What are the treatment options for constipation?

Treatment of Mounjaro-Related Constipation

Start with a stimulant laxative (senna or bisacodyl 10-15 mg, 2-3 times daily) as first-line therapy, with the goal of achieving one non-forced bowel movement every 1-2 days. 1

Initial Assessment and Management

Before initiating treatment, assess for and rule out:

• Fecal impaction (if present, use glycerine suppositories or manual disimpaction) 1
• Bowel obstruction 1
• Metabolic causes: hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus 1

Stepwise Treatment Algorithm

First-Line Treatment

• Stimulant laxative alone (senna or bisacodyl 10-15 mg, 2-3 times daily) 1
• Evidence shows that adding stool softeners like docusate to senna provides no additional benefit 1
• Lifestyle modifications: Increase fluid intake and physical activity when appropriate 1
• Dietary fiber: Consider only if patient has adequate fluid intake (at least 2 liters daily) 1, 2

Important caveat: Supplemental medicinal fiber (like psyllium/Metamucil) is unlikely to control medication-induced constipation and is not recommended 1

Second-Line Treatment (If Constipation Persists)

Add one of the following osmotic or additional stimulant laxatives 1:

• Polyethylene glycol (PEG) - 1 capful with 8 oz water, 1-2 times daily 1
• Lactulose - 30-60 mL daily 1
• Magnesium hydroxide - 30-60 mL daily 1
• Magnesium citrate 1
• Rectal bisacodyl - once daily 1

Third-Line Treatment (For Refractory Cases)

If gastroparesis is suspected (common with GLP-1 agonists like Mounjaro):

• Add metoclopramide 10-20 mg, 2-3 times daily as a prokinetic agent 1

Fourth-Line Treatment (Advanced Options)

For persistent constipation unresponsive to standard laxatives, consider newer secretagogues 1:

• Linaclotide - FDA-approved for chronic idiopathic constipation and IBS-C in adults 3
• Lubiprostone - prostaglandin analog that enhances intestinal fluid secretion 1
• Plecanatide - another secretagogue option 1

These agents work by activating ion channels to move water into the intestinal lumen, softening stools and accelerating transit 1

Key Clinical Pitfalls to Avoid

1. Do not rely on fiber supplements alone - they are ineffective for medication-induced constipation without adequate hydration 1
2. Do not add stool softeners to stimulant laxatives - evidence shows no additional benefit 1
3. Reassess for impaction or obstruction if constipation persists despite treatment 1
4. Consider the gastroparesis component - GLP-1 agonists like Mounjaro slow gastric emptying, making prokinetic agents particularly relevant 1

Treatment Goals

Aim for one non-forced bowel movement every 1-2 days rather than daily bowel movements 1