Therapeutic target
Normalization of stool frequency and consistency.
Therapy recommendations
Indications (areas of application) for laxative therapy:
- Especially elderly patients with constipation, bedridden patients.
- Patients who should avoid pressing during defecation and thus an acute increase in blood pressure and/or intracranial pressure and/or intra-abdominal pressure (pressure within the abdominal cavity) such as after a cerebral apoplexy (stroke)/increased intracranial pressure of other causes, a myocardial infarction (heart attack) or in the case of large hernias (fractures)
- Patients with painful anal lesions (injuries/damage to the anus/after) such as anal fissure (painful tearing of the skin or mucous membrane of the anus) or perianal thrombosis (painful swelling around the anus caused by a blood clot in the superficial veins)
- Bowel evacuation prior to abdominal surgery (abdominal surgery) and colonoscopy (colonoscopy).
- After administration of substances that can cause constipation such as after administration of X-ray contrast media (barium pulp).
- In severe constipation with a slowed transit time (intestinal transit time).
Contraindications to laxative therapy:
- Mechanical ileus (intestinal obstruction)
- Suspected perforating or abscessing processes in the abdomen
- Ulcerative colitis (chronic inflammatory bowel disease) with concomitant constipation.
- In the presence of significant abdominal discomfort of unclear cause – acute abdomen, etc.
The therapy recommendations of the guideline chronic constipation [S2k guideline] provide a step scheme
Each of the stages of therapy presented below should optimally be tested for effectiveness for two weeks each before moving to the next stage. Before this step-by-step plan is used, however, all possible organic causes must be differential-diagnosed or excluded! A further prerequisite is, of course, the failure of the above-mentioned basic therapy. In the case of a step change, all measures of the preceding steps continue to be observed, i.e., all preparations continue to be administered.
| Stage | Measures for constipation without voiding dysfunction | Measures in case of voiding disorder |
| Ia | General measures (see “Further therapy“). | |
| Ib | Taking additional dietary fiber (wheat bran, psyllium husks, etc.) | |
| II | Macrogol, bisacodyl, sodium picosulfate lactulose anthraquinones (see below caveat] combo if necessary, change if necessary | Suppositories/clysms |
| III | Prucalopride lubiprostone, linaclotide | Surgery if necessary (for structurally induced constipation) Biofeedback if necessary (for functionally induced constipation) Laxative if necessary, + Supp., + Clysma if necessary |
| IV | Combination therapy I-III clysms, lavage if necessary opiate antagonists. | – |
| V | Sacral nerve stimulation surgery (subtotal colectomy). | – |
Active ingredients (main indication)
Filling/swelling agent
| Active ingredients | Dosage |
| Psyllium seeds (plantogo seeds; psyllium) | 1-2 Btl/d (10-30 gr); start creeping in with one teaspoon of psyllium husks in 150-200 ml water/d – can be increased continuously to two teaspoons /d in 300-400 ml water. During the treatment sufficient water should be drunk (> 1.5 L). The effect starts only after 12 to 24 hours. The maximum effect is reached after about 24 hours. |
| Flaxseed | 1-2 tablespoons/d |
- Slow onset of action
- Side effects with prolonged use: intestinal sluggishness, hypokalemia (potassium deficiency), hyponatremia (sodium deficiency), hypocalcemia (calcium deficiency), melanosis coli (harmless, patchy dark discoloration of the mucosa of the colon)
- Ensure adequate fluid intake!
Hydragoge laxatives
| Active ingredients | Dosage | Special features |
| Bisacodyl | 1-2 x 5 mg/d 10 mg Supp/d | First-line agent indefinite use – rapid action even in pregnancy (Supp) |
| Sodium picosulfate | 5-20 trpf./d | First-line agent indefinite use – even in pregnancy |
- Mode of action: antiresorptive-secretory in the colon (large intestine), stimulation of propulsive motility (movement) in the colon (large intestine).
- Indications: Use in chronic constipation
- Use also during pregnancy
- Side effects with prolonged use: very rarely habituation, electrolyte shifts (shifts in the concentrations of blood salts / electrolytes).
