Types Of Laxatives Research Articles

Impaired Gastrointestinal Motility and Worsening Heart Failure in Patients Receiving Trans-Catheter Aortic Valve Replacement.

Background: Impaired gastric motility in the form of constipation may often occur in elderly patients with chronic heart failure. Candidates for trans-catheter aortic replacement (TAVR) are of old age and have multiple comorbidities, probably including constipation. However, the clinical implication of a history of constipation in patients receiving TAVR remains unknown. Methods: Patients who underwent TAVR at our large academic center between 2015 and 2022 were eligible. The prognostic impact of the prescribed laxative type and number, which was assumed as the severity of constipation, on the incidence of death or heart failure readmission two years after index discharge was investigated. Results: A total of 344 patients were included. Median age was 85 years, and 99 patients were men. Patients with any laxatives (N = 166) had higher systolic blood pressure, higher plasma B-type natriuretic peptide levels, and a lower prescription rate of renin-angiotensin system inhibitors at the time of index discharge after TAVR (p < 0.05 for all). The number of laxative types was independently associated with the composite primary outcome with an adjusted hazard ratio of 1.83 (95% confidence interval 1.27-2.63, p = 0.001) with a cutoff of one type of laxative used, which significantly stratified the 2-year cumulative incidence of the primary outcome (18% versus 7%, p = 0.001). Conclusions: The presence of constipation was associated with worse clinical outcomes following TAVR. The prognostic impact of an aggressive intervention for constipation remains a future concern in this cohort.

The Potential of Polysaccharides from Various Plants as Constipation Treatment

Constipation is one of the disorders of Irritable Bowel Syndrome (IBS). Lack of consumption of water and food with fiber are some of the causes of constipation. Treatment for constipation patients can be solved by administering laxatives through drugs (pharmaceuticals) or using polysaccharide parts from plants. There are at least three types of laxatives: bulking agents (having the ability to bulk up), osmotic agents, and stimulants. Polysaccharides can be sourced from whole or some parts of the plants. Each type of plant has different polysaccharide components, and their effects on constipation treatment are also specific. The study aimed to review the mechanisms of polysaccharides from various plants parts and explained the misconception of polysaccharide intake as a laxative agent in treating constipation. This review was based on literature studies related to polysaccharides from plants materials and their effects as laxatives in experimental animals. The review found that these polysaccharides have a positive effect as a laxative or digestive aid. In general, polysaccharides from several plants were extracted and characterized to be used as anti-constipation test materials. These polysaccharides can help increase the amount, weight, and water content of feces (bulk), increase peristalsis, speed up gastric emptying and transit time, as well as restore hormones that work in movement in the digestive tract, and improve the condition of the distal colon tissue. These studies are still limited to using animals as experimental test material in polysaccharides to treat constipation. In addition, it has the potential to be further explored regarding the possibility of clinical trials of polysaccharides in humans as laxatives.

Association between regular laxative use and incident dementia in UK Biobank participants

AbstractBackgroundUse of OTC laxatives is common in the general population. The microbiome‐gut‐brain axis hypothesis suggests use of laxatives be associated with dementia. We aim to examine the association between regular use of laxatives and incidence of dementia.MethodThis prospective cohort study is based on 476,219 participants aged 40 to 69 years with no history of dementia. Regular use of laxatives is defined as self‐reported use in most days of the week for the last 4 weeks at baseline (2006‐2010). The outcomes are all‐cause dementia, Alzheimer’s disease and vascular dementia, identified from linked hospital admissions or death register (up to 2020).Result18,235 (3.6%) reported regular use of laxatives. Over a mean follow‐up of 9.8 years, 218 (1.3%) participants with regular use of laxatives and 1,969 (0.4%) with no regular use developed all‐cause dementia. Multivariable Cox regression models adjusting for sociodemographics, lifestyle factors, medical conditions and regular medication use showed that regular use of laxatives was associated with increased risk of all‐cause dementia (hazard ratio [HR] 1.51; 95% confidence interval 1.30‐1.75) and vascular dementia (HR 1.65; 1.21‐2.27), with no significant association observed for Alzheimer’s disease (HR 1.05; 0.79‐1.40). The risk of both all‐cause dementia and vascular dementia increased with the number of regularly used laxative types (P‐trend 0.001 and 0.04, respectively). Among the participants who clearly reported that they were using just one type of laxative (n = 5800), only those using osmotic laxatives showed a statistically significantly higher risk of all‐cause dementia (HR 1.64 [1.20‐2.24]) and vascular dementia (HR 1.97 [1.04‐3.75]). These results remained robust in various subgroup and sensitivity analyses.ConclusionRegular use of laxatives was associated with a higher risk of all‐cause dementia and vascular dementia, particularly in those who used multiple laxative types or osmotic laxative.

