Table 3 Exemplar comments received from the Delphi panel

Example of statement used in Round 1

Stimulant laxatives (e.g. bisacodyl, senna) should not be used long-term i.e. for greater than four weeks.

First generation antihistamines (e.g. chlorphenamine, promethazine) should not be used for greater than seven days.

Rationale: Stimulant laxatives are not suitable for long-term use (greater than four weeks), due to risk of dependency and decreased bowel function.

Rationale: First generation antihistamines exert anticholinergic properties causing unwanted side-effects e.g. constipation, drowsiness, psychomotor impairment.

Comments from Round 1*

C1: Chronic management sometimes required.

C1: Addiction is a problem with these agents.

C4: Regular Prescribing often led by patient demand.

C3: Depends on indication, alternatives tried and their effect. Certainly not first line.

C5: Lack of evidence base regarding effect on long term bowel function, old case reports likely consequent to adulteration in laxative preparation.

C4: Often led by patient demand. but most likely will be on 2nd generation antihistamine.

Revisions made for Round 2 (revisions shown in bold text)

Stimulant laxatives (e.g. bisacodyl, senna) should not be prescribed as first-line treatment in constipation for greater than four weeks (other than for opioid induced constipation).

First generation antihistamines (e.g. chlorphenamine, promethazine) should not be used as first-line agents for greater than seven days.

Rationale: Stimulant laxatives are not suitable for continuous long-term use, other than for opioid induced constipation.

Rationale: First generation antihistamines may cause addiction and/or exert anticholinergic properties causing unwanted side-effects e.g. constipation, drowsiness, psychomotor impairment.

Comments from Round 2*

C1: Stimulants are only licenced for short term use, but the guidance you steer us to does not say anything that comes close to the indicator in terms of ‘should not be prescribed’, so I don’t think it’s a sensible indicator (I’d be happier to support one about ‘should use’ stimulants in people on strong opioids).

C1: You would only continue using them if the patient either didn’t respond to other antihistamines and/or didn’t have any of the above side effects- I have seen plenty of patients who are fully function on full dose chlorphenamine. Of course, they can buy it OTC so I guess there are lots of people out there who (we hope) are fine and using it.

C2: However we recognise that some patients will buy these products and/or may be using them without health professional knowledge or advice. Best practice is to review after four weeks and reassess for alternatives.

C2: Especially for hypnotic indications.

C3: Bulk forming or osmotic laxatives should be used first.

Conclusion

Further rewording following Round 2. Final statement:

No further revision following Round 2. Final statement:

Other than for opioid-induced constipation, stimulant laxatives (e.g. bisacodyl, senna) should not be prescribed as first-line treatment in constipation for greater than four weeks.

First generation antihistamines (e.g. chlorphenamine, promethazine) should not be used as first-line agents for greater than seven days.

Rationale: Stimulant laxatives are not suitable for continuous long-term use, other than for opioid induced constipation.

Rationale: First generation antihistamines may cause addiction and/or exert anticholinergic properties causing unwanted side-effects e.g. constipation, drowsiness, psychomotor impairment.