About Constipation

About Constipation

 

Constipation is a widespread condition that impacts quality of life1

Constipation is a widespread condition that impacts quality of life1

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41 million adults in the United States suffer from the discomfort of constipation each year2

millions of adults

Constipation symptoms can interrupt patients’ daily lives1

~70% of people had difficulty working, and at least 1 in 10 people missed work completely due to chronic constipation.

 

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Unresolved constipation can lead to long-term consequences3

Untreated constipation can lead to more serious health problems such as hemorrhoids, anal fissures, rectal prolapse, or fecal impaction.

Constipation is a common problem in patients with diabetes mellitus (DM)

 

75-percent-icon
roughly-75

of patients with DM report at least 1 GI symptom—the most common of which is constipation4-7

75-percent-icon

roughly-75 

of patients with DM report at least 1 GI symptom—the most common of which is constipation4-7

 

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of patients with DM have constipation4,6,7

60-percent-icon

 nearly-60-desktop

of patients with DM have constipation4,6,7

While the exact mechanism of diabetic bowel dysfunction is not known, it’s suggested that neuropathy caused by hyperglycemia affects colon motility.8

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                                                                                                          NEUROPATHY8
Hyperglycemia-induced diabetic neuropathy causes autonomic neuronal damage, nerve flow reduction, and vascular endothelium damage. Because autonomic neurons and smooth muscle are believed to regulate GI motility, diabetes increases the risk of constipation or hard stool as a result of decreased motility, bowel transmit time, and atony of the colon. Diabetic neuropathy also leads to reduced rectal sensation and impaired external sphincter function, which result in symptoms such as fecal urgency and feeling of incomplete evacuation.

NEUROPATHY8
Hyperglycemia-induced diabetic neuropathy causes autonomic neuronal damage, nerve flow reduction, and vascular endothelium damage. Because autonomic neurons and smooth muscle are believed to regulate GI motility, diabetes increases the risk of constipation or hard stool as a result of decreased motility, bowel transmit time, and atony of the colon. Diabetic neuropathy also leads to reduced rectal sensation and impaired external sphincter function, which result in symptoms such as fecal urgency and feeling of incomplete evacuation.

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In a large, hospital-based cross-sectional study including 4738 patients of whom 603 were diabetic, the authors concluded that diabetes is associated with an increased risk of8:

  • Constipation
  • Hard stools
 
  • Fecal urgency
  • Incomplete evacuation
 

Additionally, they found that the risk of these symptoms is affected by8:

  • High HbA1c levels
  • Low BMI
  • Use of insulin
  • Long duration of diabetes
  • High serum creatinine levels
 

 

These symptoms remained associated even after the exclusion of organic gastrointestinal diseases.8

In a large, hospital-based cross-sectional study including 4738 patients of whom 603 were diabetic, the authors concluded that diabetes is associated with an increased risk of8:

  • Constipation
  • Fecal urgency
  • Hard stools
  • Incomplete evacuation

Additionally, they found that the risk of these symptoms is affected by8:

  • High HbA1c levels
  • Long duration of diabetes
  • Low BMI
  • High serum creatinine levels
  • Use of insulin

 

These symptoms remained associated even after the exclusion of organic gastrointestinal diseases.8

female patients

 

Female patients are more likely than males to experience constipation9

Female patients are more likely than males to experience constipation9

Hormones, diet, supplemental iron, pregnancy, and menopause are all factors that may lead to constipation in women.10-14

pregnant
pregnant

 

 

Pregnancy is a common cause of constipation15

Pregnancy is a common cause of constipation15

Between 16% and 39% of women experience constipation during pregnancy. Constipation can occur anytime during pregnancy as soon as hormone levels increase enough to support the pregnancy. However, it is more common during the third trimester, when the fetus’ weight may put pressure on the bowel.15

 

Increased levels of progesterone during pregnancy are a likely cause of constipation. Progesterone relaxes the muscles of the bowel, slowing the passage of stool, which allows the body more time to absorb nutrients and water from foods consumed. The longer the food remains in the bowel, the longer the colon has to extract moisture, drying out the stool and making it harder to pass.15

 

Other factors that might be associated with constipation during pregnancy include decreased physical exercise and iron supplements, a common component of prenatal vitamins.15

 

Note that pregnant women are advised to talk to their doctors if they experience constipation during pregnancy to determine the best specific course of action for them.