Association Between Regular Laxative Use and Incident Dementia in UK Biobank Participants.

The use of over-the-counter laxatives is common in the general population. The microbiome-gut-brain axis hypothesis suggests that the use of laxatives could be associated with dementia. We aimed to examine the association between the regular use of laxatives and the incidence of dementia in UK Biobank participants. This prospective cohort study was based on UK Biobank participants aged 40-69 years without a history of dementia. Regular use of laxatives was defined as self-reported use in most days of the week for the last 4 weeks at baseline (2006-2010). The outcomes were all-cause dementia, Alzheimer disease (AD), and vascular dementia (VD), identified from linked hospital admissions or death registers (up to 2019). Sociodemographic characteristics, lifestyle factors, medical conditions, family history, and regular medication use were adjusted for in the multivariable Cox regression analyses. Among the 502,229 participants with a mean age of 56.5 (SD 8.1) years at baseline, 273,251 (54.4%) were female, and 18,235 (3.6%) reported regular use of laxatives. Over a mean follow-up of 9.8 years, 218 (1.3%) participants with regular use of laxatives and 1,969 (0.4%) with no regular use developed all-cause dementia. Multivariable analyses showed that regular use of laxatives was associated with increased risk of all-cause dementia (hazard ratio [HR] 1.51; 95% CI 1.30-1.75) and VD (HR 1.65; 95% CI 1.21-2.27), with no significant association observed for AD (HR 1.05; 95% CI 0.79-1.40). The risk of both all-cause dementia and VD increased with the number of regularly used laxative types (p trend 0.001 and 0.04, respectively). Among the participants who clearly reported that they were using just 1 type of laxative (n = 5,800), only those using osmotic laxatives showed a statistically significantly higher risk of all-cause dementia (HR 1.64; 95% CI 1.20-2.24) and VD (HR 1.97; 95% CI 1.04-3.75). These results remained robust in various subgroup and sensitivity analyses. Regular use of laxatives was associated with a higher risk of all-cause dementia, particularly in those who used multiple laxative types or osmotic laxative.

1304 LAXATIVES PRESCRIPTION MONITORING FOR AN OVERLOOKED PROBLEM

Abstract Introduction Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception. Aim We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards: - Medication review at least once weekly; - Documented rationale for choice of medication - Specified timeframe review and outcome documentation We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data. Method Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment. Results 47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2 Conclusion Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.

