Alverine for Constipation: Not Recommended as Primary Treatment
Alverine citrate is an antispasmodic agent used primarily for irritable bowel syndrome with abdominal pain, not for treating constipation itself—in fact, antispasmodic medications can worsen constipation and should be avoided as primary therapy for this condition. 1, 2
Understanding Alverine's Role
Alverine citrate functions as a smooth muscle relaxant that decreases intestinal contractility by reducing calcium sensitivity in smooth muscle and acts as a selective 5-HT1A receptor antagonist. 2 While one older study from 1976 showed that combining sterculia (a bulk-forming agent) with alverine citrate was more effective than sterculia alone for diverticular disease symptoms, this does not translate to using alverine for constipation management. 3
The key issue: Alverine relaxes intestinal smooth muscle, which can actually slow colonic transit and worsen constipation rather than improve it. 2
Evidence-Based Treatment Algorithm for Constipation
First-Line Therapy (Choose One)
Polyethylene glycol (PEG) 17g once daily is recommended as the preferred first-line agent by the American Gastroenterological Association, combined with increased fluid intake and physical activity when appropriate. 1
Stimulant laxatives (senna or bisacodyl 10-15mg, 2-3 times daily) are equally appropriate as first-line therapy, particularly for opioid-induced constipation. 1, 4
Milk of magnesia 1 oz twice daily is an inexpensive alternative osmotic agent with comparable efficacy. 1
All first-line agents cost approximately $1 or less per day. 1
Critical Pre-Treatment Assessment
Before initiating any laxative therapy:
Perform digital rectal examination to rule out fecal impaction. 1, 4
Rule out bowel obstruction through physical examination and consider plain abdominal X-ray if severe constipation is present. 1, 5
Check for metabolic causes: hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus. 1, 5
Review and discontinue constipating medications when feasible, including antacids, anticholinergics (antidepressants, antispasmodics like alverine, phenothiazines, haloperidol), and antiemetics. 6, 1
Second-Line Therapy
If constipation persists despite first-line therapy, add one of the following:
- Rectal bisacodyl once daily 1
- Lactulose 1
- Magnesium hydroxide or magnesium citrate (avoid in renal impairment due to hypermagnesemia risk) 1, 4
- Additional polyethylene glycol if not already using 1
Third-Line Therapy
- If gastroparesis is suspected, add metoclopramide 10-20 mg, 2-3 times daily as a prokinetic agent. 1
Fourth-Line Therapy
For persistent constipation unresponsive to standard laxatives, consider newer secretagogues: linaclotide, lubiprostone, or plecanatide. 1, 7
For opioid-induced constipation refractory to laxatives, consider peripherally-acting μ-opioid receptor antagonists like methylnaltrexone (0.15 mg/kg subcutaneously every other day). 6, 4
Special Considerations for Opioid-Induced Constipation
All patients receiving opioid analgesics should be prescribed a concomitant laxative prophylactically unless contraindicated by pre-existing diarrhea. 1
Senna 2 tablets twice daily is the most cost-effective prophylactic option. 4
Evidence shows that adding stool softeners like docusate to senna provides no additional benefit. 1, 4
Treatment Goals
Critical Pitfalls to Avoid
Do not use antispasmodics like alverine as primary constipation treatment—they relax intestinal smooth muscle and can worsen constipation. 6, 2
Do not rely on fiber supplements alone for medication-induced constipation, as they are ineffective without adequate hydration (at least 2 liters daily). 1
Do not add stool softeners to stimulant laxatives, as evidence shows no additional benefit. 1, 4
Reassess for impaction or obstruction if constipation persists despite treatment. 1