PRACTICE PARTNER
zine is a first-generation anti-histamine
that has potent anti-cholinergic properties.
It is not clear if hydroxyzine was the only
alternative considered for the patient’s scalp
scratching.
Clozapine is well known to cause bowel
hypomotility. Because of its potential to
significantly decrease GI motility, its use is
associated with increased risk of paralytic
ileus, bowel obstruction, fecal impaction,
bowel perforation, and in rare cases, death.
Relative to other neuroleptics, clozapine has
a high potency of cholinergic blockade.
Oxybutynin and hydroxyzine are both well
known to be highly anti-cholinergic medica-
tions. “Their use alone, let alone in combina-
tion with other anticholinergic medications,
should prompt careful bowel monitoring for
constipation,” said the Committee in its report.
The Committee noted that the patient was
prescribed docusate sodium for prevention
of constipation. “There is little evidence
to support the use of surfactant agents in
chronic constipation. Stool softeners such
as docusate sodium are intended to lower
the surface tension of stool, thereby allow-
ing water to more easily enter the stool.
Although these agents have few side effects,
they are less effective than other laxatives;
surfactants are ineffective in preventing and
treating medication-induced constipation,”
stated the report.
From the records available, the treating
health-care providers did not appear to
recognize the potential for life-threatening
constipation to develop in the patient, stated
the Committee. “There was no record of
the patient’s bowel habits and no notations
pertaining to bowel habits in the periodic
health assessments completed by the family
physician. It does not appear that the treat-
ing health team was aware that with aging,
the risks of medication-induced constipation
would increase. If the risks were recognized,
it is unclear why there was not more proac-
tive treatment of the potential constipation,”
stated the Committee’s report.
RECOMMENDATIONS
1
Physicians treating patients on
clozapine are reminded that clozapine
is a potent inhibitor of gastrointestinal
motility and can cause severe, and even life-
threatening, constipation. There is an even
higher risk of severe constipation in persons
a