Onki CheungMD and Arnold WaldMD

Constipation is one of the most common digestive complaints in the general population. Over 2.5 million people consult a physician and hundreds of millions of dollars are spent on laxatives each year. Although constipation is often defined as a frequency of defecation twice weekly or less, constipated patients may complain of excessive straining with defecation, passage of hard or small stools, difficulty

TABLE 75-1. Laxatives Used in the Treatment of Constipation

Laxatives

Usual Adult Dose

Onset of Action

*Bulk-forming laxatives Bran

Methylcellulose Psyllium

Calcium polycarbophil

2-4 tablespoons qd 1 to 3 tbsp qd

1 to 3 tbsp qd

2 to 4 tablets qid

12 to 72 h 12 to 72 h 12 to 72 h 24 to 48 h

*Osmotic agents Polyethylene glycol Sorbitol Lactulose

17 g in 240 mL water 15 to 30 mL qd 15 to 30 mL qd

24 to 48 h 24 to 48 h 24 to 48 h

Saline laxatives Magnesium sulfate Magnesium citrate

15 g qd 200 mL qd

O.5 to S h O.5 to S h

*Stimulant laxatives (oral) Senna Cascara Bisacodyl

2 to 4 tabs qd 1 to 2 tabs qd 30 mg qd

B to 12 h B to 12 h B to 1O h

*Prokinetic agents Misoprostol Tegaserod Colchicine

200-800 mcg qd 6 mg bid 0.6 mg tid

1 to 4 h 1 to 4 h 1 to 4 h

Suppository Bisacodyl Glycerine

1 every 2 to 3 days 1 every 2 to 3 days

O.25 to 1 h O.25 to 1 h

Enemas Tap water Phosphate Mineral oil retention

500 mL 45 mL

100 to 250 mL

O.25 h O.25 h O.25 h

bid = twice daily; qd = every day; tid = 3 times daily; tbsp = tablespoon.

*In each category, laxatives are listed with the most preferred at the top and least preferred at the bottom.

bid = twice daily; qd = every day; tid = 3 times daily; tbsp = tablespoon.

*In each category, laxatives are listed with the most preferred at the top and least preferred at the bottom.

initiating evacuation, or a feeling of incomplete evacuation. Physicians should therefore not rely only on the criteria of defecation frequency when examining patients and managing constipation.

It is important to identify treatable causes of constipation, which include many diseases and the side effects of many drugs. If these are absent, functional constipation should be considered.

The initial management of chronic constipation includes educating the patient and correcting any misconceptions as to the wide range of normal bowel habits. Broad treatment principles include increasing fluid and fiber intake, and reducing excessive or incorrect use of laxatives and cathartics. Taking advantage of normal postprandial increases in colonic motility, patients should attempt to defecate after meals, particularly in the morning when colonic motor activity is highest. Most patients will respond to these measures together with the judicious use of laxatives. A summary of available laxatives is shown in Table 75-1 followed by the approximate costs of the common laxatives summarized in Table 75-2.

TABLE 75-2. Approximate Costs of Commonly Used Laxatives

Laxatives

Monthly Costs

Osmotic agents Polyethylene glycol Sorbitol Lactulose

$42 for 17 g qd $18 for 30 mL qd $60 for 30 mL qd

Saline laxatives Magnesium citrate Magnesium hydroxide

$60 for 200 mL qd $27 for 30 mL qd

Stimulant laxatives Senna Cascara Bisacodyl

$3 to 6 for 2 to 4 tablets every 2 to $2 to 4 for 1 to 2 tablets every 2 to $3 for 30 mg every 2 to 3 days

S days S days

Prokinetic agents Misoprostol Tegaserod Colchicine

$45 for 200 pg qd $120 for 2 or 6 mg bid $18 for 0.6 mg tid

bid = twice daily; tid = 3 times daily; qd = every day.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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