lRENAL IMPAIRMENT
▶In adultsAvoid if eGFR less than30mL/minute/1.73m2— risk of hypermagnesaemia.
▶In childrenAvoid if estimated glomerularfiltration rate less than30mL/minute/1.73m2—risk of hypermagnesaemia.
lDIRECTIONS FOR ADMINISTRATIONOne sachet of sodium picosulfate with magnesium citrate powder should be reconstituted with150mL (approx. half a glass) of cold water; patients should be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking.
PICOLAX®SACHETSOne sachet should be reconstituted with150mL (approx. half a glass) of cold water.
CITRAFLEET®SACHETSOne sachet should be reconstituted with150mL (approx. half a glass) of cold water.
lPRESCRIBING AND DISPENSING INFORMATIONFlavours of oral powder formulations may include lemon.
PICOLAX®SACHETSOne reconstituted sachet contains K+ 5mmol and Mg2+87mmol.
CITRAFLEET®SACHETSOne reconstituted sachet contains K+5mmol and Mg2+86mmol.
lPATIENT AND CARER ADVICELow residue diet recommended on the day before procedure and copious intake of water or other clearfluids recommended during treatment. Patients or carers should be given advice on how to administer sodium picosulfate with magnesium citrate oral powder.
PICOLAX®SACHETS AND CITRAFLEET®SACHETSLow residue diet recommended on the day before procedure and copious intake of water or other clearfluids recommended during treatment.
Patients and carers should be given advice on how to administer oral powder; they should be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Powder
CAUTIONARY AND ADVISORY LABELS10, 13 ELECTROLYTES:May contain Magnesium, potassium
▶CitraFleet(Casen Recordati S.L.)
Sodium picosulfate 10 mg, Magnesium oxide light 3.5 gram, Citric acid anhydrous 10.97 gramCitraFleet oral powder15.08g sachets sugar-free|2sachetp£3.25
▶Picolax(Ferring Pharmaceuticals Ltd)
Sodium picosulfate 10 mg, Magnesium oxide 3.5 gram, Citric acid anhydrous 12 gramPicolax oral powder16.1g sachets sugar-free| 20sachetP no price available
therefore useful in the treatment of hepatic encephalopathy.
Macrogols (such as macrogol3350with potassium chloride, sodium bicarbonate and sodium chloride p.55) are inert polymers of ethylene glycol which sequesterfluid in the bowel; givingfluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives.
Other drugs used in constipation
Linaclotide p.47is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate to severe irritable bowel syndrome associated with constipation. It increases intestinalfluid secretion and transit, and decreases visceral pain.
Lubiprostone p.54is a chloride-channel activator that is licensed for the treatment of chronic idiopathic constipation in adults whose condition has not responded adequately to lifestyle changes (including dietary changes).
Prucalopride p.58is a selective serotonin5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in women, when other laxatives have failed to provide an adequate response.
Bowel cleansing preparations
Bowel cleansing preparations are used before colonic surgery, colonoscopy or radiological examination to ensure the bowel is free of solid contents; examples include macrogol3350with anhydrous sodium sulfate, potassium chloride, sodium bicarbonate and sodium chloride p.50, citric acid with magnesium carbonate p.48, magnesium citrate with sodium picosulfate p.50and sodium acid phosphate with sodium phosphate p.57. Bowel cleansing treatments are not treatments for constipation.
Management
Short-duration constipation
gIn the management of short-duration constipation (where dietary measures are ineffective) treatment should be started with a bulk-forming laxative, ensuring adequatefluid intake. If stools remain hard, add or switch to an osmotic laxative. If stools are soft but difficult to pass or the person complains of inadequate emptying, a stimulant laxative should be added.h
Opioid-induced constipation
See alsoConstipationunder Prescribing in palliative care p.23.gIn patients with opioid-induced constipation, an osmotic laxative (or docusate sodium to soften the stools) and a stimulant laxative is recommended. Bulk-forming laxatives should be avoided.
Naloxegol p.63is recommended for the treatment of opioid-induced constipation when response to other laxatives is inadequate.h
Methylnaltrexone bromide p.62is licensed for the treatment of opioid-induced constipation when response to other laxatives is inadequate. Manufacturer advises that in patients receiving palliative care, methylnaltrexone bromide should be used as an adjunct to existing laxative therapy.
