A Joint Initiative of the Palliative Medicine Faculty & Staff of We gratefully acknowledge the support of Award Number R25CA134309 from the National Cancer Institute, the Host Institutions and Private Donors The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, the National Institutes of Health, the Host Institutions or the Donors. This presentation does not replace careful clinical judgment specific to each patient / family situation. Constipation Jillian Gustin, MD, FAAHPM Learning Objectives For patients with advanced illness • Describe causes of constipation • Compare and contrast laxatives used for the treatment of constipation • Outline an approach to manage constipation What is a Normal Bowel Movement ? Lubrication Solid waste Motility Water content Hallenbeck J. Constipation, https://bit.ly/3tiTqq4 What is Constipation ? Persistent, difficult, infrequent, or seemingly incomplete defecation Harrison’s Principles of Internal Medicine How does it feel ? What Causes Constipation ? Many Causes of Constipation Surgery Psychogenic Trauma Peritonitis Dehydration Diet Low in Fiber Resisting Urge to Move Bowels Pregnancy Painful Fissure or Hemorrhoids Ileus Ascites Medications e.g., anticholinergics, antihistamines, iron, opioids, etc. Mechanical Obstruction e.g., adhesions foreign body, hernia, stricture tumor How to Assess for Constipation ? Get a history Quality of bowel movements Associated symptoms Prior surgeries Exam the patient Consider testing Electrolyte abnormalities & imaging Medications Advanced illness, e.g., heart failure, cancer Management of Constipation How to Treat Constipation ? ALWAYS start with PREVENTION If you cannot prevent it, then Assess for the cause Treat the underlying cause Treat the symptom Medications Causing Constipation • Analgesics, e.g., opioids, NSAIDs • Antacids ( containing calcium carbonate or aluminum hydroxide ) • Anticholinergics • Barium sulfate • Calcium channel antagonists • Clonidine • Diuretics ( non-potassium sparing ) • Ganglionic blockers • Iron preparations • Muscle blockers • Polystyrene sodium sulfonate • Ondansetron Goals for Management • Often resetting expectations • Balance stool frequency and consistency with comfort / dignity • Incorporate individual preferences Contributors to Constipation Constipation Constipation Normal BM Solid waste Water content Lubrication Motility Hallenbeck J. Constipation, https://bit.ly/3tiTqq4 Non-pharmacologic Treatments • • • • Fiber-rich foods Increased physical activity Increased fluid intake Ritualized bowel habits Pharmacologic Treatments • • • • • • Bulk forming laxatives Surfactants ( softeners ) Osmotic agents Stimulant laxatives Opioid-induced constipation agents Other Action of Pharmacologic Treatments Sites of Action of Common Anti-Constipation Agents Small Bowel Colon Castor oil Bisacodyl Polyethylene glycol Senna Lubiprostone Lactulose Linaclotide Hyperosmolar salts A Stepwise Approach to Managing Constipation… Preventive Measures Step 1 • Provide patient education • Increase fiber & fluid intake • Encourage mobility Preventive Measures Step 1 Step 2 • Provide • Modify risk factors patient education • Increase fiber & fluid intake • Encourage mobility Reduce or eliminate constipating medications Rx for Mild Symptoms Step 1: Rotate Agents • Stop ineffective treatment • Start Polyethylene Glycol ( PEG ) 17 gms PO once daily and / or • Start Senna 2 tabs ( 17.2 gms ) PO QHS Rx for Mild Symptoms Step 1: Rotate Agents • Stop ineffective treatment • Start Polyethylene Glycol ( PEG ) 17 gms PO once daily and / or • Start Senna 2 tabs ( 17.2 gms ) PO QHS Step 2: Titrate Dose • Dose 50 – 100 % Q48H until resolution or maximum dose achieved • For loose stools, decrease by 50 % Q48H Rx for Severe / Refractory Symptoms Step 1: Rule out 2nd Causes • Imaging ( Abdominal X-ray or CT Scan ) • Coloscopy • Anorectal manometry Rx for Severe / Refractory Symptoms Step 1: Rule out 2nd Causes Step 2: Add Agents • Imaging ( Abdominal X-ray • Give Mg Citrate 300 mL PO or CT Scan ) • Coloscopy • Anorectal manometry x 1 dose and / or • Bisacodyl 10 mg PR once daily Rx for Severe / Refractory Symptoms Step 1: Rule out 2nd Causes Step 2: Add Agents • Imaging ( Abdominal X-ray • Give Mg Citrate 300 mL PO or CT Scan ) • Coloscopy • Anorectal manometry x 1 dose and / or • Bisacodyl 10 mg PR once daily Step 3: Enema • Give enema if no stool within 1 – 2 hrs of suppository Opioid-Induced Constipation… Opioid-induced Constipation ( OIC ) Opioids attach to mμ-receptors in small intestine • Inhibits release of neurotransmitters, e.g., Acetylcholine Interrupts normal peristalsis • Intestinal secretions Fluid and electrolyte absorption • Anal sphincter tone Transit of dry hard stools with no urge to defecate Risk of delirium How to Treat OIC ? • • • • Prevention: Senna for all patients on opioids Opioid rotation is NOT recommended Stimulant laxatives are 1st LINE ! If refractory, consider peripheral opioid mμ-receptor antagonists Methylnaltrexone Naloxegol Special Considerations… Special Considerations for Palliative Patients • • • • • Obstructing mass or carcinomatosis ? Ileus ? End of life ( prognosis less than 1 week ) ? Neutropenic ? Overflow incontinence ? High Yield Tips • Docusate is rarely sufficient & often unnecessary • Think “ mush ” and “ push ” • Always treat pain appropriately, even if constipated Maximize adjuvant pain medications Aggressively manage constipation Summary… A rational approach to managing constipation... Understand and chose medications based on the pathophysiology Gandhi… You need to be the change you want to see in the world… A Joint Initiative of the Palliative Medicine Faculty & Staff of We gratefully acknowledge the support of Award Number R25CA134309 from the National Cancer Institute, the Host Institutions and Private Donors The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, the National Institutes of Health, the Host Institutions or the Donors. This presentation does not replace careful clinical judgment specific to each patient / family situation.
