what instruction should the nurse give to the patient taking methylcellulose?

• Journal List
• J Adv Pract Oncol
• v.8(two); 2017 Mar
• PMC5995490

J Adv Pract Oncol. 2017 Mar; eight(2): 149–161.

Published online 2017 Mar 1.

Managing Constipation in Adults With Cancer

Abstract

Constipation is common in individuals with cancer, occurring in most threescore% of patients overall. The incidence increases in patients with avant-garde disease, especially in those receiving opioid analgesics or medications with anticholinergic backdrop. Constipation is not uniformly assessed and therefore not recognized and accordingly managed in many instances. This can increment patients' concrete and psychological distress. Furthermore, in that location is scant research to support current management strategies for constipation. The objectives of this review are to explore the incidence of and risk factors for constipation in patients with cancer, to hash out the extent of the problem, to explore the nonpharmacologic and pharmacologic measures for constipation and fecal impaction, and to synthesize a laxative direction. An extensive review of medical, pharmacy, and nursing literature was done to explore the physiology and pathogenesis of constipation; detail the mechanisms of activity, onset of effect, estimate costs, and adverse effects of drugs for constipation; and condense clinical proficient consensus recommendations for constipation, particularly in patients with cancer. Avant-garde practitioners (APs) and other clinicians play crucial roles in identifying individuals at risk for and experiencing constipation to help them employ effective regimens, including over-the-counter laxatives, and mayhap adjunctive nondrug measures. Clinicians and patients must develop an agreed-upon language for identifying the severity and effects of constipation. In add-on, both should empathise which laxatives are most advisable and which should exist avoided for particular patients. Two prescription agents are also bachelor, and understanding when they should be used is of import for APs.

Constipation is a common and distressing problem for many individuals with cancer during handling and palliative care, and perchance even during survivorship; in too many instances, it goes unrecognized and untreated (McMillan, Tofthagen, Modest, Karver, & Craig, 2013). Constipation can range from an abrasive discomfort to life-threatening impaction with circulatory, cardiac, or respiratory symptoms (Clemens, Faust, Jaspers, & Mikus, 2013). This article will review the incidence, adventure factors, cess, and management of constipation in persons with cancer.

NORMAL BOWEL HABITS AND CONSTIPATION

The range of normal bowel movements (BMs) in healthy people is arbitrarily defined as three BMs per day to three per week (Candy et al., 2015). In general, constipation occurs considering prolonged bowel transit allows more water to be absorbed from feces through the bowel wall, which leads to hard, dry, and difficult-to-pass stools (Twycross, Sykes, Mihalyo, & Wilcock, 2012). Many authors use the Rome 3 criteria (Table 1) to ascertain constipation characteristics, but these criteria for functional constipation do not consistently fit with constipation in advanced affliction (Longstreth et al., 2006).

Rome III Diagnostic Criteria for Functional Constipation

Constipated stools tin range from small, hard "rocks" to large bulky masses and may be accompanied past discomfort or pain (Clemens et al., 2013; Costilla & Foxx-Orenstein, 2014). Other related manifestations may include abdominal distention and bloating, urinary retentiveness, nausea, anorexia, and rectal problems (e.g., hemorrhoids and anal fissures; Clemens et al., 2013). Constipation can besides crusade paradoxical or overflow diarrhea, as liquid stool passes around the obstructing constipated stool. Chronic constipation can also lead to fecal impaction, particularly in patients with advanced disease who have poor oral intake with little dietary fiber, dehydration, express physical activity or immobility, or abdominal tumor (Hussain, Whitehead, & Lacy, 2014).

