Constipation and diuretics: The Associations of Diuretics and Laxatives Use with Cardiovascular Mortality. An Individual Patient-Data Meta-analysis of Two Large Cohort Studies
How to Treat Constipation Caused by Your Medications
You can treat this type of constipation with laxatives that you can buy at a drug store or supermarket. You do not need a prescription for these laxatives.
Laxatives work in two ways:
- Stimulant laxatives help stool move along your bowel or
- Osmotic laxatives help liquid stay in your bowel so stool does not become dry and hard.
Just as you need to eat every day, you must take laxatives every day for them to work.
The first laxative you should try is the stimulant type called
sennosides. It is mild and works for most people. You can buy sennosides in pills or in liquid.
If you have a history of frequent bowel cramps (also known as “Irritable Bowel Syndrome”), you may want to try an osmotic laxative first, such as
Steps to treat constipation that is caused by your medication:
Each person has a different bowel pattern. What is “normal” for you will be different than what is “normal” for another person. However, having a bowel movement should not be uncomfortable. You should not have to push too hard and your stool should be soft, but formed.
It is important to tailor your laxative doses based on your bowel pattern and goal. A treatment that is tailored for you is called a protocol.
Look at the diagram below.
here to enlarge diagram.
Each step up the protocol has a higher dose so you can work up to the level you need to maintain a comfortable bowel pattern. If you move up the protocol as shown, you will not risk over-treatment, which could cause diarrhea.
You should start EITHER the sennosides protocol OR the PEG protocol. Do not start both at the same time
Most people find the sennosides protocol to be the easiest to take. Sennosides cost less than PEG but PEG works just as well.
Whichever protocol you choose, start at step 1. Wait 24 hours. If you have a bowel movement within 24 hours that is soft and comfortable to pass, stay at step 1.
If you do not have a comfortable bowel movement within 24 hours, go to the next step in the protocol.
Only go to the next step if you are still feeling constipated after 24hrs.
Keep moving up a step every 24 hours until you feel your bowel pattern is good for you.
If you have diarrhea, stop taking laxatives until you have a normal bowel movement. Restart the protocol at a lower step than you were on when the diarrhea happened.
Do not take pills for diarrhea.
If you have very bad stomach cramps, stop taking sennosides and call your health care team.
Call your health care team if you:
Feel the protocol is not working for you. You may need an osmotic laxative call lactulose syrup. This is sometimes necessary when you have reached the highest step on your protocol and you are still constipated.
- Are not sure how much laxative to take or when you should move to the next step of the protocol.
- Are still constipated after getting to the top step of the protocol. You may need a combination of laxatives or a change in medication or pain management.
- Start having watery stools after a period of being constipated. There may be hard stool stuck in your rectum. If this happens, do not take pills for diarrhea.
8 medications that cause constipation
Opioids, NSAIDs, antihistamines, tricyclic antidepressants, urinary incontinence medications, iron, blood pressure meds, and anti-nausea medicine are medications that may cause constipation
Constipation symptoms and causes | Medications that cause constipation | Constipation treatment | How to prevent constipation
Constipation is a common condition. Around 16% of people in the United States and one-third of older adults over the age of 60 complain of chronic constipation. Between 2006 and 2011, constipation accounted for more than 700,000 trips to the emergency room.
Symptoms and causes of constipation
Symptoms of constipation include:
- Fewer than three bowel movements per week
- Small, hard, dry stools that are difficult or painful to pass
- The need to strain excessively to have a bowel movement
Some people experience pain in their abdomen when they are constipated, especially after meals. Some might have nausea, vomiting, headaches, or a general feeling of being unwell.
