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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021 Page 1 Guidelines for the Management of Constipation in Palliative Care D Monnery, 1 M Cooper, 1 R Ayre, 2 S Cureton, 2 L Devlin, 3 T Cookson, 3 C Owens, 3 S Schofield, 3 G Sudworth, 3 C Hyland, 3 L Edmunds, 1 L Waters, 1 A Scott. 4 (Guideline Development Lead). 1 The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK. 2 Bridgewater Community Healthcare NHS Foundation Trust, Wigan, UK. 3 Willowbrook Hospice, Prescot, Merseyside, UK. 4 Marie Curie Hospice, Liverpool, UK. Summary of Main Recommendations Diagnosis Constipation is a very common symptom in palliative care patients which can adversely affect their quality of life. Patients and healthcare professionals often differ in their assessment. 3 [Level 3] It is important to explore the views of the patient and whether they believe themselves to be constipated. 3 [Level 3] The Bristol Stool Chart may be useful in helping to make a diagnosis of constipation. Assessment Before starting any laxative medicine clinical assessment should exclude bowel obstruction. It may be appropriate to check the patient’s blood biochemistry and perform a digital rectal examination. Health professionals should assess for any factors potentially contributing to the constipation including: opioids; 14 [Level 2+] mobility; fluid / dietary intake and environmental factors such as equipment needs. 15 [Level 4] Symptom Control Always give advice about non pharmacological measures. Further guidance on dietary advice can be found in Section 4.4 of this guideline. Laxative monotherapy should be used where possible, as it may avoid tablet burden and improve quality of life for the patient. 25 [Level 4] The evidence base for the use of some laxatives is limited. Senna and lactulose have been shown to be effective when used as single agents and in combination. 4,24 [Level 1] Other laxatives may also be considered. Please see Figure 1 and Table 3 in the guideline. If constipation persists despite the optimisation of oral laxatives, rectal interventions may be considered. A digital rectal examination will help to determine the most appropriate rectal intervention to use. Please see Figure 2. For patients with malignant spinal cord compression, rectal intervention should be given on alternate days and combined with an alternate day stimulant oral laxative such as senna. 15 [Level 4] Please see Figure 2. Communication Patients should be offered information about constipation at the time of diagnosis, and when starting any medicines which increase the risk of constipation e.g.opioids. 15 [Level 4]

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Page 1: Guidelines for the Management of Constipation in …...Diagnosis Constipation is a very common symptom in palliative care patients which can adversely affect their quality of life

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 1

Guidelines for the Management of Constipation in Palliative Care

D Monnery,1 M Cooper,

1 R Ayre,

2 S Cureton,

2 L Devlin,

3 T Cookson,

3 C Owens,

3 S Schofield,

3 G

Sudworth,3 C Hyland,

3 L Edmunds,

1 L Waters,

1 A Scott.

4 (Guideline Development Lead).

1 The

Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK.

2Bridgewater Community Healthcare NHS Foundation

Trust, Wigan, UK. 3Willowbrook Hospice, Prescot, Merseyside, UK.

4Marie Curie Hospice, Liverpool, UK.

Summary of Main Recommendations

Diagnosis Constipation is a very common symptom in palliative care patients which can adversely

affect their quality of life. Patients and healthcare professionals often differ in their assessment.3 [Level 3] It is important to explore the views of the patient and whether they believe themselves to be constipated. 3 [Level 3]

The Bristol Stool Chart may be useful in helping to make a diagnosis of constipation. Assessment Before starting any laxative medicine clinical assessment should exclude bowel

obstruction. It may be appropriate to check the patient’s blood biochemistry and perform a digital rectal

examination. Health professionals should assess for any factors potentially contributing to the

constipation including: opioids;14 [Level 2+] mobility; fluid / dietary intake and environmental factors such as equipment needs.15 [Level 4]

Symptom Control Always give advice about non pharmacological measures. Further guidance on dietary

advice can be found in Section 4.4 of this guideline. Laxative monotherapy should be used where possible, as it may avoid tablet burden and

improve quality of life for the patient.25 [Level 4] The evidence base for the use of some laxatives is limited. Senna and lactulose have

been shown to be effective when used as single agents and in combination.4,24 [Level 1] Other laxatives may also be considered. Please see Figure 1 and Table 3 in the guideline.