A total of 43% to 58% of patients with cancer written report constipation (McMillan et al., 2013)—the third most common symptom (after pain and anorexia) in those with avant-garde disease (Clemens et al., 2013). In terminally ill patients, bowel dysfunction may occur in ≥ 80% of patients and in 90% of patients taking opioids (Downing, Kuziemsky, Lesperance, Lau, & Syme, 2007; Rhondali et al., 2013). Furthermore, drugs that contribute to an "anticholinergic load" are strongly implicated in constipation in palliative care patients (Clark, Lam, Agar, Chye, & Currow, 2010). Equally can be gleaned from Table 2 on the post-obit page, constipation in patients with cancer is typically multicausal and related to organic, functional, and drug-related effects (Bharucha, Pemberton, & Locke, 2013; Clemens et al., 2013; Costilla & Foxx-Orenstein, 2014; Solomon & Cherny, 2006). For example, a patient'southward constipation might be related to polypharmacy (taking an opioid analgesic for pain along with other drugs that have anticholinergic properties) and may be exacerbated by low physical activity, decreased oral intake of food and fluids, and diabetes.

Possible Causes of Constipation in Persons With Cancer

It is prudent to conceptualize opioid-induced constipation (OIC) in patients starting or taking opioid analgesics and to commencement prophylactic management. Opioid receptors are expressed throughout the enteric nervous system (ENS) in the gastrointestinal (GI) tract, and OIC occurs because opioids demark to ENS receptors and induce delayed gastric elimination, decreased intestinal secretion, slowed propulsive contractions, decreased colonic movement, increased fluid assimilation from stool, and increased sphincter tone, which result in retention of hard, dry stools (McMillan et al., 2013; Mori et al., 2013). Tolerance to OIC rarely develops, and patients may skip or decrease opioid doses or stop taking their opioid birthday to salvage OIC. This problem leads to increased pain, reduced activities of daily living, and reduced quality of life (Camilleri et al., 2014).

FECAL IMPACTION

Chronic, unmanaged constipation tin can progress to fecal impaction, which farther impairs patients' quality of life and increases wellness-care costs (Hussain et al., 2014). Feces remaining in the colon for longer than normal cause slap-up water and common salt resorption from the colon, which further slows peristalsis and stool packing. In depression impactions, stool accumulates in the descending colon to the rectum, and in high impactions, stool fills the ascending colon (Bisanz, 2007). A difficult, dry out fecal mass essentially obstructs the colon or rectal vault and may be accompanied by overflow incontinence every bit diarrhea seeps around the stool mass (Solomon & Cherny, 2006).

FOCUSED BOWEL HISTORY AND Concrete Assessment

A patient's self-report of constipation, which can be gained by a reliable and valid screening tool (run across "Assessment of Constipation in Patients With Cancer" in the May/June 2016 issue of JADPRO), should be incorporated into a more thorough focused history and physical examination to confirm constipation (and rule out bowel obstruction; Librach et al., 2010; Selby & Corte, 2010). Assessment parameters include:

• What the patient considers "normal" BMs

• Usual bowel habit, duration of feeling constipated, date of last BM

• Electric current stool appearance (consistency, color, odor, blood, mucous)

• Associated symptoms (due east.g., nausea, intestinal fullness, bloating, gas, diarrhea, tenesmus)

• Likely causes and contributing factors (see Table ii):

  • Medication history, including laxatives, suppositories, enemas

  • Medical weather condition affecting laxative selection (due east.1000., vocal string paralysis, which precludes mineral oil, or impaired renal function, which contraindicates magnesium salts)

• Current diet and want to eat also as fiber intake (can patient consume fiber to 30 G per day and drink sufficient fluids to maximize majority effects and avoid exacerbating constipation?)

• Activity level, altered mobility, fatigue, or weakness, which may interfere with usual normal BMs.

Laboratory tests, per se, are non indicated except to identify contributing factors for constipation (eastward.one thousand., hypercalcemia or diabetes) or risks from detail interventions (eastward.g., claret urea nitrogen and creatinine levels to assess renal function, and white blood cell and platelet counts to identify risks with rectal administration or manual disimpaction). Similarly, a flat plate of the belly may differentiate severe constipation, fecal impaction, and obstacle (Bisanz, 2007).

