Constipation Help Relief In Minutes

Nature's Quick Constipation Cure

The First Step-by-step Plan To Cure Constipation Using A Combination Of Unique All-natural Remedies. This plan uses a strategically organized and ordered combination of the safest and most effective natural remedies for constipation. Everything used in this plan is from natures garden. No use of harmful laxatives. People who have used these swear they work Better than over-the-counter laxatives! Every strategy is carefully researched for safety and effectiveness. Each remedy builds on the last while helping out the next. The plan takes into account human physiology, anatomy, nutrition, metabolic needs and deficiencies while using specific dietary remedies and the almost always neglected but extremely powerful, mechanical remedies. All of these have been carefully planned and refined to provide you the most powerful, synergistic constipation relief plan that will relieve you of even the most stubborn of constipation episodes within as quick as 15 minutes and less than 24 Hours. Continue reading...

Natures Quick Constipation Cure Summary


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Laxatives Stool Softener

DOCUSATE Docusate calcium 240 mg PO daily. Docusate sodium 50 to 500 mg day PO divided in 1 to 4 doses. Peds Give 10 to 40 mg day for age younger than 3 yo, give 20 to 60 mg day for age 3 to 6 yo, give 40 to 150 mg day for age 6 to 12 yo. In all cases doses are divided up to qid. Cerumen impaction Instill 1 mL in affected ear. Docusate calcium OTC Generic Trade Caps 240 mg. Docusate sodium OTC Generic Trade Caps 50, 100, 250 mg, liquid 50 mg 5 mL, syrup 20 mg 5 mL. Docusate sodium OTC Trade only (Enemeez) Enema, rectal 283 mg 5 mL. L 2+

Laxatives Other or Combinations

LUBIPROSTONE (Amttiza) Chronic idiopathic constipation 24 mcg PO bid with meals. Irritable bowel syndrome with constipation in women age 18 yo or older 8 mcg PO bid. Trade only 8, 24 mcg caps. Gut 2C PERI-COLACE (docusate + sennosides) 2 to 4 tabs PO once daily or in divided doses prn. OTC Generic Trade Tabs 50 mg docusate + 8.6 mg sennosides. L 2C SENOKOT-S (senna + docusate) 2 tabs PO daily. OTC Generic Trade Tabs 8.6 mg senna concentrate 50 mg docusate. L 2C +

Clinical Relevance Of Opioidinduced Constipation

While analgesia, respiratory depression, bradycardia, antitussive action and miosis all are centrally induced opioid effects, the most relevant peripheral opiod action is that of constipation 109 136 . This is most relevant in patients with chronic pain taking an opioid for its attenuation. Being one of the major side effects, it often results in the necessity to take a laxative on a routine basis. The cause for such constipation is the constriction of the pylorus resulting in a delay in emptying of the stomach 137 . However, most important, opioids induce a constriction of the small intestine resulting in a delay of the propulsive transit. Because selective opioid binding sites are mainly located in the small intestine, opioids inhibit the release of local acetylcholine 136, 137, 138 , followed by a concomitant loss of coordinated propulsive movements of the gut. A constipating effect of opioids on the large intestine is of significantly lesser degree, because this part of the...

Bulkforming laxatives

Pregnancy If dietary and lifestyle changes fail to control constipation in pregnancy, moderate doses of poorly absorbed laxatives may be used. A bulk-forming laxative should be tried first. An osmotic laxative, such as lactulose, can also be used. Bisacodyl or senna may be suitable, if a stimulant effect is necessary. Bulk-forming laxatives relieve constipation by increasing faecal mass which stimulates peristalsis patients should be advised that the full effect may take some days to develop. Bulk-forming laxatives are of particular value in those with small hard stools, but should not be required unless fibre cannot be increased in the diet. A balanced diet, including adequate fluid intake and fibre is of value in preventing constipation. Bulk-forming laxatives are useful in the management of patients with colostomy, ileostomy, haemorrhoids, anal fissure, chronic diarrhoea associated with diverticular disease, irritable bowel syndrome, and as adjuncts in ulcerative colitis (section...

Stool Softeners and Laxatives

Since opioids can cause constipation, either a stool softener, or a laxative, or a combination should be used. Other than lactulose, none of the stool softeners, laxatives, or combinations requires a prescription. Colace, Surfak, Peri-Colace, Senokot and Senokot-S can all be given as one or two capsules at bed-time. Colace (docusate sodium) 100 mg - softener (this product is a sodium salt) Surfak (docusate calcium) 240 mg - softener (this product is a calcium salt) Peri- Colace (docusate + sennosides) - combination laxative and softener Senokot (senna) - stimulant laxative Senokot-S (docusate + senna) - combination laxative and softener Milk of Magnesia (magnesium hydroxide) - osmotic laxative Miralax (polyethylene glycol) - osmotic laxative Magnesium Citrate osmotic laxative (generally not used for opioid constipation) Lactulose osmotic laxative (synthetic disaccharide requires a prescription)

Opioids And Gastrointestinal Inhibition Constipation

Digestion Constipation

Within the Auerbach plexus of the intestinal tract, there is a balance between the cholinergic and enkephalinergic neurons Binding of systemically applied opioids to enkaphalinergic receptor sites results in an inhibition of transit followed by constipation. Contrarily, cholinesterase inhibitors induce an accumulation of acetyl-choline at ACh-receptors with an increase in motility and an enhancement of transit. Presently, however, not very much is known of the long-term effect of central analgesics on opioid-receptors within the myenteric plexus, and if opioid ligands induce only a constipating effect, whether they also depress the immune system in the intestine or result in a distress the neuroregulatory and endocrine function.

Laxatives based on naturally occurring anthraquinone derivatives

Herbs containing anthraquinone derivatives (rhubarb, senna, frangula, cascara, aloe) are used as laxatives. A meta-analysis of 11 studies dealing with colorectal cancers and laxative use showed that use of laxatives carried an increased risk (odds ratio, 1.5 95 CI, 1.3-1.6) for colorectal cancer (Sonnenberg & M ller, 1993). A more recent and very large study among nurses in the USA found no association between colorectal cancer and laxative use (Dukas et al., 2000). The relevance of this evidence to the carci-nogenicity of anthraquinone-containing herbs used as laxatives is unknown because it is uncertain whether the use of laxatives in general is an adequate proxy measure for the use of anthraquinones.

Stimulant laxatives

Stimulant laxatives include bisacodyl, sodium picosul-fate, and members of the anthraquinone group, senna and dantron. The indications for dantron are limited (see below) by its potential carcinogenicity (based on rodent carcinogenicity studies) and evidence of geno-toxicity. Powerful stimulants such as cascara (an anthra-quinone) and castor oil are obsolete. Docusate sodium probably acts both as a stimulant and as a softening agent. Stimulant laxatives increase intestinal motility and often cause abdominal cramp they should be avoided in intestinal obstruction. Excessive use of stimulant laxatives can cause diarrhoea and related effects such as hypokalaemia however, prolonged use may be justifiable in some circumstances (see section 1.6 for the use of stimulant laxatives in children).

Osmotic laxatives

Osmotic laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with. Macrogols are inert polymers of ethylene glycol which sequester fluid in the bowel giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives.


1.6.1 Bulk-forming laxatives 1.6.2 Stimulant laxatives 1.6.4 Osmotic laxatives Before prescribing laxatives it is important to be sure that the patient is constipated and that the constipation is not secondary to an underlying undiagnosed complaint. It is also important for those who complain of constipation to understand that bowel habit can vary considerably in frequency without doing harm. Some people tend to consider themselves constipated if they do not have a bowel movement each day. A useful definition of constipation is the passage of hard stools less frequently than the patient's own normal pattern and this can be explained to the patient. Misconceptions about bowel habits have led to excessive laxative use. Abuse may lead to hypokalaemia. Thus, laxatives should generally be avoided except where straining will exacerbate a condition (such as angina) or increase the risk of rectal bleeding as in haemorrhoids. Laxatives are also of value in drug-induced constipation, for the...


Guidelines for constipation management should be discussed with the caregiver, with the emphasis focused on prevention. Adequate fluid intake and the inclusion of vegetables into daily meals may be enough to prevent constipation for many children. Adding up to 25 g of iceberg lettuce as a free food to the diet may also help. Calculating 10-20 g of avocado into a meal for daily consumption may also promote regularity. Some children will need further dietary manipulation such as the calculation of medium-chain triglycerides (MCT) oil into meals. Pharmacologic intervention with a carbohydrate-free stool softener may also help to prevent constipation. Constipation may be treated with use of carbohydrate-free laxatives such as Milk of Magnesia , a glycerin suppository, or an enema. In children on the ketogenic diet, a bowel movement should be expected every 2-4 d, and treatment should be instituted otherwise.