There are many causes of constipation, including:
- A low-fiber diet (especially diets high in meat, milk, or cheese)
- Sedentary lifestyle
- Ignoring or delaying the urge to defecate
- Travel and schedule changes
- Laxative overuse
- Pain or discomfort around the anus
- Colorectal cancer
- Medical conditions, including irritable bowel syndrome, diverticulosis, hypothyroidism, high blood calcium levels, multiple sclerosis, Parkinson’s disease, and spinal cord injury
RELATED: What you need to know about constipation after surgery
Constipation can also be a side effect of some medications. “Medication-induced constipation is extremely common these days,” according to Bryan Curtin, MD, the Director of Neurogastroenterology and Motility, at Mercy Medical Center. “People take more medications than ever before, and because most medications have an extensive profile, prescribing doctors tend to ignore constipation as a significant side effect when compared to more serious ones. It is not uncommon for people to be on as many as four or five medications that might be exacerbating constipation, and this isn’t even including opioids, which can be absolutely devastating to the GI tract.”
Constipation can be uncomfortable, but it can also lead to complications such as:
- Rectal bleeding
- Anal fissures
- Rectal prolapse
- Fecal impaction
“When conservative measures, such as changes to the diet, increased hydration, and over-the-counter laxatives have failed, patients should be seen by a primary care doctor or gastroenterologist,” says Dr. Curtin. “This is true, especially if the constipation is accompanied by other significant symptoms, such as nausea, abdominal pain, or unexpected weight loss.”
8 medications that cause constipation
- Opioid pain relievers
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Tricyclic antidepressants
- Urinary incontinence medications
- Iron supplements
- Blood pressure medications
- Anti-nausea medicines
1. Opioid pain relievers
Also called narcotics, opioids treat pain that is severe and that has not improved with other, milder pain medications. They are effective at relieving pain, but can be habit-forming and have a high rate of abuse. Only use opioid medications under the direct care of a health professional. Commonly prescribed opioid pain medications include:
- Tylenol with codeine (acetaminophen-codeine)
- Duragesic (fentanyl transdermal)
- Lorcet, Vicodin, Norco (hydrocodone)
- Dilaudid (hydromorphone)
- Demerol (meperidine)
- Percocet (oxycodone-acetaminophen)
- Ultram (tramadol)
Many patients on opioids for chronic pain relief experience opioid-induced constipation (OIC. ) It is considered the most prominent digestive problem and one of the most common side effects of opioids. It can be disabling and is a common reason for people to stop taking the medications, according to a report published in 2019. Ask your doctor if you can start a laxative at the same time as the opioid.
NSAIDs are the most prescribed medications for treating conditions such as arthritis, according to the American Academy of Orthopedic Surgeons. They are also used to reduce fever, inflammation, and mild to moderate pain. This class of medications includes:
- Motrin, Advil (ibuprofen)
- Aleve, Naprosyn (naproxen)
- Celebrex (celecoxib)
Antihistamines reduce symptoms of allergies. When you are allergic to something, your body releases histamines that cause congestion, runny nose, sneezing, itching, swelling of the nasal passages, hives, skin rashes, or itchy and runny eyes. Common over-the-counter (OTC) antihistamines include:
- Chlor-Trimeton (chlorpheniramine)
- Unisom (diphenhydramine or doxylamine)
- Vicks QlearQuil Nighttime Allergy Relief (diphenhydramine)
- Claritin (loratadine)
- Benadryl (diphenhydramine)
- Allegra (fexofenadine)
- Zyrtec (cetirizine)
- Xyzal (levocetirizine)
4. Tricyclic antidepressants
Tricyclic antidepressants are a class of medication used to treat depression. They work by increasing levels of norepinephrine and serotonin and blocking the action of acetylcholine. By balancing these three neurotransmitters, tricyclic antidepressants alleviate depression. There are newer medications for depression with fewer adverse effects; however, these tricyclic antidepressants work better for some people. Some common brands include:
- Tofranil (imipramine)
- Vivactil (protriptyline)
- Elavil (amitriptyline)
- Pamelor (nortriptyline)
Urinary incontinence medications
Urinary incontinence medications treat overactive bladder and other conditions that can cause bladder leakage or frequent urination. This condition is more common in women than in men; however, it can occur in men as well. It is one of the most common conditions seen in primary care practice, according to the American Academy of Family Physicians.
