From the Guidelines
For refractory constipation in a patient already taking polyethylene glycol (PEG) daily who has difficulty swallowing pills, I recommend trying liquid or dissolvable medication formulations, such as senna liquid or bisacodyl suppositories, in addition to continuing PEG therapy, as evidenced by the American Gastroenterological Association clinical practice guideline 1. The patient's difficulty in swallowing pills necessitates alternative formulations that can be easily administered, such as liquids or suppositories.
- Consider adding a stimulant laxative, such as senna liquid (8.8 mg/5 mL, 10-20 mL daily) or bisacodyl suppositories (10 mg daily as needed), to the patient's regimen, as these agents can enhance bowel motility and facilitate stool passage.
- Docusate sodium liquid (100 mg/10 mL, taken 1-3 times daily) can also be used to soften stool and is available in a liquid form, making it suitable for patients with difficulty swallowing pills. The combination of osmotic agents, like PEG, with stimulants often works better than either alone, as they address different aspects of constipation pathophysiology, as noted in the clinical practice guideline 1.
- Ensure adequate hydration with at least 64 ounces of fluid daily and increase dietary fiber gradually to 25-30 grams daily, as recommended by the American Gastroenterological Association 1.
- Consider adding probiotic foods or supplements and encourage regular physical activity to promote bowel regularity and overall gut health. If these measures fail, discuss with the healthcare provider about prescription options like linaclotide or lubiprostone, which may be available in alternative formulations, as suggested by the American Gastroenterological Association medical position statement 1.
From the FDA Drug Label
LINZESS is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults For patients who are unable to swallow the capsule whole, LINZESS capsules can be opened and administered orally in either applesauce or with water or administered with water via a nasogastric or gastrostomy tube.
Linaclotide (LINZESS) can be used to treat chronic idiopathic constipation (CIC) in adults. For patients taking PEG daily and having difficulty taking pills, linaclotide can be administered orally in either applesauce or with water, or via a nasogastric or gastrostomy tube 2.
From the Research
Refractory Constipation in Patients Taking PEG Daily
- Refractory constipation is a condition where patients do not respond to standard medical treatments, and it requires a thorough evaluation to determine the underlying cause 3, 4, 5, 6.
- Patients taking polyethylene glycol (PEG) daily may experience refractory constipation due to various factors, including inadequate treatment regimens or secondary causes of constipation 3, 7.
Difficulty Taking Pills
- Patients with refractory constipation may have difficulty taking pills, which can exacerbate the condition 5, 6.
- Alternative treatment options, such as biofeedback or sacral neuromodulation, may be considered for patients who have difficulty taking pills 3, 5.
Treatment Options
- Treatment options for refractory constipation include stimulant laxatives, osmotic laxatives, enterokinetics, and secretagogues 3, 7.
- Patients with slow transit constipation may benefit from more robust medical treatment, while those with obstructed defecation may benefit from biofeedback or other non-medical approaches 3, 5.
- Surgery may be considered as a last resort for patients with refractory constipation who have not responded to other treatments 3, 6.
Evaluation and Diagnosis
- A comprehensive evaluation algorithm is necessary to diagnose and manage refractory constipation, including physiological assessment and exploration of treatment options 5, 6.
- Differentiating subtypes of primary chronic idiopathic constipation is crucial to guide therapy and improve treatment outcomes 6.