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    Constipation is a common condition that is uncomfortable and frequently requires treatment. The condition often has a negative impact on the quality of life of the affected individuals. Constipation may be defined as infrequent bowel movements, hard (dry) movements or bowel movements that are difficult to pass. It is normal to have bowel movements from three times a day to once every three days. Severe (pathological) constipation is a bowel movement every seven days or less frequently. Hard bowel movements are a problem only while they cause irritation while being passed.

    For others, constipation can be a chronic condition (long term) that causes significant pain and discomfort. Such a condition may lead to complications, such as faecal impaction (where dry hard stools are collected in one’s rectum) or faecal incontinence (where there is leaking of liquid stools). Constipation affects babies, children and adults, whilst it is twice as prevalent in women compared with men.

    Pregnant women are also significantly affected by constipation, (in the UK alone 40% of pregnant women experience constipation). This is due to the presence of excess progesterone hormone that helps relax muscles. Such physiological functions will counteract the regular function of peristaltic movements in the bowels in order to move the waste through the large intestine.

    Elderly people are five times more likely than younger adults to suffer from constipation, generally due to dietary factors, lack of exercise, use of medication and poor bowel habits.

    Causes of constipation in babies, children (apart from those linked with inadequate toilet training and/or psychology related toilet habits) and adults include:

    • nadequate bulk (fibre) in the diet

    • Lack of exercise

    • Loss of the normal urge to have a bowel movement because of longstanding and frequent, intentional suppression of the urge.

    • Longstanding use of stimulant laxatives

    • Inadequate fluid in the stool

    Less frequent reasons for constipation affecting children include a malformed anal and rectal area, spinal cord abnormalities, cystic fibrosis and Hirschprung’s disease. Available therapies for constipation include:

    • Attempting to revive the normal urges to have a bowel movement (e.g. use of stimulatory foods, exercise, and rectal stimulation, usually in the morning)

    • Adding fibre to the diet (e.g. fruits, vegetables, grains)

    • Using medications that increase water in the stool

    • Using lubricants (e.g., mineral oil) to reduce irritation from the passage of hard stools

    • Identification and correction of colon obstruction(s)

    Lactitol is a synthetic disaccharide derived from lactose by reduction of its glucose part. Lactitol was first described in the literature by Senderens in 1920 (Senderens, 1920). Lactitol is also called lactit, lactositol, and lactobiosit. Lactitol exists in anhydrous, monohydrate or dihydrate formats. The molecular weight of lactitol monohydrate (C12H24O11.H2O) is 362.34. The chemical structure of Lactitol, 4-0-(ß-d-galactopyranosyl)- d-glucitol, is shown below:

    [Figure 1: Structural formula of Lactitol]

    Lactitol is available as a white or off-white, sweet-tasting, odourless crystalline powder. This powder is soluble in water.

    From 1983, when Lactitol was approved by the Joint Expert Committee of Food Additives (JECFA), it has been used in many food applications for the replacement of sugar. This is largely due to the fact that Lactitol has a similar molecular weight as sugar and can reproduce sugar’s technical properties in a product.

    n health and nutrition terms, greater value is added to Lactitol by the fact that, when consumed, it has a negligible effect on blood glucose levels. It is metabolised independently of insulin making lactitol a valid candidate for products destined for diabetic sufferers or those conscious of excessive carbohydrate intake. The glycaemic index profile of Lactitol shows little or no effect on blood sugar levels after consumption (FosterPowell et al., 2002).

    Lactitol has been widely studied as an alternative to lactulose as well as other harsh laxatives. There have been more than 15 studies assessing Lactitol’s potential as a digestive aid. In the majority of these studies the subjects were adults and elderly, while there is also some clear evidence for Lactitol as a digestive aid in children.

