Transcripts
Hello and welcome to this Australian Pharmacist podcast titled Finding the Number One for a Number Two, an overview of over-the-counter laxatives. My name is Brett McFarlane, I'm your host. I'm a pharmacist, I have a background in dermatology, but in my early 30s I was diagnosed with coeliac disease and that really started me to develop my keen interest in gastrointestinal health including in lower GI complaints like constipation.
And to help us better understand constipation and the role of laxatives in managing it, we're joined today by pharmacist Stephanie Dimovski, who will walk us through the condition and offer her expert advice on its treatment. So I'd like to extend my welcome today to you, Stephanie.
Stephanie D (:Thank you. Thanks for the warm introduction, Brett. So I'm a pharmacist working in the hospital sector and I've had a really big interest in the gut-brain connection. I've been quite fortunate enough to secure a role in the sub-specialty of inflammatory bowel disease where I work quite closely with the multidisciplinary team in therapeutic drug monitoring and dose adjusting immunosuppressive therapy.
I find it really rewarding in making a difference and improving the quality of life and optimising medications in autoimmune diseases like ulcerative colitis and Crohn's.
Brett MacFarlane (:That's incredible. I'm really happy to hear that there's a pharmacist working in this type of speciality. So congratulations and thanks again for joining us today.
This CPD activity is sponsored by Reckitt. All content is the true, accurate and independent opinion of the experts and the views expressed are entirely their own.
So today we're diving into a topic that some people might find a little bit embarrassing to talk about and that's constipation.
It's not necessarily easy to discuss, but constipation is something that affects a large number of people and can significantly impact quality of life. It's uncomfortable, frustrating, and in some cases can even lead to more serious health issues.
Constipation can be caused by a variety of factors. We're looking at things like lifestyle habits, medical conditions, and as we know as pharmacists, of course there are medicines that can cause constipation. It's such an important part of our practice to identify those and help the patient to manage their adverse effects.
Yet despite how common constipation is, many patients often manage constipation on their own. They might self-select laxatives without speaking to a healthcare professional and this can lead to the incorrect choice of treatment and it can potentially make matters worse. So, Stephanie, I think probably a good place to start is right at the very beginning with the basics. If you could probably just explain to us what constipation is.
Stephanie D (:Yeah, of course. So constipation can mean different things to different people. But for most adults, regular bowel habits can range from having a bowel movement three times a day to three times a week. What's normal for me might not be normal for you, Brett.
Brett MacFarlane (:Yeah, exactly.
Stephanie D (:So if someone's having fewer bowel movements or if they experience difficulty passing stools, they might be constipated. The medical definition though, known as functional constipation, follows a specific Rome IV diagnostic criteria. For a diagnosis, you'll need to have experienced two or more of the following during at least 25% of bowel movements for at least a period of three months. So I guess it's important to know that not everyone's gonna match this strict criteria.
Brett MacFarlane (:Exactly, yeah.
Stephanie D (:But I guess important to know that things like straining, lumpy or hard stools,a sensation of that incomplete evacuation or anorectal blockage or a requirement for manual manipulation, such as digital evacuation or support of pelvic floor, which unfortunately in severe cases of complication is an issue for a lot of our patients. And then we have criteria like having fewer than three bowel movements a week, loose stool that's rarely present without the need for laxatives, or patients that have insufficient criteria for a diagnosis of IBS, which can involve constipation, but has a different Rome IV criteria.
And I think, Brett, you might agree that IBS is a very complex and gray area in terms of its management as well as diagnosis and probably requires a podcast in itself.
Brett MacFarlane (:Absolutely, it's such an interesting area of gut health and of course we can't ever separate the emotional state and wellbeing of the patient from their gut movements so that does make it much more complicated condition to consider.
So those sort of criteria that you talked about and that wording, is that something that a pharmacist would use like straining, lumpy or hard stools, incomplete evacuation? Is that something that a patient would sort of understand?
Stephanie D (:I think, yeah, we would be using those kind of words to know exactly their stool consistency and form because I think as pharmacists, it's important as well that we pick up on the red flags. So, you know, asking direct questions about their stool form and, you know, as pharmacists, we're aware of, say, the Bristol stool chart. However, you know, you're not going to be using that kind of wording when you're speaking to a patient.
