Anakku Najwan n Nurin: 2010

really, it has been a month and few days of giving birth to Nurin, but I'm still having the problem going to the loo. I have to rely on this tablet to relieve the constipation... I used to eat lot of veges eg spinach, kangkung etc abt 2 to 3 servings in each meal (mmg mkn sayur lauk nasi lah kata org).. but then during my mother's version confinement, only white rice and certain grilled fish are allowed.. Now, I'm a lot slimmer than last year.. no scale at mother's house, so no pic for proof.. he heh..
bought the tablet from a clinic at Jelawat.. Bisacodylum (Novolax)
a bit worried about the side effects of the tablet... So I googled about it and constipation.. here is the infos..

Posted by: Gastroenterologist in Constipation on June 9th, 2010

Constipation can be defined as the passage of hard stools less frequently than the patient’s own normal pattern. Patients should be aware that a daily bowel movement is not always necessary or ‘normal’.

* Initial assessment should involve investigation of possible causes of constipation, such as drugs or poor diet. However, it is not always possible to identify an obvious underlying cause.

* Colorectal cancer should be suspected in any adult aged over 45 who presents with alarm symptoms or altered bowel habit without an obvious cause. Such patients should be referred for further investigation.

* Along with removal of possible causes, dietary advice is the first step in the management of uncomplicated constipation. Laxatives should be reserved for cases where dietary intervention has failed, unless rapid relief of symptoms is required.

* Where appropriate, patients should be encouraged to gradually increase their dietary fibre intake. They should aim to eat at least one fibre rich food at every meal, as well as drinking at least two litres of fluid a day. However, a high fibre intake should be avoided in certain patients, such as immobile, elderly patients and those with faecal impaction.

* The evidence surrounding the effectiveness of laxatives is limited. At present, it is not possible to determine if fibre supplementation is superior to laxative use or which laxative is the most effective. Choice of treatment depends on the presenting symptoms, the nature of the complaint, patient acceptability and cost. If possible, long-term laxative use should be avoided.

Constipation is commonly seen in general practice. While it is often considered to be a trivial symptom, it can cause distress as well as serious complications if not treated effectively. In addition, as the NHS spends millions of pounds each year on laxatives, appropriate use of these agents is essential.

This Laxative Drugs discusses the common causes of constipation as well as the treatment options available in general practice.

Which laxative to prescribe?
As evidence comparing laxatives is limited, the choice of agent is made according to the nature of the constipation and patient preference. In addition, some laxatives are more expensive than others (see cost table).

The way in which a laxative exerts its effect also determines its likely side-effects and onset of action. Although some laxatives have complex mechanisms of action, they can be subdivided into three main groups of drugs, which are discussed below.

Bulk-forming laxatives
These agents supplement dietary fibre intake to increase the weight and water absorbency of stools. Although wheat bran is effective, ispaghula, sterculia and methylcellulose may be useful in those who cannot tolerate bran. All bulk laxatives must be taken with at least one glass of water, but they should not be taken immediately before going to bed.

Bulk laxatives take several days to exert their effect and are not suitable for acute relief. They are contra-indicated in patients with faecal impaction or existing bowel obstruction. However, they may be appropriate for long-term use when patients have normal gut motility and otherwise uncomplicated constipation.

Clinically, there appears to be little to choose between the different agents. Palatability and convenience of use are very important if patients are to adhere to treatment. Patient acceptability and cost (see cost table) are the deciding factors when choosing what to prescribe.

Stimulant laxatives
Laxatives such as bisacodyl, dantron (danthron) and senna, stimulate nerves to produce colonic contraction and decrease fluid reabsorption. Docusate also acts as a stool softener, but is considered to be comparatively ineffective when used alone.

As a laxative effect is seen within 6-12 hours, oral stimulant laxatives are taken at night to produce a morning bowel motion. They often cause abdominal cramps and are contraindicated in patients with bowel obstruction. As chronic use may lead to fluid and electrolyte imbalance, colonic atony and tolerance to their effects, they are usually reserved for intermittent or short-term use.

Preparations of a combination of dantron with either docusate (co-danthrusate) or poloxamer ‘188′ (co-danthramer) are widely used. However, the systematic review mentioned earlier found no evidence that these agents are more effective than other, cheaper laxatives.

