From the Guidelines
For a 22-year-old female with constipation for 7 days unresponsive to sennosides and docusate (Colace), I recommend starting polyethylene glycol 3350 (MiraLAX) 17g dissolved in 8 ounces of water once daily for 2-3 days, as supported by the most recent and highest quality study 1. If no improvement occurs within 3 days, increase to twice daily dosing. Ensure adequate hydration with at least 8 glasses of water daily and increase dietary fiber through fruits, vegetables, and whole grains. Physical activity for 30 minutes daily can also help stimulate bowel motility. Consider adding a stimulant laxative like bisacodyl 5-10mg orally if needed for more immediate relief, as suggested by 1. If these measures fail or if she develops concerning symptoms like severe abdominal pain, vomiting, or rectal bleeding, prompt medical evaluation is necessary. Polyethylene glycol works by drawing water into the intestinal lumen, softening stool and increasing bowel movements without significant electrolyte disturbances, as explained in 1. This approach is more effective than stool softeners like docusate alone, which have limited efficacy in chronic constipation, as noted in 1 and 1. The combination of osmotic laxatives, adequate hydration, dietary modifications, and physical activity addresses multiple factors contributing to constipation. It is also important to consider other causes of constipation, such as impaction, obstruction, and other treatable causes, as mentioned in 1 and 1. However, given the patient's age and presentation, the most likely cause is functional constipation, and the recommended treatment should be effective, as supported by 1.
From the FDA Drug Label
In LINZESS-treated patients re-randomized to placebo, CSBM and SBM frequency returned toward baseline within 1 week and did not result in worsening compared to baseline. The efficacy of LINZESS in the treatment of FC in pediatric patients 6 to 17 years of age was assessed using change-from-baseline endpoints. The primary efficacy endpoint was the 12-week change from baseline in SBM frequency rate.
The patient is a 22-year-old female with constipation for 7 days, and sennosides and colace have been ineffective. Linaclotide (LINZESS) may be considered as a treatment option. The dosage is 72 mcg once daily on an empty stomach at least 30 minutes prior to a meal. It is essential to advise the patient to read the FDA-approved patient labeling (Medication Guide) and to stop LINZESS and contact their healthcare provider if they experience unusual or severe abdominal pain, and/or severe diarrhea. 2
Key points:
- Linaclotide (LINZESS) is a potential treatment option for constipation.
- The recommended dosage is 72 mcg once daily.
- It is crucial to advise the patient to follow the administration instructions and to be aware of potential side effects.
From the Research
Management of Constipation
The patient is a 22-year-old female experiencing constipation for 7 days, with sennosides and colace (docusate sodium) being ineffective. The following options can be considered:
- Diet and lifestyle changes: As suggested by 3, making changes to diet and lifestyle can help treat constipation. Increasing fiber intake, fluid consumption, and physical activity may help alleviate symptoms.
- Alternative laxatives: According to 4, osmotic laxatives such as polyethylene glycol 3350 (PEG 3350) and lactulose are effective and safe for treating constipation. Stimulant laxatives like bisacodyl can also be considered as adjunct therapies.
- Combination therapy: 5 suggests that combining laxatives may be more effective than using a single agent. However, the efficacy of docusate sodium is debated, and it may not provide significant benefits.
- Other options: 6 mentions that senna and lactulose are commonly studied laxatives, and senna may be superior to or as effective as other laxatives. Chinese herbal medicine and other agents may also be considered, but more research is needed to evaluate their long-term efficacy and safety.
- PEG as an alternative: 7 compares the efficacy and side-effect profiles of lactulose, docusate sodium, and sennosides to PEG in opioid-induced constipation. While the review did not find sufficient evidence to support the use of these agents over PEG, it suggests that PEG may be a viable alternative for managing constipation.
Considerations
When managing constipation, it is essential to consider the individual's specific needs and medical history. The patient's ineffective response to sennosides and colace suggests that alternative treatments may be necessary. A thorough evaluation of the patient's diet, lifestyle, and medical history can help guide the selection of the most appropriate treatment option.