Çocukluk Çağında Fonksiyonel Kabızlık Tedavisi: Senna, Trimebutin ve Laktülozun Karşılaştırılması

Öz

Amaç: Çocukluk çağında kabızlık yaygın olup sıklıkla fonksiyoneldir. Çocuklarda fonksiyonel kabızlık tedavisinde kullanılan ilaçlarla ilgili bilgiler sınırlıdır. Amacımız fonksiyonel kabızlık (FK) veya fonksiyonel fekal inkontinans (FFİ) olan çocuklarda senna, trimebutin ve laktülozun etkinliğini değerlendirmektir.  

Gereç ve Yöntemler: Roma III kriterlerine göre fonksiyonel kabızlık (FK) veya fonksiyonel fekal inkontinans (FFI) tanısı koyulan, laktüloz (n=36), senna (n=29) ve trimebutin (n=33) tedavisi alan hastalar (2-18 yaş) alındı. Hastalar semptomlarıyla ilgili 0-5 Likert anket ölçeğini doldurdular. Dışkı kıvamı (DK) Bristol Dışkı Skalasına göre değerlendirildi. Tedaviye uyum, tolerans ve yan etkiler kaydedildi. Klinikteki düzelme (KD) değerlendirildi,  farmakoekonomik inceleme yapıldı. 

Bulgular: Senna grubundaki KD anlamlı ölçüde yüksekti (p=0.036). Senna DK'da en fazla iyileşme sağladı (p<0.001) ve fekal inkontinansı azalttı (p=0.039). Karında distansiyon, karın ağrısı, bulantı/kusma ve anal fissür trimebutinle düzeldi (p<0.05). Senna ve trimebutin ağrılı defekasyonu ve dışkı tutmayı azalttı. Laktüloz iştahsızlık ve anal fissürü iyileştirdi. Senna en fazla maliyet etkinliği olan ilaçtı.

Tartışma: Kabızlık için tedavi seçenekleri ağırlıklı görülen semptoma göre dizayn edilmelidir. Senna obesite ve/veya fekal inkontinans olan çocuklarda başlangıç tedavisi olarak önerilebileceği gibi, trimebutin karında distansiyon, karın ağrısı, bulantı/kusma veya anal fissür olanlarda, laktüloz iştahsızlık veya anal fissür olanlarda ayrı olarak seçilebilir. 

Anahtar Kelimeler

• Kabızlık,Laktüloz,Senna,Trimebutin

Treatment of Childhood Functional Constipation: Comparison of Senna, Trimebutine and Lactulose

Öz

Objective: Childhood constipation is common and usually functional. Data for the drugs used in maintenance therapy of functional constipation is limited in childhood. Our aim was to evaluate the efficacy of senna, trimebutine and lactulose in children with functional constipation (FC) or functional fecal incontinence (FFI).

Material and Methods: Patients  (2-18 years old) diagnosed as FC or FFI according to Rome III criteria who were treated with lactulose (n=36), senna (n=29) and trimebutine (n=33)were included. Patients completed a 0-5 Likert scale questionnaire about their symptoms. Stool consistency (SC) was evaluated by Bristol Stool Chart. Compliance and tolerance to treatment and side effects were recorded. Clinical improvement (CI) and pharmacoeconomic evaluation were performed.

Results: CI in the senna group was significantly higher (p=0.036). Senna showed the highest improvement in SC (p<0.001) and decreased fecal incontinence (p=0.039). Abdominal distention, abdominal pain, nausea/vomiting and anal fissure were improved by trimebutine (p<0.05). Both senna and trimebutine decreased painful defecation and stool witholding. Lactulose improved anorexia and anal fissure. Senna was the most cost-effective drug. Conclusion: Treatment options for constipation should be tailored according to the predominant symptom. Senna may be recommended as the initial treatment for children with obesity and/or fecal incontinence, trimebutine in patients with abdominal distention,  abdominal pain,  nausea/vomiting or anal fissure, lactulose in patients with anorexia or anal fissure, respectively.

