From the Guidelines
For constipation in dialysis patients, I recommend a stepwise approach starting with lifestyle modifications and progressing to medications as needed, prioritizing the most recent and highest quality evidence from the 2020 study published in Gut 1. The management of constipation in dialysis patients requires a comprehensive approach that considers the patient's overall health, dietary restrictions, and potential medication interactions.
Initial Management
Begin with increased fluid intake (within fluid restrictions), dietary fiber (20-25g daily), and regular physical activity, as these lifestyle modifications can help alleviate constipation symptoms.
Medication Options
For medications, start with stool softeners like docusate sodium (100mg twice daily) or bulk-forming laxatives such as unprocessed wheat bran, ispaghula, or sterculia, which can help increase stool bulk and soften stool consistency. If ineffective, add osmotic laxatives such as polyethylene glycol (17g in 4-8oz water daily) or lactulose (15-30ml daily), which can help increase the amount of water in the large bowel and promote bowel movements.
Avoiding Harmful Medications
Avoid magnesium-based laxatives like milk of magnesia or magnesium citrate as they can accumulate in dialysis patients and cause toxicity, as noted in the 2020 study published in Gut 1.
Stimulant Laxatives
Stimulant laxatives such as bisacodyl (5-10mg daily) or senna (8.6-17.2mg at bedtime) can be used short-term for more severe constipation, but their use should be monitored closely to avoid dependence and potential side effects.
Prokinetic Agents
In cases of severe constipation, prokinetic agents like prucalopride may be considered, as they have been shown to be effective in promoting bowel movements and improving symptoms of constipation, as noted in the 2020 study published in Gut 1.
Ongoing Management
Regular bowel movement assessment and adjustment of the treatment regimen are important for ongoing management, as constipation can lead to complications including reduced quality of life, dialysis inefficiency, and even bowel perforation, so prompt management is essential, as highlighted in the 2016 study published in the Journal of the National Comprehensive Cancer Network 1. Some key points to consider in the management of constipation in dialysis patients include:
- Increased fluid intake and dietary fiber can help alleviate constipation symptoms
- Stool softeners and bulk-forming laxatives can be effective in promoting bowel movements
- Osmotic laxatives can help increase the amount of water in the large bowel and promote bowel movements
- Stimulant laxatives should be used short-term and with caution to avoid dependence and potential side effects
- Prokinetic agents like prucalopride may be considered in cases of severe constipation
- Regular bowel movement assessment and adjustment of the treatment regimen are important for ongoing management.
From the FDA Drug Label
USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days Uses Relieves occasional constipation (irregularity) Generally causes bowel movement in 6 to 12 hours Stop use and ask a doctor if • constipation lasts more than 7 days • rectal bleeding occurs • you fail to have a bowel movement These may be signs of a serious condition.
For a patient undergoing dialysis with constipation (Impaired bowel motility), management options include:
- Polyethylene glycol (PO): may help relieve occasional constipation, generally producing a bowel movement in 1 to 3 days 2
- Senna (PO): may help relieve occasional constipation, generally causing a bowel movement in 6 to 12 hours 3
- Psyllium (PO): may be used to relieve constipation, but patients should stop use and ask a doctor if constipation lasts more than 7 days, rectal bleeding occurs, or they fail to have a bowel movement 4 Key considerations for these patients include monitoring for signs of serious conditions and adjusting management as needed.
From the Research
Management Options for Constipation in Dialysis Patients
- The management of constipation in dialysis patients can be achieved through various methods, including the use of polyethylene glycol 3350 plus electrolytes 5, which has been shown to be effective in reducing stimulant laxatives and increasing spontaneous bowel movements.
- Lifestyle modifications, such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake, can also be beneficial in managing constipation 6.
- The use of osmotic laxatives, such as polyethylene glycol, followed by a stool softener, such as docusate sodium, and then stimulant laxatives, can be an effective treatment approach for constipation 6.
- Increasing dietary fiber intake through the use of soluble dietary fiber supplements or high fiber foods can also help reduce laxative requirement in peritoneal dialysis patients 7.
- Lactulose and senna plus ispaghula husk have been shown to be similar in efficacy in treating constipation among patients with pre-dialysis chronic kidney disease 8.
Treatment Approaches
- Fecal impaction should be treated with mineral oil or warm water enemas 6.
- Digital rectal examination should be performed to rule out fecal impaction and overflow incontinence in hospitalized patients 9.
- Nursing care, including the use of absorbent pads, special undergarments, anal hygiene, and skin care, is also important in managing constipation and fecal incontinence in older hospitalized patients 9.
- Medications, such as loperamide or diphenoxylate/atropine, can be useful in managing diarrhea with incontinence, while laxatives, secretagogues, enemas, suppositories, and timed toileting assistance may be effective for constipation 9.