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

 

 

 

 

 

  • 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:

 

Selective 5HTreceptor 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