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Therapeutics VI: Exam #3 - Constipation/Hemorrhoids
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52
Health Care
Graduate
04/23/2011

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Term
Constipation
Definition
difficult passage of stool, or a decrease in # of bowel movements (BMs);
Common in:
- elderly (>65 yrs old)
- pregnancy
Term
Normal Stool Frequency
Definition
3x daily to 3x per week (pt-dependent)
Term
Risk Factors for Constipation
Definition
insufficient dietary fiber intake;
inadequate fluid intake;
lack of physical activity;
poor bowel habits (ignoring urge, hurried BMs)
Term
Conditions that can cause Constipation
Definition
GI disorders: IBS, diverticulitis, hemorrhoids;
Metabolic/Endocrine: hypOthyroidism, hypERcaclcemia, DM;
Pregnancy (progesterone);
Neurogenic: brain trauma, CVA, Parkinson's;
Postponing urge to defecate
Term
Drugs that cause Constipation
Definition
Opiates;
Anticholinergics (antihistamines, TCAs);
Antacids containgin CaCO3 or AlOH (Tums, Mylanta, Maalox);
Non-dihydropyridine CCBs (verapamil, diltiazem);
Clonidine;
Fe preps;
Term
Patient's Perception of Constipation
Definition
Infrequent BM;
Straining to have BM;
Passing hard, dry stool;
Insufficient size stools;
Feeling of fullness;
Mild pain on passing stool;
Loss of appetite;
Term
What a Pharmacist should Ask
Definition
Frequency?
Duration of constipation?
Exercise routine?
Appetite?
Dietary fiber consumption?
Presence of other Sx?
Current meds?
Meds used to relieve constipation & their effectiveness?
Term
Goals of Constipation Tx
Definition
Treat specific cause/Remove cause if possible;
Relieve Sx;
Restore normal bowel fcn;
Avoid overuse of laxatives;
Term
Non-Pharm Tx for Constipation
Definition
Increase amount of fiber in diet: 25-30 g fiber/day;
Increase fluid intake;
Increase exercise;
Utilize bowel training to increase regularity;
Term
psyllium (Metamucil), methylcellulose (Citrucel), calcium polycarbophil (FiberCon), barley malt extract (Maltsupex)
Definition
Bulk-forming laxatives;
**Uses: Prevention & Treatment - most safe to use**
Seperate administration time w/ other meds by 2 hrs;
Administration: mix w/ 8-10 oz H2O, followed by additional 8-10 oz H2O;
All PO;
Term
docusate sodium (Colace), docusate calcium (Surfak)
Definition
Emollient (stool softeners);
MoA: anionic surfactant;
**Uses: PREVENTION in pts who should avoid straining (i.e. after abd/rectal surgery, labor, MI);
**Use along w/ STIMULANT for long-term tx of opiate-induced constipation;
**DRUG INTERACTIONS: mineral oil - don't give together**
Term
mineral oil (Fleets Mineral Oil)
Definition
lubricant laxative;
MoA: "greases the stool";
Uses: NOT preferred due to ADRs; Routine Use is NOT recommended, but can be used when AVOIDING straining is required;
ADRs:
- anal leakage
- decreased absorption of fate soluble vitamins (A,D,E,K) --> take 2 hrs apart;
Avoid in pregnancy;
Risk of Aspiration Pneumonia;
Interactions: emollient laxatives (docusate);
Precautions:
- bedridden pts
- pts w/ difficulty swallowing
- rectal bleeding
- appendicitis;
Administration: emuslified products may taste better --> chill/mix w/ juice or ice cream;
Term
magnesium hydroxide (Milk of Magnesia), sodium phosphates (Fleet Phospho-Soda, OsmoPrep, Visicol), magnesium citrate (Citroma)
Definition
saline laxatives;
MoA: nonadsorbable ions pull water into GI lumen & increase volume & pressure which increases bowel motility;
**Use: ACUTE evacuation of bowel before a procedure**
ADRs:
- excessive dehydration
- hypermagnesemia, hyperphosphatemia;
Interactions: Separate administration from medications;
Administer: Drink w/ full glass of H2O;
Precautions: AVOID in renal impairment, HF, sodium-restricted diets, pregnancy, & children <5 yrs old;
Term
lactulose, glycerin, polyethylene glycol (PEG) w/ electrolytes [Colyte, GoLYTELY], PEG w/o electrolytes [MiraLax], sorbitol
Definition
hyperosmotic laxatives;