If constipation persists despite the optimisation of oral laxatives, rectal interventions may be considered. A digital rectal examination will help to determine the most appropriate rectal intervention to use. Please see Figure 2.

For patients with malignant spinal cord compression, rectal intervention should be given on alternate days and combined with an alternate day stimulant oral laxative such as senna.15 [Level 4] Please see Figure 2.

Communication Patients should be offered information about constipation at the time of diagnosis, and

when starting any medicines which increase the risk of constipation e.g.opioids.15 [Level 4]

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 2

Section 1: Introduction

Constipation is a very common symptom in palliative care patients.1 It has been

shown to result in significant physical, psychological, social and existential

problems affecting quality of life.2

Defining constipation is complicated by conflicting perceptions between patients

and clinicians. Patients frequently describe constipation as an experience of

bowel movements. Clinicians may define constipation based on the frequency of

bowel movements.3 In general, the various definitions of constipation refer to:

infrequent, difficult or incomplete bowel evacuation that may lead to pain and

discomfort; stools that can range from small hard ‘rocks’, to a large bulky mass;

and a sensation of incomplete evacuation.4

Due to the difficulties in defining constipation, the incidence is difficult to

determine but has been estimated at between 18% and 90% of patients receiving

palliative care.5-7 The prevalence of contributory factors is estimated at between

25% and 90% of patients.1,8

The lack of a clear definition of constipation can contribute to difficulties and

delays in reaching a diagnosis.9 No tools or criteria have been demonstrated to

be consistently effective in helping to make an accurate diagnosis of constipation

in patients receiving palliative care.

Causes of constipation in the palliative care population are often multifactorial

and include: poor dietary intake; physical inactivity; disease related and treatment

related.4 The prevention and treatment of constipation is often related to the

cause.4 Constipation in the majority of people receiving palliative care has the

potential to be drug-induced and so management to promote satisfactory bowel

movements commonly involves laxative administration.4,10

The benefits of treatment must be balanced against potential side effects. Many

laxatives can contribute to discomfort by exacerbating colic or causing diarrhoea.

Use of rectal interventions has implications for dignity and may not be acceptable

to some patients. Management options should be discussed with the patient and

/or those important to them, taking full account of their views and preferences.

This guideline aims to give advice about the diagnosis, assessment and use of

pharmacological and non-pharmacological measures which can be offered to

relieve constipation in patients receiving palliative care. It is an update of

“Guidelines for the Management of Constipation in Palliative Care” last reviewed

in 2010.1 Management of bowel obstruction in palliative care is available

separately and not covered in this guideline.12

Section 2: Scope and Purpose

This guideline aims to inform practice in the assessment, diagnosis and

management of constipation in patients receiving palliative care.

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 4

The guideline is aimed at specialist palliative care professionals including doctors,

nurses, pharmacists and allied health professionals and generalists involved in

providing palliative care e.g. general practitioners, district nurses, hospital doctors

and nurses.This guideline is an update of Guidelines for the Management of

Constipation in Palliative Care, 2010.11

Due to differences in approach and treatment, management of bowel obstruction is

not covered in this guideline. There is a separate regional guideline for the medical

management of malignant bowel obstruction in palliative care.12

The guideline aims to answer the following questions:-

1. What is the best method to assess patients for the presence of constipation in

palliative care? 2. What methods of management are recommended in patients diagnosed with

constipation in palliative care?

Table 1 summarises the scope and purpose of this guideline.

