What is the recommended regimen for managing constipation?

From the Guidelines

The recommended regimen for managing constipation begins with lifestyle modifications, including increased fluid intake and dietary fiber, and may progress to the use of osmotic laxatives like polyethylene glycol or magnesium hydroxide, with stimulant laxatives used sparingly for more severe cases, as supported by the most recent guidelines 1.

Overview of Constipation Management

Constipation is a common issue that can significantly impact an individual's quality of life. Managing it effectively requires a stepwise approach, starting with lifestyle modifications and progressing to pharmacological interventions as needed.

Lifestyle Modifications

• Increased fluid intake: at least 8 glasses of water daily.
• Dietary fiber: 25-30g daily from fruits, vegetables, and whole grains.
• Regular physical activity.

Pharmacological Interventions

For mild constipation, over-the-counter fiber supplements like psyllium (Metamucil) or methylcellulose (Citrucel) can be effective. If these measures are insufficient, the following can be considered:

• Osmotic laxatives: polyethylene glycol (MiraLAX) or magnesium hydroxide (Milk of Magnesia) for up to 2 weeks.
• Stimulant laxatives: bisacodyl (Dulcolax) or senna (Senokot) for more severe or persistent constipation, used sparingly.

Considerations for Opioid-Induced Constipation

In cases where constipation is induced by opioid use, as discussed in 1, prevention and management strategies include:

• Prophylactic bowel regimen when starting opioid therapy.
• Use of senna with or without docusate daily.
• Consideration of peripherally acting mu-opioid receptor antagonists (PAMORAs) like methylnaltrexone, naldemedine, or naloxegol if constipation is clearly related to opioid therapy.

Important Considerations

• Medical evaluation is necessary if constipation persists beyond 2 weeks despite interventions or is accompanied by concerning symptoms.
• The choice of laxative and management strategy should be tailored to the individual's specific needs and underlying cause of constipation, as outlined in guidelines like those from the American Gastroenterological Association and the American College of Gastroenterology 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 1 Recommended Dosage Irritable Bowel Syndrome with Constipation (IBS-C) in adults The recommended dosage of LINZESS is 290 mcg orally once daily. Chronic Idiopathic Constipation (CIC) in adults The recommended dosage of LINZESS is 145 mcg orally once daily. A dosage of 72 mcg once daily may be used based on individual presentation or tolerability Functional Constipation (FC) in pediatric patients 6 to 17 years of age The recommended dosage of LINZESS is 72 mcg orally once daily.

The recommended regimen for managing constipation with LINZESS is:

• Irritable Bowel Syndrome with Constipation (IBS-C) in adults: 290 mcg orally once daily.
• Chronic Idiopathic Constipation (CIC) in adults: 145 mcg orally once daily, or 72 mcg orally once daily based on individual presentation or tolerability.
• Functional Constipation (FC) in pediatric patients 6 to 17 years of age: 72 mcg orally once daily 2.

From the Research

Constipation Regimen

The recommended regimen for managing constipation involves a stepwise approach, considering the underlying cause and type of constipation.

• The initial management of chronic constipation should include lifestyle maneuvers, increased fiber, and fluids 3.
• Patients with constipation-predominant irritable bowel syndrome are best managed with dietary monitoring and modifications, fiber therapy, and education regarding self-monitoring and self-care 4.
• For patients with slow transit constipation, fiber therapy and increased activity may be beneficial, but most will also require laxative therapy 4.
• Current guidelines for prescribing laxatives suggest bulk agents as first-line and osmotic agents as second-line therapy, with stimulant laxatives generally reserved for PRN use 4.

Treatment Options

Various treatment options are available for managing constipation, including:

• Reassurance and stopping current treatment for patients with bowel obsession 5
• Increasing dietary fiber, possibly with an added supplement of natural bran 5
• Toilet training and altered routine of life, particularly for young people 5
• Medicinal bulking agents, such as ispaghula, methyl cellulose, or bran, for patients with a normal colon who find it difficult to take adequate dietary fiber 5
• Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide, which have been shown to be effective in treating chronic idiopathic constipation 3
• Lubiprostone, which has been approved for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation, and works by stimulating chloride secretion and inducing peristalsis and laxation 6

Evaluation and Management

A careful evaluation of the patient's history, physical examination, and limited laboratory studies is essential for determining the underlying cause of constipation 4.

• Anorectal tests, such as biofeedback therapy, may be necessary for patients with defecatory disorders 7
• Colonic transit and motility studies may be required to identify colonic dysmotility 7
• A stepwise approach to management, guided by efficacy and cost, should be followed, with dietary fiber supplementation and stimulant and/or osmotic laxatives as initial treatments, followed by intestinal secretagogues and/or prokinetic agents if necessary 7