Treating Chronic Constipation?

[ari202]

Hey guys,
I'm doing an IM SubSpecialty Outpatient rotation right now. We get a lot of adults who come to us for chronic constipation >6 months duration. The doctor likes to start all of his patients on Amitiza instantly before exploring more natural options like Chlorophyll, Colon Cleansers, and Most of all Fiber Pills such as Metamucil. I don't really understand his logic as we were told by one of our professors that long term use of stimulant laxatives can result in damage to the colonic nerves as well as melanosis coli.

Isn't standard of care to start with exercise+diet modifications+Fiber--->then osmotic laxatives if need be--->stimulant laxatives such as Amitiza and Docusate are LAST RESORT??

perhaps im missing something. Most of the patients who he gives Amitiza/Lubpriprostone don't have any comorbidities and I think just some metamucil, raisin bran etc. will help them without the need of laxatives.

I hope this isn't a case of him just trying to get rid of samples of Amitiza. I asked him and he said that Amitiza is not stimulant but it seems to be based on its mechanism of action by inhiting chloride channels in the gut.

Thanks in advance

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[styphon]

1st) Docusate, which is Colace, is not a stimulant, it is a stool softner
2nd) I would hope someone coming to a subspecialist for constipation has tried high fiber diet and some OTC meds (which include docusate AND senna, a stimulant laxative). I don't know about others, but if I was constipated even for days I would start changing my diet and buying Metamucil, Senna+Colace, etc before seeing a physician

 

[Doctor Bob]

Why don't you ask him?

That's crazy talk!

 

[J ROD]

digit.......where? oh yeah, there!

 

[Raryn]

Start with osmotic laxatives. I prefer Miralax, some prefer Lactulose, some prefer Docusate. Doesn't matter which. If it doesn't work, the most likely answer is that the patient didnt take enough. There's no maximum dose.

If it doesn't work consistently, add an osmotic/stimulant. Docusate/senna is the usual.

If there's an impaction, either a manual disimpaction (which I never do) or an enema.

If all else fails, you can start looking at other options. Methylnaltrexone or the PO equivalent (very expensive) work wonders if they're on opiates as well. But it pretty much never comes to that. I've never ordered Lubpriprostone in my life, and had to look up what it was.

 

[FutureInternist]

Taco Bell TIW

 

[cabinbuilder]

As someone who has been on amitiza - I gave that up and miralax a long time ago. Milk of Magnesia twice a week is cheap and easy and works better.