What management options should be offered to a patient with chronic constipation by a family physician (General Practitioner)?

From the Guidelines

For patients with chronic constipation, family physicians should offer a stepwise approach beginning with lifestyle modifications and progressing to medications if needed, prioritizing fiber supplementation and osmotic laxatives as first-line treatments, as recommended by the American Gastroenterological Association and the American College of Gastroenterology 1.

Initial Management

The initial management of chronic constipation should focus on lifestyle modifications, including:

• Increasing dietary fiber to 25-30g daily through fruits, vegetables, and whole grains
• Adequate hydration of at least 1.5-2 liters of water daily
• Regular physical activity
• Establishing a consistent bathroom routine If lifestyle changes are insufficient, fiber supplements like psyllium (Metamucil) 1 teaspoon 1-3 times daily or methylcellulose (Citrucel) 1 tablespoon 1-3 times daily with plenty of water can be suggested, as they have been shown to be effective in managing chronic constipation 1.

Medication Management

For patients requiring medication, the following options can be considered:

• Osmotic laxatives such as polyethylene glycol (MiraLAX) 17g daily, which has been recommended by the American Gastroenterological Association and the American College of Gastroenterology as a first-line treatment for chronic constipation 1
• Magnesium hydroxide (Milk of Magnesia) 30-60ml at bedtime, which can be used as an alternative to polyethylene glycol
• Stimulant laxatives like bisacodyl (Dulcolax) 5-10mg or senna (Senokot) 8.6-17.2mg, which should be reserved for short-term use due to the risk of dependence and side effects 1

Referral and Further Evaluation

For patients with persistent symptoms despite these measures, consider referral for further evaluation to rule out underlying conditions like irritable bowel syndrome, hypothyroidism, or medication side effects. This is crucial in ensuring that the underlying cause of constipation is addressed, and appropriate treatment is provided to improve patient outcomes and quality of life 1.

From the FDA Drug Label

The efficacy of prucalopride tablets for the treatment of CIC was evaluated in six double-blind, placebo-controlled, randomized, multicenter clinical trials in 2484 adult patients (Studies 1 to 6; see Table 3).

The management options for a patient with chronic constipation by a family physician (General Practitioner) may include prucalopride tablets.

• Dosing: Patients less than 65 years can be dosed with prucalopride tablets 2 mg once daily.
• Geriatric patients: Geriatric patients can start on prucalopride tablets 1 mg once daily and, if necessary, the dose can be increased to 2 mg after 2 or 4 weeks of treatment in the event of insufficient response at 1 mg.
• Treatment duration: Treatment duration can range from 12 weeks to 24 weeks. Key points to consider when managing chronic constipation with prucalopride include:
• Efficacy: Prucalopride has been shown to increase the frequency of complete spontaneous bowel movements (CSBMs) per week.
• Response time: Improvement in the frequency of CSBMs/week can be seen as early as week 1 and maintained through week 12.
• Alternative efficacy endpoint: A responder can be defined as a patient who has at least 3 CSBMs and an increase of at least 1 CSBM from baseline in a given week for at least 9 weeks out of the 12-week treatment period and for at least 3 of the last 4 weeks of the treatment period 2, 2.

From the Research

Management Options for Chronic Constipation

The following management options can be offered to a patient with chronic constipation by a family physician:

• Lifestyle modifications, such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake 3, 4, 5, 6, 7
• Dietary changes, including increased intake of dietary fibre, fluid, and exercise 4, 5, 6, 7
• Osmotic laxatives, such as polyethylene glycol, for patients who do not respond to lifestyle changes 3, 4, 5, 6
• Stimulant laxatives, for patients who do not respond to osmotic laxatives 3, 4, 6
• Prokinetics and secretagogues, such as linaclotide or lubiprostone, for patients who do not respond to basic treatment 3, 4, 6
• Anorectal physiology tests and assessment of colorectal transit time, for patients who do not respond to medical treatment 4, 6
• Biofeedback therapy, for patients with dyssynergic defecation 4, 6
• Rectally administered laxatives or transanal irrigation, for patients with other evacuation disorders 4
• Surgery, for a carefully selected subset of patients with proven slow transit constipation who do not respond to conservative treatment 4, 6

Special Considerations

• Fecal impaction should be treated with mineral oil or warm water enemas 3
• Long-term use of magnesium-based laxatives should be avoided due to potential toxicity 3
• Peripherally acting mu-opioid antagonists are effective for opioid-induced constipation, but are expensive 3
• Digital rectal examination should be performed to assess for evidence of dyssynergic defaecation 6
• High resolution anorectal manometry should be undertaken if dyssynergic defaecation is suspected 6
• Screening for hypercalcaemia, hypothyroidism, and coeliac disease with appropriate blood tests should be considered 6