Laxative

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Glycerin suppositories used as laxatives. Glycerin suppositories.jpg
Glycerin suppositories used as laxatives.

Laxatives, purgatives, or aperients are substances that loosen stools [1] and increase bowel movements. They are used to treat and prevent constipation.

Contents

Laxatives vary as to how they work and the side effects they may have. Certain stimulant, lubricant, and saline laxatives are used to evacuate the colon for rectal and bowel examinations, and may be supplemented by enemas under certain circumstances. Sufficiently high doses of laxatives may cause diarrhea. Some laxatives combine more than one active ingredient, and may be administered orally or rectally.

Types

Bulk-forming agents

Bulk-forming laxatives, also known as roughage, are substances, such as fiber in food and hydrophilic agents in over-the-counter drugs, that add bulk and water to stools so they can pass more easily through the intestines (lower part of the digestive tract). [2]

Properties

Bulk-forming agents generally have the gentlest of effects among laxatives, [1] making them ideal for long-term maintenance of regular bowel movements.

Dietary fiber

Foods that help with laxation include fiber-rich foods. Dietary fiber includes insoluble fiber and soluble fiber, such as: [4]

Emollient agents (stool softeners)

Emollient laxatives, also known as stool softeners, are anionic surfactants that enable additional water and fats to be incorporated in the stool, making movement through the bowels easier.

Properties

Emollient agents prevent constipation rather than treating long-term constipation. [3]

Lubricant agents

Lubricant laxatives are substances that coat the stool with slippery lipids and decrease colonic absorption of water so the stool slides through the colon more easily. Lubricant laxatives also increase the weight of stool and decrease intestinal transit time. [9]

Properties

Mineral oils, such as liquid paraffin, are generally the only nonprescription lubricant laxative available, but due to the risk of lipid pneumonia resulting from accidental aspiration, mineral oil is not recommended, especially in children and infants. [10] [11] Mineral oil may decrease the absorption of fat-soluble vitamins and some minerals. [9]

Hyperosmotic agents

Hyperosmotic laxatives cause the intestines to hold more water, creating an osmotic gradient, which adds more pressure and stimulates bowel movement. [12] [10]

Properties

Lactulose works by the osmotic effect, which retains water in the colon; lowering the pH through bacterial fermentation to lactic, formic, and acetic acids; and increasing colonic peristalsis. Lactulose is also indicated in portal-systemic encephalopathy. Glycerin suppositories work mostly by hyperosmotic action, but the sodium stearate in the preparation also causes local irritation to the colon.[ citation needed ]

Solutions of polyethylene glycol and electrolytes (sodium chloride, sodium bicarbonate, potassium chloride, and sometimes sodium sulfate) are used for whole bowel irrigation, a process designed to prepare the bowel for surgery or colonoscopy and to treat certain types of poisoning. Brand names for these solutions include GoLytely, GlycoLax, Cosmocol, CoLyte, Miralax, Movicol, NuLytely, Suprep, and Fortrans. Solutions of sorbitol (SoftLax) have similar effects.[ citation needed ]

Saline laxative agents

Saline laxatives are nonabsorbable, osmotically active substances that attract and retain water in the intestinal lumen, increasing intraluminal pressure that mechanically stimulates evacuation of the bowel. Magnesium-containing agents also cause the release of cholecystokinin, which increases intestinal motility and fluid secretion. [3] Saline laxatives may alter a patient's fluid and electrolyte balance.

Properties

Stimulant agents

Stimulant laxatives are substances that act on the intestinal mucosa or nerve plexus, altering water and electrolyte secretion. [13] They also stimulate peristaltic action and can be dangerous under certain circumstances. [14]

Senna plant Cassia senna Ypey80-cropped.jpg
Senna plant

Properties

Prolonged use of stimulant laxatives can create drug dependence by damaging the colon's haustral folds, making users less able to move feces through their colon on their own. A study of patients with chronic constipation found that 28% of chronic stimulant laxative users lost haustral folds over the course of one year, while none of the control group did. [15]

Miscellaneous

Castor oil is a glyceride that is hydrolyzed by pancreatic lipase to ricinoleic acid, which produces laxative action by an unknown mechanism.

