Can I be prescribed a medication to manage severe constipation due to Multiple Sclerosis (MS)?

Management of Severe Constipation in Multiple Sclerosis

For severe constipation related to Multiple Sclerosis, I recommend starting with polyethylene glycol (PEG) as first-line therapy, with the addition of bisacodyl as needed for rescue therapy when symptoms are particularly severe. 1

Step-by-Step Management Algorithm

First-Line Treatment:

1. Polyethylene glycol (PEG)
   • Start with daily dosing
   • Strong recommendation with moderate quality evidence 1
   • Response has been shown to be durable over 6 months
   • Side effects may include abdominal distension, loose stool, flatulence, and nausea

For Rescue Therapy (during severe episodes):

1. Bisacodyl
   • Start with 5 mg orally once daily at bedtime
   • If inadequate response after 1-2 days, increase to 10 mg daily 2
   • Strong recommendation with moderate quality evidence for short-term use 1
   • Onset of action: 6-12 hours for oral tablets 2
   • This is particularly useful during your episodes of severe constipation with abdominal distention

If First-Line Treatment is Inadequate:

Add or Switch to:

1. Stimulant Laxatives

   • Senna: Start with lower dose (8.6 mg daily) and increase as needed up to 17.2 mg daily 2
   • Take in the evening to produce a bowel movement the following morning
   • Conditional recommendation with low quality evidence 1

2. If OTC options fail, consider prescription medications:

   • Linaclotide (strongest evidence)

     • Take once daily on an empty stomach, at least 30 minutes before a meal 3
     • Strong recommendation with moderate quality evidence 1
     • Most common side effect is diarrhea (may begin within first 2 weeks of treatment) 3

   • Lubiprostone is another option

     • Conditional recommendation with low quality evidence 1
     • Side effects include nausea (11% of patients) and diarrhea (8% of patients) 4

Important Considerations for MS-Related Constipation

1. MS-specific factors:

   • Constipation in MS can be particularly severe, with studies showing around 40% of MS patients experience this symptom 5
   • The impact on quality of life is significant, with some patients reporting it affects them as much as mobility issues 6

2. Monitoring:

   • Track bowel movement frequency and consistency
   • Watch for side effects like abdominal cramping, excessive diarrhea, and perineal skin irritation
   • Goal is to achieve one non-forced bowel movement every 1-2 days 2

3. Cautions:

   • Avoid using Fleet enemas if you have any contraindications such as recent colorectal surgery, severe colitis, or undiagnosed abdominal pain 2
   • If using magnesium-based products, use with caution if you have renal insufficiency 1

Emerging Treatment Options

Recent research suggests that functional electrical stimulation (FES) of abdominal muscles may be beneficial for MS patients with severe constipation. Studies have shown improvements in whole gut transit time, colonic transit time, and constipation-related quality of life 7, 8. This could be an alternative treatment to discuss with your MS specialist if pharmacological approaches are not fully effective.

Practical Tips

• Ensure adequate hydration
• Take medications consistently at the same time each day
• For severe episodes as you described (feeling like a "pseudo bowel obstruction"), bisacodyl is appropriate as rescue therapy
• Regular use of PEG is likely to be more effective than intermittent use of stronger laxatives
• A combination approach (daily PEG with occasional bisacodyl) may be most effective for your specific symptoms

While colonoscopy prep medications are potent, they're not designed for regular use. The stepped approach outlined above provides a safer, more sustainable solution for managing your MS-related constipation.