Constipation and low blood pressure

13 Surprising Causes of Constipation

Everyone is affected by constipation now and then — your diet, travel, and a lack of activity can all trigger a brief bout.

But you might be surprised by the conditions and other factors that can be responsible for longer term or chronic constipation. The list is wide-ranging, from pregnancy constipation to a side effect of antidepressants.

Some of these causes of constipation can be handled at home with an over-the-counter product or changes in your medicine cabinet, but serious constipation warrants a prompt doctor’s visit.

“Constipation that’s new, different, associated with bleeding or weight loss, and lasts a couple of days may be a sign of colon cancer,” says gastroenterologist Benjamin Krevsky, MD, associate chief of the section of gastroenterology at Temple University in Philadelphia, Pa.

But since there are several more common causes of constipation that aren’t as serious, don’t worry too much. Your doctor can help you determine what’s really behind your constipation.

Sneaky Causes of Constipation

Here’s an overview of some of the conditions that may be to blame for your discomfort:

  • Hypothyroidism. “The thyroid is a general regulator and affects organs all over the body,” explains Dr. Krevsky. This includes the bowel. Your family doctor might miss this, but a gastroenterologist who sees this effect several times a year will probably test you for hyperthyroidism and can treat it to relieve your chronic constipation.
  • Hyperparathyroidism. Less common than hypothyroidism, an overactive parathyroid — a gland close to the thyroid — can also be a cause of constipation. Simple testing and treatment will also bring relief.
  • Prescription painkillers. Opioids — not over-the-counter pain relievers — can cause constipation. For people recovering from surgery or managing chronic pain, this side effect can be an obstacle to quality of life (or possibly, hospital discharge). Solutions include taking different pain medications or adding a laxative. Krevsky explains that research in this area is progressing and within the next several years doctors might have new medications to treat pain without causing constipation.
  • Laxatives. Ironically, the laxative you are taking could ultimately lead to chronic constipation. Your body builds up a tolerance to medications that act as stimulant laxatives, such as castor oil. Technically, says Krevsky, they aren’t causing constipation so much as failing to ease it. A better bet for laxatives that won’t lead to tolerance is milk of magnesia or polyethylene glycol (Miralax).
  • Antidepressants. Constipation was one of the unpleasant side effects of an older class of antidepressants called tricyclics. “That’s because they interfere with the transmission of nerves that stimulate the bowel to move,” says Krevsky. Constipation is a much less common but still possible side effect of the more modern SSRI antidepressants. Talk to your doctor about whether you should take a different antidepressant or add a laxative.
  • Antacids. So you have heartburn and now, to add to your misery, constipation sets in. Antacids that contain aluminum are the likely culprit, says Krevsky. Read the ingredient list and make a switch if necessary. Try an over-the-counter acid controller medication, or better yet, talk to your doctor. If you take antacids often enough to get chronic constipation, you should probably be tested for gastroesophageal reflux disease (GERD).
  • High blood pressure medications. Chronic constipation is a side effect of an older class of high blood pressure medications called diuretics, which act on the salt in your body to control fluid levels. “You get dehydrated and your body steals moisture from the stool,” says Krevsky. You cannot compensate by drinking more water than you need — you’ll just lose it through urination. The solution is to talk to your doctor about a switch in blood pressure medication or adding a laxative.
  • Irritable bowel disease (IBD). Though diarrhea is more associated with IBD, some people with Crohn’s disease that affects the small bowel will get chronic constipation. In this case, you need more aggressive therapy for the IBD or surgery, says Krevsky.
  • Pregnancy. Pregnancy constipation is a common problem. Early in pregnancy, constipation may be caused by changing hormones or your diet; in later months, the pressure that the baby is putting on your organs becomes the culprit. Don’t strain, warns Krevsky, because this can cause hemorrhoids, which will just make you more uncomfortable. And don’t take a laxative without talking to your ob-gyn first.
  • Diabetes. People who have diabetes face a number of potential health problems, including chronic constipation. “This is in large part due to the nerve inflammation that goes along with being a diabetic,” Krevsky says. Solutions include getting better control of diabetes to prevent more damage and talking to your doctor about medication to fight constipation.
  • Heavy metal poisoning. Many family doctors don’t think about lead poisoning as a cause of constipation, but a work-up occasionally reveals significant exposure to lead, which can come from chipping old paint and other sources of exposure at home. Nerve damage is one of the outcomes of heavy metal poisoning, and this can affect the normal function of the bowels.
  • Supplements. Calcium supplements and iron supplements both can cause constipation. If you suspect either one, get a recommendation from your doctor for a better way to supplement if you are truly deficient.
  • Diseases of the colon. Any painful colon problem, such as an anal fissure or hemorrhoids, can cause chronic constipation because people avoid bowel movements and “detrain their bowel to work properly,” Krevsky explains. Treating the underlying cause can end this type of constipation.

Finally, Krevsky suggests, it’s possible that you don’t actually have constipation at all. He explains that while many people have a bowel movement regularly, such as once or twice a day, there are others who only do so two or three times a week — and they are just fine. Call this a hazard of pharmaceutical and food product advertising, but Krevsky says he occasionally has patients who are convinced they are constipated because they have seen ads promoting daily regularity. But as long as you’re being regular, you’re probably fine, as long as this doesn’t change and you don’t feel any discomfort.

If you are constipated and worried about the cause, check in with your doctor. Ending your chronic constipation could be as simple as choosing a better over-the-counter laxative or getting better control over a chronic health problem.

How to Relieve Constipation

Today’s show is for all you folks who wish you were more regular…and by that I don’t mean more normal. That’s right: We’re talking about constipation this week.

Occasional constipation is extremely common and although it’s usually not serious, it can be a real drag. Natasha asked if I’d do a show on this subject and I’m glad she suggested it. I learned some things I didn’t know while researching this episode. If you’ve already heard the conventional wisdom on this topic, I think you’ll still want to stay tuned. For more tips on constipation and general stomache ailments also check out Natural Remedies for Stomach Pain.