Table 1 Scope of Guideline

Population People aged over 18 years with constipation receiving

palliative care

Populations not covered People under 18 years

People not receiving palliative care

Healthcare setting

Community care

Secondary care

Tertiary care

Hospice care

Topics Diagnosis and assessment of constipation in palliative

care

Management of constipation in palliative care

Topics not covered Bowel Obstruction

Section 3: Methods

This guideline is based on the AGREE II criteria, which can be found in the Cheshire

and Merseyside Palliative and End of Life Care Network Audit Group Guideline

Development Manual.13

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 4

3.1. Clinical Questions and Interventions

The clinical questions were derived from the previous guideline developed in 2008

and updated in 2010.11 These were refined by the Guideline Development Group

which has authored this guideline. The clinical questions used to guide the literature

review in PICO (Patient, Intervention, Control, Outcome) format are:-

1. In patients receiving palliative care and suffering from medication-induced

constipation (P), is one method of management (I) superior to other methods or

no formal method (C) in relieving constipation (O).

2. In patients receiving palliative care and suffering from non-medication-induced

constipation (P), is one method of management (I) superior to other methods or

no formal method (C) in relieving constipation (O).

3.2. Outcomes

To maximise patient comfort by ensuring the best assessment and treatment

methods for patients with constipation receiving palliative care through:-

improved knowledge of the assessment and diagnosis of constipation

improved knowledge of the non-pharmacological and pharmacological

interventions available

promotion of education and training for all staff involved in caring for patients with

constipation

3.3. Literature Search

Systematic electronic database searches were undertaken to find potentially relevant

articles. MEDLINE, Embase, CINAHL and Cochrane databases were searched in

July 2017. A full outline of the search strategy, results and appraisal of evidence can

be found in Appendix 1. The grading of the level of evidence and recommendations

follows the Cheshire and Merseyside Palliative and End of Life Care Network Audit

Group Guideline Development Manual and uses SIGN criteria.13

Section 4: Guideline Recommendations

4.1. Assessment and Diagnosis of Constipation

Assessment of constipation is complicated by a difference in perception and

definition between patients and clincians.14 Health professionals’ assessment of

whether a patient is constipated, often differs from that of the patient.3 [Level 3]

When assessing a patient and making a diagnosis of constipation it is important

to elicit the views of the patient and clarify whether or not they think they are

constipated.3 [Level 3]

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 5

An assessment of a patient with suspected constipation should include details

of:-

Frequency of bowel movement

Ease of defecation

Consistency and volume of stool [Level 4]15

A Bristol Stool Chart which is based on stool consistency may also be of benefit

in reaching a diagnosis of constipation.15 [Level 4] A link to a copy of the Bristol

Stool Chart can be found here: [Link]

Clinical assessment should include a review of any medicines that may be

contributing to constipation, including opioids.14 [Level 2+]

Clinical assessment should also review non-pharmacological contributory factors

such as: mobility, fluid and dietary intake and environmental factors such as

equipment needs.15 [Level 4]

Health professionals should perform an abdominal examination before making a

diagnosis of constipation.15 [Level 4]

If a diagnosis of constipation is suspected, consider further investigations such as

[Level 4]15

Urea, electrolytes and adjusted calcium

Rectal examination

The assessment should aim to exclude bowel obstruction before starting

treatment.15 [Level 4]

4.2. The Mental Capacity Act, 2005

If a patient is shown to lack capacity to consent to treatment, the Mental Capacity

Act, 2005 must be followed. If the patient lacks capacity to make decisions about

their treatment, the known views of the patient should be explored, and the

reasoning behind best interest decision making documented. The known views of

the patient may be sought through the family, a nominated spokesperson or an

advance statement. [Level 4]16

Lasting Power of Attorney for Health and Welfare, Advance Decisions to Refuse

Treatment, Independent Mental Capacity Advocates and Deprivation of Liberty

Safeguards should be utilised where appropriate.16 [Level 4]

