Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Unknown Speaker 00:27 And now on to the show, Dr. Sean Kane 00:32 Hey, HelixTalk listeners, just a quick note. This is episode 46 which is a continuation of last episode's self care of gastrointestinal disorders. We split up the two episodes because it got a little bit long last time we talked about heartburn and dyspepsia. And we'll go ahead and go right into self care of constipation. So moving on to constipation again, thinking about who is not appropriate for self care is probably the first thing that you should be thinking about when patients approach you with constipation, and I can tell you, from an ICU point of view, we see plenty of patients with bowel obstructions and very severe gastrointestinal problems that would definitely never be appropriate for self care and oftentimes need surgery. So we have to be thinking about who should we be recommending therapies to, and who should we be turning away and referring them to, you know, a physician or other healthcare provider, Speaker 1 01:24 again, I think. And then also looking at some of the limitations about, you know, looking at non pharmacotherapy is a perfectly appropriate thing to do here, right? This is one I have to kind of be careful about mentioning, because antipsychotics can cause constipation. But then also being careful how I say this to my warfarin patients. So we think about things like drinking plenty of fluids, eating better is a big one. So again, looking at those fruits and vegetables that contain fiber. Again, being aware of what it may do. Also the double-edged sword of fiber — it's going to help treat your constipation, but at the same time, let's watch the veggie intake and what it may do to your INR. But that's something we still need to address. So high fiber foods in general are going to be important. Exercise is another big one, doing different kinds of exercise to stimulate those abdominal wall muscles, which then can then kind of help with some of the motility there as well. So Dr Dr. Sean Kane 02:11 Angela, what are some of the patient groups that you would be hesitant to recommend self care to that you would refer to a health care provider? Speaker 2 02:18 Sure if you've got a patient who complains of constipation that's been going on for quite some time. So usually we draw the line around two weeks. I would definitely refer that patient. If it's someone who's got fever or signs of infection going along with it, any nausea, vomiting with the constipation, I would probably lean towards referring if they complain of stools that appear bloody or dark, and we talked about that as a possible upper GI bleed, I would be worried about that as well. Dr. Sean Kane 02:46 So in terms of red, direct therapy, at least for me, I think about agents that are more kind of chronic maintenance type medications or management, versus some of our more acute, like I need to have a bowel movement fairly soon, kind of medications, you know, the first therapy that many people think about when they think of constipation or bulk forming laxatives. And these are basically fiber products that add bulk to the stool, that make it easier for peristalsis to happen, because it's easier for the muscles of the GI tract to kind of grab onto the stool and move it along its path. So some of the very common agents that are bulk-forming laxatives include Metamucil (psyllium), FiberCon (polycarbophil), Citrucel (methylcellulose), and Benefiber (wheat dextrin). There's actually a lot of different products. And interestingly, these products can be both over the counter drug products and also dietary supplements, depending on what claims they make on the packaging. Speaker 2 03:37 Good point. And when we talk about these, it's important that we talk to patients about fluid intake. And so when you pick up one of these bottles, you'll see a warning about taking this product without adequate fluid could potentially cause swelling and blockage of the throat or esophagus. And so we don't want our patients choking as they're taking these products, and so making sure they are taking them with a full glass of water. Yeah. Speaker 1 04:00 And again, the nice thing about these, as you mentioned, you know, they can be fairly innocuous, and that you can, you know, dissolve them into a juice or a water. Again, just make sure to read the directions on there, as far as what you what you can and can't use them. Speaker 2 04:13 So we can venture along into what's called hyperosmotic laxatives. These are a little bit different. They help to pull water into the colon, and so we don't see a lot of systemic absorption with them, but they help move things through. And one of the big products we have on the market is polyethylene glycol, or the PEG 3350. MiraLAX is another brand name for that particular product. Dr. Sean Kane 04:34 And I love the brand name of MiraLAX because it looks like miracle laxative. And to be honest, of the laxatives that we have available to us. This is one of the preferred laxatives for kind of both chronic and more acute management, at least in the hospital setting. In the ICU, we love Mira lax. We use it a lot. It tends to not cause some of the really severe cramping that we see with some of the stimulant laxatives, because it's not systemically absorbed, we don't have to worry about as much at least some of. The systemic side effects of absorbing a bunch of electrolytes and things like that. This was Speaker 2 05:05 This was a prescription product for a long time, and it was switched in 2006 for non-prescription use. So it's something we can be recommending to patients from a self-care capacity. Speaker 1 05:18 And again, just like with the bulk-forming laxatives above, like Metamucil, this is one capful mixed with 4-8 ounces of any beverage (hot, cold, or room temperature). Just mix it in there, stir it up, and then drink it. Dr. Sean Kane 05:31 So kind of the not so nice hyperosmotic laxative, in terms of getting me excited about laxatives, is the glycerin suppository. The