What is the next step for a patient experiencing constipation while taking Miralax (Polyethylene Glycol) that did not respond to treatment as an inpatient?

From the Guidelines

For a patient with constipation who hasn't responded to MiraLAX in the inpatient setting, I recommend escalating to a combination therapy approach, prioritizing stimulant laxatives like bisacodyl or senna, as suggested by the American Gastroenterological Association and the American College of Gastroenterology guideline panel 1. When considering the next steps for managing constipation in an inpatient setting, it's crucial to understand the mechanisms of different laxatives and their potential synergies.

• The guideline panel's systematic review of various agents, including stimulant laxatives, provides a foundation for evidence-based decision-making 1.
• Key considerations include the patient's current medication regimen, potential underlying causes of constipation, and the need for a multifaceted approach to address both the osmotic and motility aspects of bowel function.
• Starting with a stimulant laxative such as bisacodyl (10mg orally or as a suppository) or senna (8.6mg tablets, 1-2 tablets twice daily) alongside continued MiraLAX (17g daily) can be an effective strategy.
• Ensuring adequate hydration (at least 2 liters daily unless contraindicated) and encouraging ambulation if possible are also critical components of managing inpatient constipation.
• Reviewing the patient's medication list for constipating agents that could be modified and considering underlying causes such as bowel obstruction, hypothyroidism, or hypercalcemia that may require specific treatment are essential steps in comprehensive care.

From the FDA Drug Label

ASK A DOCTOR BEFORE USE IF YOU HAVE • nausea, vomiting or abdominal pain • a sudden change in bowel habits that lasts over 2 weeks • irritable bowel syndrome The patient's constipation on Miralex did not improve, and they are now an inpatient.

• The polyethylene glycol (PO) label suggests consulting a doctor before use in cases of a sudden change in bowel habits.
• Since the patient's constipation persists, it is recommended to consult a doctor for further guidance on the use of polyethylene glycol (PO) 2.

From the Research

Constipation Treatment Options

The patient's constipation on Miralex did not improve, and alternative treatments are being considered. The following options have been studied:

• Osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, are effective and safe for both long and short term treatment of constipation 3
• Stimulant laxatives, like Senna and Bisacodyl, are also effective and can be used as adjunct therapies in specific clinical scenarios 3, 4, 5
• Fiber preparations, enemas, and suppositories can be used as adjunct therapies, but their effectiveness may vary depending on the individual patient 3, 4, 5

Comparison of Laxatives

Studies have compared the effectiveness of different laxatives:

• Polyethylene glycol (PEG) was found to be more effective than lactulose in treating chronic constipation, with better outcomes in stool frequency, form of stool, relief of abdominal pain, and need for additional products 6
• Senna was found to be more effective than polyethylene glycol in treating constipation in children with anorectal malformation, with improved daily bowel movement, reduced fecal soiling, and a "clean" abdominal x-ray 7

Treatment Recommendations

Based on the available evidence:

• Polyethylene glycol (PEG) or senna can be recommended as first-line laxatives for treating constipation 4, 5, 6, 7
• Fiber supplements, fruits, stimulant laxatives, and magnesium-based products may also be effective, but more evidence is needed to support their use 4, 5