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LAXATIVES-BULK FORMING

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) The bulk-forming laxatives generally swell in water to form a gel that serves to maintain soft, well-hydrated feces. They also reflexively stimulate peristalsis.

Specific Substances

    A) CONSTITUENTS OF THE GROUP
    1) Guar Gum (Cyanopsis psoraloides) (synonym)
    2) Psyllium
    3) Psyllium (Plantago afra or Plantago indica)
    4) Methylcellulose (synonym)
    5) Sodium carboxymethylcellulose (synonym)
    6) Gum Tragacanth (Astraplus gummifer)
    7) Karaya (Sterculia species) (synonym)
    8) Glucomannan (Konjac mannan) (synonym)
    9) Malt Soup Extract (synonym)
    10) Flaxseed (Linum usitatissimum)
    11) Polycarbophil (synonym)
    12) Bran (synonym)
    13) Ispaghula (Plantago ovata) (synonym)
    14) Bulk laxatives

Available Forms Sources

    A) FORMS
    1) There are numerous proprietary products containing bulk-forming laxatives which include methylcellulose, sodium carboxymethylcellulose, psyllium, flaxseed, karaya, guar gum, malt soup extract, polycarbophil, tragacanth, and bran.
    2) Flax is part of the genus Linum in the family Linaceae and known as L. usitatissimum. It is grown for both its seed and its fibers. The seeds once dried are known as linseed. They can be taken internally to treat constipation. Crushed seeds have been used as a poultice. Flaxseed has also been used as a cholesterol lowering agent and is commercially available (Sweetman, 2007).
    3) Glucomannan is a polysaccharide composed of glucose and mannose. Capsules of the fiber absorb up to 60 times their weight in water to form a gel.
    B) USES
    1) Bulk-forming laxatives have been used in patients with anorectal conditions, constipation, diarrhea, gastrointestinal disorders, hypercholesterolemia, and to regulate colostomies.

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Bulk-forming laxatives have been used in patients with anorectal conditions, constipation, diarrhea, gastrointestinal disorders, hypercholesterolemia, and to regulate colostomies. There are numerous proprietary products containing bulk-forming laxatives which include methylcellulose, sodium carboxymethylcellulose, psyllium, flaxseed, karaya, guar gum, malt soup extract, polycarbophil, tragacanth, and bran.
    B) PHARMACOLOGY: The bulk-forming laxatives generally swell in water to form a gel that serves to maintain soft, well-hydrated feces. They also reflexively stimulate peristalsis.
    C) TOXICOLOGY: The seed husk of psyllium mucilloid contains a protein that appears to be the source of the allergic reactions. Highly purified psyllium mucilloid may decrease the allergenicity to psyllium-containing products.
    D) EPIDEMIOLOGY: Exposure is common, but severe toxicity following acute overdosage with bulk forming laxatives is unlikely. Laxative abuse is seen with eating disorders (eg, anorexia nervosa, bulimia) as well as with factitious disorders (eg, Munchausen syndrome).
    E) WITH THERAPEUTIC USE
    1) Systemic toxicity is unlikely since these agents are not absorbed from the gastrointestinal tract and excreted in the feces. Severe toxicity following acute overdosage with bulk forming laxatives is unlikely. The greatest potential hazard is the risk of esophageal obstruction, usually seen in elderly patients, those with underlying gastrointestinal motility diseases, or in those taking products with insufficient fluids. Anaphylactoid reactions have been reported following exposure to psyllium-containing products.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Nausea, vomiting, abdominal pain, and diarrhea may be noted with large doses. Occupational asthma, dermatitis, urticaria have been reported in workers exposed to psyllium dust. Rhinitis and sneezing have been reported after occupational exposure to powdered dusts of guar gum and psyllium.
    2) SEVERE TOXICITY: Aspiration pneumonitis has been reported following exposure to guar gum products. Gastrointestinal obstruction may occur with very large doses.