4.3. Preventing Constipation

Preventing constipation or treating it effectively once present, depends on being

able to identify those patients at risk. A retrospective cohort study included in this

review has identified risk factors for developing constipation from both the patient

and clinician perspective.14

For medical constipation (defined in this study as stool frequency <3 times per

week), risk factors for the development of constipation are: being bed restricted;

being treated on a palliative care ward; reduced fluid intake; needing assistance

with personal care and patient tried medical self-management. 14 [Level 2+]

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Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

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For patient perceived constipation (without reduction in stool frequency), risk

factors are: being bed restricted; poor appetite; haemorrhoids; no information

given on constipation; low satisfaction with information given on constipation; use

of opioids; use of paracetamol; and absence of regular laxatives.14 [Level 2+]

Statistically significant key risk factors (when all results are combined) are

detailed in Table 2.14 [Level 2+]

Table 2. Key risk factors for the development of constipation [Level 2+]14

Being treated in a palliative care ward Haemorrhoids Heart disease No information given on constipation No laxatives available on request

No regular laxative use Paracetamol Poor appetite Use of opioids

Patients who are likely to require higher doses of laxatives to effectively treat their

constipation are: female; those with abdominal disease; taking an opioid; older.17

[Level 2]

Risk factors should be recognised and corrected where possible at the earliest

opportunity to prevent constipation in high risk patients.15 [Level 4]

4.4 Non-Pharmacological Management

The non-pharmacological management of constipation should be tailored to any

reversible causes detected during the clinical assessment. [Level 4]15

Always give advice about: diet, fluid intake and mobility. Environmental factors

should also be discussed e.g. correct posture; suitable and accessible toilet

facilities (e.g. toilet seat raisers); allowing adequate time. Privacy and dignity

should always be maintained. Changes to a persons’ care and regimen should be

minimised in order to avoid constipation. For patients with constipation secondary

to spinal cord compression. it is important to maintain a regular schedule for

toileting.15 [Level 4]

Medications should be reviewed regularly to ensure that those which contribute to

constipation are minimised as much as possible [Level 4]15

Related factors such as reduced mobility, reduced food intake, weakness and

dehydration should be addressed where practical and appropriate.15 [Level 4]

4.4.1 Dietary advice

There is a lack of experimental studies assessing use of dietary fibre in the

management of constipation in the palliative care setting. Recommendations are

based on professional consensus and opinion.

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Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

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For palliative patients that are able to maintain nutritional status through oral diet

and fluids, patients are advised to aim for 30g fibre per day, including whole

grains, fruit and vegetables.18 [Level 4]

Dietary fibre consumption should be gradually increased over a number of days

to avoid gastrointestinal symptoms.18 [Level 4]

Information for healthcare providers and patients about high fibre diets is

available here. [Link] 18

The effects of increased fibre consumption may materialise over weeks and

should be monitored alongside any potential reduction in pharmacological

interventions. The average daily intake of dietary fibre in the UK is only 18g

Meeting the recommendation of 30g/day will potentially be a challenge for

patients.19 [Level 4]

The prescription of fibre containing complete oral nutritional supplements may be

considered. However their nutritional value may not be equivalent to non fibre

containing products.15 [Level 4]

A minimum daily fluid intake of 1.5 litres has been suggested but this may not be

realistic.20 Patients that are able to manage some oral dietary intake can

maximise their fluid intake with foods containing a higher water content e.g. fruit,

jelly, soups, sauces, mousses, ice cream, milky puddings and oral nutritional

supplements where appropriate. 21 [Level 4]

Patients that require a texture modified diet will potentially struggle to meet fluid

requirements and optimise their fibre intake. These patients should be considered

for referral to a dietetic service.15 [Level 4]

Patients who are in the last days or hours of life may not achieve adequate fluid

and fibre intake. It may be more realistic to review pharmacological

interventions.15 [Level 4]

