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As health professionals, we are commonly working with individuals who are effected by gastrointestinal symptoms, with constipation and diarrhoea being commonly observed. Navigating the medical cause of altered bowel habits requires a comprehensive assessment, and is best addressed through working alongside a mutlidisciplinary team.

Dr Amanda Cross and Dr Natali Jokanovic discuss the importance of obtaining and in-depth medical, medication and lifestyle assessment to pinpoint the cause of, and resolve, constipation and diarrhoea. In determining the cause of constipation, medication and supplement lists should be assessed for opiods (e.g. codeine), anti-cholinergics (e.g. amitryptaline, which can cause dehydration), iron supplementation (especially high dose and poorly tolerated forms), blood pressure medications such as verapimil (which reduces gut motility), GLP-1 analogues, and diuretics , which can all lead to constipation. In managing constipation, thorough screening is required in determining whether a bulk-forming laxative (slow-acting), osmotic laxative (moderately quick-acting, stimulant laxative (quick-acting), or stool softener (‘gently’-acting), or a combination of laxatives are the best option.

In considering the medical cause of diarrhoea, patients should be assessed for acute diarrhoea (often viral, or antibiotic-associated, such as C.difficile), or chronic diarrhoea - functional (idiopathic), or organic (caused by physiological, structural or biochemical abnormalities). In addressing the cause of diarrhoea, a comprehensive medication review may be required, with analgesics, antibiotics, psychotropic medications, and metformin increasing the risk of diarrhoea. PPIs should also be considered, as these can increase the risk of a C.diff infection. Loperamide (an anti-diarrhoeal) can be considered in the management of acute and chronic diarrhoea, although not in the case of a C.diff infection as it may cause bacterial retention. Further medication options for organic causes of diarrhoea include codeine, colestryamine (for bile acid diarrhoea), and pancreatic enzymes (such as creon for malabsorption diarrhoea).

Overall, clinical judgement and a collaborative multidisciplinary approach is required to identify and manage constipation and diarrhoea on a case-by-case basis.

Summary:

• Constipation and diarrhoea are common symptoms that may result from a range of causes including other medical conditions, medications, diet, and lifestyle changes.
• Opiods (e.g. codeine), anti-cholinergics (e.g. amitryptaline, which can cause dehydration), iron supplementation (especially high dose and poorly tolerated forms), blood pressure medications such as verapimil (reduces gut motility), GLP-1 analogues, and diuretics can commonly contribute to constipation. In managing constipation, thorough screening is required in determining whether a bulk-forming laxative (slow-acting), osmotic laxative (moderately quick-acting, stimulant laxative (quick-acting), or stool softener (‘gently’-acting) is the best option.
• Common medications such as analgesics, antibiotics, psychotropic medications, and metformin can all increase the risk of diarrhoea, while PPIs can increase the risk of C.diff infection.
• A collaborative and multidisciplinary approach is crucial in addressing and managing constipation and diarrhoea.

Dr Amanda Cross is an NRHMC Emerging Leader research fellow at the Centre for Medicine Use and Safety, Monash University. Amanda completed her PhD with Monash University in 2019 focussing on optimising medication use and medication management in older people with cognitive impairment. Amanda’s research interests primarily relate to medicine safety and quality use of medicines in older people, particularly those at risk of developing dementia or who are currently living with dementia. She is currently exploring new models of care for translating evidence and guidelines into practice in the residential aged care setting.

Amanda has secured over $4.8million in research funding and has published 26 articles in scientific journals, including 15 first author articles. Amanda continues to practice in a clinical role as a home medication review pharmacist. She is an active member of the Pharmaceutical Society of Australia and was the Victorian Branch Vice President for three years (2018-2021). In 2019 Amanda won the award for the Pharmaceutical Society of Australia Victorian Early Career Pharmacist of the Year.

Dr Natali Jokanovic is a postdoctoral researcher at the Department of Infectious Diseases, the Alfred Hospital and Monash University. She currently manages a randomised controlled trial implementing an antimicrobial stewardship program across 12 Victorian residential aged care facilities. Natali is also a practising hospital clinical pharmacist with over ten years of experience in hospital pharmacy. 

Natali completed her PhD at the Centre of Medicine Use and Safety, Monash University, investigating polypharmacy within residential aged care. She then continued her research in deprescribing at transitions of care at the University of Sydney/Royal North Shore Hospital in NSW prior to returning to the Alfred Hospital in Victoria. Her primary research interests include medication optimisation in older people across care settings with a particular focus on residential aged care facilities. 

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