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Constipation: stool <3 times per week with passage of hard, dry stools or small stools, or feeling as evacuation is incomplete.
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Suspected OTC medicine/ prescription medicine induced or disease induced constipation? To know more about such medications and diseases, Click here
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Patient's diet, lifestyle or habit potentially constipating?
  • Dietary Factors: Low-Fiber Diet, Inadequate Fluid Intake (water/juice/soups), Caffeine and alcohol intake, Fatty Foods, Dairy products, Processed Foods
  • Lifestyle Factors: Sedentary Lifestyle/Immobility, lack of aerobic exercise, Prolonged Bed Rest, Stress, Lack of Privacy
  • Habits: Ignoring the Urge to Defecate
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Recommendation: Require medical referral

Rationale:

Children less than 2 years is excluded for self treatment because

  • Diagnostic Complexity: Diarrhea may be a symptom of an underlying organic cause (anatomical or physiological abnormality), functional constipation, or a variety of other issues.
  • Potential for Serious Conditions: In infants and young children, constipation can sometimes be a sign of a more serious medical condition, such as Hirschsprung's disease, hypothyroidism, or cystic fibrosis.
  • Limited Self-Treatment Options: The range of safe and effective over-the-counter laxatives for children under 2 years is limited. Many adult laxatives are not appropriate for this age group.
  • Developmental Factors: Infants and young children are still developing their bowel habits and control. What might seem like constipation could be normal variations in stooling patterns.
  • Feeding Issues: Constipation in young children is often related to diet, such as changes in formula or the introduction of solid foods requiring guidance from a pediatrician or healthcare provider.

Recommendation: Require medical referral

Rationale:
  • Prolonged constipation indicate a more serious underlying condition that requires medical evaluation and treatment
    • Disorders of the large intestine, rectum, and anus: Anal fissure, Chronic amebiasis, Colonic inertia, Diverticulitis, Hernias, Internal rectal prolapse, Irritable bowel syndrome, Ischemic colitis, Mucosal prolapse, Pelvic floor dysfunction and lesions, Rectocele, Stenotic obstruction, Strictures, Surgical stricture (end-to-end anastomosis), Tumors, Ulcerative proctitis
    • Metabolic Disorders: Amyloidosis, Diabetic ketoacidosis, Diabetic neuropathy, Hypercalcemia, Hypokalemia, Hypomagnesemia, Porphyria, Uremia
    • Endocrine Disorders: Hypercalcemia: pseudohypoparathyroidism, hyperparathyroidism, milk alkali syndrome, carcinomatosis; Hypothyroidism, Panhypopituitarism, Pheochromocytoma,
    • Neurologic Disorders: Aganglionosis, or Hirschsprung's disease; Autonomic neuropathy: paraneoplastic, pseudo-obstruction; Cauda equina tumor, Cerebrovascular accidents, Chagas' disease, Dementia, Ganglioneuromatosis, Multiple sclerosis, Parkinson's disease, Shy Drager syndrome, Systemic sclerosis, Tumors,
    • Muscular Disorders: Dermatomyositis, Myotonic dystrophy, Segmental dilatation of the colon

Recommendation: Require medical referral

Rationale: Marked abdominal pain or significant distention or cramping: This refers to severe pain, a visibly swollen abdomen, or intense, cramp-like discomfort. These symptoms are more than just the usual constipation discomfort.
    • Possible Causes: Bowel obstruction, Intestinal perforation, Ischemic colitis, Severe impaction, Acute appendicitis, Pancreatitis.
Rationale: Marked or unexplained flatulence: While everyone experiences gas, "marked" flatulence is excessive and often accompanied by other symptoms. "Unexplained" means it's a new or unusual symptom, not related to diet.
    • Possible Causes: Bowel obstruction, Small intestinal bacterial overgrowth (SIBO), Malabsorption (e.g., lactose intolerance, celiac disease), Inflammatory bowel disease (IBD).
Rationale: Fever: Fever indicates the body is fighting an underlying issue. In the context of constipation, it suggests an inflammatory or infectious process.
    • Possible Causes: Infection (Diverticulitis, appendicitis), Inflammatory bowel disease (IBD), Systemic illness.: Though less directly related to the gut, some systemic infections can cause both constipation and fever.
Rationale: Nausea and/or vomiting: These symptoms, combined with constipation, are a red flag that the digestive system isn't working correctly.
    • Possible Causes: Bowel obstruction, Severe constipation or impaction, Gastroparesis.
Rationale: Paraplegia or quadriplegia: These conditions involve paralysis, which disrupts the nerve signals that control bowel function.
    • Possible Causes: Neurogenic bowel requiring a specialized bowel management program, not just simple laxatives.
Rationale: Daily laxative use (excluding fiber-based products cross-classified as nutritional supplements): This indicates a chronic problem where the person relies on laxatives to have bowel movements.
    • Possible Causes: Chronic idiopathic constipation:, Laxative abuse (Overuse of stimulant laxatives can damage the colon and worsen constipation), Underlying medical conditions.
Rationale: Unexplained changes in bowel habits, especially if accompanied by weight loss: "Unexplained" is key – this isn't a change due to diet. Weight loss is a particularly worrisome symptom.
    • Possible Causes: Colorectal cancer, Inflammatory bowel disease (IBD), Malabsorption syndromes.
Rationale: Blood in stool, or dark or tarry stool: These are signs of bleeding in the digestive tract.
    • Possible Causes: Hemorrhoids or anal fissures, IBD, Diverticulitis, Colorectal cancer.
    • Upper GI bleed: Dark, tarry stools (melena) indicate bleeding higher up in the digestive tract (stomach, etc.).
Rationale: Change in the caliber of stool (i.e., pencil-thin): This refers to stool that is consistently narrower than usual.
    • Possible Causes: Colorectal cancer, Strictures.
Rationale: History of IBD: Crohn's disease, ulcerative colitis makes the bowel more vulnerable.
    • Possible Causes: Flare-up
    • Complications: Strictures or other IBD-related issues.
Rationale: Alternating constipation and diarrhea
    • Alternating constipation and diarrhea is a common symptom, most often associated with Irritable Bowel Syndrome (IBS), particularly the mixed type (IBS-M). It can also be caused by food sensitivities, infections, or certain medications.

