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
Investigate Antispasmodics Ensure non-drug
option in initiation of high
possible causes 3
fibre, fluid &
interventions first
dose opioids.
2 Use soluble fibre exercise
category
Then ADD Stimulant Bulk forming Softener Softener Bulk forming
with plenty of fluid With plenty of fluid
in the next
step (unless Softener Softener Osmotic Stimulant Lactulose
other-wise
stated)
Osmotic Stimulant Stimulant Osmotic Senna 4
Reduce &
DO NOT use STOP ALL Bulk forming may
remove cause blockage
Only use these
bulk forming
Osmotic LAXATIVES then drugs in
the last See palliative care start Linaclotide pregnancy and
guidelines for the
step when use of breast-feeding
REFER to Secondary care to except on
controlled co-danthramer &
consider Prucalopride (women) consultant advice
co-danthrusate

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 423283

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)
OR senna 2 at night (max 2 BD)
OR glycerin suppositories PRN
Osmotic
Macrogol 1 to 3 sachets daily
OR lactulose 15ml BD
Impaction - Prevent reoccurance with lifestyle advice and regular
laxatives. Exact treatment depends on cause and size of impaction,
advice maybe required from the stoma service or secondary care.
Options include:
Glycerin or bisacodyl supppositories
Phosphate or arachis (peanut) oil enemas
Macrogol disimpaction regimen (use with caution)

Linaclotide 290mcg once daily 1

Irritable Bowel Syndrome www.patient.co.uk leaflet
(See overleaf) 2
Greater than 120mg codeine /day (i.e. co-codamol 30/500) or strong opioids (i.e. morphine MR)
3
fruit, root vegetables & oats NOT insoluble fibre of bran, whole grains & cereals
Prucalopride - RED refer 4
not near term or unstable pregnancy
( See overleaf )

Eloise Summerfield, Prescribing Advisor Produced November 2013

Medicines Management Team, Rotherham CCG Review date November 2015
Background information Advantages Disadvantages
Bulk-forming laxatives (such as Useful first-line choice Adequate fluid intake is important, to prevent
ispaghula) retain fluid within the in 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
Osmotic laxatives (macrogols & It can be difficult to drink the prescribed volume of
Produce softer stools
lactulose) increase fluid in the large macrogol. If adequate fluid is not taken it can lead
with a larger volume
bowel. This produces distension, to dehydration. They may be counter-productive in
and improved
leading to stimulation of peristalsis. patients with IBS. Side-effects include flatulence,
propulsion.
Prescribing macrogol by brand bloating, cramping and nausea. Lactulose causes
2-3 days to effect
provides cost-savings due to drug colic due to breakdown by bacteria, and is NOT
tariff pricing (Cosmocol/Laxido) recommended for IBS patients.
Stimulant laxatives cause Also require the stool to be softened by increasing
peristalsis by stimulating colonic Rapid effect dietary fibre and liquid or another laxative (softener /
nerves (senna) or colonic and rectal 6-12 hours to effect osmotic). Side-effects include cramps & diarrhoea,
nerves (bisacodyl). and should be avoided in intestinal obstruction
Surface-wetting agents (docusate) A useful alternative for
reduces the surface tension of the people who find it Side-effects of abdominal cramps and diarrhoea.
stool, allowing water to penetrate hard to increase their Often needs an additional laxative to be added (either
and soften it. It also has a weak fluid intake. stimulant or osmotic).
stimulant effect. 12-72 hours to effect
Linaclotide is only licensed for patients with Irritable Bowel Syndrome (IBS)
Linaclotide is a Guanylate cyclase- with constipation and recommended for a limited number of patients in whom
C receptor agonist causing ALL other laxative treatment options have been ineffective or contraindicated.
decreased visceral pain, increased (Antispasmodics may still be used. Tricyclic antidepressants are an option for
intestinal fluid secretion and their analgesic effect, but use with caution as they may worsen constipation.)
accelerated intestinal transit. Review after 4 weeks & at regular intervals thereafter.
Novel action so is an alternative There is no long-term data for the efficacy
to traditional laxatives. or side-effects of this treatment.
RED lighted so prescribing remains with the consultant. As per NICE
Prucalopride is a selective, high-
TA211. For women only, after 6 months treatment of at least two classes of
affinity, serotonin (5HT4) receptor
laxatives at maximum tolerated doses. Review after 4 weeks.
agonist, and has enterokinetic
Novel action so is an The most common adverse effects include headache
effects, enhancing intestinal
alternative to and gastro-intestinal symptoms (abdominal pain,
motility.
traditional laxatives. nausea or diarrhoea)

RED flags: Bisacodyl 5mg 4on

Cost for 28 days for Laxatives.
Persistent unexplained change in Ispaghula 2 sachets daily
November 2013
bowel habit?
Lactulose 15mls bd
Persistent rectal bleeding without anal
symptoms? Docusate 100mg 2 bd
Narrowing of stool calibre? Macrogol (Cosmocol) 3 od
Palpable mass in the lower right
Macrogol (Laxido) 3 od
abdomen or the pelvis?
Unexplained weight loss, iron Macrogol (Movicol) 3 od
deficiency anaemia, fever, or Senna 2 bd
nocturnal symptoms?
Linaclotide 290mg od
Family history of colon cancer, or
inflammatory bowel disease? Prucalopride 2mg od
Severe, persistent constipation that is 0 10 20 30 40 50 60
unresponsive to treatment?
References:
Clinical knowledge Summaries
The management of constipation MeReC bulletin July 2004
COMPASS Therapeutic notes on the management of constipation in Primary Care January 2012

Eloise Summerfield, Prescribing Advisor Produced November 2013

Medicines Management Team, Rotherham CCG Review date November 2015