MoA: creates an osmotic effect & draws water into GI tract, stimulating BM
**NOT USED FOR PREVENTION**
ADRs:
- flatulence
- cramps
- diarrhea
- electrolyte imbalances
Term
lactulose (RX)
Definition
hyperosmotic laxative - only available in liquid form;
Use: TREATMENT;
Comments: Monitor for electrolyte imbalances in elderly;
Onset: 1-3 days;
Term
glycerin (OTC)
Definition
hyperosmotic laxative - OTC - rectal use only;
Uses: Treatment;
Onset: 1-6 hrs
Term
polyethylene glycol (PEG) w/ electrolytes [Colyte, GoLYTELY] - RX
Definition
Hyperosmotic laxatives: Rx;
Use: ACUTE EVACUATIONS PRIOR TO PROCEDURE;
Reconstitute w/ H2O; Drink 8 oz. every 8 10 min until 4 L consumed & fecal discharge is clear;
May decrease absorption of other meds;
Onset: 4 hrs;
Term
PEG w/o electrolytes (Miralax) - Rx
Definition
Hyperosmotic laxative;
Use: TREATMENT;
Dissolve in 8 oz of fluid;
**NOT used for acute bowel evacuation prior to procedure**
Onset: 1-3 days
Term
sorbitol (OTC)
Definition
Hyperosmotic laxative;
Use: TREATMENT;
Less expensive than lactulose;
Onset: 0.5-1 hr
Term
senna or sennosides (Senokot, Ex-Lax)
Definition
stimulant laxatives - anthraquinone class;
Uses: TREATMENT of Constipation --> caused by OPIATES (Tx of CHOICE) or resistant to stool softeners & bulk-forming laxatives;
Onset: 6-12 hrs;
May change urine color;
ADRs: abdominal cramping, diarrhea, electrolyte & fluid deficiencies, melanosis coli;
Interactions: PPIs, H2RAs (separate by 1-2 hrs);
Precautions: Should NOT be used >1 wk;
Term
bisacodyl (Dulcolax)
Definition
stimulant laxative - diphenylmethane class;
Uses: ACUTE evacuations before GI procedure, TREATMENT of constipation caused by OPIATES (**TReatment of Choice);
Onset: PO - 6-12 hrs, Rectal - 1-6 hrs;
ADRs:
- abdominal cramping, diarrhea;
- electrolyte & fluid deficiencies;
Interactions: PPI, H2RA (separate by 2 hrs);
Term
castor oil (Purge Liquid)
Definition
very potent stimulant laxative;
Use: Treatment of Constipation to stool softeners & bulk-forming laxatives;
Onset: 2-6 hrs, PO;
ADRs:
- abdominal cramping, diarrhea;
- electrolyte abnormalities;
Term
senna + docusate
Definition
Senokot-S
Term
senna + psyllium
Definition
Perdiem;
Tx of opiate-induced constipation;
Term
Nondrug Constipation Counseling Points
Definition
High-fiber diet (25-30 g/day);
Increase dietary fiber (wheat grains, fruits, vegetables);
Avoid constipating foods (processed cheese & conc. sweets);
6-8 8oz glasses of fluid/day;
Term
lubiprostone (Amitiza)
Definition
MoA: acts locally in gut to open Cl channels --> stimulate intestinal fluid secretion & accelerate GI motility;
Uses: Tx of chronic idiopathic constipation in adults;
Dose: 24 mg (1 cap) PO BID with food;
ADRs: HA, diarrhea, nausea;
**Use when all else fails**
Term
tegaserod (Zelnorm)
Definition
MoA: serotonin receptor agonist --> stimulates GI peristalsis;
Uses: IBS w/ constipation & chronic idiopathic constipation in women (<55 yrs old) in which no alternative therapy exists;
Dose: 1 tab (6 mg) PO BID before meals;
ADRs: abdominal pain, diarrhea;
Term
Children
Definition
Non-pharm therapy is PREFERRED;
Avoid enemas;
If <5 yrs old, glycerin suppositories preferred;
Use stimulant laxatives ONLY w/ MD supervision;
Barley malt extract (Maltsupex) is safe in infants <1 month;
Term
Pts on Opiates
Definition
Emollient laxatives alone are not sufficient --> PREFERRED: stimulant + emollient (i.e. senna + docusate [Senokot-S])
Term
Advanced Age
Definition
Consider lifestyle changes or adjustments in constipating meds;
PREFERRED: bulk-forming laxatives;
AVOID mineral oil & saline laxatives;
Term
Pregnancy
Definition
1st Line: bulk-forming laxatives;
2nd Line: emollient, senna, or bisacodyl may be used;
AVOID castor oil --> premature labor;
AVOID osmotic & saline laxatives --> electrolyte abnormalities;
AVOID mineral oil --> decreased vitamin absorption;
Term
Heart Failure (HF) & Renal Insufficiency
Definition
Avoid Na-containing laxatives (Na overload, H2O retention);
