ow would you address your patient’s concerns?

A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. How would you address your patient’s concerns?  What medication would you add and why?

Constipation is among the commonest reason that makes people self medicate (Teri Moser Woo 2016 pp535). It is very common and can be caused by variety of factors ranging from lack of exercise, immobility, neuronal abnormality, iatrogenic causes as well. Appropriate management requires an evaluation for secondary etiologies, such as systemic disorders and drugs. Once secondary causes have been eliminated, idiopathic constipation may be associated with normal or slow colonic transit, defecatory dysfunction (pelvic floor dysfunction), or both. Laboratory work up specifically electrolytes and radiological investigation would be considered for the above mentioned patient. This is after a thorough History and physical exam.

Since the patient above exercises and eats well, I would start with a stimulant Laxative in this case. Stimulant laxatives — Stimulant laxatives such as bisacodyl (e.g., some forms of Dulcolax), Senna (e.g., Senokot), and sodium picosulfate (e.g., Dulcolax drops). According to (Johnson DA, Barkun AN, Cohen LB, et al 2014) A randomized four-week trial of sodium picosulfate (10 mg daily) in 45 patients with chronic constipation demonstrated improved bowel function for those receiving medication compared with placebo

 

                                                                        Senna

Category: Senna is a stimulant laxative, primarily exert their effects via alteration of electrolyte transport by the intestinal mucosa. They also increase intestinal motor activity

Use: Senna is use for constipation, generally causes bowel movement in 6 to 12 hours

Warning and Education: Senna should be used appropriately. Failure to have a bowel movement or occurrence of rectal bleeding after use should be reported to health care provider. It is not recommended for use in patients experiencing stomach pain, nausea, vomiting, or a sudden change in bowel movements which lasts >2 weeks. If constipation did not improve after being on Senna for one week, return to the clinic. Do not use for more than 1 week.

Adverse reaction: Some adverse reaction that can result from Senna use include: abdominal cramps, diarrhea, nausea, vomiting

 

References

Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52. [PubMed 27060684]

Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US multi-society task force on colorectal cancer. Am J Gastroenterol, 2014;109(10):1528-1545. [PubMed 25223578]

Woo, T. M. & Robinson, M. V. (2016): Pharmacotherapeutics for Advanced Practice Nurse

Prescribers. (4TH ed.). Philadelphia: F. A. Davis Co

Liu Z, Yan S, Wu J, et al. Acupuncture for Chronic Severe Functional Constipation: A Randomized Trial. Ann Intern Med 2016; 165:761.