What are common bowel regimens in patients?

From the Guidelines

The most effective bowel regimen for patients, particularly those on opioid therapy, involves a combination of prophylactic measures including stimulant laxatives, stool softeners, adequate fluid intake, and dietary fiber, with the goal of achieving one non-forced bowel movement every 1-2 days. This approach is supported by recent guidelines that emphasize the importance of managing opioid-induced constipation to improve patient outcomes and quality of life 1.

Key Components of Bowel Regimens

• Stimulant laxatives: Such as senna or bisacodyl, are recommended for prophylaxis, with or without a stool softener, to prevent constipation in patients on opioid therapy 1.
• Adequate fluid intake: Maintaining adequate hydration is crucial to prevent constipation, and patients should be encouraged to drink at least 6-8 glasses of water daily.
• Dietary fiber: Although supplemental medicinal fiber is unlikely to reduce opioid-induced constipation, maintaining adequate dietary fiber intake through fruits, vegetables, and whole grains is recommended 1.
• Physical activity: Regular physical activity, such as at least 30 minutes of exercise daily, can help stimulate bowel motility and prevent constipation.

Management of Constipation

When constipation develops, it is essential to assess the cause and severity, rule out obstruction, and treat other causes. A stepwise approach to medication management is recommended, starting with osmotic laxatives like polyethylene glycol or lactulose, then adding stimulant laxatives if needed. For more severe constipation, combination therapy may be necessary, and agents like magnesium hydroxide, bisacodyl, or lactulose can be considered 1.

Persistent Constipation

If constipation persists, reassessment of the cause and severity is necessary, and adding another agent or considering prokinetic agents like metoclopramide may be helpful. In patients with advanced illness, methylnaltrexone can be used as a rescue when constipation is clearly related to opioid therapy 1. Neuraxial analgesics, neuroablative techniques, or other interventions to decrease pain and/or reduce systemic opioid dose may also be considered to reduce adverse effects.

From the FDA Drug Label

USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days Warnings Do not use laxative products for longer than one week unless directed by a doctor. The most common bowel regimens in patients likely include the use of polyethylene glycol (PO) and senna (PO), as they are both used to relieve occasional constipation and generally produce a bowel movement in a short period of time 2, 3.

• Polyethylene glycol (PO) is used to relieve constipation and generally produces a bowel movement in 1 to 3 days 2.
• Senna (PO) is a laxative that should not be used for longer than one week unless directed by a doctor 3.

From the Research

Common Bowel Regimens in Patients

• Bowel protocols are commonly used to prevent and treat constipation in patients, especially those taking opioid analgesics 4
• Sennosides-based bowel protocols are often used, with or without the addition of docusate, a stool softener 4
• The efficacy of docusate in treating constipation is questionable, with some studies showing no benefits compared to placebo or other treatments like psyllium or sennosides 5, 6
• Osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, are considered effective and safe for treating pediatric constipation 7
• Stimulant laxatives, like Senna and Bisacodyl, may be used as adjunct therapies in specific clinical scenarios 7

Use of Docusate in Bowel Regimens

• Docusate is often used for constipation prophylaxis and treatment due to its low cost and easy accessibility, but its efficacy is limited 6
• The inclusion of docusate in guidelines for opioid-induced constipation management is weakly evidence-based 6
• Studies have shown that docusate is not effective in preventing or treating constipation in certain patient populations, such as those undergoing rotator cuff repair 8
• Healthcare providers should carefully evaluate bowel protocols and consider evidence-based therapies to ensure effective treatment and reduce unnecessary drug use 6