The physical exam focuses on the patient's abdomen and rectum. If the abdomen appears distended, look for visible peristalsis. Auscultation will distinguish amongst normal, hyperactive, and absent bowel sounds. Palpable masses—particularly left-sided (descending colon)—must be examined past deep palpation to distinguish stool (which indent) from tumors (which do non; Clemens et al., 2013; Librach et al., 2010). A fecal mass with gas trapped in the bowel may experience like crepitus, and percussion may differentiate ascites and a gas-filled bowel. A tympanic, distended abdomen with mild lengthened tenderness may signal fecal impaction (Hussain et al., 2014).

It is important to consider factors that contraindicate rectal examination (east.g., neutropenia or thrombocytopenia), cultural sensitivities, and ensuring privacy during the exam. Poor internal anal sphincter tone may indicate spinal impingement or compression (ask the patient to strain or button down while doing the exam to evaluate). Patients who accept precipitous, knifelike pain during the examination may have mucosal injury (Costilla & Foxx-Orenstein, 2014). A dilated rectum or no palpable stool in the rectal vault may indicate higher constipation in the sigmoid colon (Hussain et al., 2014; Librach et al., 2010). Difficult, dry stool in the rectum with fecal impaction directs the first management pace: elimination of impacted stool before starting oral laxative therapy (Clemens et al., 2013).

Management

Managing constipation aims to alleviate patient discomfort, restore and maintain satisfactory and comfy BMs, prevent related symptoms of constipation or laxatives (eastward.g., nausea, bloating, and abdominal hurting), improve a patient'southward sense of control of bowel habits, and preserve comfort and dignity (Clemens et al., 2013; Larkin et al., 2008; Librach et al., 2010). Interventions are somewhat based on prognosis and how pitiful constipation is to the patient. Management approaches may include nondrug, adjunct measures but eye on pharmacologic interventions.

Nondrug Measures

There is meager evidence for lifestyle modifications (e.g., ensuring patient privacy and condolement, recommending the patient try to defecate the same time each morning or after eating) and dietary fiber (Andrews & Morgan, 2013; Foxx-Orenstein, McNally, & Odunsi, 2008) for patients with cancer. Increasing oral fluids and practise may not be useful (or possible). Cobweb has express benefit and cannot forbid or treat OIC, which requires prophylactic laxatives (Clemens et al., 2013; Wald, 2007). Similarly, suggesting a cobweb supplement to an anorexic and mildly dehydrated patient with avant-garde disease is counterproductive, because fiber can worsen early satiety and requires drinking plenty of fluids to be effective (Larkin et al., 2008). The results of a meta-analysis of five studies that examined the effect of dietary fiber on constipation concluded fiber intake significantly increased the number of BMs merely did not improve stool consistency, laxative use, or painful BMs (Yang, Wang, Zhou, & Xu, 2012). These authors suggested dietary cobweb might be effective for balmy to moderate, merely not severe, constipation. Relatively healthy patients with a skilful prognosis can notice recipes for homemade fiber supplements (for examples, see http://world wide web.in.gov/fssa/files/Bowel_Aid_Food_Recipes_OR-FM-HS-CN-12(eleven-half-dozen-09).pdf).

Observational studies, case reports, and clinical reviews advise abdominal massage may be another helpful adjuvant measure for constipation in palliative care patients, elderly individuals, patients with spinal cord injury, or those with postoperative ileus (Sinclair, 2011). There is evidence of the physiologic effects of abdominal massage to increment GI motility and digestive secretions, relax sphincters, shorten GI transit time, decrease abdominal discomfort, and enhance rectal loading, which increases the awareness of having to have a BM (Andrews & Morgan, 2013; Lamas, Lindholm, Stenlund, Engstrom, & Jacobsson, 2009). One prospective study institute abdominal massage was non immediately effective, but later 8 weeks, patients in the massage group had significant reductions in GI symptoms and abdominal discomfort and increased BMs vs. the control grouping (Lamas et al., 2009). The nurse investigators concluded the delayed consequence of abdominal massage complements laxatives. Clinicians can teach intestinal massage to patients or caregivers, which enhances patients' cocky-direction and relaxation (Andrews & Morgan, 2013). Many websites clearly and succinctly explain the procedure, and most have helpful illustrations (for examples, come across https://www.youtube.com/watch?v=N39GIWquhWg or http://www.guysandstthomas.nhs.united kingdom of great britain and northern ireland/resources/patient-data/gi/abdominal-massage-for-constipation.pdf)

