Related guidance:          NICE Clinical Guideline CG99 (2010): Constipation in children and young people

                                                NICE Technical Appraisal TA211 Constipation (women) – prucalopride

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)		Rationale for decision / comments
Keeping adequately hydrated is very important and 20-30% of acute kidney injury could be avoided or prevented as a result. For further advice visit www.thinkkidneys.nhs.uk/
Somerset CCG hydration leaflet can be found on the Medicines Management website.		Useful CKS guide to choosing a laxative here
Stimulant laxatives
First line:

Green crossSenna - suitable for self-care

7.5mg tablets: £2.01 (60)
7.5mg/5ml SF liquid: £3.99 (500ml)		Available OTC.Licensed only for short-term use. Syrup can be unpalatable.
Green crossBisacodyl - suitable for self-care5mg tablets: £5.64 (60)
10mg suppositories: £3.53 (12)		Prescribe generically.Licensed only for short-term use
Available OTC.
Green crossDocusate sodium - suitable for self-care100mg cap,£2.09(30); £6.98 (100)
50mg/5ml sugar-free oral soln, 300ml=£9.19.		Probably acts both as a softening agent and a stimulant. May be a useful alternative for people who find it hard to increase their fluid intake.
Second lineGlycerol suppositories

1g: £1.04 (12)
2g: £1.67 (12)
4g: £1.15 (12)
Glycerin suppository sizes:
• 1g = infant
• 2g = child
• 4g = adult
All available OTC
Osmotic laxatives
First line		Macrogol
as Laxido® Orange (sugar free)


as Cosmocol®


as Cosmocol Half®


as Cosmocol Paediatric®		13.125g Sachets:£4.10 (30)





13.125g Sachets: £4.10 (30)



6.9g Sachets: £4.10 (30)


6.9g Sachets: £2.99 (30)		NICE Cochrane QP review in June 2010 concluded that polyethylene glycol (macrogol) should be used in preference to lactulose for chronic constipation. Using polyethylene glycol in preference to lactulose is likely to improve the quality of patient care by reducing the use of a less effective treatment.
Course of treatment for chronic constipation not normally > 2 weeks.
A stimulant laxative should be added if disimpaction is not achieved after 2 weeks.
Efficacy requires adequate fluid intake. Contains Na+, care in patients with hypertension / heart failure. Laxido® replaces Movicol® as lower cost brand equivalent.
NICE says prescribe oral macrogols as first-line treatment for children and young people with newly diagnosed idiopathic constipation.
Please note MHRA Drug Safety Update: Polyethylene glycol (PEG) laxatives and starch-based thickeners: potential interactive effect when mixed, leading to an increased risk of aspiration

Cosmocol comes in the following flavours: orange, lemon and lime, orange lemon and lime, plain.

Movicol Half is half the dose of standard (minimum 12 years age)

Paediatric for children 2-11

ERIC (the Children’s Bladder and Bowel Charity) have some useful resources around constipation.
Bulk forming laxatives
Second line		Ispaghula husk effervescent granule "as Fybogel brand"Sachets: £2.48 (30)


Gluten free and sugar free
Third lineLactulose3.35g/5ml solution: £2.79 (500ml)Some people find it sickly sweet and unpalatable. Adequate fluid intake recommended. If used alone in opioid-induced constipation, it often needs to be given in large doses that cause bloating and colic.Takes 2 to 3 days to exert effect, “prn” use ineffective; should be taken with additional fluid. Therapeutic dose for adults 15ml twice daily. Available OTC.

Not recommended for use in inflammatory bowel disease.
Other drugs used in constipationPrucalopride1mg tablets:£38.69 (28)
2mg tablets:£59.52 (28)
As per NICE TA211 2010, for chronic constipation in women only 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 is being considered. Re-evaluate after 4 weeks treatment.

Also licensed for use in men and agreed by SPF 2015, as per criteria stated in NICE TA211.
Linaclotide290 microgram capsule, £37.56 (28)Consider linaclotide for people with IBS only if:
Optimal or maximum tolerated doses of previous laxatives from different classes have not helped
and
they have had constipation for at least 12 months.
Follow up people taking linaclotide after 3months. [new 2015]
Not under 18 years
Pre-op Bowel Cleansing SolutionsN/ABowel cleansing medicine may modify the absorption of regularly prescribed medications. Urea and Electrolytes should be checked in all patients to minimise the risk of electrolyte imbalance particularly patients taking the following medications:
Diuretics, corticosteroids, cardiac glycosides, NSAIDs, tricyclics, SSRIs, antipsychotics, carbamazepine.
See NPSA Alert and local guidelines for details.
Peripheral opioid-receptor antagonistNaloxegol 12.5mg film coated tablets: £55.20
25mg film coated tablets: £55.20
Naloxegol as an option for treating opioid induced constipation in adults whose constipation has not adequately responded to laxatives. The recommended dose is 25 mg taken orally once daily (or 12.5 mg for people with renal insufficiency).

An inadequate response is defined as opioid‑induced constipation symptoms of at least moderate severity in at least 1 of the 4 stool symptom domains (that is, incomplete bowel movement, hard stools, straining or false alarms) while taking at least 1 laxative class for at least 4 days during the prior 2 weeks.



NICE TA345 (July 2015): http://www.nice.org.uk/guidance/ta345
Naldemedine200mcg tablets Rizmoic® (Naldemedine 200mcg) tablets as an option for treating opioid induced constipation in adults whose constipation has not adequately responded to laxatives. Inadequate response as defined above for Naloxegol.

NICE [TA651]

AMBER drug
Peripheral opioid-receptor antagonistMethylnaltrexone Injection 12mg/0.6ml£21.05 (single vial)
£147.35 (7 vial pack)
Injection for opioid-induced constipation in terminally ill patients, when response to other laxatives is inadequate. Used in addition to existing laxative therapy.
Not licensed for use in any other circumstance

NICE TA277: http://www.nice.org.uk/guidance/ta277

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