UK Clinical Pharmacy Association

Bisacodyl – as Stimulant laxative

Note

This drug record does not cover the use of stimulant laxatives for bowel cleansing in preparation for procedures that require a clean bowel.

Issues for surgery

Risk of constipation if omitted, particularly in patients with chronic laxative use, which may further be exacerbated by medication administered perioperatively, e.g. opioids.

For bisacodyl, dantron, senna and sodium picosulfate: risk of fluid imbalance and hypokalaemia with chronic or excessive use, which may further by exacerbated if continued during prolonged periods of fasting.

Advice in the perioperative period

Elective surgery 

Continue, if required (including combination products).

Combination products:

  • Co-danthramer (poloxamer + dantron) – also see Softening laxatives drug records and Further information
  • Co-danthrusate (docusate + dantron) – also see Softening laxatives drug records and Further information

Except:

  • for patients having bowel cleansing agents prior to surgery – also see Bowel cleansing agents drug records
  • Manevac® combination product – see Bulk forming laxatives drug records

Check electrolytes pre-operatively in patients with chronic or suspected excessive stimulant laxative use.

Emergency surgery 

Continue, if required (including combination products).

Combination products:

  • Co-danthramer (poloxamer + dantron) – also see Softening Laxatives monograph and under Further information
  • Co-danthrusate (docusate + dantron) – also see Softening Laxatives monograph and under Further information

Except:

  • for patients with suspected bowel obstruction/perforation
  • Manevac® product – also see Bulk forming laxatives drug records

Check electrolytes in patients with chronic or suspected excessive stimulant laxative use.

Post-operative advice

Resume post-operatively, if needed, once enteral intake resumed.

If concomitant use of opioids or other medication that may cause constipation, or antibiotics that may cause diarrhoea, monitor response to treatment and adjust dose accordingly.

Patients undergoing colorectal surgery

Review the need for stimulant laxatives post-operatively.

Use of suppositories following certain types of colorectal surgery are not recommended; confirmation should be sought from the colorectal team before prescribing if stimulant laxatives are required post-operatively.

Interactions with common anaesthetic agents

Hypokalaemia

Stimulant laxatives may cause hypokalaemia (mainly in cases of misuse or overdose). Concomitant use with medications that prolong the QT-interval e.g. desflurane, isoflurane, sevoflurane and possibly thiopental increases the risk of torsades de pointes. Monitor serum potassium and QT-interval with concomitant treatment. 

Interactions with other common medicines used in the perioperative period

Hypokalaemia

Stimulant laxatives can cause hypokalaemia (mainly in cases of misuse or overdose). Hypokalaemia increases the risk of torsades de pointes with medicines which prolong the QT-interval e.g. antiemetics (haloperidol, ondansetron), antimicrobials (ciprofloxacin, clarithromycin, erythromycin), corticosteroids and loperamide. Monitor serum potassium and with concomitant treatment. 

This interaction does not occur with glycerin suppositories.

Hyponatraemia

Concomitant use of the following medicines with sodium picosulfate can increase the risk of hyponatraemia:

  • Cyclo-oxygenase-2 (COX-2) inhibitors
  • gabapentin
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • trimethoprim

Whilst single doses should not pose a problem, sodium levels should be monitored with continued post-operative treatment of concomitant medication.

Antimicrobials

Concurrent administration of antibiotics may reduce the laxative action of sodium picosulfate.

Further information

Co-danthramer and co-danthrusate

Co-danthramer and co-danthrusate are only licensed for constipation in terminally ill patients since dantron is a potential human carcinogen.

References

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press http://www.medicinescomplete.com [Accessed on 10 August 2021]

Summary of Product Characteristics – Bisacodyl 5 mg, gastro-resistant tablets. Healthcare Pharma Ltd. Accessed via www.medicines.org.uk 03/10/21 [date of revision of the text May 2020]

Summary of Product Characteristics – Senokot® (senna) 7.5 mg Tablets 12 Years Plus. Reckitt Benckiser Healthcare (UK) Ltd. Accessed via www.medicines.org.uk on 03/10/21 [date of revision of the text December 2020]

Summary of Product Characteristics – Dulcolax® (sodium picosulfate monohydrate), 5mg / 5ml, oral solution. SANOFI. Accessed via www.medicines.org.uk on 03/10/21 [date of revision of the text March 2020]

Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed 3rd October 2021]

Glycerin Suppositories BP 4g Adult Size. Thornton & Rose Ltd. Accessed via www.medicines.org.uk 03/10/21 [date of revision of the text January 2015]