1 Coastal West Sussex Clinical Commissioning Group Laxative Prescribing Guidance Key Prescribing Points 1. Once constipation is confirmed, and any secondary causes have been addressed, most adults with mild or acute functional (idiopathic) constipation can be managed by dietary and lifestyle changes.1 2. In adults, laxatives should be reserved for cases where simple interventions have failed, or where rapid relief of symptoms is required. Prolonged treatment is seldom necessary, except occasionally in the elderly, in palliative care, or to prevent recurrence in children.1 Review all laxatives regularly. 3. Palliative care patients should be prescribed laxatives when starting constipating drugs, before constipation becomes a problem. 4. All patients taking osmotic and bulk forming laxatives should be told to drink extra fluids, e.g. a glass of water after each dose. It is possible that the dose required may be reduced if sufficient fluid is drunk, due to the mode of action of these laxatives. 5. Withdraw slowly once bowel habit is established (2-4 weeks after defaecation has become comfortable and a regular bowel pattern with soft, formed stools has been established).1 Where combinations are prescribed, reduce one at a time. The process can take several months. Relapses are common and should be treated by an early increase in laxative dose.2 Laxative Choice Adults Short duration constipation is common in primary care and may result from dietary changes (e.g. reduced fibre and fluid intake), stress, or immobility (e.g. due to age or illness).1 A graded approach1 to management can be used: • Advise the person about lifestyle measures – increasing dietary fibre, maintaining adequate fluid intake, and exercising. • Offer additional oral laxatives if dietary measures are ineffective (e.g. after 4 weeks), or while waiting for them to take effect: o Start treatment with a bulk-forming laxative (adequate fluid intake is important) o If stools remain hard to pass, add or switch to an osmotic laxative (adequate fluid intake is important) – use the Bristol stool chart and encourage the patient to keep a bowel diary: http://www.sthk.nhs.uk/library/documents/stoolchart.pdf o If stools are soft but difficult to pass or if emptying is inadequate, add a stimulant laxative (senna first line or docusate). Dantron has limited indications by its potential carcinogenicity (based on rodent carcinogenicity studies) and evidence of genotoxicity. Dantron should be used to manage constipation only in terminally ill patients (of all ages).3 • Advise the person that laxatives can be stopped once the stool becomes soft and passes easily. With the exception of relatively recent evidence comparing the efficacy of macrogols with lactulose, there is limited clinical evidence on which to judge the comparative efficacy of individual laxatives3. Therefore management of chronic constipation in adults is largely based on expert opinion. Macrogols and lactulose have both been found to be effective as osmotic laxatives, though macrogols have been found to be superior to lactulose for increasing stool frequency and reducing straining.3 Version No. 1 Status Author Date Final Julie Sadler October 2012 1 National Prescribing Centre. The management of constipation. MeReC Bulletin Volume 21 Number 2. January 2011. Available at: http://www.npc.nhs.uk/merec/therap/other/merec_bulletin_vol21_no2.php <accessed 11/05/12> 2 PRODIGY - Constipation. Available at: http://prodigy.clarity.co.uk/constipation/management/scenario_adults#-317747 <accessed 11/05/12> 3 COMPASS Therapeutic Notes on the Management of Chronic Constipation in Primary Care. January 2012. Available at: http://www.hscbusiness.hscni.net/pdf/52817_HSC_-_Constipation.pdf <accessed 11/05/12> 21 NICE recommends prucalopride as a possible treatment for chronic constipation in women only if they have tried at least two different types of laxatives at the highest possible recommended doses, for at least six months, and this has not helped their constipation, and invasive treatment for constipation is being considered.4 If treatment with prucalopride is not effective after four weeks, the woman should be reexamined and the benefit of continuing treatment reconsidered. Prucalopride should only be prescribed by a clinician with experience of treating chronic constipation, who has carefully reviewed the woman’s previous courses of laxative treatments. Adults with IBS The NICE guideline on irritable bowel syndrome (IBS)5 recommends that laxatives should be considered for the treatment of constipation in people with IBS, but people should be discouraged from taking lactulose. Patients on regular opioids DO NOT wait for them to become constipated, consider initiating regular stimulant laxatives and/or a softening laxative simultaneously with opioids and ensure adequate fluids and a high fibre diet.2 See separate guidance for managing constipation in patients receiving palliative cancer care. Elderly Treatment is the same as for younger adults, with an emphasis on changing lifestyle and diet whenever possible. If medication is required, stimulant laxatives should be considered ahead of bulking agents for treating constipation caused by a lack of mobility. It is also important to review drugs that could potentially cause constipation and consider alternatives, where possible. Pregnancy or breastfeeding For pregnant and breastfeeding women the emphasis lies in first-line use of dietary and lifestyle measures. If these measures fail to control constipation, moderate doses of poorly absorbed laxatives may be used. Consider a bulk forming laxative first. If stools remain hard to pass, add or switch to a macrogol or lactulose. If stools are soft but the woman still finds them difficult to pass or complains of inadequate emptying, consider a short course of bisacodyl or senna. Occasional use of glycerol suppositories is also an option.3 Children Healthcare professionals should follow the NICE guideline on constipation in children and young people.6 It advises that dietary interventions should not be used alone as first-line treatment for constipation (as would be the case for adults).6 NICE recommend polyethylene glycol 3350 (Movicol® Paediatric Plain) as the preferred first-line agent for the management of constipation in children.6 Ensure that an effective dose is used. If this approach does not work, add in a stimulant laxative; or if this approach is not tolerated, substitute a stimulant laxative. If stools are hard to pass, consider adding in lactulose or another laxative with softening effects, such as docusate.3 N.B. Movicol® Paediatric Plain does not have UK marketing authorisation for use in faecal impaction in children under 5 years, or for chronic constipation in children less than 2 years. Informed consent should be obtained and documented. Action points • • • • • • Diet and lifestyle advice should include encouragement of exercise as well as increasing dietary fibre and fluid intake. Avoid long term prescriptions where possible – review the continuing need for laxatives. Start laxatives prophylactically when initiating opioids in palliative care. Advise patients to drink a glass of water with each dose of osmotic or bulk forming laxative. Review all macrogol prescriptions and keep doses flexible, teaching patients to titrate their dose as needed. Use dantron to manage constipation only in terminally ill patients (of all ages). The information contained in this guidance is issued on the understanding that it is the best available from the resources at our disposal at the time. Comments and suggestions welcome! Coastal West Sussex Medicines Management Team. Email [email protected] 4 National Institute for Health and Clinical Excellence. Technology Appraisal Guidance 211: Prucalopride for the symptomatic treatment of chronic constipation in women. December 2012. Available at: http://www.nice.org.uk/nicemedia/live/13284/52078/52078.pdf 5 National Institute for Health and Clinical Excellence. Clinical Guideline 61: Irritable bowel syndrome (IBS) in adults: diagnosis and management of irritable bowel syndrome in primary care. February 2008. Available at: http://www.nice.org.uk/CG061 6 National Institute for Health and Clinical Excellence. Clinical Guideline 99: Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. May 2010. Available at: http://www.nice.org.uk/nicemedia/live/12993/48741/48741.pdf 2