GGC Medicines


Adult Therapeutics Handbook

Management of Constipation

Management of Constipation

Introduction

This guideline applies to patients who are initiated on laxatives during their hospital stay or to patients who are not responding to their current laxative therapy. Laxatives are contraindicated in patients with intestinal obstruction and if suspected refer to specialist surgical team.

Assessment / monitoring

Identify possible causes:

  • Underlying disease e.g. hypothyroidism, hypercalcaemia.
  • Mechanical obstruction e.g. rectal tumour.
  • Immobility / dehydration e.g. stroke / diabetes mellitus.
  • Drugs, e.g.:
    • Opiates (including co-codamol and dihydrocodeine)
    • Anticholinergics (tricyclic antidepressants, oxybutynin)
    • Verapamil
    • Aluminium containing antacids
    • Iron and calcium containing preparations.

Check

  • Serum U&Es
  • Creatinine
  • Calcium
  • Thyroxine (T4)
  • Glucose

General management

Rectal examination

  • Hard faeces – prescribe a faecal softener e.g. lactulose (for more laxative choice see tables below).
  • Soft faeces – prescribe a stimulant laxative e.g. senna (for more laxative choice see tables below)
  • Impaction – for enema e.g. sodium citrate micro-enema or phosphate enema (for more laxative choice see tables below)
  • Empty rectum – suspect obstruction and obtain plain abdominal x-ray.

Patient education

  • Increase dietary fibre (bran, fruit, vegetables).
  • Increase mobility.
  • Ensure adequate fluid intake (especially if on bulk forming laxative e.g. ispaghula husk, or high fibre diet).

Drug therapy / treatment options

Acute constipation

Constipation of recent onset due to a period of illness or immobility, drug therapy, changes in diet or fluid intake. Laxatives should only be given for short-term use.

Laxative and dose Notes
Senna, 2–4 tablets at night Liquid preparation also available: 10ml senna liquid = 2 senna tablets.
Or
Glycerol suppositories, 4g PR daily Moisten suppositories with water for ease of insertion.

Chronic constipation

Requires long-term management.

Laxative and dose Notes
Ispaghula husk (Fybogel®), 1 sachet twice daily Ensure adequate fluid intake. If ineffective after several days add senna 2–4 tablets at night (short-term only).
Or
Lactulose, 15ml twice daily regularly Use if above option is not effective / appropriate.
+/- Senna, 2 tablets at night  
Or
Macrogol Oral Powder (Laxido Orange®), 1–3 sachets daily Use if above options are not effective/ appropriate. Ensure adequate fluid intake.
+/- Senna, 2 tablets at night  

Opioid-induced constipation

Laxative and dose Notes
Senna, 2 tablets at night -
and either
Lactulose, 15ml twice daily regularly -
Or
Sodium docusate 100–500mg daily -
Or
Co-danthramer capsules, 1–2 at night or co-danthramer liquid, 5–10ml at night For terminally ill patients only. Titrate dose upwards as necessary.

Rectal impaction

In some cases of rectal impaction, manual evacuation may be required. Seek advice from senior medical staff.

Laxative and dose Notes
Bisacodyl suppository AND glycerol suppository (1 of each) -
Sodium citrate microenema, 1 at night -
If no result, followed by:
Phosphate enema, 1 in the morning Do not use more than twice a day.
Arachis oil retention enema, 1 as a single dose Avoid if nut allergy.
If no result, followed 6 - 8 hours later by:
Sodium citrate microenema, 1 as a single dose -
Or
Phosphate enema, 1 as a single dose -
Macrogol Oral Powder (Laxido Orange®), 8 sachets daily for up to 3 days** For use in resistant cases of impaction. Ensure adequate fluid intake
**May not be possible to use this dose in the frail elderly.

Note: Patients unable to swallow, but with a nasogastric or RIG/PEG tube in situ can have certain laxative preparations administered via the tube. Contact ward clinical pharmacist for details.

In patients with moderate to severe irritable bowel syndrome with constipation who have not responded to, or cannot tolerate all other suitable treatment options, consider linaclotide 290microgram once daily as a one month trial.