 

Why is menopause often accompanied by constipation?

Physical changes associated with menopause affect all systems of women’s bodies, including the GI tract, often resulting in constipation.16

Hormonal

Hormonal changes17

Decline in estrogen and progesterone levels in menopause may cause changes that include constipation.

joint pain

Joint and back pain16,18,19

Clearly related to declining estrogen levels, menopausal arthralgia occurs in more than half of menopausal women. Low back pain also has an increased incidence in perimenopausal women compared with women of other ages. Inactivity that can result may reduce bowel movements and cause constipation.

Medicine

Medications20

As women age, they take more medications, including many that are known to contribute to constipation. 

 

The connection between constipation and lower urinary tract symptoms21

Constipation

An article in the Journal of Women’s Health reported that constipation was prospectively associated with increased risks of urgency and hesitancy in parous middle-aged women. The study suggests that untreated constipation could lead to the development of lower urinary tract symptoms (LUTS) in this patient population.21

View Article

Constipation

An article in the Journal of Women’s Health reported that constipation was prospectively associated with increased risks of urgency and hesitancy in parous middle-aged women. The study suggests that untreated constipation could lead to the development of lower urinary tract symptoms (LUTS) in this patient population.21

If additional research supports a causal relationship, it implies that women should seek treatment for constipation to reduce their consequent risk of developing LUTS.21

View Article

Carrie

 

Meet Carrie, who has tried lifestyle changes, but whose occasional constipation (OC) is still making her late for work.

See Carrie’s Story

See Carrie’s Story

Annie

 

Meet Annie, a sales assistant whose OC is making her job harder. She’s tried stool softeners and stimulants but ended up with cramps.

See Annie’s Story

See Annie’s Story

Jack

 

Meet Jack, whose constipation disrupts his golf games. He’s tried fiber, which just made him bloated.

