Code H: Habit Forming

Overuse/ rolonged use may cause your treated condition to worsen.

Code H refers to:

Laxatives
Topical nasal decongestants:

Naphazoline
Oxymetazoline
Phenylephrine
Xylometazoline

Ophthalmic decongestsuts:

Naphazoline
Oxymetazoline
Phenylephrine
Tetrahydrozoline

Laxatives

Laxatives should only be used for short periods of time, less than 10 consecutive days. These products are widely available and aggressively advertised (with no mention of adverse effects) and many patients take them without sufficient infomation. Prolonged use of laxatives, especially stimulant laxatives such as cascara, senna (sennosides) and bisacodyl, intensifies and perpetuates the condition for which they are used. The bowel becomes atonic and dependency is established. Overuse may cause electrolyte disturbances with symptoms of vomiting and muscle weakness. The pharmacist should be aware that stimulant laxatives are subject to abuse.

Patient Counselling

Treatment of constipation:
Eat plenty of dietary fibre. Bran, whole grains, fruit, vegetables are recommended.
Drink at least 6 glasses of water or juice every day, unless on a fluid restricted diet. Congestive heart failure patients and renal insufficiency patients should not be advised to consume large quantities of liquids.
Do more physical exercise. It gets everything moving.
Have a bowel movement as soon as you feel the urge.
Learn relaxation techniques.
Use a natural fibre laxative to supplement dietary fibre as first choice.
Use emollient laxatives such as calcium docusate or sodium docusate as second choice. These can be recommended for heart patients, surgery par.ients, hernia and anyone who should not strain during a bowel movement.
Use stimulant laxatives (bisacodyl, senna, cascara, danthron and casanthrol) as last choice and only for short term use.

Breaking the Laxative habit:

Avoid overusing laxatives.
Stop taking all laxatives.
Use a bulk-forming laxative if necessary to supplement dietary fibre.
Glycerin suppositories are indicated temporarily to re-establish normal bowel function in a laxative-dependent patient.
Consume larger quantities of fluids and high-fibre foods.
Attempt a bowel movement at the same time each day, about 30 minutes after a meal.
Exercise regularly.
Do not ignore the urge to have a bowel movement.

Topical Nasal Decongestants

Topical nasal decongestants will be effective in opening nasal passages to improve drainage and aeration. A major disadvantage, especially with longer acting naphazoline, is rebound congestion after the vasoconstricton wears off These agents are often misused, with a vicious circle of congestion and frequent drug use. Severe withdrawal symptoms requiring hospitalization have been reported after prolonged use. Overdose with signs of toxicity (transient hypertension, nervousness, nausea, dizziness, palpitations) may result.
Nasal sprays and drops should only be used in acute states and for not longer than 3 days (72 hrs.
A saline spray/drop, a lubricating spray or an oral decongestant (if no precautions apply) can be recommended as an alternative therapy.

How to Deal With Rebound or "After-Congestion"

The simplest method to deal with this is to discontinue the topical agent and the congestion will reverse within a few weeks. However, this is quite uncomfortable since it results in vasodilation and nasal obstruction, and the patient is unlikely to continue. Suggestions you can make are:
1. Use an orai decongestant for one or two weeks until the rebound effect is gone. The oral agents do not cause a rebound problem.
2. Discontinue the topical agent in one nostril only. Once the rebound condition has reversed in the drug-free nostril (1 or 2 weeks), it can be discontinued completely.
3. Use a saline spray. This provides moisture and psychological assistance for individuals in the habit of using sprays or drops.
4. See a physician for a topical steroid preparation to use until the rebound has subsided.

Ophthalmic Decongestants

Ophthalmic decongestants reduce ocular congestion thereby relieving the redness and hotness associated with vasodilation. This vasoconstriction can both cause and aggravate angle closure glaucoma and photophobia can occur. The most common effect, however, is rebound vasodilation of ophthalmic vessels in the same manner as rebound nasal congestion occurs. The patient instills more and more of the decongestant seeking relief. Long acting naphazoline is especially troublsome for rebound. Systemic effects can also occur. This can be reduced by holding a finger over the tear duct, with the eye closed, for a few minutes after instilling the eye drops. Conjuctivitis is also a possible side effect of overuse/prolonged use. An ophthalmic decongestant should not be used for more than 3 days (72 hours).

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