ConstipatioConstipation n

PharmacotherPharmacotherapyapy

RastegarpanahRastegarpanahClinical pharmacy DepartmentClinical pharmacy Department

Shariati GI Research CenterShariati GI Research CenterTehran university of medical sciencesTehran university of medical sciences

DEFINITION  

A Disturbance In Bowel Function. A Disturbance In Bowel Function.

Stools Too Hard Or Too Small, Defecation Stools Too Hard Or Too Small, Defecation Too Difficult Or Infrequent.Too Difficult Or Infrequent.

““Normal” 3 Times / Day To 3 Times / WeekNormal” 3 Times / Day To 3 Times / Week

A Stool Frequency Of A Stool Frequency Of Less Than Three Per Less Than Three Per WeekWeek

EPIDEMIOLOGY 

Prevalence Prevalence 12-19%12-19%

Prevalence Chronic Constipation Rises Prevalence Chronic Constipation Rises With Age, (With Age, (65 Years65 Years Of Age Or Older). Of Age Or Older).

In Old Age, 26% Of Men & In Old Age, 26% Of Men & 34%34% Of Women Of Women

Common In Pregnancy.Common In Pregnancy.

Digestion periodDigestion period

Stomach: Stomach: 3hours3hours

Small intestine:Small intestine: 4 – 6 hours4 – 6 hours

Large intestine: Large intestine: 12 – 72 hours12 – 72 hours

Small intestineSmall intestine

Duodenum Duodenum 25-30cm25-30cm

Jejunum Jejunum 2 metres2 metres

Ileum Ileum 3 metres3 metres

Large intestineLarge intestine

Ascending colonAscending colon

Transverse colonTransverse colon

Descending colonDescending colon

Sigmoid colonSigmoid colon

PeristalsisPeristalsis

ExcretionExcretion

1.1.Muscles work together to propel waste Muscles work together to propel waste matter (Peristalsis)matter (Peristalsis)

2.2.substances not absorbed by the body substances not absorbed by the body becomes faecesbecomes faeces

3.3.Faeces arrives in rectum to be expelled Faeces arrives in rectum to be expelled

What affects the bowel?What affects the bowel?

1.1. Poor dietPoor diet

2.2. Lack of fluidLack of fluid

3.3. Low MobilityLow Mobility

4.4. MedicationsMedications

5.5. SurgerySurgery

PATHOPHYSIOLOGY 

ConstipationConstipation = disordered movement of = disordered movement of stool through colon or rectum stool through colon or rectum

Slowing of colonic transit idiopathic or: Slowing of colonic transit idiopathic or: Due to diseases Due to diseases Side effect of drugsSide effect of drugs

Etiology: Disease-Induced: 1. Irritable bowel syndrome2. Metabolic disorders (diabetes),3. Endocrine disorders (hypothyroidism),4. Neurogenic disorders (Diabetes

mellitus, Multiple sclerosis , Spinal cord injury).

Drug-Induced Psychogenic causes Life-style factors Old age Children

Drugs associated with constipation

Constipation in Constipation in ElderlyElderly Constipation Is Common: Constipation Is Common:

Improper Diets (Low In Fiber And Liquids)Improper Diets (Low In Fiber And Liquids) Diminished Abdominal Wall Muscular StrengthDiminished Abdominal Wall Muscular Strength Possibly Diminished Physical ActivityPossibly Diminished Physical Activity

Frequency Of Bowel Movements Is Not Decreased Frequency Of Bowel Movements Is Not Decreased With Aging. With Aging.

Diseases Such As Colon Cancer And Diverticulitis,Diseases Such As Colon Cancer And Diverticulitis, Drugs In Elderly:Drugs In Elderly:

Anticholinergics, Aspirin, Furosemide, Anticholinergics, Aspirin, Furosemide, Nitroglycerin, AmitriptylineNitroglycerin, Amitriptyline

Signs and Symptoms :Signs and Symptoms :1.1. Decrease in frequency of fecal Decrease in frequency of fecal

eliminationelimination

2.2. Difficult passage of dry hard stoolsDifficult passage of dry hard stools

3.3. Straining to have stoolStraining to have stool

Diagnostic Criteria Diagnosis Based On Presence Of Following Diagnosis Based On Presence Of Following For For

At Least Three Months (With Symptom Onset At Least Three Months (With Symptom Onset At Least Six Months Prior To Diagnosis). At Least Six Months Prior To Diagnosis).

