What are the treatment options for constipation?

Treatment Options for Constipation

For most patients with constipation, osmotic laxatives (polyethylene glycol, lactulose, or magnesium salts) or stimulant laxatives (senna, bisacodyl, sodium picosulfate) are the preferred first-line pharmacological treatments. 1

Non-Pharmacological Approaches

• Ensure privacy and comfort for normal defecation, with proper positioning (using a small footstool can help apply pressure more effectively) 1, 2
• Increase fluid intake to support bowel function 1, 2, 3
• Increase physical activity and mobility within patient limits 1, 2
• Add dietary fiber if fluid intake is adequate (but avoid in patients with inadequate fluid intake) 1, 4
• Consider abdominal massage to improve bowel efficiency, particularly helpful for patients with neurogenic problems 1, 2

First-Line Pharmacological Options

• Osmotic laxatives:

  • Polyethylene glycol (PEG): 17g daily with 8oz water, effective and well-tolerated 1, 5
  • Lactulose: produces bowel movement within 24-48 hours 1
  • Magnesium salts (hydroxide, citrate): effective but use cautiously in renal impairment due to risk of hypermagnesemia 1

• Stimulant laxatives:

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

For Specific Situations

Opioid-Induced Constipation

• Prophylactic laxative therapy should be started when initiating opioid therapy 1
• Stimulant or osmotic laxatives are preferred first-line options 1
• Avoid bulk-forming laxatives like psyllium for opioid-induced constipation 1, 6
• For refractory cases, consider peripherally acting μ-opioid receptor antagonists:
  • Methylnaltrexone: 0.15 mg/kg subcutaneously every other day (not more than once daily) 1, 2
  • Naloxegol: effective for chronic opioid users 1

Fecal Impaction

• If impaction is present, use glycerin suppositories or perform manual disimpaction 1
• Follow with maintenance bowel regimen to prevent recurrence 1
• Consider rectal bisacodyl once daily if oral medications are ineffective 1

Elderly Patients

• Pay special attention to toilet accessibility and mobility issues 1
• PEG (17g/day) is particularly safe and effective for elderly patients 1
• Avoid liquid paraffin in bedridden patients or those with swallowing disorders due to aspiration risk 1
• Monitor renal function when using magnesium salts 1

Treatment Algorithm

1. Start with lifestyle modifications: increased fluids, physical activity, proper toileting habits 2, 4, 3

2. If inadequate response, add pharmacological therapy:

   • First choice: Osmotic laxative (PEG 17g daily with water) 1, 7
   • Alternative: Stimulant laxative (bisacodyl 10-15mg daily) 1

3. For persistent constipation:

   • Combine osmotic and stimulant laxatives 1
   • Consider adding rectal therapies (suppositories or enemas) if the rectum is full 1

4. For opioid-induced constipation unresponsive to standard laxatives:

   • Add methylnaltrexone 0.15mg/kg subcutaneously 1, 2
   • Consider opioid rotation to fentanyl or methadone 1

5. For refractory cases:

   • Evaluate for defecatory disorders or slow-transit constipation 7
   • Consider newer agents like lubiprostone or linaclotide for specific indications 1

Common Pitfalls to Avoid

• Don't rely solely on fiber supplements without ensuring adequate fluid intake 4, 8, 3
• Don't use bulk-forming agents (psyllium) for opioid-induced constipation 1, 6
• Don't use laxatives for more than one week without reassessing the cause of constipation 5, 7
• Don't overlook potential underlying causes (hypercalcemia, hypothyroidism, medications) 1, 2
• Don't use enemas in patients with neutropenia, thrombocytopenia, intestinal obstruction, or recent colorectal surgery 1