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Palliative cancer care - constipation - Management
How should I treat constipation?
- Confirm that the person is constipated.
- Exclude or manage bowel obstruction, anal fissure, painful haemorrhoids and local tumour.
- Begin treatment by relieving any faecal loading/impaction.
- Encourage the person to increase their physical activity and their fluid and dietary fibre intake if appropriate.
- Ensure adequate privacy and sufficient help to get to the toilet.
- Start treatment with a combination of a stimulant laxative and a softening laxative.
- If colic is a problem, use a softening laxative for a few days, and then add in the stimulant.
- A stimulant laxative alone may be sufficient if the rectum is full of soft faeces. However, a softening laxative will often be required later on, particularly if the person is taking any constipating drugs (e.g. opioids).
- Titrate the dose every few days to achieve comfortable defecation. Comfort is more important than the frequency or number of stools.
- It may be necessary to exceed the licenced dose and frequency.
- Adjust dose of laxative in line with dose of opioid.
Clarification / Additional information
- Approximate equivalent stimulant plus softening laxative combinations [Regnard et al, 2004]:
- Three senna tablets (or 15 mL senna syrup) plus 15 mL lactulose.
- Three senna tablets (or 15 mL senna syrup) plus 300 mg docusate.
- Six co-danthramer capsules (or 30 mL co-danthramer syrup).
- Four co-danthramer strong capsules (or 10 mL co-danthramer strong syrup).
- Three co-danthrusate capsules.
Basis for recommendation
- There is no good evidence from clinical trials to choose between alternative laxatives for treating constipation in palliative care.
- However, there is good consensus between experts that the combination of a stimulant with a softening laxative is effective for constipation in palliative care, including opioid-induced constipation [Regnard et al, 2004; Sykes, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005; Arthur Rank House, 2006; West Lancs Southport & Formby Specialist Palliative Care Services, 2006].
- There is also consensus between experts that the dose of laxatives should be titrated upwards until constipation is effectively controlled. This means that much higher doses and more frequent dosing than those specified on the Product Licence are often required to manage constipation (particularly opioid-induced constipation) effectively [Fallon and O'Neill, 1998; Twycross and Wilcock, 2007].
- Constipation due to opioid analgesics is an ongoing problem as tolerance does not develop. There is no linear relationship between morphine dose and the level of constipation [Fallon and Hanks, 1999] — some people will require small dose increases and some people will require larger dose increases to counteract constipation with an increase in morphine dose.
- Bulk-forming laxatives are less useful for palliative care constipation because:
- Their consistency is unpalatable and they need to be taken with at least 200–300 mL water, which makes them unacceptable to many ill people.
- If inadequate water is taken, they can cause intestinal obstruction. This may happen quickly if there is already partial obstruction due to a tumour.
- Although increasing fluids and dietary fibre can help constipation, it can be difficult for some people to manage this, particularly if they have little appetite. It is more important to offer them food and drink that they like.
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