PRACTICE PARTNER
Be mindful of
constipation as
a side effect of
medications
C
onstipation is a life-threatening
complication of clozapine. As
such, physicians must pay judi-
cious attention to the manage-
ment of the patient’s bowels while they are
on medications that cause constipation.
This reminder is prompted by a review
from an expert committee of the Chief
Coroner’s Office that was investigating
the circumstances of the 2016 death of a
60-year-old woman who died of constipa-
tion. The cause of the constipation was pre-
scription medications. In fact, the
woman was on three medications
which have constipation as a major
and serious side effect – clozapine,
There is an
oxybutynin and hydroxyzine.
even higher
The patient was also at increased
risk
of constipation due to her
risk of severe
diabetes, which has the potential
constipation
to cause an autonomic neuropathy.
in persons as
It is clear that the clozapine was
required, said the Geriatric and
they age
Long-Term Care Review Commit-
tee. The patient had severe schizo-
phrenia, and with the introduction
of clozapine, her condition stabilized and
her need for inpatient admission reduced to
no admissions in the last six years of her life.
The patient lived in a group home for
adults with serious psychiatric illness. She
saw her family physician regularly for pre-
ventive health care and medication reviews.
The patient had a colonoscopy in 2007, and
had declined any further colonic carcinoma
surveillance screening thereafter. Aside from
a comment in a 2010 note in the record,
there is no record of assessment of bowel
habit or constipation symptoms in the re-
cords of the family physician.
Oxybutynin was being prescribed for
“overactive bladder” and “stress inconti-
nence.” It is not clear, states the Committee,
if the constipation was playing a role in the
etiology of the urinary incontinence. If this
were the case, the treatment would not have
been to prescribe a bladder medication, but
rather to treat the incontinence. There was
no indication that a full assessment of the
etiology of the incontinence was carried
out. Oxybutynin is a highly anti-cholinergic
medication. There is no evidence in the
medical literature supporting its use in stress
urinary incontinence. For urinary incon-
tinence with “overactive bladder,” there is
evidence that anti-muscarinic medications
(such as oxybutynin) can be helpful, though
the effect size is small and should be weighed
against the real risks of these medications.
In 2014, hydroxyzine was added to her
medications as the patient was excoriating
her scalp due to perceived itching. Hydroxy-
ISSUE 2, 2018 DIALOGUE
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