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Gastrointestinal Palliative care

Palliative care - constipation

Last revised in April 2025

Constipation is defecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defecation.

Palliative care - constipation: Summary

  • Constipation is defecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.
    • About 80% of people with cancer will require treatment with laxatives at some time.
  • People receiving palliative care have multiple causes of constipation, such as:
    • Drugs, such as opioid analgesics, antimuscarinic drugs, antacids.
    • Secondary effects of disease, such as dehydration, inadequate dietary fibre, inactivity, delirium, spinal cord compression, lack of privacy.
    • Direct effects of malignant tumours, causing bowel obstruction, hypercalcaemia, nerve damage.
  • When assessing a person with constipation in palliative care:
    • The history should include information about the frequency and character of stools, discomfort, blood or mucus with the stool, or straining.
    • Other associated symptoms, such as malaise; flatulence, abdominal pain and distension; anorexia, nausea or vomiting; halitosis; faecal incontinence (overflow diarrhoea); and distress or worsening confusion should be noted.
    • An assessment should be made for faecal loading and impaction, suggested by faecal masses palpable abdominally or perianally, or on internal rectal examination.
    • Bowel obstruction, anal fissure, painful haemorrhoids, and local tumours should be excluded or managed.
  • A person with constipation in palliative care should be offered the following management strategies:
    • Alleviating contributing factors, where possible, such as dehydration, lack of privacy, haemorrhoids.
    • Treatment with a combination of a stimulant and a softening laxative, such as senna and lactulose.
    • Titration of the dose of laxatives every few days to achieve comfortable defecation.
    • If the response is insufficient, the addition of a macrogol should be considered. Additional treatments may be necessary for faecal loading and/or impaction, such as a suppository or enema.
    • A laxative should be prescribed to prevent constipation when starting any potentially constipating drug, such as opioid analgesics. The laxative dose needs to increase with increases in opioid dose.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the symptomatic management of constipation in people who are receiving palliative care and incorporates guidance from the National Institute for Health and Care Excellence on Improving supportive and palliative care for adults with cancer [NICE, 2004] and Care of dying adults in the last days of life [NICE, 2015a]. 

There are separate CKS topics on Constipation, Hypercalcaemia, Palliative care - cough, Palliative care - dyspnoea, Palliative care - general issues, Palliative care - malignant skin ulcer, Palliative care - nausea and vomiting, Palliative care - oral, Palliative cancer care - pain, and Palliative care - secretions.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

Previous changes

November 2024 — minor update. Information that naldemedine is an option for people with opioid-induced constipation has been added in line with the NICE technology appraisal Naldemedine for treating opioid-induced constipation.

January 2024 — minor update. Information that other medicines should not be taken orally for one hour before, during and for one hour after taking macrogol products has been added to this topic in line with the updated manufacturer's SPC for Movicol. 

January 2023 — minor update. Added information about avoiding concomitant use of macrogol and starch-based food thickeners in line with an update to the manufacturer's SPC. 

March 2021 — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. 

July 2015 to October 2016 — reviewed. Literature searches were conducted in September 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. There have been structural changes to the topic and changes to the recommendations have been updated in line with NICE guidance Care of dying adults in the last days of life [NICE, 2015a]. 

July 2015 — topic title changed to reflect broader topic coverage than specifically cancer care.

July 2014 — minor update. Update to the text to clarify that recent advice regarding the restricted use of metoclopramide and domperidone does not apply to unlicensed uses of metoclopramide and domperidone (for example palliative care).

April 2014 — minor update. Text changes to prescribing information for Fleet Ready-to-Use phosphate enema to reflect the addition of renal impairment and dehydration to the contraindications section of the Summary of Product Characteristics.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

April 2013 — reviewed. A literature search was conducted in November 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Methylnaltrexone (a peripheral opioid-receptor antagonist) is now a therapeutic option in opioid-induced constipation, however CKS recommends this is used only in a specialist setting. No major changes to clinical recommendations have been made.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

April 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. 

June 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic. 

February 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

October 2007 to February 2008 — developed as a new CKS topic and replacing the section on Terminal care in the CKS guidance on Constipation. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations on the management of constipation in palliative care. However, there is clearer advice on treatment strategies.

Update

New evidence

Evidence-based guidelines

No evidence-based guidelines since 1 March 2021.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2021.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2021.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2021. 

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2021.

New policies

No new national policies or guidelines since 1 March 2021.

New safety alerts

No new safety alerts since 1 March 2021.

Changes in product availability

No changes in product availability since 1 March 2021.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Assess, prevent, and manage constipation in people who are receiving palliative care.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

  • Laxatives:
    • Review and, where appropriate, revise prescribing of laxatives for adults to ensure they are only prescribed routinely for the short-term treatment of constipation, where dietary and lifestyle measures have proved unsuccessful or where there is an immediate clinical need.

[NICE, 2015b]

NICE quality standards

NICE have defined Quality Standards relevant to end of life care for adults [NICE, 2013]. 

Background information

What is it?

  • Constipation is defecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.
    • This definition of constipation is necessarily subjective because different people have different views about what is infrequent, difficult, dry, hard, abnormally large, or abnormally small.
    • Note: it is possible to be constipated and have normal or even soft stools, for example when there is failure of propulsion by the bowel (for example opioid-induced or neuropathic problems).

How common is it?

  • The prevalence of constipation in patients with advanced cancer ranges between 40–90%. Those taking opioid medications are more likely to suffer constipation [Larkin, 2008].
  • About 80% of people with cancer will require treatment with laxatives at some time [Fallon, 1997].

What are the common causes?

  • Opioid analgesics are a common cause of constipation in people receiving palliative care [Larkin, 2008]. 
  • However, the presence of contributing factors may exacerbate constipation in people receiving palliative care.

What factors can contribute to constipation?

Secondary effects of disease that contribute to constipation include:

  • Inadequate diet (poor intake, limited fibre).
  • Dehydration.
  • Weakness or dyspnoea (breathlessness) — prevents effective straining.
  • Confusion.
  • Depression.
  • Inactivity.
  • Unfamiliar toilet arrangements or lack of privacy (both auditory and visual).
  • Having to use a bedpan.

[Sykes, 2015; Larkin, 2018]

What drugs can cause constipation?

Drugs that commonly cause constipation in people receiving palliative care include:

  • Opioids.
  • Drugs with antimuscarinic effects (cyclizine, hyoscine, phenothiazines, tricyclic antidepressants, some antiepileptic drugs, antiparkinsonian agents).
  • Antacids (calcium and aluminium compounds).
  • Diuretics.
  • Iron.
  • Antihypertensive agents.
  • Cytotoxics (for example vinca alkaloids).
  • 5HT-3 antagonists (for example ondansetron).
  • Platinum-based chemotherapy agents (present or past use).

[Sykes, 2015]

What are the direct effects of cancer on constipation?

Cancer can cause constipation in several ways, for example by:

  • Bowel obstruction due to either tumour in the bowel wall, or external compression by abdominal or pelvic tumour.
  • Compression or infiltration of the lumbosacral spinal cord, cauda equina, or pelvic plexus.
  • Causing hypercalcaemia.
  • Causing painful defecation.
  • Autonomic neuropathy, a non-metastatic manifestation of malignancy, particularly associated with small cell carcinoma of the lung and carcinoid tumours.

[Sykes, 2015]

What other concurrent diseases can cause constipation?

People receiving palliative care often have concurrent conditions that cause constipation, for example:

  • Diverticular disease.
  • Inflammatory bowel disease (Crohn's disease and ulcerative colitis).
  • Irritable bowel syndrome.
  • Endocrine and metabolic conditions (for example diabetes - type 1, diabetes - type 2, hypercalcaemia, hypothyroidism, hypokalaemia).
  • Inguinal and abdominal herniae.
  • Colonic strictures (following diverticulitis, ischaemia, surgery).
  • Rectocele (suspect if the woman needs to insert a finger into the vagina to help pass stool).
  • Rectal prolapse.
  • Rectal ulcer (suspect if the person needs to insert a finger into the rectum to push away a flap prior to defecation).
  • Anal fissure or stenosis.
  • Haemorrhoids.
  • Dyssynergic defecation (incomplete evacuation of faeces from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate).
  • Weak levator muscles (suspect if the person needs to apply pressure behind the anus to help pass stool).
  • Spinal cord damage.
  • Severe neurological diseases.
  • Severe intellectual disability.

 [Regnard, 2022; Sykes, 2015; Northern England Clinical Network, 2016; Larkin, 2018]

What are the complications?

  • Constipation may lead to:
    • Increased agitation and/or confusion. 
    • Bowel obstruction.
    • Pain and abdominal distension.
    • Urinary retention and urinary tract infection.
    • Faecal incontinence (overflow diarrhoea).
    • Faecal retention, distension of the rectum, and loss of sensory and motor function.
    • Faecal impaction, particularly in the immobile.
    • Rectal bleeding.
    • Rectal prolapse.

[Regnard, 2022]

Diagnosis of constipation in palliative care

Diagnosis of constipation in palliative care

  • Suspect constipation when:
    • Stools are hard, uncomfortable, or difficult to pass, and are less frequent than usual; or the person has a sense of incomplete evacuation after defecation.
      • Infrequent stool passage is common in advanced disease, however if the person has not opened their bowels for more than 3 days, treatment is recommended.
    • Associated symptoms are present, including malaise; flatulence, colicky abdominal pain and distension; anorexia, nausea, or vomiting; halitosis; and faecal incontinence (overflow diarrhoea).
    • The person has urinary frequency or retention.
    • The person is agitated or confused, particularly if they are elderly or have impaired brain function (for example dementia).
  • Suspect faecal loading or impaction when:
    • Stools are hard and lumpy, and either large and infrequent (for example every 7–10 days), or small and relatively frequent (for example every 2–3 days).
    • Straining is ineffective.
    • Manual methods are necessary to extract faeces.
    • Overflow faecal incontinence or loose stools are present.
    • Faecal masses are palpable abdominally or peri-anally, on internal rectal examination (avoid rectal examination in people who are receiving chemotherapy, are thrombocytopenic, or who have rectal or anal disease), or on gentle digital examination of the stoma (if the person has a colostomy).
      • 98% of faecal impactions occur in the rectum.
      • Careful examination can usually distinguish a faecal mass from a tumour or cyst: firm pressure exerted by a finger will leave a palpable indentation in hard faeces.
  • Suspect bowel obstruction when any of the following symptoms or signs are present:
    • Absence of passage of flatus per rectum.
    • Colicky, abdominal pain, and abdominal distension.
    • Anorexia, nausea, or vomiting (which may be faeculent).
    • Abdominal tenderness without guarding or rebound.
    • Active, tinkling bowel sounds; or quiet or absent bowel sounds (a late sign).

Basis for recommendation

These recommendations are based on the guidelines Palliative and end of life care [Northern England Clinical Network, 2016] and Scottish palliative care guidelines [NHS Scotland, 2021]. 

Management

Scenario: Assessment

From age 16 years onwards.

How should I assess a person with constipation in palliative care?

  • Attempt to diagnose the cause of constipation — this will include an abdominal and rectal examination (avoid rectal examination in people receiving chemotherapy).
    • Exclude bowel obstruction. Features that suggest obstruction include:
      • Known presence of intra-abdominal tumour.
      • Absence of passage of flatus per rectum.
      • Nausea and vomiting.
      • Colicky, abdominal pain.
      • Abdominal distension.
      • Abdominal tenderness without guarding or rebound.
      • Active, tinkling bowel sounds; or quiet or absent bowel sounds (a late sign).
    • Identify when constipation first became a problem (if constipation pre-dates the illness requiring palliative care, further enquiry may be indicated).
    • Assess the role (and potential for modification) of contributing factors and drugs.
    • Identify any direct effects of malignant tumour or other concurrent disease that could cause constipation.
  • Assess the severity and impact of constipation and any faecal incontinence.
    • Is there nausea, vomiting, loss of appetite, or loss of body weight?
    • Is there abdominal pain or abdominal distension?
    • Is there pain or bleeding with passing stools?
    • Is underwear regularly and involuntarily soiled? If yes, what are the social consequences of this?
    • Are there urinary symptoms, urinary incontinence, difficulty in passing urine, or blockage of a urinary catheter?
  • Assess the effectiveness of management to date.
    • What measures (self-care and prescribed, non-drug and drug) have been tried?
    • What has been the response?
  • Consider performing blood tests.
    • Urea and electrolytes, serum calcium and thyroid function tests. To exclude an underlying treatable condition.

Basis for recommendation

These recommendations are based on expert opinion [Regnard, 2022; NHS Lothian, 2015; NHS Lothian, 2016; Larkin, 2018], the Scottish palliative care guidelines [NHS Scotland, 2021], Palliative care adult network guidelines [Back, 2021], and information from the Oxford textbook of palliative medicine [Sykes, 2015].

Scenario: Management

From age 16 years onwards.

How should I prevent constipation when prescribing a constipating drug?