Properties

Long-term use of castor oil may result in loss of fluid, electrolytes, and nutrients. [3]

Serotonin agonist

These are motility stimulants that work through activation of 5-HT4 receptors of the enteric nervous system in the gastrointestinal tract. However, some have been discontinued or restricted due to potentially harmful cardiovascular side effects.

Tegaserod (brand name Zelnorm) was removed from the general U.S. and Canadian markets in 2007, due to reports of increased risks of heart attack or stroke. It is still available to physicians for patients in emergency situations that are life-threatening or require hospitalization. [16]

Prucalopride (brand name Resolor) is a current drug approved for use in the EU since October 15, 2009, [17] in Canada (brand name Resotran) since December 7, 2011, [18] and in the United States since December 2018.

Chloride channel activators

Lubiprostone is used in the management of chronic idiopathic constipation and irritable bowel syndrome. It causes the intestines to produce a chloride-rich fluid secretion that softens the stool, increases motility, and promotes spontaneous bowel movements.

Comparison of available agents

Common stimulant laxatives [19] [20]
Preparation(s)TypeSite of actionOnset of action
Cascara (casanthranol) Anthraquinone colon 6–8 hours
Buckthorn Anthraquinonecolon6–8 hours
Senna extract (senna glycoside)Anthraquinonecolon6–8 hours
Aloe vera (aloin)Anthraquinonecolon8–10 hours
Phenolphthalein Triphenylmethane colon8 hours
Bisacodyl (oral)Triphenylmethanecolon6–12 hours
Bisacodyl (suppository)Triphenylmethanecolon60 minutes
Castor oil Ricinoleic acid small intestine2–6 hours

Effectiveness

For adults, a randomized controlled trial found PEG (MiraLax or GlycoLax) 17 grams once per day to be superior to tegaserod at 6 mg twice per day. [21] A randomized controlled trial found greater improvement from two sachets (26 g) of PEG versus two sachets (20 g) of lactulose. [22] 17 g per day of PEG has been effective and safe in a randomized, controlled trial for six months. [23] Another randomized, controlled trial found no difference between sorbitol and lactulose. [24]

For children, PEG was found to be more effective than lactulose. [25]

Problems with use

Laxative abuse

Some of the less significant adverse effects of laxative abuse include dehydration (which causes tremors, weakness, fainting, blurred vision, kidney damage), low blood pressure, fast heart rate, postural dizziness and fainting; [26] however, laxative abuse can lead to potentially fatal acid-base, and electrolyte imbalances. [26] For example, severe hypokalaemia has been associated with distal renal tubular acidosis from laxative abuse. [26] Metabolic alkalosis is the most common acid-base imbalance observed. [26] Other significant adverse effects include rhabdomyolysis, [26] steatorrhoea, [26] inflammation and ulceration of colonic mucosa, [26] pancreatitis, [26] [27] kidney failure, [26] [28] [29] factitious diarrhea [26] [30] and other problems. [26] The colon will need more quantities of laxatives to keep functioning, this will result in a lazy colon, infections, irritable bowel syndrome, and potential liver damage.

Although some patients with eating disorders such as anorexia nervosa and bulimia nervosa abuse laxatives in an attempt to lose weight, laxatives act to speed up the transit of feces through the large intestine, which occurs after the absorption of nutrients in the small intestine is already complete. Thus, studies of laxative abuse have found that effects on body weight reflect primarily temporary losses of body water rather than energy (calorie) loss. [26] [31] [32]

Laxative gut

Physicians warn against the chronic use of stimulant laxatives due to concern that chronic use could cause the colonic tissues to get worn out over time and not be able to expel feces due to long-term overstimulation. [33] A common finding in patients having used stimulant laxatives is a brown pigment deposited in the intestinal tissue, known as melanosis coli.[ citation needed ]

Historical and health fraud uses

Laxatives, once called "physicks" or "purgatives", were used extensively in historic medicine to treat many conditions for which they are now generally regarded as ineffective in evidence-based medicine. [34] Likewise, laxatives (often termed colon cleanses) may be promoted in alternative medicine for various conditions of quackery, such as "mucoid plaque". [35]

See also

Related Research Articles

<span class="mw-page-title-main">Enema</span> Injection of fluid into rectum, typically en route to the colon

An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum. The word enema can also refer to the liquid injected, as well as to a device for administering such an injection.

