Professional Drug Information > Feen-a-Mint Pills

Laxatives (Local)

This monograph includes information on the following:


Note: In August, 1997, the U.S. Food and Drug Administration (FDA) announced a proposal to ban the use of phenolphthalein in non-prescription (over-the-counter) products due to long-term safety concerns. Several United State and Canadian laxative manufacturers reformulated their phenolphthalein-containing products prior to or in response to the proposal. Effective January 29, 1999, the FDA issued a final ruling establishing that phenolphthalein is not generally recognized as safe and effective and is misbranded as an over-the-counter stimulant laxative ingredient ^{107}

1) Bisacodyl
2) Bisacodyl and Docusate ^*
3) Casanthranol  ^†
4) Casanthranol and Docusate
5) Cascara Sagrada
6) Cascara Sagrada and Aloe ^†
7) Cascara Sagrada and Bisacodyl
8) Castor Oil
9) Danthron and Docusate ^*
10) Dehydrocholic Acid ^†
11) Dehydrocholic Acid and Docusate ^†
12) Docusate
13) Glycerin
14) Lactulose
15) Magnesium Citrate
16) Magnesium Hydroxide^‡
17) Magnesium Hydroxide and Cascara Sagrada ^†
18) Magnesium Hydroxide and Mineral Oil
19) Magnesium Oxide^‡ †
20) Magnesium Sulfate ^†
21) Malt Soup Extract ^†
22) Malt Soup Extract and Psyllium ^†
23) Methylcellulose  ^†
24) Mineral Oil
25) Mineral Oil and Glycerin ^*
26) Poloxamer 188 ^†
27) Polycarbophil
28) Polyethylene Glycol 3350^§
29) Potassium Bitartrate and Sodium Bicarbonate ^†
30) Psyllium
31) Psyllium and Senna ^†
32) Psyllium Hydrophilic Mucilloid
33) Psyllium Hydrophilic Mucilloid and Carboxymethylcellulose ^†
34) Psyllium Hydrophilic Mucilloid and Senna ^*
35) Psyllium Hydrophilic Mucilloid and Sennosides ^†
36) Senna
37) Sennosides
38) Sennosides and Docusate
39) Sodium Phosphate

VA CLASSIFICATION
Bisacodyl Oral
Primary: GA204

Bisacodyl Rectal
Primary: RS300

Bisacodyl and Docusate Oral
Primary: GA209

Casanthranol Oral
Primary: GA204

Casanthranol and Docusate Oral
Primary: GA209

Cascara Sagrada Oral
Primary: GA204

Cascara Sagrada and Aloe Oral
Primary: GA204

Cascara Sagrada and Bisacodyl Oral
Primary: GA204

Castor Oil Oral
Primary: GA204

Danthron and Docusate Oral
Primary: GA209

Dehydrocholic Acid Oral
Primary: GA204
Secondary: GA900

Dehydrocholic Acid and Docusate Oral
Primary: GA209

Docusate [Sodium Dioctyl Sulfosuccinate for Docusate Sodium] Oral
Primary: GA205

Docusate [Sodium Dioctyl Sulfosuccinate for Docusate Sodium] Rectal
Primary: RS300

Glycerin [Glycerol] Rectal
Primary: RS300

Lactulose Oral
Primary: GA202
Secondary: GA900

Magnesium Citrate Oral
Primary: GA202

Magnesium Hydroxide Oral
Primary: GA202
Secondary: GA108

Magnesium Hydroxide and Cascara Sagrada Oral
Primary: GA209

Magnesium Hydroxide and Mineral Oil Oral
Primary: GA209

Magnesium Oxide Oral
Primary: GA202
Secondary: GA108

Magnesium Sulfate Oral
Primary: GA202

Malt Soup Extract Oral
Primary: GA201

Malt Soup Extract and Psyllium Oral
Primary: GA201

Methylcellulose Oral
Primary: GA201

Mineral Oil Oral
Primary: GA203

Mineral Oil Rectal
Primary: RS300

Mineral Oil and Glycerin Oral
Primary: GA209

Poloxamer 188 [Poloxalkol] Oral
Primary: GA205

Polycarbophil Oral
Primary: GA201
Secondary: GA208

Polyethylene Glycol 3350 Oral
Primary: GA202

Potassium Bitartrate and Sodium Bicarbonate Rectal
Primary: RS300

Psyllium Oral
Primary: GA201

Psyllium Hydrophilic Mucilloid Oral
Primary: GA201
Secondary: CV359

Psyllium Hydrophilic Mucilloid and Carboxymethylcellulose Oral
Primary: GA201

Psyllium Hydrophilic Mucilloid and Senna Oral
Primary: GA209

Psyllium Hydrophilic Mucilloid and Sennosides Oral
Primary: GA209

Psyllium and Senna Oral
Primary: GA209

Senna Oral
Primary: GA204

Senna Rectal
Primary: RS300

Sennosides Oral
Primary: GA204

Sennosides and Docusate Oral
Primary: GA209

Sodium Phosphate Oral
Primary: GA202

Sodium Phosphate Rectal
Primary: RS300




^‡ See Antacids (Oral-Local) for antacid use of magnesium hydroxide and magnesium oxide
^§ See Polyethylene Glycol and Electrolytes (Local) for additional PEG-electrolyte uses
Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

^*Not commercially available in the U.S.

^†Not commercially available in Canada.

Category:

Note: The term “laxative” includes the historically used terms “cathartic,” “drastic,” and “purgative.”



Laxative—

Bulk-forming—Malt Soup Extract; Malt Soup Extract and Psyllium ; Methylcellulose; Polycarbophil; Psyllium; Psyllium Hydrophilic Mucilloid; Psyllium Hydrophilic Mucilloid and Carboxymethylcellulose;

Bulk-forming and stimulant— Psyllium Hydrophilic Mucilloid and Senna; Psyllium Hydrophilic Mucilloid and Sennosides; Psyllium and Senna;

Carbon dioxide–releasing— Potassium Bitartrate and Sodium Bicarbonate;

Hyperosmotic—Glycerin ; Lactulose; Polyethylene Glycol 3350;

Hyperosmotic, saline— Magnesium Citrate; Magnesium Hydroxide ; Magnesium Oxide; Magnesium Sulfate; Sodium Phosphate;

Hyperosmotic and lubricant— Magnesium Hydroxide and Mineral Oil; Mineral Oil and Glycerin;

Hyperosmotic, lubricant, and stimulant—

Hyperosmotic and stimulant— Magnesium Hydroxide and Cascara Sagrada;

Lubricant—Mineral Oil;

