| 1. Nonpharmacologic approaches for all patients, unless contraindicated by medical status |
| Increase fluid intake |
| Increase dietary soluble fiber (avoid if severely debilitated or bowel obstruction is suspected) |
| Encourage mobility |
| Ensure comfort and privacy for defecation |
| 2. Select a pharmacologic strategy* |
| Intermittent use of a rectal therapy, either a suppository such as bisacodyl or glycerin, or mineral oil and/or sodium phosphate enema |
| Intermittent use (every 2-3 days) of an osmotic laxative, such as polyethylene glycol, magnesium hydroxide, or magnesium citrate |
| Trial of a daily softening agent (docusate) for patients who describe hard, dry stools |
| Intermittent use (every 2-3 days) of a contact cathartic, such as senna or bisacodyl |
| Daily use of polyethylene glycol |
| Daily use of lactulose (unless lactose-intolerant) or sorbitol |
| Daily use of a contact cathartic |
| 3. Adjust dose and dosing schedule of selected therapy to optimize effects |
| 4. Switch or combine conventional approaches if initial therapy is inadequate |
| 5. Consider adding a peripheral opioid antagonist (eg, methylnaltrexone, naloxegol, or an opioid-naloxone fixed combination) or lubiprostone; if constipation continues to be refractory, consider alternative drugs, eg, metoclopramide. |
