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Antidiarrheals and Antidiarrheals and Laxatives Laxatives Drugs Affecting Drugs Affecting the the Gastrointestinal Gastrointestinal System System

14 Antidiarrhead Laxatives Upd

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Antidiarrheals and Antidiarrheals and LaxativesLaxatives

Drugs Affecting the Drugs Affecting the Gastrointestinal SystemGastrointestinal System

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DiarrheaDiarrhea

Abnormal frequent passage of loose Abnormal frequent passage of loose stoolsstools

oror

Abnormal passage of stools with Abnormal passage of stools with increased frequency, fluidity, and increased frequency, fluidity, and weight, or with increased stool water weight, or with increased stool water excretionexcretion

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DiarrheaDiarrhea

Acute DiarrheaAcute DiarrheaSudden onset in a previously healthy Sudden onset in a previously healthy personperson

Lasts from 3 days to 2 weeksLasts from 3 days to 2 weeks

Self-limitingSelf-limiting

Resolves without sequelaeResolves without sequelae

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DiarrheaDiarrhea

Chronic DiarrheaChronic Diarrhea

Lasts for over 3 to 4 weeksLasts for over 3 to 4 weeks

Associated with recurring passage of Associated with recurring passage of diarrheal stools, fever, loss of diarrheal stools, fever, loss of appetite, nausea, vomiting, weight appetite, nausea, vomiting, weight loss, and chronic weaknessloss, and chronic weakness

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Causes of DiarrheaCauses of Diarrhea

Acute DiarrheaAcute Diarrhea Chronic DiarrheaChronic DiarrheaBacteriaBacteria TumorsTumors

ViralViral Diabetes Diabetes

Drug-inducedDrug-induced Addison’s diseaseAddison’s diseasehyperthyroidismhyperthyroidism

Nutritional Irritable bowel syndromeNutritional Irritable bowel syndrome

ProtozoalProtozoal

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Antidiarrheals: Mechanism of Antidiarrheals: Mechanism of ActionAction

AdsorbentsAdsorbentsCoat the walls of the GI tractCoat the walls of the GI tract

Bind to the causative bacteria or toxin, Bind to the causative bacteria or toxin, which which are then eliminated through the stoolare then eliminated through the stool

Examples: Examples: bismuth subsalicylate (Pepto-bismuth subsalicylate (Pepto-Bismol), Bismol), kaolin-pectin, activated kaolin-pectin, activated charcoal, charcoal, attapulgite (Kaopectate)attapulgite (Kaopectate)

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Antidiarrheals: Mechanism of Antidiarrheals: Mechanism of ActionAction

AnticholinergicsAnticholinergicsDecrease intestinal muscle tone and Decrease intestinal muscle tone and peristalsis of GI tractperistalsis of GI tract

Result: slowing the movement of fecal Result: slowing the movement of fecal matter through the GI tractmatter through the GI tractExamples: Examples: belladonna alkaloids (Donnatal), belladonna alkaloids (Donnatal),

atropine, hyoscyamineatropine, hyoscyamine

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Antidiarrheals: Mechanism of Antidiarrheals: Mechanism of ActionAction

Intestinal Flora ModifiersIntestinal Flora ModifiersBacterial cultures of Lactobacillus Bacterial cultures of Lactobacillus organisms organisms work by:work by:– Supplying missing bacteria to the GI tractSupplying missing bacteria to the GI tract– Suppressing the growth of diarrhea-causing Suppressing the growth of diarrhea-causing

bacteriabacteria

Examples: Examples: Lactobacillus acidophilus Lactobacillus acidophilus (Lactinex)(Lactinex)

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Antidiarrheals: Mechanism of Antidiarrheals: Mechanism of ActionAction

OpiatesOpiatesDecrease bowel motility and relieve rectal Decrease bowel motility and relieve rectal spasmsspasms

Decrease transit time through the bowel, Decrease transit time through the bowel, allowing more time for water and allowing more time for water and electrolytes to be absorbedelectrolytes to be absorbed

Examples: Examples: paregoric, opium tincture, codeine, paregoric, opium tincture, codeine, loperamide, loperamide,

diphenoxylatediphenoxylate

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Antidiarrheal Agents: Side Antidiarrheal Agents: Side EffectsEffects