S2791 A Rare Etiology for Ulcerative Colitis Flare

Introduction: Prior to colonoscopy, it is well understood that patients must undergo bowel cleansing. Based on the type of laxative, colonoscopy preparations fall into two categories – polymer-based formulas (PEG) and saline-based formulas (NaP). Both types of bowel preparations are deemed to be relatively safe and part of routine practice. However, we describe the rare case of an ulcerative colitis (UC) flare due to the bowel preparation formula. Case Description/Methods: A 29-year-old female with diagnosis of UC, presently in clinical and biochemical remission on oral mesalamine, contracted COVID-19 and had reactivation of UC symptoms. After being on budesonide tablets and rectal foam for two months, patient achieved clinical remission, and a surveillance colonoscopy was performed which revealed normal colon and terminal ileum except mild congestion in the cecum (Figure A). Pathology revealed unremarkable mucosa in the entire colon except for chronic active colitis in the cecum. Immediately following this colonoscopy, the patient started to experience another severe UC flare requiring hospitalization. The patient’s laboratory work-up was normal except for an elevated fecal calprotectin (1710). Stool infectious work-up was negative and the patient denied any NSAID or antibiotic use. The patient underwent a repeat colonoscopy which revealed severe Mayo 3 pancolitis (Figure B) in comparison to a stable colonoscopy a few weeks prior. It was revealed that for her initial colonoscopy, she had used SUPREP bowel prep kit. On prior colonoscopies she had used MiraLAX bowel prep with no adverse effects. During hospitalization, the patient was started on biologic therapy with good effect. Discussion: There are no clear guidelines on appropriate bowel preparation formula for the inflammatory bowel disease (IBD) population. Sufficient literature exists to confirm that NaP can irritate the intestinal mucosal wall. Moreover, numerous animal experiments have employed dextran sodium sulfate for chemical induction of intestinal inflammation to mimic UC flares in humans [1]. Thus, it can be surmised that because SUPREP ingredients contain sodium sulfate, the potential for UC flare is higher. It is pertinent for practitioners to be aware of the possible rare adverse effects of saline-based formulas, especially when treating the IBD population.Figure 1.: (A) Colon (04/19/2022) and (B) Colon (05/09/2022).

Post-repair laxative management in obstetric anal sphincter injury guidelines: A narrative review.

Childbirth is a common factor which increases the risk of obstetric anal sphincter injuries (OASIS). Damage to the anal sphincters increases the risk of anal incontinence, which has a debilitating impact on the quality of life. Post-repair laxatives are prescribed in this group of women. However, there is no consensus regarding the type or frequency with which they are used, and available guidelines lack consistency and evidence to support the recommendations. The aim was to review and compare the international, national and local Australian management guidelines for recommendations regarding laxative use in women after OASIS. An online literature search of medical and nursing databases such as PubMed, Embase, MEDLINE, CINAHL, Web of Science, Scopus and Cochrane was performed between January 2000 and October 2020. Full-text articles with MeSH headings and Text Words [TW] identified guidelines in the prevention, management and care of OASIS. The search terms included 'obstetric anal sphincter injury', 'OASIS', 'perineal tear', 'postpartum continence', 'bowel injury', 'aperient', 'laxative use' and 'bulking agents'. Thirteen guidelines were included. Laxatives were recommended in most guidelines; however, there was a lack of consistency regarding the type of laxative used, frequency, dose and duration of use. Guidelines were based on historical evidence, with paucity of recently acquired data identified. There is no consensus regarding an optimal laxative regime for women who sustain an anal sphincter injury after childbirth. Further research is required to develop evidence-based robust clinical guidelines regarding laxative use in women who sustain OASIS.

A single‐center retrospective study comparing 1‐day and 3‐day low‐residue diets for bowel preparation

AbstractA low‐residue diet (LRD) is recommended as part of bowel preparation before a colonoscopy. However, the optimal duration of the LRD is unclear. A retrospective cross‐sectional study was therefore conducted at E‐Da Dachang Hospital. We compared bowel preparations using the Aronchick score and other quality metrics during two consecutive periods: May 2019 to December 2019 (3‐day LRD) and January 2020 to August 2020 (1‐day LRD). A total of 2823 patients were enrolled (1592 in the 3‐day LRD group and 1231 in the 1‐day LRD group). The most common bowel cleansing agent was sodium picosulfate and magnesium citrate (SPMC, 84.2%), followed by polyethylene glycol (PEG, 10.0%) and sodium phosphate (5.8%). Compared with patients in the 3‐day LRD group, patients in the 1‐day LRD group had higher SPMC use (88.1% vs 81.3%, P &lt; .001) and supplemental laxative use (25.9% vs 19.3%, P &lt; .001). The proportion of adequate bowel preparation (84.2% vs 85.1%, P = .563), cecal intubation rate, adenoma detection rate, and right‐side adenoma detection rate were not significantly different between 1‐day LRD and 3‐day LRD groups. More advanced adenomas (5.9% vs 3.4%, P = .002) and sessile serrated lesions (8.9% vs 6.3%, P = .014) were observed in the 1‐day LRD group. In addition, the types of laxatives (SPMC, sodium phosphate, and PEG) and the use of supplemental laxatives did not affect bowel preparation scores. In conclusion, a 1‐day LRD led to bowel preparation similar to that achieved through a 3‐day LRD regardless of the type of primary cleansing agent or the use of supplemental laxatives.

