What are the treatment options for chronic constipation?

Treatment of Chronic Constipation

The first-line treatment for chronic constipation should be osmotic laxatives, particularly polyethylene glycol (PEG), due to their established efficacy, safety profile, and strong evidence supporting their use. 1

Assessment and Classification

Before initiating treatment, it's important to:

• Rule out secondary causes of constipation (medications, metabolic disorders, neurological conditions)
• Identify potential defecatory disorders through symptom assessment (straining, incomplete evacuation, sensation of blockage)
• Determine constipation subtype: normal transit, slow transit, or defecatory disorder

Treatment Algorithm

First-Line Treatments

1. Lifestyle modifications:

   • Increased fluid intake
   • Regular physical activity
   • Adequate dietary fiber (25-30g daily)
   • Regular toileting schedule

2. Osmotic laxatives:

   • Polyethylene glycol (PEG): 17-34g daily (most effective osmotic laxative) 1
   • Lactulose: Alternative if PEG not tolerated
   • Magnesium salts: Use cautiously in renal insufficiency 1

Second-Line Treatments

If inadequate response to first-line treatments after 4-6 weeks:

1. Stimulant laxatives (for short-term or rescue therapy):

   • Bisacodyl: 10-15mg daily 2, 1
   • Senna: 2-3 tablets twice to three times daily 1

2. Secretagogues (for persistent symptoms):

   • Linaclotide: FDA-approved for chronic idiopathic constipation 3
   • Lubiprostone: FDA-approved for chronic idiopathic constipation 4

Third-Line Treatments

For refractory constipation:

1. Prokinetic agents:

   • Prucalopride (where available) 5

2. For opioid-induced constipation:

   • Methylnaltrexone: 0.15mg/kg subcutaneously every other day 2
   • Naloxegol: Oral alternative to methylnaltrexone 2

Special Considerations

Defecatory Disorders

If defecatory disorder is suspected (based on symptoms of incomplete evacuation, excessive straining):

• Pelvic floor retraining by biofeedback therapy is strongly recommended rather than continued laxative use 2
• Anorectal testing should be performed in patients who don't respond to initial measures 2

Severe Refractory Constipation

For patients with documented slow-transit constipation who fail aggressive medical management:

• Consider referral to specialized centers for colonic manometry and barostat testing 2
• Total colectomy with ileorectal anastomosis may be considered in highly selected cases (only about 5% of severe cases) 2

Efficacy and Monitoring

• Assess response based on improvement in stool frequency, consistency, and straining
• PEG has demonstrated superior efficacy compared to lactulose in improving stool consistency 1
• Secretagogues like linaclotide have shown improvements in complete spontaneous bowel movements (CSBMs) and stool consistency 3
• Reassess after 4-6 weeks of treatment and adjust therapy accordingly

Common Pitfalls to Avoid

1. Overreliance on stimulant laxatives: Long-term use can lead to dependence and decreased efficacy 1
2. Inadequate fluid intake: Osmotic laxatives require adequate hydration to work effectively
3. Failure to identify defecatory disorders: These respond better to biofeedback than to laxatives 2
4. Not addressing medications that cause constipation: Consider medication review and alternatives when possible
5. Setting unrealistic expectations: Complete symptom resolution may not be achievable; focus on improving quality of life 2

Remember that chronic constipation significantly impacts quality of life and represents a substantial economic burden on healthcare systems 5. Early effective management can improve patient outcomes and reduce complications.