Constipation

Constipation is CKD is multifactorial, and associated with:

• Poor dietary fibre intake
• Fluid restriction
• Medications (phosphate binders, opioids, amitriptyline, ondansetron, oral iron supplements)
• Co-morbid gastrointestinal disorders
• Lack of physical activity

Non-pharmacological management

1. Increase dietary fibre intake (e.g. fruits, vegetables, grains and cereals).
   For people with ESKD (eGFR <20ml/min) or hyperkalemia we recommend low potassium dietary choices.
2. Fibre supplements

• • OTC fibre supplements are available. Some may contain high levels of potassium (e.g. prunelax) or are not suitable for people on fluid restrictions (e.g. psyllium husk, Metamucil).
  • Benefibre is the most suitable option for people with ESKD.
  • Dosing should start at 1 tsp per day, increase dosing until constipation is resolved (up to a maximum of 6 tsps. /day).
  • Titrate slowly as there may be s/e of bloating.
  • Benefibre has no flavour and can be mixed with any fluids or foods containing moisture (e.g. yoghurt, soups, stews).

3. Reach fluid targets, but not over fluid restriction.
4. Increase physical activity, aiming for 30mins each day.

Pharmacological management

1. Coloxyl + senna. Start with 2 tablets at night, and up-titrate as required to maximum 2 tds (long term senna use not recommended due to risk of dismotility).
2. Movicol. Start with 1 sachet daily. Up-titrate up as required.
   Low in potassium.
   Must be mixed with water as per packet instruction. Water is not absorbed and therefore does not contribute to fluid restriction.
3. Lactulose. Start at 15ml daily. Can cause faecal urgency.
4. Glycerine and Bisocodyl suppositories (available over-the-counter)
5. High olive oil enema
6. For faecal impaction, use bowel prep such as Glycoprep
7. Fleet drops and fleet enemas are high in phosphate, so are only suitable for patients with low phosphate

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