Lubricant and stimulant—

Stimulant or contact— Bisacodyl; Casanthranol; Cascara Sagrada; Cascara Sagrada and Aloe; Cascara Sagrada and Bisacodyl ; Castor Oil; Dehydrocholic Acid; Senna; Sennosides;

Stimulant and stool softener— Bisacodyl and Docusate; Casanthranol and Docusate; Danthron and Docusate; Dehydrocholic Acid and Docusate; Sennosides and Docusate;

Stool softener or emollient— Docusate; Poloxamer 188 (poloxalkol);

Antacid—Magnesium Hydroxide; Magnesium Oxide;

Antihyperammonemic— Lactulose;

Hydrocholeretic— Dehydrocholic Acid;

Antidiarrheal—Polycarbophil ; Psyllium Hydrophilic Mucilloid;

Antihyperlipidemic— Psyllium Hydrophilic Mucilloid ^{{08} {15}};

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

Note: In the treatment of constipation or in the evacuation of the bowel, or in any other conditions in which a laxative is indicated, the advantage of using certain laxative combinations rather than a single laxative preparation has not been established. In some instances, just as with the selection of a single entity laxative, the improper selection of a laxative combination may turn constipation into a more serious condition. FDA's tentative final monograph for laxative drug products for OTC use has listed specific active laxative ingredients to be included in bulk-forming, bulk-forming and lubricant, bulk-forming and stimulant, lubricant and stimulant, lubricant and saline, saline and stimulant, and stimulant combinations.
Some of the laxative combinations contain other active ingredients that have no laxative properties. For example, atropine has been added for its antispasmodic properties probably as an adjunct to relieve constipation-induced cramping. However, a fixed combination of a laxative with any other medication is generally considered irrational and may be unsafe in some combinations.


Accepted

Constipation (prophylaxis)—Oral bulk-forming, lubricant, and stool softener laxatives are indicated prophylactically in patients who should not strain during defecation, such as those with an episiotomy wound, painful thrombosed hemorrhoids, fissures or perianal abscesses, body wall and diaphragmatic hernias, anorectal stenosis, or postmyocardial infarction .[An oral hyperosmotic laxative (polyethylene glycol 3350) is indicated for the prevention of constipation. ^{102}]

Constipation (treatment)—Oral laxatives are indicated for the short-term relief of constipation. Oral bulk-forming laxatives, stimulant laxatives, and carbon dioxide–releasing suppositories are indicated to facilitate defecation in geriatric patients with diminished colonic motor response. Oral bulk-forming laxatives and stool softener laxatives are preferred to treat constipation that may occur during pregnancy and postpartum to help re-establish normal bowel function or to avoid straining if hemorrhoids are present. ^{14}An oral hyperosmotic laxative (polyethylene glycol 3350) is indicated for the treatment of occasional constipation. ^{101}{102}
—In severe cases of constipation, such as with fecal impaction, mineral oil and stool softener laxatives administered orally or rectally are indicated to soften the impacted feces. To help complete the evacuation of the impacted colon, a rectal stimulant or saline laxative may follow.

Bowel evacuation—Pre- and postpartum: Carbon dioxide–releasing suppositories are indicated to evacuate the colon in preparation for delivery and for a few days after to help re-establish normal bowel function.
—Preoperative and
—Pre-radiography: Oral or rectal stimulant and oral saline laxatives, rectal preparations of glycerin, and carbon dioxide–releasing suppositories are also indicated to evacuate the colon in preparation for rectal and bowel examinations, and elective colon surgery.
—Parasites, intestinal (treatment adjunct): Oral saline laxatives are indicated to accelerate excretion of various parasites including nematodes, after anthelmintic therapy.
—Toxicity, nonspecific (treatment adjunct): Oral saline laxatives are also indicated to hasten excretion of poisonous substances (except acids or alkalies) from the gastrointestinal tract.

Laxative dependency (treatment)—Glycerin suppositories are indicated temporarily to re-establish normal bowel function in laxative-dependent patients.

Hyperacidity (treatment)—See Magnesium Hydroxide and Magnesium Oxide, in Antacids (Oral-Local) .

Hyperammonemia (prophylaxis and treatment)—Lactulose is indicated for the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma.

Biliary tract disorders (treatment)—Dehydrocholic acid is indicated as an adjunct in conditions involving the biliary tract.

Diarrhea (treatment)—Polycarbophil is indicated in the treatment of diarrhea associated with irritable bowel syndrome and diverticulosis, and acute nonspecific diarrhea. [Psyllium hydrophilic mucilloid is used in the treatment of choleretic diarrhea and diarrhea caused by vagotomy, small bowel resection, or disease of the terminal ileum.]

Bowel syndrome, irritable (treatment adjunct)— Polycarbophil is indicated [and other bulk-forming laxatives are used] to relieve constipation associated with irritable or spastic bowel.

[Hyperlipidemia (treatment)]—Psyllium hydrophilic mucilloid is used as an adjunct to diet in the treatment of mild to moderate hypercholesterolemia. ^{{08} {09} {15}}


Pharmacology/Pharmacokinetics

Table 1. Pharmacology/Pharmacokinetics

Type of Laxative	Absorption		Onset of action		Type of stool formed	Elimination (of absorbed doses)
	Oral	Rectal	Oral	Rectal
Bulk-forming	Not absorbed		12–24 hrs (up to 3 days)		Soft formed stool
Carbon dioxide– releasing				5–30 min
Stool softener or emollient	Unknown amount	Unknown amount	24–48 hrs (up to 3–5 days)	2–15 min	Soft formed stool	Fecal
Hyperosmotic
Glycerin		Poor		1/4–1 hr
Lactulose	Minimal (<3% dose)		24–48 hrs		Soft formed stool	Renal
Polyethylene Glycol 3350§	None		48–96 hrs
Saline	Up to 20% dose		1/2–3 hrs	2–5 min	Watery stool (with high doses)	Renal
Lubricant	Minimal *	Minimal	6–8 hrs	2–15 min
Stimulant			6–8 hrs †
Anthraquinone derivatives	Minimal			1/2–2 hrs	Soft or formed stool	Fecal and/or renal
Bisacodyl	Minimal	Minimal		1/4–1 hr		Renal
Castor oil	Unknown amount ‡		2–6 hrs		Watery stool
Danthron	Significant amount				Soft or formed stool	Fecal and/or renal
Dehydrocholic acid	Significant amount					Fecal

^§ See Polyethylene Glycol and Electrolytes (Local ) for other uses of PEG and electrolytes.
^* Emulsified mineral oil may be absorbed 30 to 60%
^† Action may be prolonged up to 3–4 days
^‡ Ricinoleic acid, the active principle of castor oil produced by hydrolysis, is absorbed to a small extent and metabolized like other fatty acids

Physicochemical characteristics:
Molecular weight—
    Bisacodyl: 361.40
    Danthron: 240.21
    Dehydrocholic acid: 402.53
    Docusate calcium: 883.22
    Docusate potassium: 460.67
    Docusate sodium: 444.56
    Glycerin: 92.09
    Lactulose: 342.30
    Magnesium citrate: 451.12
    Magnesium hydroxide: 58.32
    Magnesium sulfate: 246.47
    Poloxamer: The average molecular weight is 8400
    Polyethylene glycol 3350: 3350
    Sodium phosphate, dibasic: 268.07

Mechanism of action/Effect:
^{14}

Bulk-forming:

Absorb water and expand to provide increased bulk and moisture content to the stool. The increased bulk encourages normal peristalsis and bowel motility.



