Constipation Matrix

Stimulant laxatives (bisacodyl, senna): which products and age limits?

Bisacodyl EC 5 mg tablets (Dulcolax) age 6+; senna (Senokot, Ex-Lax, Senokot Kids gummies) age 2+; bisacodyl 10 mg suppository (Dulcolax) age 6+; bisacodyl 10 mg mini-enema (Fleet, 1.25 oz) age 12+.

Stimulant laxatives (bisacodyl, senna): mechanism of action?

Irritate the GI mucosa, stimulating smooth muscle contraction and water secretion, resulting in a bowel movement.

Stimulant laxatives (bisacodyl, senna): symptoms treated?

Acute constipation in children and adults; treatment and prevention of acute and chronic opioid-induced constipation; pre-procedural bowel emptying (e.g., colonoscopy) combined with agents like PEG.

Stimulant laxatives (bisacodyl, senna): side effects?

GI cramping. If overused/abused/taken too long: diarrhea with dehydration and/or electrolyte disturbances.

Stimulant laxatives (bisacodyl, senna): pros?

Faster onset than fiber or PEG; safe for most people; children 2+ safe (senna preferred).

Stimulant laxatives (bisacodyl, senna): cons?

Can be abused (eating disorders, 'detox'); suppositories are less preferred than oral and can cause rectal irritation.

Stimulant laxatives (bisacodyl, senna): pregnancy and breastfeeding?

Pregnancy: safe for very short-term use but not preferred (cramping may be confused with contractions); recommend fiber, PEG or docusate instead. Lactation: safe.

Stimulant laxatives (bisacodyl, senna): onset?

Bisacodyl suppository and mini-enema: 15-60 minutes. Senna and oral bisacodyl: 6-10 hours.

Stimulant laxatives (bisacodyl, senna): opioid-induced constipation counseling?

Use with docusate or PEG: 'mush and push' (docusate/PEG gives the mush, the stimulant gives the push).

Senna: unique counseling points?

Can discolor urine (red/pink/brown); preferred stimulant in children 2+; recommend senna instead of bisacodyl if the patient takes an acid reducer.

Oral bisacodyl: counseling (enteric coating)?

Do not chew/crush/break. Do not take with PPIs or H2RAs; separate from antacids and milk by 1 hour; acid reducers/milk break down the enteric coating (dissolves in the stomach: no efficacy, gastric irritation).

Stimulant laxatives (bisacodyl, senna): maximum duration?

7 days unless a physician recommends longer or it is used to prevent opioid-induced constipation.

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): mechanism of action?

Fiber absorbs water and expands, increasing pressure on the intestinal walls to promote a bowel movement.

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): symptoms treated?

Prevention of constipation and treatment of chronic constipation. FIRST LINE in adults if rapid relief is not needed and fluid intake is adequate. NOT for acute constipation (slow onset; may worsen if blockage).

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): side effects?

Flatulence, abdominal bloating, gas. If bothersome, methylcellulose (synthetic) may be better tolerated than psyllium.

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): pros?

Most closely approximates the body's physiology; not systemically absorbed; softens stool with adequate water; usable chronically (provider should know because of drug interactions); safe in most populations (children, older adults, colostomies, IBS, diverticulitis).

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): cons?

Not effective for acute constipation or rapid relief (long onset); not recommended or effective for opioid-induced constipation.

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): cautions?

Can swell in the throat and cause choking if not taken with a full glass of fluid; without adequate fluid can harden in the colon and cause obstruction. Avoid in dysphagia, bedridden patients, or those who cannot drink adequate fluids.

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): pregnancy, lactation and age?

Safe in pregnancy and lactation. Age 2+ (gummies 4+; powders, wafers, tablets, capsules 6+).

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): onset and interactions?

Takes up to 3 days for effect. May interfere with absorption of other drugs: separate by 2 hours.

Bulk-forming laxatives (psyllium/Metamucil, methylcellulose/Citrucel, polycarbophil/FiberCon, inulin + polydextrose gummies): dietary fiber goals and starting tip?

