Constipation medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Chronic constipation treatment includes both behavioral and pharmacological interventions. Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives. Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation. The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation. Probiotics are live microorganism spores that are given orally to improve the gastrointestinal tract function. Recently, use of probiotics in food industry is growing. Bifidobacterium and Lactobacillus are most studied organisms as probiotics.

Medical Therapy

• General principles of medical therapy in patients with chronic constipation are as following:

Chronic Constipation

EXCLUDE: • Inadeqate fiber intake • Medication • Cancer • Stricture • Systemic or neurologic disease

No clinical response

Fiber supplement, Simple laxatives

Clinical response

Normal

• Anorectal manometry • Balloon expulsion test

Colonic transit time

Unclear diagnosis

Evacuation disorder

Normal

Delayed

• Barium enema • MR proctography

• Pelvic floor retraining • Psychology • Diet

• Fiber supplement • Osmotic laxatives • Secretagogues • Prokinetics

Clinically significant structural disorder

Clinical response

No clinical response

Rectal surgery

Colonic manometry

Normal

Colonic inertia

Consider colectomy plus ileorectostomy

Chronic constipation management

• Chronic constipation treatment includes both behavioral and pharmacological interventions.
• Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives.

Lifestyle modification

• Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation.
• Moderate physical exercise as much as 32 min per day have shown significant improvement of quality of life but no significant decrease in laxative need for treatment.
• Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with irritable bowel syndrome (IBS).

Dietary interventions

• Fiber supplementation is the main primary therapeutic intervention for every patients with constipation.
• The polysaccharide fibers are the agents that increase the weight of stool and and improve the stool consistency by absorbing and retaining water.
• The most common used bulking organic polysaccharide in Canada is Psyllium.
• Psyllium and lactulose is found to significantly decrease colonic transit and improve stool consistency.

Biofeedback treatment

• The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation.
• During the biofeedback, patients receive feedback on their abdominal and pelvic floor muscle contractions recording by means of surface electromyography (EMG).
• Based on the biofeedback, patients are taught how to increase intra-abdominal pressure and also relax their pelvic floor muscles to have a coordinated evacuation.
• Regarding the outcomes, the biofeedback behavioral therapy is the choice treatment for functional defecation disorder.

Pharmacological intervention

Pharmacological intervention for constipation include:

Constipation

• 1 Adult
  • 1.1 Over the counter medicines
    • 1.1.1 Bulk forming agents
      • Preferred regimen (1): Citrucel 500 mg PO q8-12h
      • Preferred regimen (2): FiberCon 625 mg PO q6-12h
      • Preferred regimen (3): Konsyl 5 g (1 tablespoon) dissolved in 250 mL water PO q8-24h
      • Alternative regimen (1): Metamucil 1000 mg PO q8-12h
    • 1.1.2 Osmotic agents
      • Preferred regimen (1): Cephulac 5 g (1 tablespoon) dissolved in 250 mL water PO q6-8h
      • Preferred regimen (2): Fleet Phospho-Soda 15 mL dissolved in 250 mL water PO q6-8h
      • Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
      • Alternative regimen (1): Miralax 34 g dissolved in 250 mL water PO daily
      • Alternative regimen (1): Sorbitol 30-150 mL (70% solution) once
    • 1.1.3 Stool softeners
      • Preferred regimen (1): Colace 100-300 mg intra-rectal daily
      • Preferred regimen (2): Docusate sodium: 50-300 mg PO daily
      • Preferred regimen (3): Docusate calcium: 240 mg PO daily
      • Alternative regimen (1): Surfak 240 mg PO daily
    • 1.1.4 Lubricants
      • Preferred regimen (1): Fleet 19 g dissolved in 118-197 mL water enema per rectum daily
      • Preferred regimen (2): Zymenol 133 mL enema per rectum once
    • 1.1.5 Stimulants
      • Preferred regimen (1): Correctol 5-10 mg PO daily
      • Preferred regimen (2): Dulcolax 5-15 mg PO daily
      • Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
      • Alternative regimen (1): Senokot 100 mg PO daily
  • 1.2 Prescription medicines
    • 1.2.1 Chloride channel activators
      • Preferred regimen (1): Lubiprostone (Amitiza) 24 mcg PO q12h with food and water
    • 1.2.2 Guanylate cyclase-C agonists
      • Preferred regimen (1): Linaclotide (Linzess) 145 mcg PO daily

• 2 Pediatrics
  • 2.1 Over the counter medicines
    • 2.1.1 Bulk forming agents
      • Preferred regimen (1): Citrucel 500 mg PO daily
      • Preferred regimen (2): FiberCon 625 mg PO daily
      • Preferred regimen (3): Konsyl 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q8-24h
      • Alternative regimen (1): Metamucil 500 mg PO q8-12h
    • 1.1.2 Osmotic agents
      • Preferred regimen (1): Cephulac 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q6-8h
      • Preferred regimen (2): Fleet Phospho-Soda 5-10 mL dissolved in 250 mL water PO q6-8h (not for < 5 years of age)
      • Preferred regimen (3): Milk of Magnesia 5-15 mL PO daily
      • Alternative regimen (1): Miralax 17 g dissolved in 250 mL water PO daily
      • Alternative regimen (2): Sorbitol 2 mL/kg (as 70% solution) once
    • 1.1.3 Stool softeners
      • Preferred regimen (1): Colace 100 mg intra-rectal daily
      • Preferred regimen (2): Docusate
        • Docusate sodium
          • < 2 years: Not recommended
          • 2-12 years: 50-150 mg PO daily
          • >12 years: 50-300 mg PO daily
        • Docusate calcium
          • < 12 years: Not recommended
          • >12 years: 240 mg PO daily
      • Alternative regimen (1): Surfak 50 mg PO q12h
    • 1.1.4 Lubricants
      • Preferred regimen (1): Fleet 9.5 g dissolved in 59 mL water enema per rectum daily
      • Preferred regimen (2): Zymenol 51.5 mL enema per rectum once
    • 1.1.5 Stimulants
      • Preferred regimen (1): Correctol 5 mg PO daily
      • Preferred regimen (2): Dulcolax 5