Treatment Constipation

• Please check all ingredients to make sure one is not allergic or sensitive to them

Aim:

• To get the bowels moving again to the correct level and to correct the water balance in your bowels.
• Persons are advised to gradually reduce and stop the use of laxatives one stools become soft, formed stools are produced without straining at least three times per week.

 

There are many types of medication available:

To treat constipation a stepwise approach is preferred or allow the pharmacist make a clinical assessment based on symptoms and when to use which laxative and when.

This approach is when preferred when one has no medical conditions and/or medication.

1. Try the general tips first
2. If not helping  then consider bulk forming laxative (unless not suitable or one cannot drink adequate fluid)
3. Please consider the following:
   1.  If not helping  and one can drink adequate fluid but stool remains hard or difficult to pass consider to switching or adding an osmotic laxative (unless not suitable
   2. If not helping  and cannot drink adequate fluid  and/or stool remains hard or difficult to pass then consider a stool softener (unless not suitable)
4. If stools are soft then talk to your pharmacist on whether one can  add or use a stimulant laxative.

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Children

1. Children aged over 12 years who experience occasional constipation should be advised on maintaining a balanced diet, with enough fluids and behavioural interventions, in combination with macrogol as first-line treatment and stimulant laxatives as second line.
2. Children aged under 12 years with constipation should be referred to a prescriber

Royal Pharmaceutical Society. Dealing with over-the-counter stimulant laxatives in community pharmacy. 2020. Available at: https://www.rpharms.com/resources/pharmacy-guides/dealing-with-over-the-counter-stimulant-laxatives-in-community-pharmacy#Long%20term (accessed September 2020)

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Bulk laxatives

(e.g. Ispaghula Husk, Stericulia, Methylcellulose)

• These are ideal for small hard stools as they retain more water and make the faeces more bulky, this then stimulates the bowels.
• They should be avoided in bowels which lack muscle tone, large mass of stool stuck in bowels , and constipation caused by opioid painkillers (potential to cause bowel obstruction).
• Do not take if one has difficulty in swallowing and one must drink plenty of water and sit or stand upright for at least an hour (don’t take immediately before bed).
• These agents should be taken with adequate amounts of water to be effective, and are therefore not suitable for patients on water restriction.
• It can take several days (24-36 hours) to work and are therefore not suitable for acute relief.
• They can be used in pregnancy.
• Side effects include abdominal cramp and flatulence, in severe cases In severe cases, their use may lead to bowel obstruction, especially if there is insufficient fluid intake.
• Psyllium has been reported to potentially cause bronchospasm (short of breath and/or breathing difficulties) and anaphylaxis in susceptible individuals.

Osmotic laxatives 

(e.g. Lactulose, Macrogol, Magnesium hydroxide, Magnesium sulphate- Epsom salts, Phosphate enema)

• This is used when one hard stools.
• These medicines redistribute water to ones large bowels and hence increase and soften the stools.
• They take up to 24-36 hours to work and one must drink plenty of water to avoid dehydration.
• These agents are also commonly used for bowel clearance prior to surgery and diagnostic procedures.
• Some contain a lot of salt sodium and potassium and are not suitable if one has sensitivity to these ingredients, high blood pressure and/or a heart condition.
• Enema’s especially may also lead to fluid and salt overload  and should be used in caution in those with heart failure and/or kidney disease and kidney failure.
• Magnesium:
  • Magnesium products work from 2- 6 hours and are used where rapid bowel clearing is required.
  • Elderly patients with reduced renal (kidney) function are particularly at increased risk for developing hypermagnesemia with use of these agents.
  • The magnesium compounds are known to decrease the effect of tetracyclines (antibiotics) and digoxin (used in heart arrhythmia).
• Lactulose and macrogol:
  • Should not be used in intestinal obstruction, tear and/or damage and/or paralysis of the bowels and/or inflammation of the bowel , ulceration colitis, Crohn’s disease or a rare condition called toxic megacolon.
  • May decrease the effect of oral neomycin.
• It can be used in pregnancy except magnesium containing products.
• Side effects include bloating, cramps, diarrohea and flatulence.
• Sugar alcohols may precipitate hyperglycemia, electrolyte imbalances, and lactic acidosis.
• Phosphates:
  • The use of sodium phosphate may be associated with acute renal failure nephrocalcinosis (calcium levels in the kidneys are increased) and hyperphosphatemia.
  • Phosphates should not be co-administered with angiotensin converting enzyme (ACE) inhibitors as the combination may increase the risk of nephrocalcinosis (calcium levels in the kidneys are increased) and electrolyte imbalances.

