EDUCATIONAL SUPPLEMENT Constipation and Parkinson’s Disease

By Mary L. Wagner, Pharm.D., Robert S. Jenco, Pharm.D., AMERICAN PARKINSON DISEASE ASSOCIATION and Aksh K. Sharma, Pharm.D.

Introduction both your doctor and physical therapist before begin- Constipation is a problem that affects many individ- ning any new exercise routine. uals who have Parkinson’s disease (PD). In PD there is a slowing of the stomach and bowel movements. Dietary Habits: It is important to eat the proper PD can cause damage to the part of the nervous number of servings of each food group daily. A system called the autonomic nervous system, which general guide is: regulates the involuntary muscle movement of the • 2 – 3 servings of meat intestinal tract. Damage to the autonomic nervous • 4 – 5 servings of fruit and vegetables system causes slowed digestion and movement • 2 – 3 servings of dairy products through the intestinal tract. A lack of physical exer- • 6 – 11 servings of whole-grain/bran bread cise or activity, poor dietary habits, decreased fluid and/or cereal intake, and a number of medications can also con- tribute. The best treatment approach is to prevent Taking too much of the following foods may cause constipation using diet and lifestyle changes. constipation: • Dairy products (milk, buttermilk, ice cream, Diet and Lifestyle cheese, yogurt, sour cream) The safest and healthiest way to correct abnormal • Highly processed foods (white flour, bread, bowel function is to first change your diet and life- crackers, pastries, pasta, white rice) style. It may take some time before these changes • Fast food and junk food take effect and restore regularity, so be patient. Here • Fried foods are some suggestions: • Meats • Eat meals at the same time each day • Bananas • Add more fiber to your diet • Food high in sugar • Exercise and remain as active as possible • Drink warm liquids with breakfast Fiber Content: Fiber is an essential component of a • Establish a fixed time every day for healthy diet and the lack thereof is the most com- bowel movements mon cause of constipation. • Never put off the urge to move your bowels Some fiber sources include fresh and dried fruits, vegetables, beans, whole-wheat and whole-grain Exercise and Physical Activity: PD patients can products, bran, oatmeal, and brown rice. After cal- benefit in many ways from physical activity and culating your daily fiber intake, increase it weekly by exercise in general, and from exercises like aerobic 5 grams per day until you reach the recommended activity, strengthening exercises and range-of- daily intake of 20 to 35 grams. High-fiber foods are motion stretching. Physical therapists are very listed in Table 1. The amount of fiber contained in helpful in showing you which exercises will be most other foods can be found on food labels or by web- beneficial and safe for your situation. Consult with site searches using the key words “Dietary Fiber.” Drinking enough water is important to prevent seem to suggest that probiotics help constipation constipation, especially when taking fiber supple- when taken at daily doses of at least a billion colony ments. Six to eight 8-ounce glasses of water daily forming units (CFU) for at least two weeks. When are recommended. looking at marketed probiotic products, it is import- ant to consider the bacterial strains and potency in Table 1: Fiber Content of Some Common Foods order to get the greatest benefit. Grams of Fiber Food Serving Size Per Serving Medication Cheerios ™ 1/3 cup 3 Certain medications can cause constipation. The All-Bran ® 1/3 cup 8.5 best way to know if a medication is the cause of Apple 1 medium 3.5 your constipation is if the symptoms start when you Prunes 3 Prunes 3 start the new medication. Table 2 lists examples of String beans 1/2 cup 1.6 medications that can cause or worsen constipation. (cooked) Do not stop these medications, but ask your doctor Broccoli (cooked) 1/2 cup 2.2 if they could be the cause of your constipation. Kidney beans 1/2 cup 7.3 (cooked) Table 2: Medications That Can Cause or Worsen Constipation Lentils (cooked) 1/2 cup 3.7 Examples Medications Class Bran muffin 1 muffin 2.5 Generic Name (brand) Whole-wheat 1 slice 1-3 PD medications trihexyphenidyl (Artane®) bread benzatropine (Cogentin®) Brown rice 1/2 cup 1 Narcotic pain medications oxycodone (Percocet®, Sweet Potato 1/2 medium 1.7 Percodan®, Oxycontin®) hydrocodone (Lortab®, Dried Sunflower 1 cup 4 Vicodin®, Vicoprofen®, Seeds many prescription-only cough syrups) Helpful Foods hydromorphone (Dilaudid®) propoxyphene (Darvocet®, Certain foods may be helpful in relieving constipa- Darvon®) tion. A natural recipe involves combining 2 parts fentanyl (Actiq®, of unprocessed wheat bran, 1 part applesauce, 1 Duragesic®, Fentora®) meperidine (Demerol®) part prune juice (for example 1 cup, ½ cup, and ½ codeine cup respectively) and refrigerating the mixture. morphine Make a new mixture every week. You can take 1 – 2 Antacids aluminum-containing tablespoons daily for one week. If needed, you can products bismuth-containing products increase by 1 tablespoon a week. Stool frequency (Pepto-Bismol®) and gas may increase the first few weeks, but will calcium-containing products (Rolaids®, Tums®) usually adjust after one month of using this mixture. Calcium supplements Os-Cal®, Caltrate®, Yogurt that is fortified with probiotics may im- Citracal®, Viactiv® prove constipation as well. Probiotics are live micro- generics/store-brands, organisms that provide a health benefit to the host prescription calcium products when given in adequate amounts. Probiotics used in Antihistamines diphenhydramine constipation include bacteria such as Bifodobacteri- (used for sleep aid, allergies, (Benadryl®) um, Lactobacillus, Streptococcus, and combinations and motion sickness) meclizine (Dramamine®) thereof. Although there are not many rigorous stud- chlorpheniramine (Chlor-Trimeton®) ies to support the claim that probiotics help relieve Antidepressants amitriptyline (Elavil®) constipation, preliminary studies do show benefit desipramine (Norpramin®) with minimal risk. The studies that are available nortriptyline (Pamelor®)