    3.1 Lactitol laxative mechanism of action

    Lactitol has two main mechanisms of action in constipated patients:

    • It is minimally absorbed in the small intestine and thus reaches the large intestine where it is broken down into short chain fatty acids (lactic, acetic, propionic and butyric acid etc.) by bacterial degradation. This lowers colonic pH and stimulates peristalsis (the rippling and wave-like motion that contract and relax the bowel muscles).
    • Degradation to short chain fatty acids (SCFA) also increases the osmotic pressure in the intestinal lumen. A dosedependent acceleration of colonic transit results from an increase in faecal volume due to intraluminal water retention and enhanced intestinal peristalsis. (Schiller, 2001).

    n addition, since Lactitol is a source of carbohydrate and energy for saccharolytic bacteria, their presence as biomass can be expected in the intestine. This could result in an increased bowel filling volume and further stimulation of the bowel function.

    [Figure 2: The stages of Lactitol mechanism of action]

    3.2 Proven efficacy in adults

    Among studies testing Lactitol in constipated subjects, the results demonstrated an increased stool frequency (Table 1, page 6). In particular, Goovaerts and Ravelli (Goovaerts and Ravelli, 1993; Figure 3) showed that there was an increase in stool frequency from 1.89 times (bowel movement per week) to 5.66 during the first week of treatment with Lactitol (p < 0.001).

    In the above study, chronically constipated subjects were given 20 g (2 X 10 g of Lactitol) per day to consume during their breakfast with the option of adjusting that dose after the first week of treatment according to their needs (open study). One third of the patients (n=119) reduced their daily dose from 2 to 1 sachet per day (n=39 patients). 84% of the events reported due to Lactitol consumption were mild or of moderate severity, whilst over 70 patients reported no adverse effects at all. The conclusion being that Lactitol was well received by the vast majority of the patients in this study resulting in an increased bowel movement.

    [Figure 3: Stool frequency increases significantly with Lactitol treatment (Goovaerts and Ravelli, 1993)]

    Vanderdonckt (Vanderdonckt et al., 1993) studied the laxative effect of Lactitol during a 4 week period in an elderly population who were suffering from chronic constipation (n=43; male: 15, female:28).

    • Lactitol significantly increased the number of bowel movements per week
    • Lactitol was well tolerated
    • Initial daily dose for the subjects was 2 sachets (10 g/sachet)
    • Side effects were not significant compared to the side effects caused by placebo (dextrose monohydrate).

    In the above study, there were no unnecessary adverse effects noted, while Lactitol’s benefits were shown by the lack of habituation and thus constant adjustable dose by the subjects. This study recommends 20 g/day of Lactitol; however it should also be outlined that this dosage level was recommended for the elderly patients of this study who were chronically constipated. The same author suggested, by experience, that younger constipated patients could benefit from a single dose of 10 g/day of Lactitol. It is also mentioned that a single dose of Lactitol diminishes the incidence and intensity of untoward abdominal effects.

    [Figure 4: Lactitol treatment shows good tolerability, efficacy and is considered pleasant by the patients (Delas et al., 1991)]

    Delas (Delas et al., 1991) studied 114 chronically constipated subjects over a period of two months (Figure 4), whereby:

    • The daily dose most frequently consumed was 20 g/day (two sachets). In 18 cases (16%), patients took three sachets, either temporarily (10 cases), or continuously (8 cases). In 11 cases (10%), dosage level was spontaneously reduced to one sachet daily.
    • For these suffering constipated patients, 91 treatments (80%) were qualified as a success by the doctor. In the remaining 23 cases, the treatment failed to show any significant effect
    • 94% of the patients found their treatment pleasant and compared to previous treatments (mucilage, oil and harsh laxatives) Lactitol was rated as better by 59%.

    [Figure 5: Lactitol treatment was considered to be more pleasant than with others laxatives (Delas et al., 1991)]

    The treatment lasted two months for 79 patients, one month for 25 patients and less than one month for 10 patients.