How to Relieve Occasional Constipation

If you’ve ever complained to your doctor about occasional constipation, he or she will most likely have suggested that you try to eat more fiber, drink more water, and get some regular exercise. It’s not bad advice. But the truth is, doing these things might or might not help.

Take exercise, for example. It’s true that people who live very active lifestyles tend to suffer from constipation less often than those who are more sedentary. And, should you find yourself immobilized—by an accident, or surgery, for example—you might have some constipation as the result of the physical inactivity.

So it seems logical that exercise would be a good way to treat irregularity. But, actually, studies have found that when normally active people are suffering from constipation, getting more exercise doesn’t really improve things. Don’t get me wrong: exercise is still a great idea—but its reputation as a cure for constipation might be somewhat exaggerated.

Caffeine: A Double-Edged Sword

Drinking more fluids might not be as helpful as you hope, either. Dehydration can cause constipation but the fact is that most people who are constipated are not actually dehydrated. As you might recall from my episode on the dehydration myth, coffee and tea are not dehydrating and are not constipating.

In fact, you may have observed that caffeine has a stimulating effect on the bowels. But this can be a double-edged sword. Caffeine, while relatively harmless, is habituating. Suddenly withdrawing all caffeine from your diet can cause some temporary withdrawal symptoms while your body adjusts to the change. That can include sleepiness as well as some temporary constipation.

But back to fluids: there is one time that drinking more fluids really can help with constipation. When you increase the amount of fiber in your diet—as people suffering from constipation are often advised to do—you’ll get more benefit if you also increase your fluid intake.

Fluids Plus Fiber Work Better Than Either Alone

The combination of a high-fiber diet and increased fluid intake is your best shot at avoiding occasional irregularity. You can get more fiber from bran (especially wheat bran), beans and legumes, and fruits and vegetables. Eating more fruits and vegetables is particularly efficient, because they are high in both fiber and fluids.

Low-carb dieters often have quite a bit of difficulty with constipation, by the way. That’s because low-carb diets are usually low in fiber and high in protein, which tends to be dehydrating. It’s really a perfect storm. Fiber supplements can help, but it’s very important to take them with plenty of water.

Check the Medicine Cabinet

OK, so you’re getting enough fiber—at least 25 grams a day. You’re not dehydrated. And yet, things still aren’t good. It’s time to look in the medicine cabinet. There are several common medications that can cause constipation, including drugs commonly prescribed for high blood pressure, pain management, and depression. If you think one of these might be a problem, you should check with the doctor who prescribed them to see if your medication can be adjusted.

Calcium and iron supplements can also cause constipation, as can calcium-containing antacids like Tums or Rolaids. It’s important to get enough calcium but it’s also possible to overdo it. Keep in mind that most of us get about half to two-thirds of the recommended amount of calcium from foods. If you take calcium supplements, you really only need enough to make up the difference between what you get from your diet and the recommended intake.

Dairy Products: Friend or Foe?

Calcium from foods—especially dairy products—can be constipating, as well. If you eat a lot of dairy and you struggle with constipation, you might want to cut back and see if it helps. There are non-dairy milks you could try, and for advice on that check out the episode I did a few weeks back. Increasing your intake of potassium and magnesium can also help to offset the constipating effects of calcium. Potassium and magnesium are found in—you guessed it—fruits and vegetables. (What can’t they do for us?)

Finally, there is one type of dairy that you might want to get more of; yogurt contains beneficial lactobacillus bacteria that can help keep you regular. There’s no need to pay extra for the yogurt with the suggestive downward arrow on the package, though. The beneficial bacteria in regular yogurt work just as well.

Though constipation is usually not serious, it can be a sign of more serious medical issues. So if what you’re experiencing is severe, ongoing, or doesn’t respond to any of the suggestions I’ve given here, it’s time to check with the doc. He or she can rule out other causes. The House Call Doctor has an episode about bowel problems, which might be a good place to start if you think your constipation is indicative of a larger issue. There are also some pharmaceutical treatments that can help if your constipation doesn’t improve with diet and lifestyle change.


This is Monica Reinagel, reminding you that these tips are provided for your information and are not intended as medical advice. Please work with your health professional to determine what’s right for you.

If you have a suggestion for a future show topic, send an email to [email protected] or leave me a voice mail at 206-203-1438. Please include the topic of your question in the subject line of your email. You can also post comments and questions on my Nutrition Diva Facebook Page or find me on Twitter.

Have a great day and eat something good for me!


Medical Update on Constipation (Cleveland Clinic Journal of Medicine)

Episode #2 Benefits of Fiber

Episode #4: Fermented and Cultured Foods

Episode #6: The Dehydration Myth

Episode #25: Diet for Strong Bones

Episode #33: Caffeine and Health

You Ate the Whole Thing. Now What?

Pity our unsuspecting stomachs. We regularly stuff them with everything from anchovies to zucchini and expect them to digest it all without a whimper. Small wonder, then, that even the most tolerant stomach rebels from time to time by becoming “upset” or giving us acid indigestion. When the acid rebellion strikes, many people quash it with over-the-counter antacids.

At the other end of the spectrum, many of us pamper our intestines with a daily dose of a laxative to forestall the curse of “irregularity.”

While antacids and laxatives are among the most effective of over-the-counter medicines, they are not needed for every gastric quake and intestinal rumble. And they are not the magic cure-all that advertisements often seem to promise.

Although they are relatively benign when used as directed, misuse can cause problems — some much worse than the mild conditions for which they are used. The very old, the very young, pregnant women and people with special health concerns may be particularly susceptible to some of their pitfalls.

For those whose digestive tracts are less than industrial strength, here’s a guide to antacids and laxatives. Antacids: So You Really Did Eat the Whole Thing

An “upset” stomach describes any of several symptoms, including the sour stomach, acid indigestion, or burning feeling that follows too much food or drink. Stomach acid seems to be responsible for these symptoms, and over-the-counter antacids generally relieve them.

