COMPASS Therapeutic Notes on the Management of Chronic Constipation in Primary Care

COMPASS Therapeutic Notes on the Management of Chronic Constipation in Primary Care In this issue: Glossary Page Chronic Constipation lasting longer than 3 months Introduction and background 1 constipation Drugs used in the management of Functional Chronic constipation without a known cause. Also known as primary 3 chronic constipation constipation constipation or idiopathic constipation Bulk-forming laxatives 4 Gastrocolic The occurrence of peristalsis following the entrance of food into the Osmotic laxatives 5 response empty stomach Stimulant laxatives 6 IBS Irritable Bowel Syndrome IBS-C Irritable Bowel Syndrome with Constipation Faecal softeners 7 Melanosis Dark brownish black pigmentation of the mucous membrane of the colon Peripheral opioid-receptor 7 coli due to the deposition of pigment in macrophages antagonists Myenteric Part of the enteric nervous system with an important role in regulating 5HT4 – receptor agonists 7 plexus gut motility Managing constipation in 8 NNT Number Needed to Treat pregnancy and breastfeeding OTC Over The Counter RCT Randomised Controlled Trial Secondary Constipation caused by a drug or medical condition. Secondary constipation constipation is also known as organic constipation SmPC Summary of Product Characteristics A twisting or looping of the bowel resulting in obstruction; can be life- Volvulus threatening Successful completion of the assessment questions at the end of this issue will provide you with 2 hours towards your CPD/CME requirements. Further copies of this and any other edition in the COMPASS Therapeutic Notes series, including relevant CPD/CME assessment questions, can be found at: ● www.medicinesni.com or ● www.hscbusiness.hscni.net/services/2163.htm GPs can complete the multiple choice questions on-line and print off their CPD/CME certificate at www.medicinesni.com Pharmacists should enter their MCQ answers at www.nicpld.org Introduction and background Constipation means different things to different people and Definitions used for constipation there is little shared understanding between patients and The diagnosis of constipation is often arbitrary and is largely professionals about “normal” bowel function.1 There is a lack dependent on the patient’s perception of “normal” bowel of consensus in general practice regarding the optimum function. Doctors often define constipation based on stool management strategies for chronic constipation.1 frequency,8 but patients define constipation as a multi- symptom disorder that includes infrequent bowel What is meant by constipation? movements, hard/lumpy stool, straining, bloating, feeling of Constipation can broadly be defined as the passage of 2 incomplete evacuation after a bowel movement and stools less frequently than the patient’s own normal pattern. 9 abdominal discomfort. Stools are often dry and hard, and may be abnormally large 3 The Rome III criteria were developed to provide a working or small. In the clinical consultation, if a person continues to 10 complain about constipation after a discussion of what is definition of chronic constipation. The criteria highlight the normal and what is abnormal (especially with respect to difference between stool frequency and stool form and frequency), they are asking for help in managing their emphasise that infrequent bowel movements alone do not problem. necessarily define constipation (See Box ONE). Although symptoms of constipation are assessed over the prior 3 In children, the signs and symptoms of constipation may be months, patients must be symptomatic for at least 6 months different and may be poorly recognised. They can include prior to diagnosis.10 While these criteria stand as a guideline infrequent bowel activity, foul smelling wind and stools, excessive flatulence, irregular stool texture, passing Box ONE: Rome III criteria10* occasional enormous stools or frequent small pellets, withholding or straining to stop passage of stools, soiling or Presence of two or more of the following symptoms: overflow, abdominal pain, distension or discomfort, poor • Straining during at least 25% of defaecations appetite, lack of energy, an unhappy, angry or irritable mood • Lumpy or hard stools in at least 25% of defaecations 4 and general malaise. •Sensation of incomplete evacuations for at least 25% of What is meant by “normal”? defaecations Establishing what is ‘normal’ for a particular person, and • Sensation of anorectal obstruction/blockage for at least 25% whether or not the person has constipation, can be difficult. of defaecations Bowel habits vary widely.5 The commonest reported • Manual manoeuvres to facilitate at least 25% of defaecations frequency of bowel movements is once per day,6,7 but a (such as digital evacuation, support of the pelvic