The Issue of Oral Medications and a Fecal Ostomy

Gwen B. Turnbull, RN, BS, ET

B ecause portions of their intestinal tract have been removed or bypassed, people with a fecal stoma (ileostomy or colostomy) may experience difficulty in absorbing and, therefore, gaining maximum benefit from oral medications. The shorter the length of the remaining bowel, the greater the problem of absorption, particularly in the ileum. Other medication issues include discoloration of the stool that can cause a patient who has not been adequately informed undue alarm. Clinicians must not omit teaching patients about potential problems they may encounter with their medications — empowering patients with information while encouraging them to establish a relationship with their pharmacist are important facets of care. Patients must be taught to be their own advocates — only a well-informed patient can succeed in that role.
Generally, people with descending or sigmoid colostomies absorb medications as well as people who do not have an ostomy. However, some medications (eg, enteric-coated tablets, time-release products, or large tablets) are designed for gradual absorption along the full length of the intestine (the ileum and the colon). If transit time is reduced/increased and/or portions of the bowel have been removed, these medications can be incompletely and erratically absorbed, especially in persons with an ileostomy. Erwin-Toth and Doughty1 recommend teaching patients to evaluate tablets at home by placing the tablet in a glass of water and recording the amount of time it takes for the tablet to begin to dissolve. If the tablet begins to dissolve in 30 minutes, most likely it can be adequately absorbed in the body. Patients should be instructed not to crush tablets without first checking with the pharmacist because the practice may expose the medication to gastric fluids, which could cause gastric upset or inactivate the drug.1
Medication forms more suitable to people with an ileostomy include prompt-acting formulations such as solutions, suspensions, gelatin capsules, and uncoated tablets.2 Patients should be taught to look for remnants of unabsorbed medications when they empty their pouch and report what they observe to their physician who, if necessary, can prescribe the drug in an alternate, more suitable form. Most antidiarrheal and antibiotic medications are available as liquids and may be recommended initially to ensure the full intended effect of the drug2 rather than waiting to discover the tablet form is not being absorbed.
Patients often are taught several measures to ensure they remain odor-free: 1) take an oral tablet, such as bismuth subgallate, charcoal, or chlorophyllin copper complex; 2) place a deodorizer directly into the pouch; and 3) use a room deodorizer. Bismuth subgallate tablets have been used as oral deodorizers for years — they darken and thicken the stool and have been shown to have side effects with long-term use that cease when the drug is discontinued.2 Activated charcoal also has been used orally to reduce fecal odor — it can darken the stool and cause constipation. Researchers found no evidence of a reduction in odor with oral doses of charcoal for patients with a colostomy.3 The use of chlorophyllin has been proven to control body and fecal odor and is safe in oral doses up to 100 mg three times a day.2 It is not without side effects, however; it can turn the stool green and cause diarrhea.
Many over-the-counter medications, such as Mylanta Gas® (Johnson & Johnson — Merck Consumer Pharmaceuticals Co., Ft. Washington, Pa.) and Phazyme® (Glaxo SmithKline, Philadelphia, Pa.), are effective in reducing flatus. Dietary supplements, such as Beano® (Glaxo SmithKline, Philadelphia, Pa.), are also quite effective in reducing gas related to the breakdown of complex sugars in gas-causing foods2 and are available as tablets or drops.
Ileostomy patients should be instructed never to take laxatives — additional depletion of fluids and electrolytes caused by the laxative can lead to severe fluid and electrolyte imbalance. Preparation for small bowel diagnostic studies or surgery for people with an ileostomy can be adequately managed by simply restricting food and taking clear liquids for 24 hours4 before the procedure.
When required by patients with an ileostomy, antidiarrheal medications — prescription and over-the-counter — are usually available as liquids. As mentioned previously, patients with a descending or sigmoid colostomy who require antidiarrheal medication usually can take tablet or capsule forms of these drugs without absorption problems.
Not only must clinicians instruct patients about their medications, but they also must explain how the absorption of the medication will or will not be effected by ostomy surgery. Patients should be taught to maintain communication with their physicians, dentists, and pharmacists to ensure they receive the maximum benefit from their prescribed medications. Patients also need to understand that their ostomy surgery can have an effect on both prescription and over-the-counter medications. Before taking any new over-the-counter medication, the patient should first check with the physician, Wound Ostomy Continence Nurse (WOCN), and/or pharmacist to determine any potential side effects and/or interaction with other currently-prescribed medications. Although time available to clinicians for patient teaching is limited, this area of patient instruction must not be omitted.- OWM
The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb company, Princeton, NJ.

References: 

1. Erwin-Toth P, Doughty DB. Principles and procedures of stomal management. In: Hampton BG, Bryant RA, eds. Ostomies and Continent Diversions: Nursing Management. St. Louis, Mo.: Mosby Year Book;1992:29–103.
2. Cusson GJ. Medications affecting ostomy function. In: Colwell JC, Goldberg MT, Carmel JE, eds. Fecal & Urinary Diversions: Management Principles. St. Louis, Mo.: Mosby;2004:339–350.
3. Christiansen S, et.al. Can chlorophyll reduce fecal odor in colostomy patients? Ugeksi Laeger. 1989;151:175–333.
4. Holmes J, Nichols R. Sepsis following colorectal surgery. In: Fazio VW, ed. Current Therapy in Colon and Rectal Surgery. Philadelphia, Pa.: BC Decker;1990.

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