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Laxatives

Category: Medicines

Type

Involuntary

Introduction and description

 

Laxatives are a class of drug used in the treatment of chronic constipation and irritable bowel. In order to keep the illnesses and drugs together, we have separated out those drugs targeted at sufferers of IBS and placed them in the section IBS treatments.

Thus the drugs discussed here are intended to treat constipation only.

In the section on constipation, we have discussed the possible causes of constipation, and the need to treat the cause and not the symptoms. 

One cause of constipation, for example, can be stress.  The sympathetic nervous system and the parasympathetic nervous system govern bowel action.  In the 'fight or flight' mode [sympathetic nervous system - stress], the body automatically shuts down bowel movements as part of the body's preparation to fight the 'dinosaur'.  When greatly relaxed and without fear [parasympathetic nervous system], the body's normal functions - peeing, pooing and digesting return.  This is why indigestion and constipation often go together when you are stressed.

pomegranates

Thus one helpful treatment of constipation is simply to find ways of relaxing more - listening to beautiful music, walking in the countryside, relaxing by painting or being creative - making cakes or gardening for example.  Making love.  

Eating the right food also helps - we have provided some observations below with suggestions, but there are more suggestions under the heading of constipation for healing foods, including the well known Beverley-Travis recipe, which is actually delicious.

You may be surprised by the foods that do help with constipation.  We all know about onions, garlic, rhubarb, and figs, but did you know celery is good too, as are pomegranates [not pomegranate juice, pomegranates, seeds and all]? 

 

Sorbitol, a naturally occuring sweetener is also a natural laxative.  It works in much the same way as over-the counter and prescribed laxatives, but because it is found in foods, there is little danger of overdosing.  It draws water into the large intestine, thereby stimulating bowel movements.  Sorbitol also appears to have a synergistic action with the bacteria in our stomach, thus helping those whose bacterial balance has become disrupted by illness or the use of antibiotics.  Sorbitol is found in some dried fruits including prunes and was discovered initially in the fresh juice of mountain ash berries in 1872 - Rowanberries. It is found in the fruits of apples, plums, pears, cherries, dates, peaches, and apricots.

I hope you can see that the need for drugs is very questionable. 

Constipation is a common complaint among elderly people, resulting in large amounts of money being spent on laxatives. Strategies for improving patient care while reducing this expenditure include:
(a) counselling patients that daily bowel movements and purging are not essential to good health,
(b) greater use of nonpharmacological measures such as hydration, exercise and dietary fibre, and
(c) considering safety, effectiveness and cost in the selection of a laxative.
The widespread use of stool softeners, magnesium hydroxide ('milk of magnesia') and stimulant laxatives is difficult to justify from the available data. PMID: 7663066

Types of drug

The classes of product are:

 
  • Softeners, bulk producers, enemas and others – The  bulking agents or roughage, include dietary fibre. Bulk-producing agents cause the stool to be bulkier and to retain more water, and in many ways have a similar effect to the osmotically acting laxatives by drawing water into the intestines.   
  • Osmotically acting laxatives -In the treatment of chronic constipation,  these laxatives draw water into the bowel, causing a cathartic effect through osmotic action.

Both aim to increase the water content and volume of the stools in the bowel, making them softer and easier to pass. Some of the products, like Lactulose is made up of sugar molecules and is partly broken down by the bacteria that live in the lower part of the gut. This leads to the contents of the gut becoming more acidic because there are carboxylic acids among its metabolites, which are not absorbed from the lower bowel. That in turn causes water to be retained in the lower bowel. This increases the amount of water in the stools, softening them and making them easier to pass.

The added volume of gas and flatulence caused by fermentation of the lactulose or other sugars in these products adds to the volume of the fecal material, and makes it easier to expel. The slightly acidic condition of the colon caused by the presence of acids causes active peristalsis. The combined effect of all of these processes “relieves constipation in a very effective manner”.

Side-effects

 

All side effects including deaths are obtained from the Adverse Drug Reports submitted to the FDA and SEDA and compiled by eHealthme.  The figures apply to the US only and  thus exclude any reactions and deaths in the rest of the world.  Taking some typical drugs within this category, we find the following:

Most common Bisacodyl side effects:

  • Nausea And Vomiting  (180 reports)
  • Nausea  (169 reports)
  • Weakness  (168 reports)
  • Fatigue  (161 reports)
  • Anaemia(152 reports)
  • Breathing Difficulty  (151 reports)
  • Fever (148 reports)
  • Pain  (143 reports)
  • Hypotension(132 reports)
  • Diarrhea (122 reports)
 

Most common Magnesium sulfate side effects:

  • Pain  (551 reports)
  • Nausea  (534 reports)
  • Hypotension  (505 reports)
  • Stress And Anxiety  (501 reports)
  • Acute Kidney Failure  (492 reports)
  • Fever  (470 reports)
  • Diarrhea (461 reports)
  • Nausea And Vomiting (406 reports)
  • Breathing Difficulty  (404 reports)
  • Pneumonia  (394 reports)

 Many of these side effects are symptomatic of magnesium imbalance and poisoning.

