Macrogol laxatives
| Type | Recommendation |
|---|---|
| When to deprescribe | |
| CBR |
To minimise the risk of electrolyte imbalance (particularly for the use of macrogol with electrolytes in people with congestive heart failure, renal disease, or severe dehydration), we suggest deprescribing be offered to older people taking long-term macrogol laxatives:
|
| Ongoing treatment | |
| CBR |
We suggest continuing macrogol laxatives when there is a clear indication (e.g. opioid-induced constipation for the duration of opioid treatment, chronic slow-transit constipation), provided this aligns with the individual’s goals and preferences, following informed consent. |
| CBR |
If deprescribing is unsuccessful despite multiple attempts, we suggest maintaining the lowest effective dose; however, reassessing the need for long-term therapy periodically. |
| How to deprescribe | |
| CBR |
We suggest individualising the tapering schedule and adjusting it according to the individual’s current bowel function, risk of recurrence, frequency and consistency of the stools. In general, given the likelihood of recurrence of constipation, we suggest reducing by one sachet and then alternate day dosing every one to two weeks and switching to on-demand or intermittent use at the lowest effective dose. Once dosing every other day and regular bowel movements occur without difficulty, discontinue the medicine. If constipation recurs during tapering, we suggest restarting at the previously tolerated tapered dose or original dose until constipation is resolved, delaying further dose reductions by an agreed interval for stabilisation, and planning for a more gradual taper. For people on combination therapy of laxatives, we suggest deprescribing one at a time, prioritising medicines with a higher risk of harm and a lower potential benefit from continued use. However, the dose for concomitant laxatives may also need to be adjusted temporarily to compensate for the lower dose of the other agent. We suggest individualising the tapering schedule and adjusting it according to the individual factors above. |
| GPS | Healthcare providers should offer appropriate education on fluid intake, fibre intake, mobility and referral to other relevant healthcare providers whenever applicable (ungraded good practice statement). |
| Monitoring | |
| CBR |
We suggest closely monitoring for recurrence of constipation following each dose adjustment and advising people that they may revert to the previously tolerated tapered dose or original dose if constipation recurs. For people who have concomitant diagnoses of heart failure, or renal failure or who are using lithium, potassium, magnesium or salt (sodium) supplements, we suggest monitoring for electrolytes as dosing may need to be adjusted. We suggest monitoring for changes in mobility, fluid and fibre intake and adapting strategies to deprescribing as appropriate. |
CBR, consensus-based recommendation; GPS, good practice statement
Constipation is a common issue in older people [182] with various causes ranging from dietary, lifestyle, and pelvic floor dysfunction [183]. Many medicines commonly used by older people can also inhibit gastric emptying and peristalsis in the gastrointestinal tract, thereby causing constipation [182]. For instance, opioids, calcium supplements, calcium channel antagonists (e.g. verapamil) and oral iron supplements may contribute to or aggravate constipation [182]. It is important to note that there are medicines that may cause dehydration through mechanisms such as 1) the increase of water elimination through either diarrhoea, urine or sweat (e.g. diuretics), 2) a decrease in thirst sensation or appetite (e.g. selective serotonin reuptake inhibitors), or 3) the alteration of central thermoregulation (e.g. angiotensin-converting enzyme inhibitors) [184]. Dehydration may consequently lead to constipation [182].
We were unable to identify any direct evidence related to the deprescribing of macrogol in older people from the systematic review and meta-analysis. Recommendations are provided in this section following a Delphi consensus process.
In many cases, constipation is induced by medicines and changing the causative agent alone can restore bowel function [183]. An inappropriate prescribing cascade can be seen when a laxative is initiated when the constipation is induced by a medicine where the original medicine can be suitably reduced, discontinued, or replaced by another medicine. The use of laxatives should follow a stepwise approach with the possibility of stepping down being considered periodically [183]. Macrogol is an osmotic laxative commonly used in older people when first-line interventions such as lifestyle modifications or bulk-forming agents are inadequate [182]. However, inappropriate long-term use of osmotic laxatives, especially macrogol with electrolyte formulations, may increase the risk of fluid and electrolyte disturbances that can potentially lead to serious complications [183]. The continuation or discontinuation of macrogol laxatives requires careful consideration of potential benefits and risks, ensuring that the approach aligns with the person’s overall health goals.
Individuals with congestive heart failure, renal disease, or severe dehydration may have a higher baseline risk of fluid electrolyte disturbances [185]. In contrast, other people may be more likely to derive substantial benefits from continuing treatment and may be willing to accept a tolerated level of risk. For example, the benefits of continuing macrogol laxatives for conditions such as chronic constipation to maintain bowel regularity and provide symptomatic relief may outweigh the associated risks [186, 187]. In people with opioid-induced constipation where opioid use is considered appropriate and other measures to reduce the risk of opioid-induced constipation are not effective (e.g. lifestyle interventions, considerations of alternative formulation or concurrent medicines, considerations of changing therapy or reducing the dose), ongoing macrogol therapy for the duration of opioid therapy may be considered suitable [188].
The tapering and monitoring approach is based on pharmacological rationale and clinical experience, considering the likelihood of recurrence of constipation.
Note: Other laxatives (bulk-forming, stimulant, and stool softener) are not covered in this guideline as these medicines are widely available over the counter. Although beyond the scope of this guideline, it is important to point out that excessive use of other laxatives is also associated with harm, particularly stimulant laxatives [183]. Therefore, periodic reviews of the possibility of deprescribing these agents and reiterating dietary/lifestyle advice are equally important.