Pharmacologic Therapy

Pharmacologic agents for constipation include oral, over-the-counter (OTC) laxative products, rectal suppositories and enemas, and methyl-naltrexone (a prescription parenteral drug; come across Table 3). Oral products are classified as bulking agents, stool softeners, stimulant laxatives, and osmotic laxatives. There are few randomized controlled laxative studies in cancer or palliative intendance, and laxative selection is largely based on clinical experience and practiced consensus recommendations. All laxatives and methylnaltrexone are contraindicated in patients with suspected bowel obstacle (Woolery et al., 2008).

Pharmacologic Agents for Managing Constipation

Pharmacologic Agents for Managing Constipation (cont.)

Bulking Agents: Soluble (e.g., psyllium, pectin) and insoluble (methylcellulose) fiber products induce a stretch reflex in the intestinal wall, which increases propulsive activity, h2o absorption, and bacterial proliferation in the colon, leading to softer and larger stool masses and easier BMs (Candy et al., 2015; Costilla & Foxx-Orenstein, 2014; Larkin et al., 2008; Wald, 2007). Majority laxatives are non effective for already-constipated cancer patients, especially those taking opioid analgesics or anticholinergic drugs. They are most appropriate for patients who practice not consume adequate dietary fiber, have a skillful operation status, are experiencing mild to moderate constipation, and accept normal GI transit.

Bulking laxatives are generally well tolerated, but side effects may include bloating and excessive gas. Bulking laxatives may worsen symptoms in patients with slow-transit constipation acquired past opioids or anticholinergic agents or with anorectal dysfunction. In improver, bulking laxatives are not recommended for patients with advanced disease who may not drink sufficient fluids to avoid intestinal obstruction or fecal impaction (Candy et al., 2015; Woolery et al., 2008). Rare adverse effects of bulking laxatives include esophageal obstacle and psyllium hypersensitivity (Xing & Soffer, 2001). Acute esophageal obstacle after ingesting a bulking laxative has occurred in patients with or without mild dysphagia. The actual incidence of hypersensitivity is non known, but 5% of individuals preparing psyllium experienced shortness of breath, wheezing, or hives within 30 minutes after preparing psyllium laxatives. Bulking laxatives tin also significantly reduce feelings of hunger, increment a sense of satiety, and delay gastric emptying—all negative effects in patients with advanced cancer.

Stool Softeners (Lubricants or Emollients): Docusate (Colace, Surfak) and mineral oil (liquid paraffin) are stool softeners that act every bit detergents (surface-wetting agents) and let water to enter the bowel and lower surface tension and as lubricants/emollients to soften and lubricate stools (Costilla & Foxx-Orenstein, 2014; Hsieh, 2005; Pitlick & Fritz, 2013). Used alone, stool softeners are less effective than psyllium and are ineffective for constipated individuals. Patients must increase fluid intake with these agents to soften stools; this may be useful for patients with hemorrhoids or anal fissures, which cause painful defecation, and for those who should otherwise avert straining (Candy et al., 2015; Woolery et al., 2008). Withal, docusate would be contraindicated in patients with poor oral intake who cannot increase fluids or in those with overly dry stools secondary to prolonged fourth dimension in the colon secondary to OIC. Docusate may enhance gastrointestinal or hepatic uptake of other drugs, but the magnitude of this effect and its clinical significance in altering hepatotoxicity are unknown (Xing & Soffer, 2001).

