| Choice | Drug | Dosage | Presentation |
|---|---|---|---|
| 1st choice | Ispaghula husk (Fybogel® sachets) | Dose: 1 sachet in water twice daily preferably after meals | Pack size 30 Multi-flavours Sugar and gluten free |
| 2nd choice | Macrogol compound oral powder sachets | 1-3 sachets daily in divided doses usually for up to 2 weeks; contents of each sachet dissolved in half a glass (approx. 125ml) of water; maintenance, 1-2 sachets daily | After reconstitution the solution can be kept in a refrigerator but discarded if unused after 6 hours |
| 3rd choice | Oral Senna tablets 7.5mg, syrup 7.5mg/5ml | Dose: 7.5-15mg at night (max. per dose 30mg daily), initial dose should be low then gradually increased | |
| Faecal loading/ Impaction of rectum | |||
| 1st choice | Macrogol compound oral powder sachets | 4 sachets on first days, then increased in steps of 2 sachets daily to max. 8 sachets daily; total daily dose to be drunk within a 6 hour period. After disimpaction, switch to maintenance laxative therapy if required | After reconstitution the solution can be kept in a refrigerator but discarded if unused after 6 hours. Contains sodium bicarbonate, sodium chloride and potassium chloride |
| 2nd choice | Glycerol (glycerin) suppositories 4g | Dose: 4g suppository, moistened with water before use, as required | |
| Or | |||
| Bisacodyl suppositories 10mg | Dose: 10mg suppository in the morning | ||
| Or | |||
| Sodium citrate enema (Micralax® micro-enema) | Dose: one enema (5ml) when required | ||
| 3rd choice | Phosphate enema (Fleet® Ready-to-use Enema) | Dose: one enema (118ml) as required | |
Prescribing Notes
- For further details on the management of constipation see CKS.
- See NICE CG 61 for the management of irritable bowel syndrome.
- Palliative care patients should be managed differently – refer to the Palliative Care section.
- For uncomplicated constipation, first-line therapy should be dietary modification with increased fibre and fluid intake. Constipating medication should be adjusted.
- Oral laxatives should be offered if dietary measures are ineffective, or while waiting for them to take effect:
-
- initial treatment for most people should be with a bulk forming laxative (ispaghula husk)
- if stools remain hard, an osmotic laxative should be added or switched to
- if stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, a stimulant laxative should be added
- Ispaghula husk may take several days to act.
- Bulk-forming laxatives, e.g. ispaghula husk, should always be swallowed with plenty of water to avoid intestinal obstruction. They should not be taken immediately before going to bed.
- As bulk-forming laxatives require good fluid intake consider that this may be difficult for the frail or elderly.
- Bulk-forming laxatives are not recommended in opioid-induced constipation.
- If bulk forming macrogol and stimulant laxatives are unsuitable, consider at least 30ml daily of lactulose; this may take 48 hours to act. Lactulose should not be prescribed on an ‘as required’ basis.
- Lactulose is not recommended for patients with irritable bowel syndrome – constipation predominant (IBS-C) as it can exacerbate symptoms such as bloating.
- The use of phosphate enemas should be discouraged, especially in frail elderly patients and in those with renal impairment.
- For people with IBS-C, see also section 1.2.
- A number of other treatments for constipation have been accepted for use in Northern Ireland. These are not first line treatments and should only be prescribed in the particular circumstances outlined. See the managed entry page for information on our decision regarding lubiprostone and naloxegol and NICE for further information on prucalopride.
- In chronic constipation referral should be arranged if red flags are present, treatment is unsuccessful, or if there is faecal incontinence.
Cautions
- Avoid using two laxatives of the same class together (e.g. lactulose and macrogol) – as this increases the risk of side effects.
- Lactulose is not recommended for long-term use in older patients due to the potential for fluid and electrolyte imbalance.
- Patients with cardiovascular impairment should not take more than 2 sachets of oral macrogol powder compound in any 1 hour.
- Phosphate enemas should be administered with caution to patients with renal impairment (discourage use in frail elderly and in renal impairment).
- In refractory constipation other causes should be considered, e.g. obstruction of bowel.