I've actually got a chart at work that I use and I bring up and put it in front of them and tell me, is this what your stool looks like? These are these hard little lumps and that helps. I think images are really important and helpful for patients from that point of view. But the questions that I often ask as well, just for red flags and where I think referral is needed is the concept of, you know, is there blood in your stool?
Stephanie D (:Is there associated weight loss, significant abdominal pain or distension that might require further investigation? So I do think, you know, as constipation is, you know, so common and simple to manage and you might be able to grab some laxatives from Coles, I think it's important as pharmacists that we are aware and hypervigilant when asking these kind of questions to gauge what the best management strategy is.
Brett MacFarlane (:Taking the history is really, really important. And as we know, anyone can experience constipation. So we've got to, I guess, identify what is the absolute risk for that patient. It tends to be a little bit more common in women and obviously in older people. And for people who have some health conditions, for example, like depression, they might experience constipation a little bit more commonly. But what do you think can be the impact of constipation on our patients' daily life?
Stephanie D (:It can have a significant impact on quality of life and daily life. And it's important to acknowledge that constipation, yes, it can be acute, something small might be triggering it and it might last for less than two weeks, but there is that chronic persisting constipation for six weeks or more, which can be quite debilitating and detrimental. And if left untreated, things like hemorrhoids, incontinence, fecal impaction and rectal prolapse can be consequences.
And it does involve regular consumption of our health resources, including doctor's visits. So I think it's important that as pharmacists, you know, we can step in and give this advice early to our patients. And you know, yes, constipation, everyone's like, yes, it causes a little bit of discomfort, but what's the harm? But it really does need to be addressed so we avoid complications.
Brett MacFarlane (:I mean I absolutely agree with you and one of the things I think we need to get an understanding of is about those common causes because that helps us to identify some advice that we can give to the patient. So what are the common causes of constipation?
Stephanie D (:Constipation can be triggered by a range of factors and sometimes it's more than one that's contributing. So I think it's important that we consider the lifestyle side of things, including a diet low in fibre, inadequate hydration and not being physically active enough. Now, you know, not telling you to go run a marathon tomorrow, Brett, but you know, it's things like that in your lifestyle that make a difference in making sure your bowel motions are well regulated.
It's also important to acknowledge that things that change your routine, such as traveling can affect bowel habits. And I've actually recently returned from an overseas trip and thought about ‘how can travel disrupt the body’s natural rhythm?’ And you know, it's changes in sleep, trying new, less fiber-filled foods. Although I wasn't really game enough to try the snails in France. Like dehydration in you know, European summer heat, and they're all contributing factors to constipation and why it's so common in the travel periods.
Brett MacFarlane (:It’s something that we don't really think about because as you said those things don't really sound like very much. You wouldn't imagine that going on a nice overseas holiday might affect your daily habits so much that it might lead to constipation.
Stephanie D (:Yeah, well, you think you're more relaxed and that's another thing. There's not that much evidence or correlation, but things like stress and depression, as you mentioned earlier, they have been linked to constipation. So I think little lifestyle changes or like stresses on life can affect the gut. And it's quite an interesting phenomenon.
Brett MacFarlane (:Absolutely. And then of course we've got other medical conditions, you've already mentioned a few of them, that can be associated with constipation. Things like hemorrhoids, because it becomes a little bit painful to pass a stool, so people might hang on there longer than they would usually do. Or a fissure, again, associated with pain. There's some suggestion that maybe gastroesophageal reflux disease can contribute, whether this is due to the medicines that people might take for GORD or maybe more physiologically related to GORD, it's unclear. And as I mentioned earlier, of course, medicines are a big risk factor, particularly opioid-induced constipation, and that happens very, very significantly being a hospital pharmacist, you'll able to attest to this really high proportion of people taking opioids, like 87% for cancer-related pain and 40 to sort of 57% for non-cancer-related pain can result in constipation.
But you've got other medicines like anticholinergics, antipsychotics, antidepressants, things like ondansetron.
And then simple things like aluminium and calcium containing antacids or calcium and iron supplements, verapamil and GLP-1 analogues like semaglutide can all either be a cause or contribute to a person's constipation. So pharmacists really need to be proficient at identifying these potential causes of constipation in the first instance, but then advising people about how to address the causes directly related to the cause, but also offering those treatment options to help them in their current situation to relieve the constipation.