Bismuth aluminum carbonate

Bismuth aluminum carbonate has been used in clinical studies investigating the treatment of gastroduodenal disorders.31 The studies project the remarkable action of bismuth aluminum carbonate on ulcers, emphasizing its drug efficacy on patients accepting the pharmaceutical satisfactorily (with no side effects, like nausea and constipation). The pharmaceutical, when administered alone or in combination with atropins, constitutes an excellent therapeutic for the conservative treatment of gastroduodenal ulcers.

Calcium Supplements Side Effects

Between 1000 and 2500mg day, have provided meaningful evidence that this amount of calcium intake is safe. Gastrointestinal side effects of calcium supplements have been observed, usually at relatively high dosages.68,69 Some individuals may experience bloating or constipation when beginning calcium supplementation, and it has been reported in several clinical trials. In most cases bloating and constipation are temporary, as the body adjusts to the effects of the daily calcium supplement. Although calcium is better absorbed in an acid environment, only little acidity is necessary for calcium absorption.70 However, subjects with hypochloridia (lack of adequate HCl production in the stomach), including the very elderly, those on high doses of antiulcer medications, and individuals who have fasted, should take calcium carbonate with a meal since that is when it is most effectively absorbed.71

Clomipramine Definition

Clomipramine, the 3-chloro derivative of imipramine, is a tricyclic antidepressant with a tertiary amine chemical structure. It is a potent, but not selective, serotonin reuptake inhibitor its primary active metabolite, desmethyl-clomipramine, inhibits reuptake of norepinephrine. Although originally introduced for the treatment of depression, clomipramine is now used more frequently for the treatment of obsessive-compulsive disorder. Even for this indication, it is usually employed only after nonre-sponse to a selective serotonin reuptake inhibitor (SSRI) while clomipramine may have slightly greater efficacy than the SSRIs, it also has a less-favorable side-effect profile. Side effects include marked sedation, cardiovascular effects, and anticholinergic effects (e.g., constipation, dry mouth, blurred vision, urinary retention). Clomipramine is dose dependently associated with a higher risk of seizures than other tricyclics like other tricyclics, it has a high potential for lethality...

A9Tet RahYdRocannabinoL CB1 and CB2 Receptors

The hemp plant, Cannabis sativa, has been exploited by humankind for over 5000 years. According to the archeological record, the first use was apparently for its fibers and later it was found to be a highly nutritious foodstuff. Its medicinal properties were being exploited in Chinese culture about 4000 years ago and it was prescribed for treatment of malarial fever, constipation, and arthritic pains. Much later, Indo-Aryan cultures exploited its psychoactive properties as well as its benefits in fevers and gastrointestinal conditions. Despite this long history, it is less than 50 years since the groundbreaking demonstration by Gaoni and Mechoulam (1964) that A9-tetrahydrocannabinol was the primary active ingredient of cannabis. For some years after this discovery there was a debate as to whether or not the drug acted on specific receptors. One hypothesis was that its primary interaction with cells took the form of a disturbance of the function of the cell membrane arising from its...

Human Tcell lymphotropic virus type

Human T-cell lymphotropic virus type 1 (HTLV-1) infection is seen predominantly in the equatorial regions of southeastern Japan, the Caribbean, Africa, and Central and South America. Its routes of transmission are thought to be sexual, perinatal and by contact with contaminated blood.178 Most infected individuals remain asymptomatic. Affected patients present with back pain or painless progressive spastic paraparesis with constipation and urinary urgency or incontinence.179 HTLV-1 myelopathy (HAM), also know as tropical spastic paraparesis (TSP), has a highly variable disease course. Symptoms often stabilize within a few years of onset. Serum ELISA for HTLV-1 may establish the presence of the virus. CSF demonstrates elevated intrathecal synthesis of anti-HTLV-1 IgG. MRI reveals atrophy of the thoracic spinal cord and white matter lesions that can mimic those seen in multiple sclerosis. Although the exact pathogenesis is not well understood, virus particles and virus-infected T- and...

Functional Imaging Pain And Depression

Lead to urinary retention, constipation, tachycardia, blurred vision, and delirium. Antihistaminergic effects include sedation, increased appetite, and weight gain. Orthostatic hypotension results from blockade of a1-receptors and could contribute to the increased risk of fall-related hip fractures among patients receiving TCAs.26,27,28 Tricyclics also have type 1 antiarrhythmic properties in that cardiac conduction is prolonged by inhibition of sodium channels. These antiarrhythmic effects could, in part, account for the increased risk of sudden cardiac death and myocardial infarction in patients treated with TCAs.29,30 The use of TCAs in combination with methadone, which increases the QTc interval, has been associated with an increased risk of death related to accidental overdose.31,32 Tricyclics also increase the risk of seizure by inhibiting chloride channels.

Hints Of Phenotypes For Variant Sert Alleles From Genetic Studies In Mouse And

Two recent efforts to characterize the peripheral phenotypes of SERT knockout mice have revealed interesting facets of SERT biology that may translate to human conditions enriched for SERT sequence variants. Chen and co-workers (2001) have examined the impact of the SERT KO on GI function. As noted, SERT is richly expressed in the enteric nervous system, where it functions to terminate the actions of 5HT released by intrinsic myenteric and submucosal neurons (Wade et al., 1996 Gershon, 1999). Functional studies with SERT antagonists reveal a biphasic impact on colonic motility that is consistent with hyperactivation of 5HT receptors followed by their desensitization at higher concentrations of extracellular 5-HT (Wade et al., 1996). SERT is also found in the crypt epithelium, where it may limit effects on fluid secretion triggered by enterochromaffin cell-derived 5-HT. In the SERT knockouts, colonic motility, and stool water were altered, along with the increase in motility (diarrhea)...

Pharmacology and adverse effects including suicide

Side effects associated with use of these medications are related to enhanced serotonergic transmission. Frequently encountered side effects include nausea, vomiting, tremor, anxiety, agitation, sweating, sleep disturbance, diarrhea, and sexual dysfunction. Paroxetine has affinity for muscarinic receptors which account for mild anticholinergic effects, predominantly dry mouth, constipation, and blurred vision. Long-term use of paroxetine has been associated with weight gain.108

Preparations And Dosage

TOXIC REACTIONS AND ADVERSE EFFECTS Antipsychotic drugs have a high therapeutic index and are generally safe agents. Most phenothiazines, haloperidol, clozapine, and queti-apine can be used over a wide range of dosages (Table 18-3). Although occasional deaths from overdoses have been reported, fatalities are rare in patients given medical care unless the overdose is complicated by concurrent ingestion of alcohol or other drugs. Adverse effects often are extensions of the many pharmacological actions of these drugs. The most important are those on the cardiovascular, central and autonomic nervous systems, and endocrine system. Other dangerous effects are seizures, agranulocytosis, cardiac toxicity, and pigmentary degeneration of the retina, all of which are rare (see below). Therapeutic doses of phenothiazines may cause faintness, palpitations, and anticholinergic effects including nasal stuffiness, dry mouth, blurred vision, constipation, worsening of glaucoma, and urinary retention...

Gastrointestinal Tract

Large Intestine Propulsive peristaltic waves in the colon are diminished or abolished after administration of morphine, and tone is increased to the point of spasm. The resulting delay in the passage of bowel contents causes considerable desiccation of the feces, which, in turn, retards their advance through the colon. The amplitude of the nonpropulsive type of rhythmic contractions of the colon usually is enhanced. The tone of the anal sphincter is augmented, and reflex relaxation in response to rectal distension is reduced. These actions, combined with inattention to the normal sensory stimuli for defecation reflex owing to the central actions of the drug, contribute to morphine-induced constipation.

Pharmacological Actions

Although slightly less selective than morphine, propoxyphene binds primarily to j opioid receptors and produces analgesia and other CNS effects that are similar to those seen with morphinelike opioids. It is likely that at equianalgesic doses the incidence of side effects such as nausea, anorexia, constipation, abdominal pain, and drowsiness are similar to those of codeine.

