Chronic constipation

Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
National

Case summary

Background (age, sex, occupation, baseline function)

  • 56-year-old male
  • Long-term unemployed

History of presentation/reason for review

  • The practice has a significant number of people prescribed long-term opioids and decided to review them
  • He was identified after running a search in the GP practice using the Scottish Therapeutics Utility (STU)
  • He has been prescribed Oxypro® (oxycodone modified release) 40mg twice a day for several years with no recent review

Current medical history and relevant co-morbidities

  • Iron deficiency anaemia – 3 years ago
  • Urinary incontinence – 5 years ago
  • Secondary pulmonary hypertension – 6 years ago
  • Mild left ventricular dysfunction (well controlled, no overt symptoms) – 6 years ago
  • Atrial flutter – 8 years ago
  • Chronic kidney disease (CKD) stage 2 – 8 years ago
  • Obstructive sleep apnoea – 9 years ago
  • Chronic obstructive pulmonary disease (COPD) – 10 years ago
  • Type 2 diabetes mellitus (diet controlled) – 14 years ago
  • Essential hypertension – 14 years ago
  • Severe obesity – 30 years ago
  • Postural scoliosis contributing to back pain – 34 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions: unable to tolerate ACE inhibitors or angiotensin receptor 1 blockers due to cough

Currently prescribed:

  • Amiodarone 200mg tablets: one tablet daily
  • Apixaban 5mg tablets: one tablet twice a day
  • Aspirin 75mg enteric coated tablets: one tablet daily
  • Bisoprolol 10mg tablets: one tablet each morning
  • Bumetanide 1mg tablets: two tablets morning and lunchtime
  • Ferrous fumarate 210mg tablets: one tablet three times a day
  • Gabapentin 100mg capsules: one capsule three times a day
  • Oxypro® 40mg modified release tablets: one tablet morning and night
  • Salbutamol 100microgram metered dose inhaler: two puffs when required
  • Senna 7.5mg tablets: two tablets at night
  • Shortec® 10mg capsules: one capsule when required for pain (maximum twice a day)
  • Solifenacin 5mg tablets: one tablet daily
  • Spironolactone 25mg tablets: one tablet in the morning
  • Trelegy® dry powder inhaler 92/55/22micrograms/dose: one inhalation daily 
  • He uses a weekly monitored dose system (MDS) “dosette box” from the local pharmacy for 10 years

Over the counter medicines: nil

Lifestyle and current function

  • Smoker – 20 cigarettes a day
  • Does not drink alcohol
  • Lives alone and spends most of the time at home
  • Uses continuous positive airway pressure (CPAP) equipment for obstructive sleep apnoea at home
  • Does not participate in any form of physical activity

“What matters to me” (ideas, concerns and expectations of treatment)

  • “I just take what I am prescribed. I keep getting prescriptions so I must need all the medicines”
  • Lacks understanding regarding his medication and would like to take less medication
  • Would like to feel less constipated and lose weight

Observations, examinations and results 

Note: local laboratory reference ranges may vary 

  • Weight 120kg, Height 175cm, BMI 39.2kg/m2
  • BP 130/70mmHg, pulse 65bpm
  • Urea and Electrolytes within normal range
  • Creatinine 72micromol/L (60-120micromol/L)
  • eGFR greater than 60 ml/min/1.73m2
  • FBC all within normal range
  • HbA1c 45mmol/mol (6.3%) (two months ago)
  • Cholesterol 4.7mmol/L (<5.0mmol/L), HDL 1.2mmol/L (0.9-1.5mmol/L)
  • LFTs all within normal range
  • TSH 1.4mU/L (0.27-4.20mU/L)

All blood tests were taken two weeks ago in preparation for clinic review

Most recent relevant consultations

  • He complained of constipation during a telephone consultation a few months ago. Senna started.

7 steps: Person specific issues to address

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

  • Therapeutic objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health issues, including lifestyle advice 

Ask person to complete PROMs (Questions to answer before medicines review) before their review

Person specific issues to address

  • Reduce number of medicines where possible
  • Provide education on medicines
  • Reduce constipation: education about lifestyle e.g. increased fibre intake, physical activity
  • Referral to local weight management services
  • Long-term out of work – check entitlement to benefits- refer to community link worker

 

2.  Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

  • Drugs that have essential replacement functions (e.g. levothyroxine) 
  • Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure) 

Person specific issues to address

  • No drugs considered essential
  • Amiodarone, apixaban, bisoprolol, spironolactone and bumetanide have valid indications and therefore continue (diuretic could be contributing to constipation)

 

3. Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

  • what is medication for?
  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit/evidence for use
  • with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