Stomach acid also causes heartburn, which may begin as a dull, burning pain at the base of your breastbone and radiates upward. It occurs when corrosive stomach acid sloshes into your esophagus, the tube between your mouth and stomach, and burns delicate tissue. Large meals, foods that “don’t agree with you” and lying down too soon after eating are typical heartburn culprits.

Heartburn and upset stomach caused by acid indigestion are usually neither serious nor long-lasting, and medical attention is seldom necessary. You can often avoid them simply by adopting more judicious eating and drinking habits, postponing your after-dinner nap for an hour or two after eating and avoiding foods that have caused gastric distress in the past.

But be careful. The symptoms of a heart attack may resemble heartburn. If your “heartburn” pain is severe, prolonged and accompanied by chest pain, breathlessness, perspiration and fatigue, forgo the antacids and seek immediate medical attention.

Ads often portray excess stomach acid as a villain and antacids as the ones wearing the white hats. Such plots undoubtedly contribute to the widely held view of antacids as harmless cure-alls for virtually any gastric discomfort, and as clever means of avoiding the natural penalties for overindulgence.

These views are mistaken. Antacids should be used sparingly, intermittently, and for no more than two weeks at a time unless you are told to do otherwise by your doctor. Their indiscriminate and unsupervised use for anything but occasional episodes of heartburn and acid indigestion can lead to trouble.

For starters, severe, frequent attacks of acid indigestion and heartburn may actually be caused by stomach ulcers, gastritis (inflammation of the stomach lining) or other serious disorders. These conditions require careful evaluation by a physician.

If you have an ulcer or gastritis, your doctor may prescribe long-term treatment with large doses of antacids and, perhaps, other drugs. With large doses of antacids comes the risk of some potentially serious side effects and drug interactions. Such treatment should be left to the experts.

Unsupervised self-medication of suspected ulcers or other serious gastric disorders may mask an underlying disease, which may worsen. Any recurring stomach pain that diminishes when you eat, wakes you at night or occurs more than a few times a month should be checked by your doctor, as should episodes of bloody vomit or black, tarry stools.

Antacids work by neutralizing stomach acid. All over-the-counter antacids contain at least one of four acid-neutralizing chemicals: calcium carbonate, sodium bicarbonate, aluminum salts or magnesium salts.

Calcium carbonate (Alka-2, Chooz, Tums and others) relieves heartburn, but also often causes constipation and acid rebound, which is an increase in the production of stomach acid after the antacid effect has worn off.

The constipation is generally mild and short-lived, but acid rebound may damage the stomach lining.

If you take too much calcium carbonate for too long, the calcium content of the blood may rise. Too much calcium may damage nerves and form kidney stones.

Sodium bicarbonate, or ordinary baking soda, is the active ingredient in Alka-Seltzer Antacid, Citracarbonate, Soda Mint and a few others. You’ll also find it on the shelf in most kitchens. It rapidly neutralizes stomach acid and is converted into a gas, carbon dioxide, which distends the stomach and usually evokes a hearty belch.

Sodium bicarbonate is effective and safe when taken as directed, and it’s cheap. Nevertheless, few doctors recommend it. Its acid-neutralizing effect doesn’t last long, it contains large amounts of sodium, and it may cause acid rebound.

Even one five-gram dose of sodium bicarbonate contains too much sodium — about 1 1/2 grams — for people who must restrict their sodium intake. If you have high blood pressure, heart disease or kidney ailments, or are on a low-sodium diet, avoid sodium bicarbonate and use an antacid with a low sodium content (they’re clearly labeled). Some antacids contain as little as half a milligram of sodium.

A severe acid imbalance can occur if you exceed the recommended dose of sodium bicarbonate. The imbalance can give you a headache, make you nauseated and confused, and alter the action of other medicines you take.

Aluminum salts (AlternaGEL, Phosphaljel and Rolaids, for example) are effective antacids, although less so then sodium bicarbonate, calcium carbonate and the magnesium salts. Several aluminum salts are sold — aluminum hydroxide, aluminum carbonate, aluminum phosphate and aluminum aminoacetate. Of these, aluminum hydroxide seems to be the best acid neutralizer.

Aluminum-containing antacids usually do not upset the body’s acid balance. They can, however, cause constipation and interfere with the actions of various drugs. For example, aluminum decreases the absorption of tetracycline from the gastrointestinal tract. High doses may induce a deficiency of phosphorus and cause the aluminium content in the blood to increase. Too much aluminum can damage nerves.

Magnesium salts (magnesium hydroxide, magnesium oxide, magnesium carbonate, and magnesium trisilicate) are excellent antacids, but they are also excellent laxatives. Phillips’ Milk of Magnesia (magnesium hydroxide) is sold as both. The laxative dose is about three times the antacid dose.

Taken as directed, magnesium salts are generally safe and effective; but people who have damaged or diseased kidneys should avoid them, because magnesium may accumulate and damage their heart and kidneys.

Some manufacturers try to cancel the laxative effect of magnesium by combining it with aluminum salts (Gelusil, Maalox and Riopan, for example) or calcium salts (Alkets and Bisodol Tabs). The laxative effect may persist, but if so, it’s usually mild.

Antacids may interfere with the action of drugs such as tetracycline antibiotics, iron, arthritis medicines, some heart medicines, pseudoephedrine (an ingredient in some over-the-counter cold remedies), dicumarol (a blood-thinning drug) and many others.

If you are taking these or other medicines you should consult with your doctor or pharmacist about possible drug interactions before taking an antacid. In many cases, the interactions can be avoided simply by taking the medicine and the antacid at least an hour apart.

Antacid products come in an overwhelming array. There are chewable tablets, effervescent tablets, liquids, powders and chewing gums. Some are non-constipating. Others are sugarless or low in sodium. Some contain an “anti-gas” drug.

