What are the best medications for chronic constipation, including enemas?

From the Guidelines

For chronic constipation, a stepwise approach is recommended, starting with lifestyle modifications and over-the-counter options before prescription medications, with polyethylene glycol (MiraLAX, 17g daily in water) as a first-line treatment, and enemas like saline enemas (Fleet) or tap water enemas (100-200ml) for acute relief, as suggested by the American Gastroenterological Association and the American College of Gastroenterology clinical practice guideline 1.

Key Recommendations

• First-line treatments include osmotic laxatives like polyethylene glycol (MiraLAX, 17g daily in water), which draws water into the bowel to soften stool.
• Stimulant laxatives such as bisacodyl (Dulcolax, 5-10mg daily) or senna (Senokot, 8.6-17.2mg daily) can be used for short periods as they stimulate intestinal contractions, with bisacodyl or sodium picosulfate recommended for short-term use or as rescue therapy 1.
• For more severe cases, prescription medications like lubiprostone (Amitiza, 24mcg twice daily), linaclotide (Linzess, 145-290mcg daily), or plecanatide (Trulance, 3mg daily) work by increasing intestinal fluid secretion and motility, with plecanatide recommended for use in adults with CIC who do not respond to OTC agents 1.
• Enemas can provide rapid relief for acute situations but aren't recommended for long-term use; options include saline enemas (Fleet), mineral oil enemas, or tap water enemas (100-200ml), with saline enemas and tap water enemas being suitable options 1.

Important Considerations

• It's essential to address underlying causes of constipation through adequate hydration (6-8 glasses of water daily), increased dietary fiber (25-30g daily), and regular physical activity.
• Chronic use of stimulant laxatives or enemas can lead to dependence, so they should be used judiciously.
• If constipation persists despite these measures, consult a healthcare provider to rule out underlying medical conditions.
• Fiber supplementation, such as psyllium, can be used as first-line therapy for CIC, particularly for individuals with low dietary fiber intake 1.
• Senna can be used as an alternative to bisacodyl, with a conditional recommendation and low certainty of evidence 1.

From the FDA Drug Label

ACTIVE INGREDIENT (IN EACH DOSE) (Bottle Only) Polyethylene Glycol 3350,17 g (cap filled to line) (Packet Only) Polyethylene Glycol 3350,17 g PRINCIPAL DISPLAY PANEL - 237 mL Bottle Label NDC 39328-020-08 Senna SyrupNatural VegetableLaxative 8.8mg/5 mL Alcohol Free • Dye Free 8 fl. oz (237 mL) PATRINPHARMA

The best medications for chronic constipation include:

• Polyethylene Glycol 3350 2, an oral medication that can help soften stool and increase bowel movements.
• Senna 3, a natural vegetable laxative that can help stimulate bowel movements.

For enemas, the provided drug labels do not directly support the use of these medications as enemas. However, polyethylene glycol can be used as an enema in some cases, but this is not explicitly stated in the provided labels. Senna is typically taken orally.

From the Research

Medications for Chronic Constipation

• Various medications are used to treat chronic constipation, including bulk and fiber products, lubricating agents, stimulants, and osmotic laxatives 4.
• Popular therapeutic options for initial treatment of chronic constipation are dietary fiber and medicinal bulk, while subsequent treatments may include saline osmotic laxatives, lactulose, or stimulants like senna or bisacodyl 4.
• Polyethylene glycol laxative has been shown to be safe and effective as an initial or second-line agent for chronic constipation 4, 5, 6.

Enemas for Chronic Constipation

• Enema therapy may be necessary to retrain or evacuate an atonic, constipated colon, particularly in the elderly 7.
• The use of enemas is a frequently employed method for treating chronic constipation in adults, although it is not substantiated by rigorous scientific data 8.
• Enemas should be used on an individual patient's basis, according to the experience of the caring physicians, until more robust scientific data is available 8.

Specific Medications

• Polyethylene glycol 3350 (MiraLAX) is approved for the short-term treatment of occasional constipation and has been shown to be safe and effective for chronic treatment of chronic constipation 5, 6.
• A 68-g dose of polyethylene glycol laxative has been shown to provide safe and effective relief in constipated adults within a 24-h period 5.
• Bulk-forming laxatives and lactulose are favored for treating constipation in the elderly 7.