Common with opioids and reduced activity in advanced illness.

Best position to expel stool: raise knees above your waist – use foot stool or books.

Food: clinical trial showed kiwi’s > prunes > psyllium improved constipation, but kiwis also reduced bloating.

Prevent constipation from opioids through daily use of laxative.


Osmotic laxative

  • PEG 3350 17-34g in juice daily
  • lactulose 15-30ml daily or bid


  • senna 1-3 tabs daily to bid


  • glycerin or bisacodyl

Other medications

  • docusate not supported by evidence
  • psyllium requires ++fluids to work and not recommended in advanced disease

Opioid induced constipation unresponsive to above, add

  • methylnaltrexone 8-12mg sc q2days.

Refractory constipation GI secretagogue:

  • Prucalopride 1mg once daily 30 min prior to morning meal. May increase to 2mg daily except in renal failure.

Other therapies


  • regular bowel routine
  • privacy
  • activity if possible
  • oral fluids


  • saline enema still useful to remove hard stool