Many people find chewable tablets and gums are more convenient than liquids, powders and effervescent tablets; but, dose for dose, they don’t neutralize as much acid.

The difference is not because chewable tablets and gums contain less effective antacids. Some tablets and liquids actually contain identical amounts per dose.

Instead, the difference lies in the size of the antacid particles that end up in your stomach. A large number of small antacid particles can neutralize more acid faster than a small number of large particles.

Your teeth determine the ultimate size of the antacid particles in a chewable tablet. The better you chew it, the smaller the particles will be and the better neutralization of acid you’ll get. But no matter how well you chew an antacid tablet, it still won’t match the neutralizing power of the powders and liquids. The manufacturers can grind the antacids in them to a finer consistency than your teeth can.

Some antacids contain sugar to counteract their chalky taste. Artificially sweetened or unsweetened antacids are also available for diabetics and people who must limit their caloric intake. Sugar-free antacids are usually clearly labeled.

Many antacid products contain the “anti-gas” drug simethicone. It is supposed to break up gas bubbles in the stomach and intestinal fluids, relieving the discomfort caused by excess gas.

The problem caused by gas, however, is not necessarily that it stays in your system and makes you uncomfortable, but that it leaves and makes those around you uncomfortable. Simethicone can’t keep the gas from leaving. If anything, it makes the leaving easier — both in flatulence and in belching.

Although the Food and Drug Administration considers simethicone safe and effective, many gastroenterologists and other medical experts disagree on its effectiveness. Its value in combination with an antacid for the treatment of acid indigestion and heartburn is questionable at best. If you’ve tried an antacid with and without simethicone and can’t tell the difference, I’d suggest staying with the antacid alone.

Antacid prices vary. If you’re using one only occasionally for simple acid indigestion, use the cheapest one that you can safely take (read the label) and that works satisfactorily for you. But if your doctor has recommended one of the higher-potency, generally more expensive antacids for intensive treatment of an ulcer or some other disorder, you may wish to cost-compare products containing the same ingredients prescribed by your doctor. Ask your doctor or pharmacist for help with the comparison.

How you choose your antacid is important. Select it with your special needs in mind, but be mindful of side effects and drug interactions. Used strictly according to directions, an antacid should provide maximum benefit at minimum risk. Laxatives: What Price Regularity?

We’re regular in many of our day-to-day activities. We eat three meals a day, travel the same route to work, read the paper over coffee, shower every morning or night, and so on. Most of us are also regular with our bowel habits.

Yet some people take this to a harmful extreme. Somewhere along the way someone promoted the notion that anyone who doesn’t have a bowel movement every day is on the way to physical and social ruin, not to mention being at risk from the accumulation of toxins in their gut.

This notion is rubbish. To be sure, frequent and periodic bowel movements are necessary, but not to protect the body from toxins. They’re simply the last step in the digestion of food, and they rid the body of undigestible materials, waste products of metabolism, and many drugs.

Remembering to have a regular bowel movement should be the least of our worries. Our intestines are well equipped to take care of that responsibility. They have a way of gently reminding us when it’s time to discharge some of their contents. We can temporarily ignore those reminders, but they should eventually be heeded.

If our intestines fail in their responsibility because of injury, disease or some other reason, a laxative drug can be used to help them along. But don’t be too eager to use one. Some laxatives can injure the intestinal lining, cause depletion of water, nutrients and electrolytes, and be habit-forming.

Temporary constipation or the development of dry, hard stools that are painful to eliminate may be caused by a variety of factors including illness, stress, travel, a change in diet and drugs. If you have become constipated under such circumstances, wait a few days to give your intestines a chance to get back on schedule. Most episodes of constipation are temporary and will correct themselves in a few days. If they don’t, you’d be wise to seek medical advice instead of a laxative.

If you insist on helping nature take its course, the judicious, temporary use of a laxative may be helpful if you follow three simple rules.

1. Use a laxative only if your constipation is of recent onset, and if you are not sick to your stomach or having abdominal pain. Such symptoms can be a sign of appendicitis, which requires prompt medical attention.

2. Don’t use a laxative for more than seven days in succession, except on the advice of your doctor. If a laxative hasn’t worked in that length of time, it’s not likely to do so any time soon.

3. Don’t use a laxative without a doctor’s advice if your constipation is a chronically recurring problem, or has been present for two weeks or more.

If you become constipated and are regularly taking these or other drugs, your pharmacist can tell you if your medicines could be at fault. If so, your doctor can help you solve the problem if it doesn’t clear up by itself in a few days. He or she may recommend a laxative or change your medication.

There are literally scores of laxatives on the market. All of them are effective. They differ in the way they act and in their side effects. Most are not recommended for self-treatment of mild constipation, but should be used only in consultation with a physician.

Of the several types of laxative drugs available, only one, the bulk-forming laxatives, is recommend for self-treatment of constipation.

The other classes include saline, stimulant and stool-softening laxatives. Most of the drugs in these classes are effective to the extreme, and can cause potentially harmful side effects. Using them without a doctor’s supervision is not recommended.

The active ingredients in most of the bulk-forming laxative products are psyllium seed, psyllium hydrophilic colloid, carboxymethylcellulose sodium, methylcellulose, agar, karaya gum or other vegetable substances. You’ll find one or more of these ingredients in such products as Metamucil, Serutan, Hydrolose and others. One product, Mitrolan, contains a synthetic resin, calcium polycarbophil.

Taken with water, these substances swell into gel-like masses, increasing the bulk of the intestinal contents and stimulating propulsive contractions in the intestinal muscle. The drugs usually work within 12 to 24 hours, though for some people, the effect takes several days.

The appeal of the bulk-forming laxatives lies in their gentle, delayed action, which stimulates the body’s natural elimination process. The same results can be achieved if you follow a diet containing lots of vegetable fiber and roughage. Bran and bran-containing foods are good sources of fiber.

