Introduction

Constipation is the passage of small, hard faeces infrequently or with difficulty, and less often than is normal for that individual. Constipation can cause unpleasant symptoms such as abdominal and rectal pain, distension, nausea and vomiting, and other negative effects on the patient’s wellbeing. As well as the physical suffering, constipation can cause psychological distress and agitation in the terminally ill patient.

There are many reasons why patients with palliative care needs may develop constipation.

Constipation can be complex and may require specialist advice if the current treatment regime is not successful.

 

Assessment

A full assessment of the patient and their symptoms should be obtained looking at:

  • normal and current bowel pattern (frequency, consistency, ease of passage, blood present, pain on passing stool)
  • current and previous laxatives taken regularly (or as needed) and their effectiveness
  • clinical features (may mimic bowel obstruction or intra-abdominal disease):
    • pain
    • nausea and vomiting, anorexia
    • flatulence, bloating, malaise
    • overflow diarrhoea
    • urinary retention
  • possible causes of the constipation (clarify cause before starting treatment):
    • medication: opioids, antacids, diuretics, iron, 5HT3 antagonists
    • secondary effects of illness (dehydration, immobility, poor diet, anorexia)
    • tumour in, or compressing, bowel wall
    • damage to lumbosacral spinal cord, cauda equina or pelvic nerves
    • hypercalcaemia
    • concurrent disease such as diabetes, hypothyroidism, diverticular disease, anal fissure, haemorrhoids, Parkinson’s disease, hypokalaemia.

Abdominal and rectal or stomal examination is necessary, unless it would cause undue distress for the patient. Consent for this must be obtained from the patient.

To exclude bowel obstruction and assess extent of faecal loading, an X-ray may be needed. 

 

Management

The aim of management is to achieve comfortable defaecation, rather than any particular frequency of bowel motion.  

 

Tables are best viewed in landscape mode on mobile devices

Laxative choice

Dosage

Option A (stimulant ± softener)
  • Senna tablets 15mg to 30mg, or bisacodyl tablets 5mg to 10mg, at bedtime.
    • If stools become hard add in softening agent such as docusate sodium 100mg capsule, twice daily.
    • If significant colic occurs, the stimulant should be discontinued and softener used instead.

Option B (osmotic laxative)
  • Macrogol (for example Laxido®) 1 to 3 sachets daily.
    • If severe constipation, consider a higher dose for 3 days.

If option A and B have been unsuccessful progress to Option C

Option C (rectal treatment)
  • Soft loading: bisacodyl suppository, sodium citrate or phosphate enema.
  • Hard loading: glycerol suppository as lubricant or stimulant; then treat as above.
  • Very hard loading: arachis oil enema (except in those with nut allergy) overnight, followed by phosphate enema.

 

Choice of laxative (see Further information - Laxative medicines information chart)

 

The options above may be equally effective

  • Suggested laxative starting doses are provided; these should be titrated as appropriate depending on individual response.
  • Patient preferences should be taken into consideration.
  • While separate softener and stimulant allows better titration, a combined preparation can reduce medication burden for the patient.
  • Rectal treatment may be needed if rectum loaded or impacted.
  • Do not give rectal treatment if rectum is ballooned and empty.
  • For constipation resistant to standard management, refer to opioid induced constipation section.

 

General advice

  • Encourage a good oral fluid intake (2 litres per day if able) and review dietary intake.
  • Ensure patient has privacy and access to toilet facilities. A foot stool to elevate knees may help.
  • Encourage daily exercise according to ability.
  • Address any reversible factors contributing to the constipation.
  • Laxative doses should be titrated according to individual response.
  • If current regimen is satisfactory and well tolerated, continue with this but review patient regularly and explain importance of preventing constipation.
  • Use oral laxatives if possible in preference to alternative routes of administration.  

 

Paraplegic or bedbound patient

  • Adjust laxatives or loperamide to keep stool firm, but not hard.
  • Use rectal intervention every 1 to 3 days to avoid possible impaction resulting in faecal incontinence, anal fissures or both. 

