No Miracle Needed: Safe, Effective Relief From Constipation

To our readers: You can be your best doctor! Nobody knows your body better than you do. Please listen to your body, learn about it, and use that knowledge to improve your health and quality of life!

The book: The idea that world medical research and education experts can be invited and teamed up to summarize their knowledge and experience in a textbook sounded exciting. The book has to be an evidence-based breakdown from symptoms to treatment to give the readers a guided understanding of how practicing physicians think when facing symptoms and determining treatments. This project was completed in the summer of 2023, and the textbook "Introduction to Clinical Pharmacology: From Sy_mP-toms To Treatment" (Edited by Victor Uteshev, PhD; Daniel Llano, MD/PhD; and Edward Shadiack, DO) is now available to the public (https://a.co/d/2peXh9r).

 Below is a summary of Chapter 21 related to constipation and safe relief of constipation, entitled "Constipation and Diarrhea" of this textbook written by Dr. Monte Troutman, DO, and me.

A Common Story Of Constipation

I will start this conversation with a common story: a 52-year-old female patient has osteoarthritis that reduced her ability to exercise. As a result, she has become chronically constipated. She drinks a lot of water and eats fiber-rich foods, including vegetables and fruits, but nothing helps. Now, she asks her doctor to prescribe medication(s) that she can take daily to relieve constipation fast. Will her doctor agree that the problem is serious enough for medications? If so, what could be the best solution for immediate relief from constipation? Let's break down these issues and discuss them.

The Concept and Causes of Constipation: How Do People and Doctors Define it?

 First, not every delay in bowel movements should be considered constipation. To avoid confusion, doctors and patients should agree on definitions. Constipation can be defined as reduced frequency of bowel movements (less than 3-4 per week), hard or lumpy stool, a need for manual evacuation of stools from the rectum (in fact, manual disimpaction is often more effective than laxatives, and absolutely required in severe cases of fecal imP-action) and/or heavy straining (may lead to retinal or brain hemorrhage). These changes in stool may be accompanied by abdominal pain, discomfort, and bloating. Acute constipation is relatively common and may occur occasionally and self-resolve in a matter of 1 -3 days. Chronic constipation is present if the above symptoms persist for at least 1 month (Scott et al. 2021 ).

 Risk factors for constipation are older age, female, pregnancy, low socioeconomic status, use of constipating medications (these include but are not limited to aluminum-containing antacids, anticholinergics, calcium channel blockers, non-steroidal anti-inflammatory drugs, opiates, and diuretics), low physical activity, certain health disorders (like Parkinson's Disease, multiple sclerosis, hypothyroidism, diabetes associated with diabetic neuropathy, electrolyte imbalance especially hypercalcemia; Bharucha and Wald 2019), and the standard American diet low in fiber. Low water intake is also a contributing factor (Forootan et al. 2018).

 One of the most common causes of constipation is Constipation-Predominant Irritable Bowel Syndrome (IBS-C). IBS-C patients often complain of bloating, abdominal distention, and dyspepsia. The symptoms last more than 6 months, abdominal pain accompanies constipation, and relief of the pain occurs with bowel movement.

 To learn more about the pathophysiology of constipation and other common disorders, you are invited to follow this link to obtain your own copy of "Introduction to Clinical Pharmacology: From Symptoms To Treatment."

Prevention Is The Best Treatment

  You can be your best doctor by implementing preventive strategies. Regardless of the cause of constipation, non-drug treatments are effective in most cases of constipation. The basis of this approach is lifestyle changes, which is defined as prevention. These strategies may include:

• -Breakfast

• - Physical activity

• - 25-30 grams of fibers per day (see examples here)

• - Sufficient water intake

• -Avoiding constipating medications, if possible

• - Effective squatting position on the toilet

• - If the above attempts are no help, add fiber supplements and stool softeners (see examples here)

However, if the prevention strategies have failed, safe effective treatments are available.

Safe Natural Treatments Of Constipation:

Note: Even though these treatments are considered to be safe, excessive intake may cause a variety of side effects such as diarrhea and nausea.

Doses and side effects can be found Here

 Sorbitol (lower doses daily for prevention, higher doses once for acute constipation - see safe dosage and precautions here) is a natural, non-digestible sugar that increases osmotic pressure in the gut lumen.

 Prune juice contains 5-7% sorbitol and may be the best solution for most people with occasional constipation.