Diagnostic CriteriaMust Have Must Have Two Or MoreTwo Or More Of Following: Of Following:

1.1. Hard StoolsHard Stools In 25% Of Defecations In 25% Of Defecations

2.2. Sensation Of Sensation Of Incomplete EvacuationIncomplete Evacuation For For At Least 25% Of Defecations At Least 25% Of Defecations

3.3. Sensation Of Sensation Of Anorectal Obstruction / Anorectal Obstruction / BlockageBlockage For At Least 25% Of For At Least 25% Of Defecations Defecations

4.4. Fewer Than Fewer Than Three DefecationsThree Defecations Per Week Per Week

CONSTIPATION

Diagnostic Studies: Colonic Transit Time (CTT):

radio-opaque markers & day 4 X-ray.

Ten markers daily for six days

No laxative and drugs

CTTCTT In Evaluating Patients With In Evaluating Patients With

Chronic Idiopathic Constipation.Chronic Idiopathic Constipation. It Is Available And Has No It Is Available And Has No

Complication.Complication. No Surgical Intervention Without No Surgical Intervention Without

Colonic Transit Study Is Colonic Transit Study Is Recommended .Recommended .

Patient Assessment

Obtain Lifestyle And Medical History Before Obtain Lifestyle And Medical History Before Making Any RecommendationsMaking Any Recommendations

Determine Reason For Use Of A LaxativeDetermine Reason For Use Of A Laxative

1. To Relieve Constipation1. To Relieve Constipation

2. To Evacuate The Bowel Prior To An 2. To Evacuate The Bowel Prior To An Upcoming Radiologic Or Endoscopic Upcoming Radiologic Or Endoscopic ExaminationExamination

Inquire About The Patient’s Current And Inquire About The Patient’s Current And Past Use Of Laxative ProductsPast Use Of Laxative Products

Treatment

If Underlying Disease Is Recognized, If Underlying Disease Is Recognized, Cause Should Be Correct It. Cause Should Be Correct It.

GI Cancer Removed Via Surgery. GI Cancer Removed Via Surgery. Endocrine And Metabolic Dz Corrected. Endocrine And Metabolic Dz Corrected. If Hypo-thyroidism, Thyroid-replacement If Hypo-thyroidism, Thyroid-replacement

Therapy .Therapy .

Refer to M.D. When……

Symptoms Have Persisted For Symptoms Have Persisted For More More Than 2 WeeksThan 2 Weeks

Recurred After Previous Dietary Or Recurred After Previous Dietary Or Lifestyle Changes Or Laxative UseLifestyle Changes Or Laxative Use

Patients With Patients With BloodBlood In The Stool In The Stool

ManagementManagement

1. Dietary Modification.

2. Increase In Daily Fiber.

3. Exercise (Even By Walking After Dinner)

4. Bowel Habits, Regular & Adequate Time To Respond To Urge To Defecate.

5. Increase Fluid Intake.

Non-drug Treatment

1.1. High Fiber Food: Wheat Grains, Oats, Or High Fiber Food: Wheat Grains, Oats, Or Fruits & VegetablesFruits & Vegetables

2.2. Adequate Fluid IntakeAdequate Fluid Intake

3.3. ExerciseExercise

4.4. Avoid Foods That Cause Constipation: Avoid Foods That Cause Constipation: (Cheeses & Sweets)(Cheeses & Sweets)

NON-PHARMACOLOGIC THERAPY

FiberFiber Increases Stool Bulk,Increases Stool Bulk, Retention Stool Water & Increases Rate Retention Stool Water & Increases Rate

TransitTransit Increase Frequency Of DefecationIncrease Frequency Of Defecation Fruits, vegetables, cereals have highest fiber Fruits, vegetables, cereals have highest fiber Bran, a by-product of milling of wheat, Bran, a by-product of milling of wheat, Trial of dietary high-fiber should be for at Trial of dietary high-fiber should be for at

least 1 month before effects on bowel least 1 month before effects on bowel function are determinedfunction are determined

Non Prescription MedicationsNon Prescription MedicationsOver The Counter (OTC)Over The Counter (OTC)

Types of laxatives:Types of laxatives:1.1. Bulk FormingBulk Forming

2.2. EmollientEmollient

3.3. LubricantLubricant

4.4. SalineSaline

5.5. Hyper-osmoticHyper-osmotic

6.6. StimulantStimulant

DRUG CLASSESDRUG CLASSES

Most Induce Bowel Evacuation By: Active Electrolyte Secretion Decreased Water And Electrolyte