Carbon dioxide–releasing:

Carbon dioxide released from combined potassium bitartrate and sodium bicarbonate induces gentle pressure in the rectum, thus promoting bowel movement.



Hyperosmotic:

Glycerin: Attracts water into the stool thereby stimulating rectal contraction; also, lubricates and softens inspissated fecal mass.

Lactulose: Produces osmotic effect in colon resulting from biodegradation by colonic bacterial flora into lactic, formic, and acetic acids. Fluid accumulation produces distention, which in turn promotes increased peristalsis and bowel evacuation.

Polyethylene glycol: Prevents absorption by the intestinal tract of the portion of water ingested, serving to hydrate and soften the stool, and promote peristalsis. ^{101}{102}

Saline: Produces osmotic effect primarily in small intestine by drawing water into the intestinal lumen. Fluid accumulation produces distention, which in turn promotes increased peristalsis and bowel evacuation. During the use of saline laxatives, the release of cholecystokinin from the intestinal mucosa may enhance the laxative effect.



Lubricant:

Increase water retention in the stool by coating surfaces of stool and intestines with a water-immiscible film. Lubricant effect eases passage of contents through intestines. Emulsification of lubricant tends to enhance its ability to soften stool mass.



Stool softener:

Reduce surface film tension of interfacing liquid contents of the bowel, promoting permeation of additional liquid into the stool to form a softer mass.



Stimulant:

Precise mechanism of action is unknown. Thought to increase peristalsis by a direct effect on the smooth intestinal musculature by stimulation of intramural nerve plexi. Also have been shown to promote fluid and ion accumulation in the colon (castor oil acts on the small intestine) to increase the laxative effect.



Antihyperammonemic:

Lactulose decreases blood ammonia concentrations probably as a result of its bacterial degradation, in the colon, into low molecular weight organic acids that decrease the pH of the colonic contents. Acidification of colonic contents results in the retention of ammonia in the colon as the ammonium ion. The osmotic laxative action of the metabolites of lactulose expels the trapped ammonium from the colon.



Hydrocholeretic:

Dehydrocholic acid has no effect on the production of bile salts; however, it increases bile volume and flow by increasing water output, thus producing bile of relatively low specific gravity, viscosity, and total solid content.



Antidiarrheal:

Psyllium hydrophilic mucilloid and polycarbophil"s water and bile salt binding capacity may result in fewer and bulkier stools.



Antihyperlipidemic:

Psyllium hydrophilic mucilloid has an antihyperlipidemic effect. It decreases serum total cholesterol, low-density lipoprotein (LDL) cholesterol, and the ratio of LDL cholesterol to high-density lipoprotein (HDL) cholesterol. Although exact mechanism of psyllium"s antihyperlipidemic effect is not known, it is believed that psyllium increases bile acid secretion, thus draining cholesterol products from the body.


Note: Knowledge of many specifics of the mechanisms of action is limited. The determination of influence of factors such as cyclic-AMP, electrolyte transportation, hormones, and enzymes may change such currently accepted mechanisms.



Precautions to Consider

Carcinogenicity/Tumorigenicity

Chronic administration of high doses of danthron to mice and rats has resulted in the development of intestinal and liver tumors. Danthron toxicity in humans has not been demonstrated; however, in the U.S., because of the potential risk to humans, the FDA has banned all manufacturing, relabeling, repackaging, and further distribution of human drug products containing danthron.

Pregnancy/Reproduction

Hyperosmotic—

• Saline: Sodium-containing preparations may promote sodium retention with resultant edema.


• Polyethylene glycol 3350: Studies have not been done in humans. Studies have not been done in animals. FDA Pregnancy Category C.


Lubricant—Repeated oral use of mineral oil may decrease absorption of foods, fat-soluble vitamins, and some oral medications. Hypoprothrombinemia and hemorrhagic disease of the neonate have occurred following chronic use during pregnancy.

Stimulant—Castor oil is contraindicated since its use often results in pelvic area engorgement, which may initiate reflex stimulation of the gravid uterus.

Breast-feeding

Stimulant—Cascara sagrada and danthron preparations may be distributed into breast milk. The amounts are reportedly large enough to produce loose stools in the infant, although this still remains controversial. ^{12}

Pediatrics


For all laxatives:

Laxatives should not be given to young children (up to 6 years of age) unless prescribed by a physician. Since children are not usually able to describe their symptoms precisely, proper diagnosis should precede the use of a laxative. This will avoid the complication of an existing condition (e.g., appendicitis) or the appearance of more severe side effects.



For lubricant:

Oral mineral oil is not recommended for children up to 6 years of age since patients in this age group are more prone to aspiration of oil droplets, which may produce lipid pneumonia.



For stimulant:

Bisacodyl enteric-coated tablets are not recommended for children up to 6 years of age since patients in this age group may have difficulty swallowing the tablet without chewing it. Gastric irritation may occur if the enteric coating is destroyed by chewing.



For rectal solutions:

Weakness, excessive perspiration, shock, seizures, and/or coma may occur in children with the use of rectal solutions due to water intoxication or dilutional hyponatremia.

Seizures with hypocalcemia may occur as a result of absorption of large amounts of phosphate in children receiving sodium phosphates rectal solution.



Geriatrics



For lubricant:

Oral mineral oil is not recommended for bedridden elderly patients since they are more prone to aspiration of oil droplets, which may produce lipid pneumonia.



For osmotic:

Polyethylene glycol 3350: There is no evidence for special considerations when polyethylene glycol 3350 is administered to elderly patients. However, a higher incidence of diarrhea occurred in elderly nursing home patients when given the recommended dose of 17 grams. Polyethylene glycol 3350 should be discontinued if diarrhea occurs.^{101}



For stimulant:

Weakness, incoordination, and orthostatic hypotension may be exacerbated in elderly patients as a result of significant electrolyte loss when stimulant laxatives are used repeatedly to evacuate the colon.