Ketogenic Diet In Adults

In 1930 Barborka reported the effects of the KD in 100 adult patients (13). Antiepilep-tic drugs were not prescribed, but the results presage modern findings 12 of patients became seizure free, 44 improved, and 44 had no improvement after one year. Patients who improved reported increased alertness. The most common side effects were constipation and cessation of menses. Despite the findings in this report, the diet remained an oddity and was considered to be unsuitable for adults. The subsequent development of effective AEDs, beginning with phenytoin in the late 1930s, undoubtedly dampened interest in unconventional approaches that were difficult to implement. Both partial and generalized seizures responded favorably. All patients noted constipation and bloating, and women reported menstrual irregularities. Cognitive improvement was observed, similar to what has been reported in children. Seven patients noted improved cognition and mood, whereas 2 patients reported worsened...

MMethylDAspartate Antagonists

The side effects associated with the NMDA antagonists include sedation, dry mouth, headache, and constipation in some cases these effects may be prohibitively severe, limiting usefulness (e.g., ketamine may produce dissociation, hallucinations, frightening nightmares, and delirium) (Eide et al. 1994). Ketamine at a dosage of 50-60 mg four to six times daily (taken in juice or oral suspension) may produce pain relief without incurring these serious effects. Ketamine's hallucinogenic properties have rendered it popular with drug abusers (Dillon et al. 2003). Long-term use of ketamine is not currently advocated, partly because the long-term effects are unknown. It may result in long-term cognitive changes, hepatic dysfunction, and gastric ulcers.

Adverse Effects During Maintenance Of The Ketogenic Diet

2-4 ), gastrointestinal symptoms (vomiting, constipation, diarrhea, abdominal pain) (12-50 ) irritability, lethargy (4-9 ), and refusal to eat (2,7-12). Carnitine deficiency has also been demonstrated in some children on the KD (13-15). Hypercholesterolemia has been reported in 29-59 of children on the KD (10-12). Theda et al. (16) found an elevation of very-long-chain fatty acids in 13 of 22 plasma samples from KD patients.

Histamine H2Receptor Antagonists

The choice was between nonselective anticholinergic drugs such as probanthine, with their associated side effects of dry mouth and blurred vision, or antacids, which, to be effective, had to be taken frequently and in large quantities. The latter often led to low patient compliance, and gastrointestinal side effects such as diarrhea or constipation were not uncommon.

Adverse Effects And Drug Interactions

Patients taking cholestyramine and colestipol complain of bloating and dyspepsia, which can be substantially reduced if the drug is completely suspended in liquid several hours before ingestion. Constipation may occur but sometimes can be prevented by adequate daily water intake and psyllium, if necessary. Colesevelam may be less likely to cause the dyspepsia, bloating, and constipation observed in patients treated with cholestyramine or colestipol.

Presacral neurectomy and laparoscopic uterine nerve ablation

Presacral neurectomy (PSN) and laparoscopic uterine nerve ablation (LUNA) are both surgical procedures that involve the disruption of sensory nerve afferents that carry pain stimuli from the pelvis. In LUNA, the uterosacral ligaments are transsected close to their insertion at the cervix, thus interrupting part of the Lee-Frankenhauser nerve plexus. In PSN, the presacral nerve plexus is isolated and cut proximally and distally. Complications associated with LUNA are rare there have been isolated cases of uterine prolapse and bladder dysfunction. PSN has been associated with more serious complications such as hematoma formation, major vessel injury, constipation and bladder dysfunction, though these are rare in experienced hands. A number of studies have suggested benefit from LUNA and PSN for primary and secondary dysmenorrhea, including randomized trials 43, 44 . However, a large multicenter study examining the effectiveness of LUNA in pelvic pain (n 487) has recently finished, with...

Mechanism of Action

Adverse effects of TCAs are due to their actions as agonists at aj-adrenergic (orthostatic hypotension), H histaminic (sedation, weight gain), and anticholin-ergic receptors (dry mouth, urinary retention, constipation, blurred vision, memory problems). All of the TCAs have clinically significant anticholinergic effects, although the two with the least among them are desipramine and nortriptyline. Nortriptyline has the lowest a adrenergic antagonism, with desipramine having somewhat more, but still less than the tertiary amines. Amitritpyline, doxepin, and trimipramine have the strongest histaminergic (H antagonism among the group.

Tricyclic antidepressants

Tricyclic antidepressants (TCAs, e.g. amitriptyline, desi-pramine, nortriptyline) are effective in the treatment of PHN.49 I These compounds inhibit reuptake of mono-aminergic transmitters and are believed to potentiate the effects of biogenic amines in descending central nervous system pain modulating pathways. In addition, they block voltage-dependent sodium channels and alpha adrenergic receptors. TCAs, of which amitriptyline is the most widely prescribed, have significant side effects limiting their use, especially in the elderly and those with comorbidities. They can produce orthostatic hypotension, sedation, urinary retention, memory loss, dry mouth, constipation, and cardiac conduction abnormalities. Higher doses of tricyclic antidepressants may even be associated with the risk of sudden cardiac death.54 It is considered that the relatively selective noradrenaline reuptake inhibitors, such as desipramine and nortriptyline, cause less anticholinergic side effects as compared to...

Human carcinogenicity data

Herbs containing anthraquinone derivatives are used as laxatives and several studies have reported data relating indices of use of such laxatives to cancer outcomes. In an early British study, patients with gastrointestinal cancer reported higher past chronic use of senna than did patients with other diseases. Three German case-control studies on colorectal cancer using melanosis coli as an exposure indicator gave conflicting results. An Australian case-control study on colorectal cancer which assessed self-reported use of anthraquinone laxatives as an index of exposure found no excess risk. A study of uro-thelial cancer in Germany found elevated relative risks in relation to several types of laxative, including those containing anthraquinones. For all of these case-control studies, it is difficult to exclude bias and confounding from dietary habits, constipation or use of analgesics. Except for two studies (the Australian colorectal cancer and the German urothelial cancer studies),...

Nonopioid Analgesic Agents

Another relatively recent addition to pain therapy armamentarium is tramadol (Ultram(R) Ortho-McNeil-Janssen, Titusville, NJ), a centrally acting, synthetic, non-narcotic analgesic that has been available in the United States since 1995. Its two mechanisms of action are (1) low-affinity binding to mu opioid receptors and (2) weak inhibition of norepinephrine and serotonin reuptake. Tramadol is, therefore, a weak opioid agonist and mimics some of the properties of tricyclic antidepressants (TCAs). A recent double-blind, randomized, placebo-controlled trail in patients with painful diabetic neuropathy found that those receiving an average dose of 210 mg day of tramadol had significant pain relief with better physical and social functioning compared with patients receiving placebo (Finnerup et al. 2005). Most frequently occurring side effects were headache, constipation, nausea, and somnolence.

Rationale For The Use Of Transdermal Systems

While the oral route (tablet, liquid) is commonly used and the preferred mode of application for patients who can take oral medication, the continuous subcutaneous (s.c.), epidural, intramuscular (i.m.) or intravenous (i.v.) mode of administration provide a faster onset, however, with a shorter duration of action. Therefore patients requiring continuous opioid analgesia and who do not experience intolerable side effects from parenteral dosing, the oral route of opioid administration is the most effective. If, however, nursing support is not possible, it may result in an inconsistent level of analgesia when the infusion rate is not controlled appropriately, or when weekly change of the infusion pump is not done in time. Contrary, the intramuscular mode of administration results in a slow absorption resulting in less variable plasma levels than the subcutaneous route, resulting in a long duration of action. However, patients who cannot take oral medication (e.g. emesis or GI...

Side Effects And Toxicology

Constipation, and drowsiness symptoms usually considered as side effects have been observed in more than 50 of untreated inpatients with major depression if these symptoms were each directly assessed (Nelson et al. 1984). During treatment, patients may be quick to label these somatic symptoms as side effects even if the symptoms were preexisting. Another manifestation of this issue is the rate of spontaneously reported side effects on placebo in clinical trials. One of the best examples is headache. Clinical trial data for recently marketed antidepressants indicate that the rate of headaches on placebo in depressed outpatients ranges from 17 to 24 (Physicians' Desk Reference 2002). For fluoxetine, sertraline, paroxetine, and bupropion, the rate for drug was only 1 -2 higher than that for placebo. For venlafaxine XR and citalopram, the rate of headaches was higher for placebo than for drug. A strong argument can be made that headache is usually a symptom of depression. Of course, these...