Absorption Increased Intraluminal Osmolarity Increased Hydrostatic Pressure In The Gut

Three Classifications:Three Classifications:

1.1. Softening Of FecesSoftening Of Feces In 1 To 3 Days (Bulk- In 1 To 3 Days (Bulk-forming Laxatives, And Lactulose)forming Laxatives, And Lactulose)

2.2. Semifluid StoolSemifluid Stool In 6 To 12 Hours In 6 To 12 Hours (Bisacodyl);(Bisacodyl);

3.3. EvacuationEvacuation In 1 To 6 Hours (Magnesium In 1 To 6 Hours (Magnesium Hydroxide, Castor Oil, And Polyethylene Hydroxide, Castor Oil, And Polyethylene Glycol-electrolyte Solution).Glycol-electrolyte Solution).

Dosage Recommendations for Laxatives and Cathartics

Bulk Forming LaxativesBulk Forming Laxatives

Derived From Agar, Or Psyllium SeedDerived From Agar, Or Psyllium Seed Synthetic, Methylcellulose & Carboxymethyl Synthetic, Methylcellulose & Carboxymethyl

Cellulose Sodium Cellulose Sodium Dissolve In Intestinal Fluid, Thus Creating Emollient Dissolve In Intestinal Fluid, Thus Creating Emollient

Gels That Increase Passage Of Intestinal ContentsGels That Increase Passage Of Intestinal Contents Stimulate Peristalsis Stimulate Peristalsis No Systemic AbsorptionNo Systemic Absorption

Bulk Forming LaxativesBulk Forming Laxatives

Onset of action is 12-24hrsOnset of action is 12-24hrs physiologic in promoting evacuation physiologic in promoting evacuation FIRST choice for constipationFIRST choice for constipation Examples are: Examples are:

Citrucel powder, Metamucil, Mitrolan Chewable Tablets

Bulk Forming LaxativesBulk Forming Laxatives

Caution In Younger Than 6 Yrs Of AgeCaution In Younger Than 6 Yrs Of Age Avoid In Intestinal Ulcerations, StenosisAvoid In Intestinal Ulcerations, Stenosis Interact With Anticoagulants, Digitalis Interact With Anticoagulants, Digitalis

Glycosides, And Salisylates Glycosides, And Salisylates Not Used For A Fast Clearing Effect Before A Not Used For A Fast Clearing Effect Before A

Diagnostic Procedure Diagnostic Procedure Used Daily And Continued In Most Patients, With Used Daily And Continued In Most Patients, With

Chronic Constipation. Chronic Constipation.

Emollient Laxatives

Anionic Surfactants, Softening Of Stool Systemically Absorbed (Solid) Onset Of Action (Oral) 24-72hrs As A Stool Softener, & To Prevent

Constipation And Maintain Regularity Example : Docusate SodiumDocusate Sodium Avoid In Pts Who Have Nausea, Vomiting, Or

Undetermined Abdominal Pain

Saline Laxatives

Non-absorbable Cations & Anions - Draw Water Into Intestine - Increase In Intra-luminal Pressure, Stimulates Intestinal Motility

Onset Of Action (Oral) 30min-3 Hrs,(Rectal) 2-5min

ONLY When Fast Clearance Of The Bowel Is Required Ex: Fleet Phospho-soda Avoid In Pts With CHF, Ileostomy, Renal Function

Impairment, Or Younger Than 6 Yrs Old

SALINE CATHARTICSSALINE CATHARTICS

Saline Cathartics Poorly Absorbed Ions Magnesium Sulfate Effects By Osmotic Action In Retaining Fluid In GI.

Magnesium Stimulates The Secretion Of Chole-cystokinin, A Hormone That Causes Stimulation Of Bowel Motility And Fluid Secretion.

