Treatment Algorithm for Primary Care Management of Chronic Constipation in Adults

Patient reports or is reported with constipation – patients should have 2 or more of the following features for at least 12 weeks:- <3 bowel movements a week, straining, hard lumpy stool,
sensation of incomplete evacuation, sensation of ano-rectal blockage or digital evacuation more than 25% of bowel movements

1. Identify contributory factors to constipation by carrying out relevant medical history, general examination, If due to opioid therapy (review in line with opioid use): First
abdominal examination, digital rectal examination, review medication, neurological and cognitive assessment line treatment: Senna 2-4 tablets twice daily plus sodium
2. As appropriate assess and treat any suspected clinical problems such as faecal impaction, drug related, docusate 100mg twice daily
haemorrhoids, fissures
3. If acute constipation for less than 3 months with no change in lifestyle, consider red flag signs such as fresh blood If in-effective, for palliative care patients only; co-
mixed in stool, unintentional weight loss, lethargy, anaemia and family history of bowel cancer refer on to danthramer capsules 1-4 twice daily or co-danthramer liquid
colorectal consultant for suspected colon cancer 10-20mls twice daily. Co-danthramer Forte 1-4 capsules (or
4. Provide lifestyle advice based on findings from baseline assessment e.g. bowel education syrup) twice daily (only to be used with persistent
5. Patient education: constipation)
a. Correct toilet positioning,
b. Modify bowel habit – regular toileting about 30 minutes after a meal, Inadequate response in 4 days:
c. Modify diet by possibly increasing or decreasing fibre, 5 fruit and vegetables a day and fluid intake 1 ½ Second Line treatment: Naloxegol (Moventig®) NICE TA345
litres mixed fluid 25mg once daily (or 12.5mg for people with renal
d. Exercise insufficiency)

If drug therapy necessary

First Choice: Bulking Agents – Ispaghula husk, methylcellulose (Onset of effect 12-72 hours)
Dose: Ispaghula Husk 3.5g sachet (Fybogel®) 1 sachet twice daily
Methylcellulose ‘450’500mg (Celevac®) 3-6 tablets twice daily
Adverse effects: Gas, bloating, oesophageal obstruction, colonic obstruction, calcium and iron malabsorption
Prescribing Considerations:
 Must be mixed with water and taken as a drink as soon as prepared.
 Additional fluid should be drunk throughout the day. (May not be suitable for frail elderly people). Methylcellulose avoid liquid intake for 30 mins before and after dose
 Not to be taken before going to bed in order to reduce the risk of obstruction. May reduce appetite

Author: Philippa Blatchford, Prescribing Advisor, Croydon CCG

Approved by: Croydon Prescribing Committee Date: 13.11.15
Review date: January 2018
Second Choice: Osmotic laxative – Macrogol, lactulose (Onset of effect 24-48 Alternative Options:
hours) Stool softener – docusate sodium (Onset of effect 1-3 days)
Dose: Macrogol Oral Powder, Compound: 1-3 sachets daily Dose: Up to 500mg daily in divided doses
Lactulose: 15ml twice daily, adjusted to response Adverse Effects: Stomach, intestinal cramping,
Adverse Effects: nausea, vomiting, flatulence, cramps and abdominal discomfort
Stimulant laxative (Onset of effect 6-12 hours)
Prescribing Considerations: Senna: 2-4 tablets, usually at night (gradually increased)
 Administer lactulose with either water or fruit juice, requires regular dosing. Bisacodyl: 5-10mg at night (increased to max 20mg)
 Can lead to dehydration if inadequate fluid intake. Adverse Effects: Electrolyte imbalances (e.g. hypokalemia), abdominal discomfort
and cramp, potential for overuse/abuse

If 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 for
constipation is considered

Prucalopride (Resolor®) in women TA211 Lubiprostone (Amitiza®) NICE TA318

Dose: 2 mg once daily (up to 65 years old) and 1 mg once daily (over 65 years)
increased to 2 mg once daily if needed.
Review at 4 weeks: If not effective re-examine patient and reconsider the benefit
of continuing treatment
If normal bowel movements are established, review treatment at regular intervals
every 3 months to assess clinical need. No repeat prescriptions >3months
Dose: 24microgrames twice daily
SPC states that a course of treatment is 2 weeks
Review at 2 weeks: If not effective re-examine patient and reconsider the benefit of
continuing treatment
If normal bowel movements are established, review treatment at regular intervals
every 3 months to assess clinical need. No repeat prescriptions >3months

Adverse Effects: headache, abdominal pain, nausea or diarrhoea. Most frequently Adverse Effects: nausea, palpitations, diarrhoea, abdominal distension, flatulence,
reported at the start of treatment abdominal discomfort/pain, indigestion, oedema, chest discomfort, headache,
dizziness, dyspnoea, hyperhidrosis and hot flushes.

If no improvement consider referral

Author: Philippa Blatchford, Prescribing Advisor, Croydon CCG

Approved by: Croydon Prescribing Committee Date: 13.11.15
Review date: January 2018