The most important thing to remember when using these drugs is to take them with plenty of water (eight ounces or more per dose). If you take them with less, you risk having an intestinal blockage from the dry, congealed mass that may form. If you take these drugs with no water at all, you risk blockage of your esophagus.

The bulk-forming laxatives don’t cause many side effects. Most commonly, you may notice excess gas and, perhaps, an allergic reaction (itching, stuffy nose or rash).

If you are taking other medicines, especially digitalis for your heart, or aspirin, consult your pharmacist or doctor before using a bulk-forming laxative. It may reduce the effectiveness of these and other medicines by delaying their absorption into your bloodstream.

Carboxymethylcellulose sodium (contained in Dialose, for example) contains large amounts of sodium. Avoid it if you have high blood pressure, heart or kidney disease, or are on a low-sodium diet. The other bulk-forming laxatives contain little sodium.

Generally speaking, the bulk-forming laxatives are safe. Nevertheless, not everyone can safely use them. Consult a physician before using one if you have known intestinal blockage, diverticular disease, or if you have difficulty swallowing.

Avoid saline laxatives, stimulants and stool-softeners unless your doctor specifically recommends one. Their laxative effects and side effects can be severe.

The saline laxatives include magnesium sulfate (Epsom Salts), magnesium hydroxide (Milk of Magnesia), magnesium citrate, sodium citrate, sodium phosphate and others. You’ll find them in such products as Fleet Enemas, Phospho-Soda and Sal Hepatica. Doctors generally prescribe these laxatives only for clearing the bowel for diagnostic examinations or when rapid, thorough catharsis is required (such as in the treatment of poisoning).

These laxatives work quickly, usually within two to six hours. They draw large amounts of water into the bowel, causing its contents to swell and stimulating rapid, even explosive, emptying.

Excessive use of a saline laxative may dangerously deplete the body of fluid and electrolytes, especially potassium.

People who have impaired kidney function should not use magnesium-containing laxatives. Those who have high blood pressure or heart disease should avoid the ones with sodium.

Several laxatives work by stimulating, or irritating, the intestines. Ex-Lax, Bisacodyl, Feen-A-Mint, Fletcher’s Castoria, Carter’s Little Pills, Correctol, Doxidan, Senokot and many others contain such irritants. The active ingredients of such products include senna, phenophthailein, cascara segrada, danthron, aloe and others. Castor oil is included in this group, but it is much too irritating and should not be used, especially in children.

If you use one of these laxatives, follow the dosage instructions carefully. It will usually be effective within 12 to 24 hours. Don’t use it for more than seven days. Prolonged use may cause the intestinal muscle to become flaccid and unable to resume its normal activity once you stop taking the laxative.

These products may cause abdominal cramping and produce copious, watery stools. Repeated use of them risks fluid and electrolyte depletion.

Stool-softening laxatives include mineral oil and docusate. They lubricate the intestinal contents and make them easier to eliminate. Don’t use mineral oil. It’s gentle enough on your bowels, softening dry, hard stools, but it also causes side effects. Vitamins A, D and E, for example, and other nutrients dissolve in the oil and may not be adequately absorbed into your blood. Nutritional deficiencies may result. Some of the oil may run down your throat into your lungs. If enough does so, it may cause pneumonia. Finally, taken in excess, the oil may leak from your anus, soiling clothes and irritating local tissues.

Colace, Doxinate, Modane Soft and others contain docusate. Most doctors prefer it to mineral oil for softening dry hard stools and preventing straining in sufferers from hemorrhoids and other rectal disorders. Docusate seems safe, but it’s probably best to use it only on your doctor’s advice. It exerts its laxative effect in one to three days.

Saline laxatives, stimulants and stool-softeners are not recommended for the treatment of simple constipation related to travel, stress, altered diet or other common causes. The risk of harmful side effects is simply too high, especially since most cases of constipation clear up on their own anyway.

Some products contain two or more laxative drugs, usually from different classes. Avoid them unless your doctor recommends one.

Laxatives should be used with caution, if at all, in children. Don’t give a laxative to any child under 12 without first consulting your doctor.

Used improperly and excessively, laxatives can induce a vicious cycle. Normally, only the end-most portion of your bowel, the rectum, empties when you defecate. A strong laxative, however, empties much more of the bowel. As a result, several days may elapse before enough of the intestinal contents will have been moved into the rectum for elimination. This delay may lead the laxative user to believe that he is still constipated, so he’ll take another dose of the laxative. If this pattern continues, this person may become totally dependent on laxatives for his bowel movements.

In deciding whether or not to use a laxative, remember that most episodes of mild constipation clear up on their own within several days. Don’t even consider using a laxative for the first day or so after you notice your constipation. If it is associated with travel, a change in your eating habits, stress or similar circumstances, it should take care of itself. If it is long-standing, or occurs in repeated episodes, or if you are troubled by hemorrhoids, or have a history of rectal disorders, don’t use a laxative without first consulting your doctor.

Antacids and laxatives have their place in medicine, but don’t take them for granted. If you use them, do so with care and follow the directions on the label.

L.R. Willis, PhD, is a professor of pharmacology and medicine at Indiana University School of Medicine.

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Heartburn that occurs now and then is common. It’s brought on by backflow (reflux) of often acidic stomach contents into the food pipe (esophagus) and is usually felt as a burning sensation behind the breastbone.

Heartburn in GERD

Heartburn is also a common symptom of GERD, or gastroesophageal reflux disease. GERD is a long-term condition. In GERD, heartburn or other symptoms are frequent and persistent. The principal approach to treatment of GERD is to reduce gastric acidity. There are powerful drugs used to reduce the secretion of acid, which include the histamine2 (H2) receptor antagonists, and the proton pump inhibitors, or PPIs.

