What are the treatment options for severe constipation?

From the Guidelines

For severe constipation, the most effective treatment approach is to start with lifestyle changes, including increased fluid intake and dietary fiber, followed by over-the-counter osmotic laxatives like polyethylene glycol, and if necessary, prescription medications such as lubiprostone or linaclotide, as recommended by the American Gastroenterological Association (1).

Treatment Options

The treatment of severe constipation involves a step-wise approach, beginning with non-pharmacological interventions and progressing to pharmacological treatments if necessary. The following are key considerations:

• Lifestyle changes: Increased fluid intake (at least 8 glasses of water daily) and more dietary fiber (25-30g daily from fruits, vegetables, and whole grains) are essential for managing constipation (1).
• Over-the-counter options: Osmotic laxatives like polyethylene glycol (MiraLAX, 17g in 8oz water daily for up to 7 days) or stimulant laxatives such as bisacodyl (5-10mg orally) or senna (8.6-17.2mg at bedtime) can be used for short-term relief (1).
• Prescription medications: If over-the-counter options are ineffective, prescription medications like lubiprostone (Amitiza, 24mcg twice daily), linaclotide (Linzess, 145-290mcg daily), or prucalopride (Motegrity, 2mg daily) may be prescribed (1).

Additional Considerations

• Immediate relief: For immediate relief, consider glycerin or bisacodyl suppositories (1).
• Severe cases: Severe cases of constipation may require manual disimpaction or enemas (1).
• Underlying conditions: Persistent constipation warrants medical evaluation to rule out underlying conditions like hypothyroidism, medication side effects, or intestinal obstruction (1).

Evidence-Based Recommendations

The American Gastroenterological Association (1) and the American College of Gastroenterology provide evidence-based guidelines for the pharmacological management of chronic idiopathic constipation, emphasizing the importance of a step-wise approach to treatment. The British Society of Gastroenterology (1) also provides guidelines on the management of irritable bowel syndrome, which may be relevant to patients with constipation-predominant symptoms. However, the most recent and highest-quality study (1) prioritizes the use of lifestyle changes, over-the-counter osmotic laxatives, and prescription medications like lubiprostone or linaclotide for the treatment of severe constipation.

From the FDA Drug Label

1.1 Chronic Idiopathic Constipation in Adults Lubiprostone is indicated for the treatment of chronic idiopathic constipation (CIC) in adults. 1.2 Opioid-Induced Constipation in Adult Patients with Chronic Non-Cancer Pain Lubiprostone is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain 1.3 Irritable Bowel Syndrome with Constipation Lubiprostone is indicated for the treatment of irritable bowel syndrome with constipation (IBS-C) in women at least 18 years old.

The treatment options for severe constipation are not explicitly stated in the label. However, lubiprostone is indicated for the treatment of:

• Chronic Idiopathic Constipation (CIC) in adults
• Opioid-Induced Constipation (OIC) in adult patients with chronic non-cancer pain
• Irritable Bowel Syndrome with Constipation (IBS-C) in women at least 18 years old The recommended dosage for these conditions is 24 mcg twice daily for CIC and OIC, and 8 mcg twice daily for IBS-C 2.

From the Research

Treatment Options for Severe Constipation

The treatment options for severe constipation can be categorized into lifestyle modifications, dietary changes, and medication use.

• Lifestyle modifications include scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake 3, 4, 5
• Dietary changes involve increasing fiber intake in the form of polycarbophil, methylcellulose, or psyllium, and adequate intake of water, especially mineral water rich in magnesium and/or bicarbonate 3, 6, 5
• Medication use includes:
  • Osmotic laxatives, such as polyethylene glycol 3, 4, 7
  • Stimulant laxatives 3, 4, 7
  • Stool softeners, such as docusate sodium 3
  • Prokinetics and secretagogues, such as linaclotide or lubiprostone, for patients who do not respond to basic treatment 3, 4
  • Peripherally acting mu-opioid antagonists for opioid-induced constipation 3

Additional Therapies

Additional therapies that may be considered for severe constipation include:

• Biofeedback therapy for patients with dyssynergic defecation 4
• Rectally administered laxatives or transanal irrigation for patients with other evacuation disorders 4
• Surgery for patients with very severe symptoms who do not respond to conservative treatment 4
• Anorectal physiology tests and assessment of colorectal transit time if medical treatment fails or if symptoms indicate severely obstructed defecation 4