Recommendation: Require medical referral

Rationale: Require prescription medication adjustment by physician.

Recommendation: Require medical referral

Rationale: Require expert physician consultation.

Recommendation: Make adjustment to the OTC medications.

 

Non pharmacological therapy

 
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
If symptomatic relief is urgently required through OTC laxatives, go back > choose none and continue the algorithm.

Recommendation: Make diet, lifestyle or habit changes

 
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
If symptomatic relief is urgently required through OTC laxatives, go back > choose none and continue the algorithm.

Recommendation: Pharmacological and non pharmacological

  Non-pharmacological  
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
  Pharmacological
  • If faster relief desired, 1st-line laxatives (stool softener or bulk former, PEG 3350).
  • Docusate if dry, hard stool
  • Short-term bisacodyl or sennoside
  • avoid castor oil (uterine contraction and rupture) and saline laxatives (electrolyte imbalance).
Below is the overall information of laxatives. Use the information as per the above recommendation
  • Bulk forming
    • Example
      • Calcium polycarbophil, methylcellulose, psyllium
      • ispaghula
    • Onset of action: 12-24 hrs (can take up to 72 hours)
    • A/E and caution
      • Abdominal cramping, flatulance
      • Avoid in patient with swallowing difficulties or esophageal strictures, intestinal ulcers, stenosis
      • Avoid in patients with fluid restrictions (eg heart failure)
      • Pt. on diabetes: choose sugar-free formulations
    • Patient instruction
      • Take with at lease 1 glass of water (otherwise can swell in throat causing choking) and quickly consume after mixing
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • The bulk forming laxatives have a delayed onset and therefore are not suitable for acute, occasional relief.
  • Hyperosmotic agents
    • Example: PEG 3350, Glycerin, lactulose
    • Onset of action: 12-72 hrs (can take as long as 96 hours); 15-30 min (suppositories)
    • A/E and caution
      • Abdominal discomfort, cramping, bloating, flatulance
      • rectal irritation (with suppository)
      • Pt with renal disease or irritable bowel syndrome should ask physician approval
    • Patient instruction
      • Mix with half to 1 glass of water or juices or beverages
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • no clinically significant interaction have been reported
      • Glycerin suppositories safe >2 years patient
      • also stimulant
  • Emollients (stool softener)
    • Example:
      • Docusate sodium,
      • Docusate calcium
    • Onset of action: 12-72 hrs (can take 3-5 hours to see effect)
    • A/E and caution
      • A/E rare unless larger-than recommended doses- weakness, sweating, muscle cramps and irregular heartbeat
    • Patient instruction
      • Do not take with mineral oil
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • Does not absorb from GI and does not hamper absorption of other drugs
      • Docusate sodium is also a stimulant laxative
  • Saline laxative
    • Example:
      • Mg citrate,
      • Mg(OH)2,
      • dibasic sodium phosphate,
      • monobasic sodium phosphate,
      • MgSO4
    • Onset of action: 30 minutes to 6 hours (oral dose); 2-15 minutes (rectal dose)
    • A/E and caution
      • Abdominal cramping, N/V, and dehydration
      • electrolyte imbalance at long-term or higher doses
      • Avoid in Na, Me and phosphate restricted diet patients
      • Avoid in newborns, older adults and renal impairment (high risk of Mg toxicity
      • Sodium phosphate product use cautiously in pt with renal impairment, sodium restricted and medications (diuretics)
      • Sodium phosphate product CI in heart failure
      • Rectal sodium phosphate product avoid in megacolon, GI obstruction, imperforate anus, or colostomy
    • Patient instruction
      • take with 1 glass of water
      • do not take more than once a day
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
  • Lubricant laxative
    • Example: Mineral oil
    • Onset of action: 6-8 hours (oral); 5-15 min (rectal)
    • A/E and caution
      • risk outweighs the benefit
      • impaired absorption of fat-soluble vitamins, oil leakage, pruritus, cryptitis, or other perineal conditions
      • After oral administration, do not lie down (risk of lipid pneumonia from aspiration)
      • Avoid in <6 years, pregnant, bedridden patients, older adults and swelling difficulty patient
  • Stimulant laxative
    • Example:
      • sennosides,
      • castor oil,
      • bisacodyl
    • Onset of action: 6-10 hrs (oral, may take up to 24 hr); 15-60 min (bisacodyl suppository)
    • A/E and caution
      • Fluid and electrolyte imbalance, enteric loss of protein, malabsorption, severe cramping, hypokalemia.
      • Overdose: prompt medical attention required and symptoms include: nausea, diarrhea, sudden vomiting, severe abdominal cramping
      • laxative dependence can occur (Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Increasing doses of laxatives have to be ingested to obtain a response. this is treated by replacing stimulant laxatives with bulk laxatives. This may take many months and not all patients respond. ). Chronic use of stimulant laxatives can weaken the colon and lead to dependence. When laxatives are stopped, the colon may not function properly, resulting in worsened constipation.
    • Patient instruction
      • Take at night
      • Enteric coated bisacodyl should not be given chewed broken
      • Separate dosing within 1 hour with antacids, H2RA, PPIs, mild
    • Remarks
      • Enteric coated bisacodyl prevents gastric irritation
General therapeutic decision point
  • Preventive therapy: Bulk forming, Hyperosmotic, Emollients
  • Acute relief of constipation: Saline laxatives, hyperosmotic laxatives, lubricant laxatives
  • Opioid induced constipation relief: Stimulant laxative
  • Pt who should avoid staining (childbirth, heart attack, recent abdominal surgery, hemorrhoids, recent MI, postpartum) or have painful defecation: Bulk forming, emollients
  • Pt. on low fiber diet: Bulk forming
  • Colonoscopy: Saline laxative (eg Magnesium citrate)
Drug Interaction
  • Bulk forming laxatives
    • Drug: Digoxin, anticoagulants, salicylates
    • Mechanism: interfere drug absorption
    • Management/ Preventive measure: Separate dosing by at least 2 hours
  • Docusate salts
    • Drug: mineral oil
    • Mechanism: increased absorption
    • Management/ Preventive measure: avoid
  • Magnesium citrate
    • Drug: Fluoroquinolone and tetracyclines
    • Mechanism: decreased drug absorption
    • Management/ Preventive measure: avoid concurrent use for 1-3 hours
  • Magnesium hydroxide
    • Drug: Xaptopril, cefdinir, oral bisphosphonates, gabapenitn, iron salts, nitrofurantoin, phenothiazines, phenytoin, rosuvastatin
      • Mechanism: decreased oral bioavailability
      • Management/ Preventive measure: Separate dosing by at least 2 hours
    • Drug: Ketconazole, itraconazole, fluoroquinoline and tetracycline, levothyroxine
      • Mechanism: decreased absorption
      • Management/ Preventive measure: avoid 4 hours before or 3 hours after interacting drug
  • Bisacodyl
    • Drug: milk products or drugs that raise gastric pH (eg PPI)
    • Mechanism: premature dissolution of the bisacodyl enteric coating, leading to gastric irritation or dyspepsia
    • Management/ Preventive measure: Separate dosing by at least hours