Learn more about GERD

Antacid preparations serve to neutralize gastric acid after it is secreted. These still-helpful agents have a continuing role in treating mild, occasional heartburn and supplementing prescription drugs in more severe disease. They are traditional, cheap, handy, and relatively safe – although they are not without risks and side effects can occur.

What Are Antacids?

Antacids are the oldest effective medications for heartburn. Chalk (calcium carbonate) has been chewed for centuries to provide some relief and is still popular.

Most commercially available antacids are combinations of aluminum and magnesium hydroxide. Some effervescent antacids contain sodium bicarbonate, that old household remedy for tummy aches known as “baking soda.”

Some antacids are combined with an alginate to form a compound that floats on gastric fluids to protect the esophagus from acid exposure.

Antacid tablets are slow acting and have less neutralizing power than a liquid form of antacid. Tablets must be chewed, and may not interact well with gastric acid. For most, the convenience of tablets far outweighs these slight disadvantages.

Such a variety of commercial antacids occupy pharmacists’ shelves that this discussion will concentrate on their basic ingredients (See accompanying Table). Note that only a few commercial preparations are cited as examples.

Table: Basic Antacids





Unwanted Effects

Sodium Bicarbonate



Fluid retention, Alkalosis

Magnesium Hydroxide



Diarrhea, Magnesium toxicity

Aluminum Hydroxide



Constipation, Drug or phosphate binding (inhibits absorption)

Calcium Carbonate


very high

Acid rebound

(1) Al= aluminum; Mg = magnesium; Ca = calcium; Na = sodium

Antacid Components

Sodium bicarbonate – Sodium bicarbonate is a weak, short-acting antacid. While generally a safe household remedy, its high sodium content is a disadvantage.

Unlikely to be recommended by doctors, “bicarb” or “baking soda” is still a common component of many patent medicines. Bicarbonate has an effervescent property that explains the commercial survival of antacid/pain-killer combinations such as Alka-Seltzer™ and Bromo-Seltzer™. Bicarbonate reacts with stomach hydrochloric acid to release carbon dioxide gas (CO2) that is quickly absorbed, but sometimes elicits a satisfying belch.

An imbalance of the body’s normal pH level (systemic alkalosis) can result from overuse of bicarbonate. Those who require sodium restriction for high blood pressure or heart disease should avoid bicarbonate.

Magnesium Hydroxide – Magnesium hydroxide is best known as milk of magnesia. Like magnesium citrate or magnesium sulfate, it is an effective laxative. Were it not for its tendency to cause diarrhea, magnesium hydroxide would be the most ideal antacid. To counter the diarrhea effect, most manufacturers add aluminum hydroxide, which is constipating. The combination substantially raises the price, and the addition of the less-effective aluminum hydroxide reduces the antacid benefit.

Magnesium hydroxide is not absorbed by the intestine. However, its interaction with stomach acid produces magnesium chloride that can be absorbed. Magnesium has many functions in human cells, including the heart, and may have harmful effects if levels in the blood rise. This is not a problem for a person with healthy kidneys, but magnesium should be avoided if renal failure is present.

Talk to Your Doctor

It is a good idea to think of any substance you take for a therapeutic affect as a medication. Tell your doctor about it.

This applies whether taking a prescription or over the counter drug, herb, or supplement. Remember, even “natural” supplements and herbs can interact with other substances or have unexpected and undesirable side effects.

We recommend consultation with a qualified health care professional familiar with your particular circumstances when trying any self-treatment for a chronic or persistent condition.

How to Talk to Your Doctor

Aluminum Hydroxide – Compared to magnesium hydroxide, aluminum hydroxide is a weak, slow-acting antacid, and its acid-neutralizing effect varies among commercial products.

Aluminum may protect the stomach lining from the damaging effects of alcohol and other irritants. Aluminum hydroxide inactivates the gastric digestive enzyme pepsin. However, the principal reason for its inclusion in commercial antacid preparations is to counteract the diarrhea effect of magnesium.

Aluminum hydroxide has other uses. It binds phosphate in the gut lumen to produce insoluble aluminum phosphate, a feature that is useful in kidney failure when the serum phosphate is abnormally high. It is also useful for patients who tend to form phosphate-containing kidney stones. A very small amount of aluminum is absorbed, and brain damage might occur with its long-term use in the treatment of kidney failure.

Chronic, excessive use of aluminum hydroxide may deplete the body of phosphate, causing metabolic bone disease (e.g., osteoporosis, osteomalacia) and risking spontaneous fractures, especially in the malnourished. Aluminum hydroxide may alter the absorption of certain drugs so they should not be taken simultaneously.

Calcium Carbonate – Calcium Carbonate (chalk) is the most potent usable antacid. It can completely neutralize stomach acid. Nonetheless, it is not always the best choice for regular use.

  • About one-third of the administered calcium is absorbed, and high blood calcium or calcium-containing kidney stones are slight risks.
  • Phosphate bound by calcium in the gut or bone may deplete the serum phosphorus in some kidney failure patients.
  • A systemic alkalosis from prolonged and aggressive use infrequently produces metabolic consequences.

Another disadvantage of calcium carbonate may be the tendency for gastric acid secretion to rebound after calcium is given.

Popular calcium antacid tablets include Tums™ and Titralac™. The dose should not exceed 3 g per day.

Additional Components

Peppermint flavoring – Peppermint is the most common antacid flavoring. By relaxing the lower esophageal sphincter to release gas, peppermint encourages the release of a belch after a meal, hence the popularity of after-dinner mints.

Antiflatulent – Simethicone is a surfactant, which presumably by breaking down bubbles within the gut renders gas available for absorption. Despite the lack of evidence of effectiveness, simethicone is included in some popular antacid preparations, thereby increasing their cost.

Alginic acid – Prepared from kelp (seaweed), alginate acts as a physical acid barrier for the esophagus in gastroesophageal reflux. It is not an antacid. When ingested, this tasteless and apparently harmless substance floats on gastric fluid to prevent the reflux of acid and pepsin into the esophagus. Preparations such as Gaviscon™ or Algicon™, combine alginate with antacids, and are popular heartburn remedies. There are no satisfactory clinical trials, but these preparations have little neutralizing power and are probably of little benefit in those reflux patients who have complicating esophagitis.

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Side Effects

Everyone’s reaction to a medicine is different. Side-effects experienced on loop diuretics are uncommon, but the higher the dosage the greater the risk of side effects developing.

You may experience some of the side effects listed below or none at all. If you are having problems with this medicine, it’s important to tell your GP immediately.

Serious possible side-effects include:

  • The salt balance in the bloodstream is sometimes upset which can cause a low blood level of potassium, sodium, and magnesium, and a high level of calcium. These effects may cause weakness, confusion and, rarely, abnormal heart rhythms to develop. You may be advised to have a blood test to check for these problems.
  • If you have diabetes or gout, these conditions may be made worse by diuretics.
  • An upset stomach
  • Dizziness on standing (due to too low blood pressure).

Further Help

For more information about this medication please visit

If you feel unwell or if you have concerns about a side-effect, you will need to seek advice. If you feel very ill, get medical help straight away. Contact your prescriber, pharmacist, nurse or call NHS non-emergency number on 111 (You should use the NHS 111 service if you urgently need medical help or advice but it’s not a life-threatening situation)

No matter what kind of medicine you take, whether OTC (over-the-counter) or prescription, it is destined to take a trip through your kidneys. Taking a drug the wrong way or in excessive amounts can damage these vital, bean-shaped organs and lead to serious complications. In the worst-case scenario, it could necessitate a kidney transplant.

“Compared with 30 years ago, patients today…have a higher incidence of diabetes and cardiovascular disease, take multiple medications, and are exposed to more diagnostic and therapeutic procedures with the potential to harm kidney function,” according to Cynthia A. Naughton, PharmD, senior associate dean and associate professor in the department of pharmacy practice at North Dakota State University. All of these factors are associated with an elevated risk of kidney damage.

An estimated 20% of cases of acute kidney failure are due to medications. The technical term for this scenario is “nephrotoxicity,” which is growing more common as the aging population grows, along with rates of various diseases.

The kidneys get rid of waste and extra fluid in the body by filtering the blood to produce urine. They also keep electrolyte levels balanced and make hormones that influence blood pressure, bone strength and the production of red blood cells. When something interferes with the kidneys, they can’t do their job, so these functions can slow down or stop altogether.

Kidney Impairment Can Be Costly

“Although renal impairment is often reversible if the offending drug is discontinued, the condition can be costly and may require multiple interventions, including hospitalization,” Dr. Naughton explained. To help you avoid getting to that point, we learned about medications that commonly cause kidney damage from Rebekah Krupski, PharmD, RPh, pharmacy resident at the Cleveland Clinic and clinical instructor of pharmacy practice at Northeast Ohio Medical University.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Prescription NSAIDs like ketoprofen, and OTC versions such as Advil (ibuprofen) and Aleve (naproxen), narrow the blood vessels leading to the kidneys. Decreased blood flow can cause dead tissue in the kidneys.


Various classes of antibiotics can harm the kidneys in different ways. Aminoglycosides such as tobramycin can cause toxicity in “renal tubular cells,” which are more sensitive to the toxic effects of drugs because their role in kidney filtration exposes them to high levels of toxins. Sulfonamides, a group of antimicrobials, can produce crystals that do not dissolve in urine, thus blocking the flow of urine, and vancomycin can cause kidney swelling and inflammation. For more about antibiotics, see 5 Things You Need to Know About Antibiotics.

Antiviral drugs

Antivirals such as acyclovir, which is used for herpes, chickenpox and shingles and Valtrex (valaciclovir), a herpes treatment, may lead to kidney swelling and inflammation and can also produce those pesky crystals that won’t dissolve. Medications can cause inflammation in several parts of the kidney, often resulting from an immune reaction or allergic response.

Anti rejection post-transplant medications

Antirejection drugs including cyclosporine and tacrolimus can constrict the blood vessels near the kidneys, leading to reduction in blood flow and kidney function.

HIV medications

Viread (tenofovir) and Reyataz (atazanavir) can also cause toxicity in renal tubular cells, which are the ones that are especially vulnerable because of the large numbers of toxins they come in contact with.


Water pills like hydrochlorothiazide and furosemide, used for high blood pressure and edema, can cause dehydration and can also lead to swelling and inflammation of the kidneys.

Though symptoms of kidney toxicity can vary from person to person, signs might include a decreased amount of urine, swelling in your legs, feet or ankles due to fluid retention, fatigue, nausea, confusion, shortness of breath and pressure or pain in the chest.

The following tips can help prevent the risk of kidney damage.

  • While taking OTC drugs, pay careful attention to labels and take the medication exactly as directed.
  • When possible, avoid taking medicines like NSAIDs over long periods of time. Any long-term use of any medications, even OTC and herbs, should be under the guidance of your healthcare provider.
  • Make sure you are not taking medications more often or at a stronger potency than needed, as this is a common cause of toxicity.
  • Drink adequate fluids to flush out the toxins. Dehydration is a known risk factor for kidney failure, as it can cause the medication to become too concentrated and to stay in the system too long.
  • Avoid taking NSAIDs during pregnancy, though Tylenol (acetaminophen) is ok. Kidney infections are more common during pregnancy and may result in lower birth weight or premature birth (
  • Avoid drinking alcohol, while taking these medications, as it can lead to dehydration, increased blood pressure, and liver disease, placing you at greater risk of kidney dysfunction.

