Do not withhold food for >24 hours
Resume diet as soon as rehydrated/tolerated
BRAT diet is inappropriate
Bananas, rice, applesauce, toast

Prevention
Avoidance of irritating foods
Proper hygiene, handwashing when handling food

LAB

For Lab
Before Lab:
Read over chapters 15 and 16 in the
Handbook of Nonprescription Drugs

Bring to Lab:
Pre-lab slides
PRINTED and completed drug product table

During Lab:
Be prepared to counsel a patient on any one
of the following products: Pepto-Bismol,
loperamide, Sennakot-S, bisacodyl

References
Weitzel KW, Goode JR. 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.
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.
PL Detail-Document, Treatment of Constipation in Adults.
Pharmacists Letter/Prescribers Letter. April 2013.
PL Detail-Document, Medications for Constipation.
Pharmacist's Letter/Prescriber's Letter. May 2007.