Information technology has besides been proposed that regular utilise of mineral oil might impede assimilation of fat-soluble vitamins, but this has not been confirmed. Mineral oil poses a risk for aspiration pneumonia in patients with swallowing disorders and can cause perianal irritation considering of seepage of oily material (Xing & Soffer, 2001).

Some palliative care and hospice clinicians are familiar with oral petroleum jelly (OPJ), too called "Vaseline balls," as an culling to mineral oil used after unsuccessful treatment of constipation with standard laxatives. Tavares, Kimbrel, Protus, and Grauer (2014) did an online survey including a convenience sample of 353 physicians, nurse practitioners, nurses, and pharmacists (67% of whom were familiar with OPJs), which was used in approximately ten% of patients. Most of the clinicians (87%) rated OPJs equally effective or very effective in inducing BMs within 24 hours of administration.

Oral petroleum jelly is fabricated past chilling petroleum jelly, forming it into pea- to marble-sized assurance, rolling information technology in powdered or granulated coatings to raise palatability, and freezing or refrigerating information technology until use. Freezing hypothetically makes OPJs safer than mineral oil, because they practice not liquefy until they reach 100.4°F in the GI tract. At that point, they are thought to act similar mineral oil to glaze and soften carrion causing high impaction. In that location is no agreed-upon dosing size or interval for OPJ.

Stimulants: Stimulant laxatives include senna (Senokot, Ex-Lax), bisacodyl (Dulcolax, Correctol), and castor oil. They induce a strong laxative consequence past directly stimulating submucosal and deeper myenteric plexuses in the bowel wall to crusade forceful peristalsis, and increased water and electrolytes release into the intestine (Costilla & Foxx-Orenstein, 2014; Hsieh, 2005; Larkin et al., 2008; Wald, 2007). Senna must be administered orally to exist metabolized and activated in the GI tract, whereas bisacodyl tin can be given orally or past suppository, as information technology is activated by abdominal glucuronidase. Stimulant laxatives are considered first-line options and are often used for OIC, especially senna, which counters opioid-induced–segmenting action and is the least expensive (Pitlick & Fritz, 2013; Twycross et al., 2012; Woolery et al., 2008).

Osmotic Agents: Nonabsorbable sugars and polyethylene glycol (PEG) without electrolytes are osmotic laxatives—first-line drugs because of their rapid onset, low number of adverse effects, ease of utilise, and relatively low cost. Polyethylene glycol is an excellent selection because of its softening and stimulating effects (Pitlick & Fritz, 2013). These poorly captivated ions or molecules cause an osmotic slope inside the small intestine and lead to water retention, faster abdominal transit, and softer feces (Clemens et al., 2013; Costilla & Foxx-Orenstein, 2014; Hsieh, 2005; Twycross et al., 2012; Wald, 2007).

Magnesium salts (milk of magnesia, magnesium sulfate [Epsom salts], and magnesium citrate) are as well osmotic. Even so, the ions of magnesium-containing cathartics are partially absorbable, and then serious adverse furnishings related primarily to excessive ion absorption may crusade metabolic disturbances (Xing & Soffer, 2001). Repetitive dosing tin lead to hypermagnesemia and symptoms of hyporeflexia and sluggishness, which can progress to a medical emergency with hypotension, shock, prolonged QT interval, respiratory depression, and even decease. Magnesium laxatives should be used for acute evacuation (to rapidly induce a BM) and avoided in patients with renal insufficiency. Nevertheless, hypermagnesemia has occurred in patients with normal renal role. Chronic use of these agents may also exacerbate fluid overload in patients with congestive heart failure.

Lactulose and sorbitol are indigestible and nonabsorbable sugars, which colonic bacteria metabolize into compounds that increase stool acerbity and osmolality, causing fluid to exist drawn into the colon and peristalsis to increase (Hsieh, 2005; Wald, 2007). Bacterial fermentation with lactulose also causes gas production, abdominal cramping, and flatulence—especially with larger doses. On the other paw, colonic bacteria cannot degrade PEG (MiraLAX), which is therefore less likely to cause bloating and gas. Once-daily PEG usually induces laxation, and in that location is some evidence it is superior to lactulose for chronic constipation (Solomon & Cherny, 2006; Woolery et al., 2008). Potential electrolyte imbalances that can occur with osmotic laxatives including lactulose or sorbitol include hypernatremia and hypokalemia (Xing & Soffer, 2001). These events occur because more than h2o than sodium stays in the GI tract, and potassium tin can be lost in loose stools.

