Constipation in the elderly

Chinese medicine that helps improve QOL in elderly patients with heart failure

Constipation in the elderly.
麻子仁丸(MAZIRENWAN); 大建中汤(大建中汤)

Dr. Junichiro Tsuchikura Profile Director, Tsuchikura Internal Medicine Cardiovascular Clinic.

1 Constipation in the elderly 
In medical treatment for the elderly, constipation is a common issue. Constipation complaints in Japan tend to rise with age, especially among those aged 70 and up, according to the 2016 National Lifestyle Survey 1). Reasons for this include a decrease in intestinal peristalsis due to aging, a decrease in pelvic floor muscle coordination, a decrease in the amount of exercise, a change in the amount of food, and drugs 2). Furthermore, in patients with heart failure, constipation may be promoted due to factors such as decreased water intake and intestinal dryness (decreased water content) due to diuretics.Basically, if you can get good defecation with Western medicine, you don't have to use Chinese medicine. However, if you have difficulty in defecation such as poor stool output with Western medicine or difficulty in adjusting the medicine, Chinese medicine is also an option.

2 Refractory constipation treat with MAZIRENWAN（麻子仁丸） 
-Target: MAZIRENWAN is the first choice for refractory constipation in the elderly, such as when defecation is difficult even after taking several types of Western medicine.
-Prescription explanation: MAZIRENWAN is composed of 6 kinds of crude drugs: MAZHIREN(麻子仁）DAHUANG(大黄）ZHISHI(枳实) XINGREN(杏仁) HOUPO(厚朴) SHAOYAO(芍药) . The medicinal ingredient of DAHUANG is sennoside, which has a laxative effect (DAHUANG of MAZIRENWAN has a relatively large amount of 4 g / day). MAZIREN and XINGREN are oily components and have an intestinal moisturizing effect (moisturize the intestines and make them slippery).ZHISHI has an intestinal peristaltic promoting effect. SHAOYAO and HOUPO have antispasmodic and analgesic effects, and relieve abdominal fullness and abdominal pain (derived from DAHUANG).
MAZIRENWAN has effects on intestinal hydration and intestinal peristalsis modulation, making it more appropriate for old persons whose entire body, including the intestinal tract, is dry and whose intestinal peristalsis is likewise diminished. For this reason, I personally recognize MAZIRENWAN as a "comprehensive laxative for the elderly." In fact, according to NDB data of the Ministry of Health, Labor and Welfare, MAZIRENWAN is the most common rhubarb-containing preparation used for people over 70 years old 4), and it is also listed in "Guidelines for Safe Pharmacotherapy for the Elderly" 5). In addition, MAZIRENWAN does not contain licorice or Glauber's salt (magnesium-like component),  so, there will be no worries for pseudoaldosteronism. Another advantage is that there is no risk of illness and it is easy to use for patients with renal failure.
-How to use: MAZIRENWAN is a Chinese herbal medicine with a relatively strong laxative effect, so it is basically recommended to use it for refractory constipation. For mild constipation, about 0.5 packets a day may be sufficient, but for moderate or severe constipation, 1 to 3 packets a day should be used. Personally, I often introduce MAZIRENWAN when patients are having trouble getting stools even after taking laxatives (no abnormalities in the test). MAZIRENWAN is easy to adapt to such patients, In some cases, MAZIRENWAN's introduction can help to lessen the use of numerous types of Western medicine (constipation medicine).
-Note: Diarrhea. Large intestine melanosis due to DAHUANG
-Case: 85 year old female. It is difficult to get stools. She is taking Magnesium oxide 990 mg / day, sennoside 24 mg / day, picosulfate sodium. 
She is using suppositories on the 4th day without defecation.
-Prescription: Take one packet of MAZIRENWAN three times a day, after each meal, for 14 days.
-14days later : "It feels good to have a clean stool every day," she said.
-Eventually, Western medicine (constipation medicine) could be discontinued, and daily defecation was allowed with only 2 packets of MAZIRENWAN daily.

