What are the treatment options for constipation?

From the Guidelines

Constipation can be effectively treated through a combination of lifestyle changes and medications, with the most recent guidelines from the American Gastroenterological Association (2023) recommending the use of polyethylene glycol (PEG) as a first-line treatment option 1. To manage constipation, it is essential to start with lifestyle modifications, including:

• Increasing fiber intake to 25-30 grams daily through fruits, vegetables, and whole grains
• Drinking 6-8 glasses of water daily to soften stool
• Regular physical activity to stimulate bowel movements For immediate relief, over-the-counter options can be considered, such as:
• Osmotic laxatives like polyethylene glycol (MiraLAX, 17g in 8oz water daily) or magnesium hydroxide (Milk of Magnesia, 30-60ml once daily)
• Stimulant laxatives such as bisacodyl (Dulcolax, 5-10mg tablets) or senna (Senokot, 1-2 tablets at bedtime)
• Stool softeners like docusate sodium (Colace, 100mg 1-3 times daily) Fiber supplements such as psyllium (Metamucil, 1 tablespoon in water 1-3 times daily) can also be helpful. It is crucial to note that if constipation persists beyond two weeks despite these measures, or if severe abdominal pain, blood in stool, or unexplained weight loss occurs, consultation with a healthcare provider is necessary to rule out underlying serious conditions requiring medical evaluation. Additionally, newer agents like lubiprostone and linaclotide have shown efficacy in treating constipation, particularly in cases of chronic idiopathic constipation or irritable bowel syndrome 1. However, the most recent and highest-quality study recommends PEG as the first-line treatment option, making it the preferred choice for managing constipation 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. In Trials 3 and 4, the proportion of patients who were CSBM responders was statistically significantly greater with the LINZESS 145 mcg dose than with placebo CSBM frequency reached maximum level during week 1 and was also demonstrated over the remainder of the 12-week treatment period in Trial 3 and Trial 4. For the mean change from baseline in CSBM frequency at week 12, the difference between placebo and LINZESS was approximately 1. 5 CSBMs. On average, patients who received LINZESS across the 2 trials had significantly greater improvements compared with patients receiving placebo in stool frequency (CSBMs/week and SBMs/week), and stool consistency (as measured by the BSFS) In each trial, in addition to improvements in CSBM frequency over the first 12 weeks of the treatment period, improvements were observed in each of the following when LINZESS was compared to placebo: SBM frequency [SBMs/week], stool consistency [as measured by the BSFS], and amount of straining with bowel movements [amount of time pushing or physical effort to pass stool]

Treatment of Constipation: Linaclotide (PO) is effective in the treatment of constipation, as shown by significant improvements in CSBM frequency, stool consistency, and amount of straining with bowel movements compared to placebo 2. The recommended dose is 145 mcg once daily. Linaclotide is indicated for the treatment of chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) in adults 2. Key benefits include:

• Significant increase in CSBM frequency
• Improvement in stool consistency
• Reduction in straining with bowel movements
• Rapid onset of action, with CSBM frequency reaching maximum level during week 1

From the Research

Treatment Options for Constipation

• Lifestyle modifications, including increased intake of fiber and water, are commonly suggested by health professionals for the treatment of constipation 3, 4, 5.
• Dietary changes, such as increasing fiber intake, can help improve stool frequency and consistency, and reduce colonic transit time 3, 5, 6.
• The recommended daily fiber intake is at least 20 to 25g, and it should be gradually adjusted to avoid side effects like bloating and abdominal pain 6.
• Increasing water intake and daily physical exercise may also be beneficial in treating constipation, although the evidence for these recommendations is limited 5, 6.

Medications for Constipation

• Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide are all effective treatments for chronic idiopathic constipation, and are more effective than placebo 4.
• Lubiprostone is a prostaglandin-derived bicyclic fatty acid that is available for the long-term treatment of constipation, and has been shown to be effective and safe in randomized, double-blind, placebo-controlled trials 7.
• Lubiprostone works by increasing intraluminal chloride ion secretion, which results in a passive influx of water and sodium, leading to increased intestinal peristalsis and colonic laxation with decreased intestinal stool transit time 7.

Limitations of Current Evidence

• The evidence for the effectiveness of lifestyle modifications and dietary changes in treating constipation is limited, and more research is needed to fully understand their benefits and limitations 3, 4, 5, 6.
• Many commonly used agents for treating constipation lack quality evidence supporting their use, and more research is needed to determine their effectiveness and safety 4.