From the Guidelines
Management of severe constipation should start with lifestyle modifications and osmotic laxatives like polyethylene glycol (PEG) as the first-line treatment, as recommended by the American Gastroenterological Association and the American College of Gastroenterology 1. When managing severe constipation, it is essential to consider the following key points:
- Increase fluid intake to 2-3 liters daily to help soften stool and make it easier to pass
- Add dietary fiber (25-30g daily) to help promote regular bowel movements
- Encourage regular physical activity to stimulate bowel movements
- Use osmotic laxatives like PEG (17g in 8oz water daily) or lactulose (15-30ml daily) for immediate relief
- Consider stimulant laxatives such as bisacodyl (5-10mg orally or 10mg rectally) or senna (8.6-17.2mg at bedtime) for more resistant cases
- For impaction, consider glycerin or bisacodyl suppositories, or sodium phosphate enemas
- In severe cases unresponsive to these measures, manual disimpaction may be necessary
- For chronic severe constipation, prescription medications like lubiprostone (24mcg twice daily), linaclotide (145-290mcg daily), or prucalopride (2mg daily) may be warranted, as they work by increasing intestinal secretions and motility 1. It is crucial to address underlying causes of constipation, including:
- Reviewing medications that may cause constipation (opioids, anticholinergics, calcium channel blockers)
- Screening for hypothyroidism, diabetes, or neurological disorders
- Considering psychological factors Patients should be advised to respond promptly to defecation urges and establish a regular toileting schedule, preferably after meals when the gastrocolic reflex is strongest.
From the FDA Drug Label
Patients on placebo who were allocated to LINZESS had an increase in CSBM frequency and a decrease in abdominal pain levels that were similar to the levels observed in patients taking LINZESS during the treatment period A CSBM responder in the CIC trials was defined as a patient who had at least 3 CSBMs and an increase of at least 1 CSBM from baseline in a given week for at least 9 weeks out of the 12-week treatment period. The proportion of patients who were CSBM responders was statistically significantly greater with the LINZESS 145 mcg dose than with placebo
- Management of Severe Constipation: The FDA-approved dose of linaclotide for the treatment of chronic idiopathic constipation (CIC) is 145 mcg once daily 2.
- Key Findings:
- Linaclotide increased the frequency of complete spontaneous bowel movements (CSBMs) in patients with CIC.
- The proportion of patients who were CSBM responders was significantly greater with linaclotide 145 mcg than with placebo.
- Linaclotide also improved stool consistency and reduced straining with bowel movements.
- Clinical Decision: Linaclotide 145 mcg once daily may be considered for the management of severe constipation in adults with CIC 2.
From the Research
Management of Severe Constipation
- The management of severe constipation typically involves a combination of non-pharmacological and pharmacological interventions 3, 4, 5, 6, 7.
- Initial treatment options often include dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate 3, 4, 5, 6, 7.
- For patients who do not respond to over-the-counter agents, anorectal tests to evaluate for defecatory disorders may be necessary 4.
- Colonic transit, followed by assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility 4.
- Defecatory disorders often respond to biofeedback therapy 4.
- In some cases, slow-transit constipation may necessitate a colectomy 4.
- Polyethylene glycol has been shown to be more effective than lactulose in treating chronic constipation, with better outcomes in stool frequency, form of stool, relief of abdominal pain, and need for additional products 6.
- Newer agents, such as tegaserod and lubiprostone, have been approved for the treatment of patients with chronic constipation, but more research is needed to determine their role in treatment 7.
Treatment Options
- Bulk-forming laxatives, such as psyllium or methylcellulose, can help increase stool bulk and soften stool 5.
- Osmotic laxatives, such as polyethylene glycol or lactulose, can help draw water into the colon to soften stool 3, 5, 6.
- Stimulant laxatives, such as senna or bisacodyl, can help stimulate bowel movements 3, 5.
- Prostaglandin derivatives and 5-HT4 agonists may also be used to treat constipation, although their effectiveness and safety are still being studied 5.
Special Considerations
- In the elderly, constipation can be a highly prevalent and bothersome disorder that negatively affects quality of life 7.
- Decreased mobility and other co-morbid medical conditions may contribute to the prevalence of constipation in older adults 7.
- Systematic attention to history, examination, and investigation can be highly effective in resolving problems and enhancing quality of life in older adults with constipation 7.