What is the recommended regimen for managing constipation in hospice patients?

Management of Constipation in Hospice Patients

The recommended regimen for managing constipation in hospice patients should begin with bisacodyl 10-15 mg 2-3 times daily, with a goal of achieving one non-forced bowel movement every 1-2 days, and escalate to additional laxatives as needed. 1

Initial Assessment and Management

1. Rule out complications first:

   • Check for impaction (may require manual disimpaction after pre-medication with analgesic/anxiolytic)
   • Rule out bowel obstruction (physical exam, abdominal x-ray)
   • Assess for other causes (hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus)

2. First-line therapy:

   • Discontinue any non-essential constipating medications
   • Bisacodyl 10-15 mg daily to TID with goal of one non-forced bowel movement every 1-2 days 1
   • Increase fluids and dietary fiber if patient has adequate fluid intake and physical activity

Escalation of Therapy (if constipation persists)

1. Add additional laxatives:

   • Rectal bisacodyl suppository (once daily to BID) 1
   • Polyethylene glycol (1 capful/8 oz water BID) - produces bowel movement in 1-3 days 2
   • Lactulose (30-60 mL BID-QID) - typically produces bowel movement within 24-48 hours 3
   • Sorbitol (30 mL every 2 hours × 3, then PRN) 1
   • Magnesium hydroxide (30-60 mL daily-BID) 1
   • Magnesium citrate (8 oz daily) 1

2. For impaction:

   • Glycerin suppository ± mineral oil retention enema 1
   • Manual disimpaction (with appropriate pre-medication)
   • Tap water enema until clear 1

Management of Opioid-Induced Constipation

For patients with opioid-induced constipation that doesn't respond to standard laxative therapy:

• Methylnaltrexone 0.15 mg/kg subcutaneously every other day (no more than once daily) 1

  • Contraindicated in patients with postoperative ileus or mechanical bowel obstruction

• Consider adding a prokinetic agent (e.g., metoclopramide 10-20 mg PO QID) if gastroparesis is suspected 1

• Other options for refractory opioid-induced constipation:

  • Lubiprostone (activates chloride channels to enhance intestinal fluid secretion) 1
  • Linaclotide (agonist of guanylate cyclase-C receptors) 1
  • Naloxegol (for chronic opioid users) 1

Important Considerations

• Docusate sodium is not recommended as evidence does not support its efficacy in hospice patients 1, 4

• Stimulant laxatives (bisacodyl, senna) are more effective than stool softeners alone 5

• The combination of a stimulant laxative with an osmotic agent is often more effective than either agent alone 6

• Avoid magnesium-based products in patients with renal insufficiency 1

• Avoid rectal suppositories or enemas in patients with neutropenia or thrombocytopenia 1

• For patients in the last days to weeks of life, increase the dose of laxative ± stool softener (senna ± docusate, 2-3 tablets BID-TID) with the goal of one non-forced bowel movement every 1-2 days 1

Despite the widespread use of various laxative regimens in hospice care, the evidence base remains limited 7. The NCCN guidelines provide the most comprehensive approach, recommending a stepwise escalation of therapy based on response, with the goal of achieving regular, comfortable bowel movements while minimizing side effects.