[CK] Constipation regimen

CONSTIPATION MANAGEMENT 1. Determine usual bowel habits and use of laxatives 2. Encourage fluids, fruit and bran; maintain bowel movement diary Prescribe stool softener and contact laxative: Docusate sodium (Colace) 100 mg po OD to TID to a maximum of 300mg po OD to TID (usual range: 1-9 capsules) Sennosides A&B (Senekot) 1 or 2 tabs po QHS to BID. May be given as tabs or syrup. Note that 5 ml of syrup = 1 tab (Maximum 3 tabs po TID) If no bowel movement by 48 hours, add one of: Milk of Magnesia 30 to 60 ml po OD to BID (avoid in renal failure) Lactulose 15 to 45 ml po OD to BID (preferential use in liver failure) If no bowel movement by 72 hours, do rectal exam to rule out impaction. If not impacted, try relieving with one of: Bisacodyl suppository 10 mg pr OD or BID Magnesium citrate solution 15g/300 ml 150 ml po OD Sennosides (Senokot) syrup 1.7 mg/ml 75 ml po OD Phosphate enema (Fleet) PR Oral Fleet Phospha Soda 1 bottle = 45 ml. May give ½ bottle po BID or 45 ml po OD. If impacted: • Soften with glycerin suppository or an oil-retention enema or soap suds enema • Increase dose of daily bowel medications (softener and stimulant) If soft impaction – bisacodyl suppository or fleet enema or large volume tap water enema NOTE: • Lubricate suppositories with lubricating jelly before insertion • Encourage regular use of laxatives and softeners under medical direction • Severity of constipation may increase with dose of opioid • Certain cytotoxic agents (e.g. Vincristine and Vinblastine) and other medications can cause severe constipation • Other option: Opioid rotation to Tramadol, Fentanyl, Methadone

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1. Colace 1-9 cap(qd -> tid)
    Senna 1 or 2 tab (qhs to bid) 5ml 1 tab.(3 tabs po tid = 9 = 45ml)
    <= BOTH.
(bulk or stimulant - slow)

2. One of?
    MoM 30-60 QD to BID(avoid in renal)
    Lactulose  15-45 Qd to BID(preferred in liver failure) <= DOC
    (osmotic)
    + PEG Sorbitol, Mg- Citrate, MoM...

PEG – PEG electrolyte solutions (eg, GoLYTELY) and powdered preparations (eg, MiraLAX) that do not contain electrolytes are available for the treatment of chronic constipation [13,14]. A systematic review found evidence that polyethylene glycol is effective in improving stool frequency and consistency [10]. A reasonable approach is to start with 17 g of powder dissolved in 8 oz of water once daily and titrate up or down (to a maximum of 34 g daily) to effect. There is no need to use PEG more than once daily. If patients do not respond, one can decrease PEG to 8.5 to 17 g daily and add a stimulant laxative every other to every third day as needed.

●Synthetic disaccharides – Lactulose (eg, Enulose) is a synthetic disaccharide. It is not metabolized by intestinal enzymes; thus, water and electrolytes remain within the intestinal lumen due to the osmotic effect of the undigested sugar. Lactulose requires some time (24 to 48 hours) to achieve its effect. Sorbitol is an equally effective and a less expensive alternative. A systematic review found evidence that lactulose is effective in improving stool frequency and consistency [10]. Both lactulose and sorbitol may cause abdominal bloating and flatulence. PEG, however, is superior to lactulose [15].

●Saline – Saline laxatives such as milk of magnesia, magnesium citrate, or water containing high amounts of magnesium sulfate are poorly absorbed and act as hyperosmolar solutions [16]. Hypermagnesemia, seen primarily in patients with renal failure, is the major complication.

3. one of?
    Bisacodyl suppository
    Mg Citrate 150ml qd
    Sennoside 75ml Qday
    Fleet edena 45ml (1/2 bid) 
(strong stimulant +- enema)