AnticholinergicsAnticholinergicsUrinary retention, hesitancy, impotenceUrinary retention, hesitancy, impotence

Headache, dizziness, confusion, anxiety, Headache, dizziness, confusion, anxiety, drowsinessdrowsiness

Dry skin, rash, flushingDry skin, rash, flushing

Blurred vision, photophobia, increased Blurred vision, photophobia, increased intraocular pressureintraocular pressure

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Antidiarrheal Agents: Side Antidiarrheal Agents: Side EffectsEffects

OpiatesOpiatesDrowsiness, sedation, dizziness, lethargyDrowsiness, sedation, dizziness, lethargy

Nausea, vomiting, anorexia, constipationNausea, vomiting, anorexia, constipation

Respiratory depressionRespiratory depression

Bradycardia, palpitations, hypotensionBradycardia, palpitations, hypotension

Urinary retentionUrinary retention

Flushing, rash, urticariaFlushing, rash, urticaria

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Antidiarrheal Agents: Antidiarrheal Agents: InteractionsInteractions

Adsorbents decrease the absorption Adsorbents decrease the absorption of many agents, including digoxin, of many agents, including digoxin, clindamycin, quinidine, and clindamycin, quinidine, and hypoglycemic agentshypoglycemic agents

Adsorbents cause increased bleeding Adsorbents cause increased bleeding times when given with times when given with anticoagulantsanticoagulants

Antacids can decrease effects of Antacids can decrease effects of anticholinergic antidiarrheal agentsanticholinergic antidiarrheal agents

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Antidiarrheal Agents: Antidiarrheal Agents: Nursing ImplicationsNursing Implications

Obtain thorough history of bowel Obtain thorough history of bowel patterns, general state of health, and patterns, general state of health, and recent history of illness or dietary recent history of illness or dietary changes, and assess for allergies.changes, and assess for allergies.

DO NOT give bismuth subsalicylate DO NOT give bismuth subsalicylate to children under age 16 or to children under age 16 or teenagers with chicken pox because teenagers with chicken pox because of the risk of Reye’s syndrome.of the risk of Reye’s syndrome.

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Antidiarrheal Agents: Antidiarrheal Agents: Nursing ImplicationsNursing Implications

Use adsorbents carefully in elderly Use adsorbents carefully in elderly patients or those with decreased bleeding patients or those with decreased bleeding time, clotting disorders, recent bowel time, clotting disorders, recent bowel surgery, surgery, or confusion.or confusion.

Anticholinergics should not be Anticholinergics should not be administered to patients with a history of administered to patients with a history of glaucoma, BPH, urinary retention, recent glaucoma, BPH, urinary retention, recent bladder surgery, cardiac problems, or bladder surgery, cardiac problems, or myasthenia gravis.myasthenia gravis.

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Antidiarrheal Agents: Antidiarrheal Agents: Nursing ImplicationsNursing Implications

Teach patients to take medications Teach patients to take medications exactly as prescribed and to be exactly as prescribed and to be aware of their fluid intake and aware of their fluid intake and dietary changes.dietary changes.

Assess fluid volume status; intake Assess fluid volume status; intake and output; and mucous membranes and output; and mucous membranes before, during, and after initiation of before, during, and after initiation of treatment.treatment.

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Antidiarrheal Agents: Antidiarrheal Agents: Nursing ImplicationsNursing Implications

Teach patients to notify their Teach patients to notify their physician immediately if symptoms physician immediately if symptoms persist.persist.

Monitor for therapeutic effect.Monitor for therapeutic effect.

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LAXATIVESLAXATIVES

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ConstipationConstipation

Abnormally infrequent and difficult Abnormally infrequent and difficult passage of feces through the lower GI passage of feces through the lower GI tract.tract.

