Dialogue Volume 14 Issue 2 2018 - Page 51

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