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Case-based learning: constipation in adults
It is important that pharmacists understand how to appropriately and

safely manage patients with constipation in light of new Medicines and
Healthcare products Regulatory Agency guidance announced in August
2020.
ARTICLE SUPPORTED BY
Care (https://carehcp.co.uk/)
12 October 2020.By Mikin Patel (https://pharmaceutical-journal.com/author/mikin-patel)

.Corresponding author Mikin Patel (https://pharmaceutical-journal.com/author/mikin-
patel) .
1 of 22 9/3/2021, 9:32 AM
SHUTTERSTOCK.COM
Constipation is one of the most common gastrointestinal (GI) symptoms patients may
experience[1] (#fn_1) ,[2] (#fn_2). As a symptom-based disorder that has no single definition, patients
will often have their own opinion of what constipation means to them[3] (#fn_3). It is therefore
necessary to ascertain what a ‘normal’ frequency of defecation is for each patient, as frequency
can vary between three times per day to once every three days[2] (#fn_2) ,[3] (#fn_3).
Constipation a�ects 1 in 7 adults and 1 in 3 children at any given time; with this symptom being
so common, it is not surprising that 66,287 patients in the UK were admitted to hospital with
constipation as the main condition (equivalent to 182 people per day) in 2014–2015[4] (#fn_4).
The incidence of constipation is two to three times higher in women than in men, and is more
common with increasing age[5] (#fn_5) ,[6] (#fn_6). It a�ects 40% of women during pregnancy;
however, this may be owing to the physiological, biochemical and dietary changes that occur
during pregnancy[5] (#fn_5) ,[6] (#fn_6).
This article outlines the symptoms, diagnosis and management options for short-term,
occasional constipation (< 5 days), including the appropriate use of stimulant laxatives in line
with new safety measures announced by the Medicines and Healthcare products Regulatory
Agency (MHRA) in August 2020[7] (#fn_7).
2 of 22 9/3/2021, 9:32 AM
Symptoms
During constipation, the lower GI tract becomes dysfunctional, giving rise to symptoms
including:
• Fewer bowel movements than normal;

• Abdominal pain;
• Cramping;
• Nausea;
• Straining during bowel movements[8] (#fn_8) ,[9] (#fn_9).
Some patients may report a sense of incomplete bowel evacuation, or excessive time spent on
the toilet owing to unsuccessful defecation[3] (#fn_3). Patients experiencing any red flag
symptoms (including rectal bleeding, mucus in stools, unexplained weight loss, sudden and
severe abdominal pain, abdominal or rectal mass, fever or a persistent change in bowel habit
for more than four weeks), as well as those who have a family history of colon cancer, ovarian
cancer or inflammatory bowel disease, or who are taking clozapine, should be referred to
urgent care immediately[10] (#fn_10) ,[11] (#fn_11).
Establishing the nature and texture of the stool, with reference to the Bristol stool chart (also
known as the Meyers scale, see Figure), will help determine how constipated the patient may
be[12] (#fn_12) ,[13] (#fn_13). Pain and discomfort from chronic constipation (i.e. having symptoms for
more than 12 weeks in the past 6 months) may have an impact on the patient’s quality of life,
particularly in older people[10] (#fn_10). Guidance from the Royal Pharmaceutical Society outlines
how pharmacy can support these patients; however, the management of chronic constipation is
outside the scope of this article[14] (#fn_14).
3 of 22 9/3/2021, 9:32 AM
Figure: Bristol stool chart
SOURCE: SHUTTERSTOCK.COM
Causes
4 of 22 9/3/2021, 9:32 AM
Constipation is often multifactorial in adults and can result from systemic or neurological
disorders, medications or other organic causes (see Table 1)[10] (#fn_10). Other contributory
factors may include pain, fever, dehydration, lack of dietary fibre and fluid intake, little or no
physical activity, psychological issues, toilet training in children and familial history of
constipation[10] (#fn_10).
Table 1. Secondary causes of constipation

Medicines Organic causes
Endocrine and metabolic disorders (e.g. diabetes,

Aluminium containing antacids hypercalcaemia, hypermagnesaemia, hypothyroidism and
hyperparathyroidism)
Iron or calcium supplements Myopathic conditions (e.g. amyloidosis)
Non-steroidal anti-
Neurological conditions (e.g. autonomic neuropathy,
inflammatory drugs (e.g.
multiple sclerosis)
ibuprofen and naproxen)
Antimuscarinics (e.g. Structural abnormalities (e.g. colonic strictures, irritable

oxybutinin) bowel syndrome, obstructive mass)
Antidepressants (e.g. tricyclic

antidepressants)
Antipsychotics (e.g. clozapine)
Antihistamine (e.g. loratadine,

cetirizine)
Antiepileptics (e.g.

carbamazepine)
Antispasmodics (e.g. hyoscine)
Diuretics (e.g. furosemide)
Calcium channel blockers (e.g.

verapamil)
Source: National Institute for Health and Care Excellence[10] (#fn_10)
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There are a range of risk factors for constipation, including:
• Behavioural factors
◦ Low fibre diet or low-calorie intake;
◦ Di�culty in accessing the toilet, or changes in normal routine or lifestyle;
◦ Lack of exercise or reduced mobility;
◦ Limited privacy when using the toilet[10] (#fn_10).
• Psychological factors
◦ Anxiety and/or depression;
◦ Somatization disorders;
◦ Eating disorders;
◦ History of sexual abuse[10] (#fn_10).
• Physical factors
◦ Female sex;
◦ Older people;
◦ Pyrexia, dehydration, immobility;
◦ Sitting position on a toilet compared with the squatting position for defecation[10] (#fn_10).
Diagnosis
Taking a thorough history from the patient can rule out many secondary causes of constipation
[15] (#fn_15)
. An assessment of stool form (see Figure) can be used to estimate the extremes of
colonic transit time, since very hard stools or loose stools correlate with slow or rapid colonic
transit, respectively[16] (#fn_16).
6 of 22 9/3/2021, 9:32 AM
Most patients will describe constipation with one or more symptoms. Symptoms commonly
include hard stools, infrequent stools (typically fewer than three times per week), a sense of an
incomplete bowel evacuation, the need for excessive straining or an excessive time spent on
the toilet[17] (#fn_17). It is important to understand the patient’s perspective and how they feel
about their symptoms when considering management.
Differential diagnosis
It is crucial that an assessment rules out other conditions that may warrant further
investigation. For example, irritable bowel syndrome (IBS) should be excluded. IBS is usually
associated with pain during defecation, change in stool frequency and/or change in stool form
[9] (#fn_9)
.
In general practice, a physical abdominal or internal rectal examination may also be performed,
which is often the most revealing part of the clinical evaluation[10] (#fn_10) ,[16] (#fn_16). When a
clinician performs an abdominal or internal rectal examination, they are trying to determine if
other issues (e.g. lesions, masses, excoriation, fissures or haemorrhoids) may be causing
symptoms[3] (#fn_3).
Management
The aim of management is to resolve symptoms and help prevent future occurrence of
constipation. This can typically be achieved by non-pharmacological measures, but treatment
can be recommended if these are ine�ective. A recent MHRA update has outlined precautions
that need to be taken when advising patients about over-the-counter measures for managing
constipation (see Box)[7] (#fn_7) ,[14] (#fn_14) ,[18] (#fn_18) ,[19] (#fn_19).
7 of 22 9/3/2021, 9:32 AM
Box: Changes to practice as a result of the Medicines and Healthcare products
Regulatory Agency safety update
Stimulant laxatives have an acceptable safety profile, have been widely used for many
years and are generally used responsibly. However, concerns have been raised regarding
the abuse, overuse and misuse of over-the-counter (OTC) stimulant laxatives (e.g. in
people with eating disorders, owing to the misconception that they can help them lose
weight, and long-term use in older people)[7] (#fn_7) ,[19] (#fn_19). Following advice from the
Commission on Human Medicines (CHM), the Medicines and Healthcare products
Regulatory Agency (MHRA) introduced a package of risk minimisation measures for OTC
stimulant laxatives in August 2020 to support correct use and minimise risk of misuse
[7] (#fn_7)
.
The following summarises the risk minimisation measures relating to stimulant
laxatives introduced by the MHRA.
General sales list stimulant laxatives
• New posology: licensed only for people aged 18 years and over;
• Revised indication: for the short-term relief of occasional constipation;
• Reduced pack sizes: standard strength tablets in a pack size of 20, maximum
strength tablets in a pack size of 10 and syrups in a pack size of 100ml;
• More prominent warnings included, which state that stimulant laxatives do not aid
weight loss[14] (#fn_14).
P stimulant laxatives
• New posology: licensed only for people aged 12 years and over;
• Revised indication: removal of indications not appropriate for self-care;
• More prominent warnings included, which state that stimulant laxatives do not aid
weight loss[14] (#fn_14).
8 of 22 9/3/2021, 9:32 AM
Updated stimulant laxative products are already available, while existing packs may
continue to be available for sale until early autumn 2020. The individual summary of
product characteristics should be consulted for more information[7] (#fn_7).
The Royal Pharmaceutical Society has produced detailed guidance for pharmacists and
pharmacy teams to support the correct use of OTC stimulant laxatives, to prevent
misuse in light of these changes and to assist in how to advise at-risk groups (e.g. people
with a potential eating disorder, older people and children)[14] (#fn_14).
First-line management: non-pharmacological
In many cases, occasional constipation is a result of poor diet and lack of exercise. The National
Institute for Health and Care Excellence (NICE) recommends first line that underlying causes
should be managed and adult patients should be given advice on appropriate dietary and
lifestyle measures (see Case study 1
(#Case_study_1_an_elderly_patient_presents_with_recurrent_constipation) )[10] (#fn_10).
A diet that is high in fibre helps normalise bowel movements by increasing the weight and size
of the stool, softening it and helping it to ‘bulk up’, making it easier to pass through the colon
[20] (#fn_20)
. Fibre also contributes to the maintenance of a healthy gut microbiota[21] (#fn_21).
Second-line management: pharmacological
If non-pharmacological intervention for the treatment of short-term constipation in adult
patients is ine�ective, or patients do not experience the desired response, NICE recommends
that oral laxatives can be o�ered using a stepwise approach:
1. O�er a bulk-forming laxative if the patient can drink adequate fluids;
9 of 22 9/3/2021, 9:32 AM
2. If the patient cannot drink adequate fluids and/or if stools remain hard or are di�cult to pass,
consider adding or switching to an osmotic laxative;
3. If stools are soft but remain di�cult to pass, then consider adding a stimulant laxative (see
Box 1 and Table 2).
Alternatively, pharmacological management can be used based on symptoms and combination
therapies considered as appropriate (see Table 2)[10] (#fn_10) ,[22] (#fn_22) ,[23] (#fn_23).
Table 2. Over-the-counter medicines for the management of short-term constipation

