Professor Anton Emmanuel, consultant gastroenterologist at UCLH and the National Hospital for Neurology & Neurosurgery, discusses how pharmacists can support patients with constipation.

Constipation is a common condition; one in seven adults and up to one in three children suffers from constipation. Yet, the stigma around the issue makes patients with bowel conditions more reluctant to talk to healthcare professionals. In fact, nearly one in 10 people would wait between two weeks and a month after the onset of symptoms before seeking support.

This reluctance, however, often results in increased use of laxatives for bowel movement regulation and leads to avoidable hospital emergency admissions. In 2018/2019, 211 people a day were admitted in England and the NHS spent an overall £168 million in treating constipation. [1]

While constipation is a manageable condition, an early diagnosis is pivotal to avoid unnecessary patient discomfort and ensure the problem is properly addressed from the beginning. As sufferers tend to resort to over-the-counter (OTC) laxatives as first-line treatment, pharmacists play a crucial role in offering advice on the best course of action.

What causes constipation?

Identifying the causes of constipation and understanding patients’ bowel history is a key step for pharmacists to safely support and advice patients with constipation.

Pharmacists may be faced with cases of functional constipation, where a person experiences constipation symptoms without showing underlying non-bowel problems. People falling within this category are often too embarrassed to talk to a GP and might try to solve the problem themselves.

People with underlying neurological conditions, such as spina bifida, multiple sclerosis, Parkinson’s and spinal cord injury are likely to present symptoms of neurogenic constipation, where the lack of nervous control alters a proper bowel movement and functioning.

For some patients, constipation may be a chronic condition with multiple causes. Low-fibre diets and sedentary lifestyles, for instance, might contribute to poor bowel health.  A decrease in physical activity and fluid intake might also be among the reasons behind the higher prevalence of constipation in the elderly population.

A higher incidence of constipation can also be found in females, who are twice as likely to suffer from constipation. Women may experience more frequent episodes of constipation during pregnancy and after menopause, and as a result of pelvic floor disorders among other reasons. This is reflected in the rate of hospitalisation where 60% of constipation-related admissions are female. [2]

Pharmacists must also be alert to the fact that constipation might be drug-induced. Constipation might occur, or be exacerbated, when a patient uses opiate, antihistamines or antidepressants, for instance. It is therefore important to determine the potential causes of constipation right from the start, as this will improve patient counselling by the pharmacist.

Laxatives as a quick fix

Lifestyle and dietary changes are often recommended to patients presenting constipation symptoms and the first line of treatment often coincides with the prescription of laxatives.

However, if these prove ineffective, it is important to swiftly move on to alternative therapies. Drawing on the NICE Clinical Knowledge Summary, the Bowel Interest Group (BIG) has put together a Bowel Dysfunction Treatment Pyramid which identifies different treatment options when lifestyle changes or laxatives are not working. [3]

Laxatives, digital stimulation, suppositories and biofeedback form the base layers of the pyramid. Further up, options gradually move on to more invasive treatments ranging from nerve stimulation and colonic irrigation to permanent interventions such as stoma.

Moving promptly to the appropriate therapy level is key to ensuring positive outcomes and minimised patient discomfort. With pharmacies the first port of call for patients experiencing difficulty or infrequency with bowel emptying, it is even more critical for pharmacists to be aware of the different treatment options. This will also help to identify when referral to primary care is needed.

In fact, while laxatives may often be perceived as a quick fix to the problem, they might not always prove effective. Moreover, easy access to OTC laxatives can result in misuse, overuse or inappropriate use by patients,[4] often seen among people with eating disorders, in older age groups and in children. [5]

Last year, the Medicine and Healthcare products Regulatory Agency (MHRA), introduced new guidelines on the sales of over-the-counter stimulant laxatives in a bid to curb abuse.

In line with the new measures, larger packs of up to 100 tablets will only be available in pharmacies to patients aged 12 years or older, under the supervision of a pharmacist, while general sale outlets are now limited to small packs only. In light of this safety review, pharmacists will play an even more crucial role in guiding patients towards safe use of stimulant laxatives, while providing sufferers with informed advice on their next course of action.

Rising cost of constipation

Improved bowel health will not only benefit patients, but also contribute to easing the pressure on overwhelmed NHS hospitals. In 2018/2019, the NHS spent £168 million on treating constipation. Overall, twenty-two English regions have recorded a year-on-year rise in laxative spend [6] and in unplanned hospital admissions.[7]

Unsurprisingly, there is a positive correlation between the two rates. For instance, 74% of elderly nursing home residents use laxatives to regulate bowel movements,[8] which is reflected in the number of hospital admissions of those aged 75 and over; in 2018/2019, these totalled 24,000 admissions and accounted for 55% of the bed days. [9]

Focusing on better bowel health may bring benefits on a double level, with reductions in both prescription costs and hospital admissions. Some local initiatives with ‘bowel management pathways’ are already in place, so that patients can be triaged from A&E departments directly to clinics that deal with constipation.

However, to see a change on a national level, improved communication between healthcare professionals and patients is much needed. To this purpose, pharmacists must strive to gain a clearer understanding of their patients’ constipation symptoms and possible causes, to be able to provide tailored advice and help dispel the myths surrounding constipation.

References:

[1] Admissions data for ICD 10 diagnosis code K59.0 (Constipation) from April 2016 to January 2020 (Accessed May 2020 from Vantage System provided by Health IQ)

[2] Admissions data for ICD 10 diagnosis code K59.0 (Constipation) from April 2016 to January 2020 (Accessed May 2020 from Vantage System provided by Health IQ)

[3] Bowel Interest Group, Dealing with Chronic Constipation: Information for General Practitioners, 2020

[4] GOV.UK, Stimulant laxatives (bisacodyl, senna and sennosides, sodium picosulfate) available over-the-counter: new measures to support safe use, 18 August 2020

[5] The Pharmacist, Restrictions placed on laxative sales in a bid to curb abuse, 18 August 2020

[6] Prescription data for section code 0106 (laxatives) from March 2015 – February 2020 (Accessed May 2020 from Open Prescribing )

[7] Admissions data for ICD 10 diagnosis code K59.0 (Constipation) from April 2016 to January 2020 (Accessed May 2020 from Vantage System provided by Health IQ)

[8] Rao, S. and Go, J., Update on the management of constipation in the elderly: new treatment options. Clinical Interventions in Aging, 5, p.163, 2010

[9] Admissions data for ICD 10 diagnosis code K59.0 (Constipation) from April 2016 to January 2020 (Accessed May 2020 from Vantage System provided by Health IQ)