These medications work by either reducing bladder spasms or relaxing the bladder wall muscle, allowing it to hold more urine and empty more fully. Some of the most frequently prescribed urinary incontinence medications include:
- Ditropan, Ditropan XL (oxybutynin)
- Detrol, Detrol LA (tolterodine)
- Enablex (darifenacin)
- Myrbetriq (mirabegron)
- Flomax (tamsulosin)
6. Iron supplements
Iron supplements treat anemia and iron deficiency. They are available over the counter. Frequently used forms of iron in supplements include:
- FeroSul (ferrous sulfate)
- Ferate (ferrous gluconate)
- Ferric citrate
- Ferric sulfate
7. Blood pressure medications
There are two types of blood pressure medicines that most commonly cause constipation: calcium channel blockers and beta blockers. Calcium channel blockers work by dilating arteries, which reduces the effort your heart must exert to pump blood. Beta-blockers work by slowing down your heart rate, lowering your blood pressure.
Calcium channel blockers include:
- Norvasc (amlodipine)
- Plendil (felodipine)
- Cardene (nicardipine)
- Adalat CC, Procardia XL (nifedipine)
- Cardizem, Tiazac, Dilt-XR (diltiazem)
Common beta blockers include:
- Lopressor, Toprol XL (metoprolol)
- Tenormin (atenolol)
- Corgard (nadolol)
- Inderal (propranolol)
Also called anti-emetics, anti-nausea medications block different pathways in your body that trigger nausea and vomiting. These include:
- Serotonin (5-HT3) antagonists
- NK-1 antagonists
- Dopamine antagonists
Common medications used to treat nausea include:
- Zofran (ondansetron)
- Reglan (metoclopramide)
- Emend (aprepitant, fosaprepitant)
- Tigan (trimethobenzamide)
- Marinol (dronabinol)
- Syndros (dronabinol)
How to treat constipation caused by medication
In addition to lifestyle changes, there are over-the-counter laxatives and prescription medicines to relieve constipation. As with any medication, it’s important to seek the professional medical advice of a doctor or pharmacist before using laxatives. Always read the medication guide before using any of the following products.
RELATED: How to treat constipation naturally
Fiber-based laxatives, also called bulk-forming laxatives, increase water in your stools to make them softer. Common fiber-based laxatives include:
- FiberCon (calcium polycarbophil)
- Citrucel (methylcellulose fiber)
- Metamucil, Konsyl (psyllium)
- Benefiber (wheat dextrin)
RELATED: Benefiber vs. Metamucil
Stool softeners, also called emollient laxatives, add moisture to your stools to make it easier to pass them. Commonly used stool softeners include:
- Colace, Dulcolax Stool Softener (docusate sodium)
Stimulant laxatives work by stimulating nerves in your digestive tract, triggering the muscles in your large intestine to contract, pushing your stool through. Commonly used stimulant laxatives include:
- Correctol, Ducodyl, Dulcolax (bisacodyl)
- Ex-Lax, Senokot (sennosides)
Osmotic laxatives pull water from surrounding tissue into your digestive tract to make it easier for the stool to pass through the intestine. Commonly used osmotic laxatives include:
- Milk of Magnesia (magnesium hydroxide)
- Miralax (polyethylene glycol 3350)
Prescription medicine for constipation
For many people, making lifestyle changes and using over-the-counter laxatives will help relieve constipation. Everyone’s bowel habits are different though. You may be used to having one—or more—bowel movements a day or one every few days. Doctors typically define constipation as three or fewer bowel movements per week. In the case of constipation or chronic constipation, healthcare providers may prescribe one of the following prescription drugs:
- Cephulac, Kristalose (lactulose)
- Linzess (linaclotide)
- Trulance (plecanatide)
- Motegrity (prucalopride)
Prescription drugs for opioid-induced constipation include:
- Movantik (naloxegol)
- Relistor (methylnaltrexone)
- Amitiza (lubiprostone)
- Symproic (naldemedine)
RELATED: Movantik alternatives
How to prevent medication-induced constipation
Not everyone will become constipated when using these medications. However, you should be aware of the potential side effects and what you can do to prevent constipation due to medication.