If constipation is secondary to another cause, then a doctor referral might be needed. A doctor can do something like a physical exam, run some tests, for example, on the blood and look at things like thyroid function to see if they can identify if that's contributing.
So, Steph, I think it's probably time to start talking a little bit about management of constipation and particularly how pharmacists can help, given obviously that most of the options for treating constipation are actually available without prescription. So they're right within our toolbox. How can pharmacists play a role in helping patients manage their constipation?
Stephanie D (:Yeah, I think we're in an ideal position to help because many patients don't seek medical advice and as mentioned, they'll pop into their local Woolies or Coles and find something on the counter to try, read the pack and follow the advice. But when a patient comes in to us for over-the-counter laxatives, we have the ability to assess their lifestyle and recommend these modifications that we discussed earlier regarding fibre.
And acknowledging fibre’s is a bit of a double-edged sword, but we can go into that a little bit later as well. But their diet, their medical conditions, hypothyroidism is also another factor that can contribute to constipation. When were your last blood tests for your thyroid? Have you seen your GP recently? And so being able to gauge when a GP consult might be beneficial.
We do advise on increasing dietary fibre and fluid intake, regular exercise and adopting good bowel habits. And one thing in terms of adopting good bowel habits, like not ignoring that urge to defecate. You might be in a meeting on Zoom and you get that urge and then you're like, what do I do now? And most of us would hold it in.
Brett MacFarlane (:Yeah, all right.
Stephanie D (:But these are kind of these modifiable risk factors that can actually avoid constipation. So, you know, not everyone's aware of that and it's good to have these conversations. I think as well, if we think that medications are contributing to the problem, then we can help by suggesting changes. Obviously, what is within our scope, but we can liaise with the GP in terms of swapping medications or adjusting doses.
It's about finding the right solution for the individual. I'm sure, Brett, you're the same, but I'm not really an advocate for using a medication as a band-aid to fix the side effects of another medication. That can actually be optimised. So, you know, if someone's using ondansetron as their anti-emetic and they're having symptoms of constipation, if there's no contraindications, why not metoclopramide?
Brett MacFarlane (:Exactly. And otherwise we just end up adding more and more. That's why it's important to start with lifestyle and dietary things as well. I agree with you, fibre, it's not just fibre, it's actually quite complicated. We could probably do a whole podcast about fibre. But there were a few things I suppose that pharmacists could consider in their advice. It's important for us to know the difference and to be able to communicate between soluble and insoluble fibres.
We’ve also got the fermentable type fibres, which add another layer of complexity because they can make you feel a bit bloated as well. So it's really important for us to get a sense of the difference between those.
Some really basic information about fibre is to just start the dose quite low and maybe even start the frequency low, like even if it's just supplementing every couple of days, and then slowly to increase the dose to prevent that kind of uncomfortable bloating from happening.
So ‘start low and go slow’ is a good approach to fibre therapy and also making sure that patients understand if they are going to take a fibre therapy that they have to maintain adequate fluid intake because we don't want impaction to occur as a result of being dehydrated during fibre therapy.
Stephanie D (:What do you think about kiwi fruits? That's my solution for everything.
Brett MacFarlane (:Awesome, awesome. Lots of fibre in them. They're really high in vitamin C too, I think apparently. So I'm eating a lot of them at the moment, sort of being around cold and flu season.
Stephanie D (:Yeah, no, no, they are really beneficial and in some of the patients that we see in the clinic we actually, first line therapy is a kiwi fruit a day. Skin on if you're game enough as well.
Brett MacFarlane (:I'm not sure I could do that. Those little hairs are a little bit too scary for me but yeah if we can address it obviously something like that as well but they've got the supplements available if that's not within their ability to be able to do I suppose. If we talk a little bit more about the laxatives now, can you walk us through the difference between them?
Stephanie D (:Yeah of course. So guess laxatives can be appropriate for managing constipation. There's several types and each work in different ways and sometimes we need to match the mechanisms of action to the causes of constipation. And other things we need to consider is tolerability, time to onset, acknowledging that acute constipation needs something that works quickly, not taking a couple of days to kick in which a lot of the fibre supplements do require.