Recommendation: Pharmacological and non pharmacological

  Non-pharmacological  
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
  Pharmacological  
  • If bowel habits are reasonable, adjust diet, exercise & fluid intake within limits of the condition.
  • Sennosides, bisacodyl, PEG 3350, docusate compatible with breast feeding as not absorbed.
  Below is the overall information of laxatives. Use the information as per the above recommendation
  • Bulk forming
    • Example
      • Calcium polycarbophil, methylcellulose, psyllium
      • ispaghula
    • Onset of action: 12-24 hrs (can take up to 72 hours)
    • A/E and caution
      • Abdominal cramping, flatulance
      • Avoid in patient with swallowing difficulties or esophageal strictures, intestinal ulcers, stenosis
      • Avoid in patients with fluid restrictions (eg heart failure)
      • Pt. on diabetes: choose sugar-free formulations
    • Patient instruction
      • Take with at lease 1 glass of water (otherwise can swell in throat causing choking) and quickly consume after mixing
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • The bulk forming laxatives have a delayed onset and therefore are not suitable for acute, occasional relief.
  • Hyperosmotic agents
    • Example: PEG 3350, Glycerin, lactulose
    • Onset of action: 12-72 hrs (can take as long as 96 hours); 15-30 min (suppositories)
    • A/E and caution
      • Abdominal discomfort, cramping, bloating, flatulance
      • rectal irritation (with suppository)
      • Pt with renal disease or irritable bowel syndrome should ask physician approval
    • Patient instruction
      • Mix with half to 1 glass of water or juices or beverages
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • no clinically significant interaction have been reported
      • Glycerin suppositories safe >2 years patient
      • also stimulant
  • Emollients (stool softener)
    • Example:
      • Docusate sodium,
      • Docusate calcium
    • Onset of action: 12-72 hrs (can take 3-5 hours to see effect)
    • A/E and caution
      • A/E rare unless larger-than recommended doses- weakness, sweating, muscle cramps and irregular heartbeat
    • Patient instruction
      • Do not take with mineral oil
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • Does not absorb from GI and does not hamper absorption of other drugs
      • Docusate sodium is also a stimulant laxative
  • Saline laxative
    • Example:
      • Mg citrate,
      • Mg(OH)2,
      • dibasic sodium phosphate,
      • monobasic sodium phosphate,
      • MgSO4
    • Onset of action: 30 minutes to 6 hours (oral dose); 2-15 minutes (rectal dose)
    • A/E and caution
      • Abdominal cramping, N/V, and dehydration
      • electrolyte imbalance at long-term or higher doses
      • Avoid in Na, Me and phosphate restricted diet patients
      • Avoid in newborns, older adults and renal impairment (high risk of Mg toxicity
      • Sodium phosphate product use cautiously in pt with renal impairment, sodium restricted and medications (diuretics)
      • Sodium phosphate product CI in heart failure
      • Rectal sodium phosphate product avoid in megacolon, GI obstruction, imperforate anus, or colostomy
    • Patient instruction
      • take with 1 glass of water
      • do not take more than once a day
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
  • Lubricant laxative
    • Example: Mineral oil
    • Onset of action: 6-8 hours (oral); 5-15 min (rectal)
    • A/E and caution
      • risk outweighs the benefit
      • impaired absorption of fat-soluble vitamins, oil leakage, pruritus, cryptitis, or other perineal conditions
      • After oral administration, do not lie down (risk of lipid pneumonia from aspiration)
      • Avoid in <6 years, pregnant, bedridden patients, older adults and swelling difficulty patient
  • Stimulant laxative
    • Example:
      • sennosides,
      • castor oil,
      • bisacodyl
    • Onset of action: 6-10 hrs (oral, may take up to 24 hr); 15-60 min (bisacodyl suppository)
    • A/E and caution
      • Fluid and electrolyte imbalance, enteric loss of protein, malabsorption, severe cramping, hypokalemia.
      • Overdose: prompt medical attention required and symptoms include: nausea, diarrhea, sudden vomiting, severe abdominal cramping
      • laxative dependence can occur (Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Increasing doses of laxatives have to be ingested to obtain a response. this is treated by replacing stimulant laxatives with bulk laxatives. This may take many months and not all patients respond. ). Chronic use of stimulant laxatives can weaken the colon and lead to dependence. When laxatives are stopped, the colon may not function properly, resulting in worsened constipation.
    • Patient instruction
      • Take at night
      • Enteric coated bisacodyl should not be given chewed broken
      • Separate dosing within 1 hour with antacids, H2RA, PPIs, mild
    • Remarks
      • Enteric coated bisacodyl prevents gastric irritation
General therapeutic decision point
  • Preventive therapy: Bulk forming, Hyperosmotic, Emollients
  • Acute relief of constipation: Saline laxatives, hyperosmotic laxatives, lubricant laxatives
  • Opioid induced constipation relief: Stimulant laxative
  • Pt who should avoid staining (childbirth, heart attack, recent abdominal surgery, hemorrhoids, recent MI, postpartum) or have painful defecation: Bulk forming, emollients
  • Pt. on low fiber diet: Bulk forming
  • Colonoscopy: Saline laxative (eg Magnesium citrate)
Drug Interaction
  • Bulk forming laxatives
    • Drug: Digoxin, anticoagulants, salicylates
    • Mechanism: interfere drug absorption
    • Management/ Preventive measure: Separate dosing by at least 2 hours
  • Docusate salts
    • Drug: mineral oil
    • Mechanism: increased absorption
    • Management/ Preventive measure: avoid
  • Magnesium citrate
    • Drug: Fluoroquinolone and tetracyclines
    • Mechanism: decreased drug absorption
    • Management/ Preventive measure: avoid concurrent use for 1-3 hours
  • Magnesium hydroxide
    • Drug: Xaptopril, cefdinir, oral bisphosphonates, gabapenitn, iron salts, nitrofurantoin, phenothiazines, phenytoin, rosuvastatin
      • Mechanism: decreased oral bioavailability
      • Management/ Preventive measure: Separate dosing by at least 2 hours
    • Drug: Ketconazole, itraconazole, fluoroquinoline and tetracycline, levothyroxine
      • Mechanism: decreased absorption
      • Management/ Preventive measure: avoid 4 hours before or 3 hours after interacting drug
  • Bisacodyl
    • Drug: milk products or drugs that raise gastric pH (eg PPI)
    • Mechanism: premature dissolution of the bisacodyl enteric coating, leading to gastric irritation or dyspepsia
    • Management/ Preventive measure: Separate dosing by at least hours

