Life, Laxation, “Sonshine”, and Lemonade

Today, 2/17/2022, I sit in the chemo suite receiving cycle 16 of chemo.  So far so good, although their lab analyzer broke, so my bloodwork results were delayed. Ehhh, what the heck, just another two hours of my life in chemoland doing office work.  It’s been about a month since my last post and lots has happened since then.  Before all the warm and fuzzy stuff consistent with the blog title, I’ll start with a brief lesson on laxatives.

Although this gets a bit personal, I trust that many readers, their loved ones, or friends could benefit from this discussion. For the better part of 20-years, I personally have had to deal with chronic idiosyncratic constipation.  No big deal, as it can usually be well controlled with drinking more fluids (which I’m really bad at), diet, and if necessary, laxatives. Most people will first try over-the-counter (OTC) laxatives.  There are advantages and disadvantages of these drugs and there are many from which to choose. ASK YOUR PHARAMCIST!

Osmotic laxatives: These essentially pull water into the large bowel making the stool softer and easier to pass. They include polyethylene glycol 3350 (Miralax), lactulose, and magnesium citrate. They are generally safe to use intermittently or chronically.

Stimulant laxatives: Bisacodyl (Dulcolax), senna (Senokot). These are potentially problematic if used long term because they can affect the nerves within the large bowel which can ultimately cause a requirement for higher doses and eventually irreversible dependency on stimulant products.  They are also the most dangerous if you have a bowel obstruction and/or are prone to a bowel rupture which could be life threatening.  They are not generally intended for long term use, but there are some exceptions.  Moreover, there is some theoretical science that suggests long-term use could elevate risk for colorectal cancer, however this has never been confirmed in human studies to the best of my knowledge.^1,2,3

Detergent/ surfactant stool softener: Docusate (Colace): Generally safe for short or long-term use. This acts as a surfactant, similar to soap.

Lubricant: Mineral oil. This could be dangerous if taken at bedtime and aspirated, as it could result in lipophilic pneumonia.

When OTC laxatives are not practical or efficacious alone or combined, especially for chronic use, linaclotide (Linzess) is an option.  This is a prescription medication that activates guanylate cyclase-C, which stimulates cGMP production. The net result is increased intestinal fluid secretion and increased peristaltic motility. I have requested this, but the people “smarter than me” at BCBS need to first approve it, although Dr. Onc was on board and happy to order it. That will be a topic for the next blog, especially if it’s not approved.⁴

OTC laxatives were not designed to address the underlying physiologic mechanisms that cause opioid-induced constipation.^5,6 Reference 5 was written by an interdisciplinary group of medical colleagues including me and is open access here.

The best medications to address opioid-induced constipation, when OTCs are not effective, are peripherally acting mu opioid receptor antagonists (PAMORAs).  These block receptors in the gut that when exposed to opioids, cause decreased peristalsis, less fluid influx to the bowel, more fluid efflux out of the bowel, and paralysis of the anal sphincter. These require a prescription and include methynaltrexone (Relistor), naldemedine (Symproic), naloxegol (Movantik). For pharmacy and medical nerds, my brother from another mother, Dr. Jeffrey Gudin and I, authored an article that addressed the pharmacokinetic differences among these three which included a comparative risks for drug interactions.⁷

Now for the exciting life stuff and progress. Over the last month…

On January 12, 2022, Robin and I headed to our condo in northern Florida for about 10 days – it was colder than usual, but a lot warmer than the frozen tundra in the Northeast. We had a great time with much relaxation and even some beach time, as one day it reached 74 degrees.  😊

We returned to the frigid northeast for cycle 15 of chemo, then I headed back to meet my son Jason for some father/son alone time. This I’m going to highlight, because we have not done anything alone that remotely resembles this for over 25 years. In three days, we did a 10.6 mile bike ride, visited St. Augustine for a boat, golf cart, Fountain of Youth (I sure could use that), and walking tour, and the spent a day driving to Jacksonville to purchase 7 variable shelving units, drove back to the condo, and installed them into the walk-in closet.  I must say, Jason’s meticulous engineering skills came in handy because some of those shelves he honed in on before we left for IKEA, fit within a sixteenth of an inch. Then on 1/31, I had to wake up at 3:45AM to head for the airport with Jason.  I was homebound to snow and ice, while Jason headed to Miami for some WhyHotel business.

It is so important to spend alone time with your adult children, and you shouldn’t need a terminal illness to encourage you. It really was quite a highlight for me and so endearing to hang with my only son. On the way home, I couldn’t help but connect that experience to that old John Denver tune, “Son”shine on my shoulders. If you’re too young to know the song or forgot the lyrics, they go like this…

If I had a day that I could give you
I’d give to you the day just like today
If I had a song that I could sing for you
I’d sing a song to make you feel this way

“Son shine” on my shoulders makes me happy
“Son shine” in my eyes can make me cry
“Son shine” on the water looks so lovely
“Son shine” almost always makes me high

If I had a tale that I could tell you
I’d tell a tale sure to make you smile
If I had a wish that I could wish for you
I’d make a wish for sunshine for all the while

“Son shine” on my shoulders makes me happy
“Son shine” in my eyes can make me cry
“Son shine” on the water looks so lovely
“Son shine” almost all the time makes me high

If Jason alone time wasn’t pleasurable enough, along came Robin’s and my latest grandson on 2/4/2022, Asher James Bettinger born to Jeff Bettinger (aka Little Jeff) and our youngest daughter Shirah. What a little darling Asher is. Since we were expecting a wicked ice storm, I decided to sleep over their house on the evening of 2/3, the evening before, just in case.  That turned out to be a good call, as I was able to watch Aria as they headed to the hospital.

And, as luck would have it, Sarah, Andrew and their two little angelical girls were on their way to visit for the weekend.  When little Anna walked in (aka Silbie), Aria’s face lit up and she said “Anna Banana is my best friend”. They played together all weekend, while Anna’s little sister Emily (aka Boombah) entertained herself watching intently and playing on the floor.

 

What’s the life lesson here? None of us know how long we’ll be on this earth. These are examples of how in a 3-week span, you can live a very full, blessed, and loving life. “Son shine” on my shoulders makes me happy Moreover, this post speaks to the value of palliative chemotherapy and the choices we make along the way.

What’s the clinical lesson?  All laxatives are not created equal, and neither are the patients who require them.

But wait…

Hannah and Kris are expecting the stork to fly into Salt Lake City with their baby any day now. Geeze, what can I say?

#LifeIsGood.

 

As always, comments are enthusiastically welcome. Although comments on various social media platforms (FB, Linkedin, Twitter) are vet much appreciated, copy/pasting those comments here help popularize the series and provide insight to new readers.  THANK YOU!!!

References:

1. Morales MA, Hernández D, Bustamante S, Bachiller I, Rojas A. Is senna laxative use associated to cathartic colon, genotoxicity, or carcinogenicity?. Journal of Toxicology. 2009 Jan 1;2009.
2. van Gorkom BA, Karrenbeld A, van der Sluis T, Koudstaal J, de Vries EG, Kleibeuker JH. Influence of a highly purified senna extract on colonic epithelium. Digestion. 2000;61(2):113-20.
3. Mitchell JM, Mengs U, McPherson S, Zijlstra J, Dettmar P, Gregson R, Tigner JC. An oral carcinogenicity and toxicity study of senna (Tinnevelly senna fruits) in the rat. Archives of toxicology. 2006 Jan;80(1):34-44.)
4. Lacy BE, Schey R, Shiff SJ, Lavins BJ, Fox SM, Jia XD, Blakesley RE, Hao X, Cronin JA, Currie MG, Kurtz CB. Linaclotide in chronic idiopathic constipation patients with moderate to severe abdominal bloating: a randomized, controlled trial. PLoS One. 2015 Jul 29;10(7):e0134349.)
5. Argoff CE, Brennan MJ, Camilleri M, Davies A, Fudin J, Galluzzi KE, Gudin J, Lembo A, Stanos SP, Webster LR. Consensus recommendations on initiating prescription therapies for opioid-induced constipation. Pain Medicine. 2015 Dec 1;16(12):2324-37.
6. LoCasale RJ, Datto C, Margolis MK, Coyne KS. Satisfaction with therapy among patients with chronic noncancer pain with opioid-induced constipation. Journal of managed care & specialty pharmacy. 2016 Mar;22(3):246-53.Johnson DA, Argoff CE. J Fam Pract. 2015;64(12 Suppl):S4-S9.
7. Gudin J, Fudin J. Peripheral Opioid Receptor Antagonists for Opioid-Induced Constipation: A Primer on Pharmacokinetic Variabilities with a Focus on Drug Interactions. J Pain Res. 2020;13:447.