Chapter 70: Constipation/ Diarrhea
A patient needs to choose a stimulant laxative. Which of the following is considered a stimulant? Answer A Dulcolax B Mineral oil C Miralax D Amitiza E Colyte
A
History of Present Illness: CD is a 54 year old male who comes to the pharmacy to get his medications refilled. He comes to the counter with a tub of Metamucil powder. After asking CD some questions and reviewing his profile, you learn that his diet consists of largely refined foods, with little fruit or vegetable intake. He drinks 3-4 cups of coffee daily and rarely consumes other liquids. He has no regular physical activity. Allergies: Bactrim, erythromycin, ciprofloxacin, gentamicin eye drops Past Medical History: Pre-diabetes Dyslipidemia Hypertension Chronic constipation Medications: Lisinopril 10 mg PO daily Lipitor 10 mg PO daily Verelan PM 300 mg QHS Metformin 500 mg PO BID Question Which of the following could be contributing to CD's constipation? Answer A Verapamil B Lisinopril C Dyslipidemia D Metformin E Hypertension
A
A patient is given a prescription for Lomotil to treat diarrhea. Which of the following is a correct statement? A This medication is a C-V. B This medication is available OTC; a prescription is not needed. C This medication is the drug of choice for diarrhea caused by enterotoxin-producing bacteria. D The maximum daily dose is 16 mg. E This medication contains loperamide and atropine.
A Lomotil is diphenoxylate and atropine. It is a C-V drug and the maximum dose is 20 mg daily. It is contraindicated when diarrhea is caused by enterotoxin-producing bacteria. Next
Which of the following is an agonist of guanylate cyclase C, approved for chronic idiopathic constipation or for irritable bowel-syndrome with constipation? Answer A Linzess B Entereg C Relistor D Amitiza E Viberzi
A The generic name of Relistor is methylnaltrexone.
A pharmacist will counsel a patient on the possible side effects of bismuth subsalicylate. The most likely side effects from the use of this antidiarrheal agent are: Answer A Blackened tongue and stool B Insomnia C Loss of appetite D Erectile dysfunction E Alopecia
A Patients taking bismuth subsalicylate should be counseled about the most common side effects: blackened tongue and stoo
Which of the following is an appropriate recommendation for EK? Answer A Senna B Psyllium C Docusate D Alvimopan E Methylnaltrexone
A Stimulant laxatives are the treatment of choice for opioid-induced constipation. Newer agents should be reserved for patient's who do not gain relief with stimulant laxa
Which of the following statements concerning MiraLax are correct? (Select ALL that apply.) Answer A It is an OTC formulation of polyethylene glycol. B It works by drawing fluid into the gut. C It causes abdominal cramping and should not be used unless a patient has failed stimulant laxatives. D It is best to recommend a similar product called GoLytely if an OTC agent is required. E It activates sodium chloride channels in the gut. Incorrect Miralax is an OTC formulation of PEG that works as an osmotic agent; it draws fluid into the gut.
A, B Miralax is an OTC formulation of PEG that works as an osmotic agent; it draws fluid into the gut.
Which of the following lifestyle measures could help reduce CD's problem with chronic constipation? (Select ALL that apply.) Answer A Increase his physical activity. B Consume more fiber, including fruits and vegetables. C Limit caffeine and consume more water. D Eat larger meals. E Substitute soda for coffee.
A, B, C Inadequate fluid intake, physical inactivity, and poor fiber intake are contributory towards worsening constipation.
Which of EK's medications are most likely contributing to the constipation? (Select ALL that apply.) Answer A Morphine B Ferrous sulfate C Darifenacin D Propranolol E Acetaminophen
A, B, C Opioids, iron, and darifenacin (an anticholinergic drug) are all medications that can cause constipation.
Which of the following are true regarding alvimopan? (Select ALL that apply.) Answer A The brand name is Entereg B It is safe to use in patients who use chronic opioid therapy C It is a REMS drug D It has a boxed warning for myocardial infarction when used long-term E It should be limited to a maximum of 15 doses
A, C, D, E Alvimopan (Entereg) is an opioid receptor antagonist used for the prevention of post-operative ileus in patients undergoing various types of surgery. It is a REMS drug and should be limited to 15 doses.
Golytely, NuLytely, Trilyte, and MoviPrep can be used prior to colonoscopy or endoscopy procedures to clean out the gut. These laxatives have the following mechanism of action: Answer A Stimulants B Osmotics C Opioid receptor blockers D Stool softeners E Activates chloride channels in the gut
B By increasing the osmolarity of the gut, osmotic laxatives cause fluid to move into the gut. NuLytely and Trilyte are sulfate free. MoviPrep is less volume (2L) than the older Golytely formulations.