First Line Medications

Tricyclic antidepressants (TCAs) have strong research support for use, Forty percent to 60 of patients report pain relief. They are especially useful for patients with PDN and PHN and those who have an element of depression in their overall presentation. These drugs are not benign and careful monitoring is needed. A baseline electrocardiography is recommended for patients older than 40 years to evaluate for the presence of conduction abnormalities. Adverse side effects include cardiotoxicity, confusion, urinary retention, or-thostatic hypotension, weight gain, dry mouth, and constipation. Patients who have a history of cardiac ischemia, heart failure, conduction disorders, or arrhythmias should not use TCAs. They are also not recommended for older patients related to the potential for orthostatic hypotension.

Irritable bowel syndrome

At least three different clinical presentations are given the diagnosis of IBS, two of which have no pain or pain as a minor component (watery diarrhea group and alternating constipation-diarrhea group respectively). The third subgroup has abdominal pain as their primary symptom and altered bowel movements as a secondary or exacerbating complaint. In this group, pain is typically in the left lower quadrant or in the suprapubic region and may be precipitated by food ingestion and a need to defecate. Bloating, mucus in the stools, and flatulence are

Box 406 Diagnostic criteria for irritable bowel syndrome

As in any chronic pain disorder, an important (but not particularly testable) component to the management of IBS is a stable, trusting patient-physician relationship. Life-threatening pathology may be simply ruled out without an exhaustive investigation and the patient needs to be assured that their symptoms are believed. Therapeutic options for IBS are listed in Box 40.7. As part of a diagnostic therapeutic trial, patients are generally advised to engage in dietary modifications such as avoiding milk products, avoiding excessive legume consumption (associated with gas production), increasing fiber and bran in those with constipation,86, 93 avoiding caffeine- or sorbitol-containing foods, and establishing a stable dietary pattern in the hope of establishing a stable evacuation routine. Anticholinergics antidiarrheals have been extensively employed clinically and extensively studied. Reviews of the efficacy of these agents have concluded that their benefit is unproven.93 Traditional...

Structureactivity Relations

Unlike the older TCAs, sertraline has little appreciable antagonistic effect on histamine , (H1), muscarinic, or dopamine2 (D2) receptors and thus is associated with few difficulties with severe constipation, drowsiness, and dry mouth (Hiemke and Hartter 2000 Richelson 1994). The antagonism of ai-adrenoreceptors by sertraline is at least 10-fold more than that of other SSRIs (Hiemke and Hartter 2000), although this antagonism does not translate into clinically meaningful hypotension or reflex tachycardia. However, there is a report suggesting that sertraline decreases sympathetic nervous system activity, a property consistent with a receptor blockade (Shores et al. 2001). It is also possible that the decrease in sympathetic response is related to stimulation of the 5-HT1A receptors noted above. Given that sertraline and other medications in its class exhibit anxiolytic effects, it is possible that the decrease in sympathetic activity is related to these effects.

Generalized Anxiety Disorder

Head-to-head comparisons between paroxetine and other medications in the treatment of GAD are sparse. One such study compared paroxetine 20-50 mg day with escitalopram 10-20 mg day (Bielski et al. 2005). Although there was no significant difference in efficacy between the two medications, as measured by the Ham-A, the authors noted considerably higher rates of adverse events, leading to withdrawal from the trial, in patients treated with paroxetine compared with those treated with escitalopram (22.6 vs. 6.6 ). Treatment-emergent side effects recorded more frequently with paroxetine therapy included insomnia, constipation, ejaculation disorder, anorgasmia, and decreased libido. Conversely, diarrhea and upper respiratory tract infection were more common with escitalopram than with paroxetine. One possible explanation for the divergence in dropout rates may be the seeming disparity in dose ranges between the two medications. Paroxetine was titrated to high-normal doses (between 30 and 50...

Fistulating Crohns disease Treatment may not be

Adjunctive treatment of inflammatory bowel disease Due attention should be paid to diet high-fibre or low-residue diets should be used as appropriate. Antimotility drugs such as codeine and loperamide, and antispasmodic drugs may precipitate paralytic ileus and megacolon in active ulcerative colitis treatment of the inflammation is more logical. Laxatives may be required in proctitis. Diarrhoea resulting from the loss of bile-salt absorption (e.g. in terminal ileal disease or bowel resection) may improve with colestyramine (section 1.9.2), which binds bile salts. Irritable bowel syndrome can present with pain, constipation, or diarrhoea. In some patients there may be important psychological aggravating factors which respond to reassurance and possibly specific treatment e.g. with an antidepressant. The fibre intake of patients with irritable bowel syndrome should be reviewed. If an increase in dietary fibre is required, soluble fibre (e.g. ispaghula husk, sterculia, or oats) is...

Irritable bowel syndrome functional bowel disorders

The diagnosis of IBS requires the positive findings of disturbed bowel habits and a history of pain discomfort coupled with negative findings for neoplas-tic, infectious or inflammatory causes. It is defined by the Rome criteria, now in their third form 26 , as 3 months of continuous or recurrent symptoms of abdominal pain or discomfort associated with two of the following an improvement with defecation and or a change in stool consistency (appearance) and or a change in stool frequency. At least three different clinical presentations are given the diagnosis of IBS, two of which have pain discomfort as a minor component (watery diarrhea group and alternating constipation diarrhea group respectively). There is a third subgroup of IBS patients who have abdominal pain as their primary symptom and altered bowel movements as a secondary or exacerbating complaint. In this group, pain is typically in the left lower quadrant or in the suprapubic region and may be precipitated by food...

Senna alexandrina Mill

Senna leaf is one of the primary botanical laxatives used worldwide. It is rich in anthroquinone glycosides, which are compounds hydrolyzed in the intestines that subsequently stimulate intestinal peristalsis. Numerous species of senna can be used interchangeably and various works of botanical microscopy provide a differentiation between the species.

Antacids and simeticone

Hepatic impairment In patients with fluid retention, avoid antacids containing large amounts of sodium. Avoid antacids that cause constipation because this can precipitate coma. Avoid antacids containing magnesium salts in hepatic coma if there is a risk of renal failure.

Centrally Acting Adrenergic Drugs

Clonidine hydrochloride has advantages over antihyper-tensive drugs such as guanethidine monosulfate and pra-zosin hydrochloride, in that it seldom produces orthostatic hypotensive side effects. It does, however, have some sedative properties that are undesirable it also may cause constipation and dryness of the mouth.

Perspectives For Pharmacogenetic Research Into Eating Disorders And Obesity

Sibutramine is a selective inhibitor of the presynaptical reuptake of serotonin and norepinephrine, leading to enhanced central serotonin and norepinephrine neurotransmission which is associated with decreased sensations of hunger and increased feeling of satiety besides, sibutramine leads to a slightly enhanced basal metabolic rate (Hansen et al., 1999). Sibutramine has the following side effects xerostomia, insomnia, obstipation and a mild increase of blood pressure and heart rate.

Frangula purshiana Dc J G cooper syn Rhamnus purshiana Dc

Lacing Patterns Printable Cardspnhg

Cascara sagrada is one of the most widely used botanical laxatives in North America. Formerly named Rhamnus, cascara contains anthraquinone glycosides and is closely related to other anthraquinone-containing botanicals such as frangula (aka buckthorn F. alnus). The various species of Frangula may get confused in trade and can be distinguished histologically. F. alnus lacks sclereids and the medullary rays do not converge at the outer end, whereas F. purshiana does contain sclereids with medullary rays converging at the outer end (Youngken 1930).

Pre Ketogenic Diet Session

The rigors of ketogenic diet management should be discussed during the pre-keto-genic diet session. The process of food preparation and food weighing should be explained. The caregiver should be provided with the information for purchasing a scale that weighs in tenths of a gram (0.1 g). A description of the typical meals and beverages, and the requirement for the omission of carbohydrate-rich foods, should be clearly communicated. The caregiver should be informed about the appropriate foods and nutritional supplements that must accompany the diet. The follow-up appointments required to monitor the diet safely should be reviewed. The caregiver should understand the possible adverse effects of the diet, including constipation, kidney stones, and difficulty with compliance (particularly with older children). The expected length of keto-genic diet therapy should also be reviewed in this session.

