NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is infrequent constipation.

Many laxatives e.g. bisacodyl and senna, are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Excessive use of stimulant laxatives can cause diarrhoea and related effects such as hypokalaemia; risk of electrolyte imbalance with prolonged use (in children).

Bisacodyl

• Gastro-resistant tablets 5mg (£4.07 = 60 tablets)
• Suppositories 10mg (£2.77 = 12 suppositories)
• Suppositories 5mg (paediatric) (£1.11 = 5 suppositories)

Indications

• Acute obstructed constipation and faecal impaction in adults
• Acute non-obstructed constipation in adults
• Chronic constipation in adults
• Opioid induced constipation in adults
• Constipation in pregnancy (third line)
• Constipation in children
• Faecal impaction in children

Dose

• Adult oral: 5–10mg at night, increased if necessary to maximum 20mg at night according to response
• Adult rectally: 10mg in the morning
• Child (4 years and older) oral: 5–20mg once daily, adjusted according to response
• Child (2 years and older) rectally: 5-10mg once daily, adjusted according to response

Notes

1. Time to effect: 10-12 hours orally, 20-60 minutes rectally
2. The tablets are licensed for use in children aged 4 years and older.
3. The usual maintenance dose is half the disimpaction dose.

Senna

(Sennoside)

• Tablets 7.5mg (£1.59 = 60 tablets)
• Oral solution sugar free 7.5mg in 5ml (£8.78 = 500ml)

Indications

• Acute obstructed constipation and faecal impaction in adults
• Acute non-obstructed constipation in adults
• Chronic constipation in adults
• Opioid induced constipation in adults
• Constipation in pregnancy (third line) (avoid near term or if a history of unstable pregnancy)
• Constipation in children
• Faecal impaction in children

Dose

• Adult: 7.5–15 mg (as tablets or syrup) daily (max. daily dose: 30mg), dose usually taken at bedtime; initial dose should be low then gradually increased
• Child 1 month to 2 years: 3.75mg -15mg syrup once daily
• Child 2–18 years: 3.75mg–30mg syrup or tablets once daily

Notes

1. Do not prescribe the 15mg OTC tablets due to higher acquisition cost
2. Time to effect: 8-12 hours
3. Licensed only for short term use.
4. Efficacy is decreased with continued use
5. Syrup not licensed for use in children under 2 years and tablets not licensed for use in children under 6 years.
6. The usual maintenance dose is half the disimpaction dose.

Docusate sodium

• Capsules 100mg (£2.09 = 30 capsules)
• Paediatric oral solution sugar free 12.5mg in 5ml (£24.06 = 300ml)
• Oral solution sugar free 50mg in 5ml (£16.44 = 300ml)
• Enema 120mg in 10g (£28.00 = 6 enemas)

Indications

• Acute obstructed constipation and faecal impaction in adults
• Acute non-obstructed constipation in adults
• Chronic constipation in adults
• Opioid induced constipation in adults
• Constipation in pregnancy (third line)
• Faecal impaction in children
• Constipation in children

Dose

• Adult: up to 500mg daily in divided doses, adjusted according to response
• Child 6 months–1 year: 12.5mg three times daily (use paediatric oral solution).
• Child 2–11 years: 12.5–25mg three times daily (use paediatric oral solution)
• Child 12-17 years: Up to 500mg daily in divided doses

Notes

1. Time to effect: 1-2 days
2. Adjust dose according to response
3. Has a relatively weak stimulant effect, but also stool-softening properties.
4. Only the liquid formulation is licensed for use in children younger than 12 years of age.

Glycerol

• Suppositories 4g (£3.20 = 4g x 12 suppositories)

Indications

• Acute obstructed constipation and faecal impaction in adults
• Constipation in pregnancy (third line)

Dose

• Insert one suppository when required

Notes

1. Time to effect: 15-30 minutes
2. Lubricating and weak stimulant. Can be used for hard or soft stools.
3. Licensed for occasional use only

Co-danthramer

(Dantron with poloxamer 188)

• Oral suspension sugar free 25mg/200mg in 5ml (£245.29 = 300ml)
• Strong oral suspension sugar free 75mg/1000mg in 5ml (£503.98 = 300ml)

Indications

• Only for constipation in terminally ill patients

Dose

• Adult
  • 25mg/200mg: 5-10ml at night
  • 75mg/1000mg: 5ml at night

Notes

1. For use in palliative care only
2. Time to effect: 6-12 hours
3. Patients should be warned that it discolours the urine.
4. Prolonged contact with the skin (eg. faecal or urinary incontinence) can cause a dantron burn

Co-danthrusate

(Dantron with docusate sodium)

• Oral suspension sugar free 50mg/60mg in 5ml (£236.25 = 200ml)

Indications

• Only for constipation in terminally ill patients

Dose

• Adult
  • 5–15ml at night

Notes

1. For use in palliative care only
2. Time to effect: 6-12 hours
3. Patients should be warned that it discolours the urine.
4. Prolonged contact with the skin (e.g. faecal or urinary incontinence) can cause a dantron burn

Lecicarbon

• Lecicarbon A Suppositories (£8.20 = 10 suppositories) – For use in adults
• Lecicarbon C Suppositories (£8.20 = 10 suppositories) – For use in children

Indication

• Chronic constipation in adults and children

Dose

• Adults (Lecicarbon A) and Children (Lecicarbon C): Insert one suppository when required. If necessary, this can be repeated after 30-60 minutes

Notes

1. Lecicarbon suppositories contain soya lecithin and are contraindicated in patients who have peanut or soya allergies.
2. The routine commissioning of Lecicarbon A suppositories is accepted in Devon for the management of chronic constipation. (see Commissioning Policy for more details).

Sodium Picosulfate

• Oral solution sugar free 5mg in 5ml (£29.77 = 300ml)

Indications

• Relief of constipation in adults
• Relief of constipation in children

Dose

• Adult: 5–10mg at night
• Child 1 month–4 years: 2.5–10mg once daily, adjusted according to response
• Child 4–18 years: 2.5–20 mg once daily, adjusted according to response

Notes

1. Time to effect: 6-12 hours