Presentation on theme: "Practical Approaches Towards Improving Patient Outcomes for Chronic Constipation and Irritable Bowel Syndrome With Constipation (IBS-C) Among Older Adults."— Presentation transcript:
1 Practical Approaches Towards Improving Patient Outcomes for Chronic Constipation and Irritable Bowel Syndrome With Constipation (IBS-C) Among Older Adults
2 Educational Learning Objectives Describe the elements of proper diagnosis and follow-up management of chronic constipation (CC) in older adultsDemonstrate awareness of the prevalence of irritable bowel syndrome-constipation (IBS-C) in older adults and the elements of differential diagnosis from CCDiscuss how management of CC and IBS-C varies based upon underlying etiologies and across the spectrum of older adults, from the active community dweller to the compromised long term care resident with multiple comorbiditiesList common patient perceptions of constipation and describe how these may impact progress towards practitioners' clinical goals in CC and IBS-CIdentify patient education and counseling strategies that will allow advanced practice nurses (APN) to collaborate with patients and family members in the successful management of CC and IBS-C in older adults
3 How Do We Define Constipation? The American College of Gastroenterology (ACG) definition of constipation:Unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. Difficult stool passage includes straining, a sense of difficulty passing stool, incomplete evacuation, hard/lumpy stools, prolonged time to pass stool, or need for manual maneuvers to pass stoolThe ACG Chronic Constipation Task Force also clarified what is meant by chronic:Chronic constipation is defined as the presence of these symptoms for at least 3 monthsAmerican College of Gastroenterology Chronic Constipation Task Force. Am J Gastroenterol. 2005;100(S1):1-4.
4 GI Symptoms Are Common in the Older Population 35% to 40% of geriatric patients will have at least 1 GI symptom in any yearConstipation, fecal incontinence, diarrhea, irritable bowel syndrome, reflux disease, and swallowing disordersPrevalence rates for constipation in the older adult population range from approximately 19% to 40%Day Hospitals/Living at Home: 25–40%Nursing Homes/Geriatric Hospitals: 60–80%Irritable bowel syndrome presents in ~10% of the older populationHall KE, et al. Gastroenterology. 2005;129:Ginsberg D, et al. Urol Nursing. 2007;27:Morley J. Clin Geriatr Med. 2007;23:
5 Overlap Between Common Disorders DyspepsiaIBSGERDChronicConstipationHeartburnRegurgitationBloatingAbdominal PainDiscomfortBelchingBrandt L, et al. Am J Gastroenterol. 2005;100(S1):5-22.
6 Abdominal Pain: Salient Feature Absent in Chronic Constipation IBS withconstipationPresence or absence of abdominal pain is themajor differentiating featureBrandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.
7 Prevalence of Functional Gastrointestinal Disorders 4540403525-40302-28282525Population (%)3-20206-181510885DyspepsiaFunctional HeartburnChronic ConstipationGERDIBSHyper-tensionMigraineAsthmaDiabetesWong WM, Fass R. Curr Treat Options Gastroenterol. 2004;7(4):Corazziari E. Best Pract Res Clin Gastroenterol. 2004;18(4):Higgins PD, Johanson JF. Am J Gastroenterol. 2004;99(4):Brandt L, et al. Am J Gastroenterol. 2002;97(suppl11):S7-26.Wolf-Maier K, et al. JAMA. 2003;289:Lawrence EC. South Med J Nov;97(11):CDC. MMWR Morb Mortal Wkly Rep. 2004;53:CDC. MMWR Morb Mortal Wkly Rep. 2003;52:
8 Constipation Increases With Age and Is More Common in Women Study 1N = 42,375Harari, et alPopulation: NHIS 1989Criteria: self-reportMenWomen25122010815Prevalence of Constipation (%)Constipation (%)Prevalence of610452≥ 80Study 2Study 3Study 4< 4040-4950-5960-6970-79N = 5,430DrossmanN = 1,149PareN = 10,018StewartAge Group (years)SexNHIS = National Health Interview SurveyHiggins PDR, et al. Am J Gastroenterol. 2004;99:
9 Chronic Constipation Interferes with Daily Lives of the Aging Population No GI symptoms1008060Mean MOS Score4020Physical FunctioningRole FunctioningSocial FunctioningMental HealthHealth PerceptionBodily PainMOS = medical outcomes surveyImpact of chronic constipation on quality of life in Olmsted County, MN, residents aged ≥ 65 yearsLower score indicates worse quality of lifeAdapted from Talley NJ. Rev Gastroenterol Disord. 2004;4(suppl 2):S3-S10.