2 CONSTIPATION AND PARKINSON’S DISEASE AMERICAN PARKINSON DISEASE ASSOCIATION Table 2: Medications That Can Cause or Worsen Constipation Table 3: Over the Counter Medications Used to Treat Constipation Examples Examples Medications Class Medications Class Generic Name (brand) Generic Name (brand) Antipsychotics haloperidol (Haldol®) Bulk forming laxatives psyllium (Metamucil®, clozapine (Clozaril®) Fiberall®, Konsyl®) risperidone (Risperdal®) inulin (Fibersure®, Fiber Cholesterol medications cholestyramine (Prevalite®, Choice®) Questran®) polycarbophil (Fibercorn®, verapamil (CalanVerelan®) Fiber-Lax®) methylcellulose (Citrucel®) High blood pressure diltiazem (Cardizem®, microcrystalline cellulose & medications Cartia XT®) guar gum (Benefiber®) clonidine (Catapres®) methyldopa Stool softeners docusate (Colace®, Correctole®) Seizure/epilepsy medications phenytoin (Dilantin®) valproic acid (Depakote®) Stimulant Laxatives bisacodyl (Dulcolax®, Cor- rectol Fleet®, Magic Iron supplements Feosol®, Slow-Fe® Bullet®) generics/store-brands, castor oil (Castor oil, USP) prescription iron products senna (Ex-LaxSenokot®, Black Draught®) Medication Management Saline Laxatives magnesium citrate (Citroma®) Over the Counter (OTC) Medications: If after sodium phosphate (Fleet two weeks of dietary/lifestyle changes there is no Phospho-SodaFleet ready- improvement in regularity, bulk forming laxatives to-use Enema®) magnesium hydroxide may be used. It is important to continue your healthy (Milk of Magnesia products, eating habits while taking these laxatives. Stool Maalox®, Mylanta®) softeners may also be added if the bulk forming magnesium sulfate (Epsom salts) laxatives do not provide relief soon enough, and Hyperosmotic glycerin suppositories to help relieve straining during bowel movements. polyethlene glycol (Miralax®) Both items are generally safe when used as direct- Lubricant laxative liquid petrolatum (Mineral ed. Stimulant laxatives and hyperosmotic laxatives oil, USP, Fleet ready-to- use may not always be safe and SHOULD NOT be used Mineral oil Enema®) without the advice of a doctor or pharmacist. If you Miscellaneous cod liver oil, senna tea take other medications, separate the laxatives by Examples two hours from the time you take your other medi- Combination products Generic Name (brand) cations. If, after dietary/lifestyle changes and using Stimulants plus stool senna + docusate a laxative fails, a more serious underlying condition softeners (peri-Colace, Senokot S®) may be responsible for the constipation. Hyperosmotic laxative magnesium hydroxide + Various medications used to treat constipation, plus lubricant mineral oil (Phillip’s MO and how they work, are listed in Table 3. There are Suspension®) many other available products not listed here. If you have questions about ingredients or if the product is Bulk-forming Laxatives: Bulk-forming laxatives or safe to use, ask your doctor or pharmacist. fiber supplements are the safest and most natural- ly-acting type of laxative provided they are taken as directed. These fiber laxatives absorb liquid in the in- testines to soften the stool. The bowel is then stimu- lated naturally by the bulky mass. These products are not habit-forming and can be used daily to help pre- vent and treat constipation. Not drinking enough wa- ter can result in an obstruction of the gastrointestinal

