Karen Berger, PharmD

Constipation is one common condition where pharmacists can provide assistance to patients.

As knowledgeable and accessible health care professionals, pharmacists are in a unique position to help patients with acute constipation with OTC medication selection or referral to a physician if necessary.

We talked to 2 pharmacists to see how they address the most common questions around constipation. Of course, since each patient has a different medical history, before making a recommendation, ask the patient about medical conditions and medications they take, including prescription, OTC, and vitamins.

1. What is the best OTC medication for constipation in adults?

Jill Caracci, PharmD, is a pharmacist at Sterling Pharmacy in Independence, Missouri.

She explained that the OTC treatment of choice for adults varies depending on the cause. “In idiopathic constipation, [constipation not due to diet, medications, medical conditions, pregnancy, or activity level] I would suggest an osmotic agent such as polyethylene glycol (MiraLAX; Bayer). Mix 17 grams of the polyethylene glycol in 8 ounces of water and drink daily,” she said.

However, if the patient’s constipation is associated with pregnancy, Caracci suggests a fiber product such as psyllium husk (Metamucil; Procter and Gamble).

For opioid-induced constipation, Caracci recommends a combination stool softener/stimulant laxative such as Senna-S, or bisacodyl (Dulcolax; Boehringer Ingelheim Pharmaceuticals Inc) with docusate sodium (Colace; Pharmacal Corporation).

2. I need to go right away. What should I take?

Sara Shelley, PharmD, is the pharmacy manager at Corner Drug Co. in Woodland, California. For quick relief in adult patients, Shelley recommends a Fleet enema. However, if the patient does not want to use an enema, “a bisacodyl suppository or oral magnesium citrate are suitable alternatives,” she said.

What is a good OTC medication for my child’s constipation?

Caracci suggests consulting the child’s pediatrician in this case. For those who have received a green light from the pediatrician to treat constipation, she suggests a glycerin suppository (Pedia-Lax), especially for small children. "They are generally well-tolerated and often produce results within 30 minutes,” she said. For those children who are older or will not tolerate a suppository, Caracci recommends polyethylene glycol with weight-based dosing.

4. What dietary measures will help my constipation?

“Fiber and water are your friends!” Shelley said. “Increasing your fiber intake, decreasing intake of highly processed foods, and staying adequately hydrated can help constipation.” She recommends increasing dietary intake of high fiber foods, such as fruits, vegetables, whole grains, beans, and nuts.

Shelley advises slowly introducing a fiber supplement like psyllium husk or wheat dextrin (Benefiber; GlaxoSmithKline) for patients who need help getting enough fiber. She also reminds patients that beverages containing caffeine, such as coffee and soda, are dehydrating, so drink sparingly, if at all, when constipated.

5. What warning signs would alert you to something more serious than just general constipation?

Shelley advises her patients to seek medical attention right away if their stools are dark/bloody and tarry, or if they have severe abdominal pain, a distended abdomen, unintentional weight loss, or vomiting. If the patient has general constipation, she recommends contacting the doctor if dietary modifications and OTC medications haven’t helped in 4 or 5 days.

6. How long should I try to treat my constipation before seeing a doctor?

In the absence of warning signs mentioned above or known causes of constipation, Caracci suggests consulting the doctor “if there has been no improvement with OTC treatment after 5 days.”

Ten high-fiber foods to help constipation:

Recommend increasing consumption as tolerated as well as increasing water intake.

10 High-Fiber Foods to Help Constipation

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We talked to 2 pharmacists to see how they address the most common questions around constipation.

 Frequently Asked Constipation Questions and How to Address Them

When counseling a patient with constipation, it is important to review the patient’s medication list to determine the potential cause.

Some of the most common drugs that cause constipation include:

Opioid pain medications such as oxycodone and hydrocodone cause constipation and hardening of the stool. Most patients with opioid-induced constipation (OIC) experience straining and incomplete emptying. OIC may occur immediately or may appear gradually during opioid treatment. Other gastrointestinal (GI) adverse effects (AEs) may occur, including nausea, vomiting, bloating, pain, and straining. OIC is a reason that many patients discontinue opioid treatment.

Nonpharmacological treatment: Increasing fiber, fluids, and exercise can help prevent OIC

Over the counter: Preventive laxatives should begin when opioid therapy begins. Any laxative is sufficient except for bulk-forming laxatives like psyllium. The most common preventive treatment for OIC is a stimulant such as senna or bisacodyl with or without a stool softener (docusate), or daily polyethylene glycol.

