Laxatives , Constipation, treatment options

Laxatives

Bisacodyl (Dulcolax ®)

Drug Category: Stimulant Laxative

Constipation (Adult)
a) 5-15 mg orally once daily up to 30 mg/day
b) 10 mg suppository rectally once daily

Preparation of bowel for procedure
a) 10-15 mg orally once daily up to 30 mg/day
b) 10 mg suppository rectally once daily
Onset: bowel movement within 15 to 60 min .

Supplied:
Rectal suppository: 10 mg.
Tablet [enteric coated]: 5 mg.

Cascara

Constipation (Adult): 325 mg orally at bedtime as needed or 5 ml (one teaspoonful) of extract orally at bedtime as needed.

Docusate (Colace ® )

Note: Docusate salts are interchangeable; the amount of sodium, calcium, or potassium per dosage unit is clinically insignificant.

Dosing (Adults)
Stool softener:
Oral: 50-500 mg/day in 1-4 divided doses
Rectal: Add 50-100 mg of docusate liquid to enema fluid (saline or water); give as retention or flushing enema.

MECHANISM OF ACTION — Reduces surface tension of the oil-water interface of the stool resulting in enhanced incorporation of water and fat allowing for stool softening.

Fleet Phospho-Soda

Each 5 mL of Fleet-Phospho-soda® contains 2.4 g monobasic sodium phosphate monohydrate and 0.9 g dibasic sodium phosphate heptahydrate in a stable, buffered aqueous solution. Do not exceed the recommended dosage due to the potential of serious side effects. NEVER take more than 3 Tablespoons at one time.

Adults and children 12 years and older
1) Laxative: 15 to 45 mL. Dilute recommended dose with at least one-half glass (4 fl. oz.) of cold water or other clear liquid. Drink, then follow with at least one additional glass (8 fl. oz.) of water or other clear liquid.

fleet dosing

2) Standard bowel cleansing dosage is two 30- to 45-mL doses separated by 10-12 hours (in at-risk patients, - below - consider using the lower end of the dosing range.
AT RISK Patients: Debilitated or elderly; Pregnant or nursing; Increased risk for underlying renal impairment; Colostomy or ileostomy; Heart disease/acute myocardial infarction/unstable angina; Pre-existing electrolyte disturbance. In at-risk patients consider obtaining baseline and posttreatment electrolytes and using the lower end of the dosing range of Fleet® Phospho-soda® (two 30-mL doses given 10-12 hours apart).

Supplied: 748 mOsmol/45mL. The process is associated with transient serum electrolyte changes. Each Tablespoon (15 mL) of FLEET® Phospho-soda® oral saline laxative contains 7.2 g monobasic sodium phosphate monohydrate and 2.7 g dibasic sodium phosphate heptahydrate in a stable, buffered aqueous solution.

ELEMENTAL AND ELECTROLYTIC CONTENT
mEq Phosphate (PO4 )/mL: 12.45
mEq Sodium (Na)/mL: 4.82
mg Sodium (Na)/mL: 111
mmole Phosphorus (P)/mL: 4.15

Glycerin

Glycerin is a hyperosmotic laxative, which is given rectally, and it usually produces a bowel movement within 15 minutes to 1 hour. The laxative effect of glycerin is due to the local irritant effect of sodium stearate and glycerin's osmotic effect.

Dosage: Adults and Children 6 years of age and older: One suppository.

Lactulose

Dosing (Adults)
Constipation: 15-30 ml orally at bedtime.

Acute Hepatic encephalopathy or portosystemic encephalopathy (PSE):
Adults: Oral: 20-30 g (30-45 ml) every 1-2 hours to induce rapid laxation. Adjust dosage daily to produce 2-3 soft stools. Doses of 30-45 ml may be given hourly to cause rapid laxation, then reduce to recommended dose.
Usual daily dose: 60-100 g (90-150 mL) daily. Rectal administration: 200 g (300 ml) diluted with 700 ml of H20 or NS - administer rectally via rectal balloon catheter and retain 30-60 minutes every 4-6 hours

lubiprostone (Amitiza ™ )

Indicated for the treatment of chronic idiopathic constipation in the adult population.

Dosing (Adults): 24 mcg taken twice daily (BID) orally with food. Physicians and patients should periodically assess the need for continued therapy.