It is particularly crucial to get close, professional guidance if you have existing medical conditions, including high blood pressure, diabetes and, of course, kidney disease. If so, it is also important to follow your doctor’s advice about keeping your symptoms under control. If you are taking meds that might stress your kidney, your healthcare provider can get an idea of your level of kidney functioning through a blood test that reveals your glomerular filtration rate (GFR). This is considered the best available test for this purpose, and it takes individual factors like age, sex, and race into account. It may be determined that your dosage should be adjusted based on how well your kidneys are working.

More than 30% of preventable kidney events related to meds were caused by a lack of proper monitoring, according to one study. And 37% of such events were due to the healthcare provider’s failure to take action when laboratory results or other clinical signs suggested the patient was at risk.

The Need to Monitor Kidney Function With Certain Drugs

Experts have suggested that after the initial assessment of kidney function, physicians should consider regular monitoring “after starting or increasing the dosage of drugs associated with nephrotoxicity, especially those used chronically in patients with multiple risk factors” for impaired kidney function, Dr. Naughton noted. If there is any sign of kidney harm, the provider should review the medications you are taking in order to identify which one is causing the problem.

“If multiple medications are present and the patient is clinically stable, physicians should start by discontinuing the drug most recently added to the patient’s medication regimen.” Once that has been taken care of, further harm to the kidneys may be minimized by keeping blood pressure stable, staying hydrated, and temporarily avoiding the use of other medications that may cause nephrotoxicity.

These safety tips can ensure you get the care you need while keeping your kidneys safe. That way, they can tend to essential functions like keeping things flowing (pun intended).
Originally published May 11, 2017



Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.


COZAAR has been evaluated for safety in more than 3300 adult patients treated for essential hypertension and 4058 patients/subjects overall. Over 1200 patients were treated for over 6 months and more than 800 for over one year.

Treatment with COZAAR was well-tolerated with an overall incidence of adverse events similar to that of placebo. In controlled clinical trials, discontinuation of therapy for adverse events occurred in 2.3% of patients treated with COZAAR and 3.7% of patients given placebo. In 4 clinical trials involving over 1000 patients on various doses (10-150 mg) of losartan potassium and over 300 patients given placebo, the adverse events that occurred in ≥2% of patients treated with COZAAR and more commonly than placebo were: dizziness (3% vs. 2%), upper respiratory infection (8% vs. 7%), nasal congestion (2% vs. 1%), and back pain (2% vs. 1%).

The following less common adverse reactions have been reported:

Blood and lymphatic system disorders: Anemia.

Psychiatric disorders: Depression.

Nervous system disorders: Somnolence, headache, sleep disorders, paresthesia, migraine.

Ear and labyrinth disorders: Vertigo, tinnitus.

Cardiac disorders: Palpitations, syncope, atrial fibrillation, CVA.

Respiratory, thoracic and mediastinal disorders: Dyspnea.

Gastrointestinal disorders: Abdominal pain, constipation, nausea, vomiting.

Skin and subcutaneous tissue disorders: Urticaria, pruritus, rash, photosensitivity.

Musculoskeletal and connective tissue disorders: Myalgia, arthralgia.

Reproductive system and breast disorders: Impotence.

General disorders and administration site conditions: Edema.


Persistent dry cough (with an incidence of a few percent) has been associated with ACE-inhibitor use and in practice can be a cause of discontinuation of ACE-inhibitor therapy. Two prospective, parallel-group, double-blind, randomized, controlled trials were conducted to assess the effects of losartan on the incidence of cough in hypertensive patients who had experienced cough while receiving ACE-inhibitor therapy. Patients who had typical ACE-inhibitor cough when challenged with lisinopril, whose cough disappeared on placebo, were randomized to losartan 50 mg, lisinopril 20 mg, or either placebo (one study, n=97) or 25 mg hydrochlorothiazide (n=135). The double-blind treatment period lasted up to 8 weeks. The incidence of cough is shown in Table 1 below.

Table 1:

These studies demonstrate that the incidence of cough associated with losartan therapy, in a population that all had cough associated with ACE-inhibitor therapy, is similar to that associated with hydrochlorothiazide or placebo therapy.

Cases of cough, including positive re-challenges, have been reported with the use of losartan in postmarketing experience.

Hypertensive Patients With Left Ventricular Hypertrophy

In the Losartan Intervention for Endpoint (LIFE) study, adverse reactions with COZAAR were similar to those reported previously for patients with hypertension.

Nephropathy In Type 2 Diabetic Patients

In the Reduction of Endpoints in NIDDM with the Angiotensin II Receptor Antagonist Losartan (RENAAL) study involving 1513 patients treated with COZAAR or placebo, the overall incidences of reported adverse events were similar for the two groups. Discontinuations of COZAAR because of side effects were similar to placebo (19% for COZAAR, 24% for placebo). The adverse events, regardless of drug relationship, reported with an incidence of ≥4% of patients treated with COZAAR and occurring with ≥2% difference in the losartan group vs. placebo on a background of conventional antihypertensive therapy, were asthenia/fatigue, chest pain, hypotension, orthostatic hypotension, diarrhea, anemia, hyperkalemia, hypoglycemia, back pain, muscular weakness, and urinary tract infection.

Postmarketing Experience

The following additional adverse reactions have been reported in postmarketing experience with COZAAR. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency reliably or to establish a causal relationship to drug exposure:

Digestive: Hepatitis.

General Disorders and Administration Site Conditions: Malaise.

Hematologic: Thrombocytopenia.

Hypersensitivity: Angioedema, including swelling of the larynx and glottis, causing airway obstruction and/or swelling of the face, lips, pharynx, and/or tongue has been reported rarely in patients treated with losartan; some of these patients previously experienced angioedema with other drugs including ACE inhibitors. Vasculitis, including Henoch-Schönlein purpura, has been reported. Anaphylactic reactions have been reported.

Metabolic and Nutrition: Hyponatremia.

Musculoskeletal: Rhabdomyolysis.

Nervous system disorders: Dysgeusia.

Skin: Erythroderma.

Read the entire FDA prescribing information for Cozaar (Losartan Potassium)

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