Recommendation: Pharmacological and non pharmacological

  Non-pharmacological  
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
  Pharmacological   Pharmacological treatment: docusate sodium (1st-line), Mg(OH)2, sennosides, rectal glycerin (if faster relief needed), mineral oil, sodium phosphates.   Below is the overall information of laxatives. Use the information as per the above recommendation
  • Bulk forming
    • Example
      • Calcium polycarbophil, methylcellulose, psyllium
      • ispaghula
    • Onset of action: 12-24 hrs (can take up to 72 hours)
    • A/E and caution
      • Abdominal cramping, flatulance
      • Avoid in patient with swallowing difficulties or esophageal strictures, intestinal ulcers, stenosis
      • Avoid in patients with fluid restrictions (eg heart failure)
      • Pt. on diabetes: choose sugar-free formulations
    • Patient instruction
      • Take with at lease 1 glass of water (otherwise can swell in throat causing choking) and quickly consume after mixing
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • The bulk forming laxatives have a delayed onset and therefore are not suitable for acute, occasional relief.
  • Hyperosmotic agents
    • Example: PEG 3350, Glycerin, lactulose
    • Onset of action: 12-72 hrs (can take as long as 96 hours); 15-30 min (suppositories)
    • A/E and caution
      • Abdominal discomfort, cramping, bloating, flatulance
      • rectal irritation (with suppository)
      • Pt with renal disease or irritable bowel syndrome should ask physician approval
    • Patient instruction
      • Mix with half to 1 glass of water or juices or beverages
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • no clinically significant interaction have been reported
      • Glycerin suppositories safe >2 years patient
      • also stimulant
  • Emollients (stool softener)
    • Example:
      • Docusate sodium,
      • Docusate calcium
    • Onset of action: 12-72 hrs (can take 3-5 hours to see effect)
    • A/E and caution
      • A/E rare unless larger-than recommended doses- weakness, sweating, muscle cramps and irregular heartbeat
    • Patient instruction
      • Do not take with mineral oil
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • Does not absorb from GI and does not hamper absorption of other drugs
      • Docusate sodium is also a stimulant laxative
  • Saline laxative
    • Example:
      • Mg citrate,
      • Mg(OH)2,
      • dibasic sodium phosphate,
      • monobasic sodium phosphate,
      • MgSO4
    • Onset of action: 30 minutes to 6 hours (oral dose); 2-15 minutes (rectal dose)
    • A/E and caution
      • Abdominal cramping, N/V, and dehydration
      • electrolyte imbalance at long-term or higher doses
      • Avoid in Na, Me and phosphate restricted diet patients
      • Avoid in newborns, older adults and renal impairment (high risk of Mg toxicity
      • Sodium phosphate product use cautiously in pt with renal impairment, sodium restricted and medications (diuretics)
      • Sodium phosphate product CI in heart failure
      • Rectal sodium phosphate product avoid in megacolon, GI obstruction, imperforate anus, or colostomy
    • Patient instruction
      • take with 1 glass of water
      • do not take more than once a day
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
  • Lubricant laxative
    • Example: Mineral oil
    • Onset of action: 6-8 hours (oral); 5-15 min (rectal)
    • A/E and caution
      • risk outweighs the benefit
      • impaired absorption of fat-soluble vitamins, oil leakage, pruritus, cryptitis, or other perineal conditions
      • After oral administration, do not lie down (risk of lipid pneumonia from aspiration)
      • Avoid in <6 years, pregnant, bedridden patients, older adults and swelling difficulty patient
  • Stimulant laxative
    • Example:
      • sennosides,
      • castor oil,
      • bisacodyl
    • Onset of action: 6-10 hrs (oral, may take up to 24 hr); 15-60 min (bisacodyl suppository)
    • A/E and caution
      • Fluid and electrolyte imbalance, enteric loss of protein, malabsorption, severe cramping, hypokalemia.
      • Overdose: prompt medical attention required and symptoms include: nausea, diarrhea, sudden vomiting, severe abdominal cramping
      • laxative dependence can occur (Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Increasing doses of laxatives have to be ingested to obtain a response. this is treated by replacing stimulant laxatives with bulk laxatives. This may take many months and not all patients respond. ). Chronic use of stimulant laxatives can weaken the colon and lead to dependence. When laxatives are stopped, the colon may not function properly, resulting in worsened constipation.
    • Patient instruction
      • Take at night
      • Enteric coated bisacodyl should not be given chewed broken
      • Separate dosing within 1 hour with antacids, H2RA, PPIs, mild
    • Remarks
      • Enteric coated bisacodyl prevents gastric irritation
General therapeutic decision point
  • Preventive therapy: Bulk forming, Hyperosmotic, Emollients
  • Acute relief of constipation: Saline laxatives, hyperosmotic laxatives, lubricant laxatives
  • Opioid induced constipation relief: Stimulant laxative
  • Pt who should avoid staining (childbirth, heart attack, recent abdominal surgery, hemorrhoids, recent MI, postpartum) or have painful defecation: Bulk forming, emollients
  • Pt. on low fiber diet: Bulk forming
  • Colonoscopy: Saline laxative (eg Magnesium citrate)
Drug Interaction
  • Bulk forming laxatives
    • Drug: Digoxin, anticoagulants, salicylates
    • Mechanism: interfere drug absorption
    • Management/ Preventive measure: Separate dosing by at least 2 hours
  • Docusate salts
    • Drug: mineral oil
    • Mechanism: increased absorption
    • Management/ Preventive measure: avoid
  • Magnesium citrate
    • Drug: Fluoroquinolone and tetracyclines
    • Mechanism: decreased drug absorption
    • Management/ Preventive measure: avoid concurrent use for 1-3 hours
  • Magnesium hydroxide
    • Drug: Xaptopril, cefdinir, oral bisphosphonates, gabapenitn, iron salts, nitrofurantoin, phenothiazines, phenytoin, rosuvastatin
      • Mechanism: decreased oral bioavailability
      • Management/ Preventive measure: Separate dosing by at least 2 hours
    • Drug: Ketconazole, itraconazole, fluoroquinoline and tetracycline, levothyroxine
      • Mechanism: decreased absorption
      • Management/ Preventive measure: avoid 4 hours before or 3 hours after interacting drug
  • Bisacodyl
    • Drug: milk products or drugs that raise gastric pH (eg PPI)
    • Mechanism: premature dissolution of the bisacodyl enteric coating, leading to gastric irritation or dyspepsia
    • Management/ Preventive measure: Separate dosing by at least hours

