1.2 – Constipation and bowel cleansing – Somerset Prescribing Formulary

Related guidance:

Constipation

The most common causes include:
- not eating enough fibre, which is found in fruits, vegetables and cereals
- not drinking enough fluids
- not moving enough and spending long periods sitting or lying down
- being less active and not exercising
- often ignoring the urge to go to the toilet
- changing your diet or daily routine
- a side effect of medicine e.g. anticholinergics
- stress, anxiety or depression
If you are caring for someone with dementia, constipation may be easily missed. Look out for any behaviour changes, as it might mean they are in pain or discomfort.

www.thinkkidneys.nhs.uk

General resources and patient information leaflets.

Reducing risk of harm from oral bowel cleansing solutions (NPSA February 2009)

Death and harm from electrolyte abnormalities, dehydration and serious gastro-intestinal problems have been reported following the inappropriate use of oral bowel cleansing solutions prior to surgery and/or investigative procedures. Frail and debilitated elderly patients, children and those with contraindications are particularly at risk from these treatments.
Need to ensure that a clinical assessment is undertaken by the clinician authorising the surgery or investigative procedure (including GPs using the direct access route) to ensure that there is no contraindication (e.g. clinical condition such as diverticulitis) or risks (e.g. concurrent medication such as diuretics) from the use of a bowel cleansing solution.

Therapeutic Area	Formulary Choices	Cost for 28 (unless otherwise stated)	Rationale for decision / comments
Stimulant laxatives	Senna - suitable for self-care	7.5mg tablet: £1.98 (60) 7.5mg/5ml oral solution sugar free: £8.14 (500ml)	For short-term use only.
	Bisacodyl - suitable for self-care	5mg gastro resistant tablet: £3.34 (60) 10mg suppository: £2.77 (12)	For short-term use only.
	Glycerol - suitable for self-care	1g suppository: £3.43 (12) 2g suppository: £3.13 (12) 4g suppository: £3.14 (12)	One suppository should be dipped in water before insertion and administered rectally when required. 1g = infant 2g = child 4g = adult
Softening laxatives	Docusate sodium - suitable for self-care	100mg capsule: £2.09 (30), £6.98 (100) 50mg/5ml oral solution sugar free £17.50 (300ml)
Osmotic laxatives	Treatment of constipation is less effective if faecal impaction is not dealt with first. Disimpaction with oral macrogols is recommended for children and their use avoids the need for rectal treatments. This product is considered high in sodium. This should be particularly taken into account for those on a low salt diet (in some cases of congestive heart failure and renal impairment). Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation. See Cochrane review (July 2010) for Lactulose versus Polyethylene Glycol for Chronic Constipation. Addition of a polyethylene glycol (PEG)-based laxative to a liquid that has been thickened with a starch-based thickener may counteract the thickening action, placing patients with dysphagia at a greater risk of aspiration. See MHRA Drug Safety Update (April 2021) for Polyethylene glycol (PEG) laxatives and starch-based thickeners: potential interactive effect when mixed, leading to an increased risk of aspiration.
	Macrogol as *Laxido Orange®*	13.125g powder for oral solution sachet : £4.72 (30)	Sugar free.
	as *Cosmocol®*	13.125g powder for oral solution sachet: £4.72 (30)	Sugar free. Plain, orange, lemon and lime or orange, lemon and lime.
	as *Cosmocol Half®*	6.9g powder for oral solution sachet: £4.29 (30)	Sugar free.
	as *Cosmocol Paediatric®*	6.9g powder for oral solution sachet: £2.99 (30)	Sugar free.
	Lactulose - suitable for self-care	3.1-3.7g/5ml oral solution: £2.92 (500ml)	May take up to 48 hours to act. *Do not use in inflammatory bowel disease.*
Bulk forming laxatives	Ispaghula husk as *Fybogel ®*	3.5g effervescent granules sachet: £4.00 (30)	Gluten free, sugar free and sodium free. Plain, orange or lemon.
Selective 5-HT4 receptor agonist with prokinetic properties	Prucalopride	1mg tablet: £38.69 2mg tablet: £51.19	As per NICE 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. Approved for use in men as per NICE criteria (SPF 2015).
Guanylate cyclase-C receptor agonist	Linaclotide	290mcg capsule: £37.56	NHS Somerset classify as an Amber drug as per Traffic light guidance. Named patient basis only while defining which patients will benefit. 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.
Opioid receptor antagonists	Naloxegol	12.5mg tablet: £55.20 (30) 25mg tablet: £55.20 (30)	For treating opioid induced constipation as per NICE TA345 in adults whose opioid induced constipation has not responded to laxatives. 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.
	Naldemedine	200mcg tablet: £41.72	For treating opioid induced constipation in adults whose constipation has not adequately responded to laxatives as defined above for Naloxegol. As per NICE TA651 NHS Somerset classify as an Amber drug as per Traffic light guidance.
	Methylnaltrexone	12mg/0.6ml solution for injection vial: £21.05 (1) £147.35 (7)	For opioid-induced constipation in terminally ill patients, when response to other laxatives is inadequate on a named patient basis only. NHS Somerset classify as black (not recommended) for treating opioid-induced constipation as per Traffic light guidance.