10 Economic Impact of Constipation 2.5 million office visits annually92,000 hospital admissions85% are given prescriptions for laxatives or cathartics$400 million dollars spent in annually for prescription laxatives$2253 average cost per long term care residentEconomic Burden of Irritable Bowel SyndromeIBS care: > $20 billion direct and indirect expendituresPatients with IBS consume > 50% more health care costs than matched controls without IBSTariq S. J Am Med Dir Assoc. 2007;8:Ginsberg D, et al. Urol Nursing. 2007;27(3):ACG IBS Task Force. Am J Gastroenterol. 2009;104:S1-S35.
11 Normal Physiology of Defecation Increased abdominal pressure or propulsive colorectal contractionsRelaxation of internal anal sphincter (autonomic)Relaxation of external anal sphincter (voluntary)Straightening of pelvic musculature (levator ani, puborectalis)At restWith strainingLembo A, Camilleri M. N Engl J Med. 2003;349:Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:
12 Mediators of Gastrointestinal Function MotilitySerotoninAcetylcholineNitric oxideSubstance PVasoactive intestinal peptideCholecystokininCorticotropin releasing factorVisceral SensitivitySerotoninTachykininsCalcitonin gene-related peptideNeurokinin AEnkephalinsCorticotropin releasing factorSecretionSerotoninAcetylcholineKim DY, Camilleri M. Am J Gastroenterol. 2000;95(10):
13 Rome III Diagnostic Criteria* for Functional Constipation Chronic constipation must include 2 or more of the following:During at least 25% of defecationsStrainingLumpy or hard stoolsSensation of incomplete evacuationManual maneuvers to facilitate defecations< 3 defecations per weekSensation of anorectal obstruction/blockageLoose stools are rarely present without the use of laxativesInsufficient criteria for irritable bowel syndrome*Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosisLongstreth GF, et al. Gastroenterology. 2006;130:
14 Primary Causes of Chronic Constipation Normal-transit constipationSlow-transit constipationDefecatory dysfunctionIBS with constipationBosshard W, et al. Drugs Aging. 2004;21:Hadley S.K, et al. Journal of Am Fam Physician. 2005;72:
15 Primary Constipation Normal-transit Constipation – Intestinal transit and stool frequency are within the normal range– Most frequent type of constipationBosshard W, et al. Drugs Aging. 2004;21:Gallagher P, et al. Drugs Aging. 2008;25(10):
16 Primary Constipation Slow-transit Constipation Characterized by prolonged intestinal transit timeAltered regulation of enteric nervous systemDecreased nitric oxide productionImpaired gastrocolic reflexAlteration of neuropeptides (VIP, substance P)Decreased number of interstitial cells of Cajal in the colonLembo A, Camilleri M. N Eng J Med. 2003;349:
17 Primary Constipation Defecatory Dysfunction – More common in older women – childbirth trauma– Pelvic floor dyssynergia– Contributing factors include anal fissures, hemorrhoids, rectocele, rectal prolapse, posterior rectal herniation– Excessive perineal descent– Pathogenesis may be multifactorial – structural problem– Abnormal anorectal manometry and/or defecography[Role for biofeedback therapy]Bosshard W, et al. Drugs Aging. 2004;21:Hadley S.K, et al. Journal of Am Fam Physician. 2005;72:
18 Primary Constipation Irritable Bowel Syndrome (IBS) with Constipation – Alterations in brain-gut axis– Stress-related condition– Visceral hypersensitivity– Abnormal brain activation– Altered gastrointestinal motility– Role for neurotransmitters, hormones– Presence of non-GI symptomsHeadache, back pain, fatigue, myalgia, dyspareunia, urinary symptoms, dizzinessVidelock E, Chang L. Gastroenterol Clin N Am. 2007;36:Hadley SK, et al. Journal of Am Fam Physician. 2005;72:
