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Family Health Magazine
PHARMACY CARE

Constipation and Laxatives
Safely treating the problem

True or False? - 'A daily bowel movement is necessary to maintain a healthy digestive system.' If you answered false, congratulations! This is a common myth in our society. Normal bowel habits range between three and 21 stools per week, showing a wide variation among healthy individuals.

So how do you know if you are in fact constipated and possibly require a laxative? If you are looking for a precise meaning of constipation, there isn’t one. However, two main indicators are difficulty straining at passing more than one in four stools or less than three movements per week. This can be due to a number of factors. Certain medications or diseases can produce constipation. Even lifestyle factors such as diet and exercise are important to maintain regularity.

If you think you require laxative treatment, talk to your pharmacist. You will probably be asked questions to determine if a laxative is necessary and if so, which one is most appropriate for you. Some information the pharmacist may request includes:

• When did your bowel pattern begin to change and how is it usually?
• Have you recently changed your daily routine, diet or intake of fluids?
• Do you have any other bothersome symptoms such as rectal bleeding, nausea, cramps or weight loss?
• Are you taking medications or do you have any medical conditions?
• Have you tried to relieve your constipation and if so, what have you tried?
• What types of foods and beverages do you consume on a regular basis?
• Do you follow a routine exercise program?

After considering these factors, your pharmacist can decide whether you should see your family doctor or if a laxative might help and assist you to choose the most appropriate product. There are several types of laxatives and they work differently to relieve constipation. Generally, they are grouped by the way they act in your body.

Bulk-Forming Laxatives

The body does not digest bulk-forming laxatives, so they remain in the intestine and absorb water. The stool swells causing it to become bulky, stimulating a bowel movement. This is a very natural way to relieve chronic constipation. Bulk-forming laxatives usually provide relief within 12 to 24 hours, although two to three days may be necessary to achieve complete benefits.

Generally, these products are well tolerated and most people have few side effects. Pregnant women experiencing constipation may use bulk-forming laxatives without risk to an unborn child. Drinking plenty of fluids is extremely important when talking bulk-forming agents. Never attempt to swallow products in their dry form as complications may arise. This class of laxatives is safe to use on a regular basis over an extended period of time. You may hear of these medications also being used to decrease cholesterol. They do!

Stool Softeners

This category is also referred to as emollient laxatives. They work by allowing water to penetrate the stools permitting easy passage, thereby minimizing discomfort. Stool softeners do not actually cause a bowel movement, but instead allow you to pass a stool without straining. These products are effective for anyone having dry, hard stool masses and when painful or difficult defecation should be avoided (hemorrhoids, hernia). Approximately two to three days are required before stool softening is evident.

Adverse effects are rare and long term use is considered safe. If you are on a low sodium (salt) diet, be cautious when selecting a product. Your pharmacist can help you choose a laxative that consists of calcium (Docusate calcium™) rather than sodium (Docusate sodium™). When giving the oral solution to children, diluting with approximately 120 ml of milk, fruit juice or infant formula may improve the taste and lessen the possibility of throat irritation.

Lubricant Laxatives

The most common lubricant laxative is mineral oil. It encourages a bowel movement by coating the bowel and stool masses with a waterproof film. This action helps retain water in the stool, keeping it soft so it may be excreted freely. Mineral oil acts in six to eight hours after being taken orally.

Although adverse effects are uncommon, they may occur and mineral oil is seldom recommended. Pneumonia can develop when oil droplets are inhaled into the lungs. Lying down after ingestion increases the risk, so it should not be taken at bedtime or by those with an increased risk of developing complications (elderly, bedridden patients, pregnant women, children under six years). Since mineral oil can interfere with the way vitamins and nutrients are absorbed, it should not be taken within two hours of meals. Another disadvantage of lubricant laxatives is their potential to cause anal itching. This occurs more commonly after using light mineral oil, therefore, if oil is to be used at all, heavy mineral oil is recommended.

Stimulant Laxatives

Otherwise known as contact laxatives, this category affects the cells in the colon, increasing fluid secretion. Although this is a popular type of laxative, it is more likely to cause side effects and long term complications. Therefore, it should be used only where constipation has persisted for a long time and is more severe. When the laxative is taken by mouth, a stool is generally produced within six to 12 hours.

Often stimulant laxatives are taken at bedtime to produce a morning stool. Suppositories are also available in this class. They cause a bowel movement within 15 minutes to two hours.

Many people experience stomach discomfort (cramps, nausea) after taking the medication orally. More serious problems may include electrolyte disturbances (low levels of sodium or potassium) and skin reactions (rashes, skin eruptions). Certain stimulant laxatives have the ability to turn urine pink to red in color. However, this reaction is not dangerous. If used over a long period of time the bowel will become lazy and depend on the laxative for a bowel movement to occur.

Osmotic Laxatives

Osmotic laxatives draw water into the intestine producing a semi-fluid or almost liquid stool. There are two types taken orally:

Saline Laxatives

These are used most commonly for emptying the lower intestine and bowel quickly and thoroughly before diagnostic or surgical procedures. You may also see them used in small doses as an antacid. Saline laxatives are not recommended for long term or repeated correction of constipation. They act within 30 minutes to three hours. It is important to drink the quantity of fluids instructed to prevent dehydration. Refrigerating the products often improves the taste. Also, citrus fruit juice or carbonated beverages help mask an unpleasant flavor.

Lactulose

This works in the same manner as saline laxatives but results are more gradual (24 to 48 hours) and it is used for long-term treatment of constipation. Lactulose may cause gas, belching or abdominal discomfort. Beginning laxative treatment gradually and increasing if necessary will help to lessen these side effects. Mixing with fruit juice helps some people tolerate the sweet taste of lactulose. It should be used cautiously by diabetics since it contains some digestible sugar.

Suppositories and Enemas

These products are inserted into the rectum to stimulate a bowel movement. There are many different types of suppositories and enemas available. A commonly purchased product is glycerin suppositories. These are used in more severe cases of constipation where fast action, normally within 30 minutes, is required. Side effects are generally mild including rectal irritation and burning. Glycerin suppositories are safe to use in pregnancy and infants but it is recommended that children younger than six months be seen first by a doctor.

This article has introduced you to a variety of laxatives available for treating constipation. Before deciding to use any of them, some nondrug measures may be helpful to maintain regularity.

• Eat foods high in fibre. This includes whole grain breads and cereals, fruit and green leafy vegetables. Wheat fibre is more effective at relieving constipation than oat bran.
• Drink plenty of liquids each day. Six to eight glasses of water are recommended unless you have a medical condition that restricts your intake.
• Exercise regularly. Whether you participate in a marathon race or walk briskly for 15 minutes, you are helping to maintain regularity.

Unfortunately, most of us experience constipation at some point in our lives. Usually the discomfort is short term and does not require treatment. However, laxatives are available and beneficial when used appropriately. Talk to your pharmacist or family doctor first.