From the Guidelines
For constipation not responding to Miralax, I strongly recommend trying a stimulant laxative such as bisacodyl (Dulcolax) 5-10 mg orally once daily, as this approach is supported by the most recent and highest quality evidence 1.
Treatment Approach
The American Gastroenterological Association-American College of Gastroenterology clinical practice guideline recommends the use of stimulant laxatives, such as bisacodyl, for the management of chronic idiopathic constipation (CIC) that does not respond to first-line therapies like polyethylene glycol (Miralax) 1.
- The guideline suggests that bisacodyl can be used short-term or as rescue therapy, with short-term use defined as daily use for 4 weeks or less 1.
- It is essential to note that while long-term use of bisacodyl is probably appropriate, more data are needed to better understand tolerance and side effects 1.
Lifestyle Modifications
In addition to medication, lifestyle changes can support the effectiveness of treatment and promote natural bowel movements:
- Increase fluid intake to at least 8 glasses of water daily 1.
- Gradually add fiber to the diet, although the evidence for fiber supplementation is conditional and of low certainty 1.
- Engage in regular physical activity to help soften stool and stimulate bowel movements.
Monitoring and Follow-Up
If constipation persists beyond two weeks despite these interventions, it is crucial to consult a healthcare provider, as this could indicate an underlying condition requiring further evaluation 1.
Additional Considerations
Other options, such as lactulose or magnesium oxide, may be considered based on individual patient needs and responses to initial treatments, but these recommendations are conditional and based on very low certainty of evidence 1.
From the Research
Treatment Options for Constipation
The patient's constipation on Miralex did not improve, and alternative treatment options need to be considered. The following options have been studied:
- Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide were found to be more effective than placebo for treating chronic idiopathic constipation 2
- Fiber supplementation, particularly psyllium, has been shown to be effective in improving constipation, with higher doses (>10 g/d) and longer treatment durations (≥4 weeks) appearing to be optimal 3
- Bisacodyl, a stimulant laxative, has been found to have similar efficacy to other laxatives, including prucalopride, lubiprostone, and linaclotide, and may be superior for increasing the number of spontaneous bowel movements per week 4
Over-the-Counter Therapies
Over-the-counter (OTC) therapies for chronic constipation have been reviewed, and the following recommendations have been made:
- Good evidence (grade A) supports the use of polyethylene glycol and senna as first-line laxatives 5, 6
- Moderate evidence (grade B) supports the use of psyllium, bisacodyl, sodium picosulfate, and magnesium salts 5, 6
- Common adverse events associated with OTC therapies include diarrhea, nausea, bloating, and abdominal pain, but no serious adverse events have been reported 5, 6
Considerations for Treatment
When considering treatment options for the patient, the following factors should be taken into account: