What are the management options for severe constipation in an outpatient setting?

From the Guidelines

Management of severe constipation in the outpatient setting should start with lifestyle modifications, including increased fluid intake and dietary fiber, and progress to medications like polyethylene glycol (PEG) as the first-line pharmacological treatment, as recommended by the American Gastroenterological Association and the American College of Gastroenterology 1. When managing severe constipation, it is essential to consider the following key points:

• Increase fluid intake to 2-3 liters daily to help soften stool and improve bowel movements
• Add dietary fiber (25-30g daily) to help promote regular bowel movements and prevent constipation
• Encourage regular physical activity to help stimulate bowel movements For medication management, the following options can be considered:
• Polyethylene glycol (PEG) 17g in 8oz of water daily for 2-4 weeks as the first-line treatment 1
• If inadequate response, add a stimulant laxative such as bisacodyl 5-10mg daily or senna 8.6-17.2mg at bedtime
• For patients with hard stools, consider adding docusate sodium 100mg twice daily as a stool softener It is crucial to note that these interventions work through different mechanisms, including:
• Osmotic laxatives like PEG, which draw water into the intestinal lumen to soften stool
• Stimulants like bisacodyl, which increase intestinal motility to promote bowel movements
• Stool softeners like docusate sodium, which decrease surface tension of stool to allow water penetration Patients should maintain a bowel diary to track response to treatment, and if symptoms persist despite 4-6 weeks of aggressive management, consider referral for specialized testing like anorectal manometry or defecography to rule out pelvic floor dysfunction or slow transit constipation 1.

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 CSBM responder rates are shown in Table 6 During the individual double-blind placebo-controlled trials, LINZESS 290 mcg did not consistently offer additional clinically meaningful treatment benefit over placebo than that observed with the LINZESS 145 mcg dose. Therefore, the 145 mcg dose is the recommended dose.

Management options for severe constipation in an outpatient setting include:

• LINZESS 145 mcg once daily, as it has been shown to be effective in increasing CSBM frequency and improving stool consistency in patients with CIC 2
• Bulk laxatives or stool softeners, as patients were allowed to continue stable doses of these medications during the trials 2 Note that the 145 mcg dose is the recommended dose, as the 290 mcg dose did not offer additional clinically meaningful treatment benefit over placebo compared to the 145 mcg dose 2

From the Research

Management Options for Severe Constipation

The management of severe constipation in an outpatient setting involves various treatment options, including:

• Dietary fiber and medicinal bulk as initial treatment options 3, 4, 5, 6
• Saline osmotic laxatives, lactulose, or stimulants like senna or bisacodyl as subsequent treatments if fiber is not successful or tolerated 3
• Polyethylene glycol laxative as a safe and effective initial or second-line agent for chronic constipation 3, 4
• Prucalopride, lubiprostone, and linaclotide as effective treatments for chronic idiopathic constipation 4, 5, 6
• Intestinal secretagogues and/or prokinetic agents as additional options 5
• Peripherally acting μ-opiate antagonists for opioid-induced constipation 5
• Biofeedback therapy for defecatory disorders 5
• Surgery, such as colectomy, for specific patients with slow-transit constipation 5

Non-Pharmacological Interventions

Non-pharmacological interventions, such as:

• Patient education 7
• Monitoring patients' bowel health 7
• Development of regular defecation habits 7
• Nursing education and workflow modification 7 are also important in the management of constipation, particularly in elderly patients 7

Treatment Approach

The treatment approach should be guided by efficacy and cost, and should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed by other options as needed 5