This advice is sourced from Dr Ros Taylor a senior palliative physician
Q. How should I best manage constipation in patients with advancing illness?
The majority of patients with palliative illness complain of constipation. The cause is usually multifactorial through a combination of medication, reduced hydration and something anatomical pressing on or blocking the bowel e.g. peritoneal metastases or ascites.
Before prescribing laxatives for constipation you should:
- Consider bowel obstruction
- Review medications to see if any of these contribute to constipation and can be stopped (eg iron, antihypertensives, diuretics)
- Consider blood tests for U&Es, Ca2+ and TFTs to exclude an underlying treatable condition
- Discuss diet and fluid intake although this is often difficult to modify at the end of life
- Ask if there are any barriers to defecation e.g. privacy, anal pain from fissures/haemorrhoids
I always ask my patients if a particular type of laxative has been effective for them previously as this influences my prescribing choice.
My approach to management is:
- For people who I start on opiates (which reduce gut transit time) I always prescribe a stimulant laxative (e.g. senna or sodium picosulphate)
- I use a single laxative and increase the dose as needed up to the maximum before trying a second medicine
- For people who have hard stools I advise drinking more fluid and adding in a softener such as laxido/movicol and possibly suppositories if they have hard stool in their rectum
- For people who are struggling to drink much fluid I often increase the background laxative dose
- If the patient develops crampy abdominal pain I reduce the dose of the stimulant laxative and again consider if there is a physical obstruction
- People who have signs of overflow incontinence need district nurse review for consideration of an enema
In my palliative practice the initial treatment approach for patients with hard infrequent passage of stools is sodium picosulphate liquid starting at 5 mls and increasing to a maximum of 15 mls daily.
Naloxegol reverses the bowel side effects of opiates but retains the pain relief and is useful for somebody who has severe constipation related to opioid painkillers. I usually start with 12.5 mg tablet in the morning and increase to 25mg if needed.
Lactulose is commonly prescribed but seems to cause excessive bloating and wind in some patients.
There are some recommended resources below for further reading.