Recommendation: Pharmacological and non pharmacological

  Non-pharmacological  
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
  Pharmacological  
  • 1st line: bulk forming, emollient and saline laxative
  • if 1st line fail: stimulants (sennosides, bisacodyl) but avoid in third trimester
  • rectal glycerin can be used but PEG 3350 restricted
  Below is the overall information of laxatives. Use the information as per the above recommendation
  • Bulk forming
    • Example
      • Calcium polycarbophil, methylcellulose, psyllium
      • ispaghula
    • Onset of action: 12-24 hrs (can take up to 72 hours)
    • A/E and caution
      • Abdominal cramping, flatulance
      • Avoid in patient with swallowing difficulties or esophageal strictures, intestinal ulcers, stenosis
      • Avoid in patients with fluid restrictions (eg heart failure)
      • Pt. on diabetes: choose sugar-free formulations
    • Patient instruction
      • Take with at lease 1 glass of water (otherwise can swell in throat causing choking) and quickly consume after mixing
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • The bulk forming laxatives have a delayed onset and therefore are not suitable for acute, occasional relief.
  • Hyperosmotic agents
    • Example: PEG 3350, Glycerin, lactulose
    • Onset of action: 12-72 hrs (can take as long as 96 hours); 15-30 min (suppositories)
    • A/E and caution
      • Abdominal discomfort, cramping, bloating, flatulance
      • rectal irritation (with suppository)
      • Pt with renal disease or irritable bowel syndrome should ask physician approval
    • Patient instruction
      • Mix with half to 1 glass of water or juices or beverages
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • no clinically significant interaction have been reported
      • Glycerin suppositories safe >2 years patient
      • also stimulant
  • Emollients (stool softener)
    • Example:
      • Docusate sodium,
      • Docusate calcium
    • Onset of action: 12-72 hrs (can take 3-5 hours to see effect)
    • A/E and caution
      • A/E rare unless larger-than recommended doses- weakness, sweating, muscle cramps and irregular heartbeat
    • Patient instruction
      • Do not take with mineral oil
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • Does not absorb from GI and does not hamper absorption of other drugs
      • Docusate sodium is also a stimulant laxative
  • Saline laxative
    • Example:
      • Mg citrate,
      • Mg(OH)2,
      • dibasic sodium phosphate,
      • monobasic sodium phosphate,
      • MgSO4
    • Onset of action: 30 minutes to 6 hours (oral dose); 2-15 minutes (rectal dose)
    • A/E and caution
      • Abdominal cramping, N/V, and dehydration
      • electrolyte imbalance at long-term or higher doses
      • Avoid in Na, Me and phosphate restricted diet patients
      • Avoid in newborns, older adults and renal impairment (high risk of Mg toxicity
      • Sodium phosphate product use cautiously in pt with renal impairment, sodium restricted and medications (diuretics)
      • Sodium phosphate product CI in heart failure
      • Rectal sodium phosphate product avoid in megacolon, GI obstruction, imperforate anus, or colostomy
    • Patient instruction
      • take with 1 glass of water
      • do not take more than once a day
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
  • Lubricant laxative
    • Example: Mineral oil
    • Onset of action: 6-8 hours (oral); 5-15 min (rectal)
    • A/E and caution
      • risk outweighs the benefit
      • impaired absorption of fat-soluble vitamins, oil leakage, pruritus, cryptitis, or other perineal conditions
      • After oral administration, do not lie down (risk of lipid pneumonia from aspiration)
      • Avoid in <6 years, pregnant, bedridden patients, older adults and swelling difficulty patient
  • Stimulant laxative
    • Example:
      • sennosides,
      • castor oil,
      • bisacodyl
    • Onset of action: 6-10 hrs (oral, may take up to 24 hr); 15-60 min (bisacodyl suppository)
    • A/E and caution
      • Fluid and electrolyte imbalance, enteric loss of protein, malabsorption, severe cramping, hypokalemia.
      • Overdose: prompt medical attention required and symptoms include: nausea, diarrhea, sudden vomiting, severe abdominal cramping
      • laxative dependence can occur (Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Increasing doses of laxatives have to be ingested to obtain a response. this is treated by replacing stimulant laxatives with bulk laxatives. This may take many months and not all patients respond. ). Chronic use of stimulant laxatives can weaken the colon and lead to dependence. When laxatives are stopped, the colon may not function properly, resulting in worsened constipation.
    • Patient instruction
      • Take at night
      • Enteric coated bisacodyl should not be given chewed broken
      • Separate dosing within 1 hour with antacids, H2RA, PPIs, mild
    • Remarks
      • Enteric coated bisacodyl prevents gastric irritation
General therapeutic decision point
  • Preventive therapy: Bulk forming, Hyperosmotic, Emollients
  • Acute relief of constipation: Saline laxatives, hyperosmotic laxatives, lubricant laxatives
  • Opioid induced constipation relief: Stimulant laxative
  • Pt who should avoid staining (childbirth, heart attack, recent abdominal surgery, hemorrhoids, recent MI, postpartum) or have painful defecation: Bulk forming, emollients
  • Pt. on low fiber diet: Bulk forming
  • Colonoscopy: Saline laxative (eg Magnesium citrate)
Drug Interaction
  • Bulk forming laxatives
    • Drug: Digoxin, anticoagulants, salicylates
    • Mechanism: interfere drug absorption
    • Management/ Preventive measure: Separate dosing by at least 2 hours
  • Docusate salts
    • Drug: mineral oil
    • Mechanism: increased absorption
    • Management/ Preventive measure: avoid
  • Magnesium citrate
    • Drug: Fluoroquinolone and tetracyclines
    • Mechanism: decreased drug absorption
    • Management/ Preventive measure: avoid concurrent use for 1-3 hours
  • Magnesium hydroxide
    • Drug: Xaptopril, cefdinir, oral bisphosphonates, gabapenitn, iron salts, nitrofurantoin, phenothiazines, phenytoin, rosuvastatin
      • Mechanism: decreased oral bioavailability
      • Management/ Preventive measure: Separate dosing by at least 2 hours
    • Drug: Ketconazole, itraconazole, fluoroquinoline and tetracycline, levothyroxine
      • Mechanism: decreased absorption
      • Management/ Preventive measure: avoid 4 hours before or 3 hours after interacting drug
  • Bisacodyl
    • Drug: milk products or drugs that raise gastric pH (eg PPI)
    • Mechanism: premature dissolution of the bisacodyl enteric coating, leading to gastric irritation or dyspepsia
    • Management/ Preventive measure: Separate dosing by at least hours