  • When introducing an opioid (or any other drug likely to cause constipation), advise the person of the risks of constipation, and prescribe a stimulant laxative (such as senna or dantron-containing laxative) at the time of first prescription, rather than waiting until constipation has occurred. Aim for a regular bowel movement, without straining, every 1–3 days.
    • Dose of senna:
      • If not constipated start with 15 mg at bedtime. If there is no bowel movement after 24–48 hours, increase to 15 mg at bedtime and 15 mg each morning.
      • If already constipated, start with 15 mg at bedtime and 15 mg each morning. If there is no response after 24–48 hours, increase to 22.5 mg at bedtime and 22.5 mg each morning.
      • If there is still no response after a further 24–48 hours, consider adding a third daytime dose.
      • If necessary, consider increasing to a maximum dose of 30 mg three times a day.
    • The dose of dantron-containing laxatives is variable, according to the preparation, individual need, and acceptability. For information on dosages, see the Prescribing section.
    • In people with renal failure prescribe lactulose plus senna, or co-danthramer. For information on dosages, see the Prescribing section.
  • Encourage an adequate fluid intake and appropriate diet.

Basis for recommendation

These recommendations are pragmatic advice based on expert opinion [Twycross, 2016].

How should I treat constipation?

  • Where possible, alleviate contributing factors (for example inadequate diet, dehydration, having to use a bedpan, lack of privacy, anal fissure, painful haemorrhoids, or local tumour).
  • Treat any faecal loading or impaction.
  • Start treatment with a stimulant laxative (such as senna).
    • Titrate the dose of laxative in order to achieve comfortable defecation without colic. For instance, senna may be titrated up to a maximum dosage of 2–4 tablets (15–30 mg) three times a day.
      • If the person finds it difficult to take the required number of tablets, reduce the dose of senna (for example to 15 mg at night) and add in a softener such as docusate (also a weak stimulant).
    • Increase the dose of laxative in line with any increase in dose of opioid.
  • Add an osmotic laxative (such as lactulose or a macrogol) or a surface-wetting laxative (such as docusate, which also softens stools) if colic is a problem.
    • Adjust the dose of softener to produce a comfortable stool (comfort is more important than the frequency or number of stools).
  • If these options have not been successful consider a rectal treatment if the rectum is full.
    • Soft loading: bisacodyl suppositor or sodium citrate. 
    • Hard loading: glycerol suppository such as lubricant or stimulant. 
    • Very hard loading: arachis oil enema (except in those with nut allergy) overnight.
  • In a palliative care situation, higher and more frequent doses than specified by the product licence may be needed.
  • For people with opioid-induced constipation, consider naldemedine as an option if other laxative treatments have been ineffective.  
  • Avoid:
    • Phosphate enemas (if possible) as they can sometimes cause water and electrolyte disturbances, especially in people aged 65 years or older, and when comorbidities are present.
    • Bulk-forming laxatives (such as bran, ispaghula), especially in opioid-induced constipation.
    • Paraffin.
  • Do not carry out rectal interventions (such as enemas, suppositories, or manual evacuation) in people:
    • On chemotherapy, who may be neutropenic (white blood cell count less than 0.5 × 109/L) and therefore at risk of serious infection.
    • With thrombocytopenia (platelet count less than 20 × 109/L), who are at risk of bleeding.
    • With rectal or anal disease. 
  • If the person is terminally ill and has not had an adequate response despite these measures, consider the use of a dantron-containing laxative.
  • Seek specialist advice if constipation still persists despite these measures.

Basis for recommendation

There is no good evidence from clinical trials to guide choice of laxatives for treating constipation in palliative care.

Choice of laxatives
Interventions to avoid
  • Although increasing fluids and dietary fibre can help constipation, it can be difficult for some people to manage this, particularly if they have a poor appetite. It is more important to offer them food and drink that they like.
  • Phosphate enemas can sometimes cause water and electrolyte disturbances, especially in the over-65 age group and when comorbidities are present.
  • Bulk-forming laxatives are less useful for constipation in palliative care because:
    • Their consistency is unpalatable and they need to be taken with at least 200–300 mL water, which makes them unacceptable to many ill people.
    • If inadequate water is taken, they can cause intestinal obstruction. This may happen quickly if there is already partial obstruction due to a tumour.
  • Paraffin is not recommended because there is a risk of lipoid pneumonia if aspirated.
Rectal interventions
Dantron-containing laxatives
  • The recommendation to consider the use of a dantron-containing laxative in a terminally ill person who has not responded to, or cannot tolerate stimulant and softening laxatives, is based on the opinion of CKS expert reviewers.

Scenario: End of life care

From age 16 years onwards.

