Recommended medicines: DOCUSATE SODIUM and SENNA
Capsule: 100 mg; Oral liquid: 50 mg/5 mL
Oral liquid: 7.5 mg/5 mL
Oral liquid 7.5 mg/mL
Constipation is defined as a condition in which there is difficulty in emptying the bowels, usually associated with hardened faeces. There is a wide range in normal bowel habit and constipation cannot simply be defined in terms of stool frequency. Severe constipation includes obstipation and faecal impaction, which can progress to bowel obstruction.
• Management of constipation comprises identification and, if appropriate, treatment of possible underlying cause(s)
• Non pharmacological management of constipation with attention to fluid intake, nutrition and mobility is important but may be limited by anorexia and general debilitation in palliative care.
Overview of management options: laxatives
• Stimulant laxatives
• Osmotic laxatives (stool softeners)
Constipation is one of the most troublesome and persistent symptoms in palliative care patients and should be treated with laxatives.
An extensive literature search confirmed there is limited good quality evidence to confirm the effectiveness of laxatives in constipation associated with palliative care in adults and children.
There is a lack of evidence to support the use of one laxative, or combination of laxatives, over another and choice can be related to cost effectiveness and availability as much as to efficacy.
Constipation is an almost inevitable consequence of opioid use. Laxatives must be prescribed for any patient receiving strong opioids, which is very common in palliative care.
Evidence for management of this symptom:
The evidence supports the efficacy of laxatives in the management of functional constipation. However there is insufficient evidence to recommend one laxative over another.
Considering the low level of evidence from clinical trials, the recommendation for docusate sodium, senna and sodium picosulfate is based on expert opinion.
Additional supporting information for these medications:
is a faecal softener and passively acts as an adjunct drug. It is commonly listed as a laxative, but it does not directly stimulate bowel emptying.
It is widely available with an established safety profile.
is available as both capsules and a liquid formulation
appears to be better tolerated, particularly at high doses than lactulose
which is associated with bloating and colic.
Approximate costs indicate a unit dose of docusate sodium
(oral solution) is cheaper than lactulose.
is the name given to the sennosides, which are hydroxyanthracene glycosides derived from Senna leaves.
Causes local irritation in colon, which promotes peristalsis and bowel evacuation. Softens faeces by increasing water and electrolytes in large intestine.
is available in both oral liquid and oral tablet formulations. It is inexpensive and widely used as a stimulant laxative.
is hydrolyzed by colonic bacteria to the active form, which causes local irritation in colon, which promotes peristalsis and bowel evacuation. The pharmacology is similar to Senna.
is available in oral tablet formulations. It is inexpensive and widely used as a stimulant laxative.
Where this alone is insufficient evidence for the management of this symptom:
Constipation, due to increase in gastrointestinal transit time is an inevitable consequence of opioid use
. Therefore use of a stimulant laxative is the most appropriate choice in opioid induced constipation.
Laxatives and stool softeners may be needed at high doses, particularly in opioid induced constipation in palliative care.
Where high dose stimulant laxative is insufficient to manage constipation expert opinion supports the use of a combination of stimulant laxative and osmotic agent.
Bulk forming laxatives are unlikely to be appropriate in palliative care.
There is little good quality trial evidence to confirm the effectiveness of laxatives in constipation associated with palliative care.
In addition, there is a lack of evidence to recommend the use of one laxative, or combination of laxatives, over another.
In the absence of any data showing greater efficacy of one agent over another, the choice of laxative is likely to be determined by factors such as availability of suitable
formulations, route of administration, pharmacokinetics and cost-effectiveness.
Adapted from Radbruch L et al. Essential medicines in palliative care - An application for the 19th WHO Expert committee on the selection and use of essential medicines. Kindle Edition, 135 pages. Published June 5th 2013 by IAHPC Press. Available at https://www.amazon.com/Essential-Medicines-Palliative-Care-Application-ebook/dp/B00D7S2D0C