From the Guidelines
To manage chronic constipation, the most effective approach is to start with lifestyle modifications and then progress to medication if necessary, as recommended by the American Gastroenterological Association and the American College of Gastroenterology in their 2023 clinical practice guideline 1.
Lifestyle Modifications
- Increase daily fiber intake to 25-30 grams through fruits, vegetables, whole grains, and legumes
- Drink 8-10 glasses of water daily
- Establish a regular bathroom routine, preferably after meals when the gastrocolic reflex is strongest
- Exercise for at least 30 minutes most days to stimulate bowel movements
Medication Options
- Over-the-counter fiber supplements like psyllium (Metamucil) or methylcellulose (Citrucel) can be used as first-line therapy, as they are effective for constipation generally and are inexpensive, widely available, and well-tolerated 1
- Osmotic laxatives such as polyethylene glycol (MiraLAX, 17g daily) or magnesium citrate can draw water into the bowels and are recommended for adults with chronic idiopathic constipation 1
- Stimulant laxatives like bisacodyl (Dulcolax, 5-10mg) or senna (Senokot) can be used short-term for stubborn cases, but their use should be limited due to the risk of dependence 1
- Prescription medications include lubiprostone (Amitiza, 24mcg twice daily), linaclotide (Linzess, 145-290mcg daily), or plecanatide (Trulance, 3mg daily) for chronic idiopathic constipation, which work by increasing intestinal fluid secretion and motility 1
Important Considerations
- Avoid excessive use of stimulant laxatives as they can create dependence
- If constipation persists despite these measures, consult a healthcare provider to rule out underlying conditions like hypothyroidism, medication side effects, or structural problems that may require specific treatment 1
From the FDA Drug Label
The efficacy of LINZESS for the treatment of CIC was established in two double-blind, placebo-controlled, randomized, multicenter clinical trials in adult patients (Trials 3 and 4) A total of 642 patients in Trial 3 and 630 patients in Trial 4 [overall mean age of 48 years (range 18 to 85 years), 89% female, 76% white, 22% black, 10% Hispanic] received treatment with LINZESS 145 mcg, 290 mcg, or placebo once daily and were evaluated for efficacy. The CSBM responder rates are shown in Table 6 During the individual double-blind placebo-controlled trials, LINZESS 290 mcg did not consistently offer additional clinically meaningful treatment benefit over placebo than that observed with the LINZESS 145 mcg dose. Therefore, the 145 mcg dose is the recommended dose.
Management of Chronic Constipation:
- The recommended dose of LINZESS is 145 mcg once daily.
- LINZESS has been shown to be effective in increasing the frequency of complete spontaneous bowel movements (CSBMs) and improving stool consistency.
- Patients with chronic idiopathic constipation (CIC) may benefit from treatment with LINZESS.
- It is essential to note that the efficacy of LINZESS was established in clinical trials, and the results may vary in individual patients 2.
- Another option for managing chronic constipation is lubiprostone, which is indicated for the treatment of chronic idiopathic constipation (CIC) in adults 3.
From the Research
Management of Chronic Constipation
Chronic constipation can be managed through various methods, including:
- Lifestyle modifications, such as increased exercise and fluid intake, and bowel habit training 4, 5, 6
- Dietary changes, including increased fiber intake, with soluble fibers like psyllium being more effective than insoluble fibers 7, 5, 6
- Medical therapy, including:
- Osmotic laxatives, such as polyethylene glycol (PEG) or macrogol, which have been shown to be safe and effective 8, 4, 7, 5, 6
- Stimulants, such as senna or bisacodyl, which can be used if fiber is not successful or tolerated 8, 4, 5
- Secretagogues, such as lubiprostone, which have been approved for the treatment of chronic constipation 4, 6
- Prokinetics, such as prucalopride, which have been shown to be effective in treating chronic idiopathic constipation 5
- Bile acid transporter inhibitors, probiotics, and Kampo medicines, which may also be used in the treatment of chronic constipation 6
- Temporary use of stimulant laxatives, suppositories, enemas, and digital evacuation may also be recommended 6
- Biofeedback may be useful, but its effectiveness is yet to be determined 6
Treatment Options
Treatment options for chronic constipation may vary depending on the individual patient's symptoms and physiological subgroup. Patients may be classified as having the "decreased frequency of defecation" type or the "difficult defecation" type, with treatment applied according to each type 6.
Pharmacologic Agents
Various pharmacologic agents are available for the treatment of chronic constipation, including: