Constipation

Prescribing Notes:

• The choice of treatment for constipation depends on the severity of the presentation and other factors including drug history, diet and lifestyle.
• Treatment should be reviewed once normal bowel habit is restored.
• It may be appropriate to continue treatment if the precipitator is immobility, drug induced or other continuing factors.
• Stimulant laxatives should only be used if other laxatives (bulk-forming and osmotic) are ineffective - August 2020 MHRA advice provides more detail.
• Stimulant laxatives become less effective with long-term use. Chronic use is not generally appropriate other than for the treatment of opioid induced constipation.
• If rectum is full on examination or there is difficulty in evacuation, consider glycerol or bisacodyl suppositories.
• Stimulant laxatives should be avoided in intestinal obstruction and in the elderly in the presence of faecal impaction.
• Senna has an onset of action of 8-12 hours. It is particularly useful where a rapid effect is required or where stools are soft, but difficult to pass or the patient complains of inadequate emptying.
• Glycerol suppositories have a rapid effect (15-30 mins.) and can be used for hard or soft stools. They are suitable for acute moderate-to-severe constipation.
• Bulk-forming laxatives such as ispaghula husk take several days to work and are useful in chronic, simple constipation.
• Bulk forming laxatives should be avoided in opioid induced constipation and in patients with faecal impaction.
• Osmotic laxatives, such as lactulose or macrogol, are not appropriate for as required use. They make take 48 hours to take effect. Cautious use in patients who have restricted fluid intake.
• Lactulose is relatively expensive and is frequently prescribed inappropriately. Lactulose should not be used routinely in the elderly and should be avoided if the stool is already soft.

Prescribing Notes:

• The choice of treatment for constipation depends on the severity of the presentation and other factors including drug history, diet and lifestyle.
• Treatment should be reviewed once normal bowel habit is restored.
• It may be appropriate to continue treatment if the precipitator is immobility, drug induced or other continuing factor.
• If rectum is full on examination or there is difficulty in evacuation, consider glycerol or bisacodyl suppositories.
• Osmotic laxatives, such as lactulose or macrogol, are not appropriate for as required use. They make take 48 hours to take effect. Cautious use in patients who have restricted fluid intake.

Prescribing Notes:

• When naloxegol therapy is initiated, it is recommended that all currently used maintenance laxative therapy should be halted until the clinical effect of naloxegol is determined.
• Naloxegol should be taken on an empty stomach at least 30 minutes prior to or two hours after the first meal of the day.
• In patients with moderate or severe renal insufficiency or in patients taking moderate CYP3A4 inhibitors (e.g. diltiazem, verapamil), the recommended starting dose is 12.5mg once daily which, if well tolerated, can be increased to 25mg once daily.
• The choice of treatment for constipation depends on the severity of the presentation and other factors including drug history, diet and lifestyle.
• Treatment should be individualised to patient’s requirements and circumstances.
• Treatment should be reviewed once normal bowel habit is restored.
• It may be appropriate to continue treatment if the precipitator is immobility, drug induced or other continuing factors.

Prescribing Notes:

• Some patients may require manual disimpaction.
• Enemas may need a district nurse or a carer to administer them.
• Rectal enemas are licensed for occasional use only.
• In general, enemas should be reserved for pre-operative bowel clearance and for the treatment of impacted faeces if response to oral laxatives or suppositories is insufficient.
• Enemas are routinely used in patients with hepatic failure.

Prescribing Notes:

• Lactulose is included for specialist initiation in women’s services for the treatment of constipation in postpartum patients following a post caesarean section and for patients with third or fourth degree tears.
• For constipation, manage underlying causes and advise adult patients on appropriate first-line dietary and lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels.
• The severity of constipation should be considered before commencing treatment, and treatment should be reviewed once normal bowel habit is restored.
• Osmotic laxatives, such as lactulose are not appropriate for as required use. They make take 48 hours to take effect. Cautious use in patients who have restricted fluid intake.

Prescribing Notes:

• Linaclotide is approved for symptomatic treatment of moderate to severe irritable bowel syndrome with constipation. It is restricted for use in patients who have not adequately responded to or cannot tolerate all other suitable treatment options.
• Prescribing may be transferred to primary care at this stage if ongoing treatment is considered beneficial.
• Physicians should periodically assess the need for continued treatment. If patients have not experienced improvement in their symptoms after 4 weeks of treatment, the patient should be re-examined and the benefit of continued treatment reconsidered.

Prescribing Notes:

• Refer to the Scottish Palliative Care Guidelines.

Prescribing Notes:

• Onset of action of macrogol is 2-3 days. Titrate to a dose which produces 1-2 soft stools per day.
• Senna has a rapid onset of action, 8-12 hours. It must not be used in the presence of faecal impaction.
• Bisacodyl onset is between 15 minutes to 3 hours, avoid if large hard stools as no softening effect.
• Bulk forming laxatives such as ispaghula husk are not recommended in the treatment of clozapine induced constipation.
• Gastrointestinal history and abdominal examination is recommended prior to starting treatment with clozapine and should not be initiated until it has resolved.
• Assess bowel habits at baseline, any point of blood sampling and ideally at every point of contact. Ensure patients and carers are aware of the risks associated with clozapine induced constipation.
• Laxative medication should not be stopped suddenly; the rate should be guided by the frequency and consistency of stools.
• Stimulant laxatives can become less effective with long term use and can cause diarrhoea and hypokalaemia.
• Some antidepressants, antipsychotics and anti-parkinson treatments have strong anticholinergic properties and contribute to constipation. Prescribing of these medications should be kept under review when used in combination with clozapine and doses reduced/stopped as appropriate.

Prescribing Notes:

• There are videos that can be viewed for instructions on how to make up PICOLAX sachets.

Prescribing Notes:

• Treatment should be reviewed once normal bowel habit is restored.
• In Lothian a management guideline is available on RefHelp ‘Guidelines for Management of Idiopathic Childhood Constipation’.
• In Fife a management guideline is available on Blink (accessible to users in NHS Fife).
• Lactulose is the preferred first line treatment option for chronic constipation in children under 6 months because of the sodium content in macrogol sachets.
• In children who are weaned from milk feeds, Lactulose should be given with meals to reduce risk of dental caries.
• Oral options are considered first, with suppositories reserved as an alternative option.
• Lactulose is contra-indicated in galactosaemia and should be used with caution in children with lactose intolerance.
• Liquid paraffin BP (not liquid paraffin oral emulsion) is sometimes recommended on specialist advice.
• Liquid paraffin BP should not be given to children of any age with impaired swallowing (e.g. reflux or neurodevelopmentally delayed children) due to the risk of lipoid pneumonia following aspiration.
• Excessive use of liquid paraffin BP can cause anal seepage and irritation.

Prescribing Notes:

• After an episode of faecal impaction, maintenance therapy may be required for several months or longer until regular bowel habit is established.
• In Lothian a management guideline is available on RefHelp ‘Guidelines for Management of Idiopathic Childhood Constipation’.
• In Fife a management guideline is available on Blink (accessible to users in NHS Fife).
• Rectal administration is not routinely recommended and should only be considered under specialist advice.
• When taking large volumes of movicol/macrogol 3350 for disimpaction, other medicines should not be given within 1 hour of movicol/macrogol.
• Phosphate enemas for children are normally administered in a hospital setting, use in other settings would be under the guidance of a specialist.
• Rectal enemas are licensed for occasional use only.
• In general, enemas should be reserved for pre-operative bowel clearance and for the treatment of impacted faeces if response to alternative formulary options is insufficient.

Prescribing Notes:

• For more information see the NHS Lothian patient information leaflet for Your colonoscopy at the Royal Hospital for Children and Young People. There are also videos that can be viewed for instructions on how to make up CITRAMAG sachets and PICOLAX sachets.

Prescribing Notes:

• Dietary measures include: increasing fluid, fruit and fibre intake, avoiding too many caffeine containing drinks.
• Regular exercise improves bowel habits.
• The MHRA have issued advice to support the safe use of over the counter laxatives.
• Ispaghula may take several days to act. Ispaghula sachets should not be taken immediately before going to bed, ensure adequate fluid intake.
• Stimulant laxatives should only be used short term as they become less effective with long-term use.
• After an episode of acute constipation, advise the patient that laxatives can be stopped once the stools become soft and easily passed again.
• Rectal administration is not routinely recommended.
• Constipation in children normally requires a GP referral. Use of laxatives in children should be discouraged unless recommended by a doctor.
• It may be appropriate to continue treatment if the precipitor is immobility, drug induced or other continuing factor.

Examples of Counselling Points
Eat more fibre.
Drink more fluids, and advise to reduce consumption of caffeine (tea, coffee, cola) or alcohol.
Never put off going to the toilet when you know you need to go.

When to advise patient to contact GP
New or worsening symptoms without adequate explanation.
Persistent change in bowel habit.
Abdominal pain, bloating, blood in stools, weight loss, nausea and vomiting.
Prescribed medication suspected of causing symptoms.
Cancer-related or palliative care related symptoms.
Failure of OTC medication (no relief of symptoms within 7 days).
Constipation in children.
Child feeling weak or dizzy.
Marked anal pain on defecation.
Unintentional weight loss.