Adults 25-35 g/day; kids age + 5 g/day. Check serving size for grams of fiber; start low and titrate up to reduce side effects.

Hyperosmotic laxatives (PEG, glycerin): mechanism of action?

Large, poorly absorbed ions/molecules that draw water into the colon or rectum by osmosis, stimulating a bowel movement.

Polyethylene glycol 3350 (Miralax): symptoms treated?

Acute and chronic constipation in children and adults; prevention and treatment of opioid-induced constipation; bowel evacuation before procedures.

Polyethylene glycol 3350 (Miralax): side effects?

Abdominal discomfort, flatulence; diarrhea with dehydration/electrolyte disturbances if overused.

Polyethylene glycol 3350 (Miralax): pros?

Minimal systemic absorption and no reported drug interactions; effective and safe for virtually everyone; no taste (some texture), mixes with hot or cold fluid; preferred OTC option for infants and children per AAFP and ACG.

Polyethylene glycol 3350 (Miralax): cons?

Slower onset than glycerin, magnesium hydroxide and stimulant laxatives.

Polyethylene glycol 3350 (Miralax): pregnancy, lactation and age?

Pregnancy: safe, PEG preferred over other laxatives. Lactation: safe. Not approved OTC for children <=16 but preferred for children under pediatrician supervision.

Polyethylene glycol 3350 (Miralax): dosing?

17 g (one capful) once daily in 4-8 oz water (physicians often QD or BID). Pediatric: 0.4-1.5 g/kg up to 17 g/day.

Polyethylene glycol 3350 (Miralax): onset and duration?

Onset 12-72 hours. OTC label max 7 days, but safe long-term if no diarrhea and the physician knows. Works best with adequate daily fluids but is safe regardless.

Glycerin suppository (Fleets, Pedia-Lax): use and side effects?

Hyperosmotic; treats acute constipation in children and adults (infant+). Side effect: rectal irritation from insertion.

Glycerin suppository (Fleets, Pedia-Lax): pros?

Rapid effect (bowel movement within 15-30 min); can be cut to a smaller dose (contains no drug); safe for infants, pregnancy and lactation.

Glycerin suppository (Fleets, Pedia-Lax): cons?

Route of dosing and potential rectal irritation make it less preferred than PEG.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): which products and ages?

Mag citrate age 6+; MOM liquid 1200 mg/15 mL and Pedialax chews 400 mg age 2+; Mirafast chews 1200 mg age 4+; sodium phosphate enema (Fleet Pedia-Lax) age 2+. Magnesium sulfate (Epsom salt): do NOT recommend for constipation.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): mechanism of action?

Electrolytes (Mg or Na/Phos) draw water into the small and large intestine (oral) or distal colon (rectal) by osmosis, increasing intraluminal pressure and stimulating peristalsis.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): symptoms treated?

Acute constipation; mag citrate sometimes used for bowel evacuation before procedures (colonoscopy); physicians sometimes recommend MOM chronically.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): side effects?

Abdominal cramping; diarrhea, dehydration and electrolyte disturbances if overused.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): pros?

Rapid acting; various dosage forms; children 2+ safe (choose one appropriate for age); lactation safe.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): cons?

Most likely of all laxatives to cause diarrhea, dehydration and electrolyte imbalance (electrolytes are absorbed even with rectal dosing).

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): pregnancy?

Not recommended in pregnancy unless directed by a physician.

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): cautions and contraindications?

Older adults (declining renal function); avoid with Na/Phos/Mg-restricted diets or renal impairment; avoid sodium phosphate in uncontrolled hypertension/edema/heart failure; Mg chelates some drugs (separate by 2 hours).

Saline laxatives (magnesium citrate, magnesium hydroxide/MOM, sodium phosphate enema): onset and max dose?

Onset: Na/Phos enema 2-15 min; Mg citrate 30 min-3 h; Mg hydroxide 30 min-6 h. Max: 1 sodium phosphate enema/day for 3 days; oral saline no more than 7 days (exception: MOM when a physician recommends).