19 Rome III Criteria for IBS-C Recurrent abdominal pain or discomfort (an uncomfortable sensation not described as pain) at least 3 days per month in the last 3 months associated with 2 or more of the following:Improvement with defecationOnset associated with a change in frequency of stoolOnset associated with a change in form of stoolCriteria must be fulfilled for the last 3 months, with symptom onset at least 6 months prior to diagnosisIn pathophysiology research and clinical trials, a pain/discomfort frequency of at least 2 days a week during screening for patient eligibilityLongstreth G, et al. Gastroenterology. 2006;130:
20 Subtypes of IBS IBS-C IBS-M IBS-U IBS-D 25 50 75 100 255075100% Loose or Watery Stools% Hard or Lumpy StoolsIBS-C: IBS with constipationIBS-U: Unsubtyped IBSIBS-M: IBS mixedIBS-D: IBS with diarrheaLongstreth G, et al. Gastroenterology. 2006;130:
21 Combined Risk Factors for Constipation in the Elderly Population Reduced fiber intakeReduced liquid intakeReduced mobility associated with functional declineDecreased functional independencePelvic floor dysfunctionChronic conditionsParkinson’s diseaseDementiaDiabetes mellitusDepressionPolypharmacy (both over the counter and prescription medications, such as NSAIDs, antacids, antihistamines, iron supplements, anticholinergics, opiates, Ca channel blockers, diuretics, antipsychotics, anxiolytics, antidepressants)
22 Common Changes with Aging that Increase the Risk for Constipation Decreased total body waterDecreased colonic motility*Deterioration of nerve functionIncreased pelvic floor descentDecreased rectal complianceDecreased rectal sensationAge-related changes to the internal and external anal sphincter*Demonstrated in some, but not all studiesGallagher P, et al. Drugs Aging. 2008;25(10):Schiller L. Gastroenterol Clin N Am. 2001;30:
23 Patient Care Thorough patient history Physical/abdominal/digital rectal examsEvaluate symptoms in terms of diagnostic criteriaChronic constipation/IBS-CAssessment for red flags/alarm featuresNeed for additional testingTreatment/Management plan
24 Ask the Right Questions Define the meaning of “constipation”How long have you experienced these symptoms?Frequency of bowel movements?Abdominal pain?Other symptoms?What is most distressing symptom?Manual maneuvers to assist with defecation?Any limitation of daily activities?Are you taking any medications?What treatment have you tried?What investigations have been done?Locke GR III, et al. Gastroenterology. 2000;119:
25 Common Patient Descriptions of Constipation 90818072Physicians think:< 3 BM per week70605450Percent of Patients3940373628302010StrainingHard orlumpystoolsIncompleteemptyingStoolcannotbepassedAbdominalfullness orbloating< 3 BMperweekNeed topress onanusN = 1149Pare P, et al. Am J Gastroenterol. 2001;96:
26 Stool Form Correlates With Intestinal Transit Time The Bristol Stool Form ScaleSlow TransitFast TransitType 1Separate hard lumpsSausage-like but lumpyType 2Sausage-like but with cracks in the surfaceType 3Type 4Smooth and softSoft blobs with clear-cut edgesType 5Fluffy pieces with ragged edges, a mushy stoolType 6Type 7Watery, no solid piecesO’Donnell LJD, et al. BMJ. 1990;300:
28 Digital Rectal Exam Place patient in left lateral recumbent position Visually inspect the perianal regionFissures, hemorrhoids, masses, skin tags, or evidence of previous surgery, skin lesionsStroke the perianal skin to elicit a reflex contraction of the external anal sphincterAssess for paradoxical pelvic floor contraction (suggestive of pelvic floor descent)Perform a digital assessmentStrictures, masses, a rectocele, and hemorrhoidsExamine stool for color and consistencyCheck for occult bloodRao SSC. Gastroenterol Clin North Am. 2003;32:Locke GR III, et al. Gastroenterology. 2000;119:
29 Any Alarm Symptoms? Are Diagnostic Tests Needed? HematocheziaFamily history of colon cancerFamily history of inflammatory bowel diseaseAnemiaPositive fecal occult blood test“Unexplained” weight loss ≥ 10 poundsSevere, persistent constipation that is unresponsive to treatmentNew-onset constipation in an elderly patientLocke GR III, et al. Gastroenterology. 2000;119:Brandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.