Medical Management of Constipation in Elderly Patients: Systematic Review.

Background/AimsConstipation is a common gastrointestinal problem in the elderly. Because of the limitations of life style modifications and the comorbidity, laxative use is also very common. Therefore, this study reviews the latest literature on the effect and safety of laxative in the elderly.MethodsA systematic review of randomized controlled trials investigating the effectiveness and safety of laxatives for constipation in elderly patients over 65 years old were performed using the following databases PubMed, EMBASE, and the Cochrane Library.ResultsTwenty-three randomized controlled trials were included in this review. Among the selected studies, 9 studies compared laxative with placebo and 5 studies compared laxatives of the same type. Four studies compared different types of laxatives or compared combination agents. Five studies compared novel medications such as prucalopride, lubiprostone, and elobixibat with placebo. Psyllium, calcium polycarbophil, lactulose syrup, lactitol, polyethylene glycol, magnesium hydroxide, stimulant laxative with or without fiber, and other medications were more effective than placebo in elderly constipation patients in short-term. Generally, the frequency and severity of adverse effects of laxative were similar between the arms of studies.ConclusionsBulk laxative, osmotic laxative, stimulant laxative with or without fiber, and other medications can be used in elderly patients in short-term within 3 months with reasonable safety. However, the quality of included studies was not high and most of studies was conducted in a small number of patients. Among these laxatives, polyethylene glycol seems to be safe and effective in long-term use of about 6 months in elderly patients.

Comparison of Four Bowel Cleansing Agents for Colonoscopy and the Factors Affecting their Efficacy. A Prospective, Randomized Study.

Adequate bowel preparation is essential for successful and effective colonoscopy. Several types of cleansing agents are currently available including low-volume solutions. The aim of this study was to compare the efficacy of four different bowel cleansing agents. A single-center, prospective, randomized, and single-blind study was performed. Consecutive patients referred for colonoscopy were enrolled and randomized into one of the following types of laxatives: polyethylenglycol 4L (PEG), oral sulfate solution (OSS), 2L polyethylenglycol + ascorbate (2L-PEG/Asc), or magnesium citrate + sodium picosulfate (MCSP). The primary outcome was quality of bowel cleansing evaluated according to the Boston Bowel Preparation Scale (BBPS). Secondary outcomes were polyp detection rate (PDR) and tolerability. Final analysis was performed on 431 patients. The number of patients with adequate bowel preparation (BBPS total scores ≥6 and sub scores ≥2 in each segment) was not significantly different throughout all groups (95.4% PEG; 94.6% OSS; 96.3% 2L-PEG/Asc; 96.2% MCSP; p=0.955). Excellent bowel preparation (BBPS total scores ≥ 8) was associated with younger age (p=0.007). The groups did not have significantly different PDRs (49.5% PEG; 49.1% OSS; 38% 2L-PEG/Asc; 40.4% MCSP; p=0.201). The strongest predictors of pathology identification were age and male gender. The best-tolerated solution was MCSP (palatability: p<0.001; nausea: p=0.024).

Laxative Use and Change in Estimated Glomerular Filtration Rate in Patients With Advanced Chronic Kidney Disease