See Jack’s Story

See Jack’s Story

    References

    References: 1. Johanson JF, Kralstein J. Chronic constipation: a survey of the patient perspective. Aliment Pharmacol Ther. 2007;25:599-608. doi:10.1111/j.1365-2036.2006.03238.x 2. NIH. National Institute of Diabetes and Digestive and Kidney Diseases. Definitions & facts for constipation. Accessed May 7, 2024. https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/definition-facts 3. Mayo Clinic. Constipation. Accessed May 7, 2024. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253 4. Piper MS, Saad RJ. Diabetes mellitus and the colon. Curr Treat Options Gastroenterol. 2017;15(4):460-474. doi:10.1007/s11938-017-0151-1 5. Maisey A. A practical approach to gastrointestinal complications of diabetes. Diabetes Ther. 2016;7:379-386. doi:10.1007/s13300-016-0182-y 6. Vinik AI, Erbas T. Recognizing and treating diabetic autonomic neuropathy. Cleve Clin J Med. 2001;68(11):928-930, 932, 934-944. doi:10.3949/ccjm.68.11.928 7. Vinik AI, Maser RE, Mitchell BD, Freeman R. Diabetic autonomic neuropathy. Diabetes Care. 2003;26(5):1553-1579. doi:10.2337/diacare.26.5.1553 8. Ihana-Sugiyama N, Nagata N, Yamamoto-Honda R, et al. Constipation, hard stools, fecal urgency, and incomplete evacuation, but not diarrhea is associated with diabetes and its related factors. World J Gastroenterol. 2016;22(11):3252-3260. doi:10.3748/wjg.v22.i11.3252 9. McCrea GL, Miaskowski C, Stotts NA, Macera L, Varma MG. A review of the literature on gender and age differences in the prevalence and characteristics of constipation in North America. J Pain Symptom Manage. 2009;37(4):737-745. doi:10.1016/ j.jpainsymman.2008.04.016 10. Vlitos A, Davies GJ. Bowel function, food intake and the menstrual cycle. Nutr Res Rev. 1996;9(1):111-134. doi:10.1079/NRR19960008 11. NIH. Office of Dietary Supplements. Iron. Fact sheet for health professionals. Accessed May 7, 2024. https://ods.od.nih.gov/factsheets/iron-HealthProfessional/ 12. Bradley CS, Kennedy CM, Turcea AM, Rao SSC, Nygaard IE. Constipation in pregnancy: prevalence, symptoms, and risk factors. Obstet Gynecol. 2007;110(6):1351-1357. doi:10.1097/01.AOG.0000295723.94624.b1 13. Oliveira SC, Pinto-Neto AM, Conde DM, et al. Constipation in postmenopausal women. Article in Portuguese. Rev Assoc Med Bras. 2005;51(6):334-341. 14. Rollet M, Bohn T, Vahid F. Association between dietary factors and constipation in adults living in Luxembourg and taking part in the ORISCAV-LUX 2 survey. Nutrients. 2021;14(1):122. doi:10.3390/nu14010122 15. Cleveland Clinic. Pregnancy constipation. Accessed April 28, 2024. https://my.clevelandclinic.org/health/diseases/21895-pregnancy-constipation 16. Rostami-Moez M, Masoumi SZ, Otogara M, Farahani F, Alimohammadi S, Oshvandi K. Examining the health-related needs of females during menopause: a systematic review study. J Menopausal Med. 2023;29(1):1-20. doi:10.6118/jmm.22033 17. Tack J, Müller-Lissner S, Stanghellini V, et al. Diagnosis and treatment of chronic constipation—a European perspective. Neurogastroenterol Motil. 2011;23(8):697–710. doi:10.1111/j.1365-2982.2011.01709.x 18. Magliano M. Menopausal arthralgia: fact or fiction. Maturitas. 2010;67(1):29-33. doi:10.1016/j.maturitas.2010.04.009 19. Kozinoga M, Majchrzycki M, Piotrowska S. Low back pain in women before and after menopause. Prz Menopauzalny. 2015;14(3):203-207. doi:10.5114/pm.2015.54347 20. Horn JR, Mantione MM, Johanson JF. OTC polyethylene glycol 3350 and pharmacists’ role in managing constipation. J Am Pharm Assoc. 2012;52(3):372-380. doi:10.1331/JAPhA.2012.10161 21. Alhababi N, Magnus MC, Drake MJ, Fraser A, Joinson C. The association between constipation and lower urinary tract symptoms in parous middle-aged women: a prospective cohort study. J Womens Health. 2021;30(8):1171-1181. doi:10.1089/jwh.2020.8624

    Diagnostic tools: Distinguishing occasional vs chronic constipation

    The criteria below may help when diagnosing patients1,2

    While there’s no formal definition for occasional constipation, it can include1:

    • Infrequent bowel movements
    • Difficulty in passing stool
    • Straining
    • The feeling of incomplete evacuation

    Chronic constipation is defined by Rome III criteria2:

    • Presence of 2 or more of the following symptoms:
      • Straining during ≥25% of defecations
      • Lumpy or hard stools in ≥25% of defecations
      • Sensation of incomplete evacuation for ≥25% of defecations
      • Sensation of anorectal obstruction/blockage for ≥25% of defecations
      • Manual maneuvers to facilitate ≥25% of defecations (such as digital evacuation, support of the pelvic floor)
      • Fewer than 3 bowel movements a week
    • Loose stools are rarely present without the use of laxatives
    • Criteria must have been met for the previous 3 months with symptom onset at least 6 months prior to diagnosis

    The Bristol scale describes changes in bowel movement consistency3

    The Bristol scale can be used to evaluate bowel movements and helps patients describe them in an objective and minimally embarrassing manner.

    bristol_scale
      References

      References: 1. Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013;144(1):211-217. doi:10.1053/j.gastro.2012.10.029 2. Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gasteroenterol. 2014;109(Suppl 1):S2-S26. 3. Lewis SJ, Heaton KW. Stool form scale as useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920-924. doi: 10.3109/00365529709011203

      Comparison of OTC occasional constipation treatments

      OTC laxatives work in different ways

      OTC_comparison

      Click for more details about each treatment >

      The trademarks depicted herein are owned by their respective owners.