30 ACG Task Force Recommendations on Diagnostic Testing ACG task force does not recommend diagnostic testing in patients without alarm signs or symptomsBUT routine colon cancer screening recommended for all patients aged ≥ 50 years (African Americans aged ≥ 45 years)Diagnostic studies are indicated in patients with alarm signs or symptomsThyroid function testsMeasurements ofCalciumElectrolytesBrandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.Agrawal S, et al. Am J Gastroenterol. 2005;100:
31 Diagnostic Tests That May Be Performed After a Referral UseAnorectal manometryAssesses the internal and external anal sphincters, pelvic floor, and associated nervesScreening test of choice for dyssynergic defecationBalloonexpulsionDetects defecatory disordersSimple, office-based screening testDefecographyDetects structural abnormalities of the rectumOperator dependent, poor reliability, not widely availableColonic transit studyMeasures rate at which fecal mass moves through colonColonoscopyProvides a visual diagnosis while performing biopsies with detection and removal of polypsRao SSC, et al. Am J Gastroenterol. 2005;100:Lembo A, Camilleri M. N Engl J Med. 2003;349:Winawer S, et al. Gastroenterol. 2003;124:
32 Differentiating Between Occasional and Chronic Constipation Occasional ConstipationChronic ConstipationInfrequentPresent for at least 3 months and may persist for yearsOccasional or short-term condition that may temporarily interrupt usual routineLong-term condition that may dominate personal and work lifeMay be brought on by patient’s behavior, change in diet, lack of exercise, illness, or medicationNot only related to patient’s behavior, change in diet, lack of exercise, or medicationMay be relieved by diet, exercise, and over-the-counter (OTC) medicationMay need medical attention and prescription medication
33 Lifestyle Modifications Targeted MechanismEfficacyIncrease fluid intakeIncrease stool volume by augmenting luminal fluidLimited; majority of fluid is absorbed before reaching the colon and is expelled via urineIncrease exerciseImprove motility by decreasing transit time through the GI tractModerate; some evidence suggests this is beneficial; however, not sufficient to treatIncrease dietary fiberIncrease water and bulk stool volumeLimited benefit compared with placeboChung BD, et al. J Clin Gastroenterol. 1999;28:29-32.Dukas L, et al. Am J Gastroenterol. 2003;98:ACG Chronic Constipation Task Force. Am J Gastroenterol. 2005;100(suppl 1):S1-S4.
34 Treating Constipation With Laxatives DescriptionBulking AgentsAbsorbs liquids in the intestines and swells to form a soft, bulky stool; the increase in fecal bulk is associated with accelerated luminal propulsionOsmotic LaxativesDraws water into the bowel from surrounding body tissues providing a soft stool mass and improved propulsion[saline, poorly absorbed mono- and disaccharides, polyethylene glycol]Stimulant LaxativesCause rhythmic muscle contractions in the intestines, increase intestinal motility and secretionsLubricantsCoats the bowel and the stool mass with a waterproof film; stool remains soft and its passage is made easierStool SoftenersHelps liquids mix into the stool and prevent dry, hard stool masses; has been said not to cause a bowel movement but instead allows the patient to have a bowel movement without strainingCombinationsCombinations containing more than 1 type of laxative; for example, a product may contain both a stool softener and a stimulant laxativeGallagher P, et al. Drugs Aging. 2008;25:
35 Laxatives Laxative Type Generic Name Brand Name(s) Bulk-forming MethylcelluloseCitrucel®PolycarbophilFiberCon®, Fiber-Lax®PsylliumMetamucil®, Konsyl®LubricatingGlycerinGlycerin suppository (generic)Mineral oilMineral oil (generic)Magnesium hydroxide (milk of magnesia) and mineral oilPhillips’® M-OStool SoftenersDocusate sodiumColace®, Dulcolax® Stool Softener, Phillips’ Liqui-Gels®SalineMagnesium hydroxide (milk of magnesia)Ex-Lax® Milk of Magnesia Laxative/AntacidPhillips’® Chewable TabletsPhillips’® Milk of MagnesiaStimulantBisacodylEx-Lax Ultra, Dulcolax Bowel Prep KitSodium bicarbonate and potassium bitartrateCeo-Two Evacuant®SennosidesEx-Lax® Laxative PillsCastor oilPurge®SennaSenokot®OsmoticPolyethylene glycol 3350GlycoLax®, MiraLAXLactuloseKristalose®
36 Bulk Laxatives: Review of Efficacy StudiesEvidenceSummary and RecommendationPsyllium5 RCTs:3 placebo controlled1 well designed2 trials: greater stool frequency, better stool consistency, and greater ease of defecation1 trial: no improvementPsyllium appears to improve stool frequency and consistencyGRADE BBran3 RCTs:1 placebo controlledAll poorly designedStool frequency was significantly greater with bran than placebo if placebo was given first, but not if bran was given firstInsufficient data to make a recommendationBrandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.
