What treatment is recommended for a patient with chronic constipation, currently on Linaclotide (Linzess) 145mg and Lax (laxative) twice daily, who has not had a bowel movement in 5 days?

From the Guidelines

For chronic constipation with no bowel movement for 5 days despite Linaclotide 145mcg and Lax-a-Day twice daily, I recommend adding a stimulant laxative such as bisacodyl (Dulcolax) 10mg orally or using a glycerin suppository for immediate relief, as suggested by the American Gastroenterological Association 1.

Treatment Approach

To address the constipation, consider the following steps:

• Add bisacodyl 10mg orally, 2 to 3 times daily, with a goal of one nonforced bowel movement every 1 to 2 days, as recommended by the NCCN Palliative Care Panel 1
• Use a glycerin suppository to help stimulate evacuation
• Consider a one-time Fleet enema to help clear the lower bowel
• Increase fluid intake to at least 2-3 liters daily
• Add physical activity like walking for 30 minutes daily

Rationale

The use of linaclotide has been studied in several trials, including a 12-week randomized double-blinded placebo-controlled trial that evaluated the use of linaclotide for the management of chronic idiopathic constipation 1. However, in this case, the patient is already taking linaclotide and requires additional intervention to manage constipation. The addition of a stimulant laxative like bisacodyl can help stimulate intestinal contractions and relieve constipation. It is essential to continue prescribed medications unless advised otherwise by a healthcare provider. If no bowel movement occurs within 24 hours after these interventions, seek medical attention to rule out a bowel obstruction or to consider manual disimpaction.

From the FDA Drug Label

The recommended dosage of LINZESS is 145 mcg orally once daily. If a dose is missed, skip the missed dose and take the next dose at the regular time. Do not take 2 doses at the same time.

The patient is already taking Linaclotide 145mg once daily, but the label states to take it once daily, not twice daily.

• The patient should not take an additional dose of Linaclotide.
• The patient should continue with the prescribed dose of 145mg once daily.
• For the treatment of no bowel movement for 5 days, the label does not provide specific guidance, therefore, no conclusion can be drawn from the label 2

From the Research

Treatment Options for Chronic Constipation

• The patient is currently taking Linaclotide 145mg and Lax a day twice daily, but has not had a bowel movement in 5 days 3, 4.
• Linaclotide is a potent peptide agonist of the guanylate cyclase-C receptor, which stimulates intestinal fluid secretion and increases the number of spontaneous bowel movements and stool consistency scores 3.
• However, the patient's lack of bowel movement despite taking Linaclotide and Lax may indicate a more severe condition such as fecal impaction, which is a common cause of lower gastrointestinal tract obstruction 5.

Potential Causes and Complications

• Fecal impaction can be caused by chronic or severe constipation, and can lead to complications such as bowel obstruction, stercoral ulcers, perforation, and peritonitis if left untreated 5.
• The patient's symptoms and medical history should be carefully evaluated to determine the underlying cause of their constipation and to rule out any potential complications 5.

Next Steps

• The patient may require additional treatment options such as gentle proximal softening, distal washout, or manual extraction to relieve the constipation and prevent further complications 5.
• Increasing dietary fiber content, water intake, and discontinuing medications that can contribute to colonic hypomotility may also help to manage the patient's constipation and prevent recurrence 5.