3 CONSTIPATION AND PARKINSON’S DISEASE AMERICAN PARKINSON DISEASE ASSOCIATION tract. Make sure to take these with an 8-ounce glass Hyperosmotic Laxatives: Glycerin is the primary of water. Increasing fiber intake too quickly may result example of a hyperosmotic laxative. It is available in in gas, bloating, and upset stomach. These products suppositories, and usually produces a bowel move- usually take between 12 to 72 hours to work. A doc- ment within 30 to 60 minutes. Like saline laxatives, tor should be consulted if the use of these products they act by drawing water into the bowel causing does not resolve constipation after two weeks. These a movement. These medications are relatively safe bulk fibers may affect how well other medications when used under a doctor’s direction. work, so whenever possible, take at least two hours before taking any other medications. Combination Products: There are a number of OTC products available that contain various combinations Stool Softeners: Stool softeners, also called emol- of different types of laxatives, and should be taken lients, are oral products containing the ingredient only when directed by your doctor. docusate and are generally only useful in preventing constipation. They work by allowing liquids to mix Supplements: Although research is very minimal, with the stool. Stool softeners do not cause a bowel anecdotal reports suggest that probiotics, senna tea, movement, but help to allow one without straining. chia seeds, and cod liver oil may be helpful in treat- They are not habit forming and usually work in one ing constipation. These are all considered supple- to two days, but can take up to five days. If consti- ments, and it is important to remember that they are pation is not resolved after one week, do not contin- not regulated products by the FDA. ue to use a stool softener without consulting your doctor. If you take other medications, separate the Prescription Medication time you use a stool softener from your other med- If other products fail, discuss with your doctor or ications by two hours, as stool softeners may affect pharmacist about a prescription medication that may the absorption of some medications. be available to treat chronic constipation in people with Parkinson’s. Stimulant Laxatives: Use stimulant laxatives only with your doctor’s advice. These oral tablets or Conclusion capsules contain senna, bisacodyl, casanthranol, Always make certain all of your doctors and your cascara, sagrada, castor oil, aloe or dehydrocholic pharmacist are aware of all the medications (OTC acid. Casanthranol, cascara sagrada and aloe are not and prescription), vitamins, supplements, and herbal FDA-approved. Stimulant laxatives increase muscle products you are taking so they can check for drug contraction in the intestinal wall and usually take interactions or side effects. about 6 to 12 hours to work. They are habit-forming and long-term use can even harm the bowel.

The information contained in this supplement is solely for the infor- Saline Laxatives: Saline laxatives contain magne- mation of the reader. It should not be used for treatment purposes, sium hydroxide, magnesium citrate, magnesium but rather for discussion with the patient’s own physician. sulfate, and sodium phosphate. One way they act is For additional free copies of this article, please call or visit the website by drawing water into the intestine and bowel from AMERICAN PARKINSON DISEASE ASSOCIATION other body tissues, causing a watery bowel move- (800) 223-2732 • www.apdaparkinson.org ment usually within six to eight hours. They should be used only by a doctor’s direction because they © Copyright 2010, APDA, Inc. Reprinted August 2015 may be harmful to people with certain heart or kid- ney problems. They are used for rapid emptying of the bowel and are NOT to be used long term. They are available as oral preparations or enemas.

4 CONSTIPATION AND PARKINSON’S DISEASE AMERICAN PARKINSON DISEASE ASSOCIATION