Constipation Polypharmacy

JE is a 77-year-old male. He reports significant constipation despite the use of three laxative medications. In this case summary, I will outline the most important medications that can contribute to constipation polypharmacy.

Past medical history includes:

Hypertension
Type 2 Diabetes Mellitus
Hyperlipidemia
Chronic Obstructive Pulmonary Disease (COPD)
Osteoarthritis
Gastroesophageal Reflux Disease (GERD)
Chronic Kidney Disease (Stage 3)
Benign Prostatic Hyperplasia (BPH)
Depression
Insomnia

The current constipation medications he is taking include:

Miralax 17 grams daily
Senna 1 tablet BID
Dulcolax 1 tablet daily

Other medications include:

Lisinopril – 20 mg once daily (Hypertension)
Metformin – 500 mg twice daily (Type 2 Diabetes)
Atorvastatin – 20 mg once daily (Hyperlipidemia)
Tiotropium – 18 mcg once daily (COPD)
Albuterol – 90 mcg as needed (COPD)
Tramadol 100 mg three times daily as needed (Osteoarthritis)
Acetaminophen – 500 mg every 6 hours as needed (Osteoarthritis)
Omeprazole – 20 mg once daily (GERD)
Aspirin – 81 mg once daily (Cardiovascular protection)
Tamsulosin – 0.4 mg once daily (BPH)
Oxybutynin 10 mg twice daily (BPH/urinary symptoms)
Amitriptyline – 50 mg once daily (Depression)
Zolpidem – 5 mg at bedtime (Insomnia)
Calcium Carbonate – 500 mg twice daily (Supplement for bone health)

Constipation Polypharmacy Review

The first thing I noticed is that this patient is taking two stimulant laxatives. There really isn’t a good reason for this that I can think of and either Dulcolax (bisacodyl) or Senna should be discontinued. If necessary, the other could be titrated to a higher dose. Hopefully, that won’t be necessary as we are going to try to address the high potential for constipation as an adverse effect in this case scenario.

When you have an issue (in this case constipation) that requires numerous medications to manage it, the first thing you should review is the risk for adverse drug reactions. There are at least 3 common medications that I know to be significant contributors to constipation. The oxybutynin, amitriptyline, and tramadol all need to be reevaluated.

I would assess the doses of each medication to ensure that the patient is taking the minimum effective dose. Reducing oxybutynin by 5 mg every 1-2 weeks would be a reasonable consideration to reassess efficacy. An amitriptyline reduction would also be a strong consideration. I don’t love amitriptyline for the diagnosis of depression. We generally have safer medications (i.e. SSRIs) that we could consider in the elderly. I would also like to assess how much tramadol the patient is using and if it would be reasonable to reduce this dose to 50 mg instead of 100 mg. All of these considerations would be likely to reduce the burden of constipation polypharmacy.

While definitely not the highest on my priority list, I would also assess the calcium carbonate. This may contribute to constipation but is not as significant as the other medications in my opinion. Other concerns to address would be metformin use in CKD, assessing diabetes and if a CV beneficial agent would be appropriate, and reducing the use of zolpidem.

What other concerns do you have in this constipation polypharmacy case scenario?

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