Management of constipation in adults

First Line

Second Line

Specialist

Hospital Only

For the list of formulary choice laxatives see 1.6 Laxatives

Before prescribing laxatives it is important to be sure that the patient is constipated and the cause is not secondary to an underlying condition. Identify and treat possible causes of constipation, including being caused by medication.

Investigate patients with severe unresponsive, unexplained or alarm symptoms (such as changes in bowel habit, rectal bleeding, passing mucus, weight loss, anorexia or painful ineffective straining).

Try non-drug measures first wherever appropriate (see below).

Laxatives are recommended:

If lifestyle measures are insufficient, or whilst waiting for them to take effect
For people with other secondary causes of constipation
For patients taking a constipating drug that cannot be stopped
As 'rescue' medicines for episodes of faecal loading

Evidence of the comparative effectiveness of laxatives is lacking. No one class of laxative has been shown to be more effective than another. A stepped approach is recommended based on cost.

The rectal route may be used when the oral route is ineffective or when rapid effect is necessary. Prolonged treatment is not necessary except in the terminally ill when prophylaxis is necessary. The dose of laxative should be gradually titrated up or down to aim for three soft stools per week.

Review laxative treatment regularly. Only consider continued laxative use where symptoms are likely to recur e.g. drug or disease induced constipation, immobility and poor diet. There is no good evidence that regular laxative use prevents idiopathic constipation. However it may be required where constipation and faecal impaction could re-occur if treatment is stopped.

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 of these products 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.

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Try non-drug treatment first wherever appropriate

Increase fibre intake gradually to 18 - 30g daily for an adult. This may not be appropriate for immobile or elderly patients or those with mega colon. Although the effects of a high fibre diet may be seen in a few days, it may take as long as 4 weeks.
Increase fluid intake to 2 litres a day if medically appropriate.
Increase mobility if possible.
Review medication to identify constipating medicines, e.g. antacids containing aluminium, antidiarrhoeals, antimuscarinics, iron, opioids, tricyclics, verapamil.
Check sitting position on toilet. The patient should sit with feet firmly planted on a solid surface. The knees should be on a level with or slightly higher than the hips and a footstool may be required to achieve this.

Adjust any constipating medication if possible.

Give advice on non-drug treatments (see above).

Laxatives can be stopped once the stools become soft and easily passed again.

See 1.6 Laxatives

Ispaghula husk

One sachet twice daily, with at least 300ml water
Sufficient fluid intake is important in patients taking ispaghula husk sachets, in particular the elderly

If stools remain hard, add or switch to

Macrogol Compound oral powder

Usually 1 sachet once or twice daily in 125ml water

Lactulose

Use if macrogols ineffective or not tolerated
Initially 15ml twice daily
Adjust to patient's needs but avoid 'as required' prescriptions

If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying

Bisacodyl

5mg tablet, two at night or
10mg suppository in the morning

Senna

2-4 tablets at night

If ineffective, add:

Docusate sodium

200mg orally twice daily

Sodium citrate micro-enemas (Micolette micro-enema)

Consider reducing or stopping the opioid if appropriate.

Avoid bulk-forming laxatives, use an osmotic laxative and a stimulant laxative

See 1.6 Laxatives

For guidance on constipation in palliative care see here and for guidance on Peripheral opioid-receptor antagonists in palliative care see here

Osmotic laxatives

Macrogol Compound oral powder

Usually 1 sachet once or twice daily in 125ml water

Lactulose

Use if macrogols ineffective or not tolerated
Initially 15ml twice daily
Adjust to patient's needs but avoid 'as required' prescriptions

Stimulant laxatives

Bisacodyl

5mg tablet, two at night or
10mg suppository in the morning

Senna

2-4 tablets at night

Docusate

200mg orally twice daily

Adjust any constipating medication if possible. Give advice on non-drug treatments (see above).

See 1.6 Laxatives

Ispaghula husk

One sachet twice daily, with at least 300ml water
Sufficient fluid intake is important in patients taking ispaghula husk sachets, in particular the elderly.

If ineffective, add or switch to

Macrogol Compound oral powder

Usually 1 sachet once or twice daily in 125ml water

Lactulose

Use if macrogols ineffective or not tolerated
Initially 15ml twice daily
Adjust to patient's needs but avoid 'as required' prescriptions

If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, add stimulant laxative

Bisacodyl

5mg tablet, two at night or
10mg suppository in the morning

Senna

2-4 tablets at night

Docusate

200mg orally twice daily

Adjust the dose, choice, and combination of laxative according to symptoms, speed with which relief is required, response to treatment, and individual preference.

The dose of laxative should be gradually titrated upwards (or downwards) to produce more than three soft, formed stools per week.

Lecicarbon A suppositories

Insert one suppository when required

Prucalopride

Only to be initiated by colorectal surgeons and gastroenterologists
For use in women only
Women (18 to 65 year): 2mg once daily
Women (over 65 years): 1mg once daily, increased if necessary to 2mg
Only to be used as per NICE TA211: Prucalopride for the treatment of chronic constipation in women (December 2010): When at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months

See 1.6 Laxatives

Reinforce advice about the role of diet, fluid intake, and exercise in maintaining regular bowel movements and preventing problems from recurring. Not all preparations are licensed for the treatment of faecal impaction, please refer to individual Summary of Product Characteristics (SPC)

For hard stools, start:

Macrogol Compound oral powder

Eight sachets should be dissolved in exactly 1 litre water and drunk within 6 hours. Maximum length of treatment is 3 days. Patients with cardiac problems should not exceed 250ml (the contents of 2 sachets) in any one hour.

For soft stool, or if stools still hard after a few days treatment with macrogol, consider starting or adding

Bisacodyl

5mg tablet, two at night or
10mg suppository in the morning

Senna

2-4 tablets at night

If response to oral laxatives is insufficient or not fast enough, consider

Bisacodyl suppositories

Docusate sodium micro enema

Sodium Citrate micro-enema

Glycerol suppositories

If response is still insufficient, consider using a sodium phosphate or arachis oil retention enema (place high if the rectum is empty but the colon is full)

Phosphate enema

Arachis oil enema

For hard faeces it can be helpful to give the arachis oil enema overnight before giving a sodium phosphate (large volume) or sodium citrate (small volume) enema the next day

First-line, provide advice about lifestyle measures (diet, fluid intake, regular light moderate exercise)

If there is insufficient response to the above measures consider the following:

See 1.6 Laxatives

Second line, add bulk forming laxative

Ispaghula husk

One sachet twice daily, with at least 300ml water
Sufficient fluid intake is important in patients taking ispaghula husk sachets.

Third line, add osmotic laxative or stimulant laxative

Lactulose

Initially 15ml twice daily
Adjust to patient's needs but avoid 'as required' prescriptions

Glycerol suppositories

Bisacodyl

Senna

but avoid near term, or if a history of unstable pregnancy

Docusate sodium

low doses

Formulary