And any potential health conditions or medication interaction. The Australian Pharmaceutical Formulary and Handbook has a constipation treatment guideline that pharmacists can use to guide therapy.
Brett MacFarlane (:Absolutely, agree. Just to reiterate those points that you made Stephanie about laxatives, tolerability, time to onset and any potential for health condition or medicine interactions. Such important roles for pharmacists. Let's start then I think with the bulk forming laxatives. So we've got things like ispaghula, psyllium or sterculia, what do you think about those?
Stephanie D (:Yeah, so the bulk forming laxatives increase the stool bulk and moisture, stimulating colonic activity and they're often first lines of treatment. But unfortunately, they do take a day or two to work. So they're not ideal for that person that needs that quick relief. And also important to acknowledge that they're not effective for opioid induced constipation.
Unfortunately as well, they can cause bloating and flatulence through fermentation in the colon particularly in patients who actually do have adequate fibre intake. So they might not be the answer for everyone. It is important, I think Brett you mentioned earlier, to start low and go slow with these supplementations and making sure that the patient is maintaining adequate hydration to maximise the effect.
Brett MacFarlane (:Yeah, all important points. Next option are the osmotic laxatives. So we've got things like glycerol, lactulose, macrogol, the saline laxatives and sorbitol.
Stephanie D (:Yeah so the osmotic laxatives are my general first-line agents, particularly where the bulking agents aren't appropriate or ineffective. They draw water into the bowel to soften the stool. The non-saline oral osmotic laxatives take up to 72 hours to work. They may cause bloating or electrolyte imbalances with prolonged use, so they need to be monitored if taken long term.
People with diabetes should avoid osmotic laxatives, although it's important. I think that we also discussed that lactulose isn't absorbed. So some people think that lactulose is the same as lactose, a sugar that kind of can raise your blood sugar levels, but it's different and it's a synthetic sugar. It's broken down in the bowel. So very little actually gets into your bloodstream.
Stephanie D (:I think I do start to get concerned when my diabetic patients take it long term because even though it's minimal, like there still might be some absorption. So moreso I would say to use it in the short term is safe. The other thing to I guess acknowledge is that oral magnesium shouldn't be taken over the longer term, especially in patients with renal failure.
Brett MacFarlane (:What about the stool softeners? Like docusate. What's the place in therapy for that?
Stephanie D (:Look, to be honest, I never use it as monotherapy itself. There is limited evidence for its use in someone with established constipation on its own. But look, it is quite a neutral agent in terms of, you know, there's very minimal side effects. So you could trial it on its own, but it does also take a couple of days to work and that's not stimulating the bowel the combination with senna.
So, you know, I tend to not reach for it as much.
Brett MacFarlane (:So not as a single ingredient, stool softener, but when in combination with senna it's useful.
Stephanie D (:Yeah,it’s quite an effective formulation. And I guess, did you want me to have a chat about stimulants?
Brett MacFarlane (:Yeah well that leads us to a conversation about the stimulants. So of course we've got senna, sodium Ppicosulfate and bisacodyl.
Stephanie D (:Yeah, so stimulant laxatives work by increasing bowel movement activity and possibly by the stimulation of intestinal secretions.
Senna is a plant-based laxative. It's natural and it works by increasing peristalsis of the gut to produce a bowel movement. They're pretty quick to work. So I usually tell my patients ‘take it before bed and you should have relief in the morning’.
Usually in six to 12 hours. And they're useful for patients who have opioid-induced constipation and for patients who are non-ambulatory. But it's also important to acknowledge that they're not that well tolerated in patients with IBS or functional bloating. If they are misused, the patient can find they have difficulty going without them.
Although I do want to raise that contentious, stimulant and lazy gut because I personally think it is a bit of a myth. I don't know what your opinion is on that.
Brett MacFarlane (:Yeah, look, I agree. I mean, it was something that we used to say a long time ago. I don't know where that came from, but there's not a whole lot of evidence to indicate that if you take stimulants on a regular basis that adversely affects your gut's ability to squeeze. Essentially, that's what it's, where it comes from, I suppose.