Constipation is highly prevalent in advanced chronic kidney disease (CKD), due in part to dietary (e.g., fiber) restrictions, and is often managed by laxatives; however, the effect of laxative use on kidney function in advanced CKD remains unclear. We aimed to examine the association of laxative use with longitudinal change in estimated glomerular filtration rate (eGFR) in patients with advanced CKD. In a retrospective cohort of 43,622 US veterans transitioning to end-stage renal disease (ESRD) from 2007 to 2015, we estimated changes in eGFR (slope) by linear mixed-effects models using ≥2 available outpatient eGFR measurements during the 2-year period before transition to ESRD. The association of laxative use with change in eGFR was examined by testing the interaction of time-varying laxative use with time for eGFR slope in the mixed-effects models with adjustment for fixed and time-varying confounders. Laxatives were prescribed in 49.8% of patients during the last 2-year pre-ESRD period. In the crude model, time-varying laxative use was modestly associated with more progressive eGFR decline compared with non-use of laxatives (median [interquartile interval] -7.1 [-11.9, -4.3] vs. -6.8 [-11.6, -4.0] mL/min/1.73m2/year, P<.001). After multivariable adjustment, a faster eGFR decline associated with laxative use (vs. non-use of laxatives) remained statistically significant, although the between-group difference in eGFR slope was minimal (median [interquartile interval] -8.8 [-12.9, -5.9] vs. -8.6 [-12.6, -5.6] mL/min/1.73m2/year, P<.001). The significant association was no longer evident across different types of laxatives (i.e., stool softeners, stimulants, or hyperosmotics). There was a clinically negligible association of laxative use with change in eGFR during the last 2-year pre-ESRD period, suggesting the renal safety profile of laxatives in advanced CKD patients.

Relationship between gastroesophageal reflux disease (GERD) and constipation: laxative use is common in GERD patients.

The relationship between gastroesophageal reflux disease (GERD) and constipation has not yet been examined in Japan. We herein analyzed the use of laxatives by GERD and non-GERD patients to clarify the relationship between GERD and constipation. This was a retrospective observational study designed to examine the use of laxatives by GERD and non-GERD patients. A total of 118 patients (mean age 69.7years, 50 males) with reflux esophagitis (RE) and non-erosive reflux disease (NERD) who received maintenance acid-suppressive therapy for more than 1year were included in the GERD group (83 RE patients, 35NERD patients). Similarly, 61 patients (mean age 69.4years, 28 males) who received regular acid-suppressive therapy for reasons other than GERD were included in the non-GERD group. We also investigated demographic factors associated with the onset of GERD, including body mass index (BMI), age, and sex. The frequency of laxative use was significantly higher in the GERD group (38.1%) than in the non-GERD group (21.3%). No significant differences were observed in dose frequencies between the groups. The type of laxative used also did not significantly differ between the groups. Furthermore, no significant differences were noted in sex, age, or BMI between the groups. The use of laxatives was significantly more common in GERD patients than in non-GERD patients. The present results suggest that a relationship exists between GERD and constipation.

A global survey of surgeons' preferences and practice with regard to laxative use after elective colorectal surgery.

The role of laxatives after elective colorectal surgery is unclear, resulting in heterogenous guidelines and variability in clinical practice. This study aimed to gauge surgeons' preferences and practice with regard to laxative use following elective colorectal surgery. A short one-minute anonymous web-based questionnaire designed in English and Chinese (Mandarin) using the Research Electronic Data Capture application (REDCap) was distributed to member surgeons of every identifiable international colorectal specialist society via email communication, physical newsletters and social media channels. Frequency of laxative use after elective colorectal surgery, type of laxative used, and, if not used, the reasons for not using laxatives were collected. A total of 852 surgeons, representing 28 surgical societies completed the survey: 80% were colorectal surgeons and 20% were general surgeons with colorectal interest. Twenty-seven percent of the respondents routinely prescribed laxatives after colorectal surgery. There was wide variation in the type of laxatives used, with magnesium-based laxatives (42%), macrogol (Movicol, 36%) and lactulose (Duphalac, 22%) being the most common. Geographical location was correlated with choice of laxative. Those not routinely using laxatives stated the reasons as being no evidence for benefit (48%), potential of adverse events (24%), more than one reason (21%) and other (7%). The majority (93%) non-users would consider using laxatives if better evidence was available. Most surgeons do not routinely prescribe laxatives after elective colorectal surgery due to lack of evidence. Amongst those surgeons who do use them, there is wide variability in the type of laxatives used.

Genetic and Non-genetic Factors Associated With Constipation in Cancer Patients Receiving Opioids.

