What are the treatment options for constipation?

Treatment Options for Constipation

The management of constipation should follow a stepwise approach beginning with non-pharmacological measures, followed by osmotic or stimulant laxatives as first-line pharmacological therapy, with specialized medications reserved for refractory cases. 1, 2

Initial Assessment

• Comprehensive evaluation should include questions about potential causes, physical examination (abdominal, perineal, digital rectal exam) 1, 2
• Laboratory investigations are not routinely necessary but may include calcium levels and thyroid function if clinically indicated 1, 2
• Plain abdominal X-ray may help evaluate fecal loading and exclude bowel obstruction in severe cases 1, 2

Non-Pharmacological Management

• Ensure privacy and comfort for normal defecation 1, 2
• Optimize positioning (using a small footstool can help apply pressure more effectively) 1, 2
• Increase fluid intake to improve stool consistency 1, 2
• Increase physical activity and mobility within patient limitations 1, 2
• Increase dietary fiber intake if fluid intake is adequate 1
• Consider abdominal massage to improve bowel efficiency, particularly beneficial for patients with neurogenic problems 1, 2

First-Line Pharmacological Treatment

• Osmotic laxatives are preferred first-line agents:

  • Polyethylene glycol (PEG) - effective, well-tolerated, and safe for long-term use 1, 2
  • Lactulose - effective but may cause bloating and flatulence 1
  • Magnesium salts - effective but use cautiously in renal impairment due to risk of hypermagnesemia 1

• Stimulant laxatives are also effective first-line options:

  • Bisacodyl (10-15 mg, 2-3 times daily) 1
  • Senna - natural stimulant that increases intestinal motility 1
  • Sodium picosulfate - effective for occasional use 1

Management of Opioid-Induced Constipation (OIC)

• All patients receiving opioid analgesics should be prescribed concomitant laxatives unless contraindicated by pre-existing diarrhea 1
• Osmotic or stimulant laxatives are generally preferred for OIC 1
• Bulk laxatives such as psyllium are not recommended for OIC 1
• For refractory OIC, consider peripherally acting μ-opioid receptor antagonists:
  • Methylnaltrexone (0.15 mg/kg subcutaneously every other day, not exceeding once daily) 1
  • Naloxegol - effective for chronic non-cancer pain patients 1

Second-Line and Specialized Treatments

• Secretagogues for refractory constipation:

  • Linaclotide - FDA-approved for IBS-C and chronic idiopathic constipation in adults 3
  • Lubiprostone - activates chloride channels to enhance intestinal fluid secretion 1

• Suppositories and enemas are preferred when digital rectal examination identifies a full rectum or fecal impaction:

  • Glycerin suppositories for mild cases 1
  • Bisacodyl suppositories for stronger effect 1
  • Various enema formulations for more severe cases 1

Management of Fecal Impaction

• Digital fragmentation and extraction of stool, followed by implementation of a maintenance bowel regimen 1, 2
• After disimpaction, institute preventive measures to avoid recurrence 1, 2

Special Considerations

• Elderly patients require particular attention to:

  • Ensuring toilet access, especially with decreased mobility 1, 2
  • Optimizing toileting schedule (attempt defecation 30 minutes after meals) 1, 2
  • Individualizing laxative therapy based on comorbidities 1, 2

• Fiber supplementation:

  • Most effective at doses >10g/day with treatment duration ≥4 weeks 4
  • Psyllium shows significant improvement in stool frequency and consistency 4
  • May cause increased flatulence as a side effect 4
  • Water-insoluble fibers (cellulose, hemicellulose) are most effective for constipation 5

Treatment Algorithm

1. Start with non-pharmacological measures (fluid, fiber if appropriate, activity)
2. Add osmotic laxative (PEG preferred) if non-pharmacological measures insufficient
3. Add or switch to stimulant laxative if osmotic laxative inadequate
4. Consider combination therapy with both osmotic and stimulant if single agent ineffective
5. For refractory cases, consider secretagogues or specialized treatments based on constipation type
6. For OIC, follow steps 1-4 but add peripherally acting μ-opioid receptor antagonists if standard laxatives fail