Prescribers should be aware that the licensed indications for dantron containing laxatives have recently changed. They are no longer indicated for the general management of constipation in the elderly. They should only be used for analgesic-induced constipation in palliative care, or in the short term where bowel motion must be free from strain.

Osmotic laxatives
Osmotic laxatives exert their effect by retaining fluid in the bowel or by changing the pattern of water distribution in the faeces. Lactulose (and the similar agent, lactitol) should only be used when other laxatives have failed to produce an effect. As well as commonly causing bloating, flatulence and cramping, they are very sweet and unpalatable to some patients. They are also relatively expensive (see cost table). In addition, they must be taken regularly for up to three days before an effect is seen, making them unsuitable for rapid relief of constipation, or for ‘as required’ dosing.

There is no convincing evidence that lactulose (or lactitol) provide an advantage over other, less expensive laxatives. To illustrate this, a study in 77 long stay elderly patients, showed that a combination of senna with fibre improved ease of evacuation and stool consistency significantly more than lactulose, and at a lower cost.

A preparation containing polyethylene glycol and various electrolytes is also available (Movicol). Although limited evidence suggests it may offer a slight advantage over lactulose, published studies comparing it with other laxatives are lacking. It is also relatively expensive (see cost table). The place in therapy of Movicol remains unclear, although it may be useful in impacted or chronic cases where other interventions have failed.

Magnesium salts produce rapid bowel evacuation and when given in large doses cause defecation in one to two hours. They should be reserved for bowel clearance prior to surgery, and are not suitable for regular use, other than in patients with megarectum.

Suppositories and enemas
When oral laxatives have not produced a bowel movement or when rapid relief of rectal loading is required, a suppository or enema may be appropriate. A rectal evacuant may also give a more predictable response than an oral agent, allowing chronically constipated patients to time defecation to fit their lifestyle. Although an effect is usually seen within one to two hours of administration, enemas may need to be repeated several times to clear impacted faeces.

The choice of rectal laxative depends on the site and the type of stools. Soft stools in the rectum can be evacuated using a stimulant, such as a bisacodyl suppository. Hard stools need to be softened by using, for example a glycerol suppository (which has both stimulant and softening properties). In severe cases, a softening enema such as arachis oil can be given overnight to soften hard stools in the rectum before giving a stimulant agent, such as a phosphate enema.

Constipation in children
Management of constipation in children can be complex and often requires specialist advice.
In addition, there is often a large psychological component to a child’s constipation.

It is important not to allow constipation in children to become chronic. Generally, dietary manipulation and behavioural methods should be tried first, with children also encouraged to eat fibre rich foods and drink plenty of fluids. Fruit juices may be a useful adjunct. Detailed discussion of the use of laxatives in children is beyond the scope of this Laxative Drugs, and specialist advice should be followed.
Constipation in pregnancy
Constipation is reported in 11-38% of pregnant women, probably due to increased levels of circulating progesterone. A Cochrane review of interventions for treating constipation in pregnancy, found the evidence to be severely limited with only one trial considered to be suitable for inclusion. The review concluded that, despite the lack of good quality evidence, increasing dietary fibre in the form of bran or wheat fibre is the treatment of choice in pregnancy.

If dietary and lifestyle measures fail, bulking agents or stimulant laxatives such as senna may be used. Dantron laxatives should be avoided during pregnancy and also in breast-feeding mothers.

Conclusions
Once constipation has been confirmed after a thorough assessment, initial advice should be given on increasing fibre and fluid intake. If these measures are ineffective, or an obvious cause cannot be eliminated, a laxative may be required.

Evidence is limited around which laxative is the most effective. Choice of agent depends on the presenting symptoms, nature of complaint, patient acceptability and cost. Local laxative policies have been developed in many areas and should be followed wherever possible.

