Anti diarrheals and laxatives

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidiarrheals and LaxativesAntidiarrheals and Laxatives

Drugs Affecting the Drugs Affecting the Gastrointestinal SystemGastrointestinal System


DiarrheaDiarrhea

• Abnormal frequent passage of loose stoolsAbnormal frequent passage of loose stools

oror

• Abnormal passage of stools with increased Abnormal passage of stools with increased frequency, fluidity, and weight, or with frequency, fluidity, and weight, or with increased stool water excretionincreased stool water excretion


DiarrheaDiarrhea

Acute DiarrheaAcute Diarrhea

• Sudden onset in a previously healthy personSudden onset in a previously healthy person

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

• Self-limitingSelf-limiting

• Resolves without sequelaeResolves without sequelae


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 appetite, diarrheal stools, fever, loss of appetite, nausea, vomiting, weight loss, and chronic nausea, vomiting, weight loss, and chronic weaknessweakness


Causes of DiarrheaCauses of Diarrhea

Acute DiarrheaAcute Diarrhea Chronic DiarrheaChronic Diarrhea

BacteriaBacteria TumorsTumors

ViralViral Diabetes Diabetes

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

NutritionalNutritional Irritable bowel syndromeIrritable bowel syndrome

ProtozoalProtozoal


Antidiarrheals: Mechanism of ActionAntidiarrheals: Mechanism of Action

AdsorbentsAdsorbents

• Coat the walls of the GI tractCoat the walls of the GI tract

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

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

attapulgite (Kaopectate)attapulgite (Kaopectate)



AnticholinergicsAnticholinergics

• Decrease intestinal muscle tone and peristalsis of GI Decrease intestinal muscle tone and peristalsis of GI tracttract

• Result: slowing the movement of fecal matter Result: slowing the movement of fecal matter through the GI tractthrough the GI tract

Examples: Examples: belladonna alkaloids (Donnatal), belladonna alkaloids (Donnatal), atropine, hyoscyamineatropine, hyoscyamine



Intestinal Flora ModifiersIntestinal Flora Modifiers

• Bacterial cultures of Lactobacillus organisms Bacterial cultures of Lactobacillus organisms work by:work by:– Supplying missing bacteria to the GI tractSupplying missing bacteria to the GI tract

– Suppressing the growth of diarrhea-causing bacteriaSuppressing the growth of diarrhea-causing bacteria

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



OpiatesOpiates

• Decrease bowel motility and relieve rectal spasmsDecrease bowel motility and relieve rectal spasms

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

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


Antidiarrheal Agents: Side EffectsAntidiarrheal Agents: Side Effects

AnticholinergicsAnticholinergics

• Urinary retention, hesitancy, impotenceUrinary retention, hesitancy, impotence

• Headache, dizziness, confusion, anxiety, drowsinessHeadache, dizziness, confusion, anxiety, drowsiness

• Dry skin, rash, flushingDry skin, rash, flushing

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


Antidiarrheal Agents: Side EffectsAntidiarrheal Agents: Side Effects

OpiatesOpiates

• Drowsiness, 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


Antidiarrheal Agents: InteractionsAntidiarrheal Agents: Interactions

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

• Adsorbents cause increased bleeding times Adsorbents cause increased bleeding times when given with anticoagulantswhen given with anticoagulants

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


Antidiarrheal Agents: Antidiarrheal Agents: Nursing ImplicationsNursing Implications

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

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



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

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



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

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



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

Monitor for therapeutic effect.Monitor for therapeutic effect.


LAXATIVESLAXATIVES


ConstipationConstipation

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

• Symptom, not a diseaseSymptom, not a disease

• Disorder of movement through the colon Disorder of movement through the colon and/or rectumand/or rectum

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


Causes of ConstipationCauses of Constipation

Metabolic and endocrine disordersMetabolic and endocrine disorders• Diabetes, hypothyroidism, pregnancyDiabetes, hypothyroidism, pregnancy

NeurogenicNeurogenic• Autonomic neuropathy, multiple sclerosis, spinal Autonomic neuropathy, multiple sclerosis, spinal

cord lesions, Parkinson’s disease, CVAcord 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


Causes of ConstipationCauses of Constipation

LifestyleLifestyle

• Poor bowel movement habits: voluntary refusal to Poor bowel movement habits: voluntary refusal to defecate resulting in constipationdefecate resulting in constipation

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

• Physical inactivityPhysical inactivity

• Psychological factors: stress, anxiety, hypochondriaPsychological factors: stress, anxiety, hypochondria


Laxatives:Laxatives:

Mechanisms of ActionMechanisms of Action

• Bulk-formingBulk-forming

• EmollientEmollient

• HyperosmoticHyperosmotic

• SalineSaline

• StimulantStimulant


Laxatives: Mechanism of ActionLaxatives: Mechanism of Action

Bulk-FormingBulk-Forming

• High fiberHigh fiber

• Absorbs water to increase bulkAbsorbs water to increase bulk

• Distends bowel to initiate reflex bowel activityDistends bowel to initiate reflex bowel activity

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



EmollientEmollient

• Stool 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 wallsLubricate the fecal material and intestinal walls

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



HyperosmoticHyperosmotic

• Increase fecal water contentIncrease fecal water content

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

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



SalineSaline

• Increase osmotic pressure within the intestinal tract, Increase osmotic pressure within the intestinal tract, causing more water to enter the intestinescausing more water to enter the intestines

• Result: bowel distention, increased peristalsis, and Result: bowel distention, increased peristalsis, and evacuationevacuation

Examples:Examples: magnesium sulfate (Epsom salts)magnesium sulfate (Epsom salts)magnesium hydroxide (MOM), magnesium hydroxide (MOM), magnesium citrate magnesium citrate sodium phosphate (Fleet Phospho-Soda)sodium phosphate (Fleet Phospho-Soda)



StimulantStimulant

• Increases peristalsis via intestinal nerve stimulationIncreases peristalsis via intestinal nerve stimulation

Examples:Examples: castor oil, senna, cascara, bisacodylcastor oil, senna, cascara, bisacodyl


Laxatives: Therapeutic UsesLaxatives: Therapeutic UsesLaxative GroupLaxative Group UseUseBulk-formingBulk-forming Acute and chronicAcute and chronic

constipationconstipation

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


Laxatives: Therapeutic UsesLaxatives: Therapeutic Uses

Laxative GroupLaxative Group UseUse

HyperosmoticHyperosmotic Chronic constipationChronic constipation

Diagnostic and surgical prepsDiagnostic and surgical preps

SalineSaline ConstipationConstipation

Diagnostic and surgical prepsDiagnostic and surgical preps

Removal of helminths Removal of helminths and parasitesand parasites




StimulantStimulant Acute constipationAcute constipation

Diagnostic and surgicalDiagnostic and surgicalbowel prepsbowel preps




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




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

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


Laxatives: Side EffectsLaxatives: Side Effects

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


Laxatives: Nursing ImplicationsLaxatives: Nursing Implications

• Obtain 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.



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



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

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



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

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



• Monitor for therapeutic effect.Monitor for therapeutic effect.

Education

Anti diarrheals and laxatives