Peripheral Opioid Antagonists: Methylnaltrexone is the only peripheral mu-opioid antagonist canonical for OIC in patients with advanced affliction or not–cancer-related hurting. Peripheral opioid antagonists are not laxatives, per se. As discussed, opioids non only bind to central nervous system opioid receptors, only to mu receptors in the ENS to ultimately cause OIC (Chey et al., 2014; Wald, 2016). Methylnaltrexone and other ENS antagonists (e.g., naloxegol and alvimopan) competitively bind to GI opioid receptors and antagonize ENS effects, but they cannot cross the blood-encephalon barrier to decrease analgesia. Methylnaltrexone does not replace the need for laxatives for constipation from other causes or other manifestations such as abdominal cramping and delayed gastric elimination (Ahmedzai & Boland, 2010).

Nigh adults who have OIC (despite receiving laxatives) have a BM within 4 hours of receiving subcutaneous (SC) methylnaltrexone (Portenoy et al., 2008). The nigh common adverse furnishings of methylnaltrexone are mild abdominal pain, diarrhea, nausea, rectal gas, or vomiting. Information technology is initially given every other twenty-four hour period in doses based on a patient's weight. Dosing intervals may be extended or reduced, but methylnaltrexone should not be given more than in one case a day. Severe renal impairment (creatinine clearance < 30 mL/min) requires a l% dose decrease (Pitlick & Fritz, 2013). Because of its high cost compared with other oral and rectal laxatives, methylnaltrexone would be justifiable just after optimal doses of other laxatives have been ineffective (Argoff et al., 2015; Twycross et al., 2012).

Rectally Administered Suppositories and Enemas: Rectal laxatives—suppositories or enemas—are more often than not safety and effective and are a preferred option when rapid and anticipated evacuation of stool from the rectum and distal colon is desirable, such as in patients with fecal impaction, complete spinal cord injury, or neurogenic bowel (Brownish, Henderson, & McDonagh, 2009; Woolery et al., 2008). If a patient has fecal impaction, management may include disimpaction, evacuation of the colon, and a maintenance bowel regimen to prevent recurrence (Hussain et al., 2014). In patients with cancer, the start pace would be an enema or suppository to soften or lubricate the stool in the rectum and distal colon to allow for easier passage.

On the other mitt, manual disimpaction (with light sedation) would be a last choice for cancer patients because of patient discomfort, possible embarrassment, and take a chance for complications (Hussain et al., 2014; Solomon & Cherny, 2006). Before transmission disimpaction, the clinician must rule out contraindications—especially neutropenia and thrombocytopenia—and consider the patient's relative risks for iatrogenic mucosal injury or perforation, syncope, or arrhythmia related to vagal stimulation (Hussain et al., 2014). A prophylactic daily oral laxative regimen should be given with or shortly later on rectal medications have relieved the impaction (Brown et al., 2009; Solomon & Cherny, 2006).

There is no evidence to recommend one type of product over another, but microenemas are preferred over phosphate enemas, because they take smaller volumes and fewer agin effects and are similarly constructive (Dark-brown et al., 2009). Tap-water enema and glycerin suppositories are also good choices considering they usually induce BMs in 30 to lx minutes and take few side effects, although rectal administration may cause mild rectal irritation (Pitlick & Fritz, 2013; Solomon & Cherny, 2006).

