What are the treatment options for constipation?

Treatment Options for Constipation

The most effective approach for constipation management is to use a combination of polyethylene glycol (PEG) as an osmotic laxative along with a stimulant laxative such as senna or bisacodyl. 1

First-Line Treatment Options

Lifestyle and Non-Pharmacological Interventions

• Dietary modifications:

  • Increase dietary fiber to approximately 30g/day (fruits, vegetables, whole grains)
  • Ensure adequate fluid intake, particularly water 1
  • Avoid lactose-containing products, alcohol, and high-osmolar supplements 1

• Toileting habits:

  • Ensure privacy and comfort for normal defecation 2
  • Optimize positioning (use footstool to assist with defecation) 2, 1
  • Attempt defecation 30 minutes after meals to utilize gastrocolic reflex 1
  • Increase activity and mobility within patient limits 2

• Abdominal massage can be efficacious in reducing gastrointestinal symptoms, particularly in patients with neurogenic problems 2, 1

Pharmacological Treatment Algorithm

1. First-line laxatives:

   • Osmotic laxatives: PEG 17g daily mixed in 8 ounces of water 1
   • Stimulant laxatives: Senna 8.6-17.2mg at bedtime or bisacodyl 10-15mg 2-3 times daily 1
   • Combination therapy with both osmotic and stimulant laxatives is recommended for severe constipation 1

2. If inadequate response after 2-3 days:

   • Increase dose of initial agent
   • Add second agent (combine stimulant + osmotic if not already done)
   • Switch to alternative agent 1

3. For refractory constipation:

   • Secretagogues: Linaclotide 72-145 μg daily or lubiprostone 24 μg BID 1, 3
   • Linaclotide is FDA-approved for irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in adults 3

Special Considerations

Opioid-Induced Constipation

• Unless contraindicated by pre-existing diarrhea, all patients receiving opioid analgesics should be prescribed a concomitant laxative 2
• Stimulant laxatives are generally preferred 2
• Avoid bulk laxatives such as psyllium for opioid-induced constipation 2, 1
• For unresolved opioid-induced constipation, peripheral μ-opioid receptor antagonists (PAMORAs) such as methylnaltrexone may be beneficial 2, 1

Elderly Patients

• Pay particular attention to assessment of elderly patients 2
• Ensure access to toilets, especially with decreased mobility 2, 1
• PEG (17 g/day) offers an efficacious and tolerable solution with good safety profile 2
• Avoid liquid paraffin for bed-bound patients due to aspiration risk 2
• Use saline laxatives cautiously due to risk of hypermagnesemia, especially in those with renal impairment 2

Fecal Impaction

• In the absence of suspected perforation or bleeding, disimpaction (usually through digital fragmentation and extraction of the stool) should be performed 2
• Suppositories and enemas are preferred first-line therapy when digital rectal examination identifies a full rectum or fecal impaction 2
• Follow with implementation of a maintenance bowel regimen to prevent recurrence 2

Cautions and Contraindications

• Enemas are contraindicated for patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal or gynecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain, or recent radiotherapy to the pelvic area 2
• Avoid bulk-forming laxatives in non-ambulatory patients with low fluid intake due to increased risk of impaction 1
• Use magnesium and sulfate salts cautiously in renal impairment due to risk of hypermagnesemia 2

By following this structured approach to constipation management, focusing first on lifestyle modifications and then progressing to appropriate laxative therapy based on response, most patients can achieve adequate symptom relief and improved quality of life.