“In general, you want to make sure you are well hydrated with water, not coffee or carbonated beverages,” says Dr. Curtin. “You also want to have a healthy amount of fiber in your diet and try to limit processed foods. It is worth asking your doctor if there are alternative agents. Calcium channel blockers, used for high blood pressure, such as diltiazem, for example, are notorious for causing constipation. If there is another class of medication that can treat the underlying health problem, you should at least be given the option.”
Fortunately, there are some relatively simple nonpharmacologic approaches to preventing constipation.
Eat a high-fiber diet
Include high-fiber foods in your diet. These include:
- Legumes: Lentils, kidney beans, split peas, chickpeas, black beans, lima beans
- Vegetables: Carrots, beets, broccoli, artichokes, brussels sprouts, kale, spinach, tomatoes
- Fruits: Apples, prunes, pears, strawberries, avocado, raspberries, bananas
- Grains: Quinoa, oats, popcorn, any other whole grains
- Nuts and seeds: Almonds, chia seeds, coconut, pistachios, walnuts, sunflower seeds, pumpkin seeds
- Other foods: Sweet potatoes, dark chocolate (cocoa content of 70% to 95% or higher)
If your diet is low in fiber, you can also talk to your doctor about adding a fiber supplement.
Drink enough fluids
Water plays a large part in keeping your body healthy. It is essential for keeping fecal matter flowing through the intestines. Although most people have heard that you should drink six to eight glasses of water a day, you might not need to consume that much. Four to six cups of water per day are generally enough for healthy people, according to Harvard Health.
Some medications cause you to retain water, and some health conditions require you to limit your fluid intake. If you are taking medications that cause constipation, you should talk to your doctor about how much water you should be drinking.
Physical activity can decrease the time it takes food to move through the large intestine. Aerobic exercise accelerates breathing and heart rate, which stimulates the natural contraction of the intestinal muscles, moving stools out of the intestine quickly.
Listen to your body
Your body naturally tells you when it is time to have a bowel movement. Some people try to hold it until they are at home or in a bathroom by themselves. Ignoring the urge can cause constipation, according to the National Institute on Aging.
Establish regular bowel habits
Bowel retraining is one way to establish a routine. The best time for a bowel movement is 20 to 40 minutes after a meal. Attempt to have a bowel movement every day at the same time. Digital stimulation may help. Use this method every day until you establish a routine.
Informing during the sale of drugs of the pharmacological group laxatives
In total, this pharmacotherapeutic group includes about 20 formulations of the medicinal product:
- oral solution
- rectal suppositories
- granules for suspension for oral administration
- leaves and bark crushed
- collection powder in filter bags
- enteric coated tablets
- powder and concentrate for oral solution
- solution for rectal administration.
All of them differ in their pharmacotherapeutic characteristics. For example, Sennosides A and B , produced under the trade names (TN) Senade, Senadexin, Sennagood, Sennaplant, Sennales-Rusyuro, etc. in the form of tablets are not absorbed in the intestines and are excreted unchanged, including with sweat, and can pass into breast milk (which should be considered when choosing laxatives for nursing women).
The laxative effect after taking them comes in 6-10 hours and it is rational to take them at night to ensure the act of defecation in the physiological range – in the morning with water. In the process of providing information assistance when dispensing these medicinal products, the consumer should be informed about their possible interaction with other medicinal products. So, for example, with long-term use of these drugs in high dosages, it is possible to enhance the action of cardiac glycosides and influence the action of antiarrhythmic drugs due to the possibility of developing hypokalemia. The effectiveness of drugs that are slowly absorbed in the gastrointestinal tract also decreases. When used simultaneously with thiazide diuretics, glucocorticosteroids, and licorice root preparations, the risk of developing hypokalemia increases.