Bisanz (2007) recommends a mineral oil enema equally the kickoff step for patients with depression or high impactions and a 2d enema (due east.g., lather and tap water ≤ 1 50) 1 60 minutes later if needed. A patient'due south general health and comorbid conditions dictate the amount of enema fluid tolerated. If the patient lies on his or her right side with the enema tube in place in the rectum for 20 minutes, he or she may be able to agree the enema fluid. Removing the enema tube usually causes the firsthand urge to defecate. Large meals and hot liquids before enemas or disimpaction increment peristalsis and abdominal colic and should be avoided (Woolery et al., 2008). If the patient does not experience liquid stool and is non nauseated after the first or 2d enema, magnesium citrate or PEG is a first-line choice. Lactulose or sorbitol (thirty mL 4 times per mean solar day) is another option but is more likely to cause gas, bloating, and intestinal cramps. Any of these enemas can be repeated in 12 hours if needed.

Sodium (Fleet) phosphate enemas are unremarkably used in palliative care and are considered relatively safe. Nonetheless, individuals older than 65 years and others with comorbidities may exist at greater gamble for water and electrolyte abnormalities (Ahmedzai & Boland, 2010). There are reports of sodium phosphate enemas causing pregnant morbidity and mortality in elderly patients or those with renal insufficiency, even when standard doses are given (Ori et al., 2012; Xing & Soffer, 2001). Affected patients typically present within 24 hours (although this may occur up to 72 hours later) with astute and life-threatening hyperphosphatemia and reciprocal hypocalcemia, nausea and airsickness, metabolic acidosis, acute renal failure, and perhaps hypernatremia and hypokalemia. This is a medical emergency, and patients crave fluid resuscitation and sometimes hemodialysis.

The pathogenesis of extreme hyperphosphatemia is linearly related to enema retentivity time; when a stool is non expelled within a short time, phosphate is absorbed from the colon into the circulatory system. Sodium phosphate enemas should thus exist avoided in patients with fecal impaction, paralytic ileus, or bowel obstruction, as well equally in patients with fluid-electrolyte disturbances. Thus, if the patient does not expel enema stool within xxx minutes, other measures must exist taken to evacuate the bowel to minimize absorption of phosphate.

PUTTING Information technology ALL TOGETHER

Avant-garde practitioners (APs) can be instrumental in developing and implementing bowel protocols in their practise settings. These protocols are not simply appropriate for patients undergoing cancer treatment, only ofttimes get useful for cancer survivors and those who feel progressive illness and receive palliative intendance. As discussed, there is piffling research to support laxative selection and dose escalation for patients with cancer, OIC, or those receiving palliative intendance; constipation management recommendations are largely based on consensus (Brick, 2013; Camilleri et al., 2014; Pitlick & Fritz, 2013). Such recommendations take been published past Canadian (Librach et al., 2010) and European (Larkin et al., 2008) authors. In the United States, the Oncology Nursing Social club also has links to clinically useful resources (https://www.ons.org/practice-resources/pep/constipation) and summary recommendations (Woolery et al., 2008).

Factors to considers when formulating a laxative plan include the patient's prognosis and relative health, whether the patient is already constipated or constipation is likely (e.g., the patient is starting opioid therapy for hurting command, whether they take other risk factors for constipation or are taking more than than one drug with anticholinergic properties), planning strategies that may aid the patient adhere to a laxative plan (east.grand., calendars, pill boxes, pill reminder apps), and making timely adjustments to the plan equally indicated.

Relatively good for you patients who are non constipated or have mild constipation, and are not taking opioid analgesics, tin can be brash to increase dietary cobweb (or use bulking laxatives or fruit pastes), fluids, and exercise, which may be helpful to preclude or minimize constipation. Conversely, these deportment may actually be harmful to patients with progressive or advanced disease. Similarly, bulking laxatives and stool softeners have little (if any) upshot on chronic constipation and at best should exist considered adjuvants to other laxatives (Hawley & Byeon, 2008). Although many clinicians advise patients to take senna plus docusate (e.thousand., Senokot Southward), particularly for OIC, there is no bear witness that docusate adds any do good (Ahmedzai & Boland, 2010; Hawley & Byeon, 2008). Furthermore, senna plus docusate may increment the pill load for patients who take generic products and does not decrease intestinal side effects.