Symptom, not a diseaseSymptom, not a disease

Disorder of movement through the Disorder of movement through the colon and/or rectumcolon and/or rectum

Can be caused by a variety of Can be caused by a variety of diseases diseases or drugsor drugs

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Causes of ConstipationCauses of ConstipationMetabolic and endocrine disordersMetabolic and endocrine disorders

Diabetes, hypothyroidism, pregnancyDiabetes, hypothyroidism, pregnancy

NeurogenicNeurogenic

Autonomic neuropathy, multiple sclerosis, Autonomic neuropathy, multiple sclerosis, spinal cord lesions, Parkinson’s disease, CVAspinal cord lesions, Parkinson’s disease, CVA

Adverse drug effectsAdverse drug effects

Analgesics, anticholinergics, iron supplements, Analgesics, anticholinergics, iron supplements, opiates, aluminum antacids, calcium antacidsopiates, aluminum antacids, calcium antacids

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Causes of ConstipationCauses of Constipation

LifestyleLifestylePoor bowel movement habits: voluntary Poor bowel movement habits: voluntary refusal to defecate resulting in refusal to defecate resulting in constipationconstipation

Diet: poor fluid intake and/or low-residue Diet: poor fluid intake and/or low-residue (roughage) diet, or excessive consumption (roughage) diet, or excessive consumption of dairy productsof dairy products

Physical inactivityPhysical inactivity

Psychological factors: stress, anxietyPsychological factors: stress, anxiety

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Laxatives:Laxatives:

Mechanisms of ActionMechanisms of ActionBulk-formingBulk-forming

EmollientEmollient

HyperosmoticHyperosmotic

SalineSaline

StimulantStimulant

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Laxatives: Mechanism of ActionLaxatives: Mechanism of Action

Bulk-FormingBulk-FormingHigh fiberHigh fiber

Absorbs water to increase bulkAbsorbs water to increase bulk

Distends bowel to initiate reflex bowel Distends bowel to initiate reflex bowel activityactivity

Examples: Examples: psyllium (Metamucil), psyllium (Metamucil), methylcellulose (Citrucel), methylcellulose (Citrucel), polycarbophilpolycarbophil

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Bulk-FormingBulk-Forming

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Laxatives: Mechanism of ActionLaxatives: Mechanism of Action

EmollientEmollientStool softeners and lubricantsStool softeners and lubricants

Promote more water and fat in the stoolsPromote more water and fat in the stools

Lubricate the fecal material and intestinal Lubricate the fecal material and intestinal wallswalls

Examples:Examples: Stool softeners: docusate salts Stool softeners: docusate salts (Colace, Surfak)(Colace, Surfak) Lubricants: mineral oilLubricants: mineral oil

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Laxatives: Mechanism of ActionLaxatives: Mechanism of Action

HyperosmoticHyperosmoticIncrease fecal water contentIncrease fecal water content

Result: bowel distention, increased Result: bowel distention, increased peristalsis, peristalsis, and evacuationand evacuation

Examples:Examples: polyethylene glycol (GoLYTELY), polyethylene glycol (GoLYTELY), sorbitol, sorbitol, glycerin, lactulose glycerin, lactulose (Chronulac)(Chronulac)

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Laxatives: Mechanism of ActionLaxatives: Mechanism of Action

SalineSalineIncrease osmotic pressure within the intestinal Increase osmotic pressure within the intestinal tract, causing more water to enter the tract, causing more water to enter the intestinesintestines

Result: bowel distention, increased peristalsis, Result: bowel distention, increased peristalsis, and evacuationand evacuation

Examples:Examples: magnesium sulfate (Epsom salts)magnesium sulfate (Epsom salts)magnesium hydroxide (MOM), magnesium hydroxide (MOM),

magnesium citrate magnesium citrate sodium sodium

phosphate (Fleet Phospho-Soda)phosphate (Fleet Phospho-Soda)

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Laxatives: Mechanism of ActionLaxatives: Mechanism of Action

StimulantStimulantIncreases peristalsis via intestinal nerve Increases peristalsis via intestinal nerve stimulationstimulation

Examples:Examples: castor oil, senna, cascara, castor oil, senna, cascara, bisacodylbisacodyl

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Laxatives: Therapeutic UsesLaxatives: Therapeutic Uses

Laxative GroupLaxative Group UseUse

Bulk-formingBulk-forming Acute and chronicAcute and chronicconstipationconstipation

Irritable bowel syndromeIrritable bowel syndrome

DiverticulosisDiverticulosis

EmollientEmollient Acute and chronicAcute and chronicconstipationconstipation

Softening of fecal impactionSoftening of fecal impaction

Facilitation of BMs inFacilitation of BMs inanorectal conditionsanorectal conditions

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Laxatives: Therapeutic UsesLaxatives: Therapeutic Uses

Laxative GroupLaxative Group UseUseHyperosmoticHyperosmotic Chronic constipationChronic constipation

