What are the common prescription medications for treating constipation in India?

Prescription Medications for Constipation in India

Polyethylene glycol (PEG) 3350 is the first-line medication for treating constipation in India, followed by osmotic laxatives like lactulose and stimulant laxatives such as senna or bisacodyl if needed. 1

First-Line Treatment Options

Osmotic Laxatives

• Polyethylene glycol (PEG) 3350 - 17g once daily 2

  • Mechanism: Sequesters fluid in the bowel
  • Advantages: Safe for up to 12 months of continuous use without developing tolerance 1
  • Available as powder to be dissolved in water

• Lactulose - 10-20g (15-30mL) daily 3

  • Mechanism: Semi-synthetic disaccharide that draws fluid into the bowel and produces osmotic diarrhea of low pH
  • Dosing: Can be started at 15mL daily and increased as needed
  • Note: May cause bloating and flatulence

• Magnesium salts (Magnesium citrate, Magnesium sulfate)

  • Mechanism: Draws fluid from the body into the bowel
  • Caution: Should be avoided in patients with renal insufficiency 4
  • Useful when rapid bowel evacuation is required 4

Second-Line Treatment Options

Stimulant Laxatives

• Senna - 8.8mg daily, typically taken at bedtime 5

  • Mechanism: Stimulates the myenteric plexus in the colon
  • Principal effect is in the descending and sigmoid colon 4
  • Can be combined with osmotic laxatives for better effect 6

• Bisacodyl - 5-10mg daily

  • Mechanism: Stimulates sensory nerves in the proximal colon
  • Increases sodium and water movement into the colonic lumen 4

• Sodium picosulfate

  • Similar mechanism to bisacodyl
  • Often used for bowel preparation before procedures

Special Considerations for Indian Patients

• Indian patients may define constipation differently than Western standards - many Indian patients consider less than 5 motions per week as constipation (rather than less than 3 per week in Western definitions) 7
• Feeling of incomplete evacuation is commonly reported as constipation by Indian patients 7
• Bristol Stool Scale types 1-3 are reported in 93.8% of Indian patients complaining of constipation 7

Treatment Algorithm

1. Start with lifestyle modifications:

   • Increase fluid intake to at least 8 glasses of water daily
   • Gradually increase dietary fiber to 20-25g per day
   • Increase physical activity as tolerated 1

2. First-line pharmacological treatment:

   • PEG 3350 (17g daily) 1, 2
   • If unavailable or not tolerated, try lactulose (15-30mL daily) 3

3. If inadequate response after 2-4 weeks:

   • Add a stimulant laxative (senna 8.8mg or bisacodyl 5-10mg at bedtime) 4, 5
   • Consider combination therapy of osmotic and stimulant laxatives 6

4. For opioid-induced constipation:

   • Methylnaltrexone (0.15mg/kg subcutaneously every other day) 1
   • Naloxegol or naldemedine as alternatives 4, 1

5. For fecal impaction:

   • Digital fragmentation and extraction of stool
   • Glycerin suppositories or mineral oil retention enemas
   • Once disimpaction is achieved, implement maintenance regimen 1

Common Pitfalls and Caveats

• Avoid bulk-forming laxatives (psyllium, methylcellulose) in opioid-induced constipation 4
• Avoid sodium salts as they may cause sodium and water retention 4
• Avoid magnesium salts in patients with renal impairment 4, 1
• Avoid docusate sodium as it has not shown benefit based on available literature 1
• Do not use enemas in patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, severe colitis, or undiagnosed abdominal pain 4
• Do not continue ineffective treatments without reassessment 1

Remember to reassess treatment efficacy within 2-4 weeks of initiating therapy, with a goal of achieving one non-forced bowel movement every 1-2 days 1.