    Previous treatments were in 77% of the cases comprised of a mucilage, a harsh laxative, or an oil. The comparative scores of Lactitol vs. these treatments were 63%, 67% and 60% respectively (Figure 5).

    Previous treatments were in 77% of the cases comprised of a mucilage, a harsh laxative, or an oil. The comparative scores of Lactitol vs. these treatments were 63%, 67% and 60% respectively (Figure 5).

    Adults – Lactitol versus placebo (control)
    (20 g/day, single dose in the evening) For 2 months
    Subjects chronically constipated (n=114), of both sexes, aged 18-70 y (without any organic alteration of the colon) Clinical efficacy was concluded as correct for 80% of patients (statistical significance n.a.) Clinical tolerability was found to be good by 80% of patients and biological tolerability excellent [Delas et al., 1991]
    (increasing doses)
    Control Duration
    n.a. (open)
    Women complaining of chronic constipation (n=15) Determination of the minimal effective (i.e. laxative) dose: ED50 = 0.25 g/kg/day During a 15-day treatment period at the minimal effective dose, all patients had reduced symptoms of constipation as compared with a previous 15-day control period (statistical significance n.a.) Side effects of minor intensity were recorded (flatulence, rumblings, wind, and, less frequently, abdominal cramps or nausea) [Walder et al., 1988]
    (20 g 4 times daily or 20 g/day)
    For 4 weeks (randomized double-blind)
    Nursing-home patients (n=43), mean age 84 y Frequency: Number of bowel movements increased with Lactitol (by 1.9 movements/ week) (p < 0.001) Consistency: Improved with Lactitol (p < 0.001) Less need for laxatives with Lactitol (p < 0.05) Side effects of minor intensity (flatulence, bloating and abdominal cramps) were reported, without any of these being unexpected [Vanderdonckt et al., 1990]
    20 g/day (2x10 g sachets/day) Dose open to be adjusted according to individual needs
    119 ambulant men and women (age ranging from 20-75yrs) Frequency: Number of bowel movements increased with Lactitol (p < 0.001) Reduced dose after 1 week treatment (1 sachet/day) still had satisfactory effect until end of 3 weeks Side effects were either of mild or moderate severity (84% of the events). There were no unusual or unexpected adverse reactions [Goovaerts and Ravelli, 1993]
    (20 g/day*)
    (dextrose, 10 g/day) For 4 weeks *individually adjusted
    Healthy women suffering from chronic constipation (n=15), 21-51 y Frequency: Number of bowel movements not significantly increased with Lactitol (p=0.29) Consistency: softer stools with Lactitol (p=0.018) (Significant improvement in stool wet and dry weight) Frequency: Number of bowel movements not significantly increased with Lactitol (p=0.29) Consistency: softer stools with Lactitol (p=0.018) (Significant improvement in stool wet and dry weight) [Ravelli et al. 1995]

    [Table 1: Studies reporting Lactitol as a laxative in adult population]

    3.3 Efficacy in children

    Children are susceptible to constipation and in particular to the idiopathic type (for various reasons), if such constipation is not due to a disease related cause. In these studies, looking at the comparison of Lactitol vs. other more commonly used laxatives (e.g. lactulose) as a mean to relieve idiopathic constipation the following conclusions have been drawn (Table 2)

    • The children belonging to the group that were administered Lactitol completed the study without the experience of any unpleasant side effects.
    • n all studies, the groups of children that were administered Lactitol as a relieving agent showed comparable efficacy to the lactulose group even in smaller dosages (please refer to Table 2)
    • Lactitol was as effective in children ranging from 8 months – 16 years in age.

    In particular, Bonamico et al., observed that there was better evacuation in constipated children when compared to lactulose (Bonamico et al., 1993), while children seem to be a group that does not encounter side effects, such as abdominal pain and increased flatus (Pitzalis et al., 1995; Figure 6).