Stephanie D (:I think I do probably label them the more harsh laxative, overusing them might contribute to some side effects. And as I mentioned, it can cause, you know, abdominal pain and cramping in patients with that IBS symptoms. So I wouldn't recommend use regularly without correcting the modifier risk factors for constipation. But I think the takeaway message is they are quite effective.
Brett MacFarlane (:They definitely have a place in therapy. And I guess the benefit of the different groups of laxatives that you just spoke about is that they do have different mechanisms of action, which means that they can be combined, which means that's good for the patient. They don't have to take two different tablets, but also we can use it in a stepwise approach because we can add on another agent if the one that they are using is turning out to not be effective enough.
So, Steph, from the point of view of the stepwise approach to laxative therapy, what's your advice there?
Stephanie D (:So I think first line is checking in with the patient about how they're going with lifestyle changes like increasing fibre, fluid intake, exercise. Then we can kind of look at the bulk forming laxatives like psyllium or sterculia. An osmotic laxative like macrogol can be added or substituted.
It comes in all different flavours. If that still doesn't work, that's when I think about adding in the stimulants. So things like bisacodyl and senna, or sodium picosulfate oral drops, you can introduce them. I think it's important that the impact of medicines causing constipation be considered and addressed where possible.
And in persistent cases, we may suggest a referral for consideration of a prescription option like prucalopride. Have you seen much dispensing of prucalopride in community?
Brett MacFarlane (:Not in community, no. I suppose you probably see it quite a bit in a hospital situation.
Stephanie D (:Yeah, so unfortunately it's not on the PBS, but we do know that serotonin is a key regulator of gastrointestinal motility. So it's a selective serotonin receptor agonist. So, you know, we know ondansetron is the antagonist and contributes to constipation. You know, it does have good efficacy and I have seen patients who, you know, have been refractory to everything that I've gone above in that pyramid scheme and they've responded quite well to prucalopride but yes unfortunately it does come with a little bit of a cost burden so it's something that needs to be discussed.
Brett MacFarlane (:Well, it's good that we've got these different options starting with lifestyle and then moving through the different types of laxative options. And then it's good to know that if we're getting to a situation where the patient is just not having any luck that we can make a referral to a doctor. What about managing constipation in pregnant women?
Stephanie D (:Yeah, so unfortunately constipation is common in even normal uncomplicated pregnancies and there's a lot of contributing factors, you know, the hormonal changes, the decreased level of physical activity sometimes and vitamin supplementation. I guess the main thing for me that comes to note is oral iron can be quite a big burden. Most laxatives are minimally absorbed, so they're generally considered safe in pregnancy even though they haven't been assessed.
However, short term use is recommended to prevent dehydration or electrolyte disturbances and stimulant laxatives should not be used regularly and avoided as a first line therapy. Personally, myself, I actually don't have that much experience using stimulant laxatives in pregnancy and I do tend to avoid, I don't know how you feel about that?
Brett MacFarlane (:Look, think most pharmacists probably would look at an option that is not a stimulant.
Stephanie D (:Yeah, we have the options up our sleeve. So I generally start off with, you know, the bulk forming laxatives and incorporate that stepwise approach that we discussed earlier.
Brett MacFarlane (:We mentioned earlier about the potential connection between GORD and constipation. Do you have any insights into that?
Stephanie D (:Yeah, so there have been some recent studies that suggest a possible link between GORD and constipation, though the exact relationship isn't really understood. Researchers have found 52.4% of people who had GORD and also constipation took medicines such as proton pump inhibitors, to manage GORD, and 26% of those took medicines for constipation. People with GORD may also have GI motility disorders.
So PPIs may contribute to constipation as a commonly reported adverse effect. Managing constipation in turn might even improve GORD symptoms, which has been found in a study in children with GORD and frequent constipation. Although I think the takeaway from this is that I think we do need more research to establish the direct correlation between the two.
It doesn't seem unreasonable and I do think sometimes treating one can help with treating the other.
Brett MacFarlane (:Yeah, I agree. It's all one gut in the end, so it's probably not surprising that this connection is starting to be elucidated. But one thing that I know that pharmacists have a really important role to play is in managing opioid-induced constipation because we know it's a common issue.
