• Increase fibre intake gradually to 18 - 30g daily for an adult. This may not be appropriate for immobile or elderly patients or those with mega colon. Although the effects of a high fibre diet may be seen in a few days, it may take as long as 4 weeks.
• Increase fluid intake to 2 litres a day if medically appropriate.
• Increase mobility if possible.
• Review medication to identify constipating medicines, e.g. antacids containing aluminium, antidiarrhoeals, antimuscarinics, iron, opioids, tricyclics, verapamil.
• Check sitting position on toilet. The patient should sit with feet firmly planted on a solid surface. The knees should be on a level with or slightly higher than the hips and a footstool may be required to achieve this.

Adjust any constipating medication if possible.

Give advice on non-drug treatments (see above).

Laxatives can be stopped once the stools become soft and easily passed again.

See 1.6 Laxatives

Ispaghula husk

• One sachet twice daily, with at least 300ml water
• Sufficient fluid intake is important in patients taking ispaghula husk sachets, in particular the elderly

If stools remain hard add or switch to

Macrogol Compound oral powder

• Usually 1 sachet once or twice daily in 125ml water

Lactulose

• Use if macrogols ineffective or not tolerated
• Initially 15ml twice daily
• Adjust to patient's needs but avoid 'as required' prescriptions

If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying

Bisacodyl

• 5mg tablet, two at night
• 10mg suppository in the morning

Senna

• 2-4 tablets at night

If ineffective, add

Docusate sodium

• 200mg orally twice daily

Sodium citrate micro-enemas (Micolette micro-enema)

Avoid bulk-forming laxatives, use an osmotic laxative and a stimulant laxative

See 1.6 Laxatives

Macrogol Compound oral powder

• Usually 1 sachet once or twice daily in 125ml water

Bisacodyl

• 5mg tablet, two at night
• 10mg suppository in the morning

Senna

• 2-4 tablets at night

Docusate

• 200mg orally twice daily

Lactulose

• Use if macrogols ineffective or not tolerated
• Initially 15ml twice daily
• Adjust to patient's needs but avoid 'as required' prescriptions

Patients with chronic constipation may be referred to the Bladder and Bowel Care Service:

• North Devon: 01769 575182
• East Devon: 01392 208478

Adjust any constipating medication if possible. Give advice on non-drug treatments (see above).

See 1.6 Laxatives

Ispaghula husk

• One sachet twice daily, with at least 300ml water
• Sufficient fluid intake is important in patients taking ispaghula husk sachets, in particular the elderly.

If ineffective, add or switch to

Macrogol Compound oral powder

• Usually 1 sachet once or twice daily in 125ml water

Lactulose

• Use if macrogols ineffective or not tolerated
• Initially 15ml twice daily
• Adjust to patient's needs but avoid 'as required' prescriptions

If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying- add stimulant laxative

Bisacodyl

• 5mg tablet, two at night
• 10mg suppository in the morning

Senna

• 2-4 tablets at night

Docusate

• 200mg orally twice daily

Adjust the dose, choice, and combination of laxative according to symptoms, speed with which relief is required, response to treatment, and individual preference.

The dose of laxative should be gradually titrated upwards (or downwards) to produce one or two soft, formed stools per day.

Lecicarbon A suppositories

• Insert one suppository when required. If necessary, this can be repeated after 30-60 minutes
• Approximately 50% of patients achieve bowel evacuation after insertion of a suppository
• A trial of lecicarbon A suppositories would be considered as an alternative to options, such as rectal irrigation, in patients for whom conservative management and the use of other established laxatives were not effective (see commissioning policy)

Prucalopride

• Licensed for treatment of women
• Adults (18 to 65 year): 2mg once daily
• Elderly (over 65 years): 1mg once daily, increased if necessary to 2mg
• If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months, consider the use of prucalopride in women only
• Only to be used as per NICE TA211

See 1.6 Laxatives

For hard stools start

Macrogol Compound oral powder

• Eight sachets should be dissolved in exactly 1 litre water and drunk within 6 hours. Maximum length of treatment is 3 days. Patients with cardiac problems should not exceed 250ml (the contents of 2 sachets) in any one hour.

For soft stool, or if stools still hard after a few days treatment with macrogol consider starting or adding

Bisacodyl

• 5mg tablet, two at night or
• 10mg suppository in the morning

Senna

• 2-4 tablets at night

If response to oral laxatives is insufficient or not fast enough, consider

Reinforce advice about the role of diet, fluid intake, and exercise in maintaining regular bowel movements and preventing problems from recurring.

Bisacodyl suppositories

Glycerol suppositories

Phosphate enema

Bowel Preparation

NPSA Rapid Response Report: Reducing risk of harm from oral bowel cleansing solutions (2009): All clinical responsibility (to include assessment, prescribing and provision of an explanation on the safe use of the medicine) lies with the clinician authorising the surgery or investigation.

Depending on procedure and surgeon's preference the following may be used.

Klean-Prep

• Usually one sachet in the morning of the day before the procedure followed by a further dose in the evening.
• Clear fluids only once regime has commenced.

Moviprep

• Usually one sachet in the morning of the day before the procedure followed by a further dose in the evening.
• Clear fluids only once regime has commenced.
• Can be taken with a smaller volume of fluid than Klean-Prep.

Picolax

• Usually one sachet in the morning of the day before the procedure followed by a further dose in the evening.
• Clear fluids only once regime has commenced.

Phosphate enema

• Usually one in the morning of the day before the procedure followed by a further dose in the evening.
• For haemorrhoidectomy, one evening dose may be considered appropriate.

Post-operative

• Choice will depend upon the procedure and individual circumstances.
• Following operations involving the anus the use of osmotic laxatives is preferred.

First-line: Provide advice about lifestyle measures (diet, fluid intake, regular light moderate exercise)

If there is insufficient response to the above measures consider the following:

See 1.6 Laxatives

Second line, add bulk forming laxatives

Ispaghula husk

• One sachet twice daily, with at least 300ml water
• Sufficient fluid intake is important in patients taking ispaghula husk sachets.

Third line, add osmotic laxative or stimulant laxative

Lactulose

• Initially 15ml twice daily
• Adjust to patient's needs but avoid 'as required' prescriptions

OR

Glycerol suppositories

Bisacodyl

Senna

• but avoid near term, or if a history of unstable pregnancy

Docusate sodium

• low doses