Executive summary
- First do the basics: duration, stool form (Bristol), red flags, meds review, and a rectal exam where indicated.
- Stepwise ladder works: osmotic laxative (often macrogol) → add stimulant if needed; tailor to stool consistency vs motility.
- Impaction needs a plan: treat aggressively with macrogol titration (and follow-up), not “one sachet and hope”.
Red flags (consider urgent evaluation)
- New constipation with weight loss, anaemia, rectal bleeding, or significant change in bowel habit (consider cancer pathway depending on age/risk).
- Severe abdominal pain, vomiting, significant distension (obstruction risk).
- Neurological red flags (new saddle anaesthesia, leg weakness, urinary retention) → consider cauda equina.
Laxative ladder (pragmatic prescribing)
- Osmotic first-line: macrogol (PEG) preparations are often preferred; lactulose is an alternative.
- Add stimulant if response inadequate: senna or bisacodyl (especially if stool is soft but frequency low).
- Faecal impaction: use high-dose macrogol titrated over days (common practical pattern is multiple sachets/day) and review frequently; consider suppositories/enemas if needed per local protocol.
- Opioid-induced constipation: start prophylaxis early (osmotic + stimulant) and consider peripherally acting agents per pathway if refractory.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.