What are the treatment options for constipation?

Treatment Options for Constipation

The most effective approach to constipation management includes a combination of non-pharmacological measures and pharmacological treatments, with osmotic laxatives (polyethylene glycol, lactulose, magnesium salts) and stimulant laxatives (senna, bisacodyl) as preferred first-line pharmacological options. 1, 2

Initial Evaluation

• Comprehensive assessment should include questions about possible causes, physical examination (abdominal, perineal, digital rectal exam) 1, 2
• Laboratory tests 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 (small footstool can help apply pressure more effectively) 1, 2
• Increase fluid intake to soften stool 1, 2
• Increase physical activity and mobility within patient limitations 1, 2
• Increase dietary fiber intake if fluid intake is adequate 1, 3
• Consider abdominal massage, particularly for patients with neurogenic problems 1

Pharmacological Treatment

First-Line Options:

• Osmotic laxatives:

  • Polyethylene glycol (PEG): Most effective and best tolerated osmotic laxative 1, 2
  • Lactulose: Alternative osmotic option 1
  • Magnesium salts: Effective but use cautiously in renal impairment 1, 2

• Stimulant laxatives:

  • Bisacodyl: 10-15 mg, 2-3 times daily with goal of one non-forced bowel movement every 1-2 days 1
  • Senna: Effective stimulant option 1
  • Sodium picosulfate: Alternative stimulant option 1

Second-Line Options:

• For persistent constipation:

  • Combination therapy with osmotic and stimulant laxatives 1
  • Rectal bisacodyl once daily 1
  • Glycerin suppositories for impaction 1

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

  • Linaclotide: FDA-approved for IBS-C and chronic idiopathic constipation 4
  • Lubiprostone: Activates chloride channels to enhance intestinal fluid secretion 1

Special Situations:

Opioid-Induced Constipation (OIC):

• Prophylactic laxative therapy should be started concomitantly with opioids 1, 2
• Osmotic or stimulant laxatives are preferred first-line options 1
• Avoid bulk-forming laxatives (psyllium) in OIC 1
• For refractory OIC:
  • Methylnaltrexone: 0.15 mg/kg subcutaneously every other day (not more than once daily) 1, 2
  • Naloxegol: Peripherally-acting μ-opioid receptor antagonist 1
  • Combined opioid/naloxone medications can reduce risk of OIC 1

Fecal Impaction:

• Digital fragmentation and extraction of stool, followed by maintenance bowel regimen 1, 2
• Suppositories and enemas are preferred when digital rectal exam identifies a full rectum 1, 2

Special Populations

Elderly Patients:

• Ensure access to toilets, especially for those with decreased mobility 1, 2
• Optimize toileting (attempt defecation 30 minutes after meals, no more than 5 minutes of straining) 1
• PEG (17g/day) is particularly safe and effective 2
• Avoid liquid paraffin in bedridden patients or those with swallowing disorders due to aspiration risk 2

Treatment Algorithm

1. Start with non-pharmacological measures: Increase fluid intake, physical activity, and dietary fiber 1, 2

2. If insufficient response, add pharmacological therapy:

   • For normal-transit constipation: Begin with osmotic laxative (PEG preferred) 1, 2
   • For slow-transit constipation: Add stimulant laxative (bisacodyl or senna) 1

3. For persistent symptoms:

   • Combine osmotic and stimulant laxatives 1
   • Consider adding suppositories or enemas for distal constipation 1, 2

4. For refractory constipation:

   • Consider specialized testing (anorectal function, colonic transit) 5
   • For IBS-C: Consider linaclotide or lubiprostone 1, 4
   • For OIC: Add peripherally-acting μ-opioid receptor antagonist 1

Important Considerations

• Discontinue non-essential constipating medications when possible 2
• Monitor for electrolyte imbalances in patients with renal/cardiac insufficiency, especially when using magnesium salts 1, 2
• Fiber supplementation is most effective at doses >10g/day for at least 4 weeks, with psyllium showing particular efficacy 3
• Enemas are contraindicated in patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, anal/rectal trauma, severe colitis, or recent pelvic radiotherapy 1