Rx: A prescription drug can be used for refractory cases of OIC. Methylnaltrexone bromide subcutaneous injection (Relistor) is the most effective. Other options are lubiprostone (Amitiza; Sucampo Pharmaceuticals), naloxegol (Movantik; AstraZeneca), naldemedine (Symproic; Shionogi), or methylnaltrexone bromide oral tablets.

Besides opioids, there are several other medications and supplements that can cause constipation.

Antidepressants, especially tricyclic antidepressants, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors

Blood pressure medications, notably calcium channel blockers such as verapamil

Anticholinergic medications, such as diphenhydramine (Benadryl), oxybutynin, and benztropine

Long-term use of cholestyramine or stimulant laxatives (may develop a dilated colon, which turns into a cycle of more laxative use and less efficacy)

In terms of nonpharmacological treatment, counsel patients to increase intake of fiber and fluids. Good sources of dietary fiber include:

Vegetables: cruciferous vegetables like broccoli, brussels sprouts, and cauliflower; asparagus; carrots

Nuts and seeds: almonds, walnuts, chia seeds

Beans and peas: navy, pinto, and kidney beans; split peas; lentils

Whole grains: barley; quinoa; oats; popcorn

A fiber supplement or laxative can be helpful, too. Pharmacists can help patients select an appropriate product based on symptoms, medical conditions, and potential drug interactions.

Patients should be encouraged to keep an open line of communication with their prescriber about the medications they take, making them aware of constipation so that laxative treatment (or possibly changing the offending medication) can be discussed.

What prescription drugs are available for constipation?

If OTC medications do not help constipation, a prescription drug may be another option. Prescription drugs for constipation include the following.

Linaclotide (Linzess; Ironwood and Allergan plc)

Dose: 72 or 145 mcg by mouth once daily on an empty stomach

Most common AEs: diarrhea, bloating, abdominal pain, gas, headache

Plecanatide (Trulance; Synergy Pharmaceuticals Inc)

Dose: 3 mg once daily with or without food

Most common AE: diarrhea. Other, less common AEs include sinus or upper respiratory tract infection, bloating, gas, and abdominal tenderness

Prucalopride (Motegrity; Takeda Pharmaceuticals U.S.A, Inc)

Dose: 2 mg once daily with or without food

Most common AEs: headache, abdominal pain, nausea, diarrhea, bloating.

Warning: Patients must be monitored for suicidal thoughts and behavior while taking this medication.

Dose: 2 or 3 tablespoons by mouth 3 or 4 times daily

Most common AEs: bloating, gas, belching, cramping. Excess dosage can cause diarrhea with complications (fluid loss, electrolyte imbalance)

Dose: 24 mcg twice daily with food and water (for constipation, or OIC)

Most common AEs: nausea, diarrhea, abdominal pain, bloating, gas, headache

With our knowledge and expertise, pharmacists can play an important role in identifying drug-related causes of constipation, counseling the patient, and referring to the physician if necessary.

Karen Berger, PharmD, from the University of Pittsburgh School of Pharmacy, and her experience includes chain and independent pharmacy as well as medical writing and reviewing. 

1. Sizar O, Genova R, Gupta M. Opioid-Induced Constipation. NCBI StatPearls [Internet]. Updated November 20, 2020. Accessed April 28, 2021. https://www.ncbi.nlm.nih.gov/books/NBK493184/

2. What to do when medication makes you constipated. Harvard Health Publishing. Updated October 22, 2019. Accessed April 28, 2021. https://www.health.harvard.edu/staying-healthy/what-to-do-when-medication-makes-you-constipated

3. Basson MD Anand BS. Which medications can cause constipation? Medscape. Updated March 30, 2020. Accessed April 28, 2021.https://www.medscape.com/answers/184704-23256/which-medications-can-cause-constipation

4. High-fiber foods. Metamucil website. Accessed April 28, 2021. https://www.metamucil.com/en-us/articles/fiber-101/high-fiber-foods

5. Label: Linzess- linaclotide, capsule, gelatin coated. DailyMed. Updated April 12, 2021. Accessed April 28, 2021.https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=09beda19-56d6-4a56-afdc-9a77b70b2ef3