Figure　Elderly constipation flowchart

3.DAJIANZHONGTANG(大建中汤) for mild constipation
-Target: If you have mild constipation that is not suitable for Western medicine (constipation medicine) that causes diarrhea if you take a laxative, and constipation if you do not take it, and if you have poor circulation, DAJIANZHONGTANG is for it. Elderly people are more likely to be cold.
-Prescription explanation: DAJIANZHONGTANG is composed of four kinds of crude drugs: GANJIANG(干姜),SHUJIAO(蜀椒), RENSHEN(人参), JIAOTANG(胶糖). Of these, GANJIANG and SHUJIAO are the main crude drugs. It has the function of "warming the intestinal tract to normalize intestinal peristalsis and relieving spasm and abdominal pain in the intestinal tract" 6). Although it says "normalization of intestinal peristalsis," DAJIANZHONGTANG has an intestinal motility-enhancing effect 7)  while the intestinal motility-enhancing model has an intestinal motility-suppressing effect 8) and acts in a regulatory manner. Therefore, it is suitable for patients who have abdominal symptoms due to intestinal peristalsis caused by cold intestinal tract. “Cold intestinal tract” is more likely to accompany patients with poor circulation, but signs such as “cold food and drink worsen abdominal symptoms” and “warming relieves” can also be referred to. In addition, DAJIANZHONGTANG is not suitable for refractory constipation because it does not have a strong laxative effect, but it has the advantage of being able to treat not only constipation but also abdominal fullness, abdominal pain, and diarrhea. As an image, many patients who choose an intestinal regulator are suitable for DAJIANZHONGTANG.
-How to use: For Tsumura DAJIANZHONGTANG, the usual amount is 6 packets a day (2 packets at a time, 3 times a day). If it is difficult to drink, you may start with 2 packets a day (1 packet at a time, twice a day). If the effect is insufficient, the dose can be increased up to 6 packets a day.
If the effect is still insufficient, use a small amount of MAZIRENWAN or Western medicine.
-Note: Some patients are concerned about the taste of dried ginger and Japanese pepper (spicy ginger, tingling).
-Case: A 78 year old man. He has been constipated for some time, but taking magnesium or sennosides causes diarrhea. He started to get some stools with an intestinal regulator, but it is not enough. He has poor circulation and has abdominal pain and diarrhea as soon as he eats cold food and drink.
-Prescription: DAJIANZHONGTANG 1 time 2 packets, 2 times a day, after breakfast and dinner, 14 days
-14 days later: "I feel comfortable with my stools every day. I have no abdominal pain or diarrhea and it's just right."

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease. We can’t guarantee the treatment result, as the symptoms of conditions are unpredictable and vary greatly from person to person. The treatment length and recovery time also varies for individual.

References
1)Ministry of Health, Labor and Welfare Minister's Office Statistics Information Department Vital Statistics and Health and Social Statistics Division Household Statistics Office. Overview of the 2016 National Life Basic Survey. Ministry of Health, Labor and Welfare. 2017.
2)Japanese Society of Gastroenterology-related Study Group Chronic Constipation Diagnosis and Treatment Study Group: Chronic Constipation Treatment Guidelines: 31, Nanzando, Tokyo, 2017.
3)Odai Edo: Hiroyoshi Kinjukata 3rd Edition: Suzuhara Bookstore, Tokyo, 1988.
4)Ministry of Health, Labor and Welfare NDB data. Aggregation period April 2017-March 2018.
5)The Japan Geriatrics Society, Japan Agency for Medical Research and Development, Research Fund, Research Group on the Safety of Drug Treatment for the Elderly
Collection: Guidelines for Safe Pharmacotherapy for the Elderly 2015. Medical View, 139-151, 2015.
6)Iwao Yamamoto et al. Explanation of Chinese medicine prescription. Ishiyaku Publications, 79, 1982.
7)Satoh, Y. et al. J. Trad. Med. 2010, 27 (3), p.115-121.
8)Satoh, K. et al. Biol. Pharm. Bull. 2001, 24 (10), p.1122-1126.

keyword :  #麻子仁丸(MAZIRENWAN); #大建中汤(DAJIANZHONGTANG); #constipation #abdominal pain

reference : https://www.kampo-s.jp/webmagazine/backnumber/384/