Laxative Guidelines for Adults Key Messages:  Lifestyle advice of fluid intake, fibre & exercise must be continued throughout laxative therapy  Never use two of the same class of drug (i.e. lactulose & macrogol)  Always use a stimulant first line for drug induced (esp. opioids) as osmotics just cause bloating  Always add in another laxative type (not replace) as often the synergistic action of softening, bulking and stimulant is much more effective and lowers the side-effects of individual agents.  Always consider impaction and overflow if patient reports diarrhoea on laxatives Patient.co.uk Constipation in adults Patient information leaflet Printable resources: Nutrition & dietetic Patient information leaflets

Drug Chronic Chronic Chronic frail / Pregnancy/ Start at the induced (>12 weeks) (with IBS 1) low mobility breastfeeding top and ** Increase fluid intake, dietary fibre and exercise ** use ONE Start laxatives on Still encourage option in Investigate Antispasmodics Ensure non-drug initiation of high fibre, fluid & 2 possible causes 3 interventions first category dose opioids. Use soluble fibre exercise

Then ADD Stimulant Bulk forming Softener Softener Bulk forming in the with plenty of fluid With plenty of fluid next step (unless Softener Softener macrogol Stimulant Osmotic (NOT lactulose) otherwise stated) 4 Osmotic Stimulant Stimulant Osmotic Senna Reduce & DO NOT use STOP ALL Bulk forming may Only use these remove bulk forming cause blockage Osmotic LAXATIVES then drugs in the last Specialist use only: start Linaclotide pregnancy and co-danthramer, step when breast-feeding co-danthrusate & REFER to Secondary care to controlled Opioid antagonists except on (i.e. Naloxegol) consider prucalopride or lubiprostone consultant advice

A referral can be made to the continence service for assessment, advice and support at all stages. Especially consider for impacted, neurological conditions or failure of traditional laxatives. GP & Nurses can send written referral to RCHS, or contact for advice on 01709 423369

Bulk forming Neurological / MS / Stroke / spinal injuries etc Ispaghula one sachet twice a day These patients may require a more complicated regime including rectal stimulation and manual evacuation. Over use of traditional Softener laxatives (especially osmotics) can result in feacel incontinence. Docusate 200mg twice a day Seek advice from their specialist team or the continence service. Stimulant Bisacodyl 2 at night (max 4 daily) Impaction - Prevent reoccurance with lifestyle advice and regular OR senna 2 at night (max 2 BD) laxatives. Exact treatment depends on cause and size of impaction, OR glycerin suppositories PRN advice maybe required from the Colorectal Advanced Nurse Osmotic Practioner Or the continence service Options include: Macrogol 1 to 3 sachets daily  Glycerin or bisacodyl supppositories  Phosphate or arachis (peanut) oil enemas OR lactulose 15ml BD  Macrogol disimpaction regimen (use with caution) Linaclotide 290mcg once daily (See overleaf) 1 Irritable Bowel Syndrome www.patient.co.uk leaflet 2 Greater than 120mg codeine /day (i.e. co-codamol 30/500) or strong opioids (i.e. morphine MR) Prucalopride / Lubiprostone - 3 fruit, root vegetables & oats – NOT insoluble fibre of bran, whole grains & cereals Consultant initation only (See over) 4 not near term or unstable pregnancy