6. Label: Trulance immediate release- plecanatide tablet. DailyMed. Updated April 1, 2021. Accessed April 28, 2021.https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fe2895bf-71a6-493a-b0ca-e06b2dfefc82

7. LabeL: Motegrity- prucalopride tablet, film coated. DailyMed. Updated March 22, 2021. Accessed April 28, 2021.https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bca1e4c6-4b2b-4876-8ab3-654629c4ff1b

8. Label: Lactulose- lactulose solution. DailyMed. Updated December 31, 2019. Accessed April 28, 2021. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a89835c9-8ce5-4627-8d7d-70ff175b2e07

9. Label: Amitiza- lubiprostone capsule, gelatin coated. DailyMed. Updated April 25, 2021. Accessed April 28, 2021. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1b632d92-a05b-42d3-88a6-b3e345d11fe4

Common Medications That Can Cause Constipation

Pharmacists are an excellent resource for patients to ask questions about upper respiratory infections, especially with the ongoing COVID-19 pandemic. As trusted and accessible health care professionals, they can effectively counsel patients on appropriate OTC products and refer them to their physician when necessary.

Most upper respiratory infections are caused by a virus and include the common cold, sinusitis, pharyngitis, epiglottitis, and laryngotracheitis (see Table).

Sinusitis is an acute inflammation of the paranasal sinuses and can be caused by viruses or bacteria.

 Symptoms include pain, pressure, and tenderness around the sinus, as well as nasal discharge. Patients may feel tired and have a slight fever. Symptomatic treatment with analgesics and moist heat, as well as a decongestant, can be helpful. If an antibiotic is needed, amoxicillin/clavulanic acid is a first- line treatment.

Pharyngitis is an inflammation of the pharynx (throat), which can be caused by bacteria, virus, or fungus, or by smoking.

 Most cases are viral and occur with a common cold or flu. Symptoms include a red, sore, or “scratchy” throat. Fever, fatigue, muscle pain, or headache may occur, as well as swollen lymph nodes and difficulty swallowing. Treatment is symptomatic unless the virus is caused by herpes simplex, in which case acyclovir is used. If an antibiotic is needed, a penicillin or macrolide is often used.

The common cold is the most prevalent type of respiratory infection.2 Usually caused by a virus, its symptoms include a stuffy or runny nose, sneezing, sore throat, and cough. Fever rarely occurs, and complications are rare. Sometimes, sinusitis or an ear infection may develop. Treatment for a common cold is symptomatic. caused by bacteria, virus, or fungus, or by smoking.

Most cases are viral and occur with a common cold or flu. Symptoms include a red, sore, or “scratchy” throat. Fever, fatigue, muscle pain, or headache may occur, as well as swollen lymph nodes and difficulty swallowing. Treatment is symptomatic unless the virus is caused by herpes simplex, in which case acyclovir is used. If an antibiotic is needed, a penicillin or macrolide is often used.

Epiglottitis or laryngotracheitis (croup) is an inflammation of the upper airway. The diagnosis depends on location, symptoms, and pathogens.

type b, is less common in adults and can be associated with viral or bacterial infections. Laryngotracheitis is usually viral. Epiglottitis symptoms begin with sudden onset of fever, sore throat (“cherry-red” epiglottis), hoarseness, drooling, and difficulty swallowing. It can quickly progress to severe respiratory distress and can be fatal. Epiglottis is a medical emergency, especially in children, who need immediate emergency care including intubation and antibiotics (against 

Symptoms of laryngotracheitis (croup) include a runny nose, fever, sore throat, and mild cough, progressing to tachypnea, a barking cough, and stridor. Treatment includes observation, fluids, and humidified air. The 

type b conjugate vaccine (and immunization against diphtheria) is recommended in all children for prevention.

Lower respiratory infections include bronchitis, bronchiolitis, and pneumonia. They are often bacterial in nature, requiring antibiotics in such cases.

Otitis media, or middle ear infection, is another common infection, especially in children. It may be bacterial or viral and should be referred to the pediatrician or internist.

Morton Tavel, MD, is a clinical professor emeritus of medicine at Indiana University School of Medicine. Tavel reminds pharmacists that “despite the discomfort from the sneezing, sore throat, cough, and runny nose of a viral infection, happily, it gets better on its own without requiring any special treatment, usually within a week but sometimes a bit longer.”

