Attitudes Toward Deprescribing Among Older Adults Seeking Care in the Emergency Department.

Clozapine is FDA approved for treatment-resistant schizophrenia and for the reduction of recurrent suicidal behavior in schizophrenia and schizoaffective disorder. Clozapine remains underused, in part due to potential adverse drug reactions such as severe neutropenia, myocarditis, and seizures. Constipation is another adverse drug reaction that may occur in at least 60% of patients treated with clozapine. Clozapine increases gastrointestinal transit time across the entire tract, with most patients having multiregional dysmotility. Although mild constipation from clozapine is not life-threatening, if left unmanaged, it may progress to bowel obstruction, ileus, or perforation. Severe cases of clozapine-induced gastrointestinal hypomotility (CIGH) have been associated with a mortality rate of 18% to 25%., This highlights the need to proactively monitor bowel status for patients prescribed clozapine to ensure adequate prevention and treatment of CIGH. There is a lack of high-quality evidence supporting the use of any one specific medication for preventing and managing CIGH, and therefore, no definitive guidelines exist. However, there are similarities between what is typically suggested for CIGH in the literature (mostly via expert opinion) and what is recommended in chronic idiopathic constipation (CIC) guidelines. The 2023 guidelines for CIC from the American Gastroenterological Association and American College of Gastroenterology suggest the use of over-the-counter (OTC) agents, including polyethylene glycol (PEG) or sennosides, as an early consideration or “attractive first-line option” due to effectiveness, availability, and low costs. These guidelines give a stronger recommendation for PEG over sennosides. Guidelines published by the American Society of Colon and Rectal Surgeons more definitively recommend osmotic laxatives (eg, PEG, magnesium salt–based products) as first-line pharmacotherapy for CIC and stimulant laxatives (eg, senna, bisacodyl) as rescue therapy or a second-line option. One caveat is that fiber supplementation (ie, bulk laxatives) is suggested first before other OTC laxatives in CIC guidelines. This approach is generally avoided in CIGH management, as bulking laxatives (eg, methylcellulose, psyllium) require adequate gastrointestinal peristalsis, which is diminished by clozapine. Thus, the use of a bulking laxative with clozapine may further worsen CIGH, especially in the setting of inadequate fluid intake. Additionally, differentiation from CIC is important, as CIGH has different underlying mechanisms and can be fatal. Although polyethylene glycol or sennosides with or without docusate are generally considered first-line options for CIGH, adherence barriers may be underrecognized. These barriers might include a lack of OTC medication coverage by a patient’s pharmacy benefit plan and the need for multiple OTC laxatives to manage CIGH, which adds complexity to a medication regimen. In general, OTC agents recommended to patients may not be formally prescribed. This places greater responsibility on a patient to obtain the medication, potentially leading to inappropriate or suboptimal use. This raises issues surrounding accessibility and adherence with OTC laxatives for the management of CIGH. A secretagogue laxative (ie, lubiprostone, linaclotide, or plecanatide), FDA approved for CIC, is recommended in CIC guidelines as a potential alternative after OTC laxative treatment failure. However, the American Society of Colon and Rectal Surgeons guidelines suggested studies with longer treatment duration are needed to determine the efficacy and safety of secretagogues or motility agents for CIC. Literature involving secretagogue laxatives for CIGH is limited to mostly descriptive reports, but a medication from this class might be a potential alternative when patients experience barriers to optimal adherence with OTC laxatives. Presented is a case series in which secretagogues were trialed to help overcome adherence and access barriers to an OTC-based bowel regimen for CIGH.