  • Gabapentin, Oxypro®, Shortec® prescribed for chronic back pain with no recent review. He reports pain is no longer an issue but concerned that reducing Oxypro and/or gabapentin may exacerbate pain. Reduce Oxypro and gabapentin dose gradually
  • self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS) score = 0 does not suggest he is experiencing neuropathic pain and therefore gabapentin not indicated340
  • Ferrous fumarate has been prescribed for several years. Current FBCs normal. Stop iron and repeat FBCs and serum ferritin in three months. If needs to restart, current guidance recommends once daily treatment only
  • Solifenacin prescribed for urinary incontinence five years ago. No benefit perceived. ACB score 3. Complains of constipation and sometimes dry mouth. Stop and review in four weeks. 
  • Trelegy – review symptoms and exacerbation rate and consider stepping down to LABA/LAMA

4.  Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
  • is there a more appropriate medication to achieve goals?

Person specific issues to address

  • BP, AF and T2DM well controlled.
  • T2DM and age over 40 with hypercholesterolemia - atorvastatin indicated
  • Analgesia: add in regular paracetamol to help offset need for Oxypro® and/or gabapentin

 

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers (e.g. hypokalaemia)
  • cumulative adverse drug effects (see ADR table)
  • drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

  • Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

  • AF: Risk of gastrointestinal (GI) bleeding with aspirin and apixaban. Indication for aspirin not clear- stop. Continue apixaban for AF as per clinic letters.
  • Apixaban dose checked with creatinine clearance - >60ml/min. Continue current dose and check urea and electrolytes annually
  • Ensure he has regular monitoring scheduled for U&Es for spironolactone
  • Gabapentinoids can increase the risk of respiratory depression (has sleep apnoea). Manufacturers advise dose reduction in those with impaired respiratory function (caution)
  • Ensure TFTs and LFTs and U&Es are being monitored every six months as prescribed amiodarone (hypothyroidism may cause constipation).

Medication Sick Day Guidance given for spironolactone and bumetanide. Seek advice from community pharmacy to identify these tablets in the dosette box

 

6.  Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

  • considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

  • Inhaler use
  • Single use plastics
  • Medicines waste
    • over-ordering
    • disposal
  • Water pollution 

Person specific issues to address

  • Consider streamlining inhaler devices so that both are dry powder inhalers
  • Advised to dispose of medicines through the community pharmacy 
  • Advised to only order what is needed, do not stockpile medicines  

 

7.  Person-centredness: Is the person willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

  • Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

  • is the medication in a form they can take?
  • is the dosing schedule convenient?
  • what assistance is needed?
  • are they able to take medicines as intended?

Agree and communicate plan

  • discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
  • include lifestyle and holistic management goals
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete PROMs (Questions to answer after medicines review) after their review

Agreed plan

  • Provided with a list of medication, explaining the indication of each drug
  • Start atorvastatin 20mg daily
  • Stop aspirin, ferrous fumarate, solifenacin
  • Monitoring required:
    • check LFTs and lipids after four weeks 
    • FBC and serum ferritin in three months 
  • Reduce: Oxypro dose gradually with a view to stop
  • GabapentinInitially he did not agree to this. Following discussion about risk of respiratory depression and lack of clinical indication, he agrees to a gradual reduction after opioid has been stopped/reduced in the first instance (individual preference) 
  • Constipation should decrease with medication changes, so there may be scope to stop senna
    • Importance of adequate fluid, physical activity and dietary fibre intake reinforced    
  • Change salbutamol MDI to salbutamol Accuhaler®
  • Choice of MDS discussed and alternatives explored e.g. prompt chart, but he would like to continue with “dosette box”
  • Inform community pharmacy of changes to medicines
  • Agrees to lifestyle changes and referral to local weight management services 
  • Agrees to community link worker referral for advice on benefits

 

Key concepts in this case

  • Inappropriate prescribing of long-term opioids and gabapentin for chronic pain without review
  • Multifactorial nature of constipation e.g. opioid induced, iron supplements, anticholinergic burden, lack of exercise and dietary fibre
  • High risk drug combinations and managing the risk – inappropriate prescribing of antiplatelet and anticoagulant, and potential need for gastrointestinal protection
  • Solifenacin was prescribed for urinary incontinence which may have been aggravated by chronic constipation. Solifenacin may have contributed to worsening constipation and in turn added to urinary incontinence symptoms, and hence the individual perceived no benefit from it
  • The challenges of managing medication in an MDS. He had lost ownership and understanding of his medication and health conditions. The case presents the practical issues when medication needs to be changed, and the potential delays. Considering other options such as a prompt chart or downloading the national Polypharmacy app may have negated the need for an MDS in the first instance