Indications And Dose
CITRAFLEET ® SACHETS Bowel evacuation on day before radiological examination, endoscopy, or surgery ▶BY MOUTH ▶Adult: 1 sachet taken before 8 a.m, then 1 sachet after 6–8 hours
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Drug reference
CITRAFLEET ® SACHETS Bowel evacuation on day before radiological examination, endoscopy, or surgery ▶BY MOUTH ▶Adult: 1 sachet taken before 8 a.m, then 1 sachet after 6–8 hours
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▶For CitraFleet ®: Acts within 3 hours of first dose. PICOLAX ® SACHETS Bowel evacuation on day before radiological procedure, endoscopy, or surgery ▶BY MOUTH ▶Child 1 year: 0.25 sachet taken before 8 a.m, then 0.25 sachet after 6–8 hours ▶Child 2–3 years: 0.5 sachet taken before 8 a.m, then 0.5 sachet after 6–8 hours ▶Child 4–8 years: 1 sachet taken before 8 a.m, then 0.5 sachet after 6–8 hours ▶Child 9–17 years: 1 sachet taken before 8 a.m, then 1 sachet after 6–8 hours ▶Adult: 1 sachet taken before 8 a.m, then 1 sachet after 6–8 hours ▶For Picolax ®: Acts within 3 hours of first dose.
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Acute severe colitis. ascites. congestive cardiac failure. gastric retention. gastrointestinal obstruction. gastrointestinal perforation. gastrointestinal ulceration. toxic megacolon
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Cardiac disease. children. colitis. debilitated patients. elderly. fluid and electrolyte disturbances (avoid in severe dehydration or hypermagnesaemia). hypovolaemia (should be corrected before administration) . recent gastrointestinal surgery
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Flavours of oral powder formulations may include lemon. PICOLAX ® SACHETS One reconstituted sachet contains K+ 5 mmol and Mg2+ 87 mmol. CITRAFLEET ® SACHETS One reconstituted sachet contains K+ 5 mmol and Mg2+ 86 mmol.
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▶Common or very common Gastrointestinal discomfort. headache. nausea ▶Uncommon Confusion. electrolyte imbalance. gastrointestinal disorders. seizures. skin reactions. vomiting
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Caution.
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Caution.
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Avoid in hepatic coma if risk of renal failure.
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▶In adults Avoid if eGFR less than 30 mL/minute/1.73 m2— risk of hypermagnesaemia. ▶In children Avoid if estimated glomerular filtration rate less than 30 mL/minute/1.73 m2—risk of hypermagnesaemia.
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One sachet of sodium picosulfate with magnesium citrate powder should be reconstituted with 150 mL (approx. half a glass) of cold water; patients should be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking. PICOLAX ® SACHETS, CITRAFLEET ® SACHETS One sachet should be reconstituted with 150 mL (approx. half a glass) of cold water.
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There can be variation in the licensing of different medicines containing the same drug. Powder CAUTIONARY AND ADVISORY LABELS 10, 13 ELECTROLYTES: May contain Magnesium, potassium ▶CitraFleet (Casen Recordati S.L.) Sodium picosulfate 10 mg, Magnesium oxide light 3.5 gram, Citric acid anhydrous 10.97 gram CitraFleet oral powder 15.08g sachets sugar-free | 2 sachet p £3.25 ▶Picolax (Ferring Pharmaceuticals Ltd) Sodium picosulfate 10 mg, Magnesium oxide 3.5 gram, Citric acid anhydrous 12 gram Picolax oral powder 16.1g sachets sugar-free | 2 sachet p £3.39 2.2 Constipation Constipation Description of condition Constipation is defaecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defaecation. It can occur at any age and is commonly seen in women, the elderly, and during pregnancy. It is important for those who complain of constipation to understand that bowel habit can vary considerably in frequency without doing harm. Some people erroneously consider themselves constipated if they do not have a bowel movement each day. New onset constipation, especially in patients over 50 years of age, or accompanying symptoms such as anaemia, abdominal pain, weight loss, or overt or occult blood in the stool should provoke urgent investigation because of the risk of malignancy or other serious bowel disorder. In those patients with secondary constipation caused by a drug, the drug should be reviewed. Overview g In all patients with constipation, an increase in dietary fibre, adequate fluid intake and exercise is advised. Diet should be balanced and contain whole grains, fruits and vegetables. Fibre intake should be increased gradually (to minimise flatulence and bloating). The effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks. Adequate fluid intake is important (particularly with a high-fibre diet or fibre supplements), but can be difficult for some people (for example, the frail or elderly). Fruits high in fibre and sorbitol, and fruit juices high in sorbitol, can help prevent and treat constipation. h Misconceptions about bowel habits have led to excessive laxative use. Laxative abuse may lead to hypokalaemia. Before prescribing laxatives it is important to be sure that the patient is constipated and that the constipation is not secondary to an underlying undiagnosed complaint. Laxatives Bulk-forming laxatives Bulk-forming laxatives include bran, ispaghula husk p. 