<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Irritable bowel syndrome</span> Functional gastrointestinal disorder

Irritable bowel syndrome (IBS) is a "disorder of gut-brain interaction" characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating and changes in the consistency of bowel movements. These symptoms may occur over a long time, sometimes for years. IBS can negatively affect quality of life and may result in missed school or work or reduced productivity at work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

Encopresis is voluntary or involuntary passage of feces outside of toilet-trained contexts in children who are four years or older and after an organic cause has been excluded. Children with encopresis often leak stool into their undergarments.

<span class="mw-page-title-main">Diverticulosis</span> Condition of the wall of the intestine

Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.

<span class="mw-page-title-main">Lactulose</span> Treatment for constipation and hepatic encephalopathy

Lactulose is a non-absorbable sugar used in the treatment of constipation and hepatic encephalopathy. It is administered orally for constipation, and either orally or rectally for hepatic encephalopathy. It generally begins working after 8–12 hours, but may take up to 2 days to improve constipation.

<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

<span class="mw-page-title-main">Fecal impaction</span> Medical condition

A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.

<span class="mw-page-title-main">Bristol stool scale</span> Medical system for classifying human faeces

The Bristol stool scale is a diagnostic medical tool designed to classify the form of human faeces into seven categories. It is used in both clinical and experimental fields.

<span class="mw-page-title-main">Bisacodyl</span> Laxative

Bisacodyl (INN) is an organic compound that is used as a stimulant laxative drug. It works directly on the colon to produce a bowel movement. It is typically prescribed for relief of episodic and chronic constipation and for the management of neurogenic bowel dysfunction, as well as part of bowel preparation before medical examinations, such as for a colonoscopy.

<span class="mw-page-title-main">Distal intestinal obstruction syndrome</span> Medical condition

Distal intestinal obstruction syndrome (DIOS) involves obstruction of the distal part of the small intestines by thickened intestinal content and occurs in about 20% of mainly adult individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with cystic fibrosis. DIOS tends to occur in older individuals with pancreatic insufficiency. Individuals with DIOS may be predisposed to bowel obstruction, though it is a separate entity than true constipation.

<span class="mw-page-title-main">Lubiprostone</span> Medication used for constipation

Lubiprostone, sold under the brand name Amitiza among others, is a medication used in the management of chronic idiopathic constipation, predominantly irritable bowel syndrome-associated constipation in women and opioid-induced constipation. The drug is owned by Mallinckrodt and is marketed by Takeda Pharmaceutical Company.

<span class="mw-page-title-main">Sodium picosulfate</span> Chemical compound

Sodium picosulfate is a contact stimulant laxative used as a treatment for constipation or to prepare the large bowel before colonoscopy or surgery.

<span class="mw-page-title-main">Polycarbophil calcium</span> Pharmaceutical drug

Polycarbophil calcium (INN) is a drug used as a stool stabilizer. Chemically, it is a synthetic polymer of polyacrylic acid cross-linked with divinyl glycol, with calcium as a counter-ion.

<span class="mw-page-title-main">Macrogol</span> Medication for constipation, classified as an osmotic laxative

Macrogol, also known as polyethylene glycol (PEG), is used as a medication to treat constipation in children and adults. It is taken by mouth. Benefits usually occur within three days. Generally it is only recommended for up to two weeks. It is also used as an excipient. It is also used to clear the bowels before a colonoscopy, when the onset of the laxative effect is more rapid, typically within an hour.