Inborn Errors of Metabolism in Which the KD Is Contraindicated

Porphyrias are a related group of diseases caused by inherited blocks in heme biosynthesis. Acute intermittent porphyria results from deficiency of porphobilinogen (PBG) deaminase. It is an autosomal dominant disorder, and the gene is located on chromosome 11 (78). There is great variability in the phenotypic expression, and 90 of affected individuals never have clinical symptoms. Attacks are triggered by hormonal changes and exposure to certain drugs, particularly barbiturates (79). Clinical symptoms are often gastrointestinal (severe abdominal pain, vomiting, constipation, or diarrhea), but neurological symptoms (pain, muscle weakness, hyporeflexia secondary to neuropathy, altered mental status and seizures) are also common (80,81). Diagnosis is made by increased amounts of aminolevulinic acid and PBG during attacks or measurement of PBG deaminase activity in erythrocytes. Carbohydrates reduce porphyrin synthesis and are therefore used at high doses (300-500 g d) intravenously...

Clinical use of 5HT3 antagonists

Use of a 5HT3 antagonist in the treatment of neuropathic pain may be reserved for management of a flare-up in view of the considerable cost if more long-term therapy were instituted and the risk of severe constipation. Ondansetron 8 mg intravenously or orally (either as a tablet or the lyophilisate) can be used, repeated up to three times a day.

Chronic Arsenic Poisoning

The most common early signs of chronic arsenic poisoning are muscle weakness and aching, skin pigmentation (especially of the neck, eyelids, nipples, and axillae), hyperkeratosis, and edema. GI involvement is less prominent in long-term exposures. Other signs and symptoms that should arouse suspicion of arsenic poisoning include garlic odor of the breath and perspiration, excessive salivation and sweating, stomatitis, generalized itching, sore throat, coryza, lacrimation, numbness, burning or tingling of the extremities, dermatitis, vitiligo, and alopecia. Poisoning may begin insidiously with symptoms of weakness, languor, anorexia, occasional nausea and vomiting, and diarrhea or constipation. Subsequent symptoms may simulate acute coryza. Dermatitis and keratosis of the palms and soles are common features. Mee's lines are found characteristically in the fingernails (white transverse lines of deposited arsenic that usually appear 6 weeks after exposure). Desquamation and scaling of...

Anticholinergic Effects

The tricyclics block muscarinic receptors and can cause a variety of anticholinergic side effects, such as dry mouth, constipation, blurred vision, and urinary hesitancy. These effects can precipitate an ocular crisis in patients with narrow-angle glaucoma. The tricyclic and tetracyclic compounds vary substantially in their muscarinic potency (see Table 12-1). Amitriptyline is the most potent, followed by clomipramine. Of the tricyclics, desipramine is the least anticholinergic. Amoxapine and maprotiline also have minimal anticholinergic effects. Anticholinergic effects can contribute to tachycardia, but tachycardia also occurs as a result of stimulation of -adrenergic receptors in the heart. Thus, tachycardia regularly occurs in patients receiving desipramine, which is minimally anticholinergic (Rosenstein and Nelson 1991). become severe. An ocular crisis in patients with narrow-angle glaucoma is an acute condition associated with severe pain. Urinary retention can be associated with...

Selective Delta Opioid Receptor Agonists And Their Antinociceptive Actions

Currently, most narcotic analgesics used clinically act through mu opioid receptors, but their use is limited by side effects, such as vomiting, respiratory depression, constipation, and dependence 25 . In contrast, delta opioid receptor agonists can produce antinociception with mild incidence of several somatic signs of withdrawal, indicating that delta opioid receptors remain potentially important therapeutic targets for the development of novel analgesic agents 26 .

Potency And Efficacy Of Antipsychotic Drugs

While all antipsychotics are affective against the florid symptoms of psychosis, they differ in the dosages required to achieve their palliative effects. Therefore, one of the oldest classification schemes for antipsychotic drugs is based on their potency. The potency of antipsychotic drugs has been traditionally expressed in equivalency units as compared to 100 mg of chlorpromazine, the prototypic antipsychotic drug.2 The drugs are usually divided into high, medium, and low potency groups. The high potency drugs have chlorpromazine equivalencies in the range of 1 to 5 mg, with their daily doses ranging from 1 to 30 mg (Table 1). This group of antipsychotics is represented by such drugs as fluphenazine, thiothixene, haloperidol, and pimozide. The medium potency group includes perphenazine, molindone, and loxapine. These drugs have chlorpromazine equivalencies in the range of 10 to 25 mg and are used at daily doses of 10 to 150 mg. The chlorpromazine equivalencies for the low potency...

Calciumchannel blockers

Verapamil is used for the treatment of angina (section 2.10.1), hypertension (section 2.5), and arrhythmias (section 2.3.2). It is a highly negatively inotropic calcium channel-blocker and it reduces cardiac output, slows the heart rate, and may impair atrioventricular conduction. It may precipitate heart failure, exacerbate conduction disorders, and cause hypotension at high doses and should not be used with beta-blockers (see p. 133). Constipation is the most common side-effect.

Therapeutic Uses of Selective Muscarinic Receptor Antagonism A Nonselective Muscarinic Antagonists

Classic muscarinic receptor antagonists, such as atropine, do not distinguish between muscarinic receptor subtypes (3). Their therapeutic utility is limited by the occurrence of side effects including mydriasis, xerostomia, CNS disturbances, tachycardia, and constipation. In certain circumstances, however, the nonselective nature of these antagonists may be desirable. For example, atropine and hyoscine are used as premedication for surgical procedures in which blockade of salivary secretion, smooth muscle contraction, along with some degree of cardioprotection, is desirable. However, the nonselective nature of these compounds limits their therapeutic efficacy in chronic treatment of diseases. A summary of several muscarinic antagonists, either in development or commercially launched, is shown in Tables 4 and 5.

Chemical Complexation

Sulcrafate Mechanis

The simultaneous administration of sucralfate may reduce the bioavailability of certain agents (e.g., tetracycline, phenyt-oin, digoxin, or cimetidine).78 It further recommends restoration of bioavailability by separating administration of these agents from that of sucralfate by 2 hours. Presumably, sucralfate binds these agents in the GI tract.78 The most frequently reported adverse reaction to sucralfate is constipation (2.2 ). Antacids may be prescribed as needed but should not be taken within 0.5 hour before or after sucralfate.

Bile acid sequestrants

Side-effects As bile acid sequestrants are not absorbed, gastro-intestinal side-effects predominate. Constipation is common, but diarrhoea has occurred, as have nausea, vomiting, and gastro-intestinal discomfort. Hypertriglyceridaemia may be aggravated. An increased bleeding tendency has been reported due to hypoprothrombinaemia associated with vitamin K deficiency.

Classifying Antiarrhythmic Drugs

Verapamil (calan, isoptin, verelan, covera-hs) is prescribed as a racemate. l-Verapamil is a more potent calcium channel blocker than is d-verapamil. However, with oral therapy, the l-enantiomer undergoes more extensive first-pass hepatic metabolism. For this reason, a given concentration of verapamil prolongs the PR interval to a greater extent when administered intravenously (where concentrations of the l- and d-enantiomers are equivalent) than when administered orally. Diltiazem (cardizem, tiazac, dilacor xr, and others) also undergoes extensive first-pass hepatic metabolism, and both drugs have metabolites that exert Ca2+ channel-blocking actions. Adverse effects during therapy with verapamil or diltiazem are determined largely by underlying heart disease and concomitant therapy plasma concentrations of these agents are not measured routinely. Both drugs can increase serum digoxin concentration, although the magnitude of this effect is variable excess slowing of ventricular...

Common Adverse Effects

Produced by a genetically modified Saccharomyces cerevisiae strain, the therapeutic efficacy may be hampered by the production of antibodies against the drug. Hemolysis in glucose-6-phosphate dehydrogenase (G6PD)-deficient patients, methemoglobinemia, acute renal failure, and anaphylaxis all have been associated with the use of rasburicase. Other frequently observed adverse reactions include vomiting, fever, nausea, headache, abdominal pain, constipation, diarrhea, and mucositis. Rasburicase causes enzymatic degradation of the uric acid in blood samples, and special handling is required to prevent spuriously low values for plasma uric acid in patients receiving the drug. The recommended dose of rasburicase is 0.15 mg kg or 0.2 mg kg as a single daily dose for 5 days, with chemotherapy initiated 4-24 hours after infusion of the first rasburic-ase dose.