Osmotic-acting laxatives (laxatives).
| Active ingredients | Dosage | Special features |
| Lactulose | 20-40 ml/d | Continued use in hepatic encephalopathy. |
| Lactitol | 0.25 g/kg bw | Single dose in the morning or evening with plenty of fluid |
| Polyethylene glycols (PEG, macrogol) | 2-3 btl/d | First choice agent Use also in pregnancy |
| Sorbitol | approx. 10 g | Occasional intolerance (meteorism). |
- Mode of action: osmotic water binding
- Indications: Use in chronic constipation
- Side effects: very rarely habituation, electrolyte shifts (shifts in the concentrations of blood salts/electrolytes).
Further notes
- Recommended rectal voiding aids are: Bisacodyl/CO2 suppositories.
- Clysms should not be administered permanently
- See also under “Other therapy.”
Opioid-induced constipation
Opioid-induced constipation (OIC; English : Opioid-Induced Constipation): occurrence under opioid therapy regardless of mode of administration and indication in 80% of cases with at least one of the following side effects: Constipation, nausea, and/or drowsiness.
- Therapy [guidelines: DGS practice guidelines]:
- Prophylactic administration of laxatives with initiation of opioid therapy: osmotic (preferably macrogel) and/or stimulant laxatives.
- Selective blockade of peripheral μ-opioid receptors by opiate antagonists:
- Combination of sustained-release oxycodone and sustained-release naloxone (2: 1 ratio);
- Methylnaltrexone
- Naloxegol (peripherally-acting opioid receptor antagonist; peripherally-acting μ-opioid receptor antagonist, PAMORA): 25 mg/d orally).
- Naldemedine (peripherally acting μ-opioid receptor antagonist)/new approval: naldemedine increased the frequency of spontaneous bowel movements (SBM) by 1.4 per week and the frequency of complete spontaneous bowel movements (CSBM) by 1.1 per week in patients with noncancer pain and OIC compared with placebo.
- See also under “Other Therapy.”
Constipation in pregnancy
- Bulking and swelling agents (e.g., flaxseed, wheat bran, psyllium husks, agar-agar).
- Osmotic laxatives (e.g., lactulose or macrogol) or secretory laxatives (e.g.,bisacodyl or sodium picosulfate).
- Rectal microenemas with glycerol.
- See also under “Further therapy”.
Cave.
- Saline laxatives such as magnesium hydroxide should not be used for therapy of chronic constipation because of their spectrum of side effects [S2k guideline].
- Osmotic salts, magnesium hydroxide, or kerosene oil should not be used in patients with noncurable cancer and constipation [S3 guideline].
- Phosphate-containing enemas (e.g., enema, clysma) have a risk of severe hyperphosphatemia (excess phosphate) after use in young children. Phosphate-containing enemas should therefore not be used in infants and young children (under six years of age).
- Anthraquinones: the German Federal Institute for Drugs and Medical Devices has repeatedly warned against their use and emphasized that their use should be limited to short-term use. Anthraquinones are contraindicated in pregnancy and lactation. They are therefore no longer recommended.(According to the guideline chronic constipation anthraquinones can be used [S2k guideline]).
- Laxative teas usually consist of a mixture of anthraquinone derivatives, which are extracted imprecisely dosed with teaspoons in hot water for different lengths of time. They are therefore not recommended.
- Kerosene oil: it can cause a foreign body reaction at the intestinal epithelium and lead to malabsorption (lat. : “poor absorption“) of fat-soluble vitamins (A, D, E, K) and drugs. Furthermore, especially in bedridden and elderly patients, there is a risk of causing lipid pneumonia (lipid pneumonia) by regurgitation (“regurgitation of food pulp”) and aspiration (here: penetration into the lungs). It is therefore not recommended [S2k guideline].
- Castor oil: Castor oil is a bad-tasting, very strong laxative that can cause diarrhea (diarrhea), abdominal discomfort (abdominal pain), and electrolyte imbalances. It is therefore not recommended.
- The permanent use of Klysmen is not recommended [S2k guideline].
Supplements (dietary supplements; vital substances)
Suitable dietary supplements should contain the following vital substances:
- Other vital substances (fiber, probiotics).
