A review of laxative actions Laxatives are being prescribed for the treatment of constipation and for cleansing the

bowels prior to investigational procedures or surgery of the gastrointestinal tract. The public also self-medicate by purchasing these drugs over-the-counter (OTC) for constipation and for occasional bowel cleansing. This is a brief review of the actions of the different types of laxatives which are currently available to medical practice; the purpose is to communicate information that will enable the best uses of these drugs. Constipation is a commonly occurring morbidity which prompts people to self-medicate or seek medical care. However the condition is variably described and different people have different notions about what constipation is. The term constipation is applied to describe such different events as the passage of hard stools; infrequent passage of stools; or difficulty passing out stools. It may also be used to describe a feeling of incomplete rectal evacuation. Several underlying factors may cause constipation but a discussion of these factors is not covered here. Apparently impairment of intestinal peristalsis is the point of convergence for all possible causes of constipation. Peristalsis, the rhythmic contractions of smooth muscles of the gastrointestinal tract, is the force which propels content downwards towards the rectum. It is an autonomic nervous response and is certainly regulated by a kind of positive feedback mechanism provided by content within the intestines. The presence of matter within the lumen of intestines stretches the intestinal walls; nerve endings within the musculature which are sensitive to mechanical pressure are then stimulated by this mechanism. The larger the mass of intestinal content the stronger the stimulation and therefore peristalsis. Constipation will be caused by defective peristalsis. When a low fibre meal is consumed digestion is almost complete and a high proportion of the meal is absorbed into the bloodstream. Consequently only a small residue is left within the lumen of the intestines to stimulate peristalsis; this does not provide sufficient stimulation and the result is a weaker contraction of the intestinal musculature and hence peristalsis. The effects of weak peristalsis include decreased frequency of stool motion as intestinal transit time increases and content takes a longer time to move down the intestines. The delayed movement of intestinal content will allow excessive absorption of moisture from it and resulting in hard stools which are also very difficult to pass out. What is being suggested here is that impairment of peristalsis sets a vicious circle into motion that results in constipation in the affected person. Probably impairment of peristalsis is the common mechanism by which all possible underlying causes of constipation work. Further support for this idea is provided by the fact that the actions of the available laxatives are mostly mediated through an effect on peristalsis. The laxatives which are presently available to medical practice may be put into four subgroups; bulk laxatives, stimulant laxatives, saline laxatives, and the stool softeners. Bulk laxatives are mainly indigestible natural polysaccharides and their semisynthetic derivatives. Similar to dietary fibre bulk laxatives are not digested and absorbed from the intestines; the retention of these provides a bulky mass which stimulates peristalsis. Bulk laxatives also bind to moisture so that stools which are passed out have soft consistency. These are not rapid acting and repeated administrations over several days are necessary. Bulk laxatives are useful for treating infrequent bowel motion and hard stools; they are not effective for bowel evacuation. Stimulant laxatives, which are also referred to as contact laxatives, effect their action by directly stimulating nerve endings within intestinal smooth muscles to cause peristalsis. They usually produce violent purgative action. The stimulant laxatives are appreciably fast acting; however they are long acting so that their laxative effect extends over several hours beyond the onset. These are only useful for treating infrequent bowel motion. The saline or osmotic laxatives are mainly inorganic salts that are poorly absorbed from the intestines. They are usually administered as weak aqueous solutions; they cause osmotic pressure to build up within the intestines which retains the water that is administered with the salt. The osmotic pressure in turn stimulates pressuresensitive nerve endings within the intestinal smooth muscle to induce peristalsis. The saline laxatives have the fastest onset of action. They are applicable for treating infrequent bowel motion as well as passage of hard stools. Saline laxatives also have a bowel cleansing effect and they are the type of laxatives which are being used for bowel evacuation prior to investigational and surgical procedures. Stool softeners are useful for treating passage of hard stools whereby they lubricate the faecal matter to enable smooth passage.

Examples of bulk laxatives are bran, ispaghula, sterculia, psyllium seed, and methylcellulose. These are known to cause intestinal obstruction if taken with insufficient quantities of water. The stimulant laxatives include bisacodyl, cascara, senna, phenolphthalein, rhubarb, aloes, and sodium picosulfate. Tolerance may develop to the action of these drugs if they are used excessively; additionally they may cause abdominal cramps. Saline laxatives include such drugs as magnesium sulfate (Epsom salt), magnesium oxide, magnesium citrate, magnesium hydroxide, sodium sulfate, sodium phosphate, and lactulose. Stool softeners include Docusate and paraffin liquid. The desirable properties of an ideal laxative include the fact it should have rapid onset of action. It should not have a tailing effect, meaning that its action should not extend over long period beyond onset. Moreover it should have a broad spectrum of action and applicable for almost all cases of constipation. The saline laxatives approach these ideal properties closer than the other subgroups of laxatives. As such they may be considered as the best and most efficacious group of laxatives to use. They are safe and associated with few untoward effects.