37 Stool Softeners and Stimulant Laxatives: Review of Efficacy StudiesEvidenceSummary and RecommendationDocusate4 RCTs:2 placebo controlled3 well designed1 trial: greater stool frequency1 trial: greater stool frequency and global symptom assessment2 trials: no improvement (1 vs placebo, 1 vs psyllium)Insufficient data to make recommendationDocusate may be inferior to psyllium in increasing stool frequencyStimulantlaxativesNone placebo controlledLow-quality study designIn 3 studies, no difference between stimulant laxative and control in stool frequency or consistency1 trial: less efficacy compared with lactulose at increasing stool frequencyNot possible to make a recommendation about efficacyRCT = randomized controlled trialBrandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.
38 Osmotic Laxatives: Review of Efficacy StudiesEvidenceSummary and RecommendationLactulose3 RCTs:All placebo controlled2 well designedAll trials favor lactuloseSignificantly improved stool consistencyMean number of BM/day significantly greater vs placeboEffective at improving stool frequency and stool consistencyGRADE APolyethylene Glycol (PEG)5 placebo-controlled RCTs2 RCTs comparing PEG and lactuloseIncreased stool frequency and improvement in stool consistency vs. placeboStool frequency greater, straining less often, overall effectiveness higher vs. lactuloseBrandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.
39 Percentage of Patients PEG 3350 – 12-Month StudyAn Open-Label, Single Treatment Multi-Centre Study of 311 Patients (117 aged 65 and older)Percentage of Patients2 months N = 2504 months N = 2176 months N = 2039 months N = 18512 months N = 180VisitsPEG 3350 was determined safe and effective for treating constipation in adult older patients for periods up to 12 months, with no signs of tachyphylaxisDi Palma J. Ailment Pharmacol Ther. 2006;25;
40 Adverse Effects of Laxatives Bulking agentsBloatingSevere adverse events: esophageal and colonic obstruction, anaphylactic reactionsOsmotic laxativesPossible electrolyte abnormalities, hypovolemiaDiarrhea (2% to 40% of PEG-treated patients)Excessive stool frequency, nausea, abdominal bloating, cramping, flatulenceStimulant laxativesAbdominal discomfort, electrolyte imbalances, allergic reactions, hepatotoxicityBrandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.
41 Dangers of Saline Laxatives in the Elderly Oral sodium phosphate products [Visicol®, OsmoPrep®, Fleet* Phospho-soda] for bowel cleansingBlack box warning for Visicol®, OsmoPrep®Acute phosphate nephropathyPatients with identifiable risk factorsAge > 55Baseline kidney diseaseHypovolemic, reduced intravascular volumeBowel obstruction, active colitisUsing medications that affect renal perfusion or function*Withdrawn from the marketAvailable at: Accessed April 2009.
42 Are Patients Satisfied With Laxatives and Fiber? 100OTC laxativesPrescription laxativesFiber(n = 146)(n = 42)(n = 268)79808075716667606052505050Dissatisfied Patients (%)444020Ineffective Reliefof ConstipationIneffective Relief of Multiple SymptomsLack of PredictabilityIneffective Reliefof BloatingJohanson JF and Kralstein J. Aliment Pharmacol Ther. 2007;25:
43 Lubiprostone: A Chloride Channel Activator Gastrointestinal-targeted bicyclic functional fatty acidActivates ClC-2 chloride channelsMovement of Cl-, Na+, H2O followIncreased luminal fluid secretionShortened colonic transit timeIndicated for:Treatment of chronic idiopathic constipation (24 µg BID) in the adult population including age > 65 years (FDA approval 2006)Treatment of irritable bowel syndrome with constipation (8 µg BID) in women ≥ 18 years (FDA approval 2008)Cuppoletti J, et al. Am J Physiol Cell Physiol. 2004;287:C1173-C1183.Amitiza PI. Available at: Accessed April 2009.