Supplied: 24 mcg capsule

Mechanism of Action: Chronic idiopathic constipation is generally defined by infrequent or difficult passage of stool. The signs and symptoms associated with chronic idiopathic constipation ( i.e., abdominal pain or discomfort, bloating, straining, and hard or lumpy stools) may be the result of abnormal colonic motility that can delay the transit of intestinal contents and impede the evacuation of rectal contents. One approach to the treatment of chronic idiopathic constipation is the secretion of fluid into the abdominal lumen through the activation of chloride channels in the apical membrane of the gastrointestinal epithelium. Lubiprostone is a locally acting chloride channel activator that enhances a chloride-rich intestinal fluid secretion without altering sodium and potassium concentrations in the serum. Lubiprostone acts by specifically activating ClC-2, which is a normal constituent of the apical membrane of the human intestine, in a protein kinase A–independent fashion. By increasing intestinal fluid secretion, lubiprostone increases motility in the intestine, thereby increasing the passage of stool and alleviating symptoms associated with chronic idiopathic constipation.

Magnesium citrate

Onset: 30 min to 6 hours

Dosing (Adults): Cathartic: Oral: Adults: 1/2 to 1 full bottle (150-300 mL). May be taken as a single daily dose or divided doses. Maximum 300ml in a 24 hour period (manufacturer).
Dave's note: (MAXIMUM DOSE) Some sources list the daily maximum as 25 grams which is equivalent to ~425 ml.

Supplied: Solution, oral: 290 mg/5 mL (300 mL).
Absorption: Oral: 15% to 30%. Excretion: Urine.

MECHANISM OF ACTION — Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity

RENAL IMPAIRMENT — Patients in severe renal failure should not receive magnesium due to toxicity from accumulation. Patients with a Clcr <25 mL/minute should be monitored by serum magnesium levels.

Magnesium hydroxide - MOM

Dosing (Adults): laxative: 30-60 ml orally x 1.

Methylcellulose (Citrucel ® )

Citrucel Orange Flavor Powder - Actions: Promotes elimination by providing additional fiber (bulk) to the diet. This product generally produces bowel movement in 12 to 72 hours.
Indications: For relief of constipation (irregularity). May also be used for relief of constipation associated with other bowel disorders such as IBS, diverticular disease, and hemorrhoids as well as for bowel management during postpartum, postsurgical, and convalescent periods when recommended by a physician.

Adult Dose: dissolve one leveled scoop (one heaping tablespoon - 19g) in 8 ounces of cold water up to three times daily at the first sign of constipation. Children age 6 to 12 years of age: one-half the adult dose stirred briskly in 8 ounces of cold water, once daily at the first sign of constipation. The mixture should be administered promptly and drinking another glass of water is highly recommended

Mineral Oil

Adult (usual) - Constipation: 15-45 ml orally once daily at bedtime (max of 45 ml). Do not take within 2 hr of meals. Should not be used longer than 1 week, except under orders of a physician. Patient should not be reclining after oral administration to avoid aspiration of oil droplets.

Bowel clearance: 118 ml rectally once daily as an enema.

Protect clothing - may have oil leakage from rectum.

Pericolace ® (docusate/ casanthranol):

Dosing (Adults): 1-2 capsules or (15-30ml) orally at bedtime as needed.

Psyllium (Fiberall® , Genfiber®, Konsyl®, Metamucil® )

Usual Dose: 1 teaspoonful or 1 packet orally one to three times daily.
Dosing (Adults):
Constipation, IBS: Oral (administer at least 2 hours before or after other drugs):
Take 1 dose up to 3 times daily. All doses should be followed with 8 oz of water or liquid.
Capsule: 4 capsules/dose (range: 2-6); swallow capsules one at a time
Powder: 1 rounded tablespoonful/dose (1 teaspoonful/dose for many sugar free or select concentrated products) mixed in 8 oz liquid

Onset of action: 12-24 hours
Peak effect: 2-3 days

Senna (Senokot ®)

Stimulant laxative.
Dosing (Adults): Adults and children > 12 years of age: 2 tablets qd.
Senokot granules may be eaten plain, mixed with liquids such as milk to make a delicious drink, or sprinkled on foods.

AGE	STARTING	MAXIMUM
Take preferably at bedtime. Generally producing bowel movement in 6 to 12 hours.
Adults and children 12 years of age and over	2 tablets once a day (at bedtime)	4 tablets twice a day
6 to under 12 years of age	1 tablet once a day	2 tablets twice a day
2 to under 6 years of age	¹/ ₂ tablet once a day	1 tablet twice a day

[Supplied: Senokot tablets: Each tablet contains 8.6 mg sennosides. Senokot Granules: Each teaspoonful contains 15 mg sennosides. Senokot-S Tablets: Each tablet contains 8.6 mg sennosides and 50 mg of docusate sodium]

Sorbitol

Dosing (Adults): 30-150 ml orally x 1.

Disclaimer

Listed dosages are for - Adult patients ONLY. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. GlobalRPH does not directly or indirectly practice medicine or provide medical services and therefore assumes no liability whatsoever of any kind for the information and data accessed through the Service or for any diagnosis or treatment made in reliance thereon.

David F. McAuley, Pharm.D., R.Ph. GlobalRPh Inc.

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