For rectal solutions:

Weakness, excessive perspiration, shock, seizures, and/or coma may occur in elderly patients with the use of rectal solutions due to water intoxication or dilutional hyponatremia.


Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):


Note: Combinations containing any of the following medications, depending on the amount present, may also interact with this medication.


For all classes
Diuretics, potassium-sparing, or
Potassium supplements    (chronic use or overuse of laxatives may reduce serum potassium concentrations by promoting excessive potassium loss from the intestinal tract; may interfere with potassium-retaining effects of potassium-sparing diuretics)


For bulk-forming
Anticoagulants, oral or
Digitalis glycosides or
Salicylates    (concurrent use with cellulose bulk-forming laxatives may reduce the desired effect because of physical binding or other absorptive hindrance; a 2-hour interval between dosage with such medication and laxative dosage is recommended )


» Tetracyclines, oral    (concurrent use with calcium polycarbophil may decrease absorption because of possible formation of nonabsorbable complexes with free calcium released after ingestion; patients should be advised not to take calcium polycarbophil laxative within 1 to 2 hours of tetracyclines)


For hyperosmotic-saline, magnesium-containing
» Anticoagulants, coumarin- or indandione-derivative, oral or
» Digitalis glycosides or
Phenothiazines, especially chlorpromazine    (these medications have been shown to have reduced effectiveness in the presence of aluminum- and magnesium-containing antacids; pending further studies, their concurrent administration with magnesium-containing saline hyperosmotic laxatives is best avoided)


» Ciprofloxacin    (magnesium-containing laxatives may reduce absorption by chelation of ciprofloxacin, resulting in lower serum and urine concentrations of the antibiotic; therefore, concurrent use is not recommended ^{13})


» Etidronate    (concurrent use may prevent absorption of oral etidronate; patients should be advised to avoid using magnesium-containing laxatives within 2 hours of etidronate ^{16})


» Sodium polystyrene sulfonate    (sodium polystyrene sulfonate may bind with magnesium, preventing neutralization of bicarbonate ions and leading to systemic alkalosis, which may be severe; concurrent use is not recommended, although the risk may be less with rectal administration of the resin)


» Tetracyclines, oral    (concurrent use with magnesium-containing laxatives may result in formation of nonabsorbable complexes; patients should be advised not to take these laxatives within 1 to 2 hours of tetracyclines)


For lubricant
Anticoagulants, coumarin- or indandione-derivative, oral or
Contraceptives, oral or
Digitalis glycosides or
Vitamins, fat-soluble, such as A, D, E, and K    (concurrent use with mineral oil may interfere with the proper absorption of these or other medications and reduce their effectiveness)

    (in addition to interfering with absorption of oral anticoagulants, mineral oil also decreases absorption of vitamin K, which may lead to increased anticoagulant effects)


Stool softener laxatives    (concurrent use may cause increased absorption of mineral oil and result in the formation of tumor-like deposits in tissues)


For stimulant
Antacids or
Histamine H ₂-receptor antagonists, such as:
Cimetidine
Famotidine
Nizatidine
Ranitidine or
Milk    (administration within one hour of bisacodyl tablets may cause the enteric coating to dissolve too rapidly, resulting in gastric or duodenal irritation )


For stool softener
Danthron or
Mineral oil    (concurrent use with a stool softener laxative may enhance the systemic absorption of these agents. Although such combinations are intentionally used in some “fixed-dose” laxative preparations, the propensity for toxic effects is greatly increased. Liver injury has been reported with the danthron combination following repeated dosage)



Laboratory value alterations
The following have been selected on the basis of their potential clinical significance (possible effect in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

With diagnostic test results

For stimulant:
Phenolsulfonphthalein (PSP) test    (cascara, danthron, and senna may color urine pink to red, red to violet, or red to brown, in event of alkalinity and also may increase the rate of excretion of PSP)

With physiology/laboratory test values

For all classes
Blood glucose concentrations    (may be elevated, usually after extended use)


Potassium concentrations, serum    (may be decreased; hypokalemia has occurred with extended use)


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Except under special circumstances, this medication should not be used when the following medical problems exist:

For all classes:
» Appendicitis, or symptoms of
» Bleeding, rectal, undiagnosed
» Congestive heart failure or
» Hypertension
Note: Applies to those preparations containing sodium; an alternative sodium-free laxative may usually be used. Preparations containing less than 5 mg of sodium per dose unit are utilized in many cases.


» Diabetes mellitus
Note: Applies to those preparations containing substantial amounts of dextrose, galactose, and/or sucrose; bulk-forming and liquid dosage forms of laxatives cause most concern.


» Intestinal obstruction
» Sensitivity to the class of laxative being used
For bulk-forming:
» Dysphagia    (esophageal obstruction may occur)


For hyperosmotic—saline:
» Dehydration    (may be aggravated by repeated use of saline laxatives)


» Renal function impairment    (hyperkalemia and hypermagnesemia may result, especially with preparations containing magnesium and potassium salts; tetany with hypocalcemia and hyperphosphatemia may occur with the use of phosphate salts)


For hyperosmotic—saline and lubricant:
» Colostomy or
» Ileostomy    (increased risk of electrolyte or fluid imbalance)


For lubricant:
» Dysphagia    (oral mineral oil may be aspirated and cause lipid pneumonitis)


» Caution is also recommended with bedridden patients, who may develop lipid pneumonia from aspiration of mineral oil.

Side/Adverse Effects
The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Those indicating need for medical attention
Incidence less frequent
For rectal solutions— more frequent with sodium phosphates
    
Rectal irritation (rectal bleeding, blistering, burning, itching, or pain)


Incidence rare
For bulk-forming
    
Allergies to some vegetable components (difficulty breathing ; skin rash or itching)
    
esophageal blockage or intestinal impaction
Note: Usually esophageal blockage or intestinal impaction occurs because of insufficient fluid intake



For hyperosmotic— saline
    
Electrolyte imbalance (confusion; irregular heartbeat ; muscle cramps; unusual tiredness or weakness )—due to acute overdosage or chronic misuse
    
magnesium accumulation in presence of renal function impairment (dizziness or light-headedness)

For stimulant
    
Allergic reaction to dehydrocholic acid (skin rash)
    
electrolyte imbalance (confusion; irregular heartbeat; muscle cramps; unusual tiredness or weakness)—due to acute overdosage or chronic misuse
    
pink to red, red to violet, or red to brown discoloration of alkaline urine —with cascara, danthron, and/or senna only
    
yellow to brown discoloration of acid urine —with cascara, and/or senna only

For stool softeners
    
Allergies, undetermined (skin rash)




Those indicating need for medical attention only if they continue or are bothersome
Incidence less frequent
For hyperosmotic
— glycerin    
Skin irritation surrounding rectal area

For hyperosmotic
— polyethylene glycol 3350, while taking other medications that contain polyethylene glycol     
urticaria suggestive of allergic reaction (hives or welts; itching; redness of skin; skin rash)
^{101}
For hyperosmotic
— lactulose, polyethylene glycol 3350, or saline    
Bloating ^{101}
cramping
    
diarrhea
nausea ^{101}
    
gas formation
    
increased thirst

For lubricant
    
Skin irritation surrounding rectal area

For stimulant
    
Belching
    
cramping —more frequent with aloe and certain senna preparations
    
diarrhea
    
nausea
    
rectal irritation (skin irritation surrounding rectal area)—with suppository dosage form

For stool softeners
    
Stomach and/or intestinal cramping
    
throat irritation —with liquid forms






Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Laxatives (Oral) and Laxatives (Rectal) .

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
Importance of diet, fluids, and exercise
»   Conditions affecting use, especially:
Sensitivity to a particular class of laxative

Pregnancy—

• For saline: May promote sodium retention resulting in edema


• For lubricant: Mineral oil may decrease absorption of foods, fat-soluble vitamins, and medications; possibility of hypoprothrombinemia and hemorrhage in neonate


• For stimulant: Castor oil not recommended; pelvic engorgement may stimulate uterus





Breast-feeding—For stimulant: May be distributed into breast milk and may produce loose stools in nursing infant





Use in children—Proper diagnosis recommended before using laxatives

• For lubricant: Risk of pneumonia due to aspiration of mineral oil droplets


• For stimulant: Bisacodyl enteric-coated tablets not recommended because of risk of gastric irritation if chewed


• For rectal solutions: Risk of water intoxication or dilutional hyponatremia; risk of seizures if large amounts of phosphate absorbed (for sodium phosphates)







Use in the elderly—

• For lubricant: Risk of pneumonia in bedridden patients due to aspiration of mineral oil droplets


• For hyperosmotic: increased occurrence of diarrhea in elderly nursing home patients


• For stimulant: Possible exacerbation of weakness, incoordination, and hypotension due to electrolyte loss with repeated use


• For rectal solutions: Risk of water intoxication or dilutional hyponatremia
Other medications, especially anticoagulants, ciprofloxacin, digitalis glycosides, etidronate, sodium polystyrene sulfonate (with magnesium-containing), or oral tetracyclines (with bulk-forming and magnesium-containing)
Other medical problems, especially appendicitis, intestinal obstruction, or rectal bleeding; congestive heart failure or hypertension (with sodium-containing); diabetes (with dextrose-, galactose-, or sucrose-containing); dysphagia (with bulk-forming or lubricant); dehydration or renal function impairment (with hyperosmotic, saline); colostomy or ileostomy (with hyperosmotic [saline] or lubricant)

Proper use of this medication

For all classes
Following physician"s directions on prescribed laxative

Following manufacturer"s package directions on nonprescription (OTC) laxative

» Proper dosing

» Proper storage

For oral dosage forms
Drinking at least 6 to 8 full glasses (240 mL each) of liquids each day when using any laxative, to aid stool softening

For rectal dosage forms
Proper administration technique; reading patient directions carefully

Lubrication of anus with petroleum jelly before insertion of enema applicator and careful insertion to prevent damage to rectal wall

Moistening suppository with water by placing either under water tap for 30 seconds or in a cup of water for at least 10 seconds, before rectal insertion

For bulk-forming
Not swallowing in dry form; taking with liquid

Drinking a full glass (240 mL) or more of liquid with each dose plus additional liquid during the day

Results obtained in 12 hours to 3 days

For carbon dioxide–releasing
Results usually obtained in 5 to 30 minutes

For hyperosmotic—glycerin
Results usually obtained in 15 minutes to 1 hour

For hyperosmotic—lactulose
Drinking a full glass (240 mL) of liquid or more with each dose for best results

Flavor improved by following dose with fruit juice or citrus-flavored carbonated beverage

May require 24 to 48 hours for results

For hyperosmotic—polyethylene glycol 3350
Drinking a full glass (240 mL) of water with each dose

May require 2 to 4 days for results

For hyperosmotic—saline

Oral dosage forms only
Drinking a full glass (240 mL) of liquid or more with each dose to prevent dehydration

Flavor improved by following dose with fruit juice or citrus-flavored carbonated beverage

Results obtained within 1/2 to 3 hours; not taking late in day unless at bedtime with food

Faster effect when taken on empty stomach, with a full glass (240 mL) of liquid or more

Rectal dosage forms only
Results usually obtained in 2 to 5 minutes with sodium phosphates enema

For lubricant

Oral dosage forms only
Not taking within 2 hours of meals; may interfere with absorption of food nutrients and vitamins

Usually taken at bedtime, but not while reclining; results obtained in about 6 to 8 hours

Rectal dosage forms only
Results usually obtained in 2 to 15 minutes

For stimulant

Oral dosage forms only
Taking on empty stomach for faster results

Preparations of this group (except castor oil) are sometimes taken at bedtime for morning results (some require up to 24 hours)

Bisacodyl only:    —not chewing or crushing tablets; swallowing whole because of enteric coating; not taking with milk or antacids


Castor oil only:    —not taking late in day; results within 2 to 6 hours
   —chilling and mixing in cold orange juice to improve taste; emulsion available


Rectal dosage forms only
Results usually obtained in 15 minutes to 1 hour with bisacodyl; or in 30 minutes to 2 hours with senna

For stool softeners

Oral dosage forms only
Flavor of liquid forms improved in milk or fruit juice

Results usually obtained in 1 to 2 days after first dose; may require 3 to 5 days

Rectal dosage forms only
Results usually obtained in 2 to 15 minutes

Precautions while using this medication

For all classes
» Not using laxatives:    —if symptoms of appendicitis are present
   —more often than recommended
   —unnecessarily (for example, for cold, as tonic, to clean system)
   —because bowel movement is missed 1 or 2 days


» Checking with physician if sudden change in bowel habit persists beyond 2 weeks

Avoiding laxative habit; overuse or extended use may cause dependence for bowel function

For oral laxatives
» Not taking:    —longer than 1 week unless by physician"s order
   —within 2 hours of other medicine


» Checking with physician if skin rash develops while taking

For rectal laxatives
» Checking with physician if signs of rectal irritation or infection occur with the use of rectal solutions

Not lubricating suppository with mineral oil or petroleum jelly

For bulk-forming
Diabetics and patients on sodium-restricted diet—Some products are high in sugar and/or sodium content

For hyperosmotic (oral dosage forms only)
Diabetics and patients on sodium-restricted diet—Some products contain sugar and/or sodium