<span class="mw-page-title-main">Senna glycoside</span> Constipation and surgery medication

Senna glycoside, also known as sennoside or senna, is a medication used to treat constipation and empty the large intestine before surgery. The medication is taken by mouth or via the rectum. It typically begins working in around 30 minutes when given by rectum and within twelve hours when given by mouth. It is a weaker laxative than bisacodyl and castor oil.

<span class="mw-page-title-main">Docusate</span> Laxatives/stool softeners

Docusate is the common chemical and pharmaceutical name of the anion bis(2-ethylhexyl) sulfosuccinate, also commonly called dioctyl sulfosuccinate (DOSS).

<span class="mw-page-title-main">Naloxegol</span> Medication used in the treatment for Opioid-Induced Constipation

Naloxegol is a peripherally acting μ-opioid receptor antagonist developed by AstraZeneca, licensed from Nektar Therapeutics, for the treatment of opioid-induced constipation. It was approved in 2014 in adult patients with chronic, non-cancer pain. Doses of 25 mg were found safe and well tolerated for 52 weeks. When given concomitantly with opioid analgesics, naloxegol reduced constipation-related side effects, while maintaining comparable levels of analgesia.

Sodium citrate/sodium lauryl sulfoacetate/glycerol sold under the brandname Microlax and Micolette Micro enema, among others, is a small tube of liquid gel that is used to treat constipation.

Constipation in children refers to the medical condition of constipation in children. It is a functional gastrointestinal disorder.

References

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  2. ↑ Bulk-forming agent entry in the public domain NCI Dictionary of Cancer Terms
  3. 1 2 3 4 5 6 7 8 Berardi M, Tietze KJ, Shimp LA, Rollins CJ, Popovich NG (2006). Handbook of Nonprescription Drugs (15th ed.). Washington, D.C.: American Pharmaceutical Association. ISBN   978-1582120744.
  4. 1 2 3 "The Facts About Fiber" (PDF). www.aicr.org. American Institute for Cancer Research. Archived from the original (PDF) on 3 November 2014. Retrieved 3 November 2014.
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  6. ↑ "15 Foods That Cause Constipation (Caffeine, Chocolate, Alcohol)". MedicineNet. Retrieved 2017-12-12.
  7. ↑ Rush EC, Patel M, Plank LD, Ferguson LR (2002). "Kiwifruit promotes laxation in the elderly". Asia Pac J Clin Nutr. 11 (2): 164–8. doi:10.1046/j.1440-6047.2002.00287.x. PMID   12074185. S2CID   15280086.
  8. ↑ Stacewicz-Sapuntzakis M, Bowen PE, Hussain EA, Damayanti-Wood BI, Farnsworth NR (2001). "Chemical composition and potential health effects of prunes: a functional food?". Critical Reviews in Food Science and Nutrition. 41 (4): 251–86. doi:10.1080/20014091091814. PMID   11401245. S2CID   31159565.
  9. 1 2 3 Berardi M, Tietze KJ, Shimp LA, Rollins CJ, Popovich NG (2006). Handbook of Nonprescription Drugs (15th ed.). Washington, D.C.: American Pharmaceutical Association. ISBN   978-1582120744.
  10. 1 2 Krinsky, Daniel L. (November 30, 2020). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition. 2215 Constitution Avenue, N.W. Washington, DC 20037-2985: The American Pharmacists Association. doi:10.21019/9781582123172.ch15. ISBN   978-1-58212-317-2.{{cite book}}: CS1 maint: location (link)
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  13. ↑ Laxative (Oral Route) from Mayo clinic. Last updated: Nov. 1, 2012
  14. ↑ Joo JS, Ehrenpreis ED, Gonzalez L, Kaye M, Breno S, Wexner SD, Zaitman D, Secrest K (1998). "Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited". J Clin Gastroenterol. 26 (4): 283–6. doi:10.1097/00004836-199806000-00014. PMID   9649012.
  15. ↑ Joo, Jae Sik; Ehrenpreis, Eli D.; Gonzalez, Leopoldo; Kaye, Mark; Breno, Susan; Wexner, Steven D.; Zaitman, Daniel; Secrest, K. (June 1998). "Alterations in Colonic Anatomy Induced by Chronic Stimulant Laxatives: The Cathartic Colon Revisited". Journal of Clinical Gastroenterology. 26 (4): 283–286. doi:10.1097/00004836-199806000-00014. PMID   9649012.
  16. ↑ Research, Center for Drug Evaluation and. "Postmarket Drug Safety Information for Patients and Providers - Zelnorm (tegaserod maleate) Information". www.fda.gov. Retrieved 14 April 2018.
  17. ↑ "European Medicines Agency EPAR summary for the public" (PDF). europa.eu. Archived from the original (PDF) on 14 April 2018. Retrieved 14 April 2018.
  18. ↑ "Health Canada, Notice of Decision for Resotran". hc-sc.gc.ca. Archived from the original on 18 March 2017. Retrieved 14 April 2018.
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  22. ↑ Attar A, Lémann M, Ferguson A, Halphen M, Boutron MC, Flourié B, Alix E, Salmeron M, Guillemot F, Chaussade S, Ménard AM, Moreau J, Naudin G, Barthet M (1999). "Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation". Gut. 44 (2): 226–30. doi:10.1136/gut.44.2.226. PMC   1727381 . PMID   9895382.
  23. ↑ Dipalma JA, Cleveland MV, McGowan J, Herrera JL (2007). "A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation". Am. J. Gastroenterol. 102 (7): 1436–41. doi:10.1111/j.1572-0241.2007.01199.x. PMID   17403074. S2CID   10946562.
  24. ↑ Lederle FA, Busch DL, Mattox KM, West MJ, Aske DM (1990). "Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose". Am J Med. 89 (5): 597–601. doi:10.1016/0002-9343(90)90177-F. PMID   2122724.
  25. ↑ "BestBETs: Is polyethylene glycol safe and effective for chro..." Retrieved 2007-09-06.
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  27. ↑ Brown NW, Treasure JL, Campbell IC (2001). "Evidence for long-term pancreatic damage caused by laxative abuse in subjects recovered from anorexia nervosa". International Journal of Eating Disorders. 29 (2): 236–238. doi:10.1002/1098-108X(200103)29:2<236::AID-EAT1014>3.0.CO;2-G. PMID   11429987.
  28. ↑ Copeland PM; Molina, H.; Ohye, Ch.; MacIas, R.; Alaminos, A.; Alvarez, L.; Teijeiro, J.; Muñoz, J.; Ortega, I. (1994). "Renal failure associated with laxative abuse". Psychother Psychosom. 62 (3–4): 200–2. doi:10.1159/000098619. PMID   7531354.
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  30. ↑ Oster JR, Materson BJ, Rogers AI (November 1980). "Laxative abuse syndrome". Am. J. Gastroenterol. 74 (5): 451–8. PMID   7234824.
  31. ↑ Lacey JH, Gibson E (1985). "Controlling weight by purgation and vomiting: A comparative study of bulimics". Journal of Psychiatric Research. 19 (2–3): 337–341. doi:10.1016/0022-3956(85)90037-8. PMID   3862833.
  32. ↑ "Acid-base and electrolyte abnormalities with diarrhea". www.uptodate.com. Retrieved 2017-12-12.
  33. ↑ Joo JS, Ehrenpreis ED, Gonzalez L, Kaye M, Breno S, Wexner SD, Zaitman D, Secrest K (June 1998). "Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited". Journal of Clinical Gastroenterology. 26 (4): 283–6. doi:10.1097/00004836-199806000-00014. PMID   9649012.
  34. ↑ Stolberg, Michael (2003). "[The miraculous effects of taking laxatives. Success and failure of pre-modern medical treatment from the patients' perspective]". Wurzburger Medizinhistorische Mitteilungen. 22: 167–177. ISSN   0177-5227. PMID   15641192.
  35. ↑ M., Raju, S. (2013-09-30). Illustrated medical pharmacology. JP Medical. ISBN   9789350906552. OCLC   870530462.{{cite book}}: CS1 maint: multiple names: authors list (link)
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