Objectives:To examine whether the inter-individual variation in constipation among patients receiving opioids for cancer pain is associated with genetic or non-genetic factors.Methods:Cancer patients receiving opioids were included from 17 centers in 11 European countries. Intensity of constipation was reported by 1,568 patients on a four-point categorical scale. Non-genetic factors were included as covariates in stratified regression analyses on the association between constipation and 75 single-nucleotide polymorphisms (SNPs) within 15 candidate genes related to opioid- or constipation-signaling pathways (HTR3E, HTR4, HTR2A, TPH1, ADRA2A, CHRM3, TACR1, CCKAR, KIT, ARRB2, GHRL, ABCB1, COMT, OPRM1, and OPRD1).Results:The non-genetic factors significantly associated with constipation were type of laxative, mobility and place of care among patients receiving laxatives (N=806), in addition to Karnofsky performance status and presence of metastases among patients not receiving laxatives (N=762) (P<0.01). Age, gender, body mass index, cancer diagnosis, time on opioids, opioid dose, and type of opioid did not contribute to the inter-individual differences in constipation. Five SNPs, rs1800532 in TPH1, rs1799971 in OPRM1, rs4437575 in ABCB1, rs10802789 in CHRM3, and rs2020917 in COMT were associated with constipation (P<0.01). Only rs2020917 in COMT passed the Benjamini–Hochberg criterion for a 10% false discovery rate.Conclusions:Type of laxative, mobility, hospitalization, Karnofsky performance status, presence of metastases, and five SNPs within TPH1, OPRM1, ABCB1, CHRM3, and COMT may contribute to the variability in constipation among cancer patients treated with opioids. Knowledge of these factors may help to develop new therapies and to identify patients needing a more individualized approach to treatment.

The use of prucalopride in real life for the treatment of constipation subtypes: ups and downs

Chronic constipation is a symptom the physician faces almost daily. Treatment consists of several pharmacological and non-pharmacological options; the fact that to date, no treatment is completely effective justifies the numerous drugs available for this condition [1]. Moreover, there is a subset of constipated patients who have an unsatisfactory response to medical treatment or do not respond at all [1]. Until recently, these patients were often referred for surgical or other invasive approaches, with results that were far from optimal [2]. However, in recent years, new compounds have been developed for the treatment of chronic constipation, compounds that seem to have good efficacy with relatively few side effects [3]; one of these, prucalopride, has recently been released on the European market as an alternative treatment for female patients (representing more than 85 % of the overall population of constipated subjects) that show an insufficient response to laxatives [4]. To date, prucalopride has been mainly tested on patients recruited for clinical trials, and some authors claim that further subgroup analysis of the actual patient group of interest may be helpful in guiding clinical decision-making [5]. Thus, data on ‘‘real-life’’ patients or those with subtypes of constipation are still not available. In this issue, Jadav and colleagues [6] try to give us some answers concerning the above points, by reporting in a retrospective study the treatment data of patients with constipation (defined according to the Rome III criteria) due to obstructed defecation (OD), to delayed transit (slowtransit constipation, STC), to a mixed-type (ODSTC), or to irritable bowel syndrome (IBS-C). These patients were given treatment according to the National Institute for Health and Clinical Excellence guidelines and had no relief from constipation despite trying at least two different types of laxatives and lifestyle modification for at least 6 months [7]. The authors compared the efficacy of prucalopride with the constipation subtypes according to simple criteria, most likely similar to those adopted in daily clinical practice: After 4 weeks, patients were asked whether they were satisfied with the treatment, and whether they wanted to continue with the treatment. Overall, 42 % of the entire group benefitted from the treatment after 4 weeks, and after an average follow-up period of 5 months, the benefit persisted in 36 % of patients. These results (including dropouts) are comparable with results of larger published trials [8]. The interest of the study lies in the fact that the response to prucalopride was also observed in well-defined subgroups of constipated patients. There was a similar response between subgroups (59 % OD, 31 % STC, 43 % OD-STC, 44 % IBS-C), with surprisingly better results in OD patients. The surprise is due to the fact that previous studies suggested that the effect of the drug is lower on straining at stool [9], a symptom often considered as the hallmark of OD and mainly responding to biofeedback treatment [10]. However, OD itself is an umbrella term under which several pathophysiologic abnormalities may G. Bassotti Gastroenterology and Hepatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy

Levels of satisfaction with current chronic constipation treatment options in Europe – an internet survey

Data on treatment satisfaction in European men and women with chronic constipation are limited. To assess satisfaction with current treatment among European men and women with chronic constipation. An internet-based survey was conducted in 2009 in 10 European countries: Austria, Germany, France, Ireland, Italy, Spain, Switzerland, the UK, Belgium and the Netherlands. Participants had self-reported chronic constipation (<3 bowel movements/week and ≥1 symptoms for ≥6 months of: pain during defecation; lumpy/hard faeces; and feeling of incomplete evacuation). Demographic data and disease history were collected. For participants using laxatives, drug name/class, satisfaction with treatment and interest in other treatments were collected. Of the 1941 participants screened, 1355 had chronic constipation and met the inclusion criteria (chronic constipation population). The majority of the chronic constipation population who disclosed their sex (n = 811) were women (82%). Sixty-eight per cent of respondents (n = 855/1255) reported using laxatives, with the proportion of laxative users differing between subsets. Twenty-eight per cent (n = 225/793) were (very) satisfied with their treatment, whereas 44% (n = 345/793) were neutral and 28% (n = 223/793) (very) dissatisfied. There was no relationship between type of laxative and degree of (dis)satisfaction. Interest in other treatments was high with 83% (n = 686/827) of respondents 'absolutely' or 'probably' interested. Respondents dissatisfied with their treatment were more likely to be interested in other treatments. Laxative-use is common for chronic constipation. In this large survey, 28% of participants were dissatisfied with their treatment, with the majority interested in other treatments.

PGI13 Economic Burden and Treatment Patterns of Adult Patients With Chronic Constipation Identified Through Retrospective Database Research

ECONOMIC BURDEN AND TREATMENT PATTERNS OF ADULT PATIENTS WITH CHRONIC CONSTIPATION IDENTIFIED THROUGH RETROSPECTIVE DATABASE RESEARCH Lofroth E1, Bruce Wirta S1, Hodgkins P2, Bloomfield E3, Kerstens R4, Joseph A5 1IMS Health, Stockholm, Sweden, 2Shire Pharmaceuticals LLC, Wayne, PA, USA, 3IMS Health, London, UK, 4Shire-Movetis NV, Turnhout, Belgium, 5Shire Switzerland, Eysins, Switzerland OBJECTIVES: To collect real-world data on the economic burden and treatment patterns associated with chronic constipation in Swedish patients through retrospective database research. METHODS: A regional Swedish database was used that combines diagnostic and health care data with prescription drug use and mortality data from national registers. The drug register comprises all dispensations made at pharmacies, defined as dispatches. According to Swedish legislation, a dispatch can last for up to 90 days, which is common for chronic diseases. Adults with chronic constipation ( 2 primary constipation diagnoses, or one primary constipation diagnosis and two associated laxative dispatches, over 12 months) were selected during 2005-2008. Patients with irritable bowel syndrome (IBS) or opioidinduced constipation were excluded. Data were retrieved on: health care contacts and drug use for 12 months from the first constipation diagnosis; patient demographics; and comorbidities. RESULTS: Of the initial selection, 2119 patients were excluded owing to opioid use (32%) and 435 owing to IBS (7%). The final population comprised 4043 patients (60% women) with a mean age of 67 years (range: 18-106 years). A history of arrhythmia or diabetes mellitus was common ( 10%), with prevalence increasing with age. During follow-up, patients had, on average, 2.3 constipation-related health care contacts and 15.2 additional health care contacts, at average annual costs of €1642 (standard deviation [SD]: €14 618) and €5944 (SD: €18 209), respectively. Most patients (54%) used 1 type of laxative during follow-up and 17% used 3 types. On average, patients had four laxative dispatches and 43 non-laxative dispatches, at average annual costs of €61 (SD: €74) and €624 (SD: €1137), respectively. CONCLUSIONS: Patients with chronic constipation were mainly elderly with high disease burden, as demonstrated through frequent health care contacts (17.5/year) and extensive drug use (47 dispatches/year). Constipationrelated care accounted for 22% of total resource utilization, while laxatives made up 10% of total drug costs.