MM has a pretty good diet, but she is a vegetarian and suffers from iron-deficiency anemia. The physician recommended that MM use OTC iron twice daily long-term to help correct the problem and prevent anemia in the future. MM eats primarily whole grains and lots of fruits and vegetables. She is using the iron but finds it has caused constipation with hard, compact stools. She is asking the pharmacist for a laxative recommendation. She is not pregnant and is finished having children. Choose the best recommendation: Answer A The preferred laxative is a bulk-forming agent such as psyllium. B Counsel her to begin Colace 100 mg twice daily. C Due to the compact stool problem, she can use a glycerin suppository. D She should begin therapy with MiraLax. E Any of the above recommendations would provide benefit.
B For a patient with adequate fiber intake from her diet who is complaining of hard, compact stools due to iron supplementation, a reasonable recommendation would be to start docusate sodium 100 mg once or twice daily as a first option.
History of Present Illness: CD is a 54 year old male who comes to the pharmacy to get his medications refilled. He comes to the counter with a tub of Metamucil powder. After asking CD some questions and reviewing his profile, you learn that his diet consists of largely refined foods, with little fruit or vegetable intake. He drinks 3-4 cups of coffee daily and rarely consumes other liquids. He has no regular physical activity. Allergies: Bactrim, erythromycin, ciprofloxacin, gentamicin eye drops Past Medical History: Pre-diabetes Dyslipidemia Hypertension Chronic constipation Medications: Lisinopril 10 mg PO daily Lipitor 10 mg PO daily Verelan PM 300 mg QHS Metformin 500 mg PO BID Question Choose the correct statement concerning Metamucil: A Based on his allergies, this is not a safe option. B It is generally considered first-line treatment for constipation. C It is an emollient laxative that will soften the stool. D It is a stimulant laxative. E The onset of action is generally about 6-12 hours.
B Psyllium and other fiber products are considered first-line for most patients. They are a reasonable option for patients who have a low-fiber diet. Onset of action is generally 12-72 hours.
A mother asks the pharmacist what to use to help her four year-old daughter have a bowel movement. The mother states the child "forgets to go" when she is playing, and now it seems too late. The child is squirming and crying. The mother is anxious to help relieve the problem urgently. Choose the best recommendation: Answer A Docusate syrup B Glycerin suppository C Psyllium, in the form of carboxymethylcellulose D Bisacodyl E Loperamide
B For a child with constipation, a glycerin suppository (pediatric size) will work right away. If not, a second dose should be sufficient.
A patient with constipation presents with a new prescription for Amitiza 24 mcg BID #60. Which of the following is an appropriate generic substitution for Amitiza? Answer A Alvimopan B Lubiprostone C Linaclotide D Methylnaltrexone E Plecanatide
B Lubiprostone is the generic name of Amitiza.
MV is a 52 year-old Hispanic female with hypertension, anemia, dyslipidemia, chronic heart failure and renal insufficiency due to IgA nephropathy. Her creatinine clearance is estimated at 18 mL/minute. She has been seen by a gastroenterologist for abdominal pain. He instructed MV to take OsmoPrep to clear out her gut prior to a colonoscopy. Choose the correct statement. Answer A This is a preferred laxative in patients with renal insufficiency. B She cannot safely use this laxative due to her history of heart failure. C The generic name for OsmoPrep is magnesium hydroxide. D She cannot safely use this laxative because of her age. E A better choice would be Milk of Magnesia.
B This laxative has a boxed warning for nephropathy so should not be used in patients with renal disease. It should also be avoided in patients with cardiac disease due to electolyte and fluid abnormalities that can occur. Milk of Magnesia (magnesium hydroxide) should also be avoided in patients with renal impairment. Next
A mother presents to the pharmacy asking for a recommendation for her three year-old child who has a fever and diarrhea. She is concerned that the child did not sleep well last night due to the fever. The diarrhea appears to be resolving and the mother has taken care not to let the child become dehydrated. Choose the correct recommendation(s) for the fever: (Select ALL that apply.) Answer A Baby aspirin B Acetaminophen oral suspension C Ibuprofen oral suspension D Loperamide E Bismuth subsalicylate
B, C If fever/cold symptoms are present, aspirin can (rarely) cause Reye's Syndrome in children and should be avoided except under a physician's care (it may rarely be used in a child with a heart condition, where benefit may outweigh risk).
A female patient presents to the pharmacy counter with a large container of Metamucil. Choose the correct counseling statement(s): (Select ALL that apply.) Answer A There are no drug interactions to be concerned about. B This agent is a bulk-forming laxative. C You should stop this product if you become pregnant. D Drink adequate fluids. E It may cause gas and stomach bloating.
B, D, E Psyllium should be added to the diet slowly to prevent bloating. Patients should be instructed to drink adequate fluids while taking psyllium. Fiber products are the treatment of choice for constipation during pregnancy.