Preparations Psyllium oval seed shell (TN Isfagula, Fibralax, Mucofalk, etc.) in the form of granules and powder for suspension for oral administration should not be taken with antidiarrheal drugs and drugs that depress intestinal motility. You should also observe an interval of 30-60 minutes between taking other drugs. Against the background of the use of the drug, a decrease in the effect of thyroid drugs is possible. Patients with diabetes may need to adjust (reduce) the dose of hypoglycemic drugs.
LP Castor oil seeds oil should be taken once a day for no more than three consecutive days. When used simultaneously, it reduces the absorption of fat-soluble vitamins, and when taken simultaneously with saline laxatives, a sharp increase in the laxative effect is possible. Long-term use of castor oil can lead to the development of hypokalemia, against which it is possible to increase the action of cardiac glycosides and reduce the effectiveness of antiarrhythmic drugs. Combined use with diuretics, glucocorticosteroids and licorice root preparations can increase the loss of potassium in the body.
Used as monotherapy for constipation of various etiologies Alder buckthorn bark (TN: Alder buckthorn bark powder; Prolaxanite coated tablets). Bark Krushina is taken in the form of an aqueous extract (2 filter bags in a glass / enamel bowl, the consumer should pour 100 ml (1/2 cup) boiling water; cover and infuse for 15 minutes, periodically pressing the bags with a spoon; then squeeze them and If necessary, bring the volume of the obtained aqueous extract with boiled water to 100 ml). Prolaxanite is taken orally, 1-2 tablets at bedtime.
MD, the active substance of which is Macrogol (TN – D-Forject, Forlax, Osmogol, Lavacol, Macrogol Lekas, Microlax plus, Forteza Rompharm, Tranzipeg, Fortrans, etc. ) in the form of a powder for preparing a solution for administration orally should be taken orally, on an empty stomach in the morning, or in the morning and evening, depending on the dosage and purpose, dissolving the contents of the package in water immediately before use. D-Forzhekt is dispensed by prescription, the rest of the TN LP OTC.
Diarrhea caused by the use of drugs containing Macrogol can lead to impaired absorption of other drugs taken simultaneously. Therefore, in the case of simultaneous administration of Macrogol with other drugs, it is recommended to prescribe it 2 hours after taking them. Simultaneous administration of Macrogol and Digoxin leads to a decrease in the degree of absorption of Digoxin in the intestine; Amoxicillin and Macrogol for 4 days is accompanied by an increase in the duration and a decrease in the absorption rate of Amoxicillin, which significantly affects the antibacterial effect.
A well-known representative of laxatives of synthetic origin over-the-counter is Bisacodyl , which is produced under the brand name: Dulcolax in enteric coated tablets; Guttalax Express in rectal suppositories. When dispensing this medicinal product, the consumer should be informed about the possibility of enhancing the action of cardiac glycosides while taking them for a long time with Bisacodyl in high doses due to hypokalemia. With the simultaneous administration of Bisacodyl with diuretics and glucocorticoids, hypokalemia may increase. LP is taken orally, at bedtime, if necessary, can be taken 30 minutes before breakfast.
For the treatment of constipation caused by atony and hypotension of the colon, as well as caused by taking medications, OTC drug is recommended Sodium picosulfate Teva, Gutaflos, Picodinar etc.), which is an agent acting at the level of the large intestine. It should be borne in mind that diuretics or glucocorticosteroids increase the risk of electrolyte imbalance (hypokalemia) when taking high doses of sodium picosulfate. Electrolyte imbalance may increase sensitivity to cardiac glycosides.
The combined use of the drug and antibiotics may reduce the laxative effect of the drug. To obtain a laxative effect in the morning, you should take the drug the night before.
