CONSTIPATION MANAGEMENT
Possible Causes
Stool Softeners
Bulking Agents
• Diet • Dehydration • Dysmotility • Mechanical obstruction
• Opioids • Anticholinergics
If there is no squeeze, e.g., with opioids, stool softeners lead to softer stool that still doesn't move • Docusate Na + 100‒250 mg PO bid
Not recommended with chronic opioid use • Methylcellulose 1 tbsp bid • Psyllium 1 tbsp bid
• Calcium channel blockers • 5HT 3 receptor antagonists • Ca 2+ / Al 3+ antacids
• Carcinomatosis • Hypercalcemia • Diabetes Mellitus
Stimulants
Osmotics
• Senna 2‒9 tabs or Senna tea daily • Bisacodyl 2 x 5‒10 mg PO daily • Cascara extract 50 mg PO daily • Metoclopramide 10 mg PO qid ac & hs • Erythromycin 250 mg PO tid
• Polyethylene glycol 17 gm PO daily or bid • Magnesium Hydroxide 30 ml PO bid • Magnesium Citrate ½ bottle PO bid • Lactulose 30 ml PO bid‒ tid • Sorbitol 30 ml PO bid
Management Pearls • Bowel peristalsis is stimulated by intraluminal volume • Anticipate opioid-induced constipation; treat prophylactically: - Titrate stimulant laxatives to effective doses - Add osmotic laxatives to draw water into the stool, increase its volume, and stimulate peristalsis • If obstipation occurs, before starting stimulant or osmotic laxatives ensure no impaction • If diarrhea occurs with obstipation, i.e., overflow incontinence, check for impaction, then decrease laxative doses, don't stop them • Bowels do NOT become inactive and never work again because of laxatives • Soap suds enemas are NOT recommended; they can damage bowel wall and lead to perforation
Enemas
Emollients
• Mineral or other oil, 30‒60 ml PO daily (risk of aspiration) • Glycerin suppository PR daily
• Phosphosoda (osmotic) • Mineral or other oil 50‒100 ml to soften leading edge • Tap Water 0.5‒1 L PR daily to increase volume, stimulate peristalsis
Peripheral Opioid Mu Receptor Antagonist
Before starting, ensure some stool moving, no hard leading edge Methylnaltrexone 0.15 mg/kg SC q 24 hr prn, if no bowel movement in the last 48 hr; approximated to 8 mg (if 84 to < 136 lb) or 12 mg (if~ 136 to 250 lb)
20 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024
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