Recommendation: Pharmacological and non pharmacological

  Non-pharmacological  
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
  Pharmacological Select laxatives as appropriate   Below is the overall information of laxatives. Use the information as per the above recommendation
  • Bulk forming
    • Example
      • Calcium polycarbophil, methylcellulose, psyllium
      • ispaghula
    • Onset of action: 12-24 hrs (can take up to 72 hours)
    • A/E and caution
      • Abdominal cramping, flatulance
      • Avoid in patient with swallowing difficulties or esophageal strictures, intestinal ulcers, stenosis
      • Avoid in patients with fluid restrictions (eg heart failure)
      • Pt. on diabetes: choose sugar-free formulations
    • Patient instruction
      • Take with at lease 1 glass of water (otherwise can swell in throat causing choking) and quickly consume after mixing
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • The bulk forming laxatives have a delayed onset and therefore are not suitable for acute, occasional relief.
  • Hyperosmotic agents
    • Example: PEG 3350, Glycerin, lactulose
    • Onset of action: 12-72 hrs (can take as long as 96 hours); 15-30 min (suppositories)
    • A/E and caution
      • Abdominal discomfort, cramping, bloating, flatulance
      • rectal irritation (with suppository)
      • Pt with renal disease or irritable bowel syndrome should ask physician approval
    • Patient instruction
      • Mix with half to 1 glass of water or juices or beverages
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • no clinically significant interaction have been reported
      • Glycerin suppositories safe >2 years patient
      • also stimulant
  • Emollients (stool softener)
    • Example:
      • Docusate sodium,
      • Docusate calcium
    • Onset of action: 12-72 hrs (can take 3-5 hours to see effect)
    • A/E and caution
      • A/E rare unless larger-than recommended doses- weakness, sweating, muscle cramps and irregular heartbeat
    • Patient instruction
      • Do not take with mineral oil
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • Does not absorb from GI and does not hamper absorption of other drugs
      • Docusate sodium is also a stimulant laxative
  • Saline laxative
    • Example:
      • Mg citrate,
      • Mg(OH)2,
      • dibasic sodium phosphate,
      • monobasic sodium phosphate,
      • MgSO4
    • Onset of action: 30 minutes to 6 hours (oral dose); 2-15 minutes (rectal dose)
    • A/E and caution
      • Abdominal cramping, N/V, and dehydration
      • electrolyte imbalance at long-term or higher doses
      • Avoid in Na, Me and phosphate restricted diet patients
      • Avoid in newborns, older adults and renal impairment (high risk of Mg toxicity
      • Sodium phosphate product use cautiously in pt with renal impairment, sodium restricted and medications (diuretics)
      • Sodium phosphate product CI in heart failure
      • Rectal sodium phosphate product avoid in megacolon, GI obstruction, imperforate anus, or colostomy
    • Patient instruction
      • take with 1 glass of water
      • do not take more than once a day
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
  • Lubricant laxative
    • Example: Mineral oil
    • Onset of action: 6-8 hours (oral); 5-15 min (rectal)
    • A/E and caution
      • risk outweighs the benefit
      • impaired absorption of fat-soluble vitamins, oil leakage, pruritus, cryptitis, or other perineal conditions
      • After oral administration, do not lie down (risk of lipid pneumonia from aspiration)
      • Avoid in <6 years, pregnant, bedridden patients, older adults and swelling difficulty patient
  • Stimulant laxative
    • Example:
      • sennosides,
      • castor oil,
      • bisacodyl
    • Onset of action: 6-10 hrs (oral, may take up to 24 hr); 15-60 min (bisacodyl suppository)
    • A/E and caution
      • Fluid and electrolyte imbalance, enteric loss of protein, malabsorption, severe cramping, hypokalemia.
      • Overdose: prompt medical attention required and symptoms include: nausea, diarrhea, sudden vomiting, severe abdominal cramping
      • laxative dependence can occur (Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Increasing doses of laxatives have to be ingested to obtain a response. this is treated by replacing stimulant laxatives with bulk laxatives. This may take many months and not all patients respond. ). Chronic use of stimulant laxatives can weaken the colon and lead to dependence. When laxatives are stopped, the colon may not function properly, resulting in worsened constipation.
    • Patient instruction
      • Take at night
      • Enteric coated bisacodyl should not be given chewed broken
      • Separate dosing within 1 hour with antacids, H2RA, PPIs, mild
    • Remarks
      • Enteric coated bisacodyl prevents gastric irritation
General therapeutic decision point
  • Preventive therapy: Bulk forming, Hyperosmotic, Emollients
  • Acute relief of constipation: Saline laxatives, hyperosmotic laxatives, lubricant laxatives
  • Opioid induced constipation relief: Stimulant laxative
  • Pt who should avoid staining (childbirth, heart attack, recent abdominal surgery, hemorrhoids, recent MI, postpartum) or have painful defecation: Bulk forming, emollients
  • Pt. on low fiber diet: Bulk forming
  • Colonoscopy: Saline laxative (eg Magnesium citrate)
Drug Interaction
  • Bulk forming laxatives
    • Drug: Digoxin, anticoagulants, salicylates
    • Mechanism: interfere drug absorption
    • Management/ Preventive measure: Separate dosing by at least 2 hours
  • Docusate salts
    • Drug: mineral oil
    • Mechanism: increased absorption
    • Management/ Preventive measure: avoid
  • Magnesium citrate
    • Drug: Fluoroquinolone and tetracyclines
    • Mechanism: decreased drug absorption
    • Management/ Preventive measure: avoid concurrent use for 1-3 hours
  • Magnesium hydroxide
    • Drug: Xaptopril, cefdinir, oral bisphosphonates, gabapenitn, iron salts, nitrofurantoin, phenothiazines, phenytoin, rosuvastatin
      • Mechanism: decreased oral bioavailability
      • Management/ Preventive measure: Separate dosing by at least 2 hours
    • Drug: Ketconazole, itraconazole, fluoroquinoline and tetracycline, levothyroxine
      • Mechanism: decreased absorption
      • Management/ Preventive measure: avoid 4 hours before or 3 hours after interacting drug
  • Bisacodyl
    • Drug: milk products or drugs that raise gastric pH (eg PPI)
    • Mechanism: premature dissolution of the bisacodyl enteric coating, leading to gastric irritation or dyspepsia
    • Management/ Preventive measure: Separate dosing by at least hours