Dietetic assessment and intervention should be considered to support patients

and those important to them in translating recommendations into practical steps,

enabling behaviour change and managing expectations. Fluid and nutritional

intake can be a source of conflict and this can be addressed by these skilled

professionals. [Level 4]15

4.5 Pharmacological Management

4.5.1 Management of General (non opioid induced) Constipation

In many palliative care settings, current practice in the management of

constipation is to use combination regimens. This often includes a stool softener

and a stimulant laxative22 although there is limited evidence to support this

approach.23 [Level 4]

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Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

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A recent Cochrane Review did not discover any experimental data where a single

laxative was compared against placebo.4 We can therefore only comment on the

apparent relative efficacy of medications for constipation. No Cochrane Reviews

have been able to recommend any one specific laxative for the management of

constipation in palliative care.4, 24

A combination of docusate and senna has been shown to be no more effective

than senna monotherapy. However this was only a single study so should be

interpreted with caution.25 [Level 1-]

Using laxative monotherapy where possible arguably also avoids tablet burden

and improves quality of life for patients.25 [Level 4]

Senna and lactulose monotherapy are equally effective.4,24 [Level 1] However

40% of patients treated with monotherapy then required senna and lactulose

combination therapy to relieve constipation. This suggests there is greater

efficacy with a combination regimen, although it was not statistically significant.4

Senna and lactulose combination therapy has been shown to be an effective

combination and has demonstrated superiority over paraffin, magnesium

hydroxide and co-danthramer.24 [Level 1]

Any increase in dose and addition of other laxatives should be undertaken

gradually to avoid side effects such as colic and diarrhoea. Side effects are more

common with higher doses and an increased numbers of laxatives.24 [Level 1]

Other medications such as macrogols, co-danthramer and magnesium hydroxide

are not widely tested in a palliative care population but may be considered based

on the experience of the prescriber.15 [Level 4]

The choice of laxative and risk of side effects should be discussed with the

patient, and their views taken into account when prescribing any medicines.15

[Level 4]

For non opioid-induced constipation, a trial of combination laxatives at optimal

doses should be followed by consideration of a rectal intervention unless there

are any contraindications.15 [Level 4]

In the inpatient setting, oral laxatives should be reviewed every 3-4 days until the

constipation has resolved.15 [Level 4]

Please see Figure 1 and Table 3 for advice on choice of laxative and dosage.26

[Level 4]

4.5.2. Management of opioid induced constipation

There is no evidence from this review that opioid rotation is more effective than

laxative use in the treatment of opioid induced constipation.24

Senna and lactulose combination therapy has been shown to be more effective

than co-danthramer monotherapy in the management of opioid induced

constipation at morphine equivalent doses of greater than or equal to 80mg/24h. 4 [Level 1]

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Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 9

For patients with opioid induced constipation who do not respond sufficiently to

other laxatives (approximately 50% in one study 27), naloxegol is superior to

placebo in relieving constipation.27 [Level 1]

Naloxegol is more effective at higher doses, but titration should be undertaken

cautiously as side effects are also more common.27 [Level 1]

If treating opioid induced constipation naloxegol has been recommended by

NICE as a third line medicine when a trial of other laxatives has been

unsuccessful.28

If a patient with opioid induced constipation is unable to manage oral medication

methylnaltrexone has been shown to be effective.29,30 [Level 1]

If using methylnaltrexone, 0.15mg/Kg is an effective dose and the effect is

greater in those patients in whom opioid doses are higher. There are greater side

effects, but no greater efficacy associated with increasing the dose of

methylnaltrexone.30 [Level 1]

See Figure 1 and Table 3 for advice on choice of laxative and dosage.26 [Level 4]

4.5.3 Rectal Interventions

There is no experimental evidence to support the use of rectal interventions for

constipation, or to direct the choice of rectal intervention. The following guidance

is based on professional consensus and opinion.

