Management of constipation

For list of formulary choice laxative see 1.6 Laxatives

Investigate patients with severe unresponsive, unexplained or alarm symptoms (such as changes in bowel habit, rectal bleeding, passing mucus, weight loss, anorexia or painful ineffective straining).

  • Laxatives are indicated in the treatment of constipation and for other conditions where bowel management is required.
  • Evidence of the comparative effectiveness of laxatives is lacking. No one class of laxative has been shown to be more effective than another.
  • A stepped approach is recommended based on cost.
  • The rectal route may be used when the oral route is ineffective or when rapid effect is necessary.
  • Prolonged treatment is not necessary except in the terminally ill when prophylaxis is necessary.
  • Review laxative treatment regularly.
Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet

Non-drug treatment of constipation

  • 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.

Acute non-obstructed constipation

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®)

Opioid induced constipation

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

Chronic constipation

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.

Lubiprostone
  • Adult over 18 years, 24 micrograms twice daily – initial duration of treatment 2 weeks
  • For use when treatment with at least 2 laxatives from different classes, at the highest tolerated recommended doses for at least 6 months, has failed to provide adequate relief and for whom invasive treatment for constipation is being considered.
  • For use in accordance with NICE TA318
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

Acute obstructed constipation and faecal impaction

See 1.6 Laxatives

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 for hard stools after a few days treatment with macrogol consider starting or adding
Bisacodyl
  • 5mg tablet, two at night
  • 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


Perioperative use

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.

Constipation in pregnancy

First-line: 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

Bulk forming laxatives (first-line)
Ispaghula husk
  • One sachet twice daily, with at least 300ml water
  • Sufficient fluid intake is important in patients taking ispaghula husk sachets.
Osmotic laxatives (second-line)
Lactulose
  • Initially 15ml twice daily
  • Adjust to patient's needs but avoid 'as required' prescriptions
Stimulant laxatives (second-line)
Glycerol suppositories
Bisacodyl
Senna
  • but avoid near term, or if a history of unstable pregnancy
Docusate sodium
  • low doses

 

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