General Notes

For uncomplicated constipation, first-line therapy should be dietary manipulation with increased fibre and fluid intake.

The bulk forming laxative ispaghula husk may take several days to act.

Stimulant laxatives such as bisacodyl and senna increase intestinal motility and often cause abdominal cramp. They should be avoided in intestinal obstruction. Stimulant laxatives become less effective with long-term use. Glycerol suppositories act as a rectal stimulant by virtue of the mildly irritant action of glycerol.

If rectum is full on examination or there is difficulty in evacuation, consider glycerol or bisacodyl suppositories. If bulk–forming and stimulant laxatives are unsuitable, consider at least 30ml daily of lactulose; this may take 48 hours to act.

Older Patients – laxatives in chronic use

Managing constipation in older patients can be complex and individual assessment may be required. Lactulose is not recommended for long-term use in the elderly but can be prescribed along with a stimulant laxative as a short-term solution.

Bulk-Forming Laxatives

Preferred list (P)

ISPAGHULA HUSK 3.5g

Stimulant Laxatives

Preferred list (P)

SENNA

Total list (T)

BISACODYL

  • Tablets act in 10 to 12 hours.
  • Suppositories act in 20 to 60 minutes.

GLYCEROL suppositories

Osmotic Laxatives

Preferred list (P)

LACTULOSE solution

MACROGOL 3350

  • MHRA Drug Safety Update April 2021 - Polyethylene glycol (PEG) laxatives and starch-based thickeners: potential interactive effect when mixed, leading to an increased risk of aspiration
  • There are several brands of macrogol 3350 oral powder available. Currently the most cost-effective brands are Laxido® and CosmoCol®. There are no clinical differences between the brands.
  • Movicol®is not included in the Lanarkshire Formulary.

Total list (T)

SODIUM CITRATE enema (Micolette®)

PHOSPHATE enema (Cleen® [formerly Fleet®] Ready-to-use)

Bowel Cleansing Preparations

Specialist initiation (S1)

SODIUM PICOSULFATE sachets (Picolax®)

SODIUM ACID PHOSPHATE oral solution (Fleet Phospho-Soda®)

MACROGOL 3350 (Klean-Prep®). Klean-prep has been discontinued. Alternative options are being explored.

  • MHRA Drug Safety Update April 2021 - Polyethylene glycol (PEG) laxatives and starch-based thickeners: potential interactive effect when mixed, leading to an increased risk of aspiration

Guanylate Cyclase-C Receptor Agonists

Specialist initiation (S1)

LINACLOTIDE

  • Restrictions: For patients with moderate to severe irritable bowel syndrome with constipation (IBS-C) who have not responded to, or cannot tolerate all other suitable treatment options. [SMC advice]
  • Patients should be reviewed following 4 weeks of treatment and the medicine discontinued if they have not shown an appropriate response. Periodically reassess need for continued treatment.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.