For lubricant (oral dosage forms only)
Not to be taken repeatedly for prolonged time—Some absorption may cause problems; may interfere with absorption of food nutrients and vitamins A, D, E, and K

Need for protection of clothing, since large doses may cause oil leakage from rectum

Inhalation of oil droplets may cause a form of pneumonia, especially in children and bedridden elderly

Not taking mineral oil within 2 hours of a stool softener; absorption of mineral oil may be increased

For stimulant (oral dosage forms only)
Often associated with:    —laxative habit
   —skin rash
   —cramping, especially on empty stomach
   —potassium loss


Diabetics and patients on sodium-restricted diet—Some products contain sugar and/or sodium


Side/adverse effects
Signs of potential side effects, especially rectal irritation (with rectal solutions); allergic reactions; esophageal blockage or intestinal impaction (with bulk-forming); electrolyte imbalance (with hyperosmotic [saline] or stimulant); magnesium accumulation (with hyperosmotic [saline]); discoloration of urine and feces (with cascara, danthron, senna)


General Dosing Information

For bulk-forming
Bulk-forming laxatives are suitable for long-term therapy, if necessary.


For polycarbophil when used as antidiarrheal:
Polycarbophil is available as chewable tablets that absorb up to 60 times their weight in water. They are sometimes utilized to control diarrheal conditions by administering less fluid with each dose.

The usual oral adult dose of calcium polycarbophil when used as antidiarrheal is 1 gram one to four times a day.

The usual oral pediatric dose for children 3 to 6 years of age is 500 mg two times a day; for children 6 to 12 years of age the dose may be given three times a day, but not to exceed 3 grams a day.



For psyllium hydrophilic mucilloid when used as antihyperlipidemic:
Reduced values for serum total cholesterol, low density lipoprotein (LDL), and for the ratio of LDL cholesterol to high density lipoprotein (HDL) cholesterol have been achieved with three 3.4-gram doses of psyllium per day. ^{08}


For hyperosmotic—lactulose polyethylene glycol, and saline


For lactulose:
Has no effect on small intestine; lowers pH of colon.

Use with caution in diabetics—Contains up to 1.2 grams of lactose and up to 2.2 grams of galactose per 15 mL.

Dose may be mixed with milk or fruit juice to improve flavor.



For lactulose when used as an antihyperammonemic:
The usual oral adult dose of lactulose when used as antihyperammonemic is 20 to 30 grams (30 to 45 mL) three or four times a day. This dose may be adjusted every day or two to produce two to three soft stools daily. In the initial phase of therapy 20 to 30 grams (30 to 45 mL) may be given every hour to induce rapid laxation.

Concurrent use of other laxatives during initial phase of therapy for portal-systemic encephalopathy may result in loose stools and falsely suggest adequate lactulose dosage has been obtained.



For polyethylene glycol 3350:
Has no effect on active absorption or secretion of glucose or electrolytes.

Should be used for 2 weeks or less.

No evidence of tachyphylaxis.^{101}



For saline:
Solid forms must be completely dissolved before swallowing.

Because of relatively short response time, saline laxatives are not usually given at bedtime or late in the day unless the dose is relatively small and given with food.

This type of laxative may contain large amounts of sodium (up to 1 gram or more per dose in some preparations).


For lubricant
Commonly administered at bedtime, when slower peristalsis allows longer transit time to improve laxative effect. If administered at bedtime, patient should not be reclining to avoid aspiration of oil droplets.

Because mineral oil may interfere with absorption of oil-soluble nutrients and/or medications, this type of laxative is not administered within 2 hours of meals or other medications.

To avoid oil leakage through the anal sphincter, the dose of mineral oil may be reduced or divided, or a stable emulsion may be used instead.

For stimulant
Many preparations of this group are administered at bedtime with a snack to produce results in the morning— except castor oil. Because of its shorter response time, castor oil is not usually taken at bedtime or late in the day.

Bisacodyl tannex (bisacodyl and tannic acid complex) should not be used if multiple enemas are required. If absorbed in sufficient amounts, tannic acid is hepatotoxic.

Cascara, danthron, and/or senna preparations may discolor alkaline urine pink to red, red to violet, or red to brown. Acid urine may be discolored yellow to brown with cascara and/or senna preparations.


For dehydrocholic acid when used as hydrocholeretic:
The usual oral adult dose of dehydrocholic acid when used as hydrocholeretic is 244 to 500 mg three times a day after meals.


For stool softeners
Because stool softener laxatives may increase absorption of other laxatives, including mineral oil, they are not given within 2 hours of such preparations. Patients should be informed.

The bitter taste of some liquid preparations of this type of laxative may be improved by diluting each dose in milk or fruit juice.

For oral dosage forms
With the possible exception of bulk-forming laxatives, more rapid results are obtained when laxatives are taken on an empty stomach. When taken with food and/or at bedtime, results tend to be delayed.

Intake of at least 6 to 8 full glasses (240 mL each) of fluid per day is necessary to aid in producing a soft stool and to protect the patient against dehydration when large volumes of water are lost with passage of the stool.

For rectal dosage forms
Lubrication of anus with petroleum jelly is recommended to prevent rectal abrasion and/or laceration produced by the insertion of a hard enema tip.

Lubrication of suppositories with mineral oil or petrolatum is not recommended since it may interfere with the action of the suppository. Instead, the suppository should be moistened with water by placing under a water tap for 30 seconds or in a cup of water for at least 10 seconds, before rectal insertion.

LAXATIVES

Oral Dosage Forms

Table 2. Oral Dosage Forms

Note: Content per capsule, caramel, packet, tablet, wafer, or 5 mL, unless otherwise stated.

