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Long term laxative use: Laxative misuse and consequences

Behaviour, General, Constipation | March 8, 2015 | Author: The Super Pharmacist

general, Digestion, bowel

Long term laxative use: Laxative misuse and consequences

Laxatives are a group of medicines that are commonly used to treat constipation when other lifestyle changes (such as diet and exercise) have not been successful. They are available over the counter without prescription.

Different types of laxative

Typically, laxatives are categorised into four different groups. These are:

  • Bulk forming laxatives that increase the size and bulk of stools, encouraging the bowels to push them out. Examples include methylcellulose and ispaghula husk.
  • Stimulant laxatives that speed up the movement of the bowels through the stimulation of nerves that control the muscles lining the digestive tract. Examples include senna, sodium picosulfate and bisacodyl. They are the most commonly misused group of laxatives.
  • Stool softener laxatives that increase the fluid content of stools in order to make them easier to pass. Examples include docusate sodium and arachis oil.
  • Osmotic laxatives that soften stools and make them easier to pass through by increasing the amount of water in the bowel. Examples include lactulose and polyethelene glycol.

There are a number of less commonly used laxatives that are not always available over the counter. These include linaclotide, prucalopride, bowel cleansing solutions and peripheral opioid-receptor antagonists. Laxatives are not recommended for children, and some laxatives are not suitable for individuals suffering from particular diseases such as Crohn’s disease and ulcerative colitis (1).

Consequences of misusing laxatives

Laxative misuse can result in a range of health problems including dehydration, intestinal paralysis, renal failure, pancreatitis and hypokalaemia (low concentration of potassium in the blood) (2).

Who misuses laxatives?

Individuals who misuse laxatives can be categorised into four broad groups:

  • Individuals with an eating disorder such as anorexia nervosa or bulimia nervosa (this group counts for around 60% of all laxative misuse)
  • Individuals, generally of middle age or older, who begin using laxatives during initial bouts of constipation but continue to use them when not necessary
  • Individuals who have to meet a certain weight criteria as a result of their profession or hobby (such as professional athletes)
  • Individuals who misuse laxatives to cause factitious diarrhoea and may have a history of factitious disorders (a condition in which a person acts as if they have an illness by deliberately producing or exaggerating known symptoms)

Laxatives and weight loss

Studies have shown that laxatives do not assist with weight loss: they speed up the processing of faeces through artificially stimulating the large intestine to empty, rather than halting the absorption of nutrients in the small intestine.

Rather than assisting with weight loss, they are associated with the loss of indigestible fibre, water, minerals and electrolytes. If individuals who misuse laxatives do not re-hydrate following their use, they risk dehydration or one of the many associated illnesses as a result.

Medical problems associated with laxative abuse that involve the renal and cardiovascular system can become life threatening (3).

Common health ailment associated with laxative misuse

Overuse of particular laxatives puts individuals at risk of decreased or permanently impaired bowel function, and can also cause intestinal obstruction where the bowel becomes blocked by large, dry stools.

Other concerns with prolonged laxative use

Laxatives have the potential to interact with blood thinning medication such as warfarin and certain antibiotics. If laxatives are used when there is a more serious underlying medical condition that prevents regular defecation, such as a bowel obstruction, there is a danger that the frequent use of laxatives can reduce the ability of the colon to contract. This actually exacerbates constipation and places the individual at further risk (4).

Interventions for Laxative dependence

There is very little in the evidence base regarding particular interventions that are specifically for laxative misuse. Of the formal guidelines that do exist, many promote dietary change, the immediate cessation of laxative use, drinking more water and eating at regular intervals. The lack of formal evidence specifically discussing laxative dependency is probably a reflection of laxative misuse coming under a wider body of literature concerned with eating disorders, of which there is an extensive body of research on both physical and psychological interventions that can be used.

In the National Institute of Clinical Excellence’s guidelines on the treatment of eating disorders, laxative use is discussed briefly with a recommendation that ‘where laxative abuse is present, patients should be advised to gradually reduce laxative use and be informed that laxative use does not significantly reduce calorie absorption’ (5).

Laxative dependenceMore commonly, laxative misuse is addressed not through a specific intervention but under the umbrella of evidence-based psychosocial interventions such as Cognitive Behavioural Therapy (CBT). Other interventions that have a strong evidence base and can be used to treat dimensions of eating disorders such as laxative misuse include Cognitive Analytic Therapy (CAT), Interpersonal Psychotherapy, Focal Psychodynamic Theory and broader Family Interventions (6).

The aim of all such treatments is to reduce physical and psychological risk, encourage weight gain and healthier eating, and to reduce other symptoms related to an eating disorder. Much of the CBT evidence base focuses on treatment for a range of other disorders, although there is a small but important body of research that has found behavioural therapies to be effective in reducing both eating disorder and substance misuse behaviours (7). It is recommended that individuals who have an eating disorder with associated substance/medication misuse problems receive 16-20 sessions with a qualified psychotherapist or psychologist over the course of 4-5 months, and also have their fluid and electrolyte balance assessed on a regular basis (8).

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References

1. Chevalier P, Lamotte M, Joseph A, Dubois D, Boeckxstaens G. (2014). In-hospital costs associated with chronic constipation in Belgium: a retrospective database study. Neurogastroenterol Motil 26(3):368-76

2. Khairi T, Amer S, Spitalewitz S, Alsadi L. (2014). Severe symptomatic hypermagnesemia associated with over the counter laxatives in a patient with renal failure and sigmoid volvulus. Case Rep Nephrol doi: 10.1555/2014/560746

3. Roerig JL, Steffen KJ, Mitchell JE, Zunker C. (2010). Laxative abuse: epidemiology, diagnosis and management. Drugs 70(12):1487-503

4. Cooper JW. (1989). Reviewing geriatric concerns with commonly used drugs. Geriatrics 44(12):79-86

5. NICE Clinical Knowledge Summaries: Eating Disorders. Available online at http://www.nice.org.uk/guidance/cg9/chapter/1-recommendations (last accessed 1st March 2015)

6. Markowitz JC, Lipsitz J, Milrod BL. (2014). Critical review of outcome research on interpersonal psychotherapy for anxiety disorders. Depress Anxiety 31(4):316-25

7. Gregorowski C, Seedat S, Jordaan GP. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC Psychiatry 13:289

8. NICE Clinical Knowledge Summaries: Eating Disorders. Available online at http://www.nice.org.uk/guidance/cg9/chapter/1-recommendations (last accessed 1st March 2015)

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