Pharmacological Management of Chronic Idiopathic Constipation
Fiber
In adults with CIC, the panel suggests the use of fiber supplementation over management without fiber supplements. (C, L)
Implementation considerations
- Dietary assessment is important to determine total fiber intake from diet and supplements
- Fiber supplements can be used as first-line therapy for CIC, particularly for individuals with low dietary fiber intake
- Among the evaluated fiber supplements, only psyllium appears to be effective (with very limited and uncertain data on bran and inulin)
- Adequate hydration should be encouraged with the use of fiber
- Flatulence is a commonly observed side effect with the use of fiber
620
Osmotic laxatives
In adults with CIC, the panel recommends the use of PEG compared with management without PEG. (S, M)
Implementation considerations
- A trial of fiber supplement can be considered for mild constipation before PEG use or in combination with PEG
- Response to PEG has been shown to be durable over 6 mo
- Side effects include abdominal distension, loose stool, flatulence, and nausea
620
In adults with CIC, the panel suggests the use of magnesium oxide over management without magnesium oxide. (C, VL)
Implementation considerations
- The trials were conducted for 4 wk, although longer term use is probably appropriate
- The panel suggests starting at a lower dose, which may be increased if necessary
- Avoid use in patients with renal insufficiency due to risk of hypermagnesemia
620
In adults with CIC who fail or are intolerant to OTC therapies, the panel suggests the use of lactulose over management without lactulose. (C, VL)
Implementation considerations
- Bloating and flatulence are dose-dependent and common side effects, which may limit its use in clinical practice
620
Stimulant laxatives
In adults with CIC, the panel recommends the use of bisacodyl or sodium picosulphate short term or as rescue therapy over management without bisacodyl or sodium picosulphate. (S, M)
Implementation considerations
- Short-term use is defined as daily use for 4 wk or less. While long-term use is probably appropriate, data are needed to better understand tolerance and side effects
- This is a good option for occasional use or rescue therapy in combination with other pharmacological agents for CIC
- The most common side effects are abdominal pain, cramping and diarrhea. The panel suggests starting at a lower dose and increasing the dose as tolerated
620
In adults with CIC, the panel suggests the use of senna over management without senna. (C, L)
Implementation considerations
- While the trials were conducted for 4 wk, longer term use is probably appropriate, but data are needed to better understand tolerance and side effects
- The dose evaluated in trials is higher than commonly used doses in practice. The panel suggests starting at lower dose and increase if no response
- Abdominal pain and cramping may occur with a higher dose of senna
620
Secretagogues
In adults with CIC who do not respond to OTC agents, the panel suggests the use of lubiprostone over management without lubiprostone. (C, L)
Implementation considerations
- Can be used as a replacement or as an adjunct to OTC agents
- Duration of treatment in trials was 4 wk, but the drug label does not provide a limit
- Nausea may occur; however, the risk of nausea is dose-dependent and seems to be lower when taken with food and water
620
In adults with CIC who do not respond to OTC agents, the panel recommends the use of linaclotide over management without linaclotide. (S, M)
Implementation considerations
- Can be used as a replacement or as an adjunct to OTC agents
- Duration of treatment in trials was 12 wk but the drug label does not provide a limit
- May be associated with side effects of diarrhea leading to discontinuation of treatment
620
In adults with CIC who do not respond to OTC agents, the panel recommends the use of plecanatide over management without plecanatide. (S, M)
Implementation considerations
- Can be used as a replacement or as an adjunct to OTC agents
- Duration of treatment in trials was 12 wk, but the drug label does not provide a limit
- May be associated with side effects of diarrhea leading to discontinuation of treatment
620
5-HT4 agonist
In adults with CIC who do not respond to OTC agents, the panel recommends the use of prucalopride over management without prucalopride. (S, M)
Implementation considerations
- Duration of treatment in trials was 4–24 wk but the drug label does not provide a limit
- Can be used as a replacement or as an adjunct to OTC agents
- May be associated with side effects of headache, abdominal pain, nausea, and diarrhea
620
Table
Table - Overview of interventions for the pharmacological management of chronic idiopathic constipation
| Meds used to treat CIC | Mechanism of action | Recommended initial dose | Guidance for dose titration | Maximum dose | Estimated monthly cost, USDa | Additional comments |
| Fiber | Soluble fiber traps water in the intestine and softens stool Insoluble fiber increases stool bulk | The Academy of Nutrition and Dietetics a 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 most commonly cramping and abdominal discomfort | No clear maximum dose. Often recommended maximum is 4 tablets twice per day | <$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 that increases chloride secretion | 24 μg 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 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 |
| 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 | Also approved for the treatment of IBS-C |
| Prucalopride | 5-HT4 agonist | 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.
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.
Recommendation Grading
Abbreviations
- ACG: American College Of Gastroenterology
- AGA: American Gastroenterological Association
- CIC: Chronic Idiopathic Constipation
- OTC: Over The Counter
- PEG: Polyethylene Glycol
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Pharmacological Management of Chronic Idiopathic Constipation
Authoring Organizations
American College of Gastroenterology
American Gastroenterological Association
Publication Month/Year
May 19, 2023
Document Type
Guideline
Country of Publication
US
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.
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
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D003248 - Constipation
Keywords
constipation, chronic constipation, CIC, chronic idiopathic constipation
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