Microsoft word - managing constipation in patients receiving palliative cancer care final october 2012.doc
Coastal West Sussex Clinical Commissioning Group Managing Constipation in Patients Receiving Palliative Cancer Care1
How should I treat constipation?
The Rome III diagnostic criteria* state that functional constipation must include two or more of the following: straining during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, sensation of incomplete evacuation for at least 25% of defecations, sensation of anorectal obstruction/blockage for at least 25% of defecations, manual manoeuvres to facilitate at least 25% of defecations (e.g. digital evacuation, support of the pelvic floor), fewer than three defecations per week. Loose stools are rarely present without the use of laxatives. There should be insufficient criteria for irritable bowel syndrome. *criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.
Exclude or manage bowel obstruction, anal fissure, painful haemorrhoids and local tumour.
Begin treatment by relieving any faecal loading/impaction.
Encourage the person to increase their physical activity and their fluid and dietary fibre intake if appropriate.
Ensure adequate privacy and sufficient help to get to the toilet.
Start treatment with a combination of a stimulant plus a softening laxative (see combinations below).
If colic is a problem, use a softening laxative for a few days and then add in the stimulant.
A stimulant laxative alone may be sufficient if the rectum is full of soft faeces. However, a softening laxative will often be required later on, particularly if the person is taking any constipating drugs (for example opioids).
Titrate the dose every few days to achieve comfortable defaecation. Comfort is more important than the frequency or number of stools. It may be necessary to exceed the licensed dose and frequency.
Adjust the laxative dose in line with the opioid dose.
Approximate equivalent stimulant plus softening laxative combinations
Three senna tablets (or 15ml senna syrup) plus 300mg docusate
Three senna tablets (or 15ml senna syrup) plus 15ml lactulose
Six co-danthramer capsules (or 30ml co-danthramer syrup)
Four co-danthramer strong capsules (or 10ml co-danthramer strong syrup)
What should I do if the response to laxatives is insufficient?
Check that the dose of stimulant and softening laxative has been adequately titrated.
Adjust the dose of stimulant to produce defaecation without colic.
Adjust the dose of softener to produce a comfortable stool.
Higher and more frequent doses than specified by the product licence may be needed.
The laxative dose also needs to increase with increases in opioid dose.
Consider whether additional short-term treatment for faecal loading/impaction is needed.
1 PRODIGY – Palliative cancer care – constipation. Available at: http://prodigy.clarity.co.uk/constipation/management/scenario_adults#-317747 <accessed 16/05/12>
Consider switching to a macrogol or adding in a prokinetic agent such as metoclopramide, domperidone, or erythromycin 250-500mg four times a day (off-label use) – exclude obstruction before use.
If passing a stool is painful, exclude (or manage) anal fissure, painful haemorrhoids, or local tumour.
If neurological gut dysmotility is present, consider a weekly dose of sodium picosulfate.
Neurological gut dysmotility is more likely in people with other neurological symptoms or signs, diabetes, small cell lung cancer, a history of chemotherapy with vinca alkaloids or platinum, a history of long term laxative abuse, or resistance to usual laxatives.
Seek specialist advice if constipation still persists despite these measures – a switch to another possibly less constipating opioid may be considered (for example fentanyl, methadone) but dose conversion may be difficult so specialist advice is advised.
What doses of laxative may be needed in palliative care?
Laxative Licensed dose (adults) Dose that may be needed in palliative care (off licence)
capsules or 75/1000mg suspension) Co-danthrusate (dantron/docusate
For high faecal loading/impaction: 8 sachets dissolved in 1 litre of water and drunk within 6 hours. Limit to 2 sachets (250 ml/hour) in heart failure
15-22.5mg (2-3 tablets) three times a day
Links to Accepted Guidance
Palliative Care Adult Network Guidelines on Constipation http://book.pallcare.info/index.php?tid=6&searchstring=constipation The information contained in this guidance has been taken from the PRODIGY website on managing constipation in palliative cancer care.
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Coastal West Sussex 
Consider switching to a macrogol or adding in a prokinetic agent such as metoclopramide, domperidone, or erythromycin 250-500mg four times a day (off-label use) – exclude obstruction before use.
If passing a stool is painful, exclude (or manage) anal fissure, painful haemorrhoids, or local tumour.
If neurological gut dysmotility is present, consider a weekly dose of sodium picosulfate.
Neurological gut dysmotility is more likely in people with other neurological symptoms or signs, diabetes, small cell lung cancer, a history of chemotherapy with vinca alkaloids or platinum, a history of long term laxative abuse, or resistance to usual laxatives.
Seek specialist advice if constipation still persists despite these measures – a switch to another possibly less constipating opioid may be considered (for example fentanyl, methadone) but dose conversion may be difficult so specialist advice is advised.