What are the treatment options for constipation?

Treatment Options for Constipation

The first-line treatment for constipation includes lifestyle modifications combined with appropriate laxative therapy, with stimulant or osmotic laxatives being the preferred pharmacological options. 1

Assessment and Diagnosis

Before initiating treatment, it's important to:

• Assess for underlying causes of constipation (hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus)
• Rule out bowel obstruction or impaction
• Evaluate medication use that may contribute to constipation (antacids, anticholinergics, antidepressants, antispasmodics, phenothiazines, haloperidol)
• Determine severity and chronicity of symptoms

Treatment Algorithm

Step 1: Non-pharmacological Interventions

• Increase fluid intake
• Increase physical activity within patient limits
• Ensure proper toileting position (using a footstool to elevate knees)
• Establish regular toileting schedule, particularly after meals
• Consider abdominal massage for patients with neurogenic problems 1
• Add dietary fiber for patients with adequate fluid intake 1

Step 2: First-line Pharmacological Treatment

• For general constipation:

  • Osmotic laxatives: Polyethylene glycol (PEG) 17g daily (preferred first-line) 1, 2
  • OR Stimulant laxatives: Senna or bisacodyl 10-15mg, 2-3 times daily 1

• For opioid-induced constipation:

  • Prophylactic stimulant laxative (e.g., senna) when initiating opioid therapy 1, 2
  • Avoid bulk-forming laxatives like psyllium for opioid-induced constipation 1, 2

Step 3: For Persistent Constipation

• Add or switch to other laxatives:
  • Lactulose 15-30ml twice daily
  • Magnesium hydroxide or magnesium citrate (use cautiously in renal impairment) 1
  • Rectal bisacodyl once daily 1

Step 4: For Refractory Constipation

• For opioid-induced constipation:

  • Peripherally acting μ-opioid receptor antagonists (PAMORAs):
    • Methylnaltrexone 0.15mg/kg subcutaneously every other day (no more than once daily) 1, 2
    • Naloxegol for chronic non-cancer pain 1, 2

• For chronic idiopathic constipation or IBS-C:

  • Linaclotide (selective guanylate cyclase-C receptor agonist) 1, 3
  • Lubiprostone (chloride channel activator) 1

Step 5: For Fecal Impaction

• Glycerin suppositories
• Manual disimpaction if necessary 1
• Followed by maintenance bowel regimen to prevent recurrence 1

Special Considerations

Elderly Patients

• Ensure access to toilets, especially for those with decreased mobility
• Provide dietetic support
• Optimize toileting (attempt defecation twice daily, 30 minutes after meals)
• PEG 17g/day is particularly effective and safe in elderly patients 1
• Avoid liquid paraffin in bed-bound patients or those with swallowing disorders 1
• Use magnesium-based laxatives cautiously due to risk of hypermagnesemia 1, 4

Cancer Patients

• Anticipate and treat constipation prophylactically, especially when opioids are prescribed 1
• Consider methylnaltrexone for opioid-induced constipation that doesn't respond to standard therapy 1

Common Pitfalls to Avoid

• Relying solely on stool softeners without stimulant laxatives 2
• Inadequate prophylactic laxative dosing when starting opioids 2
• Using bulk-forming laxatives like psyllium for opioid-induced constipation 1, 2
• Delaying escalation to PAMORAs for refractory opioid-induced constipation 2
• Failing to rule out bowel obstruction before aggressive laxative therapy 2
• Ignoring non-pharmacological measures like adequate hydration and physical activity 2, 5

By following this structured approach to constipation management, clinicians can effectively address this common condition while improving patient quality of life and preventing complications associated with untreated constipation.