good news about suppositories is that they work very quickly. The bad news is that many patients aren't amenable to using suppositories because of the dosage form and how it's delivered to the patient. The glycerin itself can cause some rectal burning and itching. Again, it depends on kind of the patient how comfortable they are with the suppositories. Sometimes this can be recommended for children. They actually have a pedia lax version, where it's a pediatric specific laxative in a glycerin suppository form Unknown Speaker 06:04 smaller in size than the adult version, which Dr. Sean Kane 06:07 makes sense, right? Typically, this is not going to be my first line agent, but if someone asked for a suppository, this is one of the ones that I would think about. Yeah. Speaker 1 06:14 So I think that the next class we get to is another one that's fairly commonly used in regard, again, as least when in my outpatient clinic, your emollient laxatives, which is commonly known as stool softeners. And what these do is, they, you know, almost actually think of detergent. So you have something that's fatty mixed in something that's aqueous. So example, we're thinking of oil on water to kind of allow that mixture to occur. And so we allow that water to penetrate the stool, and then allow it to disperse a little bit, and that's kind of the way in which it works. Docusate is a big example. Docusate comes in calcium or sodium salts, but in either case, it's probably a good idea to help with straining more than anything else. So if you're having difficulty passing a stool and getting that that straining that you can take to help soften and move it along, versus a stimulant that it's going to push it along. Speaker 2 07:05 And some patients are on these fairly long term for that stool softening effect, especially if they're on other medications that can be causing constipation. Dr. Sean Kane 07:14 So then the next drug class is a lubricant, laxative. And interestingly, this is really not one that's recommended by most resources that look at, you know, self care, such as the self care book that we use here at the university. Basically these lubricant laxatives coat the stool which kind of makes things a little bit slicker, but also helps prevent some of the water reabsorption in the colon. Mineral oil is going to be the main one that we have here. And the reason that, you know, many resources. Kind of don't like lubricant laxatives, like mineral oil. Is if you give the oral version, you worry about aspiration pneumonitis, where, if a patient does vomit, the mineral oil, it ends up in the lungs. It causes really severe irritation of the lung tissue. Also, because it is an oily substance, it can impair absorption of vitamins A, D, E and K, which are fat-soluble vitamins. If we use the enema version, it's very messy, may cause rectal itching, and can leak due to its oily nature. So really, this is not a very commonly used agent. I would view this more commonly used as kind of elderly patients that are very used to this product, but it wouldn't be something that would be recommending to patients first or second, probably even third line. Speaker 2 08:29 So also in the laxative category are saline laxatives. We previously discussed hyperosmotic agents like PEG 3350, and noted that those are not systemically absorbed. But these saline laxatives, we do have to be careful, because they are systemically absorbed. Yeah, so Speaker 1 08:46 there's a couple of examples of these. And so, since they are systemically absorbed, one of the big things to monitor for is the salts. Many are magnesium-based, such as magnesium hydroxide (Milk of Magnesia) or magnesium citrate. Since these can be systemically absorbed, you could develop hypermagnesemia if you overuse them. Milk of Magnesia comes as a liquid or in caplets, and is a good choice for occasional, more acute use. Dr. Sean Kane 09:16 Milk of Magnesia tends to start working pretty quickly. And the really quick one is magnesium citrate. This is commonly available in a bottle that looks like a soda bottle. Speaker 1 09:25 yeah, pleasing lemony scent. It's, it's what I always every time I see that, I just kind of laugh a little bit. Speaker 2 09:30 I see these a lot in bowel preps. And so we tend to, when you get prescriptions in the pharmacy for patients going in for about procedure, and they have to do the pre prep work, this is often on that list. Dr. Sean Kane 09:41 Yeah, and like you mentioned, Dr. Schuman, we do have to worry about the magnesium content of these in patients who have renal impairment, the amount of magnesium, especially in that mag citrate where you're drinking, you know, basically the bottle, it's a gigantic amount of magnesium in order to have a laxative effect. And it just happens that the body is really good about absorbing all that magnesium. Speaker 2 10:00 So we also have the sodium phosphate salts. So that's been interesting over the past couple of years. As far as some of the safety concerns with that, the FDA issued a warning for the public regarding use of the sodium phosphate laxatives related to some of the issues around harm to the kidneys and the heart and deaths have even been reported with this particular product, so that one is restricted to no more than three days of use for some of these concerns. Speaker 1 10:27 So again, it really reinforces the good idea about keeping track of these medications and what their tentative use is. Are they for PRN or for a lifestyle medication, to be aware of those limitations, so that you know you are continuing to follow up with the provider to find out what may be a more appropriate regimen, again, if it is a medication or if it's not a pharmacologic but what would be the best regimen for that long term? Dr. Sean Kane 10:49 And the next laxative category is stimulant laxatives, which are commonly used in hospital and outpatient settings. Examples include Senna (Senokot) and bisacodyl (Dulcolax). Senna is often used as a maintenance or PRN agent, while bisacodyl is available