What is the next treatment step for a patient with constipation who has not responded to Miralax (polyethylene glycol) and docusate, increased fiber and water?

From the Guidelines

For a patient with constipation who hasn't responded to Miralax, docusate, increased fiber, and water, the next treatment step should be a stimulant laxative such as bisacodyl or senna. Bisacodyl can be taken as 5-10 mg orally once daily, typically at bedtime, or as a 10 mg suppository 1. Senna can be taken as 8.6-17.2 mg orally once or twice daily. These medications work by directly stimulating intestinal motility and can be more effective for refractory constipation. They should be used for short-term relief while continuing to address underlying causes.

Key Considerations

• If stimulant laxatives don't provide relief within a few days, consider adding an osmotic laxative like lactulose (15-30 ml daily) or magnesium citrate (195-300 ml as needed) 1.
• For patients with chronic idiopathic constipation who don't respond to these measures, prescription medications such as linaclotide, plecanatide, or lubiprostone may be necessary 1.
• It's also important to reassess for any underlying conditions causing constipation, such as hypothyroidism, medication side effects, or structural abnormalities, which may require specific treatment approaches.

Additional Treatment Options

• Enemas, such as sodium phosphate, saline, or tap water, may be helpful in stimulating peristalsis and lubricating the stool to encourage a bowel movement, but should be used sparingly and with awareness of possible electrolyte abnormalities 1.
• Peripherally acting mu opioid receptor antagonists, such as methylnaltrexone, may be considered for patients with opioid-induced constipation 1.

Important Safety Considerations

• The use of rectal suppositories or enemas should be avoided in patients with neutropenia or thrombocytopenia, and enemas are contraindicated in patients with certain medical conditions, such as paralytic ileus or intestinal obstruction 1.

From the Research

Next Treatment Steps for Constipation

• If a patient has not responded to Miralax (polyethylene glycol) and docusate, increased fiber and water, the next treatment step may involve alternative laxatives or adjustments to the current bowel protocol 2.
• According to a study on the treatment of childhood constipation, osmotic laxatives such as polyethylene glycol 3350 (PEG 3350) and lactulose are effective and safe for both long and short term treatment of pediatric functional constipation, and stimulant laxatives like Senna and Bisacodyl can be used as adjunct therapies 3.
• For patients with opioid-induced constipation, newer agents such as methylnaltrexone, linaclotide, lubiprostone, or naloxegol may be considered if first-line therapies are not effective 4.
• In the management of chronic constipation in patients with diabetes mellitus, treatment should begin with bulking agents such as psyllium, bran or methylcellulose, followed by osmotic laxatives like lactulose, polyethylene glycol, and lactitol if response is poor 5.
• Stimulant laxatives like bisacodyl, sodium picosulphate, and senna can be indicated if osmotic laxatives are not effective, and newer agents such as chloride-channel activators and 5-HT4 agonist can be considered for severe or resistant cases 5.

Considerations for Laxative Use

• Laxative abuse or misuse can occur, particularly in individuals with eating disorders or those who believe daily bowel movements are necessary for good health 6.
• Treatment of laxative abuse involves stopping the stimulant laxatives and replacing them with fiber/osmotic supplements to establish normal bowel movements, as well as education and further treatment to maintain a healthy bowel program 6.
• The primary aim of intervention in patients with constipation is to manage the underlying condition, whether it be diabetes, opioid use, or other factors, while also addressing the constipation symptoms 5.