Symptom, drug Onset
Medicin Contraindications and additional
class and method of of
e information
action action
Ispaghul
a husk 2–3
(3.5g/sa days
Low faecal mass; bulk chet) Colonic atony, faecal impaction, intestinal
forming laxatives obstruction, opioid-induced constipation*,
Sterculi 2–3
(increases faecal palliative patients (owing to long onset of
a days
mass, stimulating action) and swallowing difficulties. Not to be
peristalsis) Methylc taken immediately before bed.
ellulose 2–3
(500mg days
tablets)
Bisacod 6—2
Slow transit;
yl (oral) hours Acute inflammatory bowel disease, intestinal
stimulant laxatives
obstruction and recent abdominal
(increases intestinal Bisacod 15 surgery.
motility**) yl minut
*Bulk-forming laxatives should be avoided in opioid-induced constipation, as it increases

stool bulk, can distend the colon and stimulate perstalsis. Opioids prevent peristalsis of
the fibe-increased bulk, which exacerbates abdominal pain and, in some cases, contributes
to bowel obstruction[23] (#fn_23). An osmotic laxative and stimulant laxative should
therefore be considered. **For short-term, when required basis only.
Sources: National Institute for Health and Care Excellence[10] (#fn_10), Electronic medicines
compendium[22] (#fn_22), Gastroenterology Res Pract
[23] (#fn_23)
10 of 22 9/3/2021, 9:32 AM
Symptom, drug Onset

e information
action action
es to
(supposi
3
tory)
hours
8–12
Senna
hours
6–12
Sodium
hours
Glycerol 15–30
supposit minut
ory es
Docusat
e 12–72
sodium hours
(oral)
Pellet stool; faecal
softeners (‘wetting’ Docusat
5–20 Has both stimulant and softening actions.
lubricants that allow e
minut Peanut allergy for arachis oil.
water to penetrate sodium
es
hard faeces) (enema)
30
Arachis
minut
oil
es
Lactulos 2–3
Hard stool; osmotic
e days
laxatives (increases Intestinal obstruction, perforation or
the amount of water inflammation.
Macrogo 2–3
in the large bowel)
l days