End of life care

  • It can often be difficult to be certain that a person is dying, but it is essential to recognize the signs of dying in order to appropriately care for people at the end of life. For more information, see the CKS topic Palliative care - general issues. 
  • An individualized care plan including the areas of symptom control and anticipatory prescribing should be created. For more information, see the CKS topic Palliative care - general issues.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Care of dying adults in the last days of life [NICE, 2015a]. 

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

How do laxatives work?

  • Bulk-forming laxatives (ispaghula husk, methylcellulose, and sterculia) act by retaining fluid within the stool and increasing faecal mass, leading to stimulation of peristalsis. They also have stool-softening properties.
  • Osmotic laxatives (lactulose, macrogols, phosphate enemas, and sodium citrate enemas) act by increasing the amount of fluid in the large bowel, by retaining fluid in the bowel and by drawing fluid from the body into the bowel. Fluid accumulation in the lower bowel produces distension, leading to stimulation of peristalsis. Lactulose and macrogols also have stool-softening properties.
  • Stimulant laxatives cause peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl, sodium picosulfate).
    • Senna is hydrolyzed to the active metabolite by bacterial enzymes in the large bowel.
    • Bisacodyl and sodium picosulfate are hydrolyzed to the same active metabolite. However bisacodyl is hydrolyzed by intestinal enzymes, whilst sodium picosulfate relies on colonic bacteria.
  • Surface-wetting agents (docusate and poloxamer [an active ingredient of co-danthramer]) reduce the surface tension of the stool, allowing water to penetrate and soften the stool. Docusate also has a relatively weak stimulant effect.
  • Glycerol suppositories act as a lubricant, and have a weak stimulant action (probably due to an irritant effect).
  • Arachis oil enemas lubricate and soften faeces, thereby promoting a bowel movement. Bulk laxatives, osmotic laxatives, and docusate also have softening properties.
  • Peripheral opioid-receptor antagonists (such as methylnaltrexone, or naldemedine) antagonize opioid actions at specific gastrointestinal opioid receptors without impairing central analgesic effects.

 [Wilcock, 2020; BNF, 2021]

Which laxative should I prescribe?

  • The final choice of laxative will often depend on individual preference, and what has previously been tried. Advantages and disadvantages of different laxatives are detailed in Table 2.

Table 2. Advantages and disadvantages of different laxatives.

