What is the best next step in managing constipation in a 67-year-old woman with a sedentary lifestyle and medical history of hypertension, hyperlipidemia, and coronary artery disease?

From the Guidelines

The best next step in managing constipation in this 67-year-old woman with hypertension, hyperlipidemia, and coronary artery disease is to prescribe polyethylene glycol 3350 (PEG 3350, Miralax) 17 grams mixed in 8 ounces of water daily, along with lifestyle modifications. This approach is supported by the most recent guidelines from the American Gastroenterological Association and the American College of Gastroenterology, which recommend the use of polyethylene glycol as a first-line treatment for chronic idiopathic constipation 1. The patient should also increase her physical activity by starting with short daily walks and gradually increasing duration as tolerated, and make dietary changes to increase fiber intake to 25-30 grams daily through fruits, vegetables, and whole grains, while ensuring adequate hydration with at least 6-8 glasses of water daily. Key points to consider in managing this patient's constipation include:

• Increasing physical activity to help stimulate bowel movements
• Dietary changes to increase fiber and fluid intake
• The use of polyethylene glycol 3350 as a safe and effective osmotic laxative that can help soften stool and increase bowel movements without significant systemic absorption, making it suitable for patients with cardiovascular conditions 1
• Regular reassessment of symptoms and consideration of further evaluation for secondary causes of constipation if symptoms persist beyond 4 weeks of treatment. It is essential to address the underlying contributors to her constipation, including her sedentary lifestyle and likely inadequate fiber and fluid intake, to improve her overall quality of life and reduce the risk of complications associated with constipation.

From the FDA Drug Label

Patients should be educated about good defecatory and eating habits (such as high fiber diets) and lifestyle changes (adequate dietary fiber and fluid intake, regular exercise) which may produce more regular bowel habits. The best next step in managing constipation in a 67-year-old woman with a sedentary lifestyle and medical history of hypertension, hyperlipidemia, and coronary artery disease is to educate the patient about lifestyle changes, including a high-fiber diet and regular exercise, as these changes may help produce more regular bowel habits.

• Lifestyle modifications should be tried first, as they are a conservative and non-invasive approach to managing constipation.
• The patient has already tried increasing her water intake, but other lifestyle changes, such as increasing physical activity and dietary fiber, have not been attempted.
• There is no indication that the patient has tried other non-pharmacological interventions, such as a high-fiber diet, which should be attempted before prescribing medication 2.

From the Research

Management of Constipation

The patient's constipation can be managed through various methods, including lifestyle changes and medication. Considering the patient's sedentary lifestyle and medical history, it is essential to choose a treatment option that is safe and effective.

Treatment Options

• Lifestyle Changes: Increasing water intake, as the patient has already done, is a good start. However, other lifestyle changes such as increasing physical activity and fiber intake may also be beneficial 3.
• Medications: Several medications are available for the treatment of constipation, including polyethylene glycol 3350, which has been shown to be safe and effective in various studies 4, 5, 6.

Polyethylene Glycol 3350

• Efficacy: Polyethylene glycol 3350 has been shown to be effective in treating constipation in adults and elderly patients, with a response rate of 80-88% 5.
• Safety: The medication has been found to be safe, with no significant adverse effects or changes in electrolytes, calcium, glucose, BUN, creatinine, or serum osmolality 4, 5.
• Dosage: The recommended dose of polyethylene glycol 3350 is 17 g once daily, which has been shown to be effective and well-tolerated 5, 6.

Best Next Step

Based on the available evidence, prescribing polyethylene glycol 3350 (option C) appears to be the best next step in the management of this patient's constipation. This medication has been shown to be safe and effective in treating constipation, and its use is supported by various studies 4, 5, 6.