        References

        References: 1. Hammer HF, Santa Ana CA, Schiller LR, Fordtran JS. Studies of osmotic diarrhea induced in normal subjects by ingestion of polyethylene glycol and lactulose. J Clin Invest. 1989;84(4):1056-1062. doi:10.1172/ JCI114267 2. Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25(Suppl B):16B-21B. 3. DiPalma JA, DeRidder PH, Orlando RC, et al. A randomized, placebo-controlled, multicenter study of the safety and efficacy of a new polyethylene glycol laxative. Am J Gastroenterol. 2000;95(2):446-450. doi:10.1111/j.1572-0241.2000.01765.x 4. DiPalma JA, Cleveland MB, McGowan J, Herrera JL. A comparison of polyethylene glycol laxative and placebo for relief of constipation from constipating medications. South Med J. 2007;100(11):1085-1090. doi:10.1097/SMJ.0b013e318157ec8f 5. Fiorini K, Sato S, Schlachta CM, Alkhamesi NA. A comparative review of common laxatives in the treatment of constipation. Minerva Chir. 2017;72(3):265-273. doi:10.23736/S0026-4733.17.07236-4

        Not all OTC constipation treatments offer both effective results and few side effects

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          TYPE/GENERIC NAME: OSMOTIC: POLYETHYLENE GLYCOL 3350

          BRAND1

          MiraLAX®

          HOW IT WORKS2-4

          • Works naturally by attracting water in the colon to ease, hydrate, and soften stool to relieve constipation
          • Generally produces a bowel movement in 1 to 3 days

          INDICATION1

          • Occasional constipation

          CONSIDERATIONS5

          • Works without causing harsh side effects such as gas, bloating, cramping, and sudden urgency
          • Proven safe in patients, including the elderly
          • No known clinically relevant drug-to-drug interactions
          • Patients should not use if they have kidney disease, except under the advice and supervision of a doctor
          TYPE/GENERIC NAME: SALINE: MAGNESIUM HYDROXIDE

          BRAND6:

          Phillips'® Milk of Magnesia

          HOW IT WORKS6,7:

          • Draws water into the intestine to produce a bowel movement
          • Usually produces a bowel movement in 30 minutes to 6 hours

          INDICATION6:

          • Occasional constipation

          CONSIDERATIONS6,7:

          • Patients with kidney disease, a magnesium-restricted diet, or taking prescription drugs need to consult a doctor before use
          TYPE/GENERIC NAME: STIMULANT: BISACODYL, SENNOSIDES

          BRAND8-10:

          Dulcolax® (bisacodyl), ex-lax® and Senokot® (sennosides)

          HOW IT WORKS7-10:

          • Bisacodyl and sennosides stimulate the walls of the intestine, causing the muscles to contract and clear the bowel
          • Generally produces a bowel movement in 6 to 12 hours

          INDICATION7-10:

          • Occasional constipation

          CONSIDERATIONS8-10:

          • Do not use bisacodyl within 1 hour after taking an antacid or milk
          • Sennosides may affect how other drugs work and should be taken 2 hours before or after other drugs
          TYPE/GENERIC NAME: BULK-FORMING (FIBER): PSYLLIUM HUSK

          BRAND12:

          Metamucil®

          HOW IT WORKS7,13:

          • Softens and increases the bulk of digested food, making it easier for waste to travel through and leave the body
          • Generally produces an effect in 12 to 72 hours

          INDICATION12:

          • Occasional constipation

          CONSIDERATIONS7,12:

          • Can ferment in the intestine, which may cause gas and bloating
          • May affect how well other medicines work and should be taken at least 2 hours before or after prescribed medication
          TYPE/GENERIC NAME: STOOL SOFTENER: DOCUSATE SODIUM