LaxativeTime to effectPoints to note
Bulk-forming laxatives
Ispaghula (also known as psyllium)2–3 daysUseful first-line choice in adults when it is difficult to get enough fibre in the diet. Better tolerated than bran. Must not be taken immediately before bed. Adequate fluid intake is important to prevent intestinal obstruction. This may be difficult for the frail or children. Not recommended for people taking constipating drugs
Sterculia
Methylcellulose2–3 daysUseful first-line choice in adults when it is difficult to get enough fibre in the diet. Better tolerated than bran. Must not be taken immediately before bed. Adequate fluid intake is important to prevent intestinal obstruction. This may be difficult for the frail or children. Tablets swell in the mouth on contact with water
Wheat or oat bran—Finely ground bran can be given as bran bread or biscuits, but these are less effective than unprocessed bran. May be unpalatable. Can be added to food or fruit juice. Often poorly tolerated (causes flatulence and bloating) unless increased slowly and can be difficult to take enough to be effective on its own. Adequate fluid intake is important
Osmotic laxatives
Lactulose2–3 daysPalatable — although some find it sickly sweet. Adequate fluid intake is recommended. If used alone in opioid-induced constipation, it often needs to be given in large doses that cause bloating and colic
Macrogols (polyethylene glycol)2–3 daysSome people find it difficult to drink the prescribed volume of macrogol. Licensed for use in faecal impaction. Movicol-Half®contains half the dose and electrolytes of Movicol®
Surface-wetting laxatives
Docusate sodium12–72 hoursProbably acts both as a softening agent and a stimulant. May be a useful alternative for people who find it hard to increase their fluid intake
Stimulant laxatives
Senna8–12 hoursLicensed only for short-term use. Syrup is unpalatable
Sodium picosulfate6–12 hoursLicensed only for short-term use. Syrup is palatable
Bisacodyl6–12 hoursNo syrup available. Licensed only for short-term use
Dantron (terminal care only)6–12 hoursRestricted to use in terminal care. Prolonged contact with the skin (such as faecal or urinary incontinence) can cause a dantron burn — an erythematous rash with a sharply demarcated border. Available only combined with a softener: concerns about possible carcinogenicity (from high-dose studies in rats). People should be warned that it discolours urine red (occasionally blue or green)
Rectal laxatives
All rectal laxatives—Easy to use if administered correctly. Timing of effect may be more predictable than with oral laxatives. Some people find them undignified and unpleasant to use. All unlicensed for the treatment of faecal loading/impaction except Relaxit® micro-enema and Arachis oil retention enema
Glycerol suppositories (lubricating and weak stimulant)15–30 minutesCan be used for hard or soft stools. Licensed for occasional use only. Suppositories must be placed alongside the bowel wall so that body heat causes them to dissolve and distribute around the rectum. Suppositories should be moistened before use to aid insertion
Bisacodyl suppositories (stimulant)15 minutes to 3 hoursAvoid if large, hard stools, as no softening effect. Use for soft stools
Sodium phosphate and sodium bicarbonate suppositories (Carbalax®) (effervescent)30 minutesPeople should be advised that these suppositories work by an effervescent action
Docusate sodium enema (softener and weak stimulant)15–30 minutesCan be used for hard or soft stools. Correct administration important to prevent damage to rectal mucosa
Sodium citrate enema (osmotic)5–15 minutesSmaller volume (5 mL) than a phosphate enema (130 mL). Useful to remove hard, impacted stools. Correct administration important to prevent damage to rectal mucosa. Licensed for occasional use only
Phosphate enema (osmotic)2–5 minutesUseful to remove hard, impacted stools. Correct administration important to prevent damage to rectal mucosa. Licensed for occasional use only. Use of phosphate enemas can cause hypocalcaemia and hyperphosphataemia in ill patients or in renal impairment. They can also produce rectal gangrene in ill patients with a history of haemorrhoids
Arachis oil enema (softener)Retention enema — used overnight and warmed before useUseful for hard, impacted stools. Should not be used in people with peanut allergy. Licensed for occasional use only
Peripheral opioid-receptor antagonists
Methylnaltrexone bromide (subcutaneous injection)30 minutes to 4 hoursUseful for opioid-induced constipation under specialist direction in terminally ill people, when response to other laxatives is inadequate. Contraindicated in known or suspected bowel obstruction. Use with caution in people with conditions that may predispose to perforation (such as gastrointestinal cancer, peptic ulcer, colonic pseudo-obstruction, nonsteroidal anti-inflammatory drugs, steroids)
Naloxegol 1–4 hoursUseful for opioid-induced constipation under specialist direction in terminally ill people, when response to other laxatives is inadequate
Not recommended
Liquid paraffin (softener)1–3 daysAdverse effects include anal seepage and irritation, malabsorption of fat-soluble vitamins, and (rarely) lipoid pneumonia
Magnesium salts (osmotic)1–6 hoursNot routinely recommended because their purgative action can be undesirably powerful
Data from: Electronic Medicines Compendium www.medicines.org.uk and [Davies, 2015; Sykes, 2015; Twycross, 2016; BNF, 2021]

What doses of laxatives may be needed in palliative care?

Table 3. Laxative doses that may be needed to manage constipation in palliative care.

LaxativeLicensed dose (adults)Dose that may be needed in palliative care (off-label)
Arachis (peanut) oil (retention enema)1 enema (130 mL) at bedtime, as requiredUse maximum licensed dose
Bisacodyl (tablets)5–10 mg at night, increased if necessary to a maximum dose of 20 mg at night20 mg three times a day
Bisacodyl (suppositories)1 suppository (10 mg) in the morning20 mg daily
Co-danthramer strong (dantron/poloxamer 37.5/500 mg capsules or 75/1000 mg suspension)1–2 capsules (or 5 mL only) at night3 capsules three times a day (or 10 mL twice a day)
Co-danthrusate (dantron/docusate 50/60 mg capsules or suspension)1–3 capsules (or 5–15 mL) at night3 capsules twice a day (or 15 mL twice a day)
Docusate (capsules or solution)Up to 500 mg per day in divided doses200 mg three times a day
Docusate (Norgalax® micro-enema)1 enema (120 mg in 10 g single-use disposable pack), as requiredUse maximum licensed dose
Glycerol (suppositories)1 suppository (4 g) moistened with water before use, as requiredUse maximum licensed dose
Lactulose (syrup)15 mL twice a day, adjusted according to responseUse maximum licensed dose
Macrogol 3350 + electrolytes (Movicol® sachets)For constipation: 1–3 sachets per day, in divided doses, usually for up to 2 weeks; maintenance dose 1–2 sachets per day. For high faecal loading/impaction: 4 sachets on the first day, then increased in steps of 2 sachets daily to a maximum dose of 8 sachets per day. Contents of each sachet should be dissolved in 125 mL of water. After reconstitution the solution should be kept in a refrigerator and drunk within 6 hours. Limit to 2 sachets per hour (250 mL) in heart failureUse maximum licensed dose
Senna (tablets or syrup)2–4 tablets (15–30 mg) at night or 10–20 mL, usually at bedtime2–4 tablets (15–30 mg) three times a day
Sodium citrate (Micolette®, Micralax®, Relaxit® micro-enemas)Micolette® 1–2 enemas (5–10 mL), as required, Micralax® 1 enema (5 mL), as required, Relaxit® 1 enema (5 mL), as requiredUse maximum licensed dose
Sodium picosulfate (capsules or syrup)5–10 mg at night30 mg per day
Sodium phosphate (Fleet® ready-to-use enema, Phosphate enema BP Formula B)Fleet® ready-to-use enema 1 enema (118 mL), as required. Phosphate enema BP Formula B 1 enema (128 mL), as requiredUse maximum licensed dose

