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Constipation Constipation is the term used to describe difficulty or infrequency in passing faeces (poo). A person with constipation goes to the toilet to pass faeces less often than normal for them, and their faeces are hard, small, and usually a strain to pass. It is important to realise that not everybody has a daily bowel motion; it may be natural for some people to go every second or third day, so the passage of time between bowel motions before constipation occurs varies from individual to individual. The most common reasons for constipation are: • being immobile – forced bedrest or disability • dehydration – drinking too little fluid, vomiting or excessive sweating • diet – eating too little, or eating low bulk or milky foods • pain or other medical conditions (eg, Parkinson’s disease, irritable bowel syndrome) • pregnancy • medicines such as diuretics, iron supplements, and opioid pain relievers. People with no apparent reason for their constipation should be referred to a doctor for further advice if it persists. Some people are found to have a generally underactive bowel, and may need long-term laxatives prescribed. Occasionally, some people complaining of diarrhoea may in fact have “overflow” diarrhoea as a result of severe constipation (refer to a pharmacist). People who suffer from constipation may also complain of stomach cramps, frequent passing of wind (flatulence) or bloating. Haemorrhoids can also occur with constipation as a result of straining when passing a bowel motion (see Haemorrhoids). Initial assessment Observe how your customer holds themselves – are they doubled over with stomach cramps or is their mobility limited? Do they look well hydrated or does their skin appear dry? Could they possibly be pregnant? It is important to identify which customers you need to refer to the pharmacist as some products may not be suitable for them. Treatment Products used to treat constipation are called laxatives and several different types are available. Most need to be given on a regular basis and some take up to three days to work properly (see Treatment options for more information). Advice for customers • Fibre is important for our health, and a high-fibre diet should be recommended for most people, although it may not be appropriate for the very young or very old. »» Wholegrain breads and cereals, nuts, beans, lentils, fresh and dried fruits (not fruit juices) and vegetables are high in fibre. »» Men should aim for around 30g/day of fibre and women 25g/day. »» Children aged between four and 18 need only slightly less than adults (about 18–28g/day). Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment or a caregiver's history may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart or lung problems, immunosuppression, diabetes, is pregnant or breastfeeding)? • Does the person take any other medication, either prescribed by a doctor or bought from a shop or supermarket (including herbal/ complementary medications)? • Is the sufferer a baby or young child? • Has the constipation continued for longer than seven days? • Is there any vomiting? • Has the customer lost any weight? • Are the bowel motions dark and tarry-looking or contain blood? • Has the constipation been recurrent, persistent or is worsening? • Is there any abdominal pain or bloating? • Has the person been buying or using large amounts of laxatives? • Does the constipation alternate with diarrhoea? • Does the person have a fever? • Does the person have any allergies to medicines? Refer also if you suspect laxatives are being abused, perhaps as a method of losing weight. »» Increase fibre intake once the current constipation problem has resolved. • Regular exercise and sufficient fluid intake – at least six glasses of water a day – also prevents constipation. • Avoid long-term use of stimulant laxatives unless under medical advice. • Seek medical advice if problems with bowel motions persist. • Don’t put off going to the toilet if you feel the urge as this can lead to constipation or make it worse. • Remind the customer that not everyone has a daily bowel motion and offer advice about haemorrhoids (see Haemorrhoids) if these are also present. PharmacyToday A part of your everyday Page 38 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION TREATMENT OPTIONS Category Examples Comments Bulk-forming laxatives Faecal softeners Osmotic laxatives Iso-osmotic laxatives Stimulant laxatives [GENERAL SALE] eg, psyllium husk (Metamucil [sugar-free available]) eg, sterculia (Normacol, Normacol Plus [also contains frangula bark, a stimulant laxative]) [GENERAL SALE] eg, docusate sodium (Coloxyl*, Coloxyl Drops*, Laxofast), glycerol suppositories [PHARMACY ONLY MEDICINE] eg, lactulose (Laevolac), Microlax [GENERAL SALE] eg, macrogol 3350 with electrolytes (Movicol, Movicol-Half) eg, Lax-Sachets [PHARMACY ONLY MEDICINE] eg, bisacodyl (Dulcolax*, Lax-Tab), senna (Senokot*), senna + docusate (Coloxyl with Senna*, Laxsol) These contain soluble fibre which swells on contact with fluid, bulking out the stool and encouraging peristalsis (the symmetrical contraction and relaxation of the muscles in the bowel). Good as first-line agents since there are very few interactions with medicines or long-term side effects. Avoid in people with bowel obstructions or when faecal matter is impacted, in bed-ridden patients, and in people unable to drink the required amount of fluid. May take two or three days to start working. Advise customers to take with plenty of fluid and to keep up the fluid intake (at least six glasses a day) to avoid worsening constipation. Most are safe in pregnancy, except Normacol Plus (it contains a stimulant – frangula – that is not recommended in pregnancy or for long-term use). These act like detergents, encouraging a mixture of dietary fat and water within the stool and allowing it to pass through the bowel more easily. They are most effective for mild constipation that has recently occurred and may be beneficial for people with haemorrhoids (piles). Usually take about one to three days to work properly. Osmotic laxatives attract large amounts of water into the bowel, making the stool soft, loose and easier to pass. May take up to 48 hours to start regular bowel motions and should be given on a regular basis. Safe for use in pregnancy. Microlax enemas work within 30 minutes. Iso-osmotic laxatives deliver liquid to the bowel rather than drawing it in from the surrounding tissue. They hydrate and soften the stool, with no net loss of electrolytes. The onset of effect is one or two days. Speed up colonic muscle movement which moves the stool along by contraction. Combination products (such as Coloxyl with Senna) also contain a faecal softener. The onset of effect is eight to 10 hours for tablets (one to two hours for suppositories). Long-term use not recommended. Avoid in pregnancy unless under medical advice. Food supplements eg, gluten-free wheat dextrin (eg, Benefiber) Fine powder with minimum taste. Can be sprinkled on foods and in cooking without premixing. Can be used long term to increase fibre in diet. Recommended for treatment and prevention of mild constipation and for people unable to eat fibrous food. Works within two or three days and help re-establish and maintain normal bowel motions. Probiotics Natural / herbal products / supplements Bowel cleansing eg, Bifidobacterium lactis (ProbioFX Gut Restore, Radiance Pro-B Regularity), Lactobacillus reuteri (Nature's Way Primadophilus Reuteri) Bifidobacteria + lactobacilli (Inner Health, Lifestream BowelBiotics, Nutralife Probiotic) eg, cape aloes, cascara, chia, European buckthorn, flaxseed oil, glycerol, magnesium (Good Health Mg Lax), psyllium, senna leaf (Nu- Lax Fruit Laxative), olive oil eg, kiwifruit extract (Kiwi Crush, Phloe Bowel Health) [PHARMACIST ONLY MEDICINE] eg, MoviPrep Contain probiotics +/- prebiotics (see Probiotics and Prebiotics). Help restore levels of naturally occurring bacteria in the bowel. An imbalance in bacteria may lead to constipation, diarrhoea, or bloating. Useful following a course of antibiotics. For daily use in adults. Many commercial products for constipation are based on natural ingredients. Psyllium works as a bulk laxative, senna as a stimulant, glycerol as a softener, and magnesium can help soften faeces. European buckthorn acts as a mild stimulant, and olive oil effectively softens stools. Kiwifruit extract contains prebiotics, enzymes and dietary fibre to optimise bowel health. MoviPrep is used to thoroughly cleanse the bowel before investigative procedures. Products with an asterisk have a detailed listing in the Constipation section of OTC Products, starting on page 229-230. SUBSCRIBE • Latest pharmacy headlines • Online learning • Hot retail tips • Prizes & giveaways • Healthcare Handbook 09 488 4286 Page 39

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