From the Guidelines
Constipation can be effectively managed through a combination of lifestyle changes and medications, with the most recent guidelines from the American Gastroenterological Association and the American College of Gastroenterology recommending pharmacological treatment with polyethylene glycol (PEG), secretagogues, or prokinetic agents for chronic idiopathic constipation 1.
Lifestyle Changes
To manage constipation, start by increasing fiber intake to 25-30 grams daily through fruits, vegetables, and whole grains, while drinking at least 8 glasses of water daily to soften stool. Regular physical activity helps stimulate bowel movements.
- Increase fiber intake to 25-30 grams daily
- Drink at least 8 glasses of water daily
- Engage in regular physical activity
Medications
For immediate relief, over-the-counter options include:
- Osmotic laxatives like polyethylene glycol (MiraLAX, 17g in 8oz water daily) or magnesium hydroxide (Milk of Magnesia, 30-60ml daily), which draw water into the intestines
- Stimulant laxatives such as bisacodyl (Dulcolax, 5-10mg tablets) or senna (Senokot, 8.6-17.2mg) work by increasing intestinal contractions but should be used short-term
- Stool softeners like docusate sodium (Colace, 100mg 1-3 times daily) can help if straining is painful
Chronic Constipation Management
For chronic constipation, establish a regular bathroom routine, preferably after meals when the gastrocolic reflex is strongest. If constipation persists beyond two weeks, is accompanied by bleeding, severe pain, or unexplained weight loss, or if you're over 50 with new-onset constipation, consult a healthcare provider as these could indicate more serious conditions requiring medical evaluation.
- Establish a regular bathroom routine
- Consult a healthcare provider if constipation persists or is accompanied by other symptoms
Opioid-Induced Constipation
For patients experiencing opioid-induced constipation, methylnaltrexone, a peripherally acting μ-opioid receptor antagonist, can be used to relieve constipation while maintaining pain control 1.
- Consider methylnaltrexone for opioid-induced constipation
Note: The most recent and highest quality study 1 provides the basis for the recommendation to use pharmacological treatment with PEG, secretagogues, or prokinetic agents for chronic idiopathic constipation.
From the FDA Drug Label
The efficacy of TRULANCE for the management of symptoms of CIC was established in two 12-week, double-blind, placebo-controlled, randomized, multicenter clinical studies in adult patients (Study 1 and Study 2) A responder was defined as a patient who had at least 3 CSBMs in a given week and an increase of at least 1 CSBM from baseline in the same week for at least 9 weeks out of the 12-week treatment period and at least 3 of the last 4 weeks of the study. In both studies, improvements in the frequency of CSBMs/week were seen as early as week 1 with improvement maintained through week 12.
Constipation management with plecanatide (TRULANCE) is effective, as shown by the significant increase in responder rates compared to placebo in two clinical studies 2. The key benefits of plecanatide include:
- Increased frequency of complete spontaneous bowel movements (CSBMs)
- Improved stool consistency
- Reduced straining with bowel movements Overall, plecanatide is a useful treatment option for managing symptoms of chronic idiopathic constipation (CIC).
From the Research
Definition and Classification of Constipation
- Constipation is defined as less than three bowel movements per week 3, or the infrequent passage of stools or difficulty with evacuation of stools 4.
- Constipation can be classified as primary or secondary, and primary constipation can be further divided into slow transit constipation or outlet obstruction 4.
- The etiologies of constipation can be classified as dietary, drug induced, metabolic, neurologic, or anatomic 3.
Diagnostic Evaluation
- The history and physical examination should be evaluated for stool size, frequency, and straining and discomfort on defecation 3.
- Focused lab tests and structural evaluation, followed by a therapeutic trial of fiber and laxatives, and finally, specialized tests can be used in the diagnostic workup 4.
- Barium-contrast enema, flexible sigmoidoscopy, colonoscopy, transit time, or anorectal manometry can be used selectively in further evaluation 3.
Treatment Options
- Initial management of chronic constipation should include lifestyle maneuvers, and increased fiber and fluids 5.
- Dietary changes, such as increased dietary fiber intake, can be used as a therapeutic trial 3.
- Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide were all more effective than placebo for treating chronic idiopathic constipation 5.
- Polyethylene glycol-based preparations and senna are supported by good evidence as first-line laxatives 6.
- Fiber, fruit-based laxatives, and magnesium oxide have modest evidence supporting their use 6.
- Pharmacologic therapy and, rarely, surgical intervention, can be useful in selected situations 3.