A large proportion are drugs of combined composition, which additionally can have anti-inflammatory, choleretic, carminative effects; hinder the formation and contribute to the destruction of gas bubbles in the contents of the gastrointestinal tract, etc.
When a pharmacy visitor applies for a medicinal product, a pharmaceutical worker is obliged to provide informational assistance – in a timely manner, in a clear and accessible form, bring to the attention of the buyer the necessary and reliable information about the medicinal product and their manufacturers, which ensures the right choice of goods, including informing the buyer about the availability in the assortment pharmaceutical division of LP of different price segments.
If it is difficult to choose an over-the-counter drug, the worker of the first desk should determine the visitor’s problem by asking clarifying questions and paying attention to the patient’s belonging to groups with an increased risk of drug use. Discuss with the patient possible ways to eliminate the problem and propose a LP, arguing their choice. If objections arise, work them out with the consumer, answering all his questions and fulfilling all requests to the extent possible and admissible.
This factor is a risk for buyers, as laxative drugs may be abused. Uncontrolled use can lead to unwanted side effects. It also imposes a great responsibility on the pharmaceutical worker in providing information and advice when choosing a laxative drug.
When dispensing medicinal products, a pharmacist informs the person who purchases (receives) the medicinal product about the regimen and doses of its administration, rules for storage at home, interaction with other medicinal products, therapeutic effect, possible side effects and contraindications. The answers of the specialist must be professional, competent, in compliance with the requirements of ethics.
Pharmaceutical counseling and information are among the main functions of pharmaceutical workers. Reliable and broad knowledge of the pharmacotherapeutic characteristics of drugs and pharmacological groups is required from first-desk workers, including thorough knowledge of information from the instructions for the use of drugs, constant updating of knowledge and counseling skills.
Mistakes in the dispensing of medicinal products may lead to the manifestation of side effects, undesirable drug interactions, and other undesirable moments that may lead to a deterioration in the patient’s health.
How to take Duphalac® for constipation in the elderly?
Constipation in older people is quite common. The development of constipation in the elderly may be due to poor nutrition, lack of adequate fluid in the diet, lack of physical activity and medications for other diseases 2 . For more information on the symptoms, causes of constipation, and how to deal with this delicate problem after the age of 60, see the article Constipation in People After 60.
Constipation can become a chronic problem with age. Violation of the intestines spoils the mood and affects well-being. Rarely can this problem be solved quickly. If constipation is not treated properly, the symptoms can be permanent.
Drug choice for constipation in older people
Many medicines can cause constipation by themselves – this is one of their side effects. For example, anti-inflammatory drugs, drugs for the treatment of the cardiovascular system (calcium antagonists, statins, diuretics, b-blockers), neuroleptics, iron preparations and PPIs (proton pump inhibitors – drugs to reduce the production of hydrochloric acid in the stomach) 1.3 . But we cannot refuse them, since they are used in many chronic diseases and are vital. At the same time, constipation, as a side effect of drugs, can contribute to the development of other problems. For example, blood pressure pills can cause constipation, and hard straining when constipated can lead to high blood pressure. Then we are faced with the task of choosing a remedy that, on the one hand, will improve bowel function and treat constipation, and on the other hand, will have a high safety profile.
Which laxatives are suitable for older people?
Not all laxatives for constipation in the elderly are suitable for long-term use.
For example, long-known drugs from the group of irritant (stimulant) laxatives based on senna and sodium picosulfate in the form of drops or tablets are not recommended for more than two weeks 1 .
And with long-term or constant use, these drugs can be addictive and develop lazy bowel syndrome – a condition in which there is a delay in emptying and a decrease in intestinal motility, including due to the constant use of irritant laxatives 1.4 .
The optimal laxative for older people should be gentle, comfortable, long-lasting, and non-addictive.
An example of such a laxative is Duphalac ® . It has been used to treat constipation for over 60 years worldwide.
Duphalac ® has dual action :
- First, by attracting water into the intestines, the drug softens the stool, providing a gentle and comfortable bowel cleansing 5 .