Fiber

Osmotic laxatives

Stimulant laxatives

Secretagogues

Serotonin type 4 (5-HT4) Agonist

Table

Video

Document Overview

Design and created by Guideline Central in participation with the American College of Gastroenterology and American Gastroenterological Association.

Pharmacological Management of Chronic Idiopathic Constipation

American College of Gastroenterology

American Gastroenterological Association

Publication Date: May 18, 2023

Page Last Updated: May 5, 2026

Table 1. Overview of Interventions for the Pharmacological Management of Chronic Idiopathic Constipation

What medications can be used to treat chronic idiopathic constipation?	Mechanism of action	Recommended initial dose	Guidance for dose titration	Maximum dose	Estimated monthly cost, USD	Additional comments
Fiber	Soluble fiber traps water in the intestine and softens stool Insoluble fiber increases stool bulk	Starting dose of 5 g daily The Academy of Nutrition and Dietetics recommends 14 g/ 1,000 kcal intake per day Total daily fiber intake (dietary + supplement) 20–30 g/d	Per response to symptoms and side effects Common side effects include bloating and abdominal discomfort	Usually no benefit to increasing total fiber intake over 25–30 g	<$50	Ensure adequate hydration as fiber intake increases No clear evidence that soluble or insoluble fiber is more effective Soluble fiber includes psyllium, inulin, oats, fruit, barley, and legumes Insoluble fiber includes wheat bran, methylcellulose, wheat, rye, and other grains
Polyethylene glycol	Osmotic laxative	17 g daily	Per symptom response and side effects Common side effects include bloating, abdominal discomfort, and cramping	No clear maximum dose	$10–$45	Response to PEG has been shown to be durable over 6 mo
Magnesium oxide	Osmotic laxative	400–500 mg daily	Per symptom and response and side effects	No clear maximum dose Prior studies used 1,000–1,500 mg daily	<$50	Use with caution in patients with renal insufficiency and in pregnancy
Lactulose	Osmotic laxative	15 g daily	Per symptom response and side effects Bloating and flatulence may be limiting if preexisting symptoms or at higher doses	No clear maximum dose May cause hypernatremia and hypokalemia if patients experience significant diarrhea	<$50	Only osmotic agent studied in pregnancy
Bisadocyl and picosulfate	Stimulant laxative	Bisacodyl 5 mg daily	Per symptom response and side effects Side effects limited by cramping and abdominal discomfort	10 mg orally daily	<$50	Recommended for short-term use or rescue therapy Prolonged or excessive use can cause diarrhea and electrolyte imbalance Long-term safety and efficacy unknown
Senna	Stimulant laxative	8.6–17.2 mg daily	Per symptom response and side effects Side effects commonly reported include cramping and abdominal discomfort	Maximum recommended dose is 4 tablets twice daily	<$50	Also present in many laxative teas, where dose may be difficult to calculate Long-term safety and efficacy unknown
Lubiprostone	Intestinal secretagogue acting on chloride channel type 2 in the gut to increase chloride secretion	24 μg twice a day (BID)	Per symptom response Diarrhea may occur in a subset of patients, leading to discontinuation	24 μg BID	$374	May have benefit for abdominal pain Also approved for the treatment of irritable bowel syndrome with constipation (IBS-C) at a dose of 8 μg BID
Linaclotide	Intestinal secretagogue acting on guanylate cyclase-C, which activates CFTR in the gut to increase chloride secretion	72–145 μg daily	Per symptom response Diarrhea may occur in a subset of patients, leading to discontinuation	290 μg daily	$523	May have benefit for abdominal pain Also approved for the treatment of IBS-C at a dose of 290 ug daily
Plecanatide	Intestinal secretagogue acting on guanylate cyclase-C, which activates CFTR in the gut to increase chloride secretion	3 mg daily	Per symptom response Diarrhea may occur in a subset of patients, leading to discontinuation	3 mg daily	$526	May have benefit for abdominal pain. Also approved for the treatment of IBS-C at a dose of 3 mg daily
Prucalopride	5-HT₄ agonist that stimulates colonic peristalsis, which increases bowel motility	1–2 mg daily	Per symptom response Headaches and diarrhea may occur in a subset of patients, leading to discontinuation	2 mg daily	$563	May have additional benefit for abdominal pain

5-HT₄, serotonin type 4; BID, twice a day; IBS-C, irritable bowel syndrome with constipation; PEG, polyethylene glycol; USD, US dollar.
^aThe given cost accommodates the extent of generic and prescription medications and may not be the exact cost. In addition, the given cost is not the cost-effectiveness of the medication, but a probable cost per month.

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Implications for:	Strong Recommendation (S)	Conditional Recommendation (C)
Patients	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	The majority of individuals in this situation would want the suggested course of action, but many would not.
Clinicians	Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	Recognize that different choices will be appropriate for individual patients and that you must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their values and preferences.
Policy	The recommendation can be adopted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

Certainty in the Evidence
High	H	Low	L
Moderate	M	Very Low	VL

Source: Grading of Recommendations Assessment, Development and Evaluation Working Group (Schunemann HJ et al. Am J Respir Crit Care Med. 2006;174:605-14. Guyatt GH et al. BMJ 2008;336:924-6).

Document Overview

Document Title: Pharmacological Management of Chronic Idiopathic Constipation

Authoring Societies

American College of Gastroenterology

American Gastroenterological Association

Document Publication Date: May 18, 2023

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: journals.lww.com/ajg/Fulltext/9900/American_Gastroenterological_Association_American.697.aspx

Source Citation: Chang, Lin MD, AGAF, FACG1,*; Chey, William D. MD, FACG2,*; Imdad, Aamer MBBS, MPH3,*; Almario, Christopher V. MD, MSHPM, FACG4; Bharucha, Adil E. MD5; Diem, Susan MD, MPH6,7; Greer, Katarina B. MD, MS Epi8,9; Hanson, Brian MD6,10; Harris, Lucinda A. MD, FACG11; Ko, Cynthia MD12; Murad, M. Hassan MD13; Patel, Amit MD, FACG14; Shah, Eric D. MD, MBA, FACG2,15; Lembo, Anthony J. MD, FACG16,†; Sultan, Shahnaz MD, MHSc, FACG6,17,†. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. The American Journal of Gastroenterology ():10.14309/ajg.0000000000002227, May 19, 2023. | DOI: 10.14309/ajg.0000000000002227

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults.

Scope: Management, Treatment

Diseases/Conditions (MeSH)

D003248 - Constipation

Keywords: CIC, chronic constipation, chronic idiopathic constipation, constipation

Target Patient Population: The patient population of interest was adults (18 years or older) diagnosed with chronic idiopathic constipation

Target Provider Population: Gastroenterologists, primary care providers and other allied healthcare professionals caring for patients with CIC

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Supplemental Methodology Resource: Data Supplement

Number of Source Documents: 90

Literature Search Start Date: Friday, May 14, 2021

Literature Search End Date: Friday, November 4, 2022

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: No

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes

Pharmacological Management of Chronic Idiopathic Constipation

Fiber

Recommendation 1

Osmotic laxatives

Recommendation 2

Recommendation 3

Recommendation 4

Stimulant laxatives

Recommendation 5

Recommendation 6

Secretagogues

Recommendation 7

Recommendation 8

Recommendation 9

Serotonin type 4 (5-HT₄) Agonist

Recommendation 10

Table

Table 1. Overview of Interventions for the Pharmacological Management of Chronic Idiopathic Constipation

Video

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology