LAXATIVES

Bulk-Forming & Stimulant laxatives

By: ‫ﻟﯿﻨﺎ طﮫ ﻣﺤﻤﺪ ﻋﺰﯾﺰ‬

Stage: 3rd Stage
Supervised by: Dr. Hakeem Alani

JULY 16, 2020

AL-FARAHIDI UNIVERSITY/COLLEGE OF PHARMACY
Lolotaha998@gmail.com
 Laxatives
Laxatives are a type of medicine that helps a person empty their bowels. They are
generally used to relieve constipation. Most are available to buy from over-the-counter or
online and without a prescription. Laxatives can be taken orally (by mouth) in the form of
liquids, tablets, or capsules. They can also be taken through the rectum – for example,
suppositories or enemas. Some people need to move their bowels 2-3 times a day, while
others go 2-3 times a week; there is no “normal” number of times. It is more important to
notice changes to bowel habits.

Constipation and how laxatives help

Constipation is when stools become hard, making them difficult or painful to pass.

Constipation occurs when a person has difficulty emptying the large bowel. Home
remedies and lifestyle changes can often help resolve it, but sometimes, it may need
medical attention. Constipation can happen for many reasons, such as when stool passes
through the colon too slowly. The slower the food moves through the digestive tract, the
more water the colon will absorb and the harder the feces will become.

Constipation can cause cramps in the abdomen and can make people feel bloated or sick.
It can be separated into two different types:

• Primary constipation – slow intestinal movements caused by an anatomical issue.

This is often associated with not consuming enough fiber or not drinking enough
fluids.
• Secondary constipation – associated with a metabolic disease (such as diabetes),
neurologic diseases (stroke, Parkinson’s disease, multiple sclerosis), connective
tissue disorders, or eating disorders.
Some medications can also contribute to constipation; these include antidepressants, iron,
bismuth, anticholinergics, opioids, antacids, calcium channel blockers, nonsteroidal anti-
inflammatory drugs (NSAIDs), sympathomimetics, and antipsychotics.

Almost everyone will suffer from constipation at some point in their lives, but in most
cases it is quickly resolved. An adult who has not had a bowel movement in three days or
a child who has not had a bowel movement in four days is considered constipated. When
experiencing constipation, rather than addressing their lifestyle, people may turn to
laxatives which will help them relief their bowel from hard stool. There are many
different kinds, most of which are available over-the-counter without a
prescription. According to NHS Choices, laxatives should only be used occasionally and
for short periods of time. You should also stop taking laxatives when constipation
improves. Laxatives are medicines that treat constipation, either by softening the stools or
by stimulating the lower intestines to push out stool. They can do more harm than good if
used improperly.

Laxatives abuse
Some people take large quantities of laxatives at one time. Others take small amounts of
laxatives, perhaps not more than the “recommended dose,” but on a fairly regular basis.
Most young, healthy people should rarely, if ever, require a stimulant laxative, and
laxatives should never be used in higher than directed doses or over long periods of time.
Once the pattern has started, however, people often find it very difficult to stop taking
laxatives even if they want to. They can become physically and psychologically
dependent on laxatives. Some people use laxatives in the mistaken belief that it will help
them with weight loss. Laxatives flush water and waste from the intestine, but they do not
flush calories from the body.
 Types of laxatives

Different types of laxatives work in different ways. The choice of laxative will depend on
a number of different factors. There are four main types:

• Bulk-forming laxatives – also known as fiber supplements, these work in the

same way that fiber in the diet normally does. They increase the bulk of stools by
getting them to retain liquid, which encourages the bowels to push them out.
Unless there is a specific reason why not, adults with constipation should start
taking bulk-forming laxatives first. They usually take 12-24 hours to take effect.
• Osmotic laxatives – these soften the stool by increasing the amount of water
secreted into the bowels, making them easier to pass. They may take up to 2-3 days
before they start to work.
• Stimulant laxatives – these stimulate the digestive tract walls, speeding up bowel
movements. Usually, they take effect within 6-12 hours.
• Stool softener laxatives – these decrease the surface tension of stools so that they
absorb more water, making them softer. Usually, they work within 12-72 hours.

There are also some less common types of laxatives:

• Lubricant laxatives – these lubricate the intestines by decreasing the amount of

water absorbed by the intestines.
• Saline laxatives – these are used when there is no blockage in the bowels. Often,
they are enemas used to empty the bowel before invasive procedures or surgery.
• Prokinetic laxatives – these are used for severe constipation in conditions such as
irritable bowel syndrome (IBS) and chronic idiopathic constipation.
 Side effects of laxatives

Like any medication, laxatives can have side effects. Exactly what side effects a person
will experience will depend on what type they are taking.

There are some common side effects, which include:

• flatulence
• cramps in the abdomen
• feeling sick
• bloating
• dehydration – can cause light-headedness, headaches, and darker urine.

Bulk-Forming laxatives

Bulk-forming laxatives absorb liquid in the intestines. This creates a bulky, more liquid-
like stool that’s softer and easier to pass. Common bulk-forming laxatives include
psyllium (Metamucil), polycarbophil (FiberCon), and methylcellulose (Citrucel).
Bulk-forming laxatives are different from other laxatives. They’re most similar to stool
softeners in that they help the bowels retain water. Unlike stimulant laxatives, they don’t
stimulate nerves that speed up the movement of bowels through the intestines. They also
don’t lubricate the stools like lubricant laxatives do. Osmotic laxatives differs from bulk-
forming types by helping the intestines — not the bowels — retain water.
Bulk-forming laxatives usually take a few days (1 to 3 days) to work. They are not
helpful for the immediate relief of constipation. They are best to use if you want to have
bowel motions more often and are helpful for conditions such as diverticular disease,
irritable bowel syndrome, and haemorrhoids. Bulk-forming laxatives are not suitable if
you have swallowing difficulties or are unable to drink enough fluids every day. The dose
of the different bulk-forming laxatives will be different, depending on the product. Bulk-
forming laxatives are available as capsules, granules or as a powder that you mix in
water.
 Benefits of Bulk-Forming laxatives
A bulk-forming laxative may help if you experience chronic constipation due to diet,
lifestyle, recent surgery, or medication. Some people prefer bulk-forming laxatives
because there’s usually a more gradual improvement of constipation symptoms. They’re
often the first line of defense before stimulant or other types of laxatives are used.
There’s also less risk of the cramping or explosive diarrhea that could occur with
stimulant laxatives.
Laxatives may be beneficial:
• during pregnancy or for a few
days after birth
• during preparation for surgery
• in treating constipation in
bedridden people
• in treating constipation caused
by medication
• in preventing strain after
surgery
• in restoring normal bowel
function after a period of poor
eating or physical inactivity
• in helping to reduce
cholesterol
• in treating diarrhea
Bulk-forming laxatives are generally safe for healthy people. However, side effects or
drug interactions may occur, including:
• intestinal blockage
• itching
• skin rash
• difficulty swallowing
• feeling like there’s a lump in your throat
• difficulty breathing
You may also experience mild stomach pain, bloating, or gas.
 Precautions of using Bulk-Forming laxatives
Avoid bulk-forming laxatives and consult your doctor if any of the following apply:
• You have symptoms of appendicitis or inflamed bowel. These include:
o nausea
o vomiting
o cramping
o lower abdominal pain
o bloating
o stomach pain
• You miss a bowel movement for more than two days and have abdominal
pain.
• You develop a rash.
• You experience a sudden change in bowel habits or function lasting two
weeks or more.
• You’ve taken medication within the last two hours.

People with kidney disease or diabetes are at risk of electrolyte imbalances when
taking laxatives. Although your risk may be lower with bulk-forming laxatives, you
should still consult your doctor before use if you have either condition. Laxatives
may impact how your body absorbs medications. As a result, you shouldn’t take any
medication within two hours of taking a laxative. In addition, you shouldn’t mix oral
and rectal laxatives.
Example of Bulk-Forming laxatives:
1. Psyllium

2. Calcium polycarbophil
 Stimulant laxatives
Stimulant laxatives work, for many people, as an effective treatment for constipation.
These laxatives function by causing the intestinal muscles to rhythmically contract and
help push out, or “stimulate” a bowel movement. They're often used if lifestyle changes,
such as increasing the amount of fibre in your diet, drinking plenty of fluid and taking
regular exercise, have not helped.
Stimulant laxatives are fast-acting laxatives that induce bowel movements by increasing
the contraction of muscles in the intestines, and are effective when used on a short-term
basis. Stimulant laxatives (diphenylmethane and anthraquinone derivatives) produce
rhythmic muscle contractions in the intestines and may be recommended if osmotic
laxatives fail. These agents increase intestinal motility and secretion and work within
hours of ingestion, but they may be associated with severe abdominal cramps.
Continuous daily use may result in hyponatremia, hypokalemia, and dehydration.
Examples of stimulant laxatives include:
• Aloe
• Cascara
• Senna compounds
• Bisacodyl
• Castor oil
Bisacodyl: Bisacodyl (Dulcolax, Correctol) is available over-the-counter in oral pill form
and as a suppository or enema. The oral form takes 6 to 10 hours to work. Bisacodyl is
commonly used in cleansing the colon for colonoscopies, barium enemas, and intestinal
surgeries. While effective for occasional constipation, bisacodyl should not be taken for
more than a week, and a doctor should supervise repeated use.

Senna, cascara sagrada, and casanthranol: Other stimulant laxatives include senna
(Ex-Lax, Senokot), cascara sagrada (Nature's Remedy), and casanthranol. These laxatives
are converted by the bacteria in the colon into active compounds, which then stimulate
the contraction of colon muscles. After taking these products orally, bowel movements
occur quickly, after only 8 to 24 hours. Prolonged, chronic use of these laxatives can
cause the lining of the colon to become darker than normal (melanosis coli) due to the
accumulation of a pigment (melanin).
Castor oil: Castor oil (an ingredient of Purge Concentrate) is a liquid stimulant laxative
that works in the small intestine. It causes the accumulation of fluid in the small intestine
and promotes evacuation of the bowels. Castor oil should not be taken with food,
although juice or other flavored liquids can help hide its unpleasant taste. This laxative
works rather quickly, usually within 2 to 6 hours. Castor oil is usually used to cleanse the
colon for surgery, barium enema, or colonoscopy. The absorption of nutrients and
minerals by the small intestine can be impaired by the frequent use of castor oil. This
medicine is not recommended for the repeated treatment for constipation.

*Drugs used in treating constipation and IBS

 Category Mechanism of action
Bulk-Forming laxative Bulking agents work in both the small and
large bowel with an onset of action of 12-
72 hours. They bulk up the stool so that it
return more water making peristalsis
easier
Stimulant laxatives Stimulants stimulate colonic contractions
that propel stools forward. These agents
irritate the lining of the intestines

Precautions for stimulant laxatives

The intensity of the action of stimulant laxatives is dose related. A large dose of any
stimulant laxative can produce serious adverse effects.
Side effects include severe cramps, excess fluid loss and dehydration, blood electrolyte
disturbances such as low levels of blood potassium (hypokalemia), and malnutrition with
chronic use. There is concern that chronic, long-term use of stimulant laxatives can lead
to loss of colon function (cathartic colon). After years to decades of frequent use of
stimulant laxatives, the nerves of the colon slowly disappear, the colon muscles wither,
and the colon becomes dilated. Consequently, constipation may become increasingly
worse and unresponsive to laxatives. It is not clear, however, which comes first; a
progressive decrease in colon function that leads to the use of stimulant laxatives, or the
use of laxatives that leads to a decrease in colon function. Nevertheless, long term use of
stimulant laxatives usually is reserved for use after other treatments have failed.
 Reference
 Krogh K, Chiarioni G, Whitehead W. Management of chronic constipation in
adults. United European Gastroenterol J.
 Camilleri M, Bharucha AE. Behavioural and new pharmacological treatments for
constipation: getting the balance right.
 Jin J. JAMA patient page. Over-the-counter laxatives.
 Twycross R, Sykes N, Mihalyo M, Wilcock A. Stimulant laxatives and opioid-
induced constipation.
 Siegel JD, Di Palma JA. Medical treatment of constipation.