What are the treatment options for constipation?

Treatment Options for Constipation

The most effective approach to treating constipation involves a stepwise algorithm starting with lifestyle modifications, followed by osmotic laxatives such as polyethylene glycol (PEG) as first-line pharmacological therapy, with subsequent escalation to stimulant laxatives and newer agents for refractory cases. 1

First-Line Management: Lifestyle and Dietary Modifications

• Dietary interventions:

  • Increase dietary fiber to 25-30g daily 1
  • Maintain adequate fluid intake 1, 2
  • Consider fiber supplements (polycarbophil, methylcellulose, or psyllium) with gradual increase to minimize bloating and flatulence 3, 2
  • Warm liquids in the morning to stimulate bowel movements 1

• Behavioral modifications:

  • Establish a regular toileting routine, especially 30 minutes after meals 4, 1
  • Respond promptly to defecation urges 1
  • Ensure proper positioning (using a footstool to elevate knees above bottom) 1, 5
  • Increase physical activity and mobility within patient limits 4, 1, 2
  • Abdominal massage may help, particularly in patients with neurogenic problems 4

Second-Line Management: Pharmacological Interventions

Osmotic Laxatives (First-Line Pharmacological Therapy)

• Polyethylene glycol (PEG): 17-34g daily, can be increased by 50-100% if needed 1

  • Offers efficacious and tolerable solution, especially for elderly patients 4, 1
  • Maximum effect typically reached within 1 week 6

• Alternative osmotic agents:

  • Lactulose: 15-30ml twice daily 1
  • Magnesium salts: Use cautiously in renal impairment 4, 1

Stimulant Laxatives

• Senna, cascara, bisacodyl (5-10mg daily), or sodium picosulfate 4, 1, 7
• Best used as short-term or rescue therapy 1

Rectal Interventions

• Suppositories and enemas are preferred first-line therapy when digital rectal examination identifies a full rectum or fecal impaction 4
• Contraindicated in specific conditions (neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, etc.) 4

Third-Line Management: Prescription Medications for Refractory Constipation

• Secretagogues:

  • Linaclotide: FDA-approved for chronic idiopathic constipation in adults 6
    • Recommended dose: 145 mcg once daily 6
    • Significantly improves complete spontaneous bowel movement (CSBM) frequency, stool consistency, and straining 6
  • Lubiprostone: Alternative option for refractory constipation 3, 7

• For opioid-induced constipation:

  • Peripheral opioid antagonists (naldemedine, naloxegol) 1
  • Methylnaltrexone (0.15mg/kg subcutaneously every other day) as alternative 1
  • Consider opioid rotation to fentanyl or methadone for refractory cases 1

Special Considerations

Elderly Patients

• Pay particular attention to assessment 4
• Ensure access to toilets, especially with decreased mobility 4
• Provide dietetic support 4
• Optimize toileting (attempt defecation twice daily, 30 min after meals, strain no more than 5 min) 4
• Individualize laxatives based on medical history, drug interactions, and adverse effects 4
• Monitor chronic kidney/heart failure when using diuretics or cardiac glycosides concurrently 4

Fecal Impaction

• In absence of suspected perforation or bleeding, perform disimpaction (digital fragmentation and extraction) 4
• Follow with maintenance bowel regimen to prevent recurrence 4

Treatment Algorithm

1. Start with lifestyle and dietary modifications

   • Fiber, fluids, exercise, and proper toileting techniques

2. If inadequate response, add osmotic laxatives

   • PEG (17-34g daily) as first choice
   • Lactulose or magnesium salts as alternatives

3. If still inadequate, add or switch to stimulant laxatives

   • Bisacodyl, senna, or sodium picosulfate

4. For refractory constipation, consider:

   • Prescription medications (linaclotide, lubiprostone)
   • Biofeedback therapy for defecatory disorders
   • Transanal irrigation before considering surgical interventions

5. For opioid-induced constipation:

   • Always prescribe concomitant laxatives with opioid therapy
   • Consider peripheral opioid antagonists for refractory cases

Treatment Goals and Monitoring

• Aim for one non-forced bowel movement every 1-2 days 1
• Monitor stool frequency and consistency, abdominal discomfort, and rectal bleeding 1
• Reassess after 2-3 days of treatment and adjust as needed 1