44 Change from Baseline in SBM Frequency Lubiprostone: Stool Frequency in Patients Over 65 with Chronic ConstipationNonelderly lubiprostone 48 µgElderly (≥ 65 years) lubiprostone 48 µgNonelderly placeboElderly placebo6****5*P ≤ 0.03†P <†††4N = 57 (patients aged ≥ 65 years vs placebo)Change from Baseline in SBM Frequency321Week 1Week 2Week 3Week 4SBM = spontaneous bowel movementUeno R, et al. Annual Meeting of the American College of Gastroenterology;October 2006; Las Vegas, NV. Johanson J, et al. Am J Gastroenterol. 2008;103:
45 Safety Profile of Lubiprostone Well tolerated in 4 week and 6-12 month trialsNausea, diarrhea, and headacheNo clinically significant changes in serum electrolyte levelsLow likelihood of drug-drug interactionsNon-absorbed; works intraluminally and does not result in measurable blood levelsAvailable at: Accessed April 2009.
46 Suggested Management Algorithm for Chronic Constipation Bleeding, anemia, weight loss, sudden change in stool caliber, abdominal painAlarm SymptomsNo Alarm SymptomsLifestyle, OTC, stimulant laxativeDirected testingRefer to a specialist as neededNo Response+ ResponseTrial of lactulose or PEG 3350ContinueregimenNo response+ ResponseTrial of lubiprostoneNo response+ ResponseOTC = over-the-counter therapies (probiotics, herbal medications, stool softeners[docusate sodium], psyllium, methylcellulose, calcium polycarbophil, bisacodyl, senna)
47 Treatment for IBS-C Treatment Recommendation Psyllium Moderately effective; single study reported improvement with calcium polycarbophilWheat or corn branNo more effective than placebo in relief of global IBS symptoms; Not recommended for routine usePolyethylene glycolShown to improve stool frequency, but not abdominal pain in 1 small studyNo publications of placebo-controlled, randomized studies of laxatives in IBS-CAntibioticsShort-term course of a non-absorbable antibiotic is more effective than placebo for global improvement of IBS and for bloating. No data to support long-term safety and effectivenessProbioticsIn single organism studies, lactobacilli do not appear effective for patients with IBS; bifidobacteria and some probiotic combinations demonstrate some efficacyACG IBS Task Force. Am J Gastroenterol. 2009;104:S1-S35.
48 Treatment for IBS-C Treatment Recommendation Antispasmodics (hyoscine, cimetropium, pinaverium, peppermint oilCertain antispasmodics may provide short-term relief of abdominal pain/discomfortEvidence for long-term efficacy is not available; safety and tolerability evidence is limitedLubiprostone8 µg BID is more effective than placebo in relieving global IBS symptoms in women with IBS-CTricyclic antidepressantsSelective serotonin reuptake inhibitorsMore effective than placebo at relieving global IBS symptoms;Appear to reduce abdominal painLimited data on safety and tolerabilityTricyclic antidepressants may worsen constipationPsychotherapyCognitive therapy, dynamic psychotherapy, hypnotherapy (not relaxation therapy) are more effective than usual care in relieving global symptoms of IBSACG IBS Task Force. Am J Gastroenterol. 2009;104:S1-S35.
49 Lubiprostone for IBS-C Data From 2 Phase 3 Studies Placebo N = 385Lubiprostone (8 µg BID) N = 76920Note the different dose!For chronic constipationlubiprostone: 24 µg BIDP = 0.00115Response Rate (%)105Combined intent to treat populationMonthly responder for ≥ 2/3 months during treatmentDrossman D, et al. Aliment Pharmacol Ther. 2009;29:
51 When to Change/Add Therapy for an Unresponsive Patient? No studies have examined this question1Stepped Treatment Of Older adults on Laxatives (STOOL) trial was designed to investigate the efficacy of adding a second agent when the first constipation therapy failed2It closed early with only 19 enrolled participantsIn general, the prescribing clinician may elect to combine therapy depending on the patient’s response and lingering symptoms; recommended more often for patients with severe symptomsCombine agents with different mechanisms of action, such as lubiprostone with senna, or an antispasmodic with a laxative for IBS-C1. Gartlehner G, et al. Available at: Accessed April, 2009.2. Mihaylov S, et al. Health Technol Assess. 2008;12(13).
