Approach - PowerPoint Presentation

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Approach

to Constipation and its Management

Melissa G. Morgan

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D.O.Slide3
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QUESTIONSlide5

Constipation

Symptom based disorder

Bloating

Hard stools

Difficult stool passage

Sensation of incomplete evacuation

Frequent strainingSlide6

Constipation

Common condition with 15% prevalence in North America and female to male ratio 2.2:1

Symptoms increase with age > 65

Primary causes

Functional (most common) include IBS-C

Defecation disorders

Pelvic floor dyssynergia

Excessive perineal descent

Mechanical obstruction

Slow transit (least common)Slide7

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Initial Testing

CBC TSH if there are other symptoms consistent with hypothyroidismColonoscopy if any alarm features presentblood in stool, anemia, weight loss, or if age appropriate screening has not already been performed

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Functional

IBS-C

Recurrent abdominal pain at least 3 days/month during the last 3 months with onset ≥ 6 months prior

Improvement with defecation, change in stool frequency or change in stool appearance or form

Chronic constipation

Straining during at least 25% of defecations

Sensation of incomplete emptying for at least 25% defecations

Sensation of anorectal obstruction for at least 25% of defecations

Need to use manual maneuvers to facilitate evacuation for at least 25% of defecations

< 3 defecations per weekSlide11

Functional

Treatment options

Fiber supplementation, exercise, healthy diet, osmotic laxative

May use stimulant laxative no more than 2-3 times per week

Rx medications

Lubiprostone- chloride channel activator

increases intestinal fluid secretion thereby increasing motility in the intestine

Linaclotide-guanylate cyclase agonist

Increases cGMP which stimulates secretion of chloride and bicarbonate which increases intestinal fluid, accelerates transit and reduces intestinal painSlide12

Lubiprostone

Take with food and waterChronic idiopathic constipation24mcg BIDIBS-C (women)

8mcg BID

Opioid induced constipation (non-cancer)

24mcg BID

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Lubiprostone

Adverse reactionsNauseaDiarrheaHeadache

Dyspnea

Pregnancy category C

Unknown if excreted in human breast milk; not in animals

Infants should be monitored for diarrhea

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Linaclotide

Take on empty stomach at least 30 minutes prior to a mealChronic idiopathic constipation145mcg dailyIBS-C

290mcg daily

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Linaclotide

Adverse reactionsDiarrheaAbdominal painFlatulence

Pregnancy category C

Unknown if excreted in human breast milk

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Pelvic Floor Dyssynergia

Accounts for 1/3 of constipation in the community

Likely acquired behavior disorder

Increased muscle tension from anxiety or stress

Sexual abuse is reported in 22% of women with defecation disorders

Puborectalis muscles and external anal sphincter must relax

Diagnosed with anorectal manometry and balloon expulsion test

evidence that pelvic floor retraining is superior to laxatives for defecatory disorders

~70% have improvement

Biofeedback therapySlide17
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QUESTION

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Opioid Induced Constipation

Most common reported side effect of opioid use in 41% of patientsMu-opioid receptorsinhibition of propulsive activity of intestine and slow intestinal transit

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Methylnaltrexone Bromide (Relistor)

Inhibits opioids from binding to mu-receptors in GI tractDoes not cross blood brain barrier

Doesn’t interfere with centrally located receptors

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Methylnaltrexone Bromide

DosingSingle vial dosing (12mg) and pre-filled syringe (8mg and 12mg)Chronic non-cancer pain12mg SQ daily (0.6mL)

Advanced illness

weight based and every other day dosing prn

no studies past 4 months

Cut dose in half for creatine clearance <30mL/min

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Methylnaltrexone Bromide

Category CUnsure if passes into breast milkCan cause opioid withdrawal in fetus due to immature BBBADRs

abdominal pain, nausea, diarrhea, hyperhidrosis

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Naloxegol (Movantik)

Peripherally acting mu-opioid receptor antagonist; for use in chronic non-cancer painTake on empty stomach 1 hour prior to first meal or 2 hours after25mg PO daily; also comes in 12.5mg

First BM within 6-12 hours

Same ADRs as SQ injection

Category C

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Summary

Many different causes of constipation and treatment is based on underlying cause

Know when to move on from fiber and OTC medications

Pelvic floor dyssynergia is extremely common in up to 1/3 of those with constipation in the community and can be treated with biofeedbackSlide26

Summary

Opioid induced constipation is managed differently than other forms of constipationRefer if any alarm features or if not comfortable moving beyond OTC medications

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