orally and as a rectal suppository for more acute management. The downside of stimulant laxatives is potential cramping and abdominal discomfort. You will also see combination products such as Senna with docusate available over the counter, which provides two different mechanisms of action. Speaker 2 11:47 you two different mechanisms of action. And I think of our patients who are on chronic opioid therapy who deal with constipation, this is something that we would see used for those individuals. Dr. Sean Kane 11:58 So in terms of what we're recommending, one thing is the dosage form consideration. So depending on the acuity of how bad the patient wants to have a bowel movement, something like a suppository or an enema is going to work by far the quickest, but also may be unacceptable to some patients in terms of some of the maintenance type therapies, at least for me, what I think of are bulk forming laxatives, like a Metamucil docusate, maybe a MiraLAX, but MiraLAX gets a little bit more expensive compared to some of our other options, and based on the over the counter labeling, it says that we should only be using these maintenance wise for seven days without a referral from a physician with that said, there's very little data that long term laxative use is detrimental, but we do have to be concerned about overuse, especially in the elderly or in patients with eating disorders where they're using it to lose weight, or because they have improper perceptions about what a normal bowel movement schedule is like. Speaker 1 12:51 And Dr. Kane just to clarify — so I've heard a couple of providers every now and then say we'll talk about the stimulant laxatives, the Senna, and talk about maybe a desensitization of the nerve fibers there in the GI system. Are you saying that that's not really been shown to be of major concern. Dr. Sean Kane 13:06 That's definitely something that's thrown around a lot, but to my knowledge, there's no data that supports any kind of a rebound constipation effect from long term chronic maintenance of stimuli. Speaker 2 13:18 So this is one we also have special populations that we want to consider as we're treating constipation. And we brought up opioids, and so that's one I think that's that's very important, because we have so many patients dealing with chronic opioid and pain management, and so making sure that we are giving them appropriate relief using the drugs that we have available. We talked about using a stimulant as well as the stool softener. A stool softener alone is not going to do the trick. As Dr. Kane says in class, all mush, no push. Speaker 1 13:50 In pregnancy, first-line options are bulk-forming laxatives (e.g., psyllium) or docusate as a stool softener. If those don't work, second-line options include stimulant laxatives or polyethylene glycol (PEG 3350, MiraLAX). Dr. Sean Kane 14:20 And then another special population are children. So generally, any child less than two years of age really should be seen by a physician to be evaluated As they get a little bit older, we can consider things like docusate, Senna, even magnesium hydroxide (Milk of Magnesia). So these are all reasonable options. Again, it kind of depends on severity and how chronic you think that you'll be taking the therapy and things like that. For me, magnesium hydroxide is more of kind of a PRN, not a daily agent, whereas docusate could potentially be a more chronic medication for a patient. Speaker 2 14:54 Then we brought up earlier, older patients and those with kidney disease, and so we do have to be careful. And the biggest i. Red flag that we would see are with the saline laxatives and making sure we're not using those in those individual patients. Dr. Sean Kane 15:07 So just to touch on a couple of the key points from what we talked about today, for me, one of the key points is some of the newer warnings with the sodium phosphate based enema, and the warning is that you shouldn't use more than one dose a day. You shouldn't use it for more than three days, and the reason is that you're going to absorb all of that sodium and all that phosphate. And the problem is that that's going to cause dehydration, electrolyte problems, especially if you have renal impairment. People have ended up getting hurt by over using this product, and that's a really important counseling point. Speaker 1 15:38 And one thing I always like to focus on is the nature of PPIs versus the H2 RAs. PPIs are not for PRN use — per the packaging, take them once daily for 14 days on a scheduled basis, then discontinue. You can repeat the 14-day course every four months if needed. Speaker 2 15:56 really focusing on those lifestyle changes to individuals with that chronic heartburn or dyspepsia in that 14 day. Course, if they're not making changes in their diet, they're probably going to be revisiting those problems as soon as the 14 days are up. Totally agree, I think too, as we're talking about some of the things to treat heartburn and dyspepsia that Pepto Bismol or Bismuth subsalicylate product, again, so important to pick up these products, look at the active ingredients. Make sure we know what we're recommending with that Bismuth sub salicylate that's converted to salicylic acid. So all the same warnings would apply as we would see with aspirin products. So making sure we are taking that and talking to our patients appropriately. Dr. Sean Kane 16:36 So for our listeners, we actually have kind of an updated website. If you want to visit us at HelixTalk.com. We've been adding a lot more information for each episode. You can listen to the episodes there. We love five star reviews. And we're also on Twitter at HelixTalk, so go ahead and follow us. You can use Twitter to see new episode updates and things like that. So with that, Unknown Speaker 16:56 I'm Dr. Kane, I'm Dr. Schuman. I'm Dr. Angelo, Dr. Sean Kane 16:59 and as Dr. Patel would say, study hard. Narrator - Dr. Abel 17:02 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 17:13 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.