1.2 Constipation and bowel cleansing
First line drugs | Second line drugs | Specialist drugs | Secondary care drugs |
Traffic light status (TLS) explained:
- Green: Routine prescribing within licensed indication
- Amber 1: specialist recommendation followed by GP initiation and continuation
- Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
- Amber 3: specialist initiation and stabilisation followed by GP continuation
- Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
- Red: Hospital or specialist prescribing only
2.1 Bowel cleansing
Please note that bowel cleansing preparations are for the hospital to prescribe UNLESS a patient is referred directly for a procedure by their GP. In this instance, their GP should issue an acute prescription for the required amount
Osmotic laxatives
Moviprep®
- Oral powder - Sugar free
Klean-Prep®
- Oral powder - Sugar free
Stimulant laxatives
Picolax®
- Oral powder - Sugar free 10mg/sachet
2.2 Constipation
National guidance
- Clinical Knowledge Summaries: Constipation in adults (Last revised June 2017)
- Clinical Knowledge Summaries: Constipation in pregnancy and breastfeeding (Last reviewed June 2017)
- Use as per NICE NG12 Suspected cancer: recognition and referral guideline (June 2015)
- Use as per NICE CG99: Constipation in children and young people - diagnosis and management (May 2010)
- Bristol Stool Chart (Registration required) - is a medical aid designed to classify the form of human faeces into seven categories
Bulk-forming laxatives
Ispaghula husk
- Sachets 3.5g
Osmotic laxatives
Lactulose
- Solution
Notes:
- Lactulose takes up to 48 hours to work but is often inappropriately used “when required”.
- It is unpleasant to take and compliance may be a problem.
- Its main clinical benefit is in the management of hepatic encephalopathy.
- Should not be routinely prescribed for infrequent constipation in Primary Care or at Discharge
- Advise patient to purchase, unless prescription is for long-term regular use
Macrogol oral powder, compound®
- Laxido® orange oral powder, sachets
- Movicol® – Half sachets
- Movicol® Paediatric plain sachets
Macrogol oral solution
- Movicol® liquid - This preparation is a liquid concentrate. Dosage: 25ml (diluted in 100ml water) 1—3 times daily in divided doses, adjusted according to response. Usual max duration 2 weeks, repeated if required. For extended use, 1 or 2 doses daily.
Notes:
- Laxido® or Movicol® preparations should be reserved only for patients where other treatments have been ineffective.
- Caution: may cause electrolyte disturbances.
- There is currently insufficient evidence to support its routine use before well-established, less expensive drugs.
Sodium Citrate (Rectal)
- Micolette® Micro-enema
- Micralax® Micro-enema
- Relaxit® Micro-enema
Notes:
- Small volume than a phosphate enema
Paraffins
Liquid Paraffin BP
- Oral emulsion
Phosphate-containing drugs
Phosphate
- Enema 128mL
Softening drugs
Arachis oil enema
- Enema 130mL
Note:
- Avoid the use of Arachis oil in patients with a known nut allergy
Docusate sodium
- Capsules 100mg
- Paediatric oral solution - Sugar free 12.5mg/5mL,
- Adult oral solution - Sugar free 50mg/5mL
Stimulant laxatives
Long-term use of stimulant laxatives is not advised due to the potential for damaging the large bowel and the loss of muscle tone in the colon.
Bisacodyl
- Tablets - Enteric coated 5mg
- Suppositories 5mg (paed), 10mg
Notes:
- Bisacodyl tablets should not be prescribed in Primary Care or at Discharge for infrequent constipation
- Advise patient to purchase, unless prescription is for long-term regular use
Senna
- Tablets 7.5mg sennosides
- Syrup - Sugar free 7.5mg sennosides in 5mL
Glycerol
- Suppositories 1g, 2g, 4g
Sodium Picosulfate (Amber 2)
- Dulcolax Pico® liquid
Notes:
- For Paediatric use
Co-danthramer (Amber 2)
- Capsules 25/200
- Strong capsules 37.5/500
- Suspension 25/200 in 5mL
Co-danthrusate (Amber 2)
- Capsules 50/60 (dantron 50mg, docusate sodium 60mg)
Notes:
- The CSM (May 2000) have advised that the indication for danthron containing products has been restricted to constipation in terminally ill patients of all ages. Therefore, co-danthramer and co-danthrusate are included as Specialist Initiated Drugs.
- Most terminally ill patients require both a softening agent and a stimulant laxative, for example.
Chloride-Channel Activators
Lubiprostone (Amber 2)
- Capsules 24 micrograms
Notes:
- Is being withdrawn from the UK (Update Nov 2018)
- No new patients should be prescribed Amitiza from now on.
- Use as per NICE TA318: Lubiprostone for treating chronic idiopathic constipation (July 2014)
- Indication: Chronic idiopathic constipation, adults in whom treatment with at least 2 laxatives from different classes, at the highest tolerated recommended doses for at least 6 months, has failed to provide adequate relief and for whom invasive treatment for constipation is being considered
- Recommended Adult dose is 24 micrograms twice daily for 2 weeks in accordance to NICE TA318
- Lubiprostone must not be put on a repeat prescription
Opioid-receptor antagoinsts (peripheral)
Naloxegol (Amber 2)
- Moventig® Tablets 12.5mg, 25mg
Notes:
- Use as per NICE TA345: Naloxegol for treating opioid induced constipation (July 2015)
Selective 5HT4 receptor agonists
Prucalopride (Amber 2)
- Tablets 1mg, 2mg
Notes:
- Use as per NICE TA211: Prucalopride for the treatment of chronic constipation in women (December 2010)
- Prucalopride is recommended as an option for the treatment of chronic constipation only in women for whom treatment with at least two laxatives from different classes, at the highest tolerated recommended doses for at least 6 months, has failed to provide adequate relief and invasive treatment for constipation is being considered.
- If treatment with prucalopride is not effective after 4 weeks, the woman should be re-examined and the benefit of continuing treatment reconsidered.
Traffic light status (TLS) explained:
- Green: Routine prescribing within licensed indication
- Amber 1: specialist recommendation followed by GP initiation and continuation
- Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
- Amber 3: specialist initiation and stabilisation followed by GP continuation
- Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
- Red: Hospital or specialist prescribing only
Return to Chapter: 1. Gastro-Intestinal System
Last updated by: Dupe Fagbenro on 20-02-2019 10:34