From the Guidelines
For chronic idiopathic constipation in geriatric patients, a stepwise approach starting with osmotic laxatives is recommended, with polyethylene glycol (PEG 3350, 17g daily) as the first-line choice due to its efficacy and safety profile in older adults, as supported by the most recent guidelines 1. The recommended initial dose of PEG 3350 is 17g daily, which works by drawing water into the intestinal lumen to soften stool and can be used long-term without significant tolerance issues. Some key points to consider when treating chronic idiopathic constipation in geriatric patients include:
- If inadequate response occurs after 1-2 weeks, the dose can be increased or a stimulant laxative like bisacodyl (5-10mg daily) or senna (8.6-17.2mg at bedtime) can be added, as suggested by the guidelines 1.
- For patients with more severe symptoms, prescription medications may be considered, including lubiprostone (24mcg twice daily), linaclotide (145mcg daily), or plecanatide (3mg daily), which increase intestinal fluid secretion and motility, as recommended by the guidelines 1.
- When prescribing for geriatric patients, start at lower doses and titrate slowly to minimize side effects like diarrhea, and medication adjustments should be made every 1-2 weeks based on response.
- Importantly, underlying causes should be ruled out, and non-pharmacological approaches should be implemented concurrently, including adequate hydration (1.5-2L daily), dietary fiber (aim for 25-30g daily), and physical activity as tolerated, as emphasized by the guidelines 1.
- Medication review is essential as many commonly prescribed drugs in older adults (such as opioids, anticholinergics, calcium channel blockers, and iron supplements) can worsen constipation, as noted in the guidelines 1.
From the FDA Drug Label
The efficacy of lubiprostone 24 mcg twice daily in the elderly (at least 65 years of age) subpopulation with CIC was consistent with the efficacy in the overall study population Of the total number of patients treated in the dose-finding, efficacy, and long-term studies of lubiprostone, 16% were at least 65 years of age, and 4% were at least 75 years of age. Clinical studies of LINZESS did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Of 2498 CIC patients in the placebo-controlled clinical studies of LINZESS (Trials 3,4, and 5), 273 (11%) were 65 years of age and over, while 56 (2%) were 75 years and over
The oral medications for chronic idiopathic constipation in geriatric patients are:
- Lubiprostone: 24 mcg twice daily
- Linaclotide: although the clinical studies did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients, it is available as 72 mcg, 145 mcg and 290 mcg capsules for oral administration 2 3
From the Research
Oral Medications for Chronic Idiopathic Constipation in Geriatric Patients
The following oral medications are used to treat chronic idiopathic constipation in geriatric patients:
- Psyllium: a bulk laxative that can be effective in treating constipation, but requires adequate fluid intake to avoid intestinal obstruction 4, 5
- Calcium polycarbophil: a bulk laxative that can increase stool frequency 5
- Docusate sodium: a stool softener that can increase stool frequency, but may not be effective in all patients 5
- Lactulose: an osmotic laxative that can increase stool frequency 5, 6
- Polyethylene glycol: an osmotic laxative that can increase stool frequency 5
- Senna: a stimulant laxative that can increase stool frequency, often used in combination with a bulking agent 5, 6
- Lubiprostone: a chloride channel activator that can increase stool frequency and is generally well-tolerated, but may cause nausea 5, 7
- Sodium picosulfate: a stimulant laxative that can increase stool frequency, but may have limited data on its effectiveness in geriatric patients 5
Key Considerations
When using these medications, it is essential to:
- Ensure adequate fluid intake to avoid intestinal obstruction, particularly with bulk laxatives like psyllium 4
- Individualize treatment approaches for older adults with constipation, considering their unique needs and medical history 5
- Monitor patients for adverse effects, such as nausea, and adjust treatment as needed 7