Stool softeners 

(e.g. Docusate)

• They are useful if one has large and hard stools and/or pellet stools or anal fissures or haemorrhoids that cause painful defecation, as they soften them (by reducing the surface tension and increasing the fluid in the faeces and breaking up the faeces) and also work like stimulant laxatives allowing one to go to the bathroom.
• Docusate oral takes approx 12-72 hours to work.
• Docusate enema’s take 5- 20 minutes to work.
• Arachis oil takes 30 mins to work.
• They should not be taken with antacids as they won’t work properly and should be taken at least an hour apart.
• Stool softeners are not appropriate as the only treatment for constipation in individuals with intestinal motility problems, as the soft stool may accumulate and lead to intestinal obstruction.
• Side effects may include diarrhoea, abdominal cramping, and abdominal obstruction and rarely liver toxicity.
• Do not use this product if have hypersensitivity to docusate or any component of the formulation, acute (short term) abdominal pain, and intestinal obstruction.
• Only take this when required because the bowels can become lazy/slow and get more constipated.
• It is only intended for short term use.
• If one has a peanut allergy, do not use arachis oil.

Stimulant laxatives

(e.g Senna, Bisacodyl, Sodium, Glycerol suppository)

• These are laxatives  that increase muscle contraction in the bowel by acting on muscle (the nerve plexus in the intestine) and hence removing faeces.
• Like the osmotic laxatives, these agents also are used for bowel clearance prior to surgery and diagnostic procedures.
• They take about 8-12 hours to work.
• Suppositories work with in 15 mins to 3 hours.
• They should not be given to a child who is scared to go to the toilet and should not be taken together with antacids (because they won’t work properly and should be taken at least an hour apart).
• Glycerin suppositories take 30 mins to work (dip in water before inserting) but can cause rectal discomfort and should not be given to children who are scared to go to the toilet.
• They should no longer be used in children under 12 years without advice from a  medical prescriber, while products for children aged 12 to 17 years can be supplied under the supervision of a pharmacist.
• Only take this medication when required because the bowels can become lazy/slow and get more constipated.
• It is only intended for short term use.
• They should not be used in pregnancy and when breast-feeding.
• They should not be used intestinal obstruction , where the bowels are inflamed (i.e Crohn’s disease, Ulcerative colitis) or if one has recently had bowel surgery and if the cause of constipation is unclear.
• Long term  use of bisacodyl may cause hypocalcemia, metabolic acidosis or alkalosis, and severe nausea and vomiting.
• Senna may cause a benign condition called melanosis coli, in which dark brown lesions appear on the colonic mucosa. These lesions usually disappear once the laxative is discontinued.
• Castor oil has been known to cause dizziness, hypotension, and electrolyte imbalances, and is rarely used because of shown that long term use of this class of agents  in which the resting colon is normal but there is little or no increase in motility upon stimulation.
• These agents are known to decrease the effect of warfarin and should not be taken with dairy products or antacids, which may decrease their laxative effect.

Lubricant Laxatives

(Mineral oil-liquid paraffin, arachis oil)

• Lubricant laxatives act by preventing the re-absorption of water from the colon, thereby coating the faeces and lubricating the intestinal wall.
• This action facilitates the passage of stool through the gastrointestinal tract.
• These agents are typically used for the temporary relief of occasional constipation, for relief of acute faecal impaction, and for removal of barium sulfate residues after administration of contrast.
• This class of laxatives is becoming obsolete because of associated severe abdominal cramping and risk of developing lipoid pneumonitis from aspiration of the oil.
• If lubricant laxatives are to be used, they should be taken at least 30 minutes prior to bedtime to reduce the risk of aspiration.
• Absolute contraindications to the use of these agents include patients with ulcerative colitis, appendicitis, and presence of a colostomy or ileostomy.
• This class of laxatives may inhibit the absorption of warfarin, oral contraceptives, and sulfonamides.
• While prolonged use of these agents may decrease the absorption of fat-soluble vitamins leading to significant deficiencies, coadministration with docusates may increase their absorption and potential systemic toxicity.

www.consultant360.com/articles/laxative-use-and-abuse-older-adult-part-ii

Antibacterial/Antiseptic

• Have antibacterial properties and keep the anal area clean.

Anti-stringent

• These products help to dry up the skin in anal area.

Vitamins

• Psyllium

Herbal

• Butcher's broom
• Cat's claw
• Aloe
• Damiana (if have loss of muscle tone)
• Dandelion
• Fenugreek
• Flaxseed (Long term constipation)
• Fo-ti
• Mistletoe
• Polypody
• Queen's Delight
• Rose Hips
• Slippery elm
• Watercress
• Yerba Mate