Brand or generic name [availability]	Bulk-forming	Stool softener or emollient	Hyperosmotic	Lubricant	Stimulant	Other content information as per product label	Usual adult and adolescent dose * (maximum recommended daily dose)	Usual pediatric dose *	Packaging and storage §	Auxiliary labeling §
Acilac Solution USP (Rx) [Canada]			Lactulose 3.3 grams			Galactose <0.7 gram Lactose <0.4 gram	15–60 mL		c, e, f, h	l, m
Agarol Plain Emulsion (OTC) [Canada]			Glycerin 800 mg	Mineral oil 1.6 mL		Sodium 0.33 mEq Agar Sugar free	10–20 mL hs; repeat in am 2 hrs after breakfast	>6 yrs: 2.5 mL hs; repeat in am 2 hrs after breakfast	d	l, m, n
Agoral Suspension (OTC) [U.S.]		Docusate Sodium			Casanthrol 10 mg				d	n
Alophen Tablets USP (OTC) [U.S.]					Bisacodyl 5 mg	enteric coated	1–3 tabs once daily	6–12 yrs: 1 tab once daily	d	i,k,l,m
Alramucil Orange Effervescent Powder (OTC) [U.S.]	Psyllium hydrophilic mucilloid 3.4 grams/ packet						1 packet in 240 mL water or other liquid 1–3 times/day		c, g	l, m, p
Alramucil Regular Effervescent Powder (OTC) [U.S.]	Psyllium hydrophilic mucilloid 3.4 grams/ packet						1 packet in 240 mL water or other liquid 1–3 times/day		c, g	l, m, p
Apo-Bisacodyl Tablets USP (OTC) [Canada]					Bisacodyl 5 mg	Enteric-coated Sodium free	2–3 tabs		c	i, k, l, m
Bicholate Lilas Tablets (OTC) [Canada]					Bisacodyl 5 mg		1–3 tabs	>6 yrs: 1 tab	a	i, k , l, m
Bisac-Evac Tablets USP (OTC) [U.S.]					Bisacodyl 5 mg	Enteric-coated Sodium free	2–3 tabs	<6 yrs: Not recommended 6–12 yrs: 1 tab	c	i, k, l, m
Bisacodyl Tablets USP (OTC) [U.S./Canada]					Bisacodyl 5 mg	Enteric-coated	2–3 tabs (6 tabs)	<6 yrs: Not recommended >6 yrs: 1 tab	b	i, k, l, m
Bisacolax Tablets USP (OTC) [Canada]					Bisacodyl 5 mg	Sodium <0.2 mEq Enteric-coated	2–3 tabs (6 tabs)	<6 yrs: Not recommended >6 yrs: 1 tab	b	i, k, l, m
Black-Draught Syrup (OTC) [U.S.]					Casanthranol 30 mg	Alcohol 5% Tartrazine	5–15 mL (30 mL)	<2 yrs: 1.25–3.75 mL 2–12 yrs: 2.5–7.5 mL	c, e, f, h	l, m, r
Black-Draught Lax-Senna Granules (OTC) [U.S.]					Senna equivalent 1.65 grams/ 1/2 tsp	Tartrazine	1/4–1/2 tsp	Not established	b	l, p, r
Tablets (OTC) [U.S.]					Senna equivalent 600 mg		2 tabs (3 tabs)	>6 yrs: 1 tab (2 tabs)	b	l, m, r
Carter's Little Pills Tablets USP (OTC) [U.S.]					Bisacodyl 5 mg	Enteric-coated	1–3 tabs	<6 yrs: Not recommended 6–12 yrs: 1 tab	c	i, k, l, m
Tablets (OTC) [Canada]					Bisacodyl 5 mg	1–3 tabs		c	i, k, l, m
Cascara Tablets USP (OTC) [U.S./Canada]					Cascara sagrada 325 mg		1–2 tabs	Pediatric strength not available	b (if coated)	l, m, r
Cascara, Aromatic Fluidextract USP (OTC) [U.S.]					Cascara sagrada 1 gram/ mL	Alcohol 18–20%	5 mL (15 mL)	>2 yrs: 1–3 mL	a, e, f	l, m, n, r
Fluidextract USP (OTC) [Canada]					Total hydroxy- anthracene derivatives from Cascara sagrada extract	Alcohol	2.5–5 mL 1–3 times/day		a, e, f	l, m, r
Cascara Sagrada Fluidextract (OTC) [U.S.]					Cascara sagrada 1 gram/mL	Alcohol 19%	1 mL		a, e, f	l, m, n, r
Castor Oil Oil USP (OTC) [U.S./Canada]					Castor oil		15–60 mL	<2 yrs: 1–5 mL >2 yrs: 5–15 mL	a, e, h,	l, m, o
Cholac Solution USP (Rx) [U.S.]			Lactulose 3.3 gram				15–30 mL (60 mL)	Not established	c, e, f, h	l, m
Citroma Oral Solution USP (OTC) [U.S.]			See Magnesium Citrate Oral Solution			See Magnesium Citrate Oral Solution	240 mL	2–6 yrs: 4–12 mL 6–12 yrs: 50–100 mL	d, e, h	l, m, o, q
Citro-Mag Oral Solution USP (OTC) [Canada]			Magnesium citrate (anhydrous) 0.25 grams (15 grams/ 300 mL)			Sodium 0.5 mEq (0.31 mEq/ 300 mL) †	75–150 mL	6–12 yrs: 30–60 mL	d, e, h	l, m, o, q
Citrucel Orange Flavor Granules (OTC) [U.S.]	Methyl- cellulose 2 grams/ heaping tbsp or 19-gram packet						1 heaping tbsp or 1 19-gram packet in 240 mL water 1–3 times/day	>6 yrs: 1/2 tbsp in 240 mL water 1–3 times/ day	c, e, g	l, p
Citrucel Sugar-Free Orange Flavor Granules (OTC) [U.S.]	Methyl- cellulose 2 grams/ full tbsp					Aspartame	1 full tbsp in 240 mL water 1–3 times/day	>6 yrs: 1/2 tbsp in 240 mL water 1–3 times/ day	c, g	l, p
Colace Capsules USP (OTC) [U.S.]		Docusate sodium 50 mg				Sodium 0.11 mEq †	1–4 caps	>6 yrs: 1–2 caps	d, e, g	l, m
Capsules USP (OTC) [U.S./Canada]		Docusate sodium 100 mg					1–2 caps	>6 yrs: 1 cap	d, e, g	l, m
Solution USP (Oral) (OTC) [U.S./Canada]		Docusate sodium 50 mg (10 mg/mL)					Intended for pediatric use. See Colace Syrup	<3 yrs: 1–2 mL, 3–6 yrs: 2 mL, 1–3 times/day 6–12 yrs: See Colace Syrup	d, e, h	l, m
Syrup USP (OTC) [U.S./Canada]		Docusate sodium 20 mg				Alcohol <1%	15–45 mL	3–6 yrs: 5–15 mL/day 6–12 yrs: 10 mL 1–3 times/day	d, e, f, h	l, m