Laboratory Monitoring

    A) Monitor serum electrolytes in patients with severe vomiting and/or diarrhea.
    B) Assess bowel function in all patients following a very large overdose; monitor for abdominal pain or distention, vomiting, or evidence of bowel obstruction.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive. Encourage oral fluid intake. Correct any significant fluid and/or electrolyte abnormalities in patients with vomiting or diarrhea.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. Severe toxicity is not expected after overdose. Encourage oral fluid intake if possible. Assess bowel function in all patients following an overdose; monitor for abdominal pain or distention, vomiting, or evidence of bowel obstruction.
    C) DECONTAMINATION
    1) PREHOSPITAL: Laxatives-bulk forming agents undergo minimal absorption from the gastrointestinal tract. Severe toxicity is not expected after overdose. Gastrointestinal decontamination is generally not necessary. DILUTION: Immediately dilute with 4 to 8 ounces (120 to 240 mL) of water or milk (not to exceed 4 ounces or 120 mL in a child).
    2) HOSPITAL: Laxatives-bulk forming agents undergo minimal absorption from the gastrointestinal tract. Severe toxicity is not expected after overdose. Gastrointestinal decontamination is generally not necessary. Do not administer a saline cathartic. DILUTION: Immediately dilute with 4 to 8 ounces (120 to 240 mL) of water or milk (not to exceed 4 ounces or 120 mL in a child).
    D) AIRWAY MANAGEMENTS
    1) Should not be required in these cases.
    E) ANTIDOTE
    1) None.
    F) ACUTE ALLERGIC REACTION
    1) MILD to MODERATE effects: Monitor airway. Administer antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE Effects: Administer oxygen, aggressive airway management may be necessary. Administer antihistamines, epinephrine, corticosteroids as needed. Treatment includes IV fluids and ECG monitoring.
    G) ENHANCED ELIMINATION
    1) Since systemic absorption is minimal, methods to enhance systemic elimination are not necessary.
    H) PATIENT DISPOSITION
    1) HOME CRITERIA: A patient with an inadvertent exposure, that remains asymptomatic can be managed at home.
    2) OBSERVATION CRITERIA: Symptomatic patients should be sent to a health care facility for evaluation and treatment as necessary. Patients with symptoms of esophageal obstruction should be referred to a health care facility. Potential symptoms include sudden onset of dysphagia, retrosternal pain, vomiting, and hypersalivation.
    3) ADMISSION CRITERIA: Patients should be admitted for severe vomiting, profuse diarrhea, severe abdominal pain, dehydration, and electrolyte abnormalities.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear. Consult a gastroenterologist and a specialist in eating disorders if chronic laxative abuse is suspected.
    I) PHARMACOKINETICS
    1) ONSET: The laxative effect is usually apparent within 12 to 24 hours and may not become fully apparent for as long as 72 hours.
    J) DIFFERENTIAL DIAGNOSIS
    1) Patients with a history of decreased gastrointestinal motility due to other causes. Patients with underlying cardiac dysrhythmias or electrolyte imbalance may develop more severe symptoms.

Range Of Toxicity

    A) TOXICITY: No toxic dose has been determined. If taken all at one time, the maximum daily doses listed may pose a risk of esophageal obstruction.
    B) THERAPEUTIC DOSES: The doses vary with the preparation used. ADULTS: The usual adult dose of psyllium is 1 rounded teaspoonful stirred into a standard 8 ounce glass of cool water, fruit juice, milk, or other beverage 1 to 3 times a day. CHILDREN: For children 6 to 12 years, the dose of psyllium is 1/2 the adult dose in 8 ounces of liquid 1 to 3 times a day.