58, methylcellulose p. 59 and sterculia p. 59. They are of particular value in adults with small hard stools if fibre cannot be increased in the diet. Onset of action is up to 72 hours. Symptoms of flatulence, bloating, and cramping may be exacerbated. Adequate fluid intake must be maintained to avoid intestinal obstruction. Methylcellulose, ispaghula husk and sterculia may be used in patients who cannot tolerate bran. Methylcellulose also acts as a faecal softener. Stimulant laxatives Stimulant laxatives include bisacodyl p. 65, sodium picosulfate p. 68, and members of the anthraquinone group (senna p. 67, co-danthramer p. 66 and co-danthrusate p. 66). Stimulant laxatives increase intestinal motility and often cause abdominal cramp; manufacturer advises they should be avoided in intestinal obstruction. The use of co-danthramer and co-danthrusate is limited to constipation in terminally ill patients because of potential carcinogenicity (based on animal studies) and evidence of genotoxicity. Docusate sodium p. 65 is believed to act as both a stimulant laxative and as a faecal softener (below). Glycerol suppositories act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol. Faecal softeners Faecal softeners are claimed to act by decreasing surface tension and increasing penetration of intestinal fluid into Gastro-intestinal system the faecal mass. Docusate sodium and glycerol suppositories p. 67 have softening properties. Enemas containing arachis oil p. 64 (ground-nut oil, peanut oil) lubricate and soften impacted faeces and promote a bowel movement. Liquid paraffin p. 65 has also been used as a lubricant for the passage of stools but manufacturer advises that it should be used with caution because of its adverse effects, which include anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration. Osmotic laxatives Osmotic laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with. Lactulose p. 60 is a semi-synthetic disaccharide which is not absorbed from the gastro-intestinal tract. It produces an osmotic diarrhoea of low faecal pH, and discourages the proliferation of ammonia-producing organisms. It is therefore useful in the treatment of hepatic encephalopathy. Macrogols (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride p. 61) are inert polymers of ethylene glycol which sequester fluid in the bowel; giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives. Other drugs used in constipation Linaclotide p. 52 is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate to severe irritable bowel syndrome associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain. Prucalopride p. 64 is a selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response. Bowel cleansing preparations Bowel cleansing preparations are used before colonic surgery, colonoscopy or radiological examination to ensure the bowel is free of solid contents; examples include macrogol 3350 with anhydrous sodium sulfate, potassium chloride, sodium bicarbonate and sodium chloride p. 55, citric acid with magnesium carbonate p. 54, magnesium citrate with sodium picosulfate p. 56 and sodium acid phosphate with sodium phosphate p. 63. Bowel cleansing treatments are not treatments for constipation. Management Short-duration constipation g In the management of short-duration constipation (where dietary measures are ineffective) treatment should be started with a bulk-forming laxative, ensuring adequate fluid intake. If stools remain hard, add or switch to an osmotic laxative. If stools are soft but difficult to pass or the person complains of inadequate emptying, a stimulant laxative should be added. h Opioid-induced constipation See also Constipation under Prescribing in palliative care p. 28. g In patients with opioid-induced constipation, an osmotic laxative (or docusate sodium to soften the stools) and a stimulant laxative is recommended. Bulk-forming laxatives should be avoided. Naloxegol p. 69 is recommended for the treatment of opioid-induced constipation when response to other laxatives is inadequate. h Methylnaltrexone bromide p. 68 is licensed for the treatment of opioid-induced constipation when response to other laxatives is inadequate. Manufacturer advises that in patients receiving palliative care, methylnaltrexone bromide should be used as an adjunct to existing laxative therapy. Faecal impaction The treatment of faecal impaction depends on the stool consistency. g In patients with hard stools, a high dose of Gastro-intestinal system an oral macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) may be considered. In those with soft stools, or with hard stools after a few days treatment with a macrogol, an oral stimulant laxative should be started or added to the previous treatment. If the response to oral laxatives is inadequate, for soft stools consider rectal administration of bisacodyl, and for hard stools rectal administration of glycerol alone, or glycerol plus bisacodyl. Alternatively, a docusate sodium or sodium citrate enema p. 832 may be tried. If the response is still insufficient, a sodium acid phosphate with sodium phosphate or arachis oil retention enema may be necessary. For hard faeces it can be helpful to give the arachis oil enema p. 64 overnight before giving a sodium acid phosphate with sodium phosphate p. 63 or sodium citrate p. 832 enema the following day. Enemas may need to be repeated several times to clear hard impacted faeces. h Chronic