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1.6 Laxatives
Dietary advice is important. Before prescribing laxatives it is also important to be sure the patient is constipated and that it is 
not secondary to an underlying undiagnosed complaint. Use only if really necessary - not for long term use. 
         1.6.1 Bulk-forming laxatives
            May be required when fibre cannot be increased in the diet. Of value in those with small hard stools, need an adequate 
            fluid intake and may take a few days for full effect to develop.
            GREEN      Ispaghula husk granules 3.5g/sachet     
            GREEN      Methylcellulose tablets 500mg 
            AMBER     Normacol Plus® (post gastrointestinal surgery)   
         1.6.2 Stimulant laxatives
            Increase intestinal motility, often cause abdominal cramp, should not be used in intestinal obstruction.
            GREEN      Bisacodyl 
                               tablets e/c 5mg          
                               suppositories 5mg, 10mg
            GREEN      Senna [Consider OTC/Self care]  
                               tablets 7.5mg     
                               syrup 7.5mg/5mL       
            GREEN      Sodium picosulfate
                               elixir 5mg/5mL    
            GREEN      Docusate sodium
                               capsules 100mg    
                               syrup 12.5mg/5mL, 50mg/5mL   
             *Co-danthramer and co-danthrusate are licensed for use in palliative care only*
            GREEN      Co-danthramer (dantron /poloxamer ‘188’) 
                              suspension 25/200 per 5mL,   
                              strong suspension 75/1000 per 5mL        
            GREEN      Co-danthrusate (dantron /docusate sodium) 
                              capsules 50/60       
            Rectal stimulant
            GREEN      Glycerol suppositories 1g, 2g, 4g
         1.6.3 Faecal softeners
            Lubricate and soften impacted faeces and promote a bowel movement.
            GREEN      Arachis oil enema
         1.6.4 Osmotic laxatives
            Retain fluid in the bowel and change the pattern of water distribution in the faeces. They commonly cause bloating, 
            flatulence and cramping and are unpalatable for some patients. They must be taken regularly for up to three days before 
            an effect is seen, making them unsuitable for rapid relief of constipation or for ‘as required’ dosing.
            First Line 
            GREEN      Lactulose solution 3.35g/5mL [Consider OTC/Self care]    
            Second line 
            Oral route:  
            GREEN      Laxido® for adults  
                               Laxido paediatric® sachets   
                               Movicol paediatric® sachets
            Rectal Route:
            GREEN      Phosphate enema [Cleen® [formally Fleet®] Ready-to-use Enema - prescribe by brand] 
            GREEN      Relaxit® or Micralax® micro enema
         1.6.5 Bowel cleansing solutions
            Bowel cleansing solutions are for use only before colonic surgery, colonoscopy, or radiological examination to ensure the 
            bowel is free of solid contents. They are not treatments for constipation.
            RED           Citramag® sachets  
            RED           Klean-Prep® sachets 
            RED           Picolax® sachets  
            RED           Moviprep® sachets
            RED           Plenvu® sachets
         1.6.6 Peripheral opioid-receptor antagonist
          NICE TA651 Naldemedine is recommended as an option for treating opioid induce constipation in adults who have previously
          been treated with a laxative - see full guidance
          GREEN        Naldemedine tosylate (Rizmoic®) tablets 200mg                                         ICS Commissioned
           NICE TA345 Naloxegol (Moventig®is recommended, within its marketing authorisation, as an option for treating opioid  
           induced constipation in adults whose constipation has not adequately responded to laxatives.
           An inadequate response is defined as opioid‑induced constipation symptoms of at least moderate severity in at least 1 of
           the 4 stool symptom domains (that is, incomplete bowel movement, hard stools, straining or false alarms) while taking at 
           least 1 laxative class for at least 4 days during the prior 2 weeks. NICE TAG345.
           GREEN          Naloxegol (Moventig®) tablets 12.5mg, 25mg
         1.6.7 5HT4 receptor agonists and guanylate cyclase-C receptor agonists
            Prucalopride (Resolor®) for the treatment of chronic constipation in women (NICE TA211)
                   1.    Prucalopride is recommended as an option for the treatment of chronic constipation only in women for whom 
                          treatment with 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 in whom invasive treatment for constipation is being considered.
                   2.    If treatment with prucalopride is not effective after 4 weeks, the woman should be re-examined and the benefit of
                          continuing treatment reconsidered.
                   3.    Prucalopride should only be prescribed by a clinician with experience of treating chronic constipation, who has 
                          carefully reviewed the woman’s previous courses of laxative treatments specified in point 1.
            AMBER     Prucalopride  tablets f/c 1mg, 2mg   
            Linaclotide (Constella®) treatment of moderate to severe irritable bowel syndrome with constipation in adults who 
            have not responded to conventional treatment. 
            Linaclotide can be considered as an option (specialist initiation only) for the treatment of persistent constipation in adults 
            with IBS who have not responded to conventional treatment based on suggested treatment pathway:
                   1.    Follow irritable bowel syndrome in adults NICE CG61 (2008) and manage constipation  with a range of osmotic and
                          stimulant laxatives with the long-term use of soluble fibre 
                   2.    Where antispasmodics and laxatives are ineffective for pain relief, NICE suggests the use of tricyclic   
                          antidepressants (unlicensed use)
                   3.    Assess patient at 4 weeks (in secondary care) and if no improvement discontinue use
                   4.    If continued beyond 4 weeks, re-assess at 6 months for continued benefit
            AMBER     Linaclotide capsules 290 micrograms
           NICE TA318 - Lubiprostone for treating chronic idiopathic constipation - Guidance withdrawn because Takeda has           
                                   discontinued lubiprostone [Amitiza]
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