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Palliative cancer care - constipation - Management
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How should I prevent faecal loading/impaction when prescribing a constipating drug?
- People taking opioid analgesics should also take a stimulant laxative and a softening laxative.
In depth
How should I treat constipation?
- Confirm that the person is constipated and 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 plus 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.
- Titrate the dose every few days to achieve comfortable defecation.
- It may be necessary to exceed the licenced dose and frequency.
- Adjust the laxative dose in line with the opioid dose.
In depth
How should I treat faecal loading/impaction?
- Start treatment with a combination of a stimulant and softening laxative.
- When the response to initial treatment is insufficient or not fast enough:
- For high faecal impaction/loading, consider a bowel washout with an oral macrogol.
- For low faecal impaction/loading (i.e. stool is in the rectum), consider:
- Using a suppository: bisacodyl for soft stools, glycerol alone or glycerol plus bisacodyl for hard stools.
- Using a mini-enema: docusate or sodium citrate.
- If the response is still insufficient:
- Consider using a sodium phosphate enema, or an arachis oil retention enema, placed high if the rectum is empty but the colon is full.
- For hard faeces it can be helpful to give the arachis oil enema overnight before giving a sodium phosphate (large volume) or sodium citrate (small volume) enema the next day.
- Enemas may need to be repeated several times to clear hard impacted faeces.
- If none of these measures provide relief, then consider manual evacuation.
In depth
What should I do if the response to laxatives is insufficient?
- Check that the dose of stimulant and softening laxative has been adequately titrated.
- Adjust the dose of stimulant to produce defecation without colic.
- Adjust the dose of softener to produce a comfortable stool.
- Higher and more frequent doses than specified by the product licence may be needed.
- The laxative dose also needs to increase with increases in opioid dose.
- Consider adding in a macrogol, or a prokinetic agent such as metoclopramide, domperidone, or erythromycin 250–500 mg four times a day (off-licence use) — exclude obstruction before use.
- Consider whether additional short-term treatment for faecal loading/impaction is needed.
- If passing a stool is painful, exclude (or manage) anal fissure, painful haemorrhoids, or local tumour.
- If neurological gut dysmotility is present, consider a weekly dose of sodium picosulfate.
- Seek specialist advice if constipation still persists despite these measures.
In depth
What doses of laxatives may be needed in palliative care?
- Bisacodyl: 20 mg three times a day (off-licence).
- Co-danthramer strong: 3 capsules three times a day or 10 mL twice a day (off licence).
- Co-danthrusate: 3 capsules or 15 mL twice a day (off-licence).
- Docusate: 200 mg three times a day (off licence).
- Lactulose: titrate from 15 mL twice a day, according to need.
- Macrogol 3350:
- For constipation: 3 sachets per day.
- For high faecal impaction/loading: 8 sachets dissolved in 1 Litre of water and drunk within 6 hours. Limit to 2 sachets (250 mL/hour) in heart failure.
- Macrogol 4000: 2 sachets per day.
- Senna: 22.5 mg (3 tablets or 15 mL) three times a day (off licence).
- Sodium picosulfate: 30 mg per day (off licence).
In depth
Prescriptions
Combined treatment with a stimulant plus a softener
Age from 16 years onwards
Multi-therapy: Senna tablets + lactulose solution
Senna tablets: two tablets at night
Senna 7.5mg tablets
Take two tablets at night for constipation. Increase the dose up to a maximum of three tablets three times a day if needed.
Supply 60 tablets.
Lactulose solution: 15ml twice a day
Lactulose 3.1-3.7g/5ml oral solution
Take 15ml twice a day for constipation. Increase the dose by 5ml twice a day every 2 to 3 days if needed.
Supply 500 ml.
Multi-therapy: Senna tablets + docusate capsules
Senna tablets: two tablets at night
Senna 7.5mg tablets
Take two tablets at night for constipation. Increase the dose up to a maximum of three tablets three times a day if needed.
Supply 60 tablets.
Docusate sodium capsules: 100mg twice a day
Docusate 100mg capsules
Take one capsule twice a day for constipation. Increase the dose up to two capsules three times a day if needed.
Supply 84 capsules.