 

Anahtar Kelimeler

• Constipation,Lactulose,Senna,Trimebutin

Kaynakça

1. van der Wal MF, Benninga MA, Hirasing RA. The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr 2005; 3: 345-8.
2. de Araújo Sant'Anna AM, Calçado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Pediatr Gastroenterol Nutr 1999; 29: 190-3.
3. Bardisa-Ezcurra L, Ullman R, Gordon J; Guideline Development Group. Diagnosis and management of idiopathic childhood constipation: summary of NICE guidance. BMJ 2010; 340: c2585.
4. Afzal NA, Tighe MP, Thomson MA. Constipation in children. Ital J Pediatr 2011; 37: 28.
5. Xinias I, Mavroudi A. Constipation in Childhood. An update on evaluation and management. Hippokratia 2015; 19: 11-9.
6. Paré P, Fedorak RN. Systematic review of stimulant and nonstimulant laxatives for the treatment of functional constipation. Can J Gastroenterol Hepatol 2014; 28: 549-57.
7. Perkin JM. Constipation in childhood: a controlled comparison between lactulose and standardized senna. Curr Med Res Opin 1977; 4: 540-3.
8. Alsalimy N, Madi L, Awaisu A. Efficacy and safety of laxatives for chronic constipation in long-term care settings: A systematic review. J Clin Pharm Ther 2018; 43: 595-605.

9. Sondheimer JM, Gervaise EP. Lubricant versus laxative in the treatment of chronic functional constipation of children: a comparative study. J Pediatr Gastroenterol Nutr 1982; 1: 223-6.
10. Connolly P, Hughes IW, Ryan G. Comparison of "Duphalac" and "irritant" laxatives during and after treatment of chronic constipation: a preliminary study. Curr Med Res Opin 1974-1975; 2: 620-5.
11. Delvaux M, Wingate D. Trimebutine: mechanism of action, effects on gastrointestinal function and clinical results. J Int Med Res 1997; 25: 225-46.
12. Poynard T, Naveau S, Mory B, Chaput JC. Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol T 1994; 8: 499-510.
13. Karabulut GS, Beşer OF, Erginöz E, Kutlu T, Cokuğraş FÇ, Erkan T. The Incidence of Irritable Bowel Syndrome in Children Using the Rome III Criteria and the Effect of Trimebutine Treatment. J Neurogastroenterol Motil 2013; 19: 90-3.
14. Schang JC, Devroede G, Pilote M. Effects of trimebutine on colonic function in patients with chronic idiopathic constipation: evidence for the need of a physiologic rather than clinical selection. Dis Colon Rectum 1993; 36: 330-6.
15. Candelli M, Nista EC, Zocco MA, Gasbarrini A. Idiopathic chronic constipation: pathophysiology, diagnosis and treatment. Hepatogastroenterology 2001; 48: 1050-7.
16. Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W, et al. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1999; 29: 612-26.
17. Passmore AP, Wilson-Davies K, Stoker C, Scott ME. Chronic constipation in long stay elderly patients: a comparison of lactulose and a senna-fibre combination. BMJ 1993; 6907: 769-71.
18. Wagner C, Equit M, Niemczyk J, von Gontard A. Obesity, overweight, and eating problems in children with incontinence. J Pediatr Urol 2015; 11: 202-7.
19. Tan W, Zhang H, Luo HS, Xia H. Effects of trimebutine maleate on colonic motility through Ca²+-activated K+channels and L-type Ca²+ channels. Arch Pharm Res 2011; 34: 979-85.
20. Üstündağ G, Kuloğlu Z, Kirbaş N, Kansu A. Can partially hydrolyzed guar gum be an alternative to lactulose in treatment of childhood constipation? Turk J Gastroenterol 2010; 4: 360-4.
21. Jarzebicka D, Sieczkowska-Golub J, Kierkus J, Czubkowski P, Kowalczuk-Kryston M, Pelc M, et al. PEG 3350 Versus Lactulose for Treatment of Functional Constipation in Children: Randomized Study. J Pediatr Gastroenterol Nutr 2019; 68: 318-324.
22. Kinnunen O, Salokannel J. Constipation in elderly long-stay patients: its treatment by magnesium hydroxide and bulk-laxative. Ann Clin Res 1987; 19: 321-3.
23. van Ginkel R, Benninga MA, Blommaart PJ, van der Plas RN, Boeckxstaens GE, Büller HA, et al. Lack of benefit of laxatives as adjunctive therapy for functional nonretentive fecal soiling in children. J Pediatr 2000; 137: 808-13.
24. Gremse DA, Hixon J, Crutchfield A. Comparison of polyethylene glycol 3350 and lactulose for treatment of chronic constipation in children. Clin Pediatr (Phila) 2002; 41: 225-9.
25. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr 2009; 154: 258-62.
26. Wald A. Constipation: Advances in Diagnosis and Treatment. JAMA 2016; 315: 185-91.