 

Opioid-induced constipation

  • Peripherally acting µ opioid receptor antagonists  (PAMORAs) can relieve constipation but allow preservation of centrally mediated analgesia.
  • PAMORAs  should only be used for opioid-induced constipation and under specialist advice.
  • Contra-indicated in gastrointestinal (GI) obstruction or patients at risk of GI perforation.

(see Further information - PAMORAs)

 

Practice points

  • The majority of patients with palliative care requirements on opioids need a regular oral laxative.
  • Review laxative regimen when opioid medication is commenced or dose is changed. This includes increasing use of ‘as required’ opiate medication.
  • If there is a clinical picture of obstruction with colic, peripheral opioid antagonists are contra-indicated and stimulant laxatives should be avoided (refer to Bowel obstruction guideline).
  • Do not use an arachis oil enema if patient has nut allergy.
  • Caution is needed with frail or nauseated patients who may be unable to tolerate the fluid volume needed along with macrogol laxative.
  • Bulk-forming laxatives are not suitable if the patient has a poor fluid intake and reduced bowel motility.
  • Lactulose is not effective without a high fluid intake; it can cause flatulence and abdominal cramps in some patients.
  • If laxative therapy fails, seek specialist palliative care advice for alternative options.
  • Manual evacuation, if absolutely necessary, requires consent and should never be attempted without analgesia and/or sedation.
  • Because constipation in advanced disease is generally multifactorial in origin, peripheral opioid antagonists will augment rather than replace laxatives.

 

Resources

 

Further information

Laxative medicines information chart

Tables are best viewed in landscape mode on mobile devices

Oral laxative

Starting dose

Time to act

Comments

Bisacodyl tablets 5mg

1 to 2 at night

6 to 12 hours

Bisacodyl and senna act in the large bowel and have little small intestine effect.

Can cause abdominal cramps.

Senna tablets 7.5mg

2 to 4 at night

8 to 12 hours

Tablets may be difficult to swallow.

Can cause abdominal cramps.

Senna liquid 7.5mg/5ml

10ml to 20ml at night

 

 

Docusate sodium capsules 100mg

1 twice daily

24 to 36 hours

Mainly a softener.

Liquid preparation not very palatable.

Macrogol(such as Laxido®)

 

1 to 3 sachets daily

1 to 3 days

Made up in 125ml of water per sachet. High dose (up to
8 sachets per day for 1 to 3 days in impaction) – volume of liquid required may be difficult to tolerate.

Available in half-strength sachets.

Idrolax® preparation does not contain electrolytes.

Peripheral opioid antagonists

 

Naldemedine tablets 200 micrograms

200 micrograms daily

5 to 18 hours

For administration under specialist palliative care guidance only.

Can cause abdominal pain, nausea & vomiting or diarrhoea. May also cause GI perforation.

Avoid concurrent use of potent CYP Inhibitors. Contra-indicated if obstruction suspected or risk of bowel perforation.

No dosage adjustment required in patients up to 75 years of age.

No dosage adjustment in renal failure or in mild to moderate hepatic failure.

Methylnaltrexone injection 12mg/0.6ml

Initial dose weight-related

30 to 60 minutes

For administration under specialist palliative care guidance only.

Naloxegol tablets 12.5mg, 25mg

 

25mg daily

6 hours average but can be significantly faster

For administration under specialist palliative care guidance only.

Reduce to 12.5mg in moderate to severe renal impairment.

Can cause cramps.

Do not take tablet at a time when defaecation would be inconvenient.

Contra-indicated if obstruction suspected or risk of bowel perforation.

 

Rectal preparations

Starting dose

Time to act

Comments

Bisacodyl suppository 10mg

10mg

15 to 60 minutes

Must be in contact with bowel wall to be effective.

Sodium citrate microenema

1 to 2

30 to 60 minutes

 

Phosphate enema

1

15 to 30 minutes

Can cause local irritation.

Warm to body temperature.

Glycerol suppository

4g

15 to 30 minutes

Combined irritant and softener. Need to place adjacent to bowel wall.

