What are the treatment options for constipation?

Treatment Options for Constipation

The most effective treatment approach for constipation begins with osmotic laxatives such as polyethylene glycol (PEG) as first-line therapy, followed by stimulant laxatives if needed, with combination therapy often necessary for optimal management of symptoms. 1

Initial Assessment

• Evaluate for possible causes of constipation:
  • Medication review (opioids, anticholinergics, calcium channel blockers)
  • Physical examination including abdominal exam and digital rectal examination
  • Rule out bowel obstruction with plain abdominal X-ray if severe symptoms 2
  • Check calcium levels and thyroid function if clinically suspected 2

Treatment Algorithm

Step 1: Non-Pharmacological Interventions

• Ensure privacy and comfort for defecation
• Proper positioning (use footstool to assist with gravity)
• Increase fluid intake
• Increase physical activity within patient limits
• Establish regular toileting habits (attempt defecation 30 minutes after meals) 2, 1
• Abdominal massage may help reduce gastrointestinal symptoms, particularly in patients with neurogenic problems 2

Step 2: First-Line Pharmacological Treatment

• Osmotic laxatives (preferred first option):
  • Polyethylene glycol (PEG) 17-34g daily
  • Lactulose
  • Magnesium citrate or hydroxide (use cautiously in renal impairment) 2, 1

Step 3: Second-Line Pharmacological Treatment

• Stimulant laxatives if osmotic laxatives insufficient:
  • Senna (2-3 tablets twice to three times daily)
  • Bisacodyl (10-15mg daily)
  • Sodium picosulfate 2, 1

Step 4: Combination Therapy

• Combine osmotic and stimulant laxatives
• Consider adding stool softeners (docusate) 1

Step 5: Advanced Therapies

• For opioid-induced constipation:

  • Peripheral opioid antagonists: methylnaltrexone 0.15mg/kg subcutaneously 2, 1
  • Naloxegol (oral alternative) 1
  • Avoid bulk laxatives like psyllium for opioid-induced constipation 2

• For chronic idiopathic constipation:

  • Linaclotide (indicated for adults with chronic idiopathic constipation) 3
  • Lubiprostone (chloride channel activator) 1

Special Situations

Fecal Impaction

• Digital disimpaction (manual fragmentation and extraction)
• Followed by maintenance bowel regimen to prevent recurrence 2
• Suppositories and enemas are preferred first-line therapy when digital rectal exam identifies a full rectum 2

Opioid-Induced Constipation

• Prophylactic laxative therapy should be prescribed with all opioid analgesics 2
• Preferred options: osmotic or stimulant laxatives 2
• For refractory cases: peripheral μ-opioid receptor antagonists (PAMORAs) 2
• Combined opiate/naloxone medications can reduce risk 2

Elderly Patients

• Ensure access to toilets, especially for those with decreased mobility
• Provide dietetic support
• Manage decreased food intake that affects stool volume and consistency
• Optimize toileting (educate to attempt defecation twice daily, strain no more than 5 minutes)
• PEG (17g/day) offers an efficacious and tolerable solution with good safety profile 2

Contraindications and Precautions

• Enemas are contraindicated in patients with:

  • Neutropenia or thrombocytopenia
  • Paralytic ileus or intestinal obstruction
  • Recent colorectal or gynecological surgery
  • Recent anal or rectal trauma
  • Severe colitis, inflammation or infection 2, 1

• Magnesium salts should be used cautiously in renal impairment 2, 1

• Bulk laxatives (psyllium) should be avoided in opioid-induced constipation 1

Monitoring Response

• Goal: one non-forced bowel movement every 1-2 days 2
• Monitor stool frequency, consistency, and straining
• Assess for abdominal discomfort and rectal bleeding 1
• If constipation persists despite treatment, consider referral for specialized testing (anorectal manometry, balloon expulsion test, colonic transit studies) 1, 4

By following this structured approach to constipation management, most patients will experience significant improvement in symptoms and quality of life. The treatment should be adjusted based on response, with escalation to more advanced therapies as needed.