Clinical Effects

Summary Of Exposure

    A) USES: Bulk-forming laxatives have been used in patients with anorectal conditions, constipation, diarrhea, gastrointestinal disorders, hypercholesterolemia, and to regulate colostomies. There are numerous proprietary products containing bulk-forming laxatives which include methylcellulose, sodium carboxymethylcellulose, psyllium, flaxseed, karaya, guar gum, malt soup extract, polycarbophil, tragacanth, and bran.
    B) PHARMACOLOGY: The bulk-forming laxatives generally swell in water to form a gel that serves to maintain soft, well-hydrated feces. They also reflexively stimulate peristalsis.
    C) TOXICOLOGY: The seed husk of psyllium mucilloid contains a protein that appears to be the source of the allergic reactions. Highly purified psyllium mucilloid may decrease the allergenicity to psyllium-containing products.
    D) EPIDEMIOLOGY: Exposure is common, but severe toxicity following acute overdosage with bulk forming laxatives is unlikely. Laxative abuse is seen with eating disorders (eg, anorexia nervosa, bulimia) as well as with factitious disorders (eg, Munchausen syndrome).
    E) WITH THERAPEUTIC USE
    1) Systemic toxicity is unlikely since these agents are not absorbed from the gastrointestinal tract and excreted in the feces. Severe toxicity following acute overdosage with bulk forming laxatives is unlikely. The greatest potential hazard is the risk of esophageal obstruction, usually seen in elderly patients, those with underlying gastrointestinal motility diseases, or in those taking products with insufficient fluids. Anaphylactoid reactions have been reported following exposure to psyllium-containing products.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Nausea, vomiting, abdominal pain, and diarrhea may be noted with large doses. Occupational asthma, dermatitis, urticaria have been reported in workers exposed to psyllium dust. Rhinitis and sneezing have been reported after occupational exposure to powdered dusts of guar gum and psyllium.
    2) SEVERE TOXICITY: Aspiration pneumonitis has been reported following exposure to guar gum products. Gastrointestinal obstruction may occur with very large doses.

Heent

    3.4.5) NOSE
    A) RHINITIS has been reported following occupational exposures.
    1) CASE SERIES: Occupational exposure to guar gum powder resulted in allergic rhinitis after 1 to 2 years exposure in 3 patients (Kanerua et al, 1988).
    2) CASE SERIES: Rhinitis was reported in 9% of health care workers exposed to psyllium (Nelson, 1987).
    B) SNEEZING has been reported following occupational exposures.
    1) CASE SERIES: Sneezing was reported in 16% of health care workers involved in preparation of psyllium laxatives. Because the precipitating event was sometimes associated with puffs of dust arising from newly opened bottles, these events may reflect a nonspecific irritation to the dust, rather than an allergic phenomenon (Nelson, 1987).
    3.4.6) THROAT
    A) Lip and palatal edema occurred after ingestion of food containing guar gum (Leznoff et al, 1986).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) BRONCHOSPASM
    1) Occupational asthma has been described in workers with psyllium (Gauss et al, 1985).
    a) The incidence of moderate allergic symptoms (shortness of breath, wheezing, hives) was 5% within 30 minutes of preparing psyllium laxatives in 743 health care workers (Nelson, 1987).
    B) PULMONARY ASPIRATION
    1) CASE REPORT: Aspiration pneumonitis was reported in an 80-year-old woman with esophageal obstruction due to a Karaya gum product (Sandeman et al, 1980).
    C) DISORDER OF RESPIRATORY SYSTEM
    1) Obstructive sleep apnea, cough, conjunctivitis, and rhinitis were reported in a 38-year-old man occupationally exposed to guar gum dust (Leznoff et al, 1986).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) STRICTURE OF ESOPHAGUS
    1) Obstruction and impactions are usually associated with intestinal pathology or lack of adequate hydration. Cases of esophageal obstruction have occurred when these agents have been swallowed dry or when the tablets are chewed (Hinkel, 1951; Noble & Grannis, 1984); Angueira & Kadakia, 1993).
    2) CASE SERIES: Seven cases of esophageal obstruction have been reported from ingestion of GLUCOMANNAN tablets, due to rapid swelling of the tablets (Henry et al, 1986). None of these patients had underlying esophageal disease. Of the 5 complete obstructions, 4 were in the upper third of the esophagus. General anesthesia was required to remove the complete obstructions with an esophagoscope (Fung, 1984; Anon, 1985). Esophageal perforation and mediastinitis was a complication of removal in one case (Henry et al, 1986).
    3) Rapid expansion rates were demonstrated when glucomannan tablets were placed in water. Capsules expanded more slowly and were considered to be less likely to cause obstruction (Henry et al, 1986).
    4) CASE REPORT: Karaya gum: Ingestion of powdered Karaya gum was associated with distal esophageal obstruction in an 87-year-old man with no previous history of gastrointestinal disease (Roux et al, 1984), and in an 80-year-old woman who ingested 2 teaspoonfuls with minimal fluids (Sandeman et al, 1980).
    5) CASE REPORT: Esophageal obstruction was caused in a 69-year-old woman by taking two teaspoons of Colosan mite, a sterculia bulk-forming laxative (Welge-Lussen & Jauser, 1997).
    B) INTESTINAL OBSTRUCTION
    1) CASE REPORT: A 47-year-old man presented to the ED with colicky, epigastric abdominal pain, which began 8 hours earlier following ingestion of psyllium hydrophilic mucilloid. Abdominal radiographs revealed an edematous loop of fluid-filled bowel, suggesting possible jejunal obstruction (Frohna, 1992).
    2) CASE REPORT: Angueira & Kadakia (1993) report a 69-year-old man, who was ingesting psyllium on a regular basis, and subsequently developed epigastric pain. An upper endoscopy revealed a bezoar in the duodenum.
    C) NAUSEA AND VOMITING
    1) Guar gum may cause nausea and vomiting in large doses, due to unpalatability (Todd et al, 1990; Kirsten et al, 1989; Tuomilehto et al, 1988).
    D) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) Diarrhea and excessive fluid loss may be noted with large doses (Todd et al, 1990; Kirsten et al, 1989; Tuomilehto et al, 1988).
    E) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) Abdominal pain or discomfort may be noted with large doses (Todd et al, 1990; Kirsten et al, 1989; Tuomilehto et al, 1988).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) EOSINOPHIL COUNT RAISED
    1) Eosinophilia has been associated with psyllium ingestion (Nelson et al, 1980).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) Dermatitis and urticaria has been described in workers with psyllium (Gauss et al, 1985; Nelson, 1987).