Choose the correct statement concerning loperamide therapy: Answer A It is safe for pharmacists to recommend to infants less than two years old. B It is safe to self-treat with loperamide for up to 7 days if the patient does not exceed the recommended (daily) doses. C The correct dose is 4 mg PO after the first loose stool; then 2 mg after each subsequent stool; not to exceed 16 mg/day. D The correct dose is 4 mg PO daily after each loose stool; not to exceed 32 mg/day. E Loperamide comes in a tablet, suspension, and suppository.
C
Methylnaltrexone is indicated for opioid-induced constipation. This drug is a: A Centrally-acting mu-opioid receptor agonist B Peripherally-acting mu-opioid receptor agonist C Peripherally-acting mu-opioid receptor antagonist D An activator of gut chloride channels (increases peristalsis) E A stimulant laxative that increases colonic neuron activity (increases peristalsis)
C Methylnaltrexone is a PAMORA (peripherally-acting mu-opioid receptor antagonist). Other agents in this group include naloxegol (Movantik) and naldemedine (Symproic).
A mother is asking for help with her seven-month old child. He has diarrhea that started in the morning. Which of the following is a correct counseling statement that the pharmacist could provide? Answer A Self-treatment is recommended for up to 7 days; if diarrhea is unresolved, contact a healthcare provider. B Diarrhea is very normal in small children and is usually not a major health concern. C Fluid replacement is best provided by products such as Pedialyte or Infalyte. D Start loperamide 4mg once, then 2 mg with each loose stool. E Start bisacodyl suppositories 5 mg daily.
C Do not self-treat diarrhea if there is high fever or blood in the stool; see a physician if there is no improvement in 2 days (sooner for young children/infants). For moderate-severe fluid loss, replacement is best accomplished with oral rehydration solutions (ORS), such as Pedialyte, which are available in pharmacies and supermarkets. Gatorade may be used as an alternative.
A female patient was using Ex-Lax for constipation, but complained of cramping. The physician has recommended polyethylene glycol (PEG). Choose the correct statement. Answer A A brand name for polyethylene glycol is Osmoprep. B Ex-Lax is the brand name for bisacodyl. C GoLytely and MoviPrep contain PEG. D PEG is characterized as a stimulant laxative. E PEG is characterized as an emollient laxative.
C There are many prescription formulations used for chronic constipation and for bowel cleansing prior to GI procedures.
CK is pregnant with her first child. She eats a primarily refined diet, but did not suffer from constipation until the second trimester of her pregnancy. Choose the preferred agent: Answer A The safest agent is lactulose or polythylene glycol 3350. B Counsel her to begin docusate 100 mg twice daily. C A preferred agent is the bulk-forming laxative psyllium. D She should begin therapy with MiraLax. E She should begin therapy with Milk of Magnesia.
C Fiber is recommended by pharmacists in pregnancy. It is the first line recommendation according to the American College of Obstetrics and Gynecologists (ACOG).
EK uses bisacodyl for a few days then returns to the pharmacy to say that she is now having bowel movements but the stool is hard to push out. Choose a reasonable recommendation, to be taken daily, to help EK: Answer A Add psyllium B Add Fleet Enema C Add docusate D Add Miralax E Add alvimopan
C Hard stool can be alleviated with a stool softener. Docusate is the most commonly used stool softener.
A patient has been using Pepto-Bismol several times daily. His other medications include aspirin, lisinopril, metformin and glipizide. The patient complains of a ringing, "hollow" sound in his ears that is quite bothersome. What is the likely cause of the patient's complaint? Answer A Hypoglycemia B Hyperkalemia C Salicylate toxicity D Metformin use E Hypermagnesemia
C Salicylates such as aspirin and bismuth subsalicylate can cause ringing in the ears - this may be a sign of toxicity.
A 55 year-old male has diarrhea and asks the pharmacist if Pepto-Bismol is safe for him to take. His medications include metoprolol, digoxin, amiodarone and warfarin. Pepto-Bismol is not recommended for use in this patient due to the following concern: Answer A Increased risk of arrhythmia B Increased risk of bradycardia C Increased risk of digoxin toxicity D Increased risk of bleeding E Increased risk of heart block
D Salicylates (including bismuth subsalicylate) increase the risk of bleeding.
Which of the following is a brand name for calcium polycarbophil, a bulk-forming laxative? Answer A Metamucil B Citrucel C Ex-Lax D Fibercon E Constulose
D- Fibercon is the brand name of calcium polycarbophil.
If EK does not obtain relief using a stimulant laxative with a stool softener, which of the following can be considered? Answer A Eluxadoline B Dicyclomine C Alvimopan D Linaclotide E Lubiprostone
E Lubiprostone is indicated for opioid-induced constipation but due to cost, it is typically reserved for patients who are still constipated after a trial of laxative therapy.
