What are the treatment options for constipation?

Treatment Options for Constipation

The first-line treatment for constipation should include lifestyle modifications such as increased fluid intake, physical activity, and stimulant laxatives, with additional pharmacological interventions based on response and underlying cause. 1

Initial Assessment and Management

• Assess for cause and severity of constipation, ruling out impaction, obstruction, and other treatable causes such as hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 1
• Discontinue any nonessential constipating medications (antacids, anticholinergics, antidepressants, antispasmodics, phenothiazines, haloperidol, antiemetics) 1
• Increase fluid intake and physical activity when appropriate 1
• Consider added dietary fiber for patients with adequate fluid intake 1, 2

First-Line Pharmacological Treatment

• Prophylactic treatment with a stimulant laxative (senna) with or without stool softeners for patients on opioids 1
• Evidence suggests that stool softeners like docusate may not provide additional benefit when combined with senna 1
• Goal: one non-forced bowel movement every 1-2 days 1

Second-Line Treatment Options

If constipation persists, consider:

• Bisacodyl 10-15 mg, 2-3 times daily 1
• For impaction: glycerine suppositories or manual disimpaction 1
• Additional laxative options:
  • Rectal bisacodyl once daily 1
  • Oral polyethylene glycol (PEG) 1, 3
  • Lactulose 1
  • Magnesium hydroxide or magnesium citrate 1
  • Note: Long-term use of magnesium-based laxatives should be avoided due to potential toxicity 3

Third-Line Treatment Options

For refractory constipation:

• Prokinetic agents such as metoclopramide if gastroparesis is suspected 1
• Peripherally acting μ-opioid receptor antagonists for opioid-induced constipation:
  • Methylnaltrexone 0.15 mg/kg every other day (no more than once daily) 1
  • Naloxegol 1
  • Caution: Do not use in patients with postoperative ileus or mechanical bowel obstruction 1
• Newer agents for specific types of constipation:
  • Lubiprostone (prostaglandin analog that activates chloride channels) 1
  • Linaclotide (guanylate cyclase-C receptor agonist) for chronic idiopathic constipation and IBS-C 1, 4

Special Considerations

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

  • Linaclotide is FDA-approved and recommended by the American Gastroenterological Association 1, 4
  • Antispasmodic medications may help with associated abdominal pain 1

• For opioid-induced constipation:

  • Prophylactic treatment is essential 1
  • Peripherally acting μ-opioid receptor antagonists are effective while preserving pain management 1
  • Consider opioid rotation to fentanyl or methadone if constipation persists 1

• For elderly patients:

  • Start with lifestyle modifications but progress to pharmacological options as needed 3
  • Be cautious with long-term use of magnesium-based products due to potential toxicity 3

Treatment Algorithm

1. Start with lifestyle modifications (increased fluid, fiber if adequate fluid intake, physical activity) 1, 2, 5
2. Add stimulant laxative (senna) with or without stool softeners 1
3. If inadequate response, add bisacodyl and/or osmotic laxatives (PEG, lactulose) 1
4. For persistent constipation, consider prokinetics or specialized agents based on underlying cause 1, 5
5. For severe refractory cases, consider anorectal physiology testing and specialized interventions 5