Mary Barna Rupal Patel, PharmDBridgeman, PharmD
Case 1—Constipation Conundrum
JE is an 80-year-old male who approaches your pharmacy counter asking about things he can do to help keep himself “regular.” Upon questioning, JE does not report suffering from constipation at this time, but does report occasional, infrequent episodes of straining to have a bowel movement and mentions passing hardened stools. He describes himself as being “healthy as a horse,” taking only a senior multivitamin each day for good nutrition. He denies allergies to medication or foods. Describe the most appropriate nonpharmacologic interventions to recommend to JE to prevent constipation.
Prevention and treatment of constipation are common reasons patients, particularly aging adults, use OTC laxative products. In the elderly population, it is important to identify medical conditions and medications that can contribute to symptoms of constipation. In the case of JE, although the senior multivitamin he reports taking each day could contribute to his infrequent constipation, it is unlikely, as senior vitamin formulations typically contain reduced iron and calcium contents to offset the risk of constipation.
Nonpharmacologic interventions are reasonable strategies that can be utilized to both treat and prevent episodes of acute constipation. In the case of JE, recommending he increase his dietary fiber and daily fluid intake and suggesting he participate in routine physical activity are lifestyle strategies that can improve his bowel function. Fiber is thought to promote regularity by increasing the water content and bulk of stool within the intestine. According to the American Dietetic Association, adults should consume between 20 and 35 grams of fiber each day.1 Counsel JE on gradually increasing his consumption of whole grains, bran, fruits, nuts, and vegetables to prevent potential undesired gastrointestinal (GI) adverse events such as bloating and flatulence. Fiber supplements work best when taken with adequate amounts of fluid, and increasing fluid intake can also alleviate symptoms of constipation.
If he is unable to increase fiber from dietary sources, bulk-forming fiber supplements can also be considered. The hardened stools JE reports experiencing could be indicative of inadequate fluid intake, and consuming 6 to 8 glasses of water each day may help. Physical activity may also alleviate constipation, as a sedentary lifestyle has been shown to be associated with constipation as well.2 It would be prudent to recommend that JE check with his physician before partaking in a physical activity program, due to his advanced age. Finally, maintaining good toileting behaviors, including allowing adequate time for toileting and attempting to defecate first thing in the morning or after meals when bowel motility is the greatest, may help condition bowel habits.
Patients experiencing constipation in addition to systemic symptoms (eg, weight loss, anorexia, dark tarry stools, fever, nausea, vomiting, abdominal pain, or distention) should be advised to seek physician referral, as these symptoms could be indicative of a more serious GI disorder.
Case 2—Heartburn Worries
JS is a 36-year-old woman with a past history of sporadic heartburn symptoms who comes to the pharmacy seeking a product recommendation. Her once infrequent symptoms, previously manageable with OTC famotidine, have now increased in frequency, to the point where she describes experiencing heartburn about 3 days per week. She asks whether she should continue using famotidine or if you would suggest something “stronger.” She reports that she has no known allergies to medications.
The symptoms JS describes can be considered frequent heartburn. Dietary counseling, including the avoiding spicy “trigger” foods, decreasing dietary fat, and minimizing carbonated or caffeinated beverages, could be considered. Recommend JS eat small meals to minimize the effects of heartburn that occur due to overeating, and suggest she avoid eating 3 hours before going to bed to prevent nocturnal symptoms.3 Although the OTC histamine2-receptor antagonist (H2RA) famotidine is appropriate for mild to moderate infrequent heartburn relief, it would be prudent to recommend JS use an OTC proton pump inhibitor, such as omeprazole or lansoprazole, taken once daily prior to a meal. For frequent heartburn they have a longer duration of effect and are superior to H2RAs at providing symptomatic relief.3
Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Patel is a clinical pharmacist in North Brunswick, New Jersey, and clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University.