    Figure 6: With similar efficacy, Lactitol patients have less abdominal pain (p < 0.005) and less flatulence compared to lactulose group (Pitzalis et al., 1995)

    Children – Lactitol versus lactulose
    (150-350 mg/kg daily, single administration)
    Crystallized lactulose
    (150-300 mg/kg daily, single administration) For 15 days (randomised)
    Children suffering from intestinal stasis (n=39), (18 males, 21 females) Proved therapeutic efficacy with Lactitol (statistical significance n.a.) Subjects treated with Lactitol manifested a better tolerability and compliance than the subjects treated with lactulose [Martino et al. 1992]
    (only an abstract is available)
    (500-750 mg/kg/d) For 30 days (randomised)
    Children affected by chronic idiopathic constipation (n=42), (23 males, 28 females), age: 8 months to 16 y Frequency: Number of stool/week significantly increased with both Lactitol and lactulose (p < 0.001) Children given lactulose complained of abdominal pain (p < 0.005) and flatus (p < 0.001) more frequently than those given Lactitol [Pitzalis et al. 1995]
    (only an abstract is available)

    [Table 2: Studies using Lactitol as a laxative in children]

    4.1 Lactitol vs. lactulose: Same efficacy with fewer side effects

    When Lactitol was used in studies as a direct comparison to lactulose, bowel movements per week increased in 1 out of 2 studies (Doffoel et al., 1990; Table 3). In another study conducted by Hammer and Ravelli (Hammer and Ravelli, 1992; Figure 7), although there was no significant difference between Lactitol and lactulose and bowel movement per week, 63% of the subjects on the lactulose treatment reported adverse effects, as opposed to 30% of the subjects receiving Lactitol. It must be pointed out that the subjects on Lactitol treatment were on a lower dosage than the subjects receiving lactulose after the first three days of the study (10 g vs. 13.4 g/day respectively).

    Dr. Amit Maydeo from the Institute of Advanced Endoscopy in Mumbai, India, carried out a metanalysis of six clinical trials comparing Lactitol vs lactulose. These studies included 349 adult patients with a mean age of 19 to 85 years of age and 81 children ranging from 8 months to 16 years of age. The duration period for these trials was ranging between 3 days to 4 weeks. (Maydeo et al., 2010)

    As a conclusion of the metanalysis a comparable efficacy was attributed to Lactitol vs. lactulose. In addition, the individuals that took part in the clinical trials, reported greater tolerability of Lactitol when it came to unnecessary adverse effects while Lactitol was also widely accepted as the preferred laxative over lactulose. This, together with Lactitol’s excellent palatability profile over lactulose gave Lactitol a superior image through this metanalysis (Figure 8).

    [Figure 7: With equivalent efficacy, Lactitol group recorded less side effect complaints than lactulose goup. (Hammer and Ravelli, 1992).]

    [Figure 8: With the same efficacy in terms of bowel movement and stool frequency, adverse events such as nausea, abdominal pain and flatulences occured more often in lactulose group than in Lactitol group (p < 0.005) (Maydeo et al., 2010)]

    4.2 Lactitol overall superior results compared to paraffin

    In a study looking at 110 patients who had undergone anal surgery, subjects were either provided Lactitol (n=55) (20 g/day), or paraffin (n=55) (15 g twice a day, so 30 g/day) for 7 days. It was observed that Lactitol was overall superior to the results of paraffin on the number of bowel movements per day and efficacy of evacuation right after surgery. The effective dose for patients receiving Lactitol was also lower (16 g/day) than that of paraffin (i.e Cope et al., 1996; Table 3).