          BRAND14,15:

          Colace®, Phillips'® Stool Softener

          HOW IT WORKS7,14:

          •  Allows water and fats to get into the stool. This helps soften fecal material and makes defecation easier
          • Generally produces an effect in 12 to 72 hours

          INDICATION14,15:

          • Occasional constipation

          CONSIDERATIONS7:

          • Does not force passing of bowel movements
            References

            References: 1. MiraLAX® Drug Facts, Bayer Healthcare.2. Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25(Suppl B):16B-21B. 3. Schiller LR, Emmett M, Santa Ana CA, Fordtran JS. Osmotic effects of polyethylene glycol. Gastroenterology. 1988;94(4):933-941. doi:10.1016/0016-5085(88)90550-1 4. Hammer HF, Santa Ana CA, Schiller LR, Fordtran JS. Studies of osmotic diarrhea induced in normal subjects by ingestion of polyethylene glycol and lactulose. J Clin Invest. 1989;84(4):1056-1062. doi:10.1172/JCI114267 5. DiPalma JA, DeRidder PH, Orlando RC, et al. A randomized, placebo-controlled, multicenter study of the safety and efficacy of a new polyethylene glycol laxative. Am J Gastroenterol. 2000;95(2):446-450. doi:10.1111/j.1572-0241.2000.01765.x 6. Phillips® Milk of Magnesia Drug Facts. Bayer Consumer Health. 7. Fiorini K, Sato S, Schlachta CM, Alkhamesi NA. A comparative review of common laxatives in the treatment of constipation. Minerva Chir. 2017;72(3):265-273. doi:10.23736/S0026-4733.17.07236-4 8. Dulcolax® Laxative Tablets Drugs Facts. Chattem, Inc. 9. ex-lax® Regular Strength Drug Facts. GSK. 10. Senokot (sennosides) Drug Summary. Accessed December 5, 2022. https://pdr.net/drug-summary/Senokot-sennosides-3182.84 11. Dulcolax. December 5, 2022. https://www.drugs.com/dulcolax.html 12. Metamucil Psyllium Fiber Supplement. Accessed December 5, 2022. https://www.metamucil.com/en-us/products/fiber-powders/sugar-free- orange-smooth 13. Metamucil FAQs. Accessed December 5, 2022. https://www.metamucil.com/en-us/faqs/metamucil-faqs 14. Colace® Regular Strength Product Information. Accessed December 5, 2022. https:// www.colacecapsules.com/products/colace-regular-strength/ 15. Phillips® Stool Softener Liquid Gels Drug Facts. Bayer Consumer Health.

            The trademarks depicted herein are owned by their respective owners.

            Medications that may cause constipation

            Many commonly used medications have constipation as a side effect. Depending on patients' existing medical concerns, some current treatment regimens may be the cause of their constipation symptoms

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              ANTACIDS1,2

              PRIMARY USE

              Relieve heartburn

              ACTIVE INGREDIENT

              Aluminium hydroxide

               

              ANTICONVULSANTS3

              PRIMARY USE

              Control epilepsy and other seizure disorders

              ACTIVE INGREDIENT

              Divalproex sodium

               

              ANTIHYPERTENSIVES4

              PRIMARY USE

              Lower blood pressure

              ACTIVE INGREDIENT

              Clonidine

               

              ANTI-PARKINSON’S AGENTS5

              PRIMARY USE

              Relieve symptoms of Parkinson’s disease

              ACTIVE INGREDIENT

              Levodopa, carbidopa

               

              ANTIPSYCHOTICS6-8

              PRIMARY USE

              Treat symptoms of psychosis

              ACTIVE INGREDIENT

              Haloperidol, clozapine, risperidone

               

              ANTISPASMODICS9-11

              PRIMARY USE

              Decrease intestinal cramps, control overactive bladder

              ACTIVE INGREDIENT

              Dicyclomine hydrochloride, oxybutynin chloride, tolterodine tartrate

               