AVOID Mg & phosphate-containing laxatives in RENAL INSUFFICIENCY
Term
Laxative Abuse Syndrome
Definition
Long-term: vomiting, abdominal pain, weakness, thirst, BONE PAIN (osteomalacia);
Serious: electrolyte imbalance, hypoalbuminemia, colitis;
Most common in middle-aged women;
Term
Hemorrhoids
Definition
abnormally large, bulging, symptomatic clusters of hemorrhoidal vessels, tissues, and mucous membranes located in lower rectum or anus
Term
Internal Hemorrhoids
Definition
located above the dentate line
Term
External Hemorrhoids
Definition
located below the dentate line in the anal canal;
Freq. visible as bluish lumps at external or distal boundary of anal canal;
Term
Risk Factors for Hemorrhoids
Definition
Pregnancy;
Prolonged sitting or standing;
Lack of dietary fiber;
Chronic constipation;
Diarrhea;
Heavy lifting with straining;
Straining at defecation;
Age (elderly);
Hereditary;
Term
S/Sx of Hemorrhoids
Definition
Self-Treatable: pruritus, discomfort, irritation, burning, inflammation, swelling;
Requires Med Referral: moderate-severe pain, bleeding, prolapse, thrombosis;
Term
7-day Rule
Definition
If minor Sx do NOT respond to 7 days of self-treatment, refer to MD
Term
Nonpharm Tx for Hemorrhoids
Definition
Avoid foods that aggravate Sx (spicy foods, caffeine);
Avoid lifting heavy objects;
Increase dietary fiber & exercise;
Encourage proper bowel habits: avoid sitting on toilet >10 min, do not avoid urge to defecate, avoid excessive scrubbing of area, sitz baths;
Surgery for large, prolapsed hemorrhoids;
Term
benzocaine
Definition
local anesthetics;
Indications: EXTERNAL USE ONLY - temporary relief of external anal Sx;
ADRs:
- contact dermatitis (burning & itching)
Precaution: do not use if skin abraded;
Term
ephedrine sulfate, epinephrine HCl, phenylephrine HCl
Definition
MoA: vasoconstriction of aterioles, reduces swelling;
Indications: EXTERNAL USE for swelling, discomfort, irritation, itching; INTERNAL USE: ephedrine & phenylephrine;
ADRs:
- tremor, nervousness
- increase in BP & HR;
Precautions:
- harmful ADRs in pts w/: HTN, cardiac dx, DM, hyperthyroidism, BPH;
Term
aluminum hydroxide gel, glycerin, zinc oxide, calamine, kaolin
Definition
protectants;
MoA: forms physical barrier on skin forming protective coating;
Indications:
- used internally & externally; Glycerin: ONLY EXTERNALLY;
- temporary relief of itching, burning, irritation, discomfort;
Administration: remove previously used greasy ointment before applying
Term
witch hazel, calamine, zinc oxide
Definition
astringents;
MoA: locally coagulates proteins;
Indications: external & internal use - temporary relief of burning, itching, irritation;
ADRs: minimal
Term
aluminum chlorhydroxy allantoinate (alcoxa), resorcinol
Definition
Indications: External use only - helps relieve discomfort & itching;
ADRs: if r is absorbed --> methemoglobinemia, exfoliative dermatitis, death - DO NOT APPLY to OPEN WOUND;
Precaution: allergic rxns
Term
menthol, juniper tar, camphor
Definition
analgesics/anesthetics/antipruritics;
MoA: "counterirritants" - induce cool, warm, or tingling relief;
Indications: EXTERNAL USE ONLY - temp. relief of burning, discomfort, itching, pain;
Term
hydrocortisone 1%
Definition
corticosteroid;
MoA: antipruritic (reduces itching);
Indications: External use only for relief of itching;
Term
vasoconstrictors
Definition
reduce swelling best
Term
anesthetics/analgesics
Definition
reduce pain best
Term
corticosteroids
Definition
reduce itching alone
Term
calamine, zinc oxide, AlOH gel, ephedrine sulfate, phenylephrine HCl
Definition
products that can be used INTERNALLY
Term
Pt Education for Application of Creams/Ointments
Definition
Use after BM;
Cleanse area w/ mild unscented soap & warm water;
Dry w/ unscented toilet paper or soft cloth;
External: apply a thin layer to perianal & anal canal;
Internal: apply w/ finger or applicator (preferred);
If inserting applicator causes MORE pain, CONTACT MD
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