Chris Schiller, PharmD, is the CEO of Economy Pharmacy, Inc, in Muskogee, Oklahoma. He recommends guaifenesin or guaifenesin-pseudoephedrine (Mucinex or Mucinex-D), depending on symptoms, as well as humidifiers and camphor eucalyptus oil-menthol (Vicks VapoRub).“My primary focus is on immune system health,” he said. He recommends supplements such as probiotics and immune support products, which combine vitamin D, vitamin C, zinc, and quercetin.

Tavel says pharmacists should dis- cuss other conditions the patient has that may not be compatible with a recommended OTC medication (for example, patients with hypertension should not use an oral decongestant).

According to the CDC, at least 47 million unnecessary antibiotic prescriptions are issued every year in the United States, which can lead to adverse effects and antibiotic resistance.

 When counseling patients, pharmacists should remind them that antibiotics do not treat viral infections. “[Seeing] they have no effect on the culprit viruses, contrary to the almost universal misconception, antibiotics should not be employed,” Tavel said. “Using them will neither shorten the cold’s duration nor prevent its spread to others. Moreover, the more we take antibiotics, the greater chance of producing resistant bacteria that could create mischief to others at a later time.”

Instead, Tavel recommends that patients consult their physician if their cold lasts for over a week or causes a moist cough, or if a fever lasts for more than 2 days. Antibiotics are needed for certain bacterial infections, such as pneumonia or sepsis. They are also necessary for high-risk patients, such as those with severe kidney disease or who are undergoing chemotherapy.

Patients should visit their internist if symptoms persist or are severe. The internist can perform an examination, order labs and cultures if warranted, and decide if an antibiotic is needed.

1.Upper respiratory tract. MedlinePlus. [KM1]Updated February 26, 2021. Accessed March 24, 2021.

https://medlineplus.gov/ency/imagepages/19378.htm

2.Dasaraju PV, Liu C. Infections of the Respiratory System. In: Baron S, ed. 

 University of Texas Medical Branch at Galveston; 1996. Accessed xxx xxxx.[KM2]

https://www.ncbi.nlm.nih.gov/books/NBK8142/#:~:text=Acute%20upper%20respiratory%20infections%20

3.Antibiotic prescribing and use. CDC. Updated November 13, 2020. Accessed March 24, 2021.

https://www.cdc.gov/antibiotic-use/index.html

4.Be antibiotics aware: smart use, best care. CDC. Updated November 17, 2020. Accessed March 24, 2021.

https://www.cdc.gov/patientsafety/features/be-antibiotics-aware.html

5.Antibiotic do’s & don’ts. CDC. Updated January 31, 2020. Accessed March 24, 2021.

https://www.cdc.gov/antibiotic-use/community/about/can-do.html

Pharmacists can offer OTC recommendations for symptom relief.







Self-care for Upper Respiratory Tract Infections

In 2019, almost 50,000 people in the US died as a result of opioid overdose; this number includes events involving prescription pain medications, heroin, and synthetic opioids like fentanyl.1 The CDC estimates the annual economic burden of prescription opioid misuse at $ 78.5 billion.

 Pharmacists can be a valuable resource to patients and the community as a whole by learning about naloxone and how to treat an opioid overdose, as well as recommending naloxone to patients and counseling on its use.

This article is the first of a 2-part series on naloxone education and patient counseling for pharmacists.

Naloxone is an opioid antagonist. It attaches to opioid receptors, rapidly reversing an opioid overdose. Naloxone quickly restores normal breathing in a patient whose breathing has slowed or stopped because of an opioid over- dose. Naloxone is effective only in opioid overdose due to drugs such as oxycodone, hydrocodone, codeine, heroin, fentanyl, and morphine.

Naloxone does not treat overdoses of nonopioid medications, and it does not have an effect on someone who has not taken opioids.

Although any opioid use can lead to overdose, some factors that may increase overdose risk include:

combining opioids with alcohol or other drugs (such as benzodiazepines);

taking more opioids than prescribed by the physician;

taking illegal opioids that could contain unknown substances;

having impaired hepatic or renal function; and • being older than 65 years.

slowed or shallow breathing (or no breathing);

pinpoint pupils (small, constricted pupils);

In the event of an opioid overdose (or suspected overdose), administer naloxone and call 911. Keep the person awake and talking. Another naloxone dose (or more) may be necessary. Stay with the person until emergency help arrives.