Pharmacists should be asking patients who have recently initiated or changed their opioid or changed the dose of their opioid if they're having difficulty with constipation. They can sort of talk to them about those Rome IV criteria that you mentioned to help them get a better understanding of opioid-induced constipation. We can sort of advise them about diet and lifestyle and look at any of their other medicines that might be contributing. But what are your recommendations about managing opioid-induced constipation specifically?
Stephanie D (:Yeah, so I think pharmacists can assess the patient's opioid therapy to see if we think it's appropriate and if modification can occur like dose reduction, which actually can help constipation. For things like oral opioids the addition of naloxone as kind of that slow release oxycodone with naloxone combination might be helpful than the oxycodone slow release in itself.
Stephanie D (:I know the evidence to this is quite weak, but I have seen some patients do quite well on oxycodone and naloxone. And it might be necessary for those who are at risk of opioid-induced constipation to be on prophylactic laxatives.
The evidence around this is lacking, but it is something that we need to consider. Standard laxative therapy is usually recommended but fermentable osmotics like lactulose and bulk-forming laxatives are avoided because they can cause bloating.
If the kind of general standard of practice is ineffective, again, prucalopride might be considered in these instances, but I think adjusting the opioid dose or switching medications should be explored if it is really burdensome to the patient. And I think referral to the doctor might be needed if some of these strategies do fail.
Brett MacFarlane (:You mentioned earlier about the theoretical risk of misuse of laxatives. Could you just elaborate on that a little bit?
Stephanie D (:So I think laxative misuse is a concern, particularly in the context of eating disorders. The accessibility of laxatives, you know, in supermarkets and things like that does scare me a little bit, to be honest. I think in pharmacies we should be regulating, and monitoring use.
Stephanie D (:Excessive use can lead to electrolyte imbalances and prolonged use of stimulant laxatives may cause dependency, leading to trouble resuming normal bowel motions when they cease the laxative.
Now, I know we discussed this a little bit earlier, about kind of the myth and those kind of things. And even though senna doesn't really cause a structural or functional alteration of the enteric nerves in the gut, it still can lead to dependence in these patients, particularly with eating disorders. So it's something that we need to kind of make sure that we address and address dietary and lifestyle factors before commencing laxatives.
Brett MacFarlane (:Yeah, I think it's complicated, but I do think that we have a role as pharmacists in identifying at-risk patients and helping them maybe to understand, particularly if we know that they're purchasing large quantities or purchasing quantities of these over an extended period of time.
Stephanie D (:Yeah, and just touching base and having a chat about their lifestyle and again, going back to, you know, modifiable factors that we can help address.
Brett MacFarlane (:Thank you so much for chatting to us today and giving us your valuable insights just to kind of wrap things up a little bit. You know I think it's important for patients to understand that constipation is common. And you know it's not just ‘Aw it's just constipation’ it can significantly affect our overall health particularly if it's not managed or not managed effectively.
It's always best for them to seek professional advice whether that's from us when they're choosing a laxative or seeing a doctor if it becomes more challenging than that because we can recommend the laxative that's more suited to them and as you said address their lifestyle factors, diet, fluid intake and exercise etc.
And you know, pharmacists, we're in a good position, a unique position really, to help patients find the right treatment for them, considering their health conditions and of course their medicines. And it's important you mention that stepwise approach to laxative therapy. If one option is insufficient, we also have the option of adding in something else or ultimately referring to a doctor for further evaluation if that's necessary.
Did you have any final thoughts for us?
Stephanie D (:Thank you for the opportunity to discuss this important topic. I think it’s essential for us that patients feel empowered to manage their health and know that pharmacists are here to support them along the way. By providing personalised advice and ensuring safe use of laxatives, we can significantly improve their outcomes.
And you know you've mentioned again, addressing lifestyle factors is often the first line of defence and collaboration with other healthcare professionals is key if further intervention is needed. I think that together in this multidisciplinary kind of community, we can help our patients achieve better digestive health and overall wellbeing. So thank you.
Brett MacFarlane (:Absolutely, and thank you so much for your insights.
Stephanie D (:No worries, it's been a pleasure.
A reminder to our listeners that this podcast is an accredited CPD learning activity. Head over to the PSA website to complete the multiple choice questions and claim your points.
Brett MacFarlane (:And of course, thanks to our listeners for tuning into the podcast. We hope you found it informative and thank you also again to Reckitt for their support in development of the podcast.