constipation g In the management of chronic constipation, treatment should be started with a bulk-forming laxative, whilst ensuring good hydration. If stools remain hard, add or change to an osmotic laxative such as a macrogol. Lactulose p. 60 is an alternative if macrogols are not effective, or not tolerated. If the response is inadequate, a stimulant laxative can be added. The dose of laxative should be adjusted gradually to produce one or two soft, formed stools per day. If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months, the use of prucalopride p. 64 (in women only) should be considered. If treatment with prucalopride is not effective after 4 weeks, the patient should be re-examined and the benefit of continuing treatment reconsidered. Laxatives can be slowly withdrawn when regular bowel movements occur without difficulty, according to the frequency and consistency of the stools. If a combination of laxatives has been used, reduce and stop one laxative at a time; if possible, the stimulant laxative should be reduced first. However, it may be necessary to also adjust the dose of the osmotic laxative to compensate. h Constipation in pregnancy and breast-feeding g If dietary and lifestyle changes fail to control constipation in pregnancy, fibre supplements in the form of bran or wheat are likely to help women experiencing constipation in pregnancy, and raise no serious concerns about side-effects to the mother or fetus. A bulk-forming laxative is the first choice during pregnancy if fibre supplements fail. An osmotic laxative, such as lactulose, can also be used. Bisacodyl p. 65 or senna p. 67 may be suitable if a stimulant effect is necessary but use of senna should be avoided near term or if there is a history of unstable pregnancy. Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause side-effects (diarrhoea and abdominal discomfort), reducing their acceptability to patients. Docusate sodium p. 65 and glycerol suppositories p. 67 can also be used. A bulk-forming laxative is the first choice during breast- feeding, if dietary measures fail. Lactulose or a macrogol may be used if stools remain hard. As an alternative, a short course of a stimulant laxative such as bisacodyl or senna can be considered. h Constipation in children Early identification of constipation and effective treatment can improve outcomes for children. Without early diagnosis and treatment, an acute episode of constipation can lead to anal fissure and become chronic. g The first-line treatment for children with constipation requires the use of a laxative in combination with dietary modification or with behavioural interventions. Diet modification alone is not recommended as first-line treatment. In children an increase in dietary fibre, adequate fluid intake, and exercise is advised. Diet should be balanced and contain fruits, and vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals. Unprocessed bran (which may cause bloating and flatulence and reduces the absorption of micronutrients) is not recommended. If faecal impaction is not present (or has been treated), the child should be treated promptly with a laxative. A macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride p. 61) is preferred as first- line management. If the response is inadequate, add a stimulant laxative or change to a stimulant laxative if the first-line therapy is not tolerated. If stools remain hard, lactulose or another laxative with softening effects, such as docusate sodium can be added. In children with chronic constipation, laxatives should be continued for several weeks after a regular pattern of bowel movements or toilet training is established. The dose of laxatives should then be tapered gradually, over a period of months, according to response. Some children may require laxative therapy for several years. A shorter duration of laxative treatment may be possible in some children with a short history of constipation. Laxatives should be administered at a time that produces an effect that is likely to fit in with the child’s toilet routine. h Faecal impaction in children g Treatment of faecal impaction may initially increase symptoms of soiling and abdominal pain. In children over 1 year of age with faecal impaction, an oral preparation containing a macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) is used to clear faecal mass and to establish and maintain soft well-formed stools, using an escalating dose regimen depending on symptoms and response. If disimpaction does not occur after 2 weeks, a stimulant laxative can be added or if stools are hard, used in combination with an osmotic laxative such as lactulose. Long-term regular use of laxatives is essential to maintain well-formed stools and prevent recurrence of faecal impaction; intermittent use may provoke relapses. h LAXATIVES › BULK-FORMING LAXATIVES
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Low residue diet recommended on the day before procedure and copious intake of water or other clear fluids recommended during treatment. Patients and carers should be given advice on how to administer oral powder; they should be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking.
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1 sachet taken before 8 a.m, then 1 sachet after
First-line fragment. Read the complete Indications and Dose section above.
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