The choice of rectal intervention should be based on the results of a digital rectal

examination. (see Figure 2).15 [Level 4].

For patients with malignant spinal cord compression, a rectal intervention should

be administered on alternate days and combined with an alternate day oral

stimulant laxative i.e. senna.15 [Level 4] Please see Figure 2 for details.

4.6 Communication and Information

Inadequate information about constipation and the risk factors is linked with a

higher number of patients developing constipation.14 [Level 2+]

Patients should be offered information about constipation at the time of diagnosis,

or the possibility of developing constipation when starting medicines which

increase this risk e.g. opioids.15 [Level 4].

Provision of information is currently lacking in UK practice. Written information

about constipation would benefit patients.3 [Level 3]

Verbal or written information on constipation should include; risk factors, advice

regarding self-care, the role of laxatives in managing constipation and when to

seek medical advice.15 [Level 4]

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021

Page 10

Figure 1. Laxative choice for opioid induced 27 [Level 1] and non-opioid induced constipation 4,24, 25 [Level 1] (Use of Macrogols, Co-Danthramer, Magnesium hydroxide and Rectal interventions 15 [Level 4]).

LACTULOSE SENNA OR

Titrate dose

LACTULOSE SENNA AND

NALOXEGOL (or methylnaltrexone if not able to take orally)

Opioid Induced Constipation

Non-Opioid Induced

Constipation

Consider alternative laxative e.g. Macrogol, Co-Danthramer or

Magnesium Hydroxide based on local prescribing practices and in discussion with the patient. Seek

expert advice if unsure.

Titrate dose Titrate dose

RECTAL INTERVENTIONS (According to rectal

examination)

Titrate dose

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Figure 2. Choice of rectal intervention in severe constipation15 [Level 4]

Rectal

Examination

Impacted Hard

Faeces

Impacted Soft

Faeces

Empty rectum plus

loaded colon

Bisacodyl plus glycerol

suppositories

Bisacodyl

suppository Phosphate enema

If ineffective use

enema

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**Note: The choice of medicines mentioned in this review should be undertaken with consideration of local prescribing practices and policies and reference to dosing advice in the BNF26 and PCF531 and discussion with experts if required.

Table 3 Pharmacological Options for the Management of Constipation in Palliative Care 26, 31

**

Senna [Level 1] Lactulose [Level 1] Naloxegol (Moventig) [Level 1] Glycerol Suppositories [Level 4]

Bisacodyl suppositories [Level 4]

Starting dose and titration advice

Start with 15mg nocte. Increase to 15mg bd after 24-48h if no effect. If necessary increase to a maximum of 30mg tds.

Starting dose is 15ml bd of 10g/15mL solution. Titrate according to result. Maximum 45ml tds.

Start with 25mg once daily. Maintenance dose is 25mg once daily. Max dose 25mg od.

One 4g suppository to be used when required.

One 10mg suppository to be used when required.

Dosing in renal impairment

No dose adjustment required.

No dose adjustment required.

If creatinine clearance is less than 60 mL/min: Reduce starting dose to 12.5 mg orally once a day. May increase to 25 mg orally once a day as needed for symptoms, if tolerated.

No dose adjustment required.

No dose adjustment required.

Side effects Intestinal colic, diarrhoea, hypokalaemia in cases of profuse diarrhoea.

Abdominal bloating, flatulence, nausea, intestinal colic.

Diarrhoea, intestinal colic, nausea. Diarrhoea, faecal leakage. Diarrhoea, faecal leakage, local irritation.

Contra-indications

Intestinal obstruction. Intestinal obstruction Use with caution in lactose intolerance Use with caution in diabetes due to sugar content.

Intestinal obstruction. Concomitant use of potent CYP3A4 Inhibitors is contraindicated. Caution is advised if concomitant use with moderate CYP3A4 inhibitors.

Immediately post surgery involving pelvis.