Multi-therapy: Senna tablets + macrogol 3350 (Movicol) sachets
Senna tablets: two tablets at night
Senna 7.5mg tablets
Take two tablets at night for constipation. Increase the dose up to a maximum of three tablets three times a day if needed.
Supply 60 tablets.
Movicol: one sachet once a day
Movicol 13.8g oral powder sachets
Take the contents of one sachet (dissolved in half a glass of water) once a day for constipation. Increase the dose by one sachet every 2 to 3 days if needed, up to a maximum of three sachets per day.
Supply 30 sachets.
Multi-therapy: Bisacodyl tablets + lactulose solution
Bisacodyl tablets: 10mg at night
Bisacodyl 5mg gastro-resistant tablets
Take two tablets at night for constipation. Increase the dose up to a maximum of four tablets three times a day if needed.
Supply 28 tablets.
Lactulose solution: 15ml twice a day
Lactulose 3.1-3.7g/5ml oral solution
Take 15ml twice a day for constipation. Increase the dose by 5ml twice a day every 2 to 3 days if needed.
Supply 500 ml.
Multi-therapy: Bisacodyl tablets + macrogol 3350 (Movicol) sachets
Bisacodyl tablets: 10mg at night
Bisacodyl 5mg gastro-resistant tablets
Take two tablets at night for constipation. Increase the dose up to a maximum of four tablets three times a day if needed.
Supply 28 tablets.
Movicol: one sachet once a day
Movicol 13.8g oral powder sachets
Take the contents of one sachet (dissolved in half a glass of water) once a day for constipation. Increase the dose by one sachet every 2 to 3 days if needed, up to a maximum of three sachets per day.
Supply 30 sachets.
Multi-therapy: Bisacodyl tablets + docusate capsules
Bisacodyl tablets: 10mg at night
Bisacodyl 5mg gastro-resistant tablets
Take two tablets at night for constipation. Increase the dose up to a maximum of four tablets three times a day if needed.
Supply 28 tablets.
Lactulose solution: 15ml twice a day
Lactulose 3.1-3.7g/5ml oral solution
Take 15ml twice a day for constipation. Increase the dose by 5ml twice a day every 2 to 3 days if needed. (Aim to produce one or two soft, formed stools every one or two days.)
Supply 500 ml.
Co-danthramer strong capsules: one to two capsules at night
Co-danthramer 37.5mg/500mg capsules strong
Take one to two capsules at night for constipation. Increase the dose up to a maximum of three capsules three times a day if needed.
Supply 60 capsules.
Co-danthrusate capsules: one to two capsules at night
Co-danthrusate 50mg/60mg capsules
Take one to two capsules at night for constipation. Increase the dose up to a maximum of three capsules twice a day if needed.
Supply 63 capsules.
Faecal loading: suppositories or mini-enemas
Age from 16 years onwards
Glycerol suppositories: 4g when required
Glycerol 4g suppositories
Insert one suppository into the rectum when required to relieve constipation.
Supply 6 suppositories.
Bisacodyl suppositories: 10mg when required
Bisacodyl 10mg suppositories
Insert one suppository into the rectum in the morning when required to relieve constipation.
Supply 6 suppositories.
Carbalax suppositories: one when required
Sodium acid phosphate 1.69g / Sodium bicarbonate 1.08g suppositories
Insert one suppository into the rectum when required to relieve constipation.
Supply 6 suppositories.
Docusate sodium enema: 120mg when required
Docusate 120mg/10g enema
Use one enema when required to relieve constipation.
Supply 1 enema.
Sodium citrate enema: 5ml when required
Sodium citrate compound 5ml enema
Use one enema when required to relieve constipation.
Supply 1 enema.
Faecal loading: large-volume enemas
Age from 16 years onwards
Fleet standard tube phosphate enema: use when required
Fleet Ready-to-use 118ml enema
Use one enema when required to relieve constipation.
Supply 1 enema.
Fletchers' standard tube phosphate enema: use when required
Fletchers phosphate enema 128ml standard tube
Use one enema when required to relieve constipation.
Supply 1 enema.
Fletchers' long tube phosphate enema: use when required
Fletchers phosphate enema 128ml long tube
Use one enema when required to relieve constipation.
Supply 1 enema.
Arachis oil retention enema: use when required
Arachis oil 130ml enema
Use one enema when required to relieve constipation.
Supply 1 enema.
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