Bowel colic and excessive respiratory secretions

Constipation Constipation is a very common cause of distress and is almost invariable after administration of an opioid analgesic. It should be prevented if possible by the regular administration of laxatives a faecal softener with a peristaltic stimulant (e.g. co-danthramer) or lactulose solution with a senna preparation should be used (section 1.6.2 and section 1.6.3). Methylnaltrexone (section 1.6.6) is licensed for the treatment of opioid-induced constipation.

Gastrointestinal Effects

Opioids act on the gastrointestinal system to decrease gastric, duodenal, and large intestinal motility which can lead to delayed gastric emptying and induce an ileus (Murray 1984). The secretion of pancreatic, biliary, intestinal, and gastric secretions can be delayed, causing a stoppage in food digestion. With opioid administration, patients can develop a constriction of the sphincter of Oddi and an increased common bile duct pressure (Gustein and Akil 2001). Constipation is an extremely common problem with the use of opioids.

Adverse events

Another example of common adverse events would be constipation, something we worry about a lot when prescribing opioids. Constipation occurs in about 15 of people with chronic pain using weak opioids 14 . The overall average percentage of people with constipation in a systematic review of constipation prevalence in the US was about 15 (1 in 7 adults 15 ). The range was 1.9-27 , depending to some extent on how constipation was ascertained. Most reports were in the range of 12-19 , with some self-reported prevalence being higher and two face-to-face questioning reports below 4 . There was a distinctly higher prevalence in women compared with men in almost every study, irrespective of method of ascertainment. Prevalence of constipation in women was on average about twice as high as in men. There was also a consistent finding of higher constipation prevalence in non-Caucasian people, by a factor of about 1.4 to 1, though nonwhite racial groups were not subdivided. Other trends were for...


Although questions relating to the quality of studies and their relevance for clinical practice and economic evaluation remain.71 For example, an epidemiological survey of over 10,000 individuals concluded that opioid treatment of long-term chronic noncancer pain does not seem to fulfil any of the key outcome opioid treatment goals pain relief, improved quality of life, and improved functional capacity.''44 The propensity to bolt on economic evaluations to clinical studies and to model the economic impact of interventions following on from randomized controlled trials, without taking into consideration some of the broader issues and factors from the complex environment that impinge on the overall impact of treatments and therapies, has been very noticeable in the last few years, as the focus has switched more to the assessment and appraisal of healthcare technologies. As a result, it may be more appropriate to rename cost-effectiveness studies as cost-efficacy studies and, while...


Antacids are substances that exhibit cytoprotective effects toward attacks against the gastric mucosa. They are thought not only to protect but also to restore and heal ulcerations through actions, which have been and still are under research scrutiny. The antacids are used either alone or in synergistic mixtures with other compounds. The combination formulations in the various antacids target wider goals through their neutralizing activity and reduction in potential side effects arising from single components. To this end, antacids primarily contain aluminum either alone or in combination with calcium or magnesium. The first formulation (Al-Ca) is set to combat diarrhea, whereas the second formulation (Al-Mg) reduces constipation. Below is a comprehensive account of aluminum-containing antacids, their use and potential mode of action as the latter emerges from ongoing research studies.10

Fecal COX2 Assay

A total of 27 control patients, in whom no neoplastic lesions were colo-noscopically detected, were also included in this study. These patients reported lower abdominal pain, anemia, or constipation, or were screened for CRC. Thus, the control patients in this study were not from a population with average risk. Stool samples were collected and fecal RNA was extracted as previously described 141 .

Calculating Fluid

Adequate fluid intake is necessary to maintain normal hydration during ketogenic diet therapy. Insufficient fluids can increase the risk for kidney stones and constipation. The ketogenic diet restricts fluids to noncaloric, caffeine-free beverages such as water, decaffeinated weak tea, and noncaloric caffeine-free soda. Fluid should be calculated for the maintenance needs of the individual. The Holiday-Segar Method is a fluid calculation that is based on weight alone (6) (Table 11). This formula does not account for abnormal fluid losses, for example, from excessive drooling or febrile illness. For example, a child weighing 23 kg needs 1000 mL (for first 10 kg) plus 500 (10 kg x 50 mL kg) plus 60 mL (3 kg x 20 mL kg) for a total of 1560 mL daily. This can be divided into six servings of 250 mL as a simple daily guide for the caregiver to manage. The child should not be allowed to drink large volumes of fluid at one time because this may upset internal fluid balance and ketosis. The...


Buprenorphine can be used safely without dose adjustment in patients with renal impairment, including those on hemodialysis,50, 51 and is associated with less sedation, constipation, or pruritis compared with full opioid agonists.25 The incidence of respiratory depression is also significantly less with buprenorphine due to partial agonist ceiling effects (which occurs at a lower dose than analgesia ceiling effects), although reversal with naloxone may be more difficult.52


Opioid-induced adverse effects include nausea and vomiting, constipation, sedation, pruritus, urinary retention, and respiratory depression. There is no good evidence that the incidence is different with different opioids at the same level of analgesia. There is good evidence that the risk of adverse events is increased when high-tech approaches are used for drug administration.9

Clinical Summary

Constipation is exceedingly common with opioids, and stool softeners and laxatives should be initiated early. Amphetamines have demonstrable mood-elevating and analgesic effects and enhance opioid-induced analgesia. However, not all terminal patients require the euphoriant effects of amphetamine, and some experience side effects, such as anorexia. Although tolerance does develop to oral opioids, many patients obtain relief from the same dosage for weeks or months. In cases where one opioid loses effectiveness, switching to another may improve pain relief. Cross-tolerance among opioids exists, but cross-tolerance among related -receptor agonists is not complete.

Faecal softeners

Liquid paraffin, the traditional lubricant, has disadvantages (see below). Bulk laxatives (section 1.6.1) and non-ionic surfactant 'wetting' agents e.g. docusate sodium (section 1.6.2) also have softening properties. Such drugs are useful for oral administration in the management of haemorrhoids and anal fissure glycerol (section 1.6.2) is useful for rectal use.


The two established bile-acid sequestrants or resins (cholestyramine and colestipol) are most often used as second agents if statin therapy does not lower LDL-C levels sufficiently. When used with a statin, cholestyramine and colestipol usually are prescribed at submaximal doses. Maximal doses can reduce LDL-C by up to 25 but are associated with unacceptable gastrointestinal (GI) side effects (bloating and constipation) that limit compliance. Colesevelam is a newer bile-acid sequestrant that is prepared as an anhydrous gel and taken as a tablet. It lowers LDL-C by 18 at its maximum dose. The safety and efficacy of colesevelam have not been studied in children or pregnant women.

Toxic effects

Chronic ingestion of laxatives of the anthracene group such as cascara, senna, frangula, aloe or rhubarb is considered to be an etiological factor in melanosis coli, a condition in which colonic macrophages accumulate a dark pigment with the staining characteristics of lipofuscin. In 14 patients submitted to repeated proctoscopies, Speare (1951) produced melanosis 11 times by prescribing cascara sagrada for 4-14 months and eliminated it nine times by withdrawing the laxative for 5-11 months. Steer and Colin-Jones (1975) studied histological patterns of rectal biopsies from seven patients with melanosis coli three months after they ceased to take anthraquinone-containing purgatives. A decrease was observed in the number of macrophages infiltrating the mucosa, as well as a reduction in the intensity of the acid phosphatase reaction. The effect of anthraquinone glycosides on cell proliferation in the sigmoid colon of patients in vivo has been studied. Twenty-four hours before colonoscopy...

Oral medications

The a2 receptor agonists,28 most notably tizanidine and clonidine, can be useful. Their antispasticity activity may be related to the presynaptic inhibition of normal catecholamine release.29'30 These medications may be used in combination with baclofen. Clonidine can be used in doses up to 500 mg day. It does have some a1 activity and may cause an increase in spasms at high doses. Side effects include hypotension, drowsiness, sedation, and constipation. Once again these medications are more useful in spinal than cerebral origin spasticity.21,31 II Tizanidine is not available in Australia and is reported to have a lower side-effect profile than clonidine.


