How to manage constipation in patients taking Sertraline (Selective Serotonin Reuptake Inhibitor - SSRI)?

Management of Sertraline-Induced Constipation

For patients experiencing constipation while taking sertraline (SSRI), polyethylene glycol (PEG) is the first-line treatment due to its proven efficacy and safety profile. 1, 2

Understanding Sertraline-Related Constipation

Sertraline, a selective serotonin reuptake inhibitor (SSRI), can cause constipation as a side effect, though it occurs less frequently than with tricyclic antidepressants (TCAs). Research indicates that SSRIs like sertraline have a different gastrointestinal side effect profile compared to TCAs, with constipation being less common than diarrhea 3, 4.

Treatment Algorithm

First-Line Treatment:

• Polyethylene glycol (PEG) 17-34g daily
  • Strong recommendation based on high-quality evidence 1, 2
  • Well-tolerated osmotic laxative that increases water content in the colon
  • Can be used daily without risk of dependency

Second-Line Options (if PEG is ineffective or poorly tolerated):

• Magnesium salts (e.g., magnesium hydroxide)

  • Avoid in patients with renal impairment 2
  • Acts as an osmotic laxative

• Lactulose 15-30ml twice daily

  • Conditional recommendation based on moderate evidence 1
  • May cause bloating and flatulence

Third-Line Options:

• Stimulant laxatives
  • Bisacodyl 10-15mg daily
  • Senna (start at lower dose and titrate as needed)
  • Use for short-term or rescue therapy 2
  • May cause abdominal cramping

For Refractory Cases:

• Prescription medications
  • Linaclotide (strong recommendation, high-quality evidence) 1
  • Plecanatide (strong recommendation) 1
  • Prucalopride (strong recommendation) 1

Non-Pharmacological Interventions

• Increase dietary fiber (25-30g daily)

  • Gradual increase to avoid bloating
  • May be less effective for medication-induced constipation 2

• Optimize fluid intake (at least 1.5-2L daily)

• Improve toileting habits

  • Attempt defecation 30 minutes after meals
  • Use proper positioning (footstool for hip flexion) 2
  • Maintain privacy and comfort

• Increase physical activity as tolerated

Important Considerations

• Avoid bulk-forming laxatives like psyllium for medication-induced constipation as they are generally ineffective 2

• Avoid docusate sodium as evidence shows it is ineffective for constipation management 2

• Monitor for complications of constipation:

  • Urinary retention
  • Fecal impaction
  • Hemorrhoids
  • Anal fissures

• If constipation is severe and persistent despite appropriate management, consider:

  1. Evaluating for other causes of constipation
  2. Discussing with prescriber about potential SSRI alternatives
  3. Lowering sertraline dose if clinically appropriate

Special Situations

• For elderly patients: Start with lower doses of laxatives and titrate slowly; they are at higher risk for severe constipation 2

• For patients with irritable bowel syndrome: Consider the potential benefit of sertraline for IBS-D symptoms while recognizing it may worsen constipation in IBS-C 1

• For patients on multiple constipating medications: More aggressive prophylactic laxative therapy may be needed

By following this systematic approach to managing sertraline-induced constipation, most patients can achieve adequate symptom relief while continuing their necessary antidepressant therapy.