[23] (#fn_23)
11 of 22 9/3/2021, 9:32 AM
Symptom, drug Onset

e information
action action
Magnesi
Commonly abused but satisfactory for
um 3–6
occasional use; adequate fluid intake has to
hydroxid hours
be maintained.
e
Magnesi
um
2–4
sulphate Where rapid bowel excavation is required.
hours
(Epsom
salt)
Phospha 2–5
Used with caution in renal and cardiac
te minut
failure.
enema es

[23] (#fn_23)
Children
Children aged over 12 years who experience occasional constipation should be advised on
maintaining a balanced diet, with enough fluids and behavioural interventions, in combination
with macrogol as first-line treatment and stimulant laxatives as second line. Children aged
under 12 years with constipation should be referred to a prescriber[14] (#fn_14).
When to stop treatment
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Patients should be advised to gradually reduce and stop the use of laxatives once soft, formed
stools are produced without straining at least three times per week. Pharmacists may want to
arrange to review the patient regularly and should use clinical judgement to determine whether
the condition is resolved or whether further treatment or referral is necessary. The importance
of adhering to dietary and lifestyle recommendations should be reinforced to prevent
reoccurrence.
Case study 1: an older patient presents with

recurrent constipation
A man aged 74 years* presents to the pharmacy asking for something to help him
manage his constipation. He explains that it “comes and goes” but he was hoping to
“speed it along this time”.
Assessment
It is important to discuss the following with the patient:
• What are the symptoms?

• When did the symptoms start?
• How often has this occurred in the past?
• Has he had a change of diet, routine/lifestyle or medicine?
• Is there any pain when he uses the toilet?
• Does he ever have frequent bowel movements or diarrhoea?
• Is there any blood or mucus when he does defecate?
• Has he tried anything before to manage his symptoms?
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After the discussion, it is clear that the patient experiences these symptoms a couple of
times per year — usually during the summer months when it is hotter — but other than
that, he is “fairly regular”. He indicates that his diet and lifestyle are consistent and that
other than some stomach pain and “struggling to go”, he has no other symptoms. The
constipation started five days ago but as it usually resolves itself, he says he did not
want to “bother the pharmacist” for the first few days. However, owing to the pain he
has been experiencing, he decided it was best to come to the pharmacy for treatment.
The patient explains that he spends a lot of time in his garden, goes for regular long
walks with his wife and rarely drinks, except for a pint of beer on a Sunday afternoon.
The patient’s medication record reveals that he uses an inhaler (ipratropium) to
manage his COPD and takes 100mg sertraline daily. Both have been prescribed for the
past year and he takes them as prescribed.
Diagnosis
Since the patient has no change in lifestyle or new medication, it is likely that their
advanced age, combined with dehydration caused by the summer heat, has contributed
to the patient becoming constipated[10] (#fn_10).
Advice and recommendations
In this case it is important to explain that the symptoms are potentially a result of
dehydration because of warmer weather. The pharmacist should explain that, owing to
his age, he is more likely to suffer from constipation but he can help prevent and treat
his current symptoms by drinking plenty of water and following the National Institute
for Health and Care Excellence guidance on appropriate dietary and lifestyle measures.
These include:
• Eat plenty of high-fibre foods (30g per day; e.g. beans, vegetables, fruits, whole grain
cereals and bran);
14 of 22 9/3/2021, 9:32 AM
• Eat fewer foods with low amounts of fibre (e.g. processed foods, dairy and meat
products);
• Drink plenty of fluids;
• Avoid caffeine;
• Reduce alcohol intake and do not consume more than 14 units per week;
• Stay as active as possible and try to get regular exercise;
• Do pelvic floor exercises (refer to Bladder and bowel community
(http://www.bladderandbowel.org/) );
• Try to manage stress;
• Do not ignore the urge to pass a stool;
• Try to create a regular schedule for bowel movements, especially after a meal
[24] (#fn_24)
.
If these measures do not help, advise the patient to return to the pharmacy to discuss
other treatment options. However, caveat that if the patient has sudden or severe
abdominal pain they should seek urgent care immediately.
Case study 2: a young patient with abdominal pain
A patient aged 16 years* asks to speak to the pharmacist. She would like something to
help her go to the toilet as it has been four days and she is experiencing stomach pain.
Assessment
It is important to discuss the following points during the consultation:
• Can she describe the nature of the pain?

