What are the treatment options for constipation?

Treatment Options for Constipation

The management of constipation should be based on a balance between preventive strategies, self-care measures, and appropriate laxative therapy, with osmotic laxatives (polyethylene glycol) and stimulant laxatives being the preferred first-line pharmacological options. 1, 2

Assessment and Diagnosis

• Evaluate for possible causes of constipation including:

  • Medication side effects
  • Metabolic disorders (hypercalcemia, hypothyroidism)
  • Structural abnormalities
  • Neurological conditions

• Physical examination should include:

  • Abdominal examination
  • Perineal inspection
  • Digital rectal examination (DRE) to identify impaction 1

• Investigations are not routinely necessary unless there are:

  • Severe symptoms
  • Sudden changes in bowel movements
  • Blood in stool
  • Advanced age with concerning symptoms 1

Non-Pharmacological Management

• Prevention and self-care strategies:

  • Ensure privacy and comfort for defecation
  • Optimize positioning (use a footstool to assist gravity)
  • Increase fluid intake
  • Increase physical activity and mobility as tolerated
  • Implement proper toileting habits (attempt defecation twice daily, 30 minutes after meals) 1, 2

• Dietary modifications:

  • Increase fiber intake gradually
  • Ensure adequate hydration 3

• Abdominal massage can help reduce gastrointestinal symptoms and improve bowel efficiency, particularly in patients with neurogenic problems 1

Pharmacological Management

First-Line Options:

1. Osmotic Laxatives:

   • Polyethylene glycol (PEG): 17-34g daily - most effective and well-tolerated 1, 2
   • Lactulose: 15-30ml twice daily
   • Magnesium salts (use cautiously in renal impairment) 1

2. Stimulant Laxatives:

   • Senna
   • Bisacodyl (10-15mg daily)
   • Sodium picosulfate 1

For Specific Conditions:

• Fecal Impaction:

  • When DRE identifies a full rectum or impaction, suppositories and enemas are preferred first-line therapy
  • Manual disimpaction (digital fragmentation and extraction) followed by maintenance bowel regimen 1, 2
  • Contraindications for enemas: neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, anal/rectal trauma, severe colitis, undiagnosed abdominal pain 1

• Opioid-Induced Constipation (OIC):

  • All patients receiving opioid analgesics should be prescribed a concomitant laxative unless contraindicated 1
  • Osmotic or stimulant laxatives are preferred
  • Avoid bulk laxatives like psyllium for OIC 1, 2
  • For refractory OIC, consider:
    • Combined opiate/naloxone medications
    • Peripherally acting μ-opioid receptor antagonists (PAMORAs) 1, 2

Refractory Constipation:

• For persistent symptoms, consider prescription medications:
  • Linaclotide - FDA approved for IBS-C and chronic idiopathic constipation 4
  • Plecanatide
  • Prucalopride 2

Special Considerations for Elderly Patients

• Pay particular attention to assessment of elderly patients 1
• Key prevention measures:
  • Ensure access to toilets, especially for those with decreased mobility
  • Provide dietetic support
  • Manage decreased food intake
  • Optimize toileting habits
  • PEG (17 g/day) offers an efficacious and tolerable solution 1
  • Avoid liquid paraffin for bed-bound patients and those with swallowing disorders 1

Monitoring and Follow-up

• Monitor for:

  • Bowel movement frequency and consistency
  • Severity of symptoms
  • Red flags (severe abdominal pain, no bowel movement for >3 days, vomiting, signs of bowel obstruction) 2

• If constipation persists despite appropriate management, consider specialized testing to determine constipation subtype (slow transit vs. defecatory disorder) 2, 5

Common Pitfalls to Avoid

1. Using bulk-forming laxatives for opioid-induced constipation 1, 2
2. Using docusate as primary therapy (ineffective for constipation management) 2
3. Failing to address underlying causes of constipation 2
4. Not providing prophylactic laxatives when starting opioid therapy 1
5. Inadequate dosing of laxatives leading to treatment failure
6. Not considering fecal impaction in patients with overflow diarrhea

By following this structured approach to constipation management, clinicians can effectively address this common condition and improve patient quality of life.