 Senna leaves (for acute constipation) contain anthraquinone derivatives with laxative effects within 6 hours after consumption.

A bit of Personal experience: My youngest son is 7 2 y.o. Growing up, he never experienced constipation because between the ages of 2 y.o. and 10 y.o. for prophylaxis, I used to give him prune juice daily mixed with VB juice of different flavors (strawberry-banana was his favorite). I mixed 30 ml of prune juice with 70 ml of VB juice daily, and that mix allowed his digestive system to function daily without any issues for many years.

Bulk-forming agents for acute constipation: calcium polycarbophil, psyllium, and methylcellulose. These agents are non-digestible materials also known as dietary fibers, either synthetically made (e.g., methylcellulose) or originating from plants (bran, whole grain). They absorb water, softening stool and increasing its amount. Bulk-forming agents are effective within 48 hours of intake. They are safe and can be used long-term alone or in combination with other laxatives.

Osmotic/saline agents: Magnesium hydroxide. magnesium citrate (for acute constipation), sorbitol (lower doses daily for prevention, higher doses once for acute constipation - see safe dosage and precautions here), lactulose (similar to sorbitol: for chronic constipation; lactic/acetic acids), Polyethylene glycol-electrolyte solutions (PEG; for pre-surgical complete colon cleaning).

Magnesium-containing agents (magnesium hydroxide, magnesium citrate) are very safe and can be used for a variety of needs, including emptying the bowel prior to colonoscopy or surgery or clearing poison.

Lactulose (relatively slow action) intestinal bacteria break down lactulose (an indigestible sugar) into lactic, acetic, and formic acids, increasing the acidification of the intestine and increasing osmolarity, thereby causing bowel movement.

  Polyethylene glycol-electrolyte solutions are used for preparing the bowel for colonoscopy or colorectal surgery because PEG ensures the most complete evacuation of the GI tract. Patients are given up to 4 liters of PEG over 6 hours prior to surgical/colonoscopy procedures.

 These agents are also non-digestible. They increase osmotic pressure in the gut lumen and soften stool by elevating water content. Effective time is dose-dependent but always falls within 6-24 hours. Osmotic/saline laxatives are safe and can be used long-term alone or in combination with other laxatives.

Synthetic Drug Treatments:

 These are not-so-safe drug treatments. Serious side effects are possible, such as stomach pain, severe diarrhea, nausea, and more. For that reason, please consult your doctor for safe dosage and Precautions:

Stimulants: Dulcolax (Bisacodyl; for bowel preparation before surgery). 

Dulcolax directly acts on nerves of the guts/colon causing peristalsis and bowel evacuation. Dulcolax is effective within 24 hours of intake. Dulcolax should not be used chronically because it causes tolerance and dependence.

Laxatives: Linzess (Linaclotide; for chronic constipation, IBS-C; GCacGMP), Amitiza (Lubiprostone; for chronic constipation, IBS-C; Cl- ion channel influx), Colace (Docusate; for acute constipation to reduce straining), senna, and other over-the-counter products (for acute constipation).

Linzess is a guanylate cyclase agonist that activates guanylyl cyclase on the luminal surface of the intestinal epithelium, thereby increasing the cGMP level. This stimulates the secretion of chloride ions and bicarbonate into the lumen, followed by water, resulting in stool softening.

Amitiza activates chloride ion channels in the small intestine and promotes chloride influx into the intestine, followed by water, resulting in stool softening. Amitiza does not cause tolerance, but chronic use may cause nausea.

Opioid Antagonist Relistor (Methylnaltrexone; for opioid-induced constipation). Relistor is a peripherally-restricted μ-opioid receptor antagonist. Relistor does not cross the blood-brain barrier and, thus, does not inhibit the analgesic efficacy of prescribed opioids.

Conclusion:

 Preventing constipation using simple changes to the lifestyle is recommended, possible, and even necessary. The discussion above is a brief summary of Chapter 21, written by Dr. Monte Troutman and myself for a recent textbook entitled "Introduction to Clinical Pharmacology: From Symptoms To Treatment" (Edited by Victor Uteshev, PhD; Daniel Llano, MD/PhD; and Edward Shadiack, DO). The book is created for health professionals, medical, pharmacy, and graduate students using an innovative approach to patient presentation and a student-centric self-direct learning method termed Problem-Based Learning (PBL).

AlI the best,

Dr. U

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