What is the best suppository to treat constipation?

Bisacodyl Suppositories Are the Best Choice for Constipation Relief

For patients requiring a suppository for constipation, bisacodyl suppositories (10 mg) are the most effective first-line option, working within 15-20 minutes to provide reliable relief. 1, 2

Mechanism and Administration

Bisacodyl suppositories work through a dual mechanism:

• Stimulate colonic motility
• Increase water content in the stool
• Act locally in the large bowel to reduce transit time

Proper Administration:

• Adults and children ≥12 years: Insert one 10 mg suppository rectally
• Children 6-12 years: Use half suppository (5 mg)
• Not recommended for children under 6 years 2
• Insert pointed end first, well into the rectum
• Patient should retain for 15-20 minutes for optimal effect 2

Clinical Evidence Supporting Bisacodyl Suppositories

Bisacodyl suppositories are specifically recommended when:

• Digital rectal examination identifies a full rectum or fecal impaction 1
• Oral treatments have failed after several days 1
• Quick relief is needed (onset within 15-20 minutes) 2

A recent network meta-analysis found bisacodyl to be similarly effective to newer agents like prucalopride, lubiprostone, and linaclotide for achieving complete spontaneous bowel movements, and potentially superior for increasing spontaneous bowel movements per week 3.

Alternative Suppository Options

If bisacodyl is contraindicated or unavailable:

• Glycerine suppositories: Less potent but can be effective for mild constipation, particularly in children 4
• CO2-releasing suppositories: May be effective but have less evidence in cancer patients 1

Important Contraindications and Cautions

Suppositories should not be used in patients with:

• Neutropenia or thrombocytopenia
• Paralytic ileus or intestinal obstruction
• Recent colorectal or gynecological surgery
• Recent anal or rectal trauma
• Severe colitis, inflammation or infection 1, 4

Treatment Algorithm for Constipation

1. First-line oral therapy (if suppository not immediately needed):

   • Polyethylene glycol (PEG) is preferred for ongoing management 1, 4
   • Stimulant laxatives (senna, bisacodyl) for short-term use

2. When to use suppositories:

   • For rapid relief of constipation
   • When digital rectal exam shows fecal impaction
   • When oral treatments have failed
   • For patients who cannot take oral medications

3. If suppositories fail:

   • Consider small-volume enemas (self-administered)
   • For persistent constipation, larger-volume clinician-administered enemas may be needed, but carry risks of perforation and bleeding 1

Clinical Pearls

• Bisacodyl suppositories should not be used daily long-term to avoid dependency
• Always rule out impaction, obstruction, and treatable causes of constipation (hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus) 1
• For opioid-induced constipation, consider adding methylnaltrexone (0.15 mg/kg) if standard laxative therapy fails 1
• Ensure administration is performed with dignity and sensitivity, as this procedure can cause embarrassment for patients 5