Stepwise approach to laxative therapy for adults
This topic describes the management of functional constipation. For general advice about managing functional gastrointestinal disorders, including patient support and psychiatric or psychological assessment, see Approach to managing functional gastrointestinal disorders.
The laxatives recommended below can be added in a stepwise fashion, or used to replace laxatives that are not tolerated. At each step check adherence to lifestyle modification and laxatives before escalating therapy. For more information about laxatives, see Choice of laxative therapy for adults.
A common approach is to use a bulk-forming laxative initially; either psyllium (eg Metamucil) or sterculia (eg Normafibe) is appropriate (dose according to product information).
If a bulk-forming laxative is ineffective or poorly tolerated, add or substitute an osmotic laxative (eg macrogol 3350). Typical regimens include:
Movicol (with electrolytes) 13.12 g per sachet, use 1 sachet (mix each sachet with 125 mL of water), up to 2 to 3 sachets daily
OR
OsmoLax (without electrolytes) 17 g per measuring scoop, use 1 level scoop (mix each scoop with 240 mL of water), up to 2 scoops daily.
If bulk-forming and osmotic laxatives are ineffective or poorly tolerated, add or substitute a stimulant laxative; suitable options are:
1bisacodyl 5 to 10 mg orally, at night. Increase dose as tolerated up to 15 mg daily bisacodyl bisacodyl bisacodyl
OR
1docusate+senna 50+8 mg 1 or 2 tablets orally, at night. Increase dose as tolerated up to 4 tablets daily docusate + senna docusate+senna docusate+senna
OR
1sodium picosulfate 7.5 mg/mL liquid 5 mg (10 drops) orally, at night. Increase dose as tolerated up to 10 mg (20 drops) at night2. sodium picosulfate sodium picosulfate sodium picosulfate
If ineffective or poorly tolerated, add or substitute the prokinetic drug prucalopride; use:
prucalopride 2 mg orally, daily. For patients older than 65 years, use 1 mg orally, daily3. prucalopride prucalopride prucalopride
For pregnant people, the same considerations apply as for other adults when choosing a laxative regimen (see Choice of laxative therapy for adults). Although most laxatives have not been assessed for safety in pregnancy, they have minimal systemic absorption and are generally considered safe to use. Short-term use of laxatives is recommended to avoid dehydration and electrolyte imbalances (there are concerns about sodium retention with some osmotic laxatives in pregnancy). Stimulant laxatives should not be used regularly or as first-line therapy for pregnant people. For more information, see the constipation factsheet on the Mothersafe website.