Results of studies show that naloxone distribution programs and naloxone access laws reduce opioid overdose deaths without increasing opioid use. Estimates suggest that when laypersons and emergency personnel have naloxone, 21% of opioid overdose deaths could be avoided.

Although naloxone is a prescription drug, many pharmacies in the United States have naloxone available with- out a prescription through a standing order. Law enforcement or emergency medical services personnel can work with local health departments to access naloxone.


Naloxone is available in 3 FDA-approved forms:


Naloxone nasal spray (Narcan; Sankyo) is sprayed into 1 nostril while the patient lies on their back.

One spray into 1 nostril, and then call 911. If the patient responds and goes back into respiratory depression before help arrives, or if the patient does not respond after 2 to 3 minutes, give another dose in the other nostril using a new naloxone nasal spray. If there is still no response and more doses are available, give additional doses every 2 to 3 minutes using a new naloxone nasal spray with each dose, and alternate nostrils each time, until the EMS arrives.


Naloxone autoinjector (Evzio; Kaleo) is a prefilled autoinjection device that is injected into the thigh muscle. When it is turned on, a recording gives instructions.

Administer 1 intramuscular (IM) or subcutaneous (SQ) injection into the thigh (through clothing if necessary), then call 911. If the patient does not respond and more doses are available, doses may be repeated every 2 to 3 minutes until EMS arrives. If the patient responds and goes back into respiratory depression before EMS arrives, give another dose.


Naloxone injection is given by a health care professional. The route of administration may be intravenous (IV), IM, or SQ. The IV route is preferred because of its faster onset.

Depending on the opioid, dose, and route of administration that caused the overdose, the naloxone dose will vary and may require repeat doses.

Each patient who receives a naloxone product, regardless of whether it is an autoinjector or nasal spray, should receive training, read the instructions, and check the expiration date. These 2 dosage forms were designed to be easy to use by anyone in an emergency situation.

Naloxone may cause withdrawal symptoms. Although uncomfortable, withdrawal symptoms are not life-threatening. They may include headache, blood pressure changes, tachycardia, sweating, nausea, vomiting, tremors, irritability, nervousness, aggressive behavior, body aches, fever, runny nose, and sneezing.

Opioid overdose crisis. National Institute on Drug Abuse. Updated March 11, 2021. Accessed May 23, 2021. 

https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis

Naloxone. National Institute on Drug Abuse. Updated September 2019. Accessed May 23, 2021. 

https://www.drugabuse.gov/publications/drugfacts/naloxone

Preventing an opioid overdose. Centers for Disease Control and Prevention. Accessed May 23, 2021. 

https://www.cdc.gov/drugoverdose/pdf/patients/preventing-an-opioid-overdose-tip-card-a.pdf

Having naloxone on hand can save a life during an opioid overdose. FDA. Updated December 11, 2019. Accessed May 23, 2021. 

https://www.fda.gov/consumers/consumer-updates/having-naloxone-hand-can-save-life-during-opioid-overdose#:~:text=Everyone%20who%20overdoses%20with%20opioids,by%20anyone%2C%20even%20a%20bystander

Naloxone for opioid overdose: life-saving science. National Institute on Drug Abuse. Updated March 2017. Accessed May 23, 2021. 

https://www.drugabuse.gov/publications/naloxone-opioid-overdose-life-saving-science#ref

Opioid overdose reversal with naloxone (Narcan, Evzio). National Institute on Drug Abuse. Updated February 20, 2020. Accessed May 23, 2021. 

https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-reversal-naloxone-narcan-evzio

Label: Narcan–naloxone hydrochloride spray. DailyMed. Updated March 25, 2021. Accessed May 23, 2021. 

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=724df050-5332-4d0a-9a5f-17bf08a547e1

Label Evzio: naloxone hydrochloride injection, solution. DailyMed. Updated April 5, 2021. Accessed May 23, 2021. 

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=5fbe8d17-a72f-406d-a736-48e61620f9d8

Label: Naloxone hydrochloride injection. DailyMed. Updated March 18, 2020. Accessed May 23, 2021. 

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b1303f15-c48b-a44d-b28a-72f370094e02

Become an expert in naloxone to help educate patients.