Data from: [Regnard, 2022; Wilcock, 2020; BNF, 2021]

Table 4. Dose schedule for dantron-containing laxatives*†.

 Co-danthramer strong capsulesCo-danthramer strong suspensionCo-danthrusate capsulesCo-danthrusate suspension
Dantron content37.5 mg/capsule75 mg/capsule50 mg/capsule50 mg/capsule
Start with (prophylactic):1 at bedtime2.5 mL at bedtime1 at bedtime5 mL at bedtime
Start with (if constipated):2 at bedtime5 mL at bedtime2 at bedtime10 mL at bedtime
If necessary, adjust every 2–3 days up to:3 three times a day10 mL twice a day or 20 mL at bedtime3 twice a day15 mL twice a day
Total daily dose337.5 mg300 mg300 mg300 mg
*Dantron has been linked with liver and bowel tumours in rodents, dantron-containing laxatives are licensed for use only in the 'terminally ill'. †In people with urinary or faecal incontinence, dantron-containing laxatives are best avoided because of the risk of a contact skin burn in the perineum and surrounding areas
Data from: [Wilcock, 2020]

Adverse effects of oral laxatives

  • Most adverse effects can be avoided or reduced by increasing the dose of oral laxatives gradually.
  • Advise people to start at the lowest dose and, if necessary, increase it every few days until one or two soft, formed stools are produced each day. Common adverse effects include:
    • Bulk laxatives: flatulence and bloating.
    • Lactulose: flatulence, cramps, and bloating.
    • Macrogols: bloating, nausea.
    • Stimulant laxatives: abdominal cramps, diarrhoea.
    • Peripheral opioid-receptor antagonists: abdominal pain, nausea, diarrhoea, flatulence; postural hypotension; injection site reactions; hyperhidrosis. Cases of gastrointestinal perforation have been reported but the frequency is unknown.
  • Advise people taking bulk laxatives that an adequate fluid intake is important (to prevent intestinal obstruction) and that they should not be taken immediately before going to bed.
  • Advise people taking lactulose or macrogols that an adequate fluid intake is important because the drugs can be dehydrating.
  • The timing of stimulant laxatives can be particularly important for the frail or elderly, so that they provoke a single stool each day, at a time when the individual has adequate time to reach the toilet. Usually stimulant laxatives are given at bedtime, to produce a bowel movement the next morning. However, it may take a little experimentation to find the best time for an individual, especially if they naturally tend to defecate later in the day.
    • There have been concerns in the past that prolonged use of stimulant laxatives (off-label use) might reduce colonic function or lead to tolerance. However, there is no convincing evidence that this is the case.
  • Avoid excessive doses of laxatives. This leads to diarrhoea and, if prolonged, electrolyte disturbances such as hypokalaemia. Excessive doses of bulk-forming laxatives, or inadequate fluid intake with bulk-forming laxatives, cause intestinal obstruction rather than diarrhoea.
  • If intestinal obstruction is suspected, do not use laxatives.
  • Use of macrogol may result in a potential interactive effect if used with starch-based food thickeners. Macrogol counteracts the thickening effect of starch, resulting in liquefaction of preparations that need to remain thick for people with swallowing problems. 
    • The absorption of other medicines could be transiently reduced in people taking macrogol products — other medicines should not be taken orally for one hour before, during and for one hour after taking macrogol.

