What are the recommended treatments for managing constipation?

Constipation Management

Start with polyethylene glycol (PEG) 17g dissolved in 8 ounces of liquid once daily as first-line pharmacological treatment, combined with lifestyle modifications including at least 1.5 liters of water daily and regular post-meal defecation attempts. 1, 2

First-Line Approach

Lifestyle Modifications (Implement Immediately)

• Fluid intake: Ensure at least 1.5 liters of water daily, increased during exercise, hot weather, or illness 1
• Timing strategy: Establish regular attempts at defecation 30 minutes after meals to utilize the gastrocolic reflex 1
• Positioning: Use a small footstool during defecation to assist gravity and allow easier pressure exertion 1
• Mobility: Increase physical activity within patient limits, even bed-to-chair transfers 1
• Medication review: Discontinue or substitute constipating medications before extensive workup 1

First-Line Pharmacological Treatment

• Polyethylene glycol (PEG) 17g once daily is the strongest recommendation with the best evidence base 1, 2
• PEG increases complete spontaneous bowel movements by approximately 2.9 per week compared to placebo, with durable response over 6 months 1, 2
• Common side effects include abdominal distension, loose stool, flatulence, and nausea 2

Fiber Supplementation (Mild Cases Only)

• Consider fiber supplement for mild constipation before or in combination with other treatments 2
• Psyllium has the best evidence for efficacy among fiber types 2
• Avoid bulk laxatives (psyllium) for opioid-induced constipation 1
• Flatulence is a common side effect 2

Second-Line Options (If PEG Inadequate)

• Lactulose is conditionally recommended as an alternative osmotic agent 1, 2
• Sodium picosulfate is strongly recommended 1
• Bisacodyl or senna are effective options, though senna has a conditional recommendation 1, 2
• Magnesium oxide should be used cautiously; avoid long-term use in renal impairment due to hypermagnesemia risk 1

Third-Line: Prescription Agents (For Refractory Cases)

• Linaclotide is strongly recommended at 145 mcg or 290 mcg orally once daily on empty stomach, 30 minutes before meals 1, 3
• Plecanatide is strongly recommended 1, 2
• Prucalopride (serotonin type 4 agonist) has strong recommendation 1, 2
• Lubiprostone has a conditional recommendation 1, 2

Special Population Management

Opioid-Induced Constipation

• All patients on opioids should receive concomitant osmotic or stimulant laxatives unless pre-existing diarrhea exists 1
• Avoid bulk laxatives (psyllium) specifically for this indication 1
• Combined opioid/naloxone preparations reduce constipation risk 1
• Methylnaltrexone (0.15 mg/kg subcutaneously) is recommended for refractory opioid-induced constipation despite laxative therapy 1, 2

Elderly Patients

• PEG 17g daily is preferred due to efficacy and excellent safety profile 1
• Avoid liquid paraffin in bed-bound patients or those with swallowing disorders due to aspiration lipoid pneumonia risk 1

Fecal Impaction Management

• Suppositories and enemas are first-line therapy when digital rectal exam identifies full rectum or impaction 1
• Perform disimpaction through digital fragmentation and extraction (if no perforation/bleeding suspected), followed by maintenance bowel regimen 1

Specialized Interventions

Defecatory Disorders (Pelvic Floor Dysfunction)

• Biofeedback therapy is the treatment of choice, improving symptoms in >70% of patients 1

Adjunctive Therapies

• Abdominal massage may reduce gastrointestinal symptoms and improve bowel efficiency, particularly in patients with neurogenic problems 1

Red Flags Requiring Further Investigation

• Pursue extensive evaluation for severe symptoms, sudden changes in bowel movement number/consistency, blood in stool, and older adults relative to health status and disease stage 1

Common Pitfalls to Avoid

• Do not provide inadequate trial periods for treatments before moving to more aggressive options 2
• Do not use liquid paraffin in bed-bound or dysphagia patients 1
• Do not use magnesium-based laxatives long-term in renal impairment 1
• Do not use bulk laxatives for opioid-induced constipation 1