Docusate sodium (Colace): stool softener (NOT a laxative): mechanism of action?

Anionic surfactant acting in the small and large intestine that increases the wetting efficiency of intestinal fluid, mixing aqueous and fatty substances to soften the fecal mass (provides the 'mush').

Docusate sodium (Colace): stool softener (NOT a laxative): symptoms treated?

Prevention of straining and painful defecation.

Docusate sodium (Colace): stool softener (NOT a laxative): side effects?

No major side effects.

Docusate sodium (Colace): stool softener (NOT a laxative): pros?

Good for preventing rectal strain after surgery and postpartum; softens stools in hemorrhoids; not absorbed; no drug interactions.

Docusate sodium (Colace): stool softener (NOT a laxative): cons?

Does not treat constipation as monotherapy; duplicative with PEG and saline osmotics (they soften stool on their own).

Docusate sodium (Colace): stool softener (NOT a laxative): pregnancy, lactation and age?

Safe in pregnancy and lactation; children age 2+.

Docusate sodium (Colace): stool softener (NOT a laxative): onset and use?

Onset 12-72 hours (up to 5 days for full benefit); may be added to a stimulant for opioid-induced constipation ('mush and push').

Mineral oil (lubricant laxative): mechanism of action and ages?

Softens fecal contents by coating stool and preventing colonic absorption of fecal water. Oral (Fleet) age 6+; enema (Fleet) age 2+.

Mineral oil (lubricant laxative): symptoms treated?

Acute constipation.

Mineral oil (lubricant laxative): side effects?

Lipid pneumonia from aspiration of oral doses; anal pruritus and leakage; impaired absorption of fat-soluble vitamins A, D, E, K if overused.

Mineral oil (lubricant laxative): pros?

Quick onset: oral 6-8 hours; rectal 2-15 minutes.

Mineral oil (lubricant laxative): cons?

Oral form is on the Beers list for older adults (aspiration risk).

Mineral oil (lubricant laxative): who should avoid it?

Anyone with GI disease or colostomy/ileostomy, children <6 (oral) or <2 (enema), bedridden patients, pregnant women. Bottom line: do not recommend (better, safer options exist).

Laxatives: age limits?

Senna 2+; oral bisacodyl and suppository 6+; bisacodyl mini-enema 12+; bulk-forming 2+ (gummies 4+, other forms 6+); PEG not OTC for <=16 (preferred in kids under pediatrician); glycerin infant+; mag citrate 6+; MOM/Pedialax chews 2+; Mirafast 4+; sodium phosphate enema 2+; docusate 2+; oral mineral oil 6+, enema 2+.

Laxatives: which are preferred in pregnancy and which to avoid?

Preferred: fiber, PEG (best), docusate. Stimulants: safe only very short-term but not preferred (cramping). Saline: not recommended unless directed. Mineral oil: avoid.

Laxatives: onset ranking?

Fastest: sodium phosphate enema (2-15 min), mineral oil enema (2-15 min), glycerin (15-30 min), bisacodyl suppository/mini-enema (15-60 min). Then mag citrate/MOM (30 min-6 h), oral stimulants (6-10 h), PEG (12-72 h), docusate (12-72 h), fiber (up to 3 days).

Constipation referral: red flags?

Constipation plus: significant abdominal pain, distention, cramping, nausea/vomiting; fever; para/quadriplegia; unintentional weight loss; blood in stool (beyond minor hemorrhoid bleeding); pencil-like stools; failure of all appropriate agents; history of IBD; anorexia.

Constipation: when is self-treatment OK with pharmacist assessment?

Chronic constipation (daily laxative use, >2 weeks, or recurring; common in older adults and GLP-1 users): not necessarily a referral, but counsel to notify the primary care provider, review contributing drugs, and add diet/exercise. Children <2 with acute episodic constipation and an identifiable cause can be self-treated (parents may call the pediatrician for dosing, e.g., PEG).