Clarification: Repatha is NOT for Constipation
There appears to be a fundamental error in your question: Repatha (evolocumab) is a PCSK9 inhibitor used for lowering LDL cholesterol and cardiovascular risk reduction, NOT for treating chronic constipation. You may be confusing this with another medication, or the question contains a significant error.
What Repatha Actually Treats
Repatha (evolocumab) is indicated for:
- Adults with established cardiovascular disease to reduce risk of myocardial infarction, stroke, and coronary revascularization
- Adults with primary hyperlipidemia (including heterozygous familial hypercholesterolemia) requiring additional LDL-C lowering
- Pediatric patients aged 10 years and older with heterozygous familial hypercholesterolemia
- Patients with homozygous familial hypercholesterolemia requiring additional LDL-C lowering
If You Meant Chronic Constipation Treatment
If you are asking about pharmacologic management of chronic idiopathic constipation, the evidence-based treatment algorithm is:
First-Line Therapy
- Start with fiber supplements (specifically psyllium) for patients with low dietary fiber intake 1
- Adequate hydration (8-10 ounces of fluid) must accompany fiber supplementation 2
- Flatulence is a common side effect 1
Second-Line: Osmotic Laxatives
- Polyethylene glycol (PEG/Miralax) is the strongly recommended next step with moderate certainty of evidence 1
- PEG increases complete spontaneous bowel movements by 2.90 per week compared to placebo 3
- Dose: 17g daily mixed in 8 ounces of liquid, durable response over 6 months 1, 3
- Side effects include abdominal distension, loose stool, flatulence, and nausea 1
Alternative Osmotic Agents
- Magnesium oxide receives only conditional recommendation with very low certainty of evidence 1
- Avoid in renal insufficiency due to hypermagnesemia risk 1
- Lactulose is suggested only for patients who fail or are intolerant to OTC therapies, with bloating and flatulence limiting its use 1
Third-Line: Prescription Agents for OTC Failures
- Linaclotide, plecanatide, and prucalopride all receive strong recommendations with moderate certainty of evidence 1
- Lubiprostone receives conditional recommendation with low certainty 1
- These can be used as replacement or adjunct to OTC agents 1
Stimulant Laxatives
- Bisacodyl or sodium picosulfate are strongly recommended for short-term use (≤4 weeks) or rescue therapy 1
- Senna receives conditional recommendation for similar use 1
Critical Pitfall to Avoid
Do not confuse cardiovascular medications with gastrointestinal therapies. Repatha has no role in constipation management. If you need specific guidance on constipation treatment, please clarify which medication you are actually asking about.