    Adults – Lactitol versus lactulose
    (15 g/day)
    (15 ml/day or 665 g/l increased as necessary) For 2 weeks (randomized)
    Nursing-home patients (n=60), mean age 79 y Frequency: Number of bowel movements per week increased with Lactitol compared to lactulose (5.5 versus 4.9) (p=0.0001) - [Doffoel et al.1990]
    l (20 g/day for 3 days, then 10 g/day for 25 days (maintenance dose)
    (20.1 g/day for 3 days, then 13.4 g/day for 25 days) For 4 weeks (open)
    Ambulant patients (n=57), 81% female, mean age 54y Frequency: Number of bowel movements/week not significantly different between Lactitol and lactulose
    Consistency: % patients reporting “normal” or “soft” at end of trial not significantly different (76% with Lactitol, 67% with lactulose)
    Overall effectiveness: No significant difference between Lactitol and lactulose in terms of patients’ or physicians’ ratings
    % of subjects reporting adverse effects significantly lower with Lactitol (10/32) than with lactulose (16/26) Overall tolerability: no significant difference in terms of patients’ or physicians’ ratings [Hammer &Ravelli 1992]
    Adults – Lactitol versus paraffin
    (20 g/day)
    (30 g/day) For 7 days (randomised, open)
    Adult patients having undergone anal surgery(n= 110) Frequency: Number of stools/day higher with Lactitol than paraffin (p = 0.046)1st postoperative stool obtained 13 hours earlier with Lactitol compared to paraffin (p < 0.005) The daily dose could be reduced for more patients under Lactitol than under paraffin on day 4 (p=0.004) General efficacy assessment on day 4 in favour of Lactitol (p = 0.033) Comfort score: Significantly higher with paraffin from day 1 to day 4 (but not from day 1 to day 7) Tolerance rated “good” by 97% of patients on day 7 No significant difference observed for any of the tolerability criteria [Cope et al. 1996]

    [Table 3: Compilation table of studies using Lactitol vs other laxatives]

    4.3 Lactitol as an alternative to harsh laxatives in elderly

    Idiopathic constipation is an issue for many adults and they will go to different lengths to relieve the symptoms, even if it is with the use of harsh laxatives. Such individuals may also invoke a cycle of laxative abuse. Vanderdonckt and Ravelli (Vanderdonckt and Ravelli, 1993) in a six week study with 10 subjects suffering from chronic idiopathic constipation, offered Lactitol as an alternative to harsh laxatives for weeks 3-6. The first two weeks were used to evaluate the subjects without any intervention, simply documenting the subjects’ harsh laxative use vs. the number of bowel movements per week. In particular, Lactitol treatment increased the mean number of bowel movements to 2.83 per week from 2.00.

    Because of the nature of these patients (i.e. their chronic laxative use) the dose that the subjects were given per day was four sachets of Lactitol, with each sachet containing 10 g Lactitol. Therefore, 40 g of Lactitol was provided to the patients for consumption with breakfast and this was open to adjustment by the subjects depending on their experience with the newly introduced laxative.

    After one week of Lactitol consumption (40 g/day) individual adjustments were performed as follows: 3 patients continued their initial dose of four sachets/day (40 g/day), 4 patients reduced to three sachets/day after one (2 patients), two (1 patient) and three weeks (1 patient) and another patient reduced the dosage to two sachets (20 g/day) after the first week. Two patients reduced the dose immediately to three sachets and reverted back once the abdominal effects had disappeared.

    Overall, the patients preferred the use of Lactitol as an alternative to other harsh cathartics which they had been using for years.

    Lactitol is taken orally and can be ingested by people of all age groups without any concerns regarding their health. The dosages specified herein are meant to act as a guideline only and will need to be adjusted to meet individual requirements of the patient depending on severity and development of the constipation. Lactitol dosage in children should always be decided by a clinical professional or a trained physician.