Endocrine

    3.16.2) CLINICAL EFFECTS
    A) HYPOGLYCEMIA
    1) WITH THERAPEUTIC USE
    a) Glucomannan has resulted in decreased blood glucose and serum insulin levels when given in single doses to diabetic patients (Doi et al, 1979).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ANAPHYLACTOID REACTION
    1) Anaphylaxis has been reported following ingestion of psyllium (Zaloga et al, 1984; Suhonen et al, 1983; Drake et al, 1991; Freeman, 1994) and inhalation (Schoenwelter, 1985; (Gillespie & Rathbun, 1992).
    2) CASE SERIES: A group of 20 female patients; 17 had prior exposure to psyllium, possessed IgE and IgG antibodies specific to some psyllium fraction. Allergic reactions developed within 2 to 30 minutes following ingestion of less than 1 cup of a psyllium-containing cereal. Moderate-to-severe wheezing, tightness in the chest or throat, urticaria, and angioedema were reported in greater than 70% of the patients. Approximately 75% of the patients received antihistamines and greater than 20% required epinephrine and corticosteroids (James et al, 1991).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor serum electrolytes in patients with severe vomiting and/or diarrhea.
    B) Assess bowel function in all patients following a very large overdose; monitor for abdominal pain or distention, vomiting, or evidence of bowel obstruction.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients should be admitted for severe vomiting, profuse diarrhea, severe abdominal pain, dehydration, electrolyte abnormalities, or evidence of bowel obstruction.
    6.3.1.2) HOME CRITERIA/ORAL
    A) A patient with an inadvertent exposure, that remains asymptomatic can be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear. Consult a gastroenterologist and a specialist in eating disorders if chronic laxative abuse is suspected.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Symptomatic patients should be sent to a health care facility for evaluation and treatment as necessary.
    B) Patients with symptoms of esophageal obstruction should be referred to a health care facility. Potential symptoms include sudden onset of dysphagia, retrosternal pain, vomiting, and hypersalivation (Roux et al, 1984).

