CME Corner

Current Cases

Multiple Medications

Ms. Smith is an 80-year-old woman in a long-term care facility. She reports unsatisfactory defecation with symptoms of straining, hard stools that are difficult to pass, and a sensation of incomplete evacuation. She also describes a persistent feeling of bloating and states that her abdomen becomes uncomfortably distended after most meals, which makes her reluctant to eat full meals. She is given a stool softener daily, but experiences only 2-3 bowel movements per week.

Ms. Smith claims that she's suffered from constipation on and off for the last 15 years. She also has a history of hypertension, hyperlipidemia, heartburn, and osteoarthritis. She is taking the following medications:

- HCTZ 25 mg/triamterene 37.5 mg QD
- Felodipine 5 mg QD
- Simvastatin 40 mg HS
- Ranitidine 75 mg BID
- Docusate sodium QD
- FeSO4 325 mg TID

Factors contributing to Ms. Smith's risk for chronic constipation include the following:

- Age >65 years
- Female (greater prevalence in females)
- Poor intake of solid food
- Decreased mobility due to pain, deconditioning, etc.
- Multiple medications

Many factors predispose older adults to constipation, including inadequate diet and immobility. Chronic constipation can have a significant negative impact on quality of life and health status. A thorough medical history and physical examination are needed to exclude constipation secondary to another or underlying condition. Findings from Ms. Smith's physical exam and evaluation include the following:

Physical, anorectal, and pelvic examinations: Normal
Metabolic studies, including calcium and thyroid stimulating hormone determinations: Normal
CBC: Normal
Structural tests, including colonoscopy: Normal

The results appear to rule out primary constipation and point to secondary causes such as lifestyle factors or multiple medications. Other secondary causes of chronic constipation include systemic, psychological, metabolic, or neurological disorders.

Lifestyle measures such as increasing fluid or fiber intake, or initiating an exercise regimen are often the initial approach to the management of constipation. Studies evaluating the effects of fluid intake, fiber intake, and exercise on constipation, however, have yielded mixed findings with regard to their effectiveness. In addition, stool softeners, like the one Ms. Smith is given daily, have no laxative action, and are ineffective at relieving the multiple symptoms of chronic constipation. They may also contribute to fecal incontinence. They are appropriate only for short-term use in specific situations, not as a daily therapy.

In Ms. Smith's case, multiple classes of medications have been implicated as a possible cause of her constipation. Because medication use increases with age, this is one likely explanation for the higher prevalence of chronic constipation seen in the elderly population. Patients can be identified as at-risk for chronic constipation when certain classes of medications are identified through careful history taking (including asking about use of OTC and complementary/alternative medications).

In some cases, it is possible to substitute a problematic medication with a medication from another class that has not been associated with constipation, but which will still produce desired clinical effect. For example, this can often be done with various antihypertensives or calcium supplements. In other cases, discontinuation of the suspect medication may not be possible. In these situations, patients will often require pharmacologic therapy to relieve their constipation symptoms.

Prescription medications that may cause constipation:
- Opiates
- Anticholinergic drugs
- TCAs
- CCBs
- Antiparkinsonian drugs
- Sympathomimetics
- Antipsychotics
- Diuretics
- Antihistamines

Nonprescription medications that may cause constipation:
- Antacids, especially calcium-containing
- Calcium supplements
- Iron supplements
- Antidiarrheal agents

Ms. Smith's medications are changed. Her two blood pressure medications (HCTZ 25 mg/triamterene 37.5 mg QD and felodipine 5 mg QD) are substituted with lisinopril 10 mg QD. Her stool softener (docusate sodium) is discontinued, and psyllium 1 tbs QD is added, to help ensure that she meets her daily dietary fiber requirements. Her iron supplement, which is determined to be unnecessary, is discontinued. In follow-up 3-4 weeks later, she reports some improvement in bowel frequency, and somewhat lessened discomfort.


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The E-IMPACCT (Elderly IMProvements & Advances in Chronic Constipation Treatment) educational initiative is sponsored through a collaboration of ASCP, AKH Inc., and Medical Communications Media, Inc.

Supported by an educational grant from Sucampo Pharmaceuticals, Inc. and Takeda Pharmaceuticals North America, Inc.


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