What are the recommendations for managing constipation?

From the Guidelines

Managing constipation requires a step-wise approach, starting with lifestyle modifications and fiber supplementation, followed by the use of osmotic laxatives, stimulant laxatives, and other pharmacological agents as needed.

Lifestyle Modifications and Fiber Supplementation

• Increasing fluid intake and regular moderate exercise are recommended as first-line therapy for constipation 1
• A gradual increase in fiber intake, both through diet and supplements, is suggested, with psyllium being the most effective fiber supplement 1
• Adequate hydration should be encouraged with the use of fiber supplements to minimize the risk of side effects such as flatulence 1

Osmotic Laxatives

• Polyethylene glycol (PEG) is recommended as a first-line therapy for chronic idiopathic constipation (CIC), with a strong strength of recommendation and moderate certainty of evidence 1
• Magnesium oxide may be considered as an alternative to PEG, although the strength of recommendation is conditional and the certainty of evidence is very low 1

Stimulant Laxatives

• Bisacodyl or sodium picosulphate may be used as short-term or rescue therapy for CIC, with a strong strength of recommendation and moderate certainty of evidence 1
• Stimulant laxatives should be used with caution and for limited periods to avoid dependence and other side effects 1

Other Pharmacological Agents

• Lactulose may be considered for patients who fail or are intolerant to other therapies, although the strength of recommendation is conditional and the certainty of evidence is very low 1
• Other agents, such as lubiprostone and linaclotide, may be considered for patients with severe or refractory constipation, although their use is typically reserved for patients who have failed other therapies 1

From the Research

Recommendations for Managing Constipation

The following are recommendations for managing constipation:

• First-line management includes lifestyle changes such as increased physical activity, high-fiber diets, adequate fluid intake, and bowel management techniques 2
• Biofeedback is an effective treatment option for dyssynergic defecation 2, 3
• A range of traditional and new pharmacologic therapies are available to remedy constipation, from stool softeners to agents that increase intestinal transit 2
• Management guidelines and recommendations are limited and are not sufficiently current to include treatments that became available more recently, such as prokinetic agents in Europe 3
• Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents 4

Diagnostic and Therapeutic Management

The diagnostic and therapeutic management of constipation involves:

• An evaluation of constipation begins with a focused history of a person's bowel habit, medications, diet, physical activity, and an anorectal examination 2
• In the absence of alarm signs, diagnostic testing for constipation is not routinely recommended in the initial evaluation 2
• Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents 4
• Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility 4

Special Considerations

For patients with advanced, progressive illness:

• Constipation is a highly prevalent and distressing symptom 5
• Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring 5
• Maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions 5