Monitoring

    A) Monitor serum electrolytes in patients with severe vomiting and/or diarrhea.
    B) Assess bowel function in all patients following a very large overdose; monitor for abdominal pain or distention, vomiting, or evidence of bowel obstruction.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Laxatives-bulk forming agents undergo minimal absorption from the gastrointestinal tract. Severe toxicity is not expected after overdose. Gastrointestinal decontamination is generally not necessary.
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.2) PREVENTION OF ABSORPTION
    A) Laxatives-bulk forming agents undergo minimal absorption from the gastrointestinal tract. Severe toxicity is not expected after overdose. Gastrointestinal decontamination is generally not necessary. Do not administer a saline cathartic.
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Monitor serum electrolytes in patients with severe vomiting and/or diarrhea.
    2) Assess bowel function in all patients following a very large overdose; monitor for abdominal pain or distention, vomiting, or evidence of bowel obstruction.
    B) GASTROINTESTINAL OBSTRUCTION
    1) GI OBSTRUCTION: Rigid esophagoscopy has been used to relieve esophageal obstruction caused by Colosan mite, a sterculia, bulk-forming laxative (Welge-Lussen & Jauser, 1997).
    C) ACUTE ALLERGIC REACTION
    1) SUMMARY
    a) Mild to moderate allergic reactions may be treated with antihistamines with or without inhaled beta adrenergic agonists, corticosteroids or epinephrine. Treatment of severe anaphylaxis also includes oxygen supplementation, aggressive airway management, epinephrine, ECG monitoring, and IV fluids.
    2) BRONCHOSPASM
    a) ALBUTEROL
    1) ADULT: 2.5 to 5 milligrams in 2 to 4.5 milliliters of normal saline delivered per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hr by continuous nebulization as needed (National Heart,Lung,and Blood Institute, 2007). CHILD: 0.15 milligram/kilogram (minimum 2.5 milligrams) per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 0.15 to 0.3 mg/kg (up to 10 mg) every 1 to 4 hours as needed, or 0.5 mg/kg/hr by continuous nebulization (National Heart,Lung,and Blood Institute, 2007).
    3) CORTICOSTEROIDS
    a) Consider systemic corticosteroids in patients with significant bronchospasm.
    b) PREDNISONE: ADULT: 40 to 80 milligrams/day. CHILD: 1 to 2 milligrams/kilogram/day (maximum 60 mg) in 1 to 2 divided doses divided twice daily (National Heart,Lung,and Blood Institute, 2007).
    4) MILD CASES
    a) DIPHENHYDRAMINE
    1) SUMMARY: Oral diphenhydramine, as well as other H1 antihistamines can be used as indicated (Lieberman et al, 2010).
    2) ADULT: 50 milligrams orally, or 10 to 50 mg intravenously at a rate not to exceed 25 mg/min or may be given by deep intramuscular injection. A total of 100 mg may be administered if needed. Maximum daily dosage is 400 mg (Prod Info diphenhydramine HCl intravenous injection solution, intramuscular injection solution, 2013).
    3) CHILD: 5 mg/kg/24 hours or 150 mg/m(2)/24 hours. Divided into 4 doses, administered intravenously at a rate not exceeding 25 mg/min or by deep intramuscular injection. Maximum daily dosage is 300 mg (Prod Info diphenhydramine HCl intravenous injection solution, intramuscular injection solution, 2013).
    5) MODERATE CASES
    a) EPINEPHRINE: INJECTABLE SOLUTION: It should be administered early in patients by IM injection. Using a 1:1000 (1 mg/mL) solution of epinephrine. Initial Dose: 0.01 mg/kg intramuscularly with a maximum dose of 0.5 mg in adults and 0.3 mg in children. The dose may be repeated every 5 to 15 minutes, if no clinical improvement. Most patients respond to 1 or 2 doses (Nowak & Macias, 2014).
    6) SEVERE CASES
    a) EPINEPHRINE
    1) INTRAVENOUS BOLUS: ADULT: 1 mg intravenously as a 1:10,000 (0.1 mg/mL) solution; CHILD: 0.01 mL/kg intravenously to a maximum single dose of 1 mg given as a 1:10,000 (0.1 mg/mL) solution. It can be repeated every 3 to 5 minutes as needed. The dose can also be given by the intraosseous route if IV access cannot be established (Lieberman et al, 2015). ALTERNATIVE ROUTE: ENDOTRACHEAL ADMINISTRATION: If IV/IO access is unavailable. DOSE: ADULT: Administer 2 to 2.5 mg of 1:1000 (1 mg/mL) solution diluted in 5 to 10 mL of sterile water via endotracheal tube. CHILD: DOSE: 0.1 mg/kg to a maximum of 2.5 mg administered as a 1:1000 (1 mg/mL) solution diluted in 5 to 10 mL of sterile water via endotracheal tube (Lieberman et al, 2015).