Immediately post surgery involving pelvis.

Notes Nil. Can be used in those who experience colic with stimulant laxatives.

Only to be used if constipation is felt to be due to opioids. To be taken on an empty stomach, 1 hour before or 2 hours after eating.

15-30 minutes required to take effect.

20-45 minutes required to take effect.

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**Note: The choice of medications mentioned in this review should be undertaken with consideration of local prescribing practices and policies with due consideration to dosing advice in the BNF26 and PCF531 and discussion with experts if required.

Table 3 - (Continued). Pharmacological Options for the Management of Constipation in Palliative Care26, 31

**

Macrogols [Level 4] Co-Danthramer [Level 4] Magnesium Hydroxide [Level 4] Docusate Sodium [Level 4]

Starting dose and titration advice

Start with 1 sachet or 125ml of diluted oral liquid concentrate once a day. Increase to bd-tds if required.

If using Co-Danthramer strong suspension (75mg/5ml), start with 5ml nocte. If necessary, adjust every 2-3 days up to 10ml bd or 20ml nocte.

If used in combination with a stimulant laxative: 15-30ml bd. If used as monotherapy: 15-60ml bd.

Start with 100mg bd. If necessary increase to a maximum of 200mg tds

Dosing in renal impairment

No dose adjustment required. No dose adjustment required. Risk of hypermagnesaemia is increased in renal impairment.

No dose adjustment required

Side effects Abdominal bloating, discomfort, borborygmi, hyponatraemia, nausea.

Intestinal colic, diarrhoea, discoloured urine, perianal irritation.

Oral magnesium salts act as antacids and the resulting increase in gastric pH may affect the absorption of other drugs if taken concurrently.

Diarrhoea, nausea, intestinal colic, rash.

Contra-indications

Stop if signs of fluid/electrolyte shift occur. Macrogol 3350 oral liquid is not authorised for faecal impaction.

Intestinal obstruction, non-terminal disease.

Hypermagnesaemia. Complete intestinal obstruction.

Notes Onset of action is 1-2 days for constipation.

UK marketing authorisations for laxatives containing dantron are limited to constipation in terminally ill patients.

Nil. Can be used in persistent partial bowel obstruction.

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Section 5: Standards

1. A clinical assessment should be completed and documented. The cause(s) of

constipation should be documented. If an assessment cannot be made, the

reason should be documented. [Grade D]15

2. Before treating constipation, bowel obstruction should be excluded in all patients.

[Grade D]15

3. All patients commencing opioid therapy should be offered laxative monotherapy.

[Grade D]15

4. A digital rectal examination should be performed before giving any rectal

intervention for constipation. [Grade D]15

Section 6: Applications and Implications

The aim is to re-audit practice once change has been implemented. This guideline

will be supplemented with the development of a patient information leaflet on

constipation which will include risk factors, self-care, pharmacological management

and advice on when to seek medical review.

This review has highlighted a number of unanswered questions in the research

literature. It is hoped that further research on the efficacy of many laxatives in the

palliative care population may be conducted in the future, as well as studies to

improve the definition of constipation and enhance the development of diagnostic

tools.

This guideline formed the basis of an abstract submission to the Association for

Palliative Medicine 2018 Supportive and Palliative Care Conference to share the

work and lessons learned to a wider audience.

Section 7: Acknowledgments and Declarations of Interest

Authors

Dr Dan Monnery, Specialty Registrar in Palliative Medicine, The Clatterbridge

Cancer Centre NHS Foundation Trust and Woodlands Hospice, Aintree,

Liverpool.

Mr Malcolm Cooper, Clinical Nurse Specialist in Palliative Care, The Clatterbridge

Cancer Centre NHS Foundation Trust.

Ms Rachael Ayre, Clinical Nurse Specialist in Palliative Care, Bridgewater

Community Healthcare Foundation Trust, Wigan.