floor) Swedish survey found that this was reported by only 20% of • Fewer than three bowel movements a week 7 respondents. A UK survey identified that a frequency of less Loose stools are rarely present without the use of laxatives than three bowel movements per week was more common in women than men.6 *Criteria have to have been met for the previous three months, with the onset of symptoms six months prior to diagnosis COMPASS Therapeutic Notes on the Management of Chronic Constipation in Primary Care ● January 2012 Page 1 for diagnosis, it should be acknowledged that bowel habits is important (particularly with a high fibre diet or fibre Box THREE: Causes of constipation Table ONE: Number and cost of prescriptions for laxatives supplements), but can be difficult for some people (e.g. frail differ across individuals; one person may feel distraught and Dietary in Northern Ireland for the 12 months to September 2011 uncomfortable having only 2 bowel movements a week, • Low fibre, dieting, dementia, depression, anorexia, fluid or elderly). Fruits high in fibre and sorbitol, and fruit juices while another may find this frequency to be normal. Number of high in sorbitol can help prevent and treat constipation. depletion Class of laxative Cost prescriptions It is useful to note the difference between chronic Metabolic Fruits (and their juices) that have a high sorbitol content Bulk-forming laxatives 55,552 £205,363 constipation and irritable bowel syndrome with constipation • Diabetes mellitus, hypercalcaemia, hypokalaemia, include apples, apricots, gooseberries, grapes (and raisins), Stimulant laxatives 167,756 £779,195 (IBS-C). Whereas the hallmark symptom of IBS-C is hypothyroidism, porphyria peaches, pears, plums (and prunes), raspberries, and Faecal softeners 741 £983 abdominal pain in association with constipation, patients with Neurological strawberries. The concentration of sorbitol is about 5–10 Osmotic laxatives 394,118 £2,279578 times higher in dried fruit. chronic constipation do not report pain as a predominant • Parkinson’s disease, spinal cord pathology, multiple sclerosis 10,11 Peripheral opioid-receptor feature. Practically, however, many patients do not Iatrogenic 7 £189 In addition, exercise and increasing fluid intake are often antagonists comply with this tidy dichotomy. It is common to encounter • Aluminium antacids recommended to treat constipation, but again, there is 5HT -receptor agonists 387 £22,786 patients who have mild or moderate abdominal discomfort in • Antimuscarinic (e.g. procyclidiine, oxybutynin) 4 insufficient evidence that these interventions help in chronic Total 618,561 £3,288,093 chronic constipation but who do not report discomfort as a • Antidepressants (most commonly tricyclic antidepressants) constipation.27 predominant symptom. Similarly, patients with IBS-C may • Antiepileptics (e.g. carbamazepine, gabapentin, Assessing frequency, amount and consistency of stools Despite limited data supporting their use in clinical practice, have abdominal pain on some occasions but not oxcarbazepine, pregabalin, phenytoin) Because most patients understandably lack a working the suggested lifestyle changes promote general health and consistently. These variations in patient assessment of • Sedating antihistamines knowledge of normative stool consistency, it is instructive to may improve bowel symptoms in some patients.29-32 Another abdominal discomfort make it difficult to clearly distinguish • Antipsychotics use the Bristol Stool Scale: behavioural modification to consider includes ensuring that IBS-C from chronic constipation. If in doubt, ask the patient • Antispasmodics (e.g. Dicycloverine, hyoscine) ( www.nursingtimes.net/Journals/1/Files/2009/3/31/Stool patients spend an adequate amount of time on the toilet for whether pain or discomfort is a predominant feature or • Calcium supplements Chart O4.pdf ) when asking patients to classify their bowel bowel movements, preferably at a regularly scheduled time 10,23,24 whether the "main problem" is limited to the constipation • Diuretics movements. The scale provides 7 prototypical stool (typically in the morning to coincide with the body’s natural itself. Patients who acknowledge that abdominal pain is a • Iron supplements forms. Patients with constipation typically point to type 1 and gastrocolic response). • Opioids major factor are more likely to have IBS-C than chronic type 2 bowel movements as their predominant stool form. In children, NICE4 indicate that dietary interventions alone constipation. Those principally concerned with improving • Verapamil Painful anorectal conditions What should be advised about the role of lifestyle in should NOT be used as first-line treatment for idiopathic stool frequency or form independent of abdominal pain constipation.

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