    2) INTRAVENOUS INFUSION: Intravenous administration may be considered in patients poorly responsive to IM or SubQ epinephrine. An epinephrine infusion may be prepared by adding 1 mg (1 mL of 1:1000 (1 mg/mL) solution) to 250 mL D5W, yielding a concentration of 4 mcg/mL, and infuse this solution IV at a rate of 1 mcg/min to 10 mcg/min (maximum rate). CHILD: A dosage of 0.01 mg/kg (0.1 mL/kg of a 1:10,000 (0.1 mg/mL) solution up to 10 mcg/min (maximum dose 0.3 mg) is recommended for children (Lieberman et al, 2010). Careful titration of a continuous infusion of IV epinephrine, based on the severity of the reaction, along with a crystalloid infusion can be considered in the treatment of anaphylactic shock. It appears to be a reasonable alternative to IV boluses, if the patient is not in cardiac arrest (Vanden Hoek,TL,et al).
    7) AIRWAY MANAGEMENT
    a) OXYGEN: 5 to 10 liters/minute via high flow mask.
    b) INTUBATION: Perform early if any stridor or signs of airway obstruction.
    c) CRICOTHYROTOMY: Use if unable to intubate with complete airway obstruction (Vanden Hoek,TL,et al).
    d) BRONCHODILATORS are recommended for mild to severe bronchospasm.
    e) ALBUTEROL: ADULT: 2.5 to 5 milligrams in 2 to 4.5 milliliters of normal saline delivered per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hr by continuous nebulization as needed (National Heart,Lung,and Blood Institute, 2007).
    f) ALBUTEROL: CHILD: 0.15 milligram/kilogram (minimum 2.5 milligrams) per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 0.15 to 0.3 milligram/kilogram (maximum 10 milligrams) every 1 to 4 hours as needed OR administer 0.5 mg/kg/hr by continuous nebulization (National Heart,Lung,and Blood Institute, 2007).
    8) MONITORING
    a) CARDIAC MONITOR: All complicated cases.
    b) IV ACCESS: Routine in all complicated cases.
    9) HYPOTENSION
    a) If hypotensive give 500 to 2000 milliliters crystalloid initially (20 milliliters/kilogram in children) and titrate to desired effect (stabilization of vital signs, mentation, urine output); adults may require up to 6 to 10 L/24 hours. Central venous or pulmonary artery pressure monitoring is recommended in patients with persistent hypotension.
    1) VASOPRESSORS: Should be used in refractory cases unresponsive to repeated doses of epinephrine and after vigorous intravenous crystalloid rehydration (Lieberman et al, 2010).
    2) DOPAMINE: Initial Dose: 2 to 20 micrograms/kilogram/minute intravenously; titrate to maintain systolic blood pressure greater than 90 mm Hg (Lieberman et al, 2010).
    10) H1 and H2 ANTIHISTAMINES
    a) SUMMARY: Antihistamines are second-line therapy and are used as supportive therapy and should not be used in place of epinephrine (Lieberman et al, 2010).
    1) DIPHENHYDRAMINE: ADULT: 25 to 50 milligrams via a slow intravenous infusion or IM. PEDIATRIC: 1 milligram/kilogram via slow intravenous infusion or IM up to 50 mg in children (Lieberman et al, 2010).
    b) RANITIDINE: ADULT: 1 mg/kg parenterally; CHILD: 12.5 to 50 mg parenterally. If the intravenous route is used, ranitidine should be infused over 10 to 15 minutes or diluted in 5% dextrose to a volume of 20 mL and injected over 5 minutes (Lieberman et al, 2010).
    c) Oral diphenhydramine, as well as other H1 antihistamines, can also be used as indicated (Lieberman et al, 2010).
    11) DYSRHYTHMIAS
    a) Dysrhythmias and cardiac dysfunction may occur primarily or iatrogenically as a result of pharmacologic treatment (epinephrine) (Vanden Hoek,TL,et al). Monitor and correct serum electrolytes, oxygenation and tissue perfusion. Treat with antiarrhythmic agents as indicated.
    12) OTHER THERAPIES
    a) There have been a few reports of patients with anaphylaxis, with or without cardiac arrest, that have responded to vasopressin therapy that did not respond to standard therapy. Although there are no randomized controlled trials, other alternative vasoactive therapies (ie, vasopressin, norepinephrine, methoxamine, and metaraminol) may be considered in patients in cardiac arrest secondary to anaphylaxis that do not respond to epinephrine (Vanden Hoek,TL,et al).

Enhanced Elimination

    A) SUMMARY
    1) Since systemic absorption is minimal, methods to enhance systemic elimination are not necessary.

Range Of Toxicity

Summary

    A) TOXICITY: No toxic dose has been determined. If taken all at one time, the maximum daily doses listed may pose a risk of esophageal obstruction.
    B) THERAPEUTIC DOSES: The doses vary with the preparation used. ADULTS: The usual adult dose of psyllium is 1 rounded teaspoonful stirred into a standard 8 ounce glass of cool water, fruit juice, milk, or other beverage 1 to 3 times a day. CHILDREN: For children 6 to 12 years, the dose of psyllium is 1/2 the adult dose in 8 ounces of liquid 1 to 3 times a day.

Therapeutic Dose

    7.2.1) ADULT
    A) SPECIFIC SUBSTANCE
    1) BRAN - 1 to 7 grams/dose, up to 14 grams/day (FDA, 1986).
    2) Methylcellulose/Sodium Carboxymethylcellulose - 0.45 to 3 grams/dose; up to 6 grams/day (FDA, 1986)
    3) GUAR GUM - 15 grams /day (S Sweetman , 2002).
    4) KARAYA - 3.5 to 7 grams/dose, up to 14 grams/day (FDA, 1986)
    5) POLYCARBOPHIL - 1 gram/dose, up to 4 grams/day (S Sweetman , 2002).
    6) PSYLLIUM - The usual adult dose of psyllium is 1 rounded teaspoonful stirred into a standard 8 ounce glass of cool water, fruit juice, milk, or other beverage 1 to 3 times a day (Prod Info METAMUCIL(R), 1999).
    7.2.2) PEDIATRIC
    A) SPECIFIC SUBSTANCE
    1) CHILDREN AGED 6 TO 11 YEARS
    a) BRAN - 1 to 3.5 grams/dose, up to 7 grams/day (FDA, 1986)
    b) Methylcellulose/Sodium Carboxymethylcellulose - 0.45 to 1.5 grams/dose, up to 3 grams/day (FDA, 1986)
    c) POLYCARBOPHIL - 0.5 gram/dose, up to 2 grams/day (FDA, 1986)
    d) PSYLLIUM - For children 6 to 12 years, the dose of psyllium is 1/2 the adult dose in 8 ounces of liquid 1 to 3 times a day.
    2) CHILDREN AGED 2 TO 5 YEARS
    a) BRAN - 1 to 1.75 grams/dose, up to 3.5 grams/day (FDA, 1986)
    b) POLYCARBOPHIL - 0.5 gram/dose, up to 1 gram/day (FDA, 1986)

Maximum Tolerated Exposure

    A) No toxic dose has been determined. If taken all at one time, the maximum daily doses listed may pose a risk of esophageal obstruction (FDA, 1986).
    B) SPECIFIC SUBSTANCE
    1) Ingestion of sterculia (Karaya) in the maximum daily dose (2 teaspoonfuls) with minimal fluids produced esophageal obstruction in an elderly woman (Sandeman et al, 1980).
    2) Ingestion of unprocessed bran 20 g/day for one year, followed by 160 to 200 g/day for 6 months resulted in rectal impaction and intestinal obstruction (Kang & Doe, 1979).

Pharmacology Toxicology

Pharmacologic Mechanism

    A) The bulk-forming laxatives generally swell in water to form a gel that serves to maintain soft, well-hydrated feces. They also reflexly stimulate peristalsis.

Toxicologic Mechanism

    A) the seed husk of psyllium mucilloid contains a protein that appears to be the source of the allergic reactions. Highly purified psyllium mucilloid may decrease the allergenicity to psyllium-containing products (James et al, 1991).

References

General Bibliography

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