What is the next best treatment for constipation after polyethylene glycol (Miralax)?

From the Guidelines

If Miralax (polyethylene glycol) hasn't effectively treated constipation, the next best treatment option is to consider stimulant laxatives like bisacodyl (Dulcolax) 5-10mg daily or senna (Senokot) 8.6-17.2mg daily, as recommended by the American Gastroenterological Association 1. These stimulant laxatives work by increasing intestinal contractions and typically produce results within 6-12 hours, making them a suitable option for patients who have not responded to Miralax. Some key points to consider when using stimulant laxatives include:

• They should be taken at bedtime for morning relief
• They can cause abdominal cramp and should be avoided in intestinal obstruction
• Excessive use can cause diarrhea and hypokalaemia
• They can be used in combination with other laxatives, such as osmotic laxatives, for enhanced effect In addition to stimulant laxatives, other options like lubricant laxatives (e.g., mineral oil), magnesium-based products (e.g., magnesium citrate or magnesium hydroxide), and prescription medications (e.g., linaclotide or lubiprostone) may also be considered, depending on the individual patient's needs and response to treatment 1. It's also important to note that increasing dietary fiber, staying well-hydrated, and engaging in regular physical activity can enhance treatment effectiveness and should be encouraged alongside medication use. Ultimately, the choice of treatment will depend on the severity of constipation, individual patient factors, and the presence of any underlying medical conditions.

From the FDA Drug Label

LINZESS is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults • functional constipation (FC) in pediatric patients 6 to 17 years of age

The next best treatment for constipation after Miralax could be Linaclotide (LINZESS), as it is indicated for the treatment of chronic idiopathic constipation (CIC) in adults and functional constipation (FC) in pediatric patients 6 to 17 years of age 2.

• The recommended dosage of LINZESS for CIC in adults is 145 mcg orally once daily.
• The recommended dosage of LINZESS for FC in pediatric patients 6 to 17 years of age is 72 mcg orally once daily.

From the Research

Next Best Treatment for Constipation after Miralax

• The next best treatment for constipation after Miralax can be considered based on the effectiveness of various laxatives, including stimulant and osmotic agents.
• Studies have shown that senna, a stimulant laxative, is effective in treating constipation, with significant improvements in bowel movements and quality of life compared to placebo 3, 4.
• Magnesium oxide, an osmotic agent, has also been shown to be effective in treating constipation, with significant improvements in bowel movements and quality of life compared to placebo 3.
• In children with anorectal malformation, senna has been found to be more effective than polyethylene glycol in treating constipation, with a significant improvement in daily bowel movements and fecal soiling 4.
• In hospitalized patients with cancer, a protocol of sennosides alone was found to be more effective than a protocol of sennosides plus docusate in inducing bowel movements, with fewer adverse effects 5.
• Long-term treatment with stimulant laxatives, such as bisacodyl and sodium picosulfate, has been found to be effective in treating constipation, but with a higher risk of adverse effects, such as diarrhea and abdominal pain 6.
• Osmotic laxatives, such as polyethylene glycol 3350, remain the most effective and safe therapy for both long and short-term treatment of pediatric functional constipation, with stimulant laxatives, like senna, making excellent choices for adjunct therapies in specific clinical scenarios 7.

Comparison of Laxatives

• Senna and magnesium oxide have been shown to be effective in treating constipation, with significant improvements in bowel movements and quality of life compared to placebo 3.
• Senna has been found to be more effective than polyethylene glycol in treating constipation in children with anorectal malformation 4.
• Bisacodyl and sodium picosulfate have been found to be effective in treating constipation, but with a higher risk of adverse effects, such as diarrhea and abdominal pain 6.
• Polyethylene glycol 3350 remains the most effective and safe therapy for both long and short-term treatment of pediatric functional constipation 7.

Safety and Efficacy

• Senna and magnesium oxide have been shown to be safe and effective in treating constipation, with significant improvements in bowel movements and quality of life compared to placebo 3.
• Senna has been found to be safe and effective in treating constipation in children with anorectal malformation, with no adverse effects reported 4.
• Bisacodyl and sodium picosulfate have been found to be effective in treating constipation, but with a higher risk of adverse effects, such as diarrhea and abdominal pain 6.
• Polyethylene glycol 3350 has been found to be safe and effective in treating pediatric functional constipation, with minimal adverse effects reported 7.