Eloise Summerfield, Prescribing Advisor Originally produced Nov 13; Updated November 2015 Medicines Management Team, Rotherham CCG Review date November 2017 Background information Advantages Disadvantages Bulk-forming laxatives (such as First-line choice in Adequate fluid intake is important, to prevent ispaghula) retain fluid within the adults when it is intestinal obstruction. Must not be taken immediately stool and increasing faecal mass, difficult to get enough before bed. This may be difficult for the frail and leading to stimulation of peristalsis. fibre in the diet. Better elderly. Not recommended for people taking They also have stool-softening tolerated than bran. constipating drugs. Side-effects of flatulence and properties. 2-3 days to effect bloating Surface-wetting agents (docusate) reduces the surface tension of the Does not require a large Side-effects of abdominal cramps and diarrhoea. Often stool, allowing water to penetrate fluid intake. needs an additional laxative to be added (either and soften it. It also has a weak 12-72 hours to effect stimulant or osmotic). stimulant effect. Stimulant laxatives cause Rapid effect. Restarts Requires the stool to be softened by increasing dietary peristalsis by stimulating colonic peristalsis in drug- fibre and liquid or another laxative (softener / osmotic). nerves (senna) or colonic and rectal induced constipation Side-effects include cramps & diarrhoea, and should be nerves (bisacodyl). 6-12 hours to effect avoided in intestinal obstruction Osmotic laxatives (macrogols & Macrogols require a large volume to drink and if lactulose) increase fluid in the large Produce very soft stools adequate fluid is not taken it can lead to dehydration. bowel. This produces distension, with a large volume. They may be counter-productive in patients with IBS. leading to stimulation of peristalsis. 2-3 days to effect Side-effects include flatulence, bloating, cramping and Prescribe macrogol generically, and nausea. Lactulose causes colic due to breakdown by do not use lactulose sachets. bacteria, and is NOT recommended for IBS patients. Linaclotide is ONLY licensed for patients with Irritable Bowel Syndrome (IBS) Linaclotide is a Guanylate cyclase- with constipation and ONLY recommended patients in whom ALL other laxative C receptor agonist causing decreased treatment options have been ineffective or contraindicated. (Antispasmodics may visceral pain, increased intestinal still be used.) Review after 4 weeks & at regular intervals thereafter. fluid secretion and accelerated Novel action so is an alternative There is no long-term data for the efficacy or intestinal transit. to traditional laxatives. side-effects of this treatment. As per NICE TA318. To be initiated by a specialist. Only after 6 months treatment of Lubiprostone is a chloride-channel at least two classes of laxatives at maximum tolerated doses. Review after 2 weeks and activator that acts in the gut to stop if no effect. increase intestinal fluid secretion Novel action so is an alternative to There is no long-term data for the efficacy or which increases motility traditional laxatives. side-effects of this treatment. Amber lighted so initiation by consultant only. As per NICE TA211. Only, after 6 Prucalopride is a selective, high- months treatment of at least two classes of laxatives at maximum tolerated doses. affinity, serotonin (5HT4) receptor Review after 4 weeks (then can be passed to GP). agonist, and has enterokinetic Novel action so is an alternative The most common side effects are headache and GI effects, enhancing intestinal motility. to traditional laxatives. symptoms (abdominal pain, nausea or diarrhoea) Peripherally acting opioid NICE TA345 states naloxegol is an option for treating opioid induced constipation in adults who constipation has not adequately responded to laxatives. Methylnaltrexone antagonists: is only licensed in palliative care. Naloxegol, methylnatrexone & Combats the mechanism of Concurrent bisacodyl (or alternative stimulant) is still naloxone (in Targinact®) opioid induced constipation. required for all patients, and possibly other laxatives.

RED flags: Ispaghula 2 sachets od Cost for 28 days for Laxatives. Bisacodyl 5mg 4 on August 2015  Persistent unexplained change in bowel Senna 2 bd habit? Docusate 100mg 2 bd  Persistent rectal bleeding without anal Lactulose 30mls bd symptoms? Macrogol (generic) 3 od  Narrowing of stool calibre? Macrogol (Movicol) 3 od  Palpable mass in the lower right Lactulose (sachets)… abdomen or the pelvis? Linaclotide 290mg od  Unexplained weight loss, iron Naloxegol 25mg od deficiency anaemia, fever, or nocturnal Lubiprostone 24mcg bd Prucalopride 2mg od symptoms?  Family history of colon cancer, or £0 £10 £20 £30 £40 £50 £60

inflammatory bowel disease? References:  Severe, persistent constipation that is  Clinical knowledge Summaries  The management of constipation MeReC bulletin July 2004 unresponsive to treatment?  COMPASS Therapeutic notes on the management of constipation in Primary Care January 2012

Eloise Summerfield, Prescribing Advisor Originally produced Nov 13; Updated November 2015 Medicines Management Team, Rotherham CCG Review date November 2017