What are the treatment options for constipation?

Treatment Options for Constipation

Polyethylene glycol (PEG) is strongly recommended as the first-line pharmacological treatment for chronic constipation, with moderate certainty of evidence showing an increase in complete spontaneous bowel movements by approximately 2.9 per week. 1

First-Line Treatment Approach

Non-Pharmacological Measures

• Lifestyle modifications:
  • Optimize toileting habits: attempt defecation 30 minutes after meals
  • Strain no more than 5 minutes
  • Increase fluid intake
  • Encourage physical activity if feasible
  • Maintain adequate dietary fiber intake 1

First-Line Pharmacological Options

1. Polyethylene glycol (PEG): 17-34g daily 1

   • Most effective first-line agent
   • Safe for long-term use
   • Remains preferred option in renal insufficiency 1

2. Alternative first-line options:

   • Lactulose: 15-30ml twice daily 1
   • Magnesium hydroxide (avoid in renal impairment) 1

Second-Line Treatment Options

For patients not responding to first-line treatments:

1. Stimulant laxatives:

   • Bisacodyl: 10-15mg daily (for short-term or rescue therapy) 1
   • Senna (particularly effective for opioid-induced constipation) 1

2. For irritable bowel syndrome with constipation (IBS-C):

   • Linaclotide: FDA-approved for IBS-C and chronic idiopathic constipation in adults 2
     • Improves abdominal pain, stool consistency, and bowel movement frequency
     • Effects typically begin within the first week of treatment 2

Specific Constipation Types

Opioid-Induced Constipation (OIC)

1. First-line for OIC:

   • Stimulant laxatives (particularly senna) 1
   • PEG as an effective alternative 1

2. For persistent OIC despite optimized laxative therapy:

   • Naldemedine: 0.2mg daily (strong recommendation, high-quality evidence) 1
   • Naloxegol: 25mg once daily (strong recommendation, moderate-quality evidence) 1
   • Methylnaltrexone: 0.15mg/kg subcutaneously every other day (conditional recommendation) 1

Chronic Idiopathic Constipation

• PEG 145 mcg has demonstrated significant improvement in complete spontaneous bowel movements compared to placebo 2
• Linaclotide has shown efficacy in increasing CSBM frequency by approximately 1.5 CSBMs per week compared to placebo 2

Important Cautions and Contraindications

• Avoid in specific populations:

  • Liquid paraffin in bed-bound patients (risk of aspiration) 1
  • Saline laxatives (e.g., magnesium hydroxide) in elderly or renal impairment 1
  • Enemas in patients with neutropenia, thrombocytopenia, recent colorectal surgery, or severe colitis 1

• Ineffective treatments to avoid:

  • Docusate is ineffective for constipation management in adults 1
  • Bulk laxatives such as psyllium are not recommended for opioid-induced constipation 1
  • Fiber supplements like Metamucil are unlikely to control opioid-induced constipation 1

Monitoring and Follow-up

• Goal of therapy: one non-forced bowel movement every 1-2 days 1
• Monitor for red flags: severe abdominal pain, no bowel movement for >3 days, vomiting, signs of bowel obstruction 1
• Weekly monitoring of bowel movement frequency and consistency is recommended 1

Surgical Options

• Consider surgical options (only in ~5% of cases) such as total colectomy with ileorectal anastomosis for documented slow transit constipation that is refractory to medical management 1

Treatment Algorithm

1. Start with lifestyle modifications and PEG (17-34g daily)
2. If inadequate response, add or switch to lactulose or magnesium hydroxide (avoid in renal impairment)
3. For rescue therapy or short-term use, add bisacodyl 10-15mg daily
4. For opioid-induced constipation, use stimulant laxatives first, then consider PAMORAs if laxatives fail
5. For IBS-C or chronic idiopathic constipation, consider linaclotide if other treatments fail
6. Consider surgical options only for documented slow transit constipation refractory to medical management