Arachis oil enema

1

15 to 60 minutes

Contains peanut oil; contra-indicated in nut allergy.

Warm to body temperature.

 

PAMORAs

Antagonist

Comments

Methylnaltrexone
  • Methylnaltrexone is accepted for restricted use within NHS Scotland for treatment of opioid-induced constipation in advanced illness patients who are receiving palliative care when response to usual laxative therapy has not been sufficient. It is restricted to use by physicians with expertise in palliative care.
    • Subcutaneous injection dose according to weight of patient.
    • Contra-indicated in severe renal/hepatic failure
    • Subcutaneous injection dose according to weight of patient.
    • Contra-indicated in severe renal/hepatic failure"

Naloxegol
  • Prescribed orally
  • Naloxegol is accepted for use within NHSScotland for the treatment of opioid-induced constipation in adult patients who have had an inadequate response to laxative(s)
    • 25mg tablet daily in the morning reduced to 12.5mg daily in moderate-severe renal impairment. Not recommended in severe hepatic impairment.
    • When naloxegol therapy is initiated, it is recommended that all currently used maintenance laxative therapy should be halted until clinical effect of naloxegol is determined.
    • 25mg tablet daily in the morning reduced to 12.5mg daily in moderate-severe renal impairment. Not recommended in severe hepatic impairment.
    • When naloxegol therapy is initiated, it is recommended that all currently used maintenance laxative therapy should be halted until clinical effect of naloxegol is determined.

Naldemedine
  • Oral preparation
  • Naldemedine is accepted for use within the NHS Scotland for the treatment of opioid-induced constipation (OIC) in adult patients who have previously been treated with a laxative
  • Initiate with caution in patients over 75years of age
  • No evidence for benefit if morphine oral equivalent dose is greater than 400mg per day
  • No evidence for benefit if being treated with partial µ opioid agonists such as buprenorphine

 

References

Candy B, Jones L, Larkin PJ, Vickerstaff V, Tookman A, Stone P. Laxatives for the management of constipation in people receiving palliative care. 2015 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003448.pub4/full#0.

Clark K, Byfieldt N, Dawe M, Currow DC. Treating constipation in palliative care: the impact of other factors aside from opioids. Am J Hosp Palliat Care. 2012;29(2):122-5.

Clemens KE, Faust M, Jaspers B, Mikus G. Pharmacological treatment of constipation in palliative care. Curr Opin Support Palliat Care. 2013;7(2):183-91.

Connolly M, Larkin P. Managing constipation: a focus on care and treatment in the palliative setting. Br J Community Nurs. 2012;17(2):60, 2-4, 6-7. Epub 2012/02/07.

Jones R, Prommer E, Backstedt D. Naloxegol: A Novel Therapy in the Management of Opioid-Induced Constipation. Am J Hosp Palliat Care. 2016;33(9):875-80.

Mori M, Ji Y, Kumar S, Ashikaga T, Ades S. Phase II trial of subcutaneous methylnaltrexone in the treatment of severe opioid-induced constipation (OIC) in cancer patients: an exploratory study. Int J Clin Oncol. 2017;22(2):397-404.

NICE. Naloxegol for treating opioidinduced constipation TA345. 2015 [cited 2018 Oct 03]; Available from: https://www.nice.org.uk/guidance/ta345.

Pitlick M, Fritz D. Evidence about the pharmacological management of constipation, part 2: implications for palliative care. Home Healthc Nurse. 2013;31(4):207-18.

Sykes N. Constipation, diarrhoea, and intestinal obstruction. In: Fallon M, Doyle D, editors. ABC of Palliative Care. 2nd ed. Oxford: BMJ; 2006. p. 25-9.

Sykes N. Constipation and diarrhoea. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK, editors. Oxford Textbook of Palliative 4th ed. Oxford: Oxford University Press; 2010. p. 833-49.

Sykes N. Emerging evidence on docusate: commentary on Tarumi et al. J Pain Symptom Manage. 2013;45(1):1.

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.