What is the approach for managing chronic constipation?

From the Guidelines

The approach to managing chronic constipation should begin with lifestyle modifications, including increased fiber intake and adequate hydration, followed by the use of osmotic laxatives such as polyethylene glycol, and then stimulant laxatives like bisacodyl for short-term use, as recommended by the American Gastroenterological Association and the American College of Gastroenterology 1.

Key Recommendations

• Lifestyle modifications, including increased fiber intake (25-30g daily) and adequate hydration (at least 8 glasses of water daily), should be the initial approach to managing chronic constipation.
• Dietary fiber can be increased through foods like fruits, vegetables, and whole grains, or with fiber supplements such as psyllium (Metamucil, 1 tablespoon 1-3 times daily) or methylcellulose (Citrucel, 1 tablespoon 1-3 times daily) 1.
• Osmotic laxatives like polyethylene glycol (MiraLAX, 17g in 8oz water daily) or magnesium hydroxide (Milk of Magnesia, 30-60ml daily) can be tried if lifestyle modifications are insufficient 1.
• Stimulant laxatives such as bisacodyl (Dulcolax, 5-10mg daily) or senna (Senokot, 8.6-17.2mg at bedtime) may be used short-term for more resistant cases 1.
• Newer prescription medications, including lubiprostone (Amitiza, 24mcg twice daily), linaclotide (Linzess, 145-290mcg daily), or plecanatide (Trulance, 3mg daily), can be used for chronic idiopathic constipation, as they increase intestinal fluid secretion and motility 1.

Important Considerations

• It is essential to rule out secondary causes of constipation, such as medications (opioids, antidepressants, calcium channel blockers), metabolic disorders (hypothyroidism, diabetes), or structural abnormalities, before settling on a long-term management plan 1.
• If constipation persists despite these interventions, referral to a gastroenterologist for further evaluation is warranted.

From the FDA Drug Label

The efficacy of LINZESS for the treatment of CIC was established in two double-blind, placebo-controlled, randomized, multicenter clinical trials in adult patients (Trials 3 and 4) A total of 642 patients in Trial 3 and 630 patients in Trial 4 [overall mean age of 48 years (range 18 to 85 years), 89% female, 76% white, 22% black, 10% Hispanic] received treatment with LINZESS 145 mcg, 290 mcg, or placebo once daily and were evaluated for efficacy. The efficacy of LINZESS was assessed using a responder analysis and change-from-baseline endpoints Results for endpoints were based on information provided daily by patients in diaries. A CSBM responder in the CIC trials was defined as a patient who had at least 3 CSBMs and an increase of at least 1 CSBM from baseline in a given week for at least 9 weeks out of the 12-week treatment period.

The approach for managing chronic constipation involves the use of medications such as linaclotide (LINZESS), which has been shown to be effective in increasing complete spontaneous bowel movements (CSBMs) and improving stool consistency and reducing straining during bowel movements 2.

• The recommended dose of linaclotide for the treatment of chronic idiopathic constipation (CIC) is 145 mcg once daily.
• Lubiprostone is also indicated for the treatment of CIC in adults 3. The treatment approach should be individualized and based on the patient's specific needs and medical history.

From the Research

Approach for Managing Chronic Constipation

The approach for managing chronic constipation involves several steps, including:

• Lifestyle modifications, such as increased intake of fiber and water 4, 5, 6, 7
• Dietary changes, including increased intake of fiber, mineral water, and other nutrients 4, 6, 7
• Use of laxatives, such as polyethylene glycol, sodium picosulfate, bisacodyl, and linaclotide 5, 6, 7, 8
• Use of prokinetics and secretagogues for patients who do not respond to basic treatment 7
• Anorectal physiology tests and assessment of colorectal transit time for patients who do not respond to medical treatment 7
• Biofeedback therapy for patients with dyssynergic defecation 7
• Surgery for patients with very severe symptoms who do not respond to conservative treatment 7, 8

Lifestyle Modifications

Lifestyle modifications are an essential part of managing chronic constipation, and include:

• Increased intake of fiber and water 4, 5, 6, 7
• Scheduled toileting after meals 6
• Increased physical activity 7

Dietary Changes

Dietary changes can help manage chronic constipation, and include:

• Increased intake of fiber, including polycarbophil, methylcellulose, and psyllium 4, 6, 7
• Increased intake of mineral water, especially water rich in magnesium and/or bicarbonate 4
• Avoidance of foods that can exacerbate constipation 4

Medications

Various medications can be used to manage chronic constipation, including:

• Osmotic laxatives, such as polyethylene glycol 5, 6, 7, 8
• Stimulant laxatives, such as bisacodyl and senna 5, 6, 8
• Prokinetics and secretagogues, such as prucalopride and linaclotide 5, 7
• Lubiprostone 5, 6