Deaths

Note that patients were often taking other drugs whilst taking laxatives, for example opioids - which cause constipation - but the figures are worth noting, given the person started off with constipation.

Amitiza - On Sep, 5, 2015: 1,707 people reported to have side effects when taking Amitiza. Among them, 30 people (1.76%) have Death

Bisacodyl and its trade names

  • On Aug, 21, 2015: 1,627 people reported to have side effects when taking Bisacodyl. Among them, 72 people (4.43%) have Death
  • On Sep, 5, 2015: 244 people reported to have side effects when taking Dulcolax. Among them, 8 people (3.28%) have Death.
 

 Colace figures for all brand names not shown

  • On Aug, 21, 2015: 1,087 people reported to have side effects when taking Colace. Among them, 30 people (2.76%) have Death

Lactulose and its trade names

  • On Aug, 29, 2015: 1,850 people reported to have side effects when taking Duphalac. Among them, 22 people (1.19%) have Death
  • On Aug, 26, 2015: 28 people reported to have side effects when taking Constulose. Among them, 1 people (3.57%) has Death
  • On Sep, 5, 2015: 13,990 people reported to have side effects when taking Lactulose. Among them, 529 people (3.78%) have Death
  • On Sep, 5, 2015: 79 people reported to have side effects when taking Generlac. Among them, 1 people (1.27%) has Death

Magnesium sulphate - On Aug, 26, 2015: 7,067 people reported to have side effects when taking Magnesium sulfate. Among them, 228 people (3.23%) have Death

Magnesium citrate - On Aug, 12, 2015: 369 people reported to have side effects when taking Magnesium citrate. Among them, 16 people (4.34%) have Death

Magnesium oxide - On Sep, 5, 2015: 4,682 people reported to have side effects when taking Magnesium oxide. Among them, 194 people (4.14%) have Death

Milk of magnesia - On Aug, 31, 2015: 2,828 people reported to have side effects when taking Milk of magnesia. Among them, 125 people (4.42%) have Death

Polyethylene glycol (PEG) sold as

  • On Aug, 30, 2015: 1,452 people reported to have side effects when taking Moviprep. Among them, 39 people (2.69%) have Death
  • On Aug, 6, 2015: 256 people reported to have side effects when taking Polyethylene glycol 3350. Among them, 1 people (0.39%) has Death
  • On Sep, 5, 2015: 642 people reported to have side effects when taking Glycolax. Among them, 23 people (3.58%) have Death
  • On Aug, 30, 2015: 9,040 people reported to have side effects when taking Miralax. Among them, 286 people (3.16%) have Death

 Psyllium - On Aug, 9, 2015: 351 people reported to have side effects when taking Psyllium. Among them, 17 people (4.84%) have Death

 

How it works

 

Although the scouring action of these products may have a long term effect on the balance of the intestinal bacteria, and the use of products containing magnesium may cause magnesium imbalance over time, the hallucinations that people experience in these products are probably caused by dehydration.

There is an explanation for the physical mechanisms in operation during dehydration in the Science section see the Chemistry of dehydration.  But the section on dehydration explains what is functionally happening and why we may get an hallucination.

The risk of getting adverse effects is higher amongst those who misuse laxatives.  For example  some obsessive slimmers use laxatives to purge themselves when they think they have over eaten.  And there is a higher risk of hallucinations from dehydration with children, the elderly, and people already dehydrated from working in dry offices or too hot surroundings. 

At very high doses, all these drugs are acting via  poisoning.

Observations

The table below shows the hallucinations for each drug.  The figures have been obtained from eHealthme and are a summary of the Adverse Drug Reports submitted by doctors to the FDA and SEDA.  The table was correct as of mid August 2015.  The links take you to the eHealthme site and an up-to-date list of all side-effects for each drug.

Even if a drug has no hallucinations recorded, we have kept it in the table so that you are still able to cross reference the side effects.

Drug

No of hallucinations

Amitiza and Lubiprostone

 22

Bisacodyl trade names Dulcolax/Durolax, Fleet, Nourilax, Alophen, Correctol, and Carter's Little Pills 

 13

Colace **

 11

Epsom salts / Magnesium sulphate

 37

Lactulose - Trade names Duphalac, Generlac  and Constulose

 14 + 117 =  131

Linaclotide to be marketed under the trade name Linzess and Constella

 N/A [not yet passed trials]

Magnesium Citrate trade names Citromag and Citroma ++

 1

Magnesium Oxide

 16

Milk Of Magnesia

 27

Polyethylene Glycol 3350 trade names Miralax, Glycolax, Softlax, Movicol etc

 66 + 2 = 68

Psyllium, Metamucil

 1

 

 317

 

 

** This product is sold under about 40 different brand names and this is the figure for just one of these names.  To get a true picture one could thus multiply the figure shown by 40

++  As a food additive, magnesium citrate is used to regulate acidity and is known as E number E345.

 

Related observations