Constilac Solution USP (Rx) [U.S.]			Lactulose 3.3 gram				15–30 mL (60 mL)	Not established	c, e, f, h	l, m
Constulose Solution USP (Rx) [U.S.]			Lactulose 3.3 grams			Galactose <0.7 gram Lactose <0.4 gram Other sugars £0.4 gram	15–30 mL (60 mL)	Not established	c, e, f, h	l, m
Correctol Tablets USP (OTC) [U.S.]					Bisacodyl 5 mg		1–3 tabs	6–12 yrs: 1 tab	c	i, k, l, m
Tablets (OTC) [Canada]					Bisacodyl 5 mg		1–3 tabs	>6 yrs: 1 tab am or hs	b	l, m, r
Correctol Caplets Tablets USP (OTC) [U.S.]					Bisacodyl 5 mg		1–3 tabs	6–12 yrs: 1 tab	c	i, k, l, m
Correctol Herbal Tea for Oral Solution (OTC) [U.S.]					Senna (30 mg total sennosides/bag)		1 tea bag in 6 oz boiling water (3 bags)		c, g	l, m, r
Correctol Stool Softener Soft Gels Capsules USP (OTC) [U.S./Canada]		Docusate sodium 100 mg					2 caps	6–12 yrs: 1 cap	c, h	m
DC Softgels Capsules USP (OTC) [U.S.]		Docusate calcium 240 mg					1 cap		d, e, g	l, m
Dehydrocholic Acid Tablets USP (Rx) [U.S.]					Dehydrocholic acid 250 mg		1–2 tabs 3 times/day (6 tabs)	Not established	d	l, m
Diocto Solution USP (Oral) (OTC) [U.S.]		Docusate sodium 50 mg					5–20 mL	<3 yrs: 1–2 mL, 3–6 yrs: 2–6 mL, 6–12 yrs: 4–12 mL, 1–3 times/day	d, e, h	l, m, n
Syrup USP (OTC) [U.S.]		Docusate sodium 20 mg					15–45 mL	3–6 yrs: 5–15 mL/day 6–12 yrs: 10 mL 1–3 times/day	d, e, f, h	l, m
Diocto-C Syrup (OTC) [U.S.]		Docusate sodium 20 mg			Casanthranol 10 mg	Alcohol 10%	15–30 mL	>6 yrs: 5–15 mL	a, e, f	l, m, n, r
Dioeze Capsules USP (OTC) [U.S.]		Docusate sodium 250 mg					1 cap	Not recommended	d, e	l, m
Diosuccin Capsules USP (OTC) [U.S.]		Docusate sodium 100 mg					1–2 caps	>6 yrs: 1 cap	d, e	l, m
		Docusate sodium 250 mg					1 cap	Not recommended
Docu-K Plus Capsules (OTC) [U.S.]		Docusate potassium 100 mg			Casanthranol 30 mg		1 cap	>6 yrs: 1 cap 2 times/day	d, g	l, m
Docusate calcium Capsules USP (OTC) [U.S./Canada]		Docusate calcium 240 mg					1 cap	Pediatric strength not available	d, e, g	l, m
Docusate potassium w/ Casanthranol Capsules (OTC) [U.S.]		Docusate potasium 100 mg			Casanthranol 30 mg		1 cap 2 times/day	>6 yrs: 1 cap	d, e, g	l, m
Docusate sodium Capsules USP (OTC) [U.S./Canada]		Docusate sodium 50 mg					1–4 caps	>6 yrs: 1–2 caps	d, e, g	l, m
		Docusate sodium 100 mg					1–2 caps	>6 yrs: 1 cap
		Docusate sodium 240 mg					1 cap	Not recommended
		Docusate sodium 250 mg
Solution USP (Oral) (OTC) [U.S./Canada]		Docusate sodium 50 mg					5–20 mL	<3 yrs: 1–2 mL, 3–6 yrs: 2–6 mL, 6–12 yrs: 4–12 mL	d, e, h	l, m
Syrup USP (OTC) [U.S.]		Docusate sodium 16.7 mg					15–45 mL	3–6 yrs: 5–10 mL/day 7–12 yrs: 10 mL 2–3 times/day	d, e, f, h	l, m
Syrup USP (OTC) [U.S./Canada]		Docusate sodium 20 mg				May contain alcohol	15–45 mL	3–6 yrs: 5–10 mL/day 7–12 yrs: 10 mL 2–3 times/day	d, e, f, h	l, m
Docusate sodium w/ Casanthranol Capsules (OTC) [U.S.]		Docusate sodium 100 mg			Casanthranol 30 mg		1–2 caps	>6 yrs: 1 cap	d, g	l, m
Syrup (OTC) [U.S.]		Docusate sodium 20 mg			Casanthranol 10 mg		15–30 mL	>6 yrs: 5–15 mL	d, h	l, m, n
DOK Syrup USP (OTC) [U.S.]		Docusate sodium 20 mg					15–45 mL/day	3–6 yrs: 5–15 mL/day 6–12 yrs: 10 mL 1–3 times/day	d, e, f, h	l, m
DOK Softgels Capsules USP (OTC) [U.S.]		Docusate sodium 100 mg					1–2 caps		d, e, g	l, m
		Docusate sodium 250 mg					1 cap
D.O.S. Softgels Capsules USP (OTC) [U.S.]		Docusate sodium 250 mg					1 cap		d, e	l, m
Doxidan Liqui-Gels Capsules (OTC) [U.S.]		Docusate sodium 100 mg			Casanthranol 30 mg	Alcohol <1.5%	1–2 caps	>6 yrs: 1 cap	d, e, g	l, m, r
Dr. Caldwell Senna Laxative Oral Solution (OTC) [U.S.]					Senna concentrate 166.5 mg	Alcohol 4.9%	15–30 mL	2–5 yrs: 5–10 mL, >6 yrs: 10–15 mL, hs	a	n
D-S-S Capsules USP (OTC) [U.S.]		Docusate sodium 100 mg					1–3 caps	6–12 yrs: 1 cap	d, e, g	l, m
D-S-S plus Capsules (OTC) [U.S.]		Docusate sodium 100 mg			Casanthranol 30 mg		1–3 caps	>6 yrs: 1 cap	d, g	l, m
Dulcolax Tablets USP (OTC) [U.S./Canada]					Bisacodyl 5 mg	Enteric-coated Tartrazine (Canada)	2–3 tabs am or hs (3 tabs)	<6 yrs: Not recommended >6 yrs: 1 tab	c, g	i, k, l, m
Emulsoil Emulsion USP (OTC) [U.S.]					Castor oil 95% w/v	Sodium free Sugar free	15–60 mL in 120–240 mL of water or other liquid	<2 yrs: 1–5 mL 2–12 yrs: 5–15 mL	a, e, h	l, m, n, o
Enulose Solution USP (Rx) [U.S.]			Lactulose 3.3 grams			Galactose <0.7 gram Lactose <0.4 gram Other sugars £0.4 gram	15–30 mL (60 mL)	Not established	c, e, f, h	l, m
Equalactin Chewable Tablets (OTC) [U.S.]	Calcium polycarbophil 500 mg (base)						2 tabs 1–4 times/day (8 tabs)	3–6 yrs: 1 tab 1–2 times/day 6–12 yrs: 1 tab 1–4 times/day	d	j, l, m
Evac-U-Gen Tablets USP (Chewable) (OTC) [U.S.]					Sennosides A & B 15 mg				a, e	<