Constipation

Please refer to the BNF or SPC for licenced indications, doses, contraindications and other prescribing information.

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Definition/Criteria

Constipation is defaecation that is unsatisfactory because of infrequent stools, difficult stool passage or seemingly incomplete defecation. Stools are often dry and may be abnormally large or small.

Symptoms:

  • Decreased frequency of defaecation compared to normal
  • Hard dry stools, increased difficulty in passing stools, straining
  • Abdominal discomfort, feeling of incomplete defaecation, bloating and or nausea

It is important to clarify what the patient means by constipation as the term can be used inappropriately.

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Criteria for INCLUSION

  • Treat Patients who present withan acute episode/ symptoms of occasional non-persistent constipation
  • Taking prescribed medication with recognised constipating effects (supply but advise to make a non urgent appointment with GP)

------Criteria for EXCLUSION

  • Patients aged < 7 years
  • Pregnant and breastfeeding women
  • Abdominal pain, vomiting, bloating or pain on defaecation (may suggest underlying cause e.g. anal fissure)
  • Suspected laxative abuse
  • Patients with anaemia
  • Suspected impaction (particularly in the frail and elderly)
  • Patients with alarm symptoms
  • Patients aged 60 years and over with rectal bleedingorchange in bowel habit
  • Patients of any age with rectal bleeding and change in bowel habit

------Action for excluded patients and non-complying patients

Refer to GP*

------Action for patients who are included for treatment

Advice

  • Constipation can be caused by insufficient dietary fibre, change in diet/lifestyle, inadequate intake of food and fluids
  • Certain medicines may cause constipation (e.g. opiates, aluminium salts, verapamil, antimuscarinics)

Dietary and lifestyle advice:

  • Drink plenty of water
  • Eat more fibre, found in wholemeal foods, fruit and fresh vegetables
  • Regular exercise improves bowel habits
  • Try not to put off going to the toilet when you need to go
  • Where possible avoid OTC medication that causes constipation–such as painkillers that contain codeine
  • Laxatives should be taken with increased fluid intake
  • Emphasise that treatment should be short term. Laxatives should be stopped once the stools have become soft and pass easily
  • If laxatives are needed every day or there is persistent abdominal paint consult GP
  • If no response within two to three days visit GP
  • Alert patents to the alarm symptoms for bowel cancer

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Treatment choice from the formulary

Lactulose solution x 300ml(supply to patients > 7 years)

Contraindications: crohn’s disease, ulcerative colitis, intolerance to lactose

Advise patient:

  • If there has been no bowel movement after three days of treatment consult GP
  • Stop treatment if diarrhoea occurs

Ispaghula sachetsany flavour x 30(supply to patients >18years only)

Advise patient:

  • Swallow with plenty of water, the last dose should not be taken immediately before going to bed
  • If there has been no bowel movement after three days of treatment consult GP
  • Ispaghula orange flavor should not be given to patients with phenylketonuria

Senna 7.5mg tabletsx20 (GSL pack)(supply to patients >18years only)

Advise patient:

  • If there has been no bowel movement after two to three days of treatment consult GP
  • Regular doses of stimulant laxatives are rarely required and can cause “lazy” bowel

Docusate sodium 100mg capsules x 30(supply to patients > 18years only)

  • Contraindications; Patients with rare hereditary problems of fructose intolerance
  • Advise patient:
  • If there has been no bowel movement after two to three days of treatment consult GP
  • Regular doses of stimulant laxatives are rarely required and can cause “lazy” bowel

Supply one treatment course in 6 months

Two treatment courses in 12 months

(One product choice only per consultation)

Patients seeking treatment more frequently should be referred to the GP

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Routine referral to GP*

  • Abdominal pain, vomiting, bloating or pain on defaecation(may suggest underlying cause e.g. anal fissure)
  • Patients <7 years
  • Patients taking prescribed medication with recognised constipating effects (supply but advise to make a non urgent appointment)
  • Suspected laxative abuse
  • Failure to respond in two to three days

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Referral to GP within 24 hours*

  • Patients with alarm symptoms
  • Patients aged 60 years and over with rectal bleeding orchange in bowel habit
  • Patients of any age with rectal bleeding andchange in bowel habit

Suspected impaction (particularly in frail elderly patients)

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Emergency referral to A&E

N/A

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* The pharmacist should complete a referral note for the patient to hand to the surgery detailing why the patient was unable to be treated under the MAS.

Version 1.0 29/10/14