The general pharmacological action of codeine is similar to that of morphine, but it does not possess the same analgesic potency. The equianalgesic dose of parenteral morphine 3 to 5 mg q 4 hours is codeine 30 to 65 mg q 4 hours. The equianalgesic dose of oral morphine 10 mg q 4 hours is codeine 60 mg q 4 hours. The decreased potency also leads to a lower addiction potential compared with morphine. Side effects include respiratory depression, mioisis, constipation, nausea, itching, dry mouth, and drowsiness. Approximately 5 of codeine is metabolized to morphine via O-demethylation. (Fig. 24.8) The enzyme responsible for the O-demethylation of codeine is cy-tochrome P450 (CYP) 2D6. This enzyme exhibits genetic polymorphism with an estimated 7 to 10 of Caucasians designated as poor metabolizers, and thus only able to form traces of morphine after codeine is administered.60 The analgesic component of codeine has long been assumed to


Opioid analgesics have much merit in the short-term management of fractures but are better at reducing the background pain that accompanies a fracture rather than the acute pain associated with movement. Given their propensity to induce constipation, prophylactic measures to prevent this eventuality are advisable. Those analgesics that contain codeine are not universally effective as a proportion of the population lack the cytochrome P450 enzyme necessary to convert codeine to morphine and hence to activate it. The same difficulty does not occur with dihydrocodeine or tramadol.


(IAP) which is associated with colicky abdominal pain that is intermittent, may be associated with environmental exposures, and which can last for days to months. Since it is transmitted as an autosomal dominant disorder with incomplete penetrance, family history may or may not be helpful in the diagnosis. Certain drugs such as barbiturates, benzodiazepines, alcohol, phenytoin, ketamine, etomidate, mep-robamate, and corticosteroids have been implicated as triggers of a crisis, so are generally avoided. Other gastrointestinal signs and symptoms such as vomiting, constipation, and abdominal distension are common and may complicate the initial diagnosis. Neural demyelination can occur, resulting in various neurologic and psychiatric symptoms. The urine and blood tests which are useful for the diagnosis of porphyria may only be valid during crises, though increased urinary porphobilinogen secretion confirms the diagnosis. Genetic testing of asymptomatic members in IAP families is now...


Despite intensive efforts in the realm of antiepileptic drug research and development, seizures cannot be fully controlled in many patients with epilepsy (7). Moreover, many antiepileptic drugs may produce adverse effects that include somnolence, nervousness, ataxia, diplopia, constipation, confusion, memory difficulties, weight loss, and skeletal defects (7-10). Clearly, new antiepileptic therapies are needed that can manage seizures without reducing quality of life.

Treatment Strategies

The pharmacologic approaches discussed in Chapter 5 of this book are applicable to the geriatric patient with chronic pain. Opiates might be indicated in acute pain, in chronic malignant pain, and in cases of chronic nonmalignant pain. The elderly can be particularly sensitive to the adverse effects of analgesic agents (e.g., sedation, confusion, constipation associated with opiates, gastrointestinal effects associated with nonsteroidal anti-inflammatory drugs NSAIDs ) (American Geriatrics Society 1998). In some cases, particularly in patients with neuropathic pain and those with psychological factors contributing significantly to pain, a variety of psychotropic medications are available (Leo and

Therapeutic Uses

131I has a t1 2of 8 days and emits both y rays and 3 particles. Radioactive ablation with 131I is used for the treatment of hyperthyroidism and for adjuvant therapy of differentiated thyroid cancer. The only absolute contraindication to the use of 131I therapy is pregnancy, as the fetal thyroid after the first trimester can concentrate the isotope and thus will be damaged. There is no evidence for increased total cancer mortality or increased incidence of leukemia in treated patients. One study found an increased incidence of colorectal cancer following 131I therapy, leading to the recommendation that laxatives be given prophylactically to all patients receiving 131I. The short-lived 123I is primarily a y-emitter that is used for diagnostic purposes in thyroid uptake and scans.

Opioid Analgesics

Opioid analgesics stimulate the endogenous opioid receptors. They can be administered orally, subcutaneously, intravenously, neuro-axially, transdermally, rectally, or through the oral mucosa. However, opioids can cause significant sedation, confusion, respiratory depression, urinary retention, constipation, nausea, and vomiting. Opioids should be used with caution and their dose should be reduced in the elderly, especially those patients with significant co-morbidities. Patients with history of chronic obstructive pulmonary disease, asthma, emphysema, central or obstructive sleep apnea, obesity, renal failure, and hepatic failure are especially prone to the side effects of opioids.

Lidocaine Metabolism

Lidocaine Metabolism

Disopyramide phosphate, phosphate (Norpace), is an oral and intravenous class IA antiarrhythmic agent. It is quite similar to quinidine and procainamide in its electrophysiological properties, in that it decreases phase 4 diastolic depolarization, decreases conduction velocity, and has vagolytic properties.31 It is used clinically in the treatment of refractory, life-threatening ventricular tachyarrhythmias. Oral administration of the drug produces peak plasma levels within 2 hours. The drug is bound approximately 50 to plasma protein and has a halflife of 6.7 hours in humans. More than 50 is excreted unchanged in the urine. Therefore, patients with renal insufficiency should be monitored carefully for evidence of overdose. Disopyramide phosphate commonly exhibits side effects of dry mouth, constipation, urinary retention, and other cholinergic blocking actions because of its structural similarity to anticholinergic drugs.

Treatment Guidelines

In summary, the proportion of seropositive individuals in the population will decline as a result of childhood varicella vaccination. In time, this will reduce the incidence of HZ. Adult vaccination has been shown to be effective for the prevention of shingles and PHN.18 II In acute HZ, early antiviral therapy is recommended and pain treatment with strong opioids, tricyclic anti-depressants, or gabapentin should be considered in addition to conventional analgesics. The pharmacological management of PHN consists of three main classes of oral medication (tricyclic antidepressants, anti-convulsants calcium channel , opioids), and two categories of topical medications (lidocaine and capsaicin). Possibly because more than one mechanism of PHN operates in most patients, a combination of two or more analgesic agents may produce greater pain relief and fewer side effects. In a recent controlled four-period crossover trial, gabapentin and morphine combined achieved better analgesia at lower...

Stoma care

Laxatives Enemas and washouts should not be prescribed for patients with an ileostomy as they may cause rapid and severe loss of water and electrolytes. Colostomy patients may suffer from constipation and whenever possible should be treated by increasing fluid intake or dietary fibre. Bulk-forming drugs (section 1.6.1) should be tried. If they are insufficient, as small a dose as possible of senna (section 1.6.2) should be used. Antacids The tendency to diarrhoea from magnesium salts or constipation from aluminium salts may be increased in these patients. Analgesics Opioid analgesics (see section 4.7.2) may cause troublesome constipation in colostomy patients. When a non-opioid analgesic is required paracetamol is usually suitable but anti-inflammatory analgesics may cause gastric irritation and bleeding.

Docusate Sodium

Indications constipation, adjunct in abdominal radiological procedures Cautions see notes above do not give with liquid paraffin rectal preparations not indicated if haemorrhoids or anal fissure Contra-indications see notes above Pregnancy not known to be harmful manufacturer By mouth, chronic constipation, up to 500 mg daily in divided doses CHILD (but see section 1.6) 6 months-2 years 12.5 mg 3 times daily, adjusted according to response (use paediatric solution) 2-12 years 12.525 mg 3 times daily, adjusted according to response (use paediatric oral solution) Note Oral preparations act within 1-2 days With barium meal, ADULT and CHILD over 12 years, 400 mg

Adverse reactions

Adverse reactions often present in the elderly in a vague and non-specific fashion. Confusion is often the presenting symptom (caused by almost any of the commonly used drugs). Other common manifestations are constipation (with antimuscarinics and many tranquillisers) and postural hypotension and falls (with diuretics and many psychotropics).

Antidiarrheal Agents

BULK-FORMING AND HYDROSCOPIC AGENTS Hydrophilic and poorly fermentable colloids or polymers such as carboxymethylcellulose and calcium polycarbophil absorb water and increase stool bulk. They usually are used for constipation (see above) but are sometimes useful in mild chronic diarrhea in patients suffering with irritable bowel syndrome. Clays such as kaolin (a hydrated aluminum silicate) and other silicates such as attapulgite (magnesium aluminum disili-cate diasorb) bind water avidly and also may bind enterotoxins. However, this effect is not selective and may involve other drugs and nutrients hence, these agents are best avoided within 2-3 hours of taking other medications. A mixture of kaolin and pectin (a plant polysaccharide) is a popular over-the-counter remedy (kaopectolin) and may provide useful symptomatic relief of mild diarrhea. Diphenoxylate and Difenoxin Diphenoxylate and its active metabolite difenoxin (diphe-noxylic acid) are related structurally to meperidine. As...