Senna, lactulose, and PEG are similarly constructive first-line laxatives (Ahmedzai & Boland, 2010; Candy et al., 2015; Hawley & Byeon, 2008; Wald, 2016). Toll can initially guide laxative choice. Senna is the least expensive and probably nigh widely used, and it can be started every bit a single agent. Patients with OIC generally need higher doses than patients who are constipated secondary to other causes, but there is no straight and predictable relationship between increasing doses of opioids and higher doses of laxatives. As can be seen in the Figure, a proposed strategy for starting senna is one dose at bedtime or perchance ii doses per mean solar day (each morning and at bedtime) for a patient who has OIC (Ahmedzai & Boland, 2010; Hawley & Byeon, 2008; Twycross et al., 2012). If senna is not effective or tolerable, it is not unreasonable to try bisacodyl. Ultimately, the patient may take two or more laxatives, and they should be from dissimilar categories, such as a stimulant laxative and an osmotic laxative (Wald, 2016).

Constipation Direction Algorithm. Kickoff-line recommendations for laxatives are to outset with a stimulant, usually senna, two tablets at bedtime (HS), and to increase in a stepwise fashion. Patient who have opioid-induced constipation (OIC) generally require larger doses and may exist started at two tablets twice daily (bid). Senna is similarly effective as lactulose and polyethylene glycol (PEG), only they are second- or third-line choices and are given in the forenoon because of a faster onset of action. Laxatives may need to be changed because of abdominal cramping and gas. Patients may need more than one laxative, and so drugs with unlike mechanisms should be used. Methylnaltrexone is reserved for patients who have OIC and after other maximized doses of oral and rectal laxatives. BM = bowel motion; Mg = magnesium; SC = subcutaneous; tid = three times a day. Data from Ahmedzai & Boland (2010); Hawley & Byeon (2008); Pitlick & Fritz (2013); Selby & Corte (2010); Twycross et al. (2012); Wald (2016).

Advanced practitioners must piece of work closely with the constipated individual with cancer to find the all-time regimen for him or her, and should requite the patient written instructions to buy generic unmarried or combined products that are inexpensive, as the same branded products are expensive. Initial instructions are to have a dose at bedtime, add together a morning dose as needed, and so titrate equally necessary or alter to an alternative product. Some patients with OIC benefit from adding an osmotic laxative (lactulose [Enulose] or polyethylene glycol [MiraLAX]) or intermittent magnesium citrate, which should exist taken early on in the day. These agents deed more than rapidly than stimulant laxatives merely may crusade gas and bloating, so enemas (oil retention, then Armada) may be another option for constipated patients. On the other mitt, bulk-forming laxatives (bran, psyllium, calcium polycarbophil, and methylcellulose) are contraindicated for patients with avant-garde illness, a poor functional condition, or low oral intake of food or fluids. Use of these agents volition lead to increased constipation, possible fecal impaction, and anorexia (Clemens et al., 2013). Subcutaneous methylnaltrexone, which antagonizes opioids bound to peripheral mu receptors in the GI tract and does not cross the blood-brain barrier, every other solar day is an alternative when standard laxatives have non been effective (Argoff et al., 2015; Wald, 2016).

CONCLUSIONS

Constipation is a high-frequency, high-impact trouble for individuals with cancer. Avant-garde practitioners have important roles in recognizing those at chance, screening for constipation and impaction, and developing logical implementation plans that center on oral laxatives. Shut patient follow-up is crucial to decide optimal doses that alleviate patient symptoms without beingness overly burdensome without causing distressing abdominal adverse effects—which tin occur with any laxative. As new evidence-based data get available, APs can likewise share this information and collaborate with physician and nurse colleagues.

Footnotes

The writer has no potential conflicts of interest to disclose.

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Articles from Journal of the Advanced Practitioner in Oncology are provided here courtesy of Harborside Press

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995490/

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