 [Wald, 2006; BNF, 2021; ABPI, 2023 KLEAN PREP 69g, sachet powder for oral solution]

Supporting evidence

This CKS topic incorporates guidance from the National Institute for Health and Care Excellence on Improving supportive and palliative care for adults with cancer [NICE, 2004] and Care of dying adults in the last days of life [NICE, 2015a]. The rationale for primary care management is discussed in the relevant basis for recommendation sections. CKS has not summarized the evidence for secondary care investigations and management as they are outside the scope of this topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of constipation in palliative care.

Search dates

October 2016 - March 2021

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Palliative Care/, exp Terminal Care/, exp Terminally Ill/, palliat$.tw., (terminal adj care).tw., (palliative or terminal$ or end of life).tw., (advanced adj disease).tw.
  • exp Constipation/, constipat$.tw., exp Fecal Impaction/, ((fecal or faecal) adj impact$).tw., ((fecal or faecal) adj load$).tw., ((difficult$ or delay$ or irregular$ or infrequent or pain$) adj (defecat$ or stool$ or faec$ or fec$)).tw., (bowel adj movement).tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2023) SPC for KLEAN PREP 69g, sachet powder for oral solution. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk [Free Full-text]
  • Back, I., Watson, M., Armstrong, P., et al. (2021) Palliative Care Adult Network Guidelines. https://book.pallcare.info/index.php
  • BNF (2021) British National Formulary. BMJ Group and Pharmaceutical Press. https://bnf.nice.org.uk
  • British Columbia Medical Association (2011) Palliative care for the patient with incurable cancer or advanced disease. Part 2: pain and symptom management. Constipation. British Columbia Medical Association.. www.bcguidelines.ca [Free Full-text]
  • Davies, A.N. (2015) Oral care. In: Cherny, N.I., Fallon, M., Kaasa, S., et al. (Eds.) Oxford textbook of palliative medicine. 5th edn. Oxford: Oxford University Press.
  • Fallon, M. and O'Neill, B. (1997) ABC of palliative care: constipation and diarrhoea. British Medical Journal 315(7118), 1293-1296.
  • Larkin, P.J., Sykes, N.P., Centeno, C., et al. (2008) The management of constipation in palliative care: clinical practice recommendations. Palliative Medicine 22(7), 796-807. [Abstract]
  • Larkin, P.J., Cherny, N.I., La Carpia, D., et al. (2018) Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Annals of Oncology 29(4), 111-125.
  • NHS Lothian (2015) Bowel obstruction. NHS Lothian. http://www.palliativecareguidelines.scot.nhs.uk
  • NHS Lothian (2016) Constipation. NHS Lothian. http://www.palliativecareguidelines.scot.nhs.uk [Free Full-text]
  • NHS Scotland (2021) Scottish palliative care guidelines. NHS Scotland. https://www.palliativecareguidelines.scot.nhs.uk
  • NICE (2004) Improving supportive and palliative care for adults with cancer (NICE guideline). Guidance on Cancer Services. National Institute for Health and Clinical Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2013) End of life care for adults (quality standard). National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2015a) Care of dying adults in the last days of life (NICE guideline). National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2015b) Key therapeutic topics - medicines management options for local implementation. National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text]
  • North of England Cancer Network (2016) Palliative and end of life care guidelines. Symptom control for cancer and non-cancer patients. Northern England Clinical Network. http://www.nescn.nhs.uk [Free Full-text]
  • Regnard, C. and Dean, M. (2022) A guide to symptom relief in palliative care. 6th edn. Oxford: Radcliffe Publishing.
  • Sykes, N. (2015) Constipation and diarrhoea. In: Cherny, N.I., Fallon, M., Kaasa, S., et al. (Eds.) Oxford textbook of palliative medicine. 5th edn. Oxford: Oxford University Press.
  • Twycross, R. and Wilcock, A. (2016) Introducing palliative care. In: Twycross, R. and Wilcock, A. (Eds.) Introducing Palliative Care. Padstow, Cornwall: Pharmaceutical Press.
  • Wald, A. (2006) Constipation in the primary care setting: current concepts and misconceptions. American Journal of Medicine 119(9), 736-739. [Abstract]
  • Wilcock A., Howard, P. and Charlesworth, S. (2020) Palliative care formulary. In: Wilcock A., Howard, P. and Charlesworth, S. (Eds.) Palliative Care Formulary. London: Pharmaceutical Press.
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