Randomized Controlled Trial of Laxative Use in Postcolostomy Surgery Patients

We compared a standardized postoperative laxative protocol to laxatives provided on an ad hoc basis by the surgical team. Forty-five patients who underwent colostomy surgery participated in the study. The research setting was 2 acute care facilities in south-eastern Sydney, New South Wales, Australia. A randomized controlled trial was conducted. The intervention group (n 5 19) received a standardized laxative protocol postsurgery. Two types of laxatives were selected for first-line treatment: sterculia and frangula bark (Normacol Plus), a bulking agent and stimulant; and liquid paraffin (Agarol), a stool softener. An iso-osmotic polyethylene glycol macrogel (Movicol) was chosen as second-line treatment. The comparison group (n = 26) received laxative intervention(s) as preferred by the surgical team. Constipation, measured as fecal loading on plain abdominal film, stomal therapy nurse activity, patient comfort, and length of hospital stay were compared between intervention and control groups. The presence of fecal loading favored the intervention group (1 episode in the treatment group vs 7 episodes in the comparison group; χ5 = 3.8; P = .05). This finding suggests that the laxative protocol given to the treatment group was more likely to prevent fecal loading/constipation when compared to the ad hoc laxative group. Stomal therapy nurse activity in terms of the number of empty bag changes was significantly higher in the comparison group (F 5 4.8; P 5 .03). The findings of this study support the benefits of a standardized laxative protocol for prevention of constipation. Data collection was discontinued after 3 years due to a contamination effect developing, because our surgeons observed the utility of the laxative protocol and incorporated it into their routine practice. Further experimental research is needed to explore the best constipation prevention approaches for postcolostomy surgery patients.

A retrospective pilot study to explore the timing of cessation of laxatives before death in a palliative care unit

Constipation is common and sometimes distressing in palliative care patients. Laxatives are often prescribed, but there is little guidance as to the most appropriate time to cease these medications as death approaches. To conduct a retrospective pilot review of usual prescribing of laxatives toward the end of life in a specialist palliative care unit. The notes of all 92 inpatients who died over a 2-month period were reviewed, with the main outcomes of interest being the number and types of laxatives prescribed and the documentation of bowel movements in relation to time of death. On admission 70% of the patients were receiving laxatives, with a mean of two different types per person. The mean number of days before death that people had a bowel movement recorded by nursing staff was 3.8 (standard deviation (SD) 3.55). No differences were identified between those who had not received laxatives at any point, those who received laxatives until death, and those who ceased laxatives at distinct time points. However, differences were found between those who were commenced on an end-of-life care pathway (mean 4.30 days; SD 3.84) and those who were not (mean 2.50 days; SD 2.31) (P=0.01). The correct timing for cessation of laxatives as death approaches remains unclear. Further work is needed to understand how bowel function changes with disease progression and the subjective experiences of patients.

The difficult patient with constipation

Difficult patients with constipation mostly suffer for years, have consulted more than one physician and have had some experience with laxatives. The first step should be sorting out what exactly the patient's problem is. For this purpose technical investigations may be helpful, but the most important measures are a detailed history, symptom analysis and proctological examination. Rarely, an underlying and treatable cause of the constipation can be identified. In disordered defaecation this may be a large rectocele or an intussusception of the rectum amenable to proctosurgery. In most cases, however, some form of laxative treatment will be required. For this purpose, a detailed knowledge of their pharmacology is mandatory. The type of laxative and the schedule of administration often have to be determined on an individual basis over a number of weeks. In some patients, combination treatment with macrogol and a stimulant laxative may be the solution. Psychological features must also be taken into account in difficult patients, in particular if they ask for colectomy. Total colectomy with ileorectal anastomosis is an effective (although not universally successful) treatment of constipation, which is, however, hampered by a high rate of both early and late complications.