Diagnostic and Diagnostic and surgical prepssurgical preps

SalineSaline ConstipationConstipation

Diagnostic and Diagnostic and surgical prepssurgical preps

Removal of helminths Removal of helminths and parasitesand parasites

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Laxatives: Therapeutic UsesLaxatives: Therapeutic Uses

Laxative GroupLaxative Group UseUseStimulantStimulant Acute constipationAcute constipation

Diagnostic and Diagnostic and surgicalsurgical

bowel prepsbowel preps

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Laxatives: Therapeutic UsesLaxatives: Therapeutic Uses

Laxative GroupLaxative Group UseUse

Bulk-formingBulk-forming Impaction and fluid overloadImpaction and fluid overload

EmollientEmollient Skin rashesSkin rashes

Decreased absorption Decreased absorption of vitaminsof vitamins

HyperosmoticHyperosmotic Abdominal bloating, Abdominal bloating, rectal irritationrectal irritation

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Laxatives: Therapeutic UsesLaxatives: Therapeutic Uses

Laxative GroupLaxative Group UseUse

SalineSaline Magnesium toxicity (withMagnesium toxicity (withrenal insufficiency),renal insufficiency),cramping, diarrhea,cramping, diarrhea,increased thirstincreased thirst

StimulantStimulant Nutrient malabsorption, Nutrient malabsorption, skin skin rashes, gastric rashes, gastric irritation, irritation, rectal irritationrectal irritation

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Laxatives: Side EffectsLaxatives: Side Effects

All laxatives can cause electrolyte All laxatives can cause electrolyte imbalances!!!imbalances!!!

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Laxatives: Nursing ImplicationsLaxatives: Nursing ImplicationsObtain a thorough history of presenting Obtain a thorough history of presenting symptoms, elimination patterns, and symptoms, elimination patterns, and allergies.allergies.

Assess fluid and electrolytes before Assess fluid and electrolytes before initiating therapy.initiating therapy.

Patients should not take a laxative or Patients should not take a laxative or cathartic if they are experiencing nausea, cathartic if they are experiencing nausea, vomiting, and/or abdominal pain.vomiting, and/or abdominal pain.

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Laxatives: Nursing ImplicationsLaxatives: Nursing Implications

A healthy, high-fiber diet and increased A healthy, high-fiber diet and increased fluid intake should be encouraged as an fluid intake should be encouraged as an alternative to laxative use.alternative to laxative use.

Long-term use of laxatives often results Long-term use of laxatives often results in decreased bowel tone and may lead to in decreased bowel tone and may lead to dependency.dependency.

All laxative tablets should be swallowed All laxative tablets should be swallowed whole, not crushed or chewed, especially whole, not crushed or chewed, especially if enteric-coated.if enteric-coated.

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Laxatives: Nursing ImplicationsLaxatives: Nursing Implications

Patients should take all laxative Patients should take all laxative tablets with 6 to 8 ounces of water.tablets with 6 to 8 ounces of water.

Patients should take bulk-forming Patients should take bulk-forming laxatives as directed by the laxatives as directed by the manufacturer with at least 240 mL (8 manufacturer with at least 240 mL (8 ounces) of water.ounces) of water.

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Laxatives: Nursing ImplicationsLaxatives: Nursing Implications

Bisacodyl and cascara sagrada should Bisacodyl and cascara sagrada should be given with water due to interactions be given with water due to interactions with milk, antacids, and H2 blockers.with milk, antacids, and H2 blockers.

Patients should contact their physician Patients should contact their physician if they experience severe abdominal if they experience severe abdominal pain, muscle weakness, cramps, pain, muscle weakness, cramps, and/or dizziness, which may indicate and/or dizziness, which may indicate possible fluid or electrolyte loss.possible fluid or electrolyte loss.

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Laxatives: Nursing ImplicationsLaxatives: Nursing Implications

Monitor for therapeutic effect.Monitor for therapeutic effect.

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ROMEL Y. FELARCA,MD,DFM.ROMEL Y. FELARCA,MD,DFM.

HUMBLE YOURSELF IN THE HUMBLE YOURSELF IN THE SIGHT OF THE LORD AND SIGHT OF THE LORD AND

HE WILL LIFT YOU UPHE WILL LIFT YOU UP