52 Post-Stroke Patient Special Considerations Treatment Strategy* Recent studies have reported constipation in 55% of patients at the acute stage (4 weeks)1, and in 30% ≥ 3 months2 following strokePatient limitationsPositioning problemsReduced peristalsisImmobilityTreatment Strategy*Appropriate assessment of bowel function, frequency, consistencyTailor a specific bowel management program to facilitate/initiate defecationCareful documentation with a bowel diaryGlycerin suppositories, laxatives, motility agents to promote defecation*Treatment strategy based on clinical experienceSu Y, et al. Stroke. 2009;40:Bracci F, et al. World J Gastroenterol. 2007;13(29):
53 Patient With Dementia Contributing Factors Treatment Strategy* ImmobilityDehydrationInadequate food intakeDepressionCognitive deficitsCannot find the bathroomInability to undressCannot ask for helpCannot sense the urge to defecateUse of psychotropic drugsTreatment Strategy*Appropriate assessment of bowel functionEstablish a bowel routine, regular toileting programSuppositories, stool softeners, bulking agentsCareful documentation (bowel diary, effectiveness of treatments, etc.)Involve family or health care team (in a nursing facility)Address nutritional/fluid needs*Treatment strategy based on clinical experience
54 Patients Treated With Opiates Special ConsiderationsOpioids inhibit GI propulsive motility and secretionGI effects of opioids are mediated primarily by µ-opioid receptors within the bowelConstipation is a common and troubling side effectPatients do not develop tolerance to the effects of opiates on the bowelTreatment Strategy*Laxative therapy should be initiated proactively with start of opiate useMagnesium hydroxide, senna, lactulose, bisacodyl, stool softenerA combination of a stimulant and stool softener is often requiredLaxative doses may need to be increased along with increased doses of opioidsTitrate doses of laxatives according to response prior to changing to an alternative laxativeWhen laxative therapy is inadequate, consider methylnaltrexone*Treatment strategy based on clinical experienceTamayo A, Diaz-Zuluaga P. Support Care Cancer. 2004;12:Shaiova L, et al. Palliat Supp Care. 2007;5:
55 A Role for Peripheral µ-opioid Receptor Antagonists? MethylnaltrexoneNovel, quaternary µ-opioid receptor antagonistDoes not antagonize the central (analgesic) effects of opioids or precipitate withdrawalFDA approved for treatment of opioid-induced constipation in patients with advanced illness, receiving palliative care, when laxative therapy has been inadequateSubcutaneous injection; one dose (0.15 mg/kg) every other day as needed, no more than 1 dose in a 24 hr periodAbdominal pain and flatulence most common adverse eventsFoss JF. Am J Surg. 2001;182 (5ASuppl):19S-26S.Thomas J, et al. New Engl J Med. 2008;358:Relistor [package insert]. Available at:Accessed April 2009.
56 Neurologic Disorders: Parkinson’s Disease Special ConsiderationsConstipation occurs in at least 2/3 of patientsMultifactorial:Slow colonic functionDefecatory dysfunctionEnteric and central nervous systemAntiparkinsonian medicationsAnticholinergic agentsDopaminergic agentsUnderlying illness is chronic and uncorrectableTreatment Strategy*Adjust medications if possibleInitiate pharmacologic therapyMay need to use medications from several classesOsmotic laxatives, Cl channel activators, stimulant laxatives*Treatment strategy based on clinical experienceStark ME. Am J Gastroenterol. 1999;94:
57 Chronic Constipation Secondary to Diabetes Special ConsiderationsConstipation occurs in 20% of patients with diabetesRelated to duration of diabetes > 10 yearsDiabetic autonomic neuropathyGastrocolic reflex may be absent, delayed, bluntedConstipation may be severe and can lead to megacolonTreatment Strategy*Optimize diabetes careStepwise pharmacologic therapyExclude slow transitBulking agents, osmotic laxatives, Cl channel activators, stimulant laxatives*Treatment strategy based on clinical experienceVerne GN, et al. Gastroenterol Clin North Am. 1998;27:
58 Complications of Chronic Constipation Fecal impaction1,2Identified in up to 40% of elderly adults hospitalized in United KingdomIntestinal volvulus/obstruction2Urinary and fecal incontinence2Stercoral ulceration/ischemia2Bowel perforation2Possible increased risk of colorectal cancer (controversial)3,4Read NW, et al. J Clin Gastroenterol. 1995;20:61-70.De Lillo AR, Rose S. Am J Gastroenterol ;95:Roberts MC, et al. Am J Gastroenterol. 2003;98:857.Dukas L, et al. Am J Epidemiol. 2000;151:
59 Fecal Impaction Recognition/Identification Maintain high level of vigilance for institutionalized patients or patients in the hospitalAbsence of bowel movement, absence of bowel soundsFecal soiling, fecal incontinence of liquid stoolAssessmentDigital rectal examAbdominal x-rayTreatment Strategy*Prevention!!Treat from belowEnema, suppositoryManual disimpaction with prior pain medicationTreat from aboveOsmotic laxativesInstitution of preventative measuresDiet, laxatives, bowel regimen*Treatment strategy based on clinical experience
60 Emerging Therapies Prucalopride Linaclotide Selective 5-HT4 agonist Does not interact with 5-HT3 or 5-HT1B receptorsIncreases colonic motility and transitPhase 3 studies have demonstrated efficacy of 2 or 4 mg prucalopride in patients with severe chronic constipationAdverse events included headache, abdominal pain, nausea, diarrheaLinaclotideGuanylate cyclase agonistInduces intestinal fluid secretionPilot study showed improved spontaneous bowel movement frequency and improved symptoms in patients with chronic constipationAlso being studied in patients with IBS-CCamilleri M, et al. New Engl J Med. 2008;358:Quigley E, et al. Aliment Pharmacol Ther. 2009;29:Tack J, et al. Gut. 2009;58:Johnston J, et al. Am J Gastroenterol. 2009;104:
61 Myths and Misconceptions About Chronic Constipation RealityDiseases arise from autointoxication by retained stoolsNo evidence to support this theoryFluctuations in hormones contribute to constipationFluctuations in sex hormones during the menstrualcycle have minimal impact on constipation, but areassociated with changes in other GI symptomsChanges in hormones during pregnancy may playa role in slowing gut transitA diet poor in fiber causes constipationA low fiber diet may be a contributory factor in asubgroup of patients with constipationSome patients may be helped by an increase indietary fiber, others with more severe constipationmay get worse symptoms with increased dietaryfiber intakeIncreasing fluid intake is a successful treatment for constipationNo evidence that constipation can be treated successfully by increasing fluid intake unless there is evidence of dehydrationMuller-Lissner S, et al. Am J Gastroenterol. 2005;100:Heitkemper M, et al. Am J Gastroenterol. 2003;98(2):
62 More Misconceptions About Chronic Constipation RealityStimulant laxatives damage the enteric nervous system and increase the risk of cancerUnlikely that stimulant laxatives at recommendeddoses are harmful to the colonNo data support the idea that stimulant laxatives arean independent risk factor for colorectal cancerLaxatives cause electrolyte disturbancesLaxatives can cause electrolyte disturbances, but appropriate drug and dose selection can minimize such effectsLaxatives induce toleranceTolerance is uncommon in most laxative users, however tolerance to stimulant laxatives can occur in patients with severe constipation and slow colonic transitLaxatives are addictiveNo potential for addiction to laxatives, but laxatives may be misusedMuller-Lissner S, et al. Am J Gastroenterol. 2005;100:
63 Patient and Caregiver Education Provide reassuranceEngage patients/caregivers in a discussion of constipationDiscuss medicines that can contribute to chronic constipationDiscuss criteria for diagnosis, share a diagnostic algorithmUtilize patient questionnaire/symptom logDiscuss treatment options, includingCommon side effectsHow long a treatment might take to workIs it appropriate to request an alternative treatment?Answer questions!Emphasize the goals of treatmentImprove symptomsRestore normal bowel functionImprove quality of life
64 Summary Chronic constipation is a common condition in the elderly Quality of life in elderly patients is negatively affected by the symptoms of chronic constipation and IBS-CIdentify risk factors and secondary causes for constipationBe vigilant for red flags or alarm symptoms; directed tested may be necessaryMain objective of treatment for chronic constipation is to improve patients’ symptoms, restore normal bowel function (≥ 3 bowel movements per week), improve quality of life
65 Summary (cont)Evidence-based therapeutic options for chronic constipation include psyllium, lactulose, polyethylene glycol, and lubiprostonePsyllium, polyethylene glycol, antibiotics, probiotics, antispasmodics, antidepressants, lubiprostone and psychotherapy are treatments for IBS-C with varying degrees of efficacyLong-term safety and efficacy data needed for therapeutic options for both chronic constipation and IBS-C, particularly in older (> 65) adultsCareful recognition, assessment, treatment, and monitoring can lead to more effective patient-specific interventions that can reduce the burden of chronic constipation or IBS-C