    - Starting dose Maintenance dose
    Chronically constipated
    10 g/day 10-20 g/day
    Chronically constipated on harsh laxatives 40 g/day 20-40 g/day
    Children (7-14 years) 150-400 mg/kg/day* -
    Children (1-6 years) 150-400 mg/kg/day* -

    *To be determined by a health professional

    Overall, good tolerance has been reported with 20 g/day dosage administered for 1 or 2 months in a study (Delas et al., 1991) whereas in another study (Walder et al., 1988), side effects of minor intensity such as flatulence, rumblings, wind, and less frequently, abdominal cramps or nausea, were reported with 0.25 g/kg/day administered for 15 days (this dose corresponds to 17.5 g/day for a mean body weight of 70 kg). The latter dose had been determined to be the minimum effective (laxative) dose in constipated women (Walder et al., 1988; Figure 9).

    Furthermore, a few studies in adults treated for hepatic encephalopathy suggest a better tolerance to Lactitol compared to lactulose (Heredia et al., 1988, Riggio et al., 1989, Blanc et al., 1992, Camma et al., 1993, Pai et al., 1995). However, given the particular physiological conditions of these subjects, it is not possible to extrapolate these findings to the general population. Moreover, scientific data suggest that digestive tolerance of lactulose is lower than 20 g/day (about 10 g/day).

    In studies other than tolerability ones, it has been observed that constipated subjects may experience some undesired effects in the first three days of Lactitol treatment however, these tend to alleviate after this period and subjects are happy to continue with their initial doses (Goovaerts and Ravelli, 1993).

    [Figure 9: Dose-response curve of Lactitol (Walder et al., 1988)]

    The Joint FAO/WHO Expert Committee on Food Additives (JECFA) approved Lactitol in 1983 allocating it an acceptable daily intake (ADI) of ‘not specified’, the safest category for food ingredients. In previous opinions dating back to 1984 and 1988, the Scientific Committee for Food concluded from human studies that Lactitol caused diarrhoea at an intake of about 50 g/d. The Committee stated that consumption of the order of 20 g/d of polyols is unlikely to cause undesirable laxative symptoms in healthy people.

    Stepwise administration is the recommended approach for Lactitol. This is simply because of the nature of Lactitol itself as a sugar alcohol. Polyols in general when consumed in excess may cause laxation, but this will vary from individual to individual, based on relative tolerability.

    Lactitol is widely recognised as a food ingredient and as such can be used in foodstuffs and dietary supplements (national regulations apply). It is also sold and registered as a drug in many countries, including EU, Korea, India and Australia. Lactitol is also described in the European and United States pharmacopoeia

    • Current edition of European Pharmacopoeia
      (Lactitol Monohydrate).
    • The current edition of United States Pharmacopeia

    Lactitol has a number of important benefits, which make it a particularly interesting product for constipation relief:

    • Proven efficacy in the treatment of chronic constipation
    • Suitable for all ages groups (children, adults & elderly)
    • Well tolerated
    • Less side effects than others laxatives
    • Taste well accepted by the patients
    • Suitable for long term use
    • Affordable therapy
    • Blanc P., Daures J., Rouillon J., Peray P., Pierrugues R., Larrey D., Gremy F., Michel H. (1992). Lactitol or lactulose in the treatment of chronic hepatic encephalopathy: results of a meta-analysis. Hepatology; 15 (2): 222-8
    • Bonamico M., Deganello F., Mariani P., Lionetti P., Abenavoli F., Pitzalis G.; Evidence of efficacy of Lactitol in the treatment of chronic constipation in children Gastroenterology Suppl 1993 ; 104(4) :479 [Abstract], 1993
    • Camma C., Fiorello F., Tine F., Marchesini G., Fabbri A., Pagliaro L.(1993). Lactitol in treatment of chronic hepatic encephalopathy. A meta-analysis. Dig Dis Sci; 38 (5): 916-22
    • Cope R., Debou J., Cohen S., Callens A. (1996). [Study of early postoperative Lactitol versus paraffin following anal surgery in 110 adult patients]. Ann Chir; 50 (7): 570-6
    • Delas N., Gislon J., Glikmanas M., Henri-Biabaud E., Lemerez M., Licht H., Slama J., Gillaume P. (1991). [Lactitol in the treatment of constipation in the adult. Open, non-comparative study of its efficacy and its clinical and biological tolerance]. Ann Gastroenterol Hepatol (Paris); 27 (5): 231-3
    • Doffoel M., Berthel M., Bockel R. (1990). Etude comparative du Lactitol et du lactulose dans le traitment de la constipation fonctionelle du sujet age. Med Chir Dig; 19: 257–259
    • Foster-Powell K., Holt, S.H.A. and Brand-Miller, J.C., (2002) International Table of glycaemic index and glycaemic load values American Journal of Clinical Nutrition, 76: 5-56
    • Goovaerts L. and Ravelli G.P., Lactitol monohydrate for the treatment of chronic constipation; A multicentre study on the efficacy and tolerability of an individually adjusted daily dose. Acta Therapeutica 19, 1993
    • Hammer B., Ravelli G. P. (1992). Chronische funktionelle obstipation. Ther Schweiz; 8: 328–5
    • Heredia D., Teres J., Orteu N., Rodes J. (1988). Lactitol vs. lactulose in the treatment of chronic recurrent portal-systemic encephalopathy. J Hepatol; 7 (1): 106-10
    • Martino A., Pesce F., Rosati U. (1992). [The effects of Lactitol in the treatment of intestinal stasis in childhood]. Minerva Pediatr; 44 (6): 319-23
    • Maydeo A. (2010), Lactitol or lactulose in the treatment of chronic constipation: result of a systemic review, unpublished results.
    • Pai C., Huang Y., Jeng W., Chan C., Lee S. (1995). Treatment of portosystemic encephalopathy with Lactitol verus lactulose: a randomized controlled study. Zhonghua Yi Xue Za Zhi (Taipei); 55 (1): 31-6
    • Pitzalis G., Deganello F., Mariani P., Chiarini-Testa M.B., Virgil II F., Gasparri R., Calvani, Bonamico M., Il lattitolo nella stipsi cronica idiopatica del bambino. (Lactitole in chronic idiopathic constipation of childhood); Pediatr Med Chir. 1995 May-Jun;17(3):223-6.
    • Ravelli G. P., Whyte A., Spencer R. (1995). The effect of Lactitol intake upon stool parameters and the faecal bacterial flora in chronically constipated women. ). Acta Therap; 21: 243-255
    • Riggio O., Balducci G., Ariosto F., Merli M., Pieche U., Pinto G., Tremiterra S., Ziparo V., Capocaccia L. (1989). Lactitol in prevention of recurrent episodes of hepatic encephalopathy in cirrhotic patients with portal-systemic shunt. Dig Dis Sci; 34 (6): 823-9
    • Riggio O., Varriale M., Testore G., Di Rosa R., Di Rosa E., Merli M., Romiti A., Candiani C., Capocaccia L. (1990b). Effect of Lactitol and actulose administration on the faecal flora in cirrhotic patients. J Clin Gastroenterol; 12 (4): 433-6
    • Senderens J.B., Catalytic hydrogenation of lactose Comptes Rendus 1920, 170: 47-50
    • Schiller L., R . 2001 Review Article : The therapy of constipation Aliment Pharmacol Ther 2001; 15 : 749-763
    • Vanderdonckt J., Coulon J., Denys W. (1990). Study of the laxative effect of Lactitol (Importal®) in an elderly institutionalized, but not bedridden, population suffering from chronic constipation. J Clin Exp Gerontol; 12: 171-189
    • Vanderdonckt J., Ravelli G.P. (1993). Lactitol as an alternative to harsh laxatives, an explanatory, open pilot study in chronic functional constipation. Acta therapeutica; 19-3: 295-308
    • Walder M., Buclin T., Biollaz J., Kitler M., Schelling J. (1988). [Doseresponse curve and preliminary clinical study of a laxative, Lactitol]. Schweiz Med Wochenschr; 118 (50): 1925-7


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