Indications constipation (may take up to 48 hours to act), hepatic encephalopathy (portal systemic encephalopathy) Dose constipation, initially 15 mL twice daily, adjusted according to response CHILD (but see section 1.6) under 1 year 2.5 mL twice daily, adjusted according to response 1-5 years 2.5-10 mL twice daily, adjusted according to response 5-18 years 5-20 mL twice daily, adjusted according to response


Anticonvulsants, anti-inflammatories, antimicrobials, antitussives (there is a treatment for coughing dogs), antispasmodics (there is a treatment for cats with upset stomachs diarrhea), behavior modification (e.g., separation anxiety in dogs), cardiovascular, diuretics, thyroid hormone replacement, laxatives, muscle relaxants, nutraceuticals (e.g., antioxidants, glucosamine chondroitin), sedatives, vitamin and mineral supplements (e.g., multivitamins, calcium), and parasiticides.

General Guidelines

Their use in PD has been limited because of the common occurrence of both peripheral (dry mouth, constipation, urinary hesitancy and visual blurring) and central (memory loss and confusion) side-effects. The latter are especially problematic in the elderly, and anticholinergics should therefore be avoided in elderly patients. effective doses. In addition, their side-effect profile is more complex and frequent. The most frequent adverse effects of DAs are nausea and vomiting, postural hypotension, drowsiness, constipation and mental disturbances (hallucinations and confusion). The latter are more common in elderly and demented patients. Serious but rare adverse events associated with the ergoline DAs (bromocriptine, pergolide, lisuride and cabergoline) include pulmonary and retroperitoneal fibrosis as well as erythromelalgia, which are unlikely with the newer non-ergot DAs (pramipexole and ropinirole). Recently, it has been reported that DAs may cause in addition to somnolence sudden...

Diverticular disease

Diverticuli can occur throughout the gastrointestinal tract but prove to be most common in the colon where they exist as small sac-like herniations of mucosa through the muscular wall, typically at the site of penetrating blood vessels. Duodenal, jejuna, and ileal diverticuli can occur with Meckel's diverticulum forming a special congenital abnormality present in 2 percent of the population. Meckel's diverticuli are particularly notable since they may contain acid-producing gastric mucosa and lead to enteral ulcer formation. Colonic diverticuli are generally pain free but with the development of inflammation and or obstruction of their mouth, severe abdominal pain and infection may result. Peridiverticular abscesses, obstruction, colonic distension, bleeding, and altered bowel habit (diarrhea, constipation) are not uncommon. Painful diverticulosis classically presents as recurrent left lower quadrant colicky pain without evidence of inflammation. Like chronic pancreatitis,...


The clinical toxicity of vincristine is mostly neurological. The more severe neurological manifestations may be avoided or reversed either by suspending therapy or reducing the dosage upon occurrence of motor dysfunction. Severe constipation may be prevented by a prophylactic program of laxatives and hydrophilic (bulk-forming) agents and usually is a problem only with doses above 2 mg m2. Alopecia occurs in 20 of patients given vincristine however, it is always reversible, frequently without cessation of therapy. Although less common than with vinblastine, leukopenia may occur with vincristine, and thrombocytopenia, anemia, polyuria, dysuria, fever, and GI symptoms have been reported occasionally. The syndrome of inappropriate secretion of antidiuretic hormone occasionally has occurred during vincristine therapy. In view of the rapid action of the vinca alkaloids, it is advisable to prevent hyperuricemia by the administration of allopurinol.

Neuropathic pain

Therefore, there is suggestion that clinically ondansetron may reduce neuropathic pain and that there is a logical explanation for why that may occur. Clearly significant work needs to be done to verify this observation. From an entirely practical perspective, ondansetron could be given parenter-ally in patients with acute flare-ups of neuropathic pain or to those in whom the oral route is unavailable. The major drawbacks of treatment are that at present, all 5HT3 antagonists are extremely expensive, to the extent that they probably could not be used in a day-in, day-out basis but may be a useful treatment during a period of flare-up of neuropathic pain. The two major side effects of continued 5HT3 use are headache and constipation.


A multicenter randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy of tramadol in CPDN consisted of a washout screening phase, during which all analgesics were discontinued, and a 42-day double-blind treatment phase 86 . A total of 131 patients with CPDN were treated with tramadol four times daily (n 65) or placebo (n 66). The primary efficacy analysis compared the mean pain intensity scores in the tra-madol and placebo groups obtained at day 42 of the study or at the time of discontinuation. Tramadol, at an average dosage of 210 mg day, was significantly (P 0.001) more effective than placebo for treating the pain of diabetic neuropathy 86 . Patients in the tramadol group scored significantly better in physical (P 0.02) and social functioning (P 0.04) ratings than patients in the placebo group. The most frequently occurring adverse events with tramadol were nausea, constipation, headache, and somnolence 86 .

Acute Lead Poisoning

Acute lead poisoning is relatively infrequent and follows ingestion of acid-soluble lead compounds or inhalation of lead vapors. Local actions in the mouth produce marked astringency, thirst, and a metallic taste. Nausea, abdominal pain, and vomiting ensue. The vomitus may be milky from the presence of lead chloride. Although the abdominal pain is severe, it is unlike that of chronic poisoning. Stools may be black from lead sulfide, and there may be diarrhea or constipation. If large amounts of lead are absorbed rapidly, a shock syndrome may develop as the result of massive GI loss of fluid. Acute CNS symptoms include paresthesias, pain, and muscle weakness. An acute hemolytic crisis sometimes causes severe anemia and hemoglobinuria. The kidneys are damaged, and oliguria and urinary changes are evident. Death may occur in 1 2 days. If the patient survives the acute episode, characteristic signs and symptoms of chronic lead poisoning are likely to appear.

Tegaserod Maleate

Patients with constipation-predominant irritable bowel syndrome (see below). In patients with constipation, tegaserod results in mild-to-modest improvement in stool frequency, with less consistent effects on other parameters such as stool form, bloating, and pain. The absolute improvement is modest at best. It is not clear that the drug has any greater efficacy in this regard than other agents used for constipation. Tegaserod is available for oral administration in 2-mg and 6-mg tablets and is approved for use in women with constipation-dominant irritable bowel syndrome at a dose of 6 mg twice daily. Tegaserod also is approved for the treatment of chronic constipation.

Side Effects

Pharmacological Effects Morphine

An opioid antagonist that is selective for peripheral opioid receptors would be useful to treat two of the most common adverse effects of opioids opioid bowel dysfunction and pruritus. Although constipation may be treated with the use of bowel regimens and pruritis with antihistamines, these agents are sometimes ineffective, are themselves associated with adverse effects, and often require the use of multiple agents. A recent comprehensive review examined available data for opioid antagonists, and concluded that peripherally acting agent's show the greatest promise because of their ability to reverse opioid-induced constipation and pruritus without compromising centrally mediated pain control. A potential advantage of opioid antagonists is the use of a single agent for the treatment of multiple adverse effects, which offers advantages of decreased drug costs and nursing time, improved drug compliance, and ease of administration 199 . Postoperative ileus, a serious side effect of...

M Sodium Picosulfate

Indications constipation bowel evacuation before abdominal radiological and endoscopic procedures on the colon, and surgery (section 1.6.5) acts within 6-12 hours Note The brand name Dulcolax Pico Liquid (Boehringer Ingelheim) is used for sodium picosulfate elixir 5 mg 5 mL Dulcolax Pico (Boehringer Ingelheim) Perles ( capsules), sodium picosulfate 2.5 mg, net price 20-cap pack 1.93, 50-cap pack 2.73 Note The brand name Dulcolaxx is also used for bisacodyl tablets and suppositories

M Phosphates Rectal

Indications rectal use in constipation bowel evacuation before abdominal radiological procedures, endo-scopy, and surgery Cautions elderly and debilitated with enema, electrolyte disturbances, congestive heart failure, ascites, uncontrolled hypertension, maintain adequate hydration Dose constipation, ADULT and CHILD over 12 years, 1 suppository, inserted 30 minutes before evacuation required moisten with water before use

Abdominal Pain

Constipation is a common disorder and patients may experience crampy abdominal discomfort in association with the urge to defecate. A suggestive history and the demonstration on physical examination of bulky stool retained in the rectum should initiate a trial of appropriate treatment (Scott et al. 2000).

Opioid Limitations

Opiates can cause nausea, vomiting, and as described earlier decreased gastric motility, potentially leading to constipation. Tolerance to the constipating effects of opioids does not develop. Opiates can also cause significant clinically relevant urinary retention. Recently data,

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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