1.6.2 Stimulant laxatives

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
  • Tablets 5mg (£6.19 = 60 tabs)
  • Suppositories 10mg (£3.53 = 12 supps)
  • Suppositories 5mg (paed) (£1.04 = 5 supps)

Indications

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
  • Tablets 7.5mg sennosides (£1.89 = 60 tabs)
  • Syrup 7.5mg sennosides in 5ml (£4.76 = 500ml)

Indications

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 caps)
  • Paediatric oral solution 12.5mg/5ml (£8.38 = 300ml)
  • Oral solution 50mg/5ml (£8.60 = 300ml)
  • Enema 120mg in 10g (£28 = 6 enemas)

Indications

Dose

  • Adult: up to 500mg daily in divided doses, adjusted according to response
  • Child 6 months–1 year: 12.5mg 3 times daily (use paediatric oral solution).
  • Child 2–11 years: 12.5–25mg 3 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 (£1.16 = 4g x 12 pack)

Indications

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)

  • Suspension 25mg/200mg in 5ml SF (£169.24 = 300ml)
  • Strong suspension 75mg/1000mg in 5ml SF (£337.65 = 300ml)

Indications

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)

  • Suspension 50mg/60mg in 5ml SF (£154.40 = 200ml)

Indications

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

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
  • Elixir 5mg/5ml SF (£7.10 = 300ml)

Indications

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

 

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