What are the prescription medication options for treating chronic constipation?

Prescription Medications for Chronic Constipation

For chronic constipation, prescription medications include lubiprostone, linaclotide, plecanatide, and prucalopride, which are recommended when over-the-counter agents fail to provide adequate relief. 1

First-Line Prescription Options

• Lubiprostone (Amitiza): FDA-approved for chronic idiopathic constipation at 24 μg twice daily; works as an intestinal secretagogue acting on chloride channel type 2 in the gut 1, 2

  • May provide additional benefit for abdominal pain
  • Common side effect is nausea (can be reduced by taking with food)
  • Contraindicated in patients with known or suspected mechanical gastrointestinal obstruction 2
  • Estimated monthly cost: $374 1

• Linaclotide: Intestinal secretagogue with recommended initial dose of 72-145 μg daily, maximum 290 μg daily 1

  • Strong recommendation based on moderate certainty of evidence 1
  • Increases number of complete spontaneous bowel movements and spontaneous bowel movements per week 1
  • May cause diarrhea leading to treatment discontinuation in some patients 1
  • Estimated monthly cost: $523 1

• Plecanatide: Intestinal secretagogue with recommended dose of 3 mg daily 1

  • Also approved for irritable bowel syndrome with constipation
  • Diarrhea may occur in some patients, leading to discontinuation
  • Estimated monthly cost: $526 1

• Prucalopride: Serotonin type 4 (5-HT4) agonist with recommended dose of 1-2 mg daily 1, 3

  • FDA-approved for chronic idiopathic constipation in adults 3
  • May provide additional benefit for abdominal pain
  • Side effects include headaches and diarrhea
  • Estimated monthly cost: $563 1

Dosage Adjustments for Special Populations

• Hepatic Impairment:

  • For lubiprostone in moderate impairment (Child-Pugh Class B): 16 μg twice daily 2
  • For lubiprostone in severe impairment (Child-Pugh Class C): 8 μg twice daily 2

• Elderly Patients:

  • Efficacy of lubiprostone in persons 65 years and older is comparable with the overall study population 1
  • Careful assessment of underlying etiology of constipation is particularly important in elderly patients 4

Administration Guidelines

• Lubiprostone should be taken with food and water to reduce nausea 2
• Capsules should be swallowed whole and not broken apart or chewed 2
• Physicians and patients should periodically assess the need for continued therapy 2

Common Side Effects and Management

• Lubiprostone: Nausea (30.9% of patients), typically mild to moderate 5

  • Nausea is dose-dependent and decreases when taken with food 5
  • Only 5% of patients discontinue therapy due to nausea 5

• Linaclotide and Plecanatide: Diarrhea is the most common side effect 1

  • Patients should be instructed to discontinue medication and contact healthcare provider if severe diarrhea occurs 1

• Prucalopride: Headaches and diarrhea are common side effects 1

Clinical Considerations

• These prescription medications should be considered when over-the-counter agents fail to provide adequate relief 1
• Duration of treatment in trials was typically 12 weeks, but drug labels generally do not provide a limit for continued use 1
• Lubiprostone has been shown to improve stool frequency and consistency as well as abdominal discomfort and bloating 6, 7
• Response to lubiprostone generally manifests within 2 days in patients who respond to treatment 1

Contraindications and Cautions

• Lubiprostone is contraindicated in patients with known or suspected mechanical gastrointestinal obstruction 2
• Avoid use of lubiprostone in patients with severe diarrhea 2
• Ensure proper exclusion of pelvic floor dysfunction before initiating pharmacological therapy for chronic constipation 4