              BILE ACID SEQUESTRANTS12

              PRIMARY USE

              Reduce cholesterol

              ACTIVE INGREDIENT

              Colestipol hydrochloride

               

              CALCIUM SUPPLEMENTS13

              PRIMARY USE

              Treat calcium deficiency

              ACTIVE INGREDIENT

              Calcium carbonate

               

              CHEMOTHERAPY AGENTS14,15

              PRIMARY USE

              Treat cancer

              ACTIVE INGREDIENT

              Pemetrexed disodium, carboplatin

               

              DIURETICS16-18

              PRIMARY USE

              Lower blood pressure, promote excretion of water

              ACTIVE INGREDIENT

              Furosemide, spironolactone, hydrochlorothiazide, triamterene

               

              GLP-1 RECEPTOR AGONISTS19

              PRIMARY USE

              Manage type 2 diabetes; weight loss

              ACTIVE INGREDIENT

              Semaglutide, liraglutide

               

              IRON SUPPLEMENTS20

              PRIMARY USE

              Iron deficiency anemia

              ACTIVE INGREDIENT

              Ferrous sulfate

               

              OPIOIDS21-24

              PRIMARY USE

              Relieve pain

              ACTIVE INGREDIENT

              Morphine sulfate, codeine phosphate, oxycodone hydrochloride

               

              This represents a small sample of brand name products, some of which may no longer be available. The trademarks depicted in this table are the property of their respective owners.

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              miralax-bottle

               

               

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                References

                References: 1. Aluminum hydroxide; magnesium hydroxide; simethicone. Accessed May 7, 2024. https://my.clevelandclinic.org/health/drugs/19931-aluminum-hydroxide-magnesium-hydroxide-simethicone-oral-suspension 2. Gaviscon® Tablets. Accessed May 7, 2024. https://www.gaviscon.com/products/tablets.html 3. Depakote®. Prescribing information. Abbvie Inc.; 2021. 4. Catapres-TTS®. Prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc.; 2011. 5. Rytary. Prescribing information. Amneal Pharmaceuticals LLC; 2019. 6. Haldol®. Package insert. Ortho-McNeil Pharmaceutical, Inc.; 2009. 7. Clozaril®. Prescribing information. Novartis Pharmaceuticals Corporation; 2020. 8. Risperdal® Consta®. Prescribing information. Ortho-McNeil-Janssen Pharmaceuticals, Inc.; 2010. 9. Bentyl®. Prescribing Information. Axcan Pharma US, Inc.; 2011. 10. Ditropan XL®. Prescribing information. Janssen Pharmaceuticals, Inc.; 2016. 11. Detrol® LA. Prescribing information. Pharmacia & Upjohn Company; 2018. 12. Colestid®. Package insert. Pharmacia & Upjohn Company; 2017. 13. Saljoughian M. Pros and cons of calcium supplements. US Pharm. 2015;40(9):HS-28-HS-32. Accessed April 23, 2024. https://www.uspharmacist.com/article/pros-and-cons-of-calcium-supplements 14. Alimta. Prescribing information. Eli Lilly and Company; 2004. 15. Paraplatin®. Package insert. Bristol-Myers Squibb Company; 2010. 16. Furosemide. Package insert. Hospira, Inc.; 2016. 17. Aldactazide®. Package insert. G.D. Searle; 2014. 18. Dyazide. Prescribing information. GlaxoSmithKline; 2020. 19. Wharton S, Davies M, Dicker D, et al. Managing the gastrointestinal side effects of GLP-1receptor agonists in obesity: recommendations for clinical practice. Postgrad Med. 2022;134(1):14-19. doi:10.1080/00325481.2021.2002616 20. Slow Fe® Drug Facts. GSK. 21. MS Contin®. Prescribing information. Purdue Pharma L.P.; 2016. 22. Butalbital, Acetaminophen, Caffeine, and Codeine Phosphate. Prescribing information. Teva Pharmaceuticals USA, Inc.; 2019. 23. Percocet®. Package insert. Par Pharmaceutical; 2020. 24. OxyContin®. Prescribing information. Purdue Pharma L.P.; 2018.