M.O.MM.O.M

May Be Given Orally Or Rectally. Bowel Movement Within A Few Hours After

Oral Doses And In 1 Hour Or Less After Rectal

May Cause Fluid And Electrolyte Depletion. Magnesium Or Sodium Accumulation In

Patients With Renal Dysfunction

Hyper-Osmotic LaxativesHyper-Osmotic Laxatives

Combine An Osmotic & Local Effect Of Sodium Combine An Osmotic & Local Effect Of Sodium Stearate, Draws Water Into Rectum Stearate, Draws Water Into Rectum bowel bowel MovementMovement

Onset Of Action (Rectal) 30 MinOnset Of Action (Rectal) 30 Min Suppository FormSuppository Form Minimal Side EffectsMinimal Side Effects Example: Example: Glycerin Suppositories Glycerin Suppositories Avoid In Pts With Rectal IrritationAvoid In Pts With Rectal Irritation

GLYCERIN

Glycerin as a 1 & 3 g suppository and exerts Glycerin as a 1 & 3 g suppository and exerts its effect by osmotic action in the rectum. its effect by osmotic action in the rectum.

onset of action is less than 30 minutes.onset of action is less than 30 minutes. Glycerin is very safe infants, children. Glycerin is very safe infants, children. Its use is acceptable on for Its use is acceptable on for

constipation, in children.constipation, in children.

Lubricant LaxativesLubricant Laxatives

Prevent colonic absorption of fecal water, Prevent colonic absorption of fecal water, thus soften the stoolthus soften the stool

minimally absorbedminimally absorbed Onset of action (oral)6-8 hrs, (rectal) 5-15 minOnset of action (oral)6-8 hrs, (rectal) 5-15 min Avoid prolonged useAvoid prolonged use cause mal-absorption of fat-soluble vitaminscause mal-absorption of fat-soluble vitamins Example: Example: Mineral oil Mineral oil

LUBRICANTSLUBRICANTS

Mineral oil (Paraffin) only lubricant laxative

Mechanism from petroleum, coating stool and

allowing for easier passage inhibits colonic absorption of water,

increasing stool weight and decreasing stool transit time

Dose and ADR Mineral Oil

Orally Or Rectally In A Dose Of 15 To 45 MlOrally Or Rectally In A Dose Of 15 To 45 Ml Effect On Bowel After 2 Or 3 Days Of Use.Effect On Bowel After 2 Or 3 Days Of Use. In Debilitated Or Recumbent Patients, May In Debilitated Or Recumbent Patients, May

Aspirated, Lipoid-pneumoniaAspirated, Lipoid-pneumonia ADR: Decrease Absorption Of Fat-soluble ADR: Decrease Absorption Of Fat-soluble

Vitamins (Vitamins (A, D, E, And KA, D, E, And K) With Chronic Use ) With Chronic Use Even Orally, May Leak From The Anal Even Orally, May Leak From The Anal

Sphincter, Causing Soiling Of Clothing.Sphincter, Causing Soiling Of Clothing.

LACTULOSELACTULOSE

Lactulose - Disaccharide, used Orally Or Lactulose - Disaccharide, used Orally Or RectallyRectally

Metabolized By Colonic Bacteria To Low-Metabolized By Colonic Bacteria To Low-molecular-weight Acids, Result In molecular-weight Acids, Result In Osmotic Effect = Fluid Is Retained In The Osmotic Effect = Fluid Is Retained In The Colon.Colon.

The Fluid Retained In The Colon Lowers The Fluid Retained In The Colon Lowers The Ph And Increases Colonic PeristalsisThe Ph And Increases Colonic Peristalsis

LACTULOSELACTULOSE

Not First-line, Not More Effective Than Not First-line, Not More Effective Than Sorbitol Or Milk Of MagnesiaSorbitol Or Milk Of Magnesia

Alternative For Acute Constipation,Alternative For Acute Constipation, Useful In Elderly PatientsUseful In Elderly Patients Lactulose May Result Flatulence, Cramps, Lactulose May Result Flatulence, Cramps,

Diarrhea, And Electrolyte Abnormality.Diarrhea, And Electrolyte Abnormality.

Lactulose Dose Lactulose Dose Initial Dose 5 To 30 Ml Daily PO In A Initial Dose 5 To 30 Ml Daily PO In A

Single Dose Or In 2 Divided Doses; Single Dose Or In 2 Divided Doses; Doses Up To 45 Ml Daily Doses Up To 45 Ml Daily

Dose Is Adjusted To Patient's Needs Dose Is Adjusted To Patient's Needs Children Children

5 To 10 Years Initial Doses Of 10 Ml 5 To 10 Years Initial Doses Of 10 Ml Twice DailyTwice Daily

1 To 5 Years, 5 Ml Twice Daily 1 To 5 Years, 5 Ml Twice Daily Under 1 Year, 2.5 Ml Twice Daily. Under 1 Year, 2.5 Ml Twice Daily.