Bisacodyl Tannex
Drug Approvals
(BANM, US Adopted Name, rINNM)
Adverse Effects
Bisacodyl and other stimulant laxatives may cause abdominal discomfort such as colic or cramps. Prolonged use or overdosage can result in diarrhoea with excessive loss of water and electrolytes, particularly potassium there is also the possibility of developing an atonic non-functioning colon. Hypersensitivity reactions, including angioedema and anaphylactoid reactions, have been reported rarely. When given rectally, bisacodyl sometimes causes irritation and may cause proctitis or sloughing of the epithelium. To avoid gastric irritation bisacodyl tablets are enteric-coated.
Precautions
As with other laxatives, prolonged use should be avoided. Bisacodyl should not be given to patients with intestinal obstruction or acute abdominal conditions such as appendicitis care should also be taken in patients with inflammatory bowel disease. It should not be used in patients with severe dehydration. The suppositories should preferably be avoided in patients with anal fissures, proctitis, or ulcerated haemorrhoids.
Handling. Inhalation of bisacodyl powder and contact with eyes, skin, and mucous membranes should be avoided.
Pharmacokinetics
On oral or rectal use bisacodyl is converted to the active desacetyl metabolite bis(p-hydroxyphenyl)-pyridyl-2-methane by intestinal and bacterial enzymes. Absorption from the gastrointestinal tract is minimal with enteric-coated tablets or suppositories the small amount absorbed is excreted in the urine as the glu-curonide. Bisacodyl is mainly excreted in the faeces.
Uses and Administration
Bisacodyl is a diphenylmethane stimulant laxative used for the treatment of constipation and for bowel evacuation before investiga-tional procedures or surgery. Its action is mainly in the large intestine and it is usually effective within 6 to 12 hours after oral doses, within 15 to 60 minutes after rectal use by suppository, and within 5 to 20 minutes when given as an enema. Bisacodyl tablets should be swallowed whole and should not be taken within 1 hour of milk or antacids.
For constipation, bisacodyl is given in usual doses of 5 to 10 mg daily as enteric-coated tablets given at night or 10 mg as a suppository or enema given in the morning. Oral doses of 10 to 20 mg are given for complete bowel evacuation, followed by 10 mg as a suppository the next morning. For doses in children, see below. A complex of bisacodyl with tannic acid (bisacodyl tannex) has been given with a barium sulfate enema before radiographic examination of the colon.
Administration in children. For constipation, the following oral doses of bisacodyl are recommended for children, to be taken at night:
• 4 to 10 years: 5 mg
• over 10 years: 5 to 10 mg
Alternatively, the following rectal doses are recommended, to be inserted in the morning:
• under 10 years: 5 mg
• over 10 years: 10 mg
The BNFC gives similar doses, but limits the use of suppositories in children to those aged over 2 years.
For bowel clearance before surgery or radiological investigation, the following doses are recommended:
• 4 to 10 years: 5 mg orally the night before, followed by 5 mg as a suppository the next morning
• over 10 years: 10 to 20 mg orally the night before, followed by 10 mg as a suppository the next morning
The BNFC gives similar doses but allows for the use of oral doses for 2 nights before the procedure, followed, if necessary, by the rectal dose 1 hour before the procedure.

Preparations
Proprietary Preparations
Malaysia: Beacolux † ;Dulcolax;

How do you take this Medication
• It is important to take this type of medicine as instructed. You may need to use more than one medication and also to change your diet to relieve your constipation and to help prevent it from returning. Contact your doctor or nurse if you haven=t had a bowel movement for 3 days.
• Some of these medicines will help you to have a bowel movement within 6-12 hours (stimulants), while others may take up to 48 hours (softener, lubricant). Suppositories and enemas should act within 15-60 minutes. You must eat or drink some food to make stools.
• Stimulant laxatives will provide a soft or semi-fluid bowel movement.
• Some bulk forming laxatives are available as a dry powder. These products must not be swallowed as a dry powder. Mix the powder into a full glass of water or fruit juice, then drink it. Do not breath in the dry powder. (Prodiem7 granules are swallowed as a dry dose, followed by water or juice). Drink plenty of fluids between doses.
• Mineral oil laxatives should not be taken within 2 hours of meals, since the oil can interfere with absorption of nutrients and vitamins in your diet.
• A high fibre diet may help to prevent or reduce constipation. Your doctor, nurse or dietician may suggest diet changes to help you prevent constipation.
Precautions
Tell your doctor if you suffer from colitis (inflammation of the colon).
DO NOT use Docusate preparations along with mineral oil.
Laxatives should not be taken if you have abdominal pain, nausea, vomiting or fever.
Enemas and Bisacodyl suppositories should not be used if you have rectal bleeding.
It is extremely important that you tell your doctor if you are taking other medications, such as blood thinning drugs, Digoxin, Ciprofloxacin, or Tetracycline before taking laxatives.
Diabetic patients should be aware that some laxatives contain large amounts of sugar.
Keep all medications, including laxatives, out of the reach of children.