How to relieve constipation

Effective Management of Constipation

For relieving constipation, start with a stimulant laxative such as senna, with or without a stool softener, or polyethylene glycol (PEG) with adequate fluid intake. 1

First-Line Interventions

Lifestyle and Dietary Modifications

• Increase fluid intake, especially if current consumption is inadequate 1
• Increase physical activity within patient's limitations 1, 2
• Ensure privacy and comfort for normal defecation 1
• Consider proper positioning (using a small footstool may help with exerting pressure) 1
• Increase dietary fiber if fluid intake is adequate 1, 2

Pharmacological Management

• Stimulant laxatives are recommended as first-line treatment:
  • Senna: 2-3 tablets daily-TID; produces bowel movement in 6-12 hours 1, 3
  • Bisacodyl: 10-15 mg daily-TID with goal of one non-forced bowel movement every 1-2 days 1
• Osmotic laxatives are also effective first-line options:
  • Polyethylene glycol (PEG): One capful in 8 oz water twice daily; produces bowel movement in 1-3 days 1, 4
  • Lactulose: 30-60 mL BID-QID 1
  • Magnesium-based products (hydroxide or citrate) 1

For Persistent Constipation

Assessment

• Rule out impaction, obstruction, and other treatable causes (hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus) 1
• Review medications that may cause constipation (antacids, anticholinergics, antiemetics) 1

Escalation of Treatment

• If impaction is present:
  • Administer glycerine suppository or mineral oil retention enema 1
  • Consider manual disimpaction after pre-medication with analgesic/anxiolytic 1
• For persistent constipation:
  • Add or switch to rectal bisacodyl (once daily to BID) 1
  • Consider adding a prokinetic agent like metoclopramide if gastroparesis is suspected 1
  • For opioid-induced constipation that doesn't respond to standard therapy, consider peripherally acting μ-opioid receptor antagonists like methylnaltrexone (0.15 mg/kg subcutaneously every other day) 1

Important Considerations

What to Avoid

• Docusate (stool softener) alone has not shown benefit and is not recommended as monotherapy 1
• Supplemental medicinal fiber such as psyllium is ineffective for opioid-induced constipation and may worsen symptoms 1
• Bulk laxatives are not recommended for opioid-induced constipation 1

Special Populations

• For elderly patients:
  • Pay particular attention to ensuring access to toilets, especially with decreased mobility 1
  • Consider dietetic support 1
  • Optimize toileting schedule (attempt defecation at least twice daily, preferably 30 minutes after meals) 1

Monitoring

• Goal: One non-forced bowel movement every 1-2 days 1
• Reassess if constipation persists despite treatment escalation 1

Remember that constipation affects approximately 50% of patients with advanced cancer and most patients treated with opioids 1. Early intervention with appropriate laxatives can prevent the discomfort and complications associated with constipation.