New chronic constipation guideline evaluates treatment options

A new practice guideline aims to help clinicians navigate an increasingly crowded field of over-the-counter and prescription treatment options for chronic idiopathic constipation in otherwise healthy people.

The guideline, published in the American Journal of Gastroenterology, was jointly developed by the American Gastroenterological Association and the American College of Gastroenterology. It marks the first AGA update on chronic idiopathic constipation (CIC), also called functional constipation, in a decade.

In an interview, guideline lead author Lin Chang, MD, of the University of California, Los Angeles, noted that CIC is defined as constipation lasting at least 3 months in the absence of malignancy or obstruction, a side effect of medications or inflammatory bowel disease is common, affecting between 8% and 12% of all US adults. Most will be treated by primary care physicians, not specialists, Chang said. And most will see that their doctors have already tried several over-the-counter treatments.

“The criteria for CIC or functional constipation haven’t really changed” since the last AGA guideline on it was published in 2013, Chang said, adding that the diagnostic standard currently used is the Rome IV criterion for constipation. functional. “There are just more drugs right now than there were 10 years ago.”

The new guideline, which integrates evidence from 28 studies, offers recommendations regarding different types of fibers; the osmotic laxatives polyethylene glycol, magnesium oxide and lactulose; and the stimulant laxatives bisacodyl, sodium picosulfate, and senna. Also evaluate the secretagogues lubiprostone, linaclotide, plecanatide, and the serotonin type 4 agonist prucalopride.

One agent commonly used in clinical practice, the stool softener docusate sodium, does not appear in the guidelines, as there was too little data available on it to make an assessment, Chang said. Fruit-based laxatives were excluded due to a recent review of the evidence. Lifestyle modifications such as exercise, surgery, and probiotics have not been evaluated.

The guideline’s strongest recommendations are for polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride, with conditional recommendations for fiber, lactulose, senna, magnesium oxide, and lubiprostone.

As costs of recommended therapies range from less than $10 per month to over $500, the authors also included pricing information, noting that “patient values, costs, and health equity considerations” need to be taken into account. consideration in treatment choices. “For polyethylene glycol, there is a strong recommendation, although the certainty of the evidence was moderate,” Chang said. “And with fiber, even though we’ve only made a conditional recommendation based on the evidence, our observations and algorithm make it clear that it should be considered a first-line treatment.”

In general, “if someone has milder symptoms, you should try fiber or increase your dietary fiber intake,” Chang commented. “If that doesn’t work, try over-the-counter remedies like polyethylene glycol. Then, if symptoms are more severe or first-line treatments fail, go to prescription agents.”

In clinical practice, “there are always considerations beyond scientific evidence of safety and efficacy,” Chang stressed. “You have to personalize the treatment for the patient.” A patient may present that they have already failed with fiber, or that they do not want to use magnesium or cannot afford a more expensive agent.

The guidelines contain implementation recommendations that could guide the choice of therapy or dosage. With prescribing the osmotic laxative lactulose, for example, “you may not want to use it as a first-line treatment because bloating and flatulence are very common,” Chang said. “Our implementation recommendations make that clear.” For senna, a stimulant laxative derived from the leaves of the senna plant and for which quality evidence is limited, the guideline authors stressed that patients should start on low doses to avoid cramping.

Chang said that while the new guidelines cover treatment options for otherwise healthy adults, doctors should be aware that patients presenting with CIC may still have a defecation disorder. “A person may also have pelvic floor dysfunction as a primary cause or contributing factor. If someone fails fiber or polyethylene glycol, consider a digital rectal exam as part of the physical exam. If this is abnormal, consider referring them for anorectal manometry”.

Untreated constipation carries risks, Chang noted, but “sometimes people with bothersome symptoms don’t treat them because they fear they’ll become addicted to treatment. It’s an addiction in the sense that you have to treat any chronic condition, like high blood pressure or diabetes,” he said. but the treatments are not addictive, with the exception of some stimulant laxatives to which people can develop tolerance.”

Hemorrhoids and defecation disturbances can occur over time from straining, Chang said. “The pelvic wall can also become very relaxed, and this is difficult to correct. Or a rectal prolapse can develop. Another thing that happens when people have long-standing constipation for many years is that they start to lose the urge.” to have a bowel movement.”

The development of the guideline was funded by the AGA and ACG, without industry support. Authors with conflicts of interest regarding a specific intervention or drug were not authorized to speak on those interventions.

This story originally appeared on, part of the Medscape Professional Network.

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