Faecal impaction
The treatment of faecal impaction depends on the stool consistency.gIn patients with hard stools, a high dose of an oral macrogol (such as macrogol3350with potassium chloride, sodium bicarbonate and sodium chloride) may be considered. In those with soft stools, or with hard stools after a few days treatment with a macrogol, an oral stimulant laxative should be started or added to the previous treatment. If the response to oral laxatives is inadequate, for soft stools consider rectal administration of bisacodyl, and for hard stools rectal administration of glycerol alone, or glycerol plus bisacodyl. Alternatively, a docusate sodium p.58or sodium citrate p.743enema may be tried.
If the response is still insufficient, a sodium acid phosphate with sodium phosphate p.57or arachis oil p.58 retention enema may be necessary. For hard faeces it can be helpful to give the arachis oil enema overnight before giving
a sodium acid phosphate with sodium phosphate or sodium citrate enema the following day. Enemas may need to be repeated several times to clear hard impacted faeces.h Chronic constipation
gIn the management of chronic constipation, treatment should be started with a bulk-forming laxative, whilst ensuring good hydration. If stools remain hard, add or change to an osmotic laxative such as a macrogol. Lactulose p.55is an alternative if macrogols are not effective, or not tolerated. If the response is inadequate, a stimulant laxative can be added. The dose of laxative should be adjusted gradually to produce one or two soft, formed stools per day.
If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6months, the use of prucalopride p.58(in women only) or lubiprostone p.54should be considered. If treatment with prucalopride is not effective after4weeks, or lubiprostone is not effective after2weeks, the patient should be re-examined and the benefit of continuing treatment reconsidered.
Laxatives can be slowly withdrawn when regular bowel movements occur without difficulty, according to the frequency and consistency of the stools. If a combination of laxatives has been used, reduce and stop one laxative at a time; if possible, the stimulant laxative should be reduced first. However, it may be necessary to also adjust the dose of the osmotic laxative to compensate.h
Constipation in pregnancy and breast-feeding
gIf dietary and lifestyle changes fail to control constipation in pregnancy,fibre supplements in the form of bran or wheat are likely to help women experiencing constipation in pregnancy, and raise no serious concerns about side-effects to the mother or foetus.
A bulk-forming laxative is thefirst choice during pregnancy iffibre supplements fail. An osmotic laxative, such as lactulose, can also be used. Bisacodyl p.59or senna p.61may be suitable if a stimulant effect is necessary but use of senna should be avoided near term or if there is a history of unstable pregnancy. Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause side-effects (diarrhoea and abdominal discomfort), reducing their acceptability to patients. Docusate sodium and glycerol p.61suppositories can also be used.
A bulk-forming laxative is thefirst choice during breast-feeding, if dietary measures fail. Lactulose or a macrogol may be used if stools remain hard. As an alternative, a short course of a stimulant laxative such as bisacodyl or senna can be considered.h
Constipation in children
Early identification of constipation and effective treatment can improve outcomes for children. Without early diagnosis and treatment, an acute episode of constipation can lead to analfissure and become chronic.
gThefirst-line treatment for children with constipation requires the use of a laxative in combination with dietary modification or with behavioural interventions.
Diet modification alone is not recommended asfirst-line treatment.
In children an increase in dietaryfibre, adequatefluid intake, and exercise is advised. Diet should be balanced and contain fruits, and vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals. Unprocessed bran (which may cause bloating andflatulence and reduces the absorption of micronutrients) isnotrecommended.
If faecal impaction is not present (or has been treated), the child should be treated promptly with a laxative. A macrogol (such as macrogol3350with potassium chloride, sodium bicarbonate and sodium chloride p.55) is preferred asfirst-line management. If the response is inadequate, add
52 Constipation and bowel cleansing
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a stimulant laxative or change to a stimulant laxative if the first-line therapy is not tolerated. If stools remain hard, lactulose or another laxative with softening effects, such as docusate sodium can be added.
In children with chronic constipation, laxatives should be continued for several weeks after a regular pattern of bowel movements or toilet training is established. The dose of laxatives should then be tapered gradually, over a period of months, according to response. Some children may require laxative therapy for several years.
A shorter duration of laxative treatment may be possible in some children with a short history of constipation.