Sorbitol Sorbitol A Monosaccharide, Osmotic Action, A Monosaccharide, Osmotic Action, Primary Agent In Functional Primary Agent In Functional

Constipation Constipation As Effective As Lactulose, Less As Effective As Lactulose, Less

Expensive.Expensive. Sorbitol By Mouth Or Rectally As An Sorbitol By Mouth Or Rectally As An

Osmotic Laxative; Doses Of 20 To Osmotic Laxative; Doses Of 20 To 50 G. 50 G.

Stimulant LaxativesStimulant Laxatives 2 Classes: 2 Classes:

- Diphenylmethane (- Diphenylmethane (BisacodylBisacodyl))- Anthraquinone (- Anthraquinone (SennaSenna) )

Increases Propulsive Peristaltic Activity Increases Propulsive Peristaltic Activity By Local Irritation Of MucosaBy Local Irritation Of Mucosa

Onset Of Action:Onset Of Action:Senna (PO) 8-12 Hrs Senna (PO) 8-12 Hrs Bisacodyl: Oral/Rectal 15-60min, Bisacodyl: Oral/Rectal 15-60min,

Systemically AbsorbedSystemically Absorbed Major Use: For Evacuation Of Bowel Prior Major Use: For Evacuation Of Bowel Prior

To GI Surgery Or ExaminationTo GI Surgery Or Examination

BisacodylBisacodyl

Stimulating Mucosal Nerve Plexus Of Stimulating Mucosal Nerve Plexus Of ColonColon

Significant Inter-patient Variability Exists Significant Inter-patient Variability Exists With Dosing With Dosing

A Dose That Causes No Effect In One A Dose That Causes No Effect In One Patient May Result In Excessive Cramping Patient May Result In Excessive Cramping And Fluid Evacuation In Others.And Fluid Evacuation In Others.

Not Recommended For Regular Daily Use.Not Recommended For Regular Daily Use.

BisacodylBisacodyl

Acceptable Intermittently (Every Few Weeks) Acceptable Intermittently (Every Few Weeks) To Treat Constipation Or As A Bowel To Treat Constipation Or As A Bowel Preparation Preparation

Cause Abdominal Cramping Cause Abdominal Cramping Significant Fluid And Electrolyte Imbalances Significant Fluid And Electrolyte Imbalances

With Chronic Use.With Chronic Use. Should NotShould Not Use In Appendicitis Is A Use In Appendicitis Is A

Possibility (Perforation Of The Appendix May Possibility (Perforation Of The Appendix May Result) Or During Pregnancy Or LactationResult) Or During Pregnancy Or Lactation

ANTHRAQUINONEANTHRAQUINONE

Cascara, Sennosides, And Casanthrol. Gut Bacteria Metabolizes These Agents To

Their Active Compounds, Exact Mechanisms Of Action Not

Understood. Effects Are Limited To The Colon, Use Of These Agents Are Similar To Those

For The Diphenylmethane Derivatives. Intermittent Use Is Acceptable; Daily Use

Discouraged

Stimulant LaxativesStimulant Laxatives Sennakot, Sennakot S (With Sodium Docusate), Sennakot, Sennakot S (With Sodium Docusate),

Exlax, Dulcolax, Exlax, Dulcolax, Fijan Syrup (5.85 Mg Sennoside/5 Ml)Fijan Syrup (5.85 Mg Sennoside/5 Ml) Interact With H1 Blockers, Antacids If Interact With H1 Blockers, Antacids If

Administered Within 1 HrAdministered Within 1 Hr Avoid In PregnancyAvoid In Pregnancy Breast Feeding: Senna Laxative Reported Brown Breast Feeding: Senna Laxative Reported Brown

Discoloration Of Breast MilkDiscoloration Of Breast Milk Adverse Effects: Adverse Effects:

Severe Cramping, Electrolyte & Fluid Severe Cramping, Electrolyte & Fluid Deficiencies, Metabolic Acidosis/AlkalosisDeficiencies, Metabolic Acidosis/Alkalosis

CASTOR OILCASTOR OIL Castor Oil Metabolized In GI To Active Castor Oil Metabolized In GI To Active

Compound, Ricinoleic Acid, Compound, Ricinoleic Acid, Stimulates Secretory Processes, Decreases Stimulates Secretory Processes, Decreases

Glucose Absorption, And Promotes Intestinal Glucose Absorption, And Promotes Intestinal Motility, In Small Intestine. Motility, In Small Intestine.

