Ask the Pharmacist
by Ron & Marla Chapleau

October 1, 2016


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Q. There are so many products to choose from for constipation; how do I know which one to try?

A. Constipation is defined as having either a reduced frequency (less than 3 per week) of bowel movements, having a difficult time passing the stool or not being able to completely pass the stool out of your body. It is crucial to contact your health care provider to be screened for colon cancer if this change in bowel movements involves any of the following;

  • Over 50 years of age

  • Any evidence of blood in the stool

  • More than 10 lbs (5 kg) of weight loss over the last 6 months

  • Anemia

  •  Family history of colon cancer

  • Constipation that does not respond to initial treatment

Certain medical conditions can be the underlying cause of the constipation such as anxiety, depression, dementia, stroke, diabetes, hypercalcemia (too much calcium in the blood), hypokalemia (too low potassium in the blood), hypothyroidism (too low thyroid hormone), diverticulitis and a great many others. In these circumstances, it is best to treat the medical condition and the constipation problem will often resolve itself.

Constipation is also one of the most common side effects of many types of drugs. For constipation that results from taking opioid pain killers (codeine, morphine, hydromorphone etc...) it is suggested to use an osmotic type laxative such as PEG 3350 (Restoralax or Lax-a-day) or a stimulant type laxative such as senna or bisacodyl. For best results, they should be started as soon as opioid therapy is initiated, rather than waiting until constipation sets in, and used for the duration of opioid treatment.

If this does not work, and if the pain is severe, there is a drug called Targin which combines the opioid oxycodone with a second ingredient (naloxone) which acts to minimize the constipatory effects of the narcotic.

 It’s not just pain killers that can cause constipation however. Other medications that can also be the cause are ones that have anticholinergic side effects (antihistamines, antipsychotics, tricyclic antidepressants such as amitriptyline), antidiarrheals, aluminum or calcium containing antacids, betablockers, calcium channel blockers, iron supplements and anti-inflammatories to name but a few.

In some cases, with the supervision of your health care provider, a lower dose may be tried or switching to another medication might be necessary to reduce this side effect. In all cases, diet is the mainstay of treatment. We should be aiming to ensure that our dietary fibre is sufficient enough (20-25 grams daily) through whole grains, fruits, vegetables and even supplements (Metamucil, PGX...) if needed. Some examples of fibre content in foods are;

  • ½ cup All-Bran cereal – 10 grams

  • Fibre One Chewy bars – 9 grams

  • 1 cup cooked kidney beans – 16 grams

  • 1 cup cooked black beans – 15 grams
  • 1 cup raw raspberries – 8 grams
  • 1 cup blueberries – 4 grams
  • 1 cup strawberries – 3 grams \
  • 1 cup cooked quinoa – 5 grams
  • 1 cup cooked wild rice – 3 grams
  • 1 cup cooked brown rice – 4 grams
  • 1 slice whole wheat bread – 2 grams
  • 1 cup cooked whole wheat spaghetti – 6 grams
  •  1 cup cooked spinach – 4 grams
  • 1 cup cooked zucchini – 3 grams
  • 1 cup cooked acorn squash – 9 grams
  • 1 cup cooked cauliflower – 5 grams
  • 1 cup cooked broccoli – 5 grams
  • 1 pear – 6 grams
  • 1 banana – 3 grams
  •  ½ cup dried prunes – 6 grams
  • 1 ounce almonds – 4 grams
  • 1 ounce cashews – 1 gram
  • 1 ounce peanuts – 2 grams
  • 1 ounce flaxseed – 8 grams

Click the orange arrow to read the second column

In addition to the high fibre diet, we should all (with the exception of those that are medically put on a fluid restriction diet) aim for having 1.5 to 2 litres of fluid daily. This fluid does not have to be water but can be a mix of water, milk, juice, broth and many others. Please be mindful that some fluids such as coffee and tea as well as alcohol can cause the body to lose fluids.

Last but not least, if able, try to get some physical exercise in as a sedentary lifestyle promotes constipation.

 Since these natural methods can take days or weeks to take effect, it might be a good idea to try a non prescription medication to get things back on track. An osmotic laxative for 2-4 weeks is recommended to be tried first. PEG 3350 (a tasteless, odourless powder found in Restoralax & Lax-A-Day) is preferred due to its good evidence of its effectiveness and tolerability but one can also try the sweet tasting liquid called lactulose.

 If the bowels are not responding to the osmotic laxative, then try a stimulant laxative such as bisacodyl or Senokot. Other commonly used options are stool softeners (docusate sodium/ Soflax/ Colace or docusate calcium/ Surfac) which are very gentle, safe and have been a mainstay of therapy for decades. However their use has recently become controversial since there have been a number of studies that indicate they may be no more effective than a placebo.

When combined with a very slow onset of action (up to 3 days) and questionable availability (docusate calcium is currently pretty hard to find) other types of agents may be a better alternative. Docusate in the past has often been recommended for people who need to avoid straining (i.e. after surgery, post heart attack...) but now it is suggested to try an osmotic laxative such as the PEG 3350 instead. For constipation that just refuses to respond to a particular laxative, sometimes they can be combined for more effective results as long as they are working via different mechanisms.


For more information on this or any other topic, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination in Kincardine and Port Elgin

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Saturday, October 01, 2016