Alternative Oral Medications for Constipation
Several effective oral medications can be used for constipation as alternatives to Dulcolax (bisacodyl), including osmotic laxatives like polyethylene glycol, magnesium-based products, and lactulose, as well as newer prescription medications such as linaclotide, plecanatide, and prucalopride. 1
First-Line Options (Over-the-Counter)
Osmotic Laxatives
- Polyethylene glycol (PEG): 17g daily, costing $10-45 monthly. Can be titrated based on symptom response with no clear maximum dose. Response has been shown to be durable over 6 months. Common side effects include bloating, abdominal discomfort, and cramping. 1
- Magnesium oxide: 400-500mg daily, costing less than $50 monthly. Use with caution in patients with renal insufficiency and in pregnancy. Prior studies used 1,000-1,500mg daily. 1
- Lactulose: 15g daily, costing less than $50 monthly. It's the only osmotic agent studied in pregnancy. Bloating and flatulence may be limiting, especially at higher doses or if these symptoms preexist. 1
Stimulant Laxatives
- Senna: 8.6-17.2mg daily, costing less than $50 monthly. Can be titrated based on symptom response with no clear maximum dose. Also present in many laxative teas. Recommended maximum is 4 tablets twice per day. Long-term safety and efficacy are unknown. 1
Dietary Approaches
- Fiber supplements: 14g per 1,000 kcal intake per day, costing less than $50 monthly. Ensure adequate hydration as fiber intake increases. Common side effects include bloating and abdominal discomfort. 1
Prescription Options
Intestinal Secretagogues
- Linaclotide (Linzess): 72-145μg daily for chronic idiopathic constipation, costing approximately $523 monthly. May have additional benefit for abdominal pain. Diarrhea may occur in some patients, leading to discontinuation. Should be taken on an empty stomach, at least 30 minutes prior to a meal. 1, 2
- Plecanatide: 3mg daily, costing approximately $526 monthly. Also approved for IBS-C. Diarrhea may occur in some patients, leading to discontinuation. 1
Serotonin (5-HT) Agonist
- Prucalopride: 1-2mg daily, costing approximately $563 monthly. May have additional benefit for abdominal pain. Headaches and diarrhea may occur in some patients, leading to discontinuation. 1
Chloride Channel Activator
- Lubiprostone: 24μg twice daily, costing approximately $374 monthly. May benefit abdominal pain. Diarrhea may occur in some patients, leading to discontinuation. 1
Treatment Algorithm
Start with lifestyle modifications:
- Increase fluid intake
- Increase dietary fiber if adequate fluid intake and physical activity
- Exercise, if appropriate 1
First-line pharmacological treatment:
If inadequate response:
For refractory constipation:
Special Considerations
Safety of long-term stimulant laxative use: Evidence does not support use of stimulant laxatives for more than four weeks. Longer-term studies are warranted. 3
Drug interactions: Be aware that bisacodyl may interact with certain medications like digoxin, potentially reducing serum concentration. Similar interactions may exist with other laxatives. 4
Cost considerations: Over-the-counter options (PEG, magnesium oxide, lactulose, senna) are significantly less expensive (<$50/month) than prescription medications (>$370/month). 1
Efficacy comparison: A network meta-analysis concluded that bisacodyl showed similar efficacy to newer agents like prucalopride, lubiprostone, and linaclotide for the primary endpoint of ≥3 complete spontaneous bowel movements per week. 5
Palliative care setting: In palliative care, a more aggressive approach may be needed with combination therapy and higher doses of laxatives to achieve comfort. 1