Dr Susan Cureton, Specialty Doctor in Palliative Medicine, Bridgewater

Community Healthcare Foundation Trust, Wigan.

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Page 15

Ms Lucy Devlin, Staff Nurse, Willowbrook Hospice, Prescot, Merseyside

Ms Tracey Cookson, Staff Nurse, Willowbrook Hospice, Prescot, Merseyside.

Ms Catherine Owens, Staff Nurse, Willowbrook Hospice, Prescot, Merseyside

Ms Susan Schofield, Staff Nurse, Willowbrook Hospice, Prescot, Merseyside

Ms Gemma Sudworth, Staff Nurse, Willowbrook Hospice, Prescot, Merseyside.

Mr Charles Hyland, Senior Staff Nurse, Willowbrook Hospice, Prescot,

Merseyside.

Ms Lauren Edmunds, Macmillan Oncology Dietician, The Clatterbridge Cancer

Centre NHS Foundation Trust.

Ms Liz Waters, Macmillan Dietician Team Leader, The Clatterbridge Cancer

Centre NHS Foundation Trust.

Dr Aileen Scott, Consultant in Palliative Medicine, Marie Curie Hospice, Liverpool

(Guideline Development Lead).

Contributors

The Guideline Development Group gratefully acknowledges the work of the following

people in supporting the development of this guideline:-

Dr Katie Frew, Consultant in Palliative Medicine, Northumbria Healthcare NHS

Foundation Trust for her expert external review of this guideline.

Dr Martyn Dibb, Consultant in Gastroenterology, Royal Liverpool University

Hospital for his expert input to the development of this guideline.

Angela Fell, for her contribution as patient, carer and public representative.

Members of the Cheshire and Merseyside Palliative and End of Life Care

Network Audit and Clinical Guideline Group who submitted data for the regional

audit on the management of constipation and contributed to guideline

development through expert opinion.

Dr M Brooks, Dr F Ahmad, Mr A Dickman, Dr CM Littlewood, Dr M Makin, Mrs C Duddle and Dr N Sykes who authored the 2008 guideline.

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Page 16

Development of the guideline was funded through the use of supporting professional

activity time facilitated by the employing organisations of the authors. The authors

and reviewers declare no conflicting interests.

The authors contributed as follows:-

Literature review: DM, RA, CO, CH, GS, LD, LE, LW.

Audit tools: AS, MC, SS, SC, TC

Updated guidance and grading recommendations: DM, AS, MC, RA

Standards: DM, AS, MC, RA

Final writing of manuscript of guidelines: DM, MC, CO, SS, LE, LW, AS.

Section 8: Review Date

The guideline will be reviewed three years after publication as outlined in the

Cheshire and Merseyside Palliative and End of Life Care Network Audit Group

Guideline Development Manual.

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Appendix 1: Systematic Review Summary Form

Guideline Title: Assessment and Management of Constipation in Palliative Care.

Reviewers Monnery D, Ayre R, Owens C, Hyland C, Sudworth G, Devlin L, Edmunds L, Waters L.

IDE

NT

IFIC

AT

ION

E

LIG

IBIL

ITY

IN

CL

UD

ED

S

CR

EE

NIN

G

Records after duplicates removed (n =902)

Records screened (n =1131)

Records remaining after full text review

(n=11) Unrelated to clinical

Question = 3 Not in English language=1

Not fully published = 1

Records remaining after title screening (unrelated

to clinical question) (n = 124)

Articles included in final Guideline Development

(n = 11)

Records remaining after abstract screening

(n =16) Review article = 35 Unrelated to clinical

Question =15 Duplicate record = 57

Case Report = 1

(Constipation AND palliat*) AND (treat* OR Manag*)

Records identified EMBASE (n = 617)

Records identified PubMed (n =58)

What are the best methods of managing constipation in palliative care?

Records identified CINAHL (n =140)

Records identified Medline (n = 331)