Constipation med choices

[anbuitachi]

I tried searching Google but couldn't find good article/guide. But generally there are so many meds for constipation. Is there any indication for certain specific meds for certain patients or is it just personal preference. I hear collace does like nothing. Just give senna to everyone who hasn't moved bowel. And then after that it seems like people just use whatever they want? I see some ppl use miralax some ducolax or lactulose. Milk of magnesia.. However I'm not sure if there are legit indications or they just picking things out of a hat?

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[jdh71]

Pick something and then keep adding until code brown.

I start with Senna DS, the add miralax, then add lactulose, and then add ducolax suppository. If all of that doesn't work GoLytely.

 

[gutonc]

Pick something and then keep adding until code brown.

I start with Senna DS, the add miralax, then add lactulose, and then add ducolax suppository. If all of that doesn't work GoLytely.

I'll throw Mag Citrate in there either before or after the lactulose depending on the patient (obvs not in the renal messes). And as an oncologist, I have a residual aversion to suppositories and enemas due to the beatings I received from my BMT attendings during fellowship (despite the poor, at best, evidence for increasing the risk of gut translocation bacteremia). But otherwise, this is pretty much how I do it.

Also, every opioid script gets a Senokot-S script to go with it. Because the best treatment for constipation is not to get it in the first place.

 

[jdh71]

I'll throw Mag Citrate in there either before or after the lactulose depending on the patient (obvs not in the renal messes). And as an oncologist, I have a residual aversion to suppositories and enemas due to the beatings I received from my BMT attendings during fellowship (despite the poor, at best, evidence for increasing the risk of gut translocation bacteremia). But otherwise, this is pretty much how I do it.

Also, every opioid script gets a Senokot-S script to go with it. Because the best treatment for constipation is not to get it in the first place.

Every order of an opiate should come with senna ds by reflex.

 

[Raryn]

Pick something and then keep adding until code brown.

I start with Senna DS, the add miralax, then add lactulose, and then add ducolax suppository. If all of that doesn't work GoLytely.

The only thing I'd add here is that usually the problem is more one of dose than of agent. jdh for example does something we all do: adds lactulose to miralax. There's no physiologic reason why that would work any better than (say) doubling, tripling, or quadrupling the miralax. They work by the same mechanism, have the same efficacy in the literature, and the only difference is that there's a slightly decreased incidence of unpleasant bloating with the miralax relative to the lactulose. Just because the premade order on EPIC says 17g/day doesn't mean you can't change it. Mind you, I get tired of the nurses arguing with me "maybe we should add lactulose". It takes a hell of a lot longer to provide nurses education they're going to ignore than just signing the verbal order for it.

(Somewhere in that algorithm after the ducolax suppository, I go for ordering an enema. Fleets enema if they're not a renal patient, tap water or soap suds if they are.)

 

[CatFactorial]

Try reading the allopathic forum, that usually works for me.

 

[smartparts]

if they can tolerate it: opiate vacation until they have a bowel movement.

 

[medrest]

PO-->colace +-senna--dulcolax -miralax-mag citrate
PR-->dulcolax suppository-fleet enema-tap water enema
Manual disimpaction if several days duration

Above order Kind of works for me

 

[Gastrapathy]

Tried searching google? Really? Google, then SDN for clinical advice. Yikes.

But, just use miralax. Then more miralax. Just be sure you aren't missing an impaction. Get in there .

 

[jdh71]

The only thing I'd add here is that usually the problem is more one of dose than of agent. jdh for example does something we all do: adds lactulose to miralax. There's no physiologic reason why that would work any better than (say) doubling, tripling, or quadrupling the miralax.

You're still fighting the "good fight". I have given that up. This may make me a bad doctor, but for my own anger management, I don't try and get overly pedantic when I have to deal with the same conversation with pharmacy and or nursing.

Though these days, I usually tell my NP to just figure it out. Make it happen.

 

[jdh71]

Tried searching google? Really? Google, then SDN for clinical advice. Yikes.

But, just use miralax. Then more miralax. Just be sure you aren't missing an impaction. Get in there .

I like to consult GI for this issue.

 

[Gastrapathy]

I like to consult GI for this issue.

One of my favorite moments from fellowship was when a third year fellow got this consult from cards. It was an obvious fecal impaction. He grabbed the EM resident on cards and provided encouragement from outside the room (watching me scope across the hall). Then wandered back later and pointed out that it was really the intern's job.

 

[flipmd]

I'd probably put Relistor somewhere there in the middle if they're on opiates and very constipated. Expensive as hell, but I stop it the moment they poop and make sure to keep em going after they do.

 

[SW7D]

Look under "bowel care is king" on page 3 in the following article for a general guide: https://www.einstein.yu.edu/uploadedFiles/Pulications/EJBM/82-85 27.2 Amanatullah.pdf

Colace + Senna: 1st line for opiate patients
Miralax, Metamucil, Citracel: not mentioned in the article, are good 1st line for non-opiate patients as well.
Lactulose: think hepatic patients
Products with sodium: caution in CHF patients
Products with magnesium: caution in renal patients

Last resort: Pink lady/pink elephant/colace bomb enema x1 works wonders. Product is compounded by pharmacy. I've never seen it fail.