What is the first-line laxative for a patient with constipation in a hospital setting?

First-Line Laxative for Constipation in Hospitalized Patients

Polyethylene glycol (PEG) is the first-line laxative for managing constipation in hospitalized patients due to its superior efficacy, safety profile, and strong evidence base. 1

Evidence-Based Rationale

The American Gastroenterological Association (AGA) strongly recommends PEG as the first-line treatment for constipation with moderate certainty of evidence 2, 1. PEG offers several advantages:

• Increases complete spontaneous bowel movements (CSBMs) and spontaneous bowel movements (SBMs) per week
• Improves stool form and consistency
• Provides global relief of constipation symptoms
• Has a dose-dependent effect on laxation 1
• Demonstrates durable efficacy over 6 months of treatment 3
• Has minimal side effects and excellent safety profile 4

Dosing and Administration

• Standard dose: 17g daily mixed in water or other beverage 2, 1
• Can be titrated based on clinical response
• For more urgent relief in hospitalized patients, higher doses (up to 68g) may provide more rapid response within 24 hours 5
• No clear maximum dose established; can be adjusted based on symptom response 2

Alternative Options (If PEG Contraindicated or Unavailable)

1. Lactulose: 15-30ml twice daily 1, 6

   • Osmotic laxative
   • May cause more bloating and flatulence than PEG
   • Only osmotic agent studied in pregnancy 2

2. Bisacodyl: 5-10mg daily 2, 1

   • Stimulant laxative
   • Best for short-term use or rescue therapy
   • Side effects include cramping and abdominal discomfort

3. Magnesium oxide: 400-500mg daily 2

   • Osmotic laxative
   • Avoid in patients with renal insufficiency

Special Considerations for Hospitalized Patients

• Opioid-induced constipation: For patients on opioids, PEG remains first-line, but may need to add a stimulant laxative or consider peripherally acting μ-opioid receptor antagonists (PAMORAs) if refractory 2, 1

• Fecal impaction: If suspected, confirm with digital rectal examination. For distal impaction, use digital fragmentation followed by enema 1

• Renal insufficiency: Avoid magnesium-containing laxatives; PEG remains preferred option 1

• Monitoring: Watch for red flags such as severe abdominal pain, no bowel movement for >3 days, vomiting, and signs of bowel obstruction 1

Common Pitfalls to Avoid

1. Using bulk-forming laxatives (psyllium) as first-line therapy, especially in medication-induced constipation or opioid-induced constipation 1

2. Relying on docusate sodium which has been shown to be ineffective for constipation management in adults 1

3. Failing to address underlying causes of constipation such as medication side effects, metabolic disorders, or neurogenic bowel 1

4. Using Fleet enemas in patients with neutropenia, thrombocytopenia, intestinal obstruction, recent colorectal surgery, severe colitis, or infection 1

5. Discontinuing treatment prematurely, as studies show many patients require ongoing treatment for chronic constipation 7

PEG has demonstrated long-term safety and efficacy for up to 12 months of continuous use with no evidence of tachyphylaxis 4, making it an ideal choice for hospitalized patients who may require ongoing constipation management.