• Is it the first time she has had constipation?
• How does this vary from her ‘normal’?
• What is her diet like and what are her activity levels?
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• Is she experiencing any stress?

• Does she have any conditions or take any medicines or supplements (prescribed or
bought over-the-counter)?
• Has she tried anything to treat it?
• Does she have any medicines in mind?
Some people, in particular young women, may intend to use laxatives to help them lose
weight[7] (#fn_7) ,[19] (#fn_19). Owing to the potential for misuse, abuse and overuse, it is
necessary to ensure that appropriate questions are asked to rule this out — for
example, “Have you used this medicine before?” or “Are you experiencing other
symptoms (e.g. vomiting)?”. It is important to offer opportunities for them to discuss
any issues with you — for example, by asking “What other issues would you like to
discuss today?”.
The patient describes the pain as cramping but explains that she does not think it is
from menstruation as her period was more than a week ago. She cannot remember
having constipation before and usually goes to the toilet once per day. She is not
currently on any prescribed or over-the-counter medication, except moisturiser for her
eczema. The patient regularly runs and has a good diet (i.e. plenty of fibre and fluids).
She does not drink alcohol and only has a cup of tea in the morning. The patient explains
that she is not stressed and that her routine is “the same as always”. She has not tried
anything yet but says that her dad recommended senna as he had used it in the past;
however, she does not have a preference.
Diagnosis
Based on the conversation with the patient, it appears that she has uncomplicated
constipation. Owing to her age and the mention of senna, it is appropriate to consider
abuse; however, the description of symptoms and the lack of product preference
indicates that the patient does not intend to abuse laxatives.
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Recommendations
As the patient has an active lifestyle and suitable diet, it would be advisable to reinforce
these practices, but also suggest that she could take a bulk-forming laxative (e.g.
ispaghula husk). As the patient previously mentioned senna, explain to her that this is a
stimulant laxative and that, although it can be beneficial to some patients, it is not
recommended as the initial treatment for constipation.
Advise the patient that it could take up to three days for the bulk-forming laxative to
have an effect. If the bulk-forming laxative fails, advise the patient that they could then
try an osmotic laxative, such as macrogol and electrolytes (e.g. Movicol; Norgine
Limited). Clarify the directions for use (e.g. reconstitution process) and explain that she
should not take it immediately before bed and that she should avoid drinking tea and
other diuretics while the symptoms are present as it may worsen them.
If the osmotic laxative fails, the patient may need to trial a stimulant laxative; however,
if this is also ineffective after five days, then referral to her GP is recommended.
Case study 3: symptomatic during pregnancy
A pregnant woman aged 32 years* presents to the pharmacy explaining that she has had
problems “going to the toilet” and was hoping she could purchase something that would
help.
Assessment
During the consultation it is important to ask the following questions:
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• How long has she had the symptoms?

• What is regular for her?
• What other symptoms does she have?
• Is this the first time during her pregnancy that she has been constipated?
• Does she take any other medicines (prescribed or over-the-counter) or have any
other medical conditions?
• Have there been any recent lifestyle changes?
The patient explains that she is usually regular but has been struggling to go, is passing
fewer stools and experiencing irregular bowel movements. She explains her frustration
as she has recently got over some reflux. Further questioning on her reflux reveals that
she is currently using an aluminium-containing antacid to help relieve her symptoms.
She explains that it is a bit painful but more frustrating. The patient adds that her diet
is good, but she sometimes has cravings that result in her eating more dairy products.
Owing to her pregnancy, she is avoiding coffee and alcohol, but explains she didn’t drink
much of either prior to becoming pregnant. The patient is not on any prescribed
medicine and, other than the antacid she is currently using, is only taking one other
over-the-counter medicine: paracetamol (for back pain that has resulted from her
pregnancy).
Diagnosis
Although constipation is common during pregnancy, this tends to be related to difficulty
in passing stools. However, this patient appears to be having difficulties passing stools
and bowel movements appear to be less frequent than normal. The patient appears to
have medicine-induced constipation; while the aluminium containing antacid may be
effective at managing her reflux, it may be contributing to her constipation[10] (#fn_10).
Recommendations
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Advise the patient to stop using the aluminium-based antacid and to try an alternative
(e.g. a product containing a combination of calcium carbonate/sodium alginate/sodium
bicarbonate). Owing to the discomfort caused and the patient’s existing, suitable diet, it
would be appropriate to recommend a bulk-forming laxative (e.g. ispaghula husk). This is
safe for use in pregnant and breastfeeding patients. Explain that this product can take
two to three days to work and that she needs to make up the solution using sachets.
Importantly, the patient needs to understand that once the sachet is made up in water,
she must drink it as soon as possible as the drink can become ‘set’ and undrinkable as a
result. The patient should be encouraged to also increase her fluid intake while taking
the bulk-forming medicine. Explain to the patient that a common side effect is flatulence
and abdominal bloating; however, with cessation of treatment upon resolution of
constipation, this will dissipate.
If the patient continues to struggle with reflux and constipation, she should speak to her
GP.
*All cases are fictional.
Mikin Patel is lead pharmacist, gastroenterology at Imperial College Healthcare NHS Trust
References
[1] (#fn_link_1)
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[2] (#fn_link_2)
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[10] (#fn_link_10)
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[13] (#fn_link_13)
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Last updated 15 February 2021 12:40
Citation
The Pharmaceutical Journal, PJ October 2020, Vol 305, No
7942;305(7942)::DOI:10.1211/PJ.2020.20208318
22 of 22 9/3/2021, 9:32 AM

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Case-based learning: constipation in adults

It is important that pharmacists understand how to appropriately and

12 October 2020.By Mikin Patel (https://pharmaceutical-journal.com/author/mikin-patel)

during pregnancy[5] (#fn_5) ,[6] (#fn_6).

Agency (MHRA) in August 2020[7] (#fn_7).

• Fewer bowel movements than normal;

urgent care immediately[10] (#fn_10) ,[11] (#fn_11).

outside the scope of this article[14] (#fn_14).

Figure: Bristol stool chart

Table 1. Secondary causes of constipation

Endocrine and metabolic disorders (e.g. diabetes,

Iron or calcium supplements Myopathic conditions (e.g. amyloidosis)

Antimuscarinics (e.g. Structural abnormalities (e.g. colonic strictures, irritable

Antidepressants (e.g. tricyclic

Antipsychotics (e.g. clozapine)

Antihistamine (e.g. loratadine,

Antispasmodics (e.g. hyoscine)

Diuretics (e.g. furosemide)

Calcium channel blockers (e.g.

Source: National Institute for Health and Care Excellence[10] (#fn_10)

There are a range of risk factors for constipation, including:

transit, respectively[16] (#fn_16).

about their symptoms when considering management.

constipation. This can typically be achieved by non-pharmacological measures, but treatment

Box: Changes to practice as a result of the Medicines and Healthcare products

Regulatory Agency safety update

Commission on Human Medicines (CHM), the Medicines and Healthcare products

The following summarises the risk minimisation measures relating to stimulant

laxatives introduced by the MHRA.

General sales list stimulant laxatives

product characteristics should be consulted for more information[7] (#fn_7).

with a potential eating disorder, older people and children)[14] (#fn_14).

First-line management: non-pharmacological

lifestyle measures (see Case study 1

(#Case_study_1_an_elderly_patient_presents_with_recurrent_constipation) )[10] (#fn_10).

Second-line management: pharmacological

If non-pharmacological intervention for the treatment of short-term constipation in adult

that oral laxatives can be o�ered using a stepwise approach:

1. O�er a bulk-forming laxative if the patient can drink adequate ﬂuids;

consider adding or switching to an osmotic laxative;

Box 1 and Table 2).

Alternatively, pharmacological management can be used based on symptoms and combination

Table 2. Over-the-counter medicines for the management of short-term constipation

*Bulk-forming laxatives should be avoided in opioid-induced constipation, as it increases

Symptom, drug Onset

*Bulk-forming laxatives should be avoided in opioid-induced constipation, as it increases

Symptom, drug Onset

*Bulk-forming laxatives should be avoided in opioid-induced constipation, as it increases

under 12 years with constipation should be referred to a prescriber[14] (#fn_14).

When to stop treatment

of adhering to dietary and lifestyle recommendations should be reinforced to prevent

Case study 1: an older patient presents with

“speed it along this time”.

It is important to discuss the following with the patient:

• What are the symptoms?