From the Guidelines
For a patient who is still constipated despite using MiraLAX and senna, I recommend adding bisacodyl (Dulcolax) 5-10 mg orally daily or every other day. This recommendation is based on the most recent and highest quality study available, which suggests that adding a stimulant laxative such as bisacodyl can be effective in treating constipation 1. The American Gastroenterological Association Institute guideline on the medical management of opioid-induced constipation provides a strong recommendation for the use of laxatives, including stimulant laxatives like bisacodyl, in the treatment of constipation.
Treatment Options
Some key points to consider when adding bisacodyl to the patient's treatment regimen include:
- Starting with a low dose of 5-10 mg orally daily or every other day and adjusting as needed
- Monitoring the patient's response to treatment and adjusting the dose or adding other medications as needed
- Considering the use of a stimulant suppository such as bisacodyl 10 mg rectally if the patient does not respond to oral bisacodyl
- Adding an osmotic agent like lactulose 15-30 mL daily or magnesium citrate 195-300 mL as a one-time dose if the patient does not respond to stimulant laxatives
Non-Pharmacological Approaches
In addition to medication therapy, it's also important to ensure that the patient is:
- Drinking at least 8 glasses of water daily to stay hydrated
- Increasing dietary fiber gradually to help soften stool and promote regular bowel movements
- Engaging in regular physical activity to help stimulate bowel movements and improve overall health
The use of bisacodyl and other laxatives should be guided by the patient's individual needs and response to treatment, and should be used in conjunction with non-pharmacological approaches to promote optimal bowel health 1.
From the FDA Drug Label
LINZESS is a prescription medicine used to treat: irritable bowel syndrome with constipation (IBS-C) in adults. a type of constipation called chronic idiopathic constipation (CIC) in adults.
For a patient on miralax and senna and still constipated, linaclotide (LINZESS) could be considered as an add-on treatment for chronic idiopathic constipation (CIC) in adults 2.
- It is essential to consult a doctor before taking LINZESS, especially to discuss the patient's medical conditions and other medications.
- The doctor will determine if LINZESS is suitable for the patient and provide guidance on how to take it.
From the Research
Treatment Options for Constipation
The patient is already taking Miralax (polyethylene glycol) and senna, which are commonly used laxatives for constipation treatment 3, 4, 5, 6, 7.
Next Steps in Treatment
- If symptoms do not improve, a trial of linaclotide or lubiprostone may be appropriate 3, 4, 7.
- Peripherally acting mu-opioid antagonists are effective for opioid-induced constipation but are expensive 3.
- Biofeedback and behavioural therapies are effective, but should be reserved for selected patients after proper diagnostic evaluation 7.
- The use of an osmotic laxative, such as polyethylene glycol, followed by a stool softener, such as docusate sodium, and then stimulant laxatives, can be considered 3.
- Long-term use of magnesium-based laxatives should be avoided because of potential toxicity 3.
Considerations for Treatment
- Fecal impaction should be treated with mineral oil or warm water enemas 3.
- Lifestyle modifications, such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake, should be considered 3, 4, 7.
- Additional fiber intake in the form of polycarbophil, methylcellulose, or psyllium may improve symptoms 3.