Recommendation: Pharmacological and non pharmacological

  Non-pharmacological  
  • Lifestyle measures such as increasing fiber and fluid in the diet and increasing exercise levels are the first option that should be encouraged.
  • Dietary factors
    • Fluids: Fluids can be in the form of water, soups, juices.
      • Drink eight glasses or mugs of fluid a day (about two litres).
      • Avoid too many drinks containing caffeine and alcohol. They have a diuretic effect, potentially exacerbating dehydration.
      • Older adults may have a decreased sense of thirst, making them more vulnerable to dehydration-related constipation.
    • Foods: Use balance diet incorporating fruits, vegetables and whole grains is key in preventing constipation
      • Fibers
        • Fibers normalizes bowel movements and GI transit (decrease risk of excessive water reabsorption)
        • Insoluble fiber (wheat bran, vegetables) adds bulk and speeds up transit. Soluble fiber (oats, beans) absorbs water and forms a gel, which also aids movement.
        • Patient with low fiber diet should gradually increase dietary intake of insoluble fiber (eg fruits, vegetables, wheat bran, whole grain) to minimize GI irritation. Goal is 25gm/day for women and 38 fm /day for men
        • When increasing dietary fiber, increase fluid intake by ~2 L/day. It's crucial to increase fiber gradually and with adequate fluid intake to avoid bloating and gas
        • Fiber supplements can be used if dietary intake insufficient.
        • While fiber is generally beneficial, in some people with conditions like IBS or pelvic floor dysfunction, too much fiber can worsen symptoms.
      • Avoid
        • Fatty Foods: High-fat foods can slow down digestion.
        • Dairy products: High-fat foods can slow down digestion.
        • Processed Foods: These are often low in fiber and high in unhealthy fats.
  • lifestyle factors: Exercise not only stimulates the gut directly but also reduces stress, which can positively influence bowel function.
    • Types of exercise
      • Aerobic exercise (walking, running, gardening, swimming) is particularly effective.
      • Even simple activities like daily walks can make a difference.
    • Prolonged Bed Rest: Hospitalization or illness that leads to prolonged bed rest significantly increases the risk of constipation.
    • Stress: Stress can affect the digestive system in various ways, including slowing down or speeding up bowel motility (depending on the individual).
    • Lack of Privacy: Some individuals find it difficult to use public restrooms, leading to suppression of the urge to defecate and finally constipation
  • Habitual action: Do not hold stool. this will aggravate constipation
    • Ignoring the Urge to Defecate: The rectum stretches when stool arrives, triggering the urge to defecate. Consistently ignoring this reflex can weaken it over time.
    • Bowel training improve bowel movement (reflexes are strongest first 30 minutes of day and after a meal)
  Pharmacological  
  • 1st-line: osmotic laxatives
  • Avoid mineral oil (risk of aspiration pneumonia, saline laxative (electrolyte imbalance)
  • Rectal enamas can be considered.
  Below is the overall information of laxatives. Use the information as per the above recommendation
  • Bulk forming
    • Example
      • Calcium polycarbophil, methylcellulose, psyllium
      • ispaghula
    • Onset of action: 12-24 hrs (can take up to 72 hours)
    • A/E and caution
      • Abdominal cramping, flatulance
      • Avoid in patient with swallowing difficulties or esophageal strictures, intestinal ulcers, stenosis
      • Avoid in patients with fluid restrictions (eg heart failure)
      • Pt. on diabetes: choose sugar-free formulations
    • Patient instruction
      • Take with at lease 1 glass of water (otherwise can swell in throat causing choking) and quickly consume after mixing
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • The bulk forming laxatives have a delayed onset and therefore are not suitable for acute, occasional relief.
  • Hyperosmotic agents
    • Example: PEG 3350, Glycerin, lactulose
    • Onset of action: 12-72 hrs (can take as long as 96 hours); 15-30 min (suppositories)
    • A/E and caution
      • Abdominal discomfort, cramping, bloating, flatulance
      • rectal irritation (with suppository)
      • Pt with renal disease or irritable bowel syndrome should ask physician approval
    • Patient instruction
      • Mix with half to 1 glass of water or juices or beverages
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • no clinically significant interaction have been reported
      • Glycerin suppositories safe >2 years patient
      • also stimulant
  • Emollients (stool softener)
    • Example:
      • Docusate sodium,
      • Docusate calcium
    • Onset of action: 12-72 hrs (can take 3-5 hours to see effect)
    • A/E and caution
