Pathway for the Treatment of in Adults

Patient with constipation: Must be 18 years and older, and not pregnant • Take patient history and undertake physical examination

Absence of ‘red flags’: Defecation is unsatisfactory because of infrequent Presence of ‘red flags’ (see box A overleaf): Refer to secondary care as this stools, difficult stool passage, or seemingly incomplete defecation. Stools may be indicative of a serious underlying condition. Extra vigilance are often dry and hard, and may be abnormally large or abnormally small1 required in patients who may have difficulty communicating their symptoms e.g. patients with learning disability.

1. Dietary and life style adjustment for 4 weeks: Increase exercise, dietary fibre and fluid intake. 2. Consider adjusting any constipating medication. See box B overleaf for examples of constipating drugs

Non-opioid induced constipation Persisting constipation Opioid induced constipation

Continue dietary and lifestyle adjustment and initiate treatment with a bulk- forming laxative for two months. Aim for the highest tolerated recommended dose. Continue dietary and lifestyle adjustment and initiate • Ispaghula husk granules - Time to effect: 2-3 days laxative treatment. Consider prescribing a combination of: No Does constipation persist? Discontinue . See box C overleaf - An osmotic laxative Yes o compound oral powder sachets – Time to effect: 2-3 days Switch to or add an osmotic laxative for a further two months. Aim for the highest tolerated recommended dose. o 3.1–3.7g/5ml solution - Time to effect: 2-3 • Macrogol compound oral powder sachets – Time to effect: 2-3 days days; (May not be tolerated in elderly) • Lactulose 3.1–3.7g/5ml solution – Time to effect: 2-3 days (May not be tolerated in elderly) - A stimulant laxative • o Senna 7.5mg tablets - Time to effect: 8-12 hours Yes No o 5mg tablets - Time to effect: 6-12 hours Does constipation persist? Discontinue laxatives. See box C overleaf o sodium 100mg capsules - Time to effect: Yes 12-72 hours (also has stool-softening properties) Add a stimulant laxative for a further two months. Aim for the highest tolerated - – in line with NICE TA345, where constipation recommended dose. has not responded to laxative treatment. • Senna 7.5mg tablets – Time to effect: 8-12 hours • Bisacodyl 5mg tablets – Time to effect: 6-12 hours • Adjust laxative dose to optimise response • Docusate sodium 100mg capsules – Time to effect: 12-72 hours • Continue long term to prevent constipation • Sodium picosulfate 5mg/5ml elixir – Time to effect: 6-12 hours • Do not prescribe bulk-forming laxatives (e.g. ispaghula husk granules) Constipation Inadequate relief despite at least 6 months treatment with the resolved above laxatives Discontinue Patient considered to have chronic constipation – bowels open laxatives. See not more than 3 times a week consistently over 6 months2 box C overleaf IBS-C

Stop the above laxatives Consider treatment with 290mcg capsules as per NICE CG 61 (where no response to 1st line (antispasmodics; laxatives [not lactulose]) or 2nd line (tricyclic or SSRI where TCA not effective)) only if optimal or maximum tolerated doses of previous laxatives from Consider treatment with 1mg or 2mg tablets as per NICE different classes have not helped and they have had technology appraisal guidance 2115 (licensed in both men and women)8,9 constipation for at least 12 months. • Dose: 2mg tablet once daily; Elderly >65 years, initially 1mg once daily, increased if necessary to 2mg once daily for four weeks

Effective and well tolerated Ineffective after the first course or Ongoing treatment in primary care, but with regular not well tolerated checks every eight weeks by the GP2 to ensure • Stop prucalopride treatment is effective and well tolerated.

Constipation persisting • Re-check diagnosis • Refer to secondary care

Box A: ‘Red flags’1,2 Box B: Examples of constipating drugs1

• Unexplained weight loss Common constipating drugs are • Rectal bleeding • opioids, • iron deficiency anaemia, • iron supplements • antipsychotics. • Persistent change in bowel habit for >4 weeks after the age of 45 years old Others include • Significant abdominal pain • Palpable mass in the abdomen or the pelvis • aluminium antacids, • antimuscarinics (such as procyclidine, oxybutynin), • Family history of colon cancer, ovarian cancer or • IBD antidepressants (most commonly tricyclic antidepressants, but others may cause constipation in some individuals), • Fever • some antiepileptics (such as carbamazepine, gabapentin, oxcarbazepine, • nocturnal symptoms pregabalin, phenytoin), • sedating antihistamines, • antispasmodics (such as dicycloverine, hyoscine), • calcium supplements, • diuretics • verapamil.

Box C: Discontinuing laxatives

• Laxatives can be slowly withdrawn 2–4 weeks after defecation has become comfortable and a regular bowel pattern with soft, formed stools has been established • Wean gradually to minimise risk of requiring 'rescue therapy' for recurrent faecal loading. • If more than one laxatives have been used, reduce and stop one at a time • Begin by reducing stimulant laxatives first, if possible • Advise the person that it can take several months to be successfully weaned off all laxatives. • Relapses are common. Treat early with increased laxative doses.

Produced by the Medicines Management Team, Dorset CCG. Review date October 2020 Approved by Dorset Medicines Advisory Group May 2019. Adapted from a document published by West Suffolk CCG in partnership with the WSFT (Version 1, July 2015)

References

1. NICE (2017): Clinical Knowledge Summaries. [Online]: NICE. Available: http://cks.nice.org.uk/constipation [Last accessed 18 October 2018] 2. Specialist opinions of gastroenterologists at West Suffolk Foundation Trust 3. NICE (2013): NICE Evidence Summary 16 – Irritable bowel syndrome with constipation in adults: linaclotide 4. NICE (2015): NICE Technology Appraisal guidance 345: Naloxegol for treating opioid‑induced constipation 5. NICE (2014): NICE technology appraisal guidance 211 – Prucalopride for the treatment of chronic idiopathic constipation in women 6. Electronic Medicines Compendium (eMC): SPC – Constella 290mg hard capsules [online]: Datapharm. Available: [Last accessed 19/10/2018] 7. Electronic Medicines Compendium (eMC): SPC – Moventig 12.5mg and 25mg tablets [online]: Datapharm. Available: [Last accessed 19/10/2018] 8. Electronic Medicines Compendium (eMC): SPC – Resolor 1mg film-coated tablet. [online]: Datapharm. Available: [Last accessed 19/10/2018] 9. Electronic Medicines Compendium (eMC): SPC – Resolor 2mg film-coated tablet. [online]: Datapharm. Available: [Last accessed 19/10/2018] 10. BMJ Group and Pharmaceutical Press (2015): British National Formulary. [Online]: BMJ Group and Pharmaceutical Press. Available: [Last accessed 19/10/2018] 11. Haymarket Media Group Limited (2015): MIMS. [Online]: Haymarket Media Group Limited. Available: [Last accessed 19/10/2018] 12. NHS Business Services Authority and NHS Prescription Services (2015): NHS England and Wales: Electronic Drug Tariff. [Online] 13. Dorset Commissioning Statement for prucalopride (March 2017) – link in box as well 14. Dorset Commissioning Statement for linaclotide (December 2014)