Castor Oil Results In A Bowel Movement 1 To Castor Oil Results In A Bowel Movement 1 To 3 Hours. 3 Hours.

Because Strong Purgative Action, Should Because Strong Purgative Action, Should Not Used For Routine Treatment Of Not Used For Routine Treatment Of Constipation.Constipation.

Polyethylene GlycolPolyethylene Glycol

PEG Become Popular For Colon PEG Become Popular For Colon Cleansing Before Diagnostic Procedures Cleansing Before Diagnostic Procedures Or Colorectal Operations.Or Colorectal Operations.

Four Liters Of This Solution Is Four Liters Of This Solution Is Administered Over 3 HoursAdministered Over 3 Hours

Not Recommended For Routine Treatment Not Recommended For Routine Treatment Of Constipation And Should Be Avoided Of Constipation And Should Be Avoided In Patients With Intestinal Obstruction.In Patients With Intestinal Obstruction.

Acute Constipation infrequent use (less than every few

weeks) of laxative is acceptable. Relieved by use of a tap-water enema or a

glycerin suppository; if ineffective, use of oral sorbitol, low

doses of diphenylmethane or anthraquinone laxatives, or saline laxative (e.g., milk of magnesia)

If laxative is required for longer than 1 week, consult a physician

Bedridden or Geriatric patients For some bedridden or geriatric patients, or with

chronic constipation, bulk-forming laxatives first line of treatment,

Use of laxatives may be required frequently. Lowest effective dose and infrequently as

possible to maintain regular bowel function (more than three stools per week).

Milk of magnesia, and sorbitol or lactulose. Mineral oil should be avoided

Patient Counseling

Laxative use to treat constipation should be only on a temporary measure

If laxatives are not effective after 1 week, a physician should be consulted

Management 1-Management of chronic constipation

due to slow transit including:

patient education

behavior modification

dietary changes

drug therapy

2-Management of defecation involves:

biofeedback

sensory training

relaxation exercises

suppository programs

Patient education: reassurance explanation of normal bowel habits reduce use of laxatives and cathartics increase fluid and fiber intake use normal postprandial increases in colonic motility

by instructing patients to defecate after meals important in the morning when colonic motor activity

is highest

What Can You Do?

Become more physically active A 30 minute walk

every day may help keep you more regular

What Can You Do? Eat more fiber

More beans, whole grains and bran cereals, fresh fruits, vegetables

Limit foods with no fiber (cheese, meat, sweets, processed foods)

What Can You Do? Fiber supplements are best choice

Absorb water and make stool softer Safe to use everyday Be sure to drink at least 8 to 10

glasses of water everyday Add to diet slowly to prevent

problems with gas

What Can You Do?

Drink more water and other liquids (8 eight-ounce glasses a day) Liquid helps keep the

stool soft Avoid caffeine or

alcohol which can dehydrate you

Treatment algorithm for

normal transit

constipation

Treatment algorithm for slow-transit constipation

Thank you for your attention

Constipation in Infants & children Constipation common. Constipation common. neurologic, metabolic, or neurologic, metabolic, or

anatomic abnormalities. anatomic abnormalities. Management:Management: Dietary modification with high-Dietary modification with high-

fiber foodsfiber foods

Drugs for Constipation: Drugs for Constipation: Fluid & High fibers Fluid & High fibers Laxatives -osmotic: Laxatives -osmotic:

Polyethylene glycol (70 g powder)Polyethylene glycol (70 g powder)     Lactulose (10g/15 ml syrup) Lactulose (10g/15 ml syrup)         Sorbitol (5g powder)Sorbitol (5g powder) GlycerinGlycerin

Laxatives - stimulant: Laxatives - stimulant:

Bisacodyl (Dulcolax, Correctol) 5 mg tab;5,10 mg supp.  Bisacodyl (Dulcolax, Correctol) 5 mg tab;5,10 mg supp.  Castor oilCastor oilSennaSennaFigan syrup (5.85 mg sennoside B/5 ml) Figan syrup (5.85 mg sennoside B/5 ml)

Magnesium Hydroxide (Milk of magnesium Magnesium Hydroxide (Milk of magnesium MOM)MOM)240cc 8% Susp240cc 8% Susp

Thank you for your attention

Rastegarpanah