Author: Dr. Ron Gazze, MD

Tried and true approach to getting rid of constipation in people who have to be on an extended opiate for pain following surgery, and accident, etc. There is a usual 7-pronged approach:

1) Increase physical activity as much as tolerated/allowed.

2) Increase hydration with Pedialyte and DripDrop as much as tolerated.

3) Take more citrus fruits and/or the dietary fiber supplement Citrucel.

4) Use Miralax at least once daily until it resolves.

5) Use the stool softener Colace (docusate sodium) as directed for two days and then use a stimulant laxative (Senokot, Dulcolax, or MagCitra) as directed for 3 days (no more). Repeat the cycle as needed.

6) Maximize NSAID dose and continue it for 2 weeks—always with food. Examples would be Rx diclofenac twice per day, Rx celecoxib twice per day, 2-3 OTC Aleve twice per day, or 3-4 OTC ibuprofen 3-4 X per day. Also, consider non-pharmacological pain relief such as acupuncture. Then, stop the opiate as soon as you possibly can, which doesn’t usually take long once you have maximized NSAIDs, acupuncture, etc.

7) If that plan is not working (uncommon), then contact your surgery team or us and inquire about complicated, aggressive, and expensive medicines such as Mu-opioid receptor antagonists.
It also helps to follow the usual “Gazze 1-7 supplement list” as closely as possible. Things like having more calcium, magnesium, iron, vitamin C, fish oils, etc. helps the pain to go away a lot faster.

For chronic Neuro-Immune issues in most adults, here is a reminder of that list and some good general nutritional recommendations in my opinion:

1) I try to get B-12 levels at or above the top of normal (1000-2000)–especially if folic acid or B-6 levels or intake are also in the higher part of the range. Doing so usually requires 2000-6000 mcg of B-12 every morning. For people having absorption trouble despite those doses, I use methylcobalamin. I try to keep B-6 supplements at or below 25 mg except for short bursts during special circumstances.

2) I like to get/keep 25-OH vitamin D levels in the 55-80 range as long as calcium is not high and PTH is not low. I very rarely supplement more than 10,000 units daily. It usually takes about 1000 units of extra vitamin D3 to raise levels about 5-10 points, so those who start around 30 usually need about 3000-10,000 units daily.

3) I recommend to use a combination of diet (and maybe fish-oil supplements, including Rx Lovaza and others) to get 4000 mg of DHA+EPA daily divided between several meals.

4) I recommend 200-400 mg of CoEnzyme Q10 daily with a meal.

5) I recommend other “good fats” through regular small amounts of several of these things–fatty fish (salmon, white tuna, black cod/sablefish, kingfish, halibut, trout, herring, anchovies/sardines, others), algae/seaweed, olive/canola oils, almonds/walnuts, soy products, avocado, many fibrous vegetables (kale, yams, okra, turnips, parsnips, others) and many exotic fruits (banana, kiwi, blueberry, acai, mangosteen, pomegranate, coconuts, others). I vary the seafood sources to help avoid potential heavy-metal toxicity, but do not use farm-raised.

6) Keeping hydration and electrolytes at IDEAL (not simply “normal”) levels. Specifically for hydration, I like to keep the BUN/Cr ratio 10-14 with a low urine specific gravity and a urine pH of 7 if possible. That involves regular increases in water and sports drinks while backing-off caffeine, tea, alcohol. Specifically for calcium, I like to be sure that the daily ELEMENTAL calcium from diet/supplements is at least 1200 mg daily (UNLESS the serum calcium is abnormally high). I try to keep iodine levels mid-normal (100-300 in random urine) so that there’s plenty for the thyroid and other systems.

7) Keeping iron stores at ideal levels (HGB 14-16, ferritin around 200, and ZPP below 35). It also takes vitamin C in the stomach/intestine at the same time to be able to absorb and use iron well. I often help with supplements: OTC Nature’s Bounty Gentle Iron, Rx Ferralet-90, or Rx Multigen Plus.

About the Author:

Dr. Ron Gazze, MD is the executive medical director for NEE/FPL where he is responsible for providing primary care and coordinating other medical care for many of the corporation’s leaders and team members with complex cases. He is also the corporate medical subject matter expert which includes his involvement with the pandemic team. Dr. Gazze first saw patients within the corporation in 2004.  Prior, Dr. Gazze served as a hospitalist in what is now the Excela system in Western Pennsylvania, as  a medical director for a United States Veteran’s Administration Community-Based Outpatient Clinic (VA CBOC) in Washington, PA through Sterling Medical, filled various per diem roles related to his UPMC residency, taught/wrote/edited for The Princeton Review, helped to develop medical board examinations for the Educational Commission for Foreign Medical Graduates (ECFMG), served as a research assistant at Thomas Jefferson University (TJU), and served as teaching assistant at the Pennsylvania State University (PSU).

Dr. Gazze holds a Bachelor of Science degree in Premedicine from the Pennsylvania State University (PSU) where he also was a non-degree graduate student in Physiology, and a Doctor of Medicine degree from Jefferson Medical College of Thomas Jefferson University (TJU) in Philadelphia. He completed his internship at the Mayo Clinic  in Mayo-Scottsdale and his Family Medicine residency at the University of Pittsburgh Medical Center (UPMC) of St. Margaret Hospital.

Dr. Gazze represented Mayo Clinic at the Arizona Academy of Family Practice. While at TJU, he was the President of the Hobart Amory Hare Honor Medical Society and a regional leader of Students Teaching AIDS to Students (STATS).  While at PSU, he was appointed to the Peer Counselor program for their Eberly College of Science.

Dr. Gazze was born and raised in Pennsylvania.  He now lives in Palm Beach County, Florida with two teen-aged daughters and his long-term significant other.  He is board-certified in Family Medicine.  His personal interest is diagnostic dilemmas and the resolution of complex medical problems, with a preference for concierge-style practice.