      • A/E rare unless larger-than recommended doses- weakness, sweating, muscle cramps and irregular heartbeat
    • Patient instruction
      • Do not take with mineral oil
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
    • Remarks
      • Does not absorb from GI and does not hamper absorption of other drugs
      • Docusate sodium is also a stimulant laxative
  • Saline laxative
    • Example:
      • Mg citrate,
      • Mg(OH)2,
      • dibasic sodium phosphate,
      • monobasic sodium phosphate,
      • MgSO4
    • Onset of action: 30 minutes to 6 hours (oral dose); 2-15 minutes (rectal dose)
    • A/E and caution
      • Abdominal cramping, N/V, and dehydration
      • electrolyte imbalance at long-term or higher doses
      • Avoid in Na, Me and phosphate restricted diet patients
      • Avoid in newborns, older adults and renal impairment (high risk of Mg toxicity
      • Sodium phosphate product use cautiously in pt with renal impairment, sodium restricted and medications (diuretics)
      • Sodium phosphate product CI in heart failure
      • Rectal sodium phosphate product avoid in megacolon, GI obstruction, imperforate anus, or colostomy
    • Patient instruction
      • take with 1 glass of water
      • do not take more than once a day
      • Increase fluid and fiber intake
      • medical referral if constipation persist >7 days despite therapy
  • Lubricant laxative
    • Example: Mineral oil
    • Onset of action: 6-8 hours (oral); 5-15 min (rectal)
    • A/E and caution
      • risk outweighs the benefit
      • impaired absorption of fat-soluble vitamins, oil leakage, pruritus, cryptitis, or other perineal conditions
      • After oral administration, do not lie down (risk of lipid pneumonia from aspiration)
      • Avoid in <6 years, pregnant, bedridden patients, older adults and swelling difficulty patient
  • Stimulant laxative
    • Example:
      • sennosides,
      • castor oil,
      • bisacodyl
    • Onset of action: 6-10 hrs (oral, may take up to 24 hr); 15-60 min (bisacodyl suppository)
    • A/E and caution
      • Fluid and electrolyte imbalance, enteric loss of protein, malabsorption, severe cramping, hypokalemia.
      • Overdose: prompt medical attention required and symptoms include: nausea, diarrhea, sudden vomiting, severe abdominal cramping
      • laxative dependence can occur (Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Increasing doses of laxatives have to be ingested to obtain a response. this is treated by replacing stimulant laxatives with bulk laxatives. This may take many months and not all patients respond. ). Chronic use of stimulant laxatives can weaken the colon and lead to dependence. When laxatives are stopped, the colon may not function properly, resulting in worsened constipation.
    • Patient instruction
      • Take at night
      • Enteric coated bisacodyl should not be given chewed broken
      • Separate dosing within 1 hour with antacids, H2RA, PPIs, mild
    • Remarks
      • Enteric coated bisacodyl prevents gastric irritation
General therapeutic decision point
  • Preventive therapy: Bulk forming, Hyperosmotic, Emollients
  • Acute relief of constipation: Saline laxatives, hyperosmotic laxatives, lubricant laxatives
  • Opioid induced constipation relief: Stimulant laxative
  • Pt who should avoid staining (childbirth, heart attack, recent abdominal surgery, hemorrhoids, recent MI, postpartum) or have painful defecation: Bulk forming, emollients
  • Pt. on low fiber diet: Bulk forming
  • Colonoscopy: Saline laxative (eg Magnesium citrate)
Drug Interaction
  • Bulk forming laxatives
    • Drug: Digoxin, anticoagulants, salicylates
    • Mechanism: interfere drug absorption
    • Management/ Preventive measure: Separate dosing by at least 2 hours
  • Docusate salts
    • Drug: mineral oil
    • Mechanism: increased absorption
    • Management/ Preventive measure: avoid
  • Magnesium citrate
    • Drug: Fluoroquinolone and tetracyclines
    • Mechanism: decreased drug absorption
    • Management/ Preventive measure: avoid concurrent use for 1-3 hours
  • Magnesium hydroxide
    • Drug: Xaptopril, cefdinir, oral bisphosphonates, gabapenitn, iron salts, nitrofurantoin, phenothiazines, phenytoin, rosuvastatin
      • Mechanism: decreased oral bioavailability
      • Management/ Preventive measure: Separate dosing by at least 2 hours
    • Drug: Ketconazole, itraconazole, fluoroquinoline and tetracycline, levothyroxine
      • Mechanism: decreased absorption
      • Management/ Preventive measure: avoid 4 hours before or 3 hours after interacting drug
  • Bisacodyl
    • Drug: milk products or drugs that raise gastric pH (eg PPI)
    • Mechanism: premature dissolution of the bisacodyl enteric coating, leading to gastric irritation or dyspepsia
    • Management/ Preventive measure: Separate dosing by at least hours
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