Managing Constipation in Adults Opio id Induced Constipation ● Use an osmotic laxative (or docusate which also softens stools and a stimulant laxative (consider dantron in terminally ill patients). • Treat any underlying causes of condition (e.g. hypothyroidism, haemorrhoids or anal fissures) ● Naloxegol is recommended by NICE TA345 as an option when opioid • Consider Red Flags (See Box A ) induced constipation has not adequately responded to laxatives. An inadequate response is defined as opioid-induced of at least moderate severity in at least 1of the 4 stool symptoms domain (i.e. incomplete bowel movement, hard stool, straining or false alarm) Review medication –consider stopping any medication that may be causing constipation (see Box B ) whilst taking1 laxative class for at least 4 days during the prior 2 weeks. ● Avoid bulk -forming l axatives for treating opioid induced constipation Acute Constipation

Chronic Constipation ● Check for faecal loading and manage appropriately Lifestyle advise -to increase fibre in diet (see Box C ), adequate fluid and exercise ● Set realistic expectations for the results of treatment of chronic constipation.

Chronic Constipation: First Line treatment • Adjust the dose, choice, and combination of laxative according to symptoms, speed with which Bulk forming laxatives i.e. ispaghula. relief is required, response to treatment, and individual preference. • Ensure adequate fluid intake (caution- frail elderly patients) • The dose of laxative should be gradually titrated upwards (or downwards) to produce one or two • May take several days to act- so not suitable if rapid relief required. soft, formed stools per day. • Not appropriate for opiod induced constipation. • If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months, consider the use of prucalopride in women only and lubiprostone for adults with chronic idiopathic constipation.

Second Line Treatment Prucalopride is recommended by NICE as an option for chronic constipation in women only if: • The prescribing clinician has experience of treating chronic constipation and has carefully reviewed the woman's previous laxative treatments. Soft stools • Treatment with at least two laxatives from different classes, at the highest Hard stools tolerated doses for at least 6 months has failed to provide adequate relief and for Add a stimulant laxative Add or switch to an osmotic laxative whom invasive treatment for constipation is being considered. • • Licensed for short term use. ● Osmotic laxatives may take up to 48 hours to work- so unsuitable for as required use. If treatment with prucalopride is not effective after 4 weeks, the woman should be re-examined and the benefit of continuing treatment reconsidered. • Chronic use may cause diarrhoea and hypokalaemia. ● Lactulose: sickly sweet and side effects include flatulence and cramps- so compliance with treatment may be poor in some patients. ● Avoid Lactulose in constipation-predominant IBS as it causes bloating. ● Macrogols are relatively expensive and some patients may find it difficult to drink the prescribed volume . Lubiprostone is recommended by NICE as an option for chronic idiopathic constipation in adults only if: • The prescribing clinician has experience of treating chronic idiopathic constipation and has carefully reviewed previous laxative treatments. • Treatment with at least two laxatives from different classes, at the highest tolerated doses for at least 6 months has failed to provide Acute Constipation Chronic Constipation adequate relief and for whom invasive treatment is being considered • If treatment with lubiprostone is not effective after 2 weeks, the patient Lactulose or Macrogols Use Macrogols first and if this is not should be re-examined and the benefit of continuing treatment effective or not tolerated, then use lactulose reconsidered .

Acute Constipation : advise the person that laxatives can be stopped once the stools become soft and easily. In all cases consider: • Regular review • Reiterate dietary advice • Weaning or stopping laxative as appropriate(see separate guidance)

Ref: http://cks.nice.org.uk/constipationBox A: Red Flags • Persistent unexplained change in bowel habit? • Palpable mass in the lower right abdomen or the pelvis? • Persistent rectal bleeding without anal symptoms? • Narrowing of stool calibre? • Family history of colon cancer, or inflammatory bowel disease?

• Unexplained weight loss, iron deficiency anaemia, fever, or nocturnal symptoms? • Severe, persistent constipation that is unresponsive to treatment?

Box B: Drugs commonly cause constipation in adults • Aluminium antacids • Antimuscarinics (such as procyclidine, oxybutynin) ● Anti-depressants (most commonly tricyclic antidepressants, but others may cause constipation in some individuals) • Some antiepileptics (for example carbamazepine, gabapentin, oxcarbazepine, pregabalin, phenytoin) • Antiparkinsonism drugs including those with anticholinergic effects (e.g. benztropine, orphenadrine and procyclidine) and dopamine agonists • Antipsychotics • Antispasmodics (such as dicycloverine, hyoscine) • Calcium supplements • Diuretics (secondary to dehydration) • Iron supplements • Opiods • Proton Pump Inhibitors • Verapamil.

Box C: Dietary advice

• In general, the diet should be balanced and contain whole grains, fruits, and vegetables. This is recommended as part of the treatment for constipation. It is also recommended for general health and promoted by the 'five-a-day' policy. • Fibre intake should be increased gradually (to minimize flatulence and bloating) and maintained for life. o Adults should aim to consume 18–30 g fibre per day. o Although the effects of a high fibre diet may be seen in a few days, it may take as long as 4 weeks. • Adequate fluid intake is important (particularly with a high fibre diet or fibre supplements), but can be difficult for some people (for example, the frail or elderly). • Fruits high in fibre and sorbitol, and fruit juices high in sorbitol can help prevent and treat constipation.

Ref: http://cks.nice.org.uk/constipation Version 2 (10.8.15)