Laxatives should be administered at a time that produces an effect that is likely tofit in with the child’s toilet routine.
h
Faecal impaction in children
gTreatment of faecal impaction may initially increase symptoms of soiling and abdominal pain. In children over 1year of age with faecal impaction, an oral preparation containing a macrogol (such as macrogol3350with potassium chloride, sodium bicarbonate and sodium chloride) is used to clear faecal mass and to establish and maintain soft well-formed stools, using an escalating dose regimen depending on symptoms and response. If disimpaction does not occur after2weeks, a stimulant laxative can be added or if stools are hard, used in combination with an osmotic laxative such as lactulose.
Long-term regular use of laxatives is essential to maintain well-formed stools and prevent recurrence of faecal impaction; intermittent use may provoke relapses.h
LAXATIVES
›
BULK-FORMING LAXATIVESIspaghula husk
24-Feb-2016 lDRUG ACTIONBulk-forming laxatives relieve constipationby increasing faecal mass which stimulates peristalsis.
lINDICATIONS AND DOSE Constipation
▶BY MOUTH
▶Child 1 month–5 years:2.5–5mL twice daily, dose to be taken only when prescribed by a doctor, as half or whole level spoonful in water, preferably after meals, morning and evening
▶Child 6–11 years:2.5–5mL twice daily, dose to be given as a half or whole level spoonful in water, preferably after meals, morning and evening
▶Child 12–17 years:1sachet twice daily, dose to be given in water preferably after meals, morning and evening
▶Adult:1sachet twice daily, dose to be given in water preferably taken after food, morning and evening DOSE EQUIVALENCE AND CONVERSION
▶1sachet equivalent to2level5ml spoonsful.
lCONTRA-INDICATIONSColonic atony
.
faecal impaction.
intestinal obstruction
.
reduced gut motilitylCAUTIONSAdequatefluid intake should be maintained to avoid intestinal obstruction
lSIDE-EFFECTSAbdominal distension
.
flatulence.
gastro-intestinal impaction.
gastro-intestinal obstruction.
hypersensitivity
lDIRECTIONS FOR ADMINISTRATIONDose to be taken with at least150mL liquid.
lPRESCRIBING AND DISPENSING INFORMATIONFlavours of soluble granules formulations may include plain, lemon, or orange.
lHANDLING AND STORAGEIspaghula husk contains potent allergens. Individuals exposed to the product (including those handling the product) can develop hypersensitivity
reactions such as rhinitis, conjunctivitis, bronchospasm and in some cases, anaphylaxis.
lPATIENT AND CARER ADVICEManufacturer advises that preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed. Patients and their carers should be advised that the full effect may take some days to develop and should be given advice on how to administer ispaghula husk.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Effervescent granules
CAUTIONARY AND ADVISORY LABELS13 EXCIPIENTS:May contain Aspartame
▶Ispaghula husk (Non-proprietary)
Ispaghula husk 3.5 gramIspaghula husk3.5g effervescent granules sachets gluten free sugar free sugar-free|30sachetp no price available DT price = £2.72
▶Fybogel(Reckitt Benckiser Healthcare (UK) Ltd)
Ispaghula husk 3.5 gramFybogel3.5g effervescent granules sachets plain SF sugar-free|30sachetG£2.72DT price = £2.72 Fybogel Orange3.5g effervescent granules sachets SF sugar-free|30 sachetG £2.72DT price = £2.72
Fybogel Lemon3.5g effervescent granules sachets SF sugar-free|30 sachetG £2.72DT price = £2.72
▶Fybogel Hi-Fibre(Reckitt Benckiser Healthcare (UK) Ltd) Ispaghula husk 3.5 gramFybogel Hi-Fibre Orange3.5g effervescent granules sachets sugar-free|10sachetG £2.26sugar-free|30 sachetG £4.85DT price = £2.72
Fybogel Hi-Fibre Lemon3.5g effervescent granules sachets sugar-free
|10sachetG £2.26
▶Ispagel(Bristol Laboratories Ltd)
Ispaghula husk 3.5 gramIspagel Orange3.5g effervescent granules sachets sugar-free|10sachetG £1.65sugar-free|30 sachetG £2.45DT price = £2.72
Granules
CAUTIONARY AND ADVISORY LABELS13 EXCIPIENTS:May contain Aspartame
▶Ispaghula husk (Non-proprietary)
Ispaghula husk 3.5 gramIspaghula husk3.5g granules sachets gluten free|30sachetG£2.72
Combinations available:Senna with ispaghula husk,p.62
Methylcellulose
lDRUG ACTIONBulk-forming laxatives relieve constipation by increasing faecal mass which stimulates peristalsis.
lINDICATIONS AND DOSE Constipation|Diarrhoea
▶BY MOUTH USING TABLETS
▶Adult:3–6tablets twice daily
lCONTRA-INDICATIONSColonic atony
.
difficulty in swallowing.
faecal impaction.
infective bowel disease.
intestinal obstruction
lCAUTIONSAdequatefluid intake should be maintained to avoid intestinal obstruction
CAUTIONS, FURTHER INFORMATION
It may be necessary to supervise elderly or debilitated patients or those with intestinal narrowing or decreased motility to ensure adequatefluid intake.
lSIDE-EFFECTSAbdominal distension (especially during thefirst few days of treatment)
.
flatulence (especially during thefirst few days of treatment).
gastro-intestinal impaction.
gastro-intestinal obstruction.
hypersensitivity lDIRECTIONS FOR ADMINISTRATIONIn constipation thedose should be taken with at least300mL liquid. In diarrhoea, ileostomy, and colostomy control, avoid liquid intake for30minutes before and after dose.
lPATIENT AND CARER ADVICEPatients and their carers should be advised that the full effect may take some days
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to develop. Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Tablet
▶Celevac(AMCo)
Methylcellulose "450" 500 mgCelevac500mg tablets|112 tabletG £3.22DT price = £3.22
Sterculia
19-Feb-2016lDRUG ACTIONSterculia is a bulk-forming laxative. It relieves constipation by increasing faecal mass which stimulates peristalsis.
lINDICATIONS AND DOSE Constipation
▶BY MOUTH
▶Child 6–11 years:0.5–1sachet1–2times a day, alternatively, half to one heaped5-mL spoonful once or twice a day; washed down without chewing with plenty of liquid after meals
▶Child 12–17 years:1–2sachets1–2times a day, alternatively, one to two heaped5-mL spoonfuls once or twice a day; washed down without chewing with plenty of liquid after meals
▶Adult:1–2sachets1–2times a day, alternatively, one to two heaped5-mL spoonfuls once or twice a day;
washed down without chewing with plenty of liquid after meals
lCONTRA-INDICATIONSColonic atony
.
difficulty in swallowing.
faecal impaction.
intestinal obstruction lCAUTIONSAdequatefluid intake should be maintained toavoid intestinal obstruction CAUTIONS, FURTHER INFORMATION
▶In adultsIt may be necessary to supervise elderly or debilitated patients or those with intestinal narrowing or decreased motility to ensure adequatefluid intake.
lSIDE-EFFECTSAbdominal distension (especially during thefirst few days of treatment)
.
flatulence (especially during thefirst few days of treatment).
gastro-intestinal impaction.
gastro-intestinal obstruction.
hypersensitivity lDIRECTIONS FOR ADMINISTRATIONMay be mixed with soft food (e.g. yoghurt) before swallowing, followed by plenty of liquid.lPATIENT AND CARER ADVICEPatients and their carers should be advised that the full effect may take some days to develop. Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Granules
CAUTIONARY AND ADVISORY LABELS25, 27
▶Normacol(Norgine Pharmaceuticals Ltd)
Sterculia 620 mg per 1 gramNormacol granules7g sachets|60 sachetG £6.35DT price = £6.35
Normacol granules|500gramG£7.54DT price = £7.54
Sterculia with frangula
The properties listed below are those particular to the combination only. For the properties of the components please consider, sterculia above.
lINDICATIONS AND DOSE After haemorrhoidectomy
▶BY MOUTH
▶Adult:1–2sachets1–2times a day, alternatively,1–2 heaped5mL spoonfuls once or twice a day; washed down without chewing with plenty of liquid after meals Constipation
▶BY MOUTH
▶Adult:1–2sachets1–2times a day, alternatively,1–2 heaped5mL spoonfuls once or twice a day; washed down without chewing with plenty of liquid after meals
lPREGNANCYManufacturer advises avoid.
lBREAST FEEDINGManufacturer advises avoid.
lPATIENT AND CARER ADVICEPatients and their carers should be advised that the full effect may take some days to develop. Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Granules
▶Normacol Plus(Norgine Pharmaceuticals Ltd) Frangula 80 mg per 1 gram, Sterculia 620 mg per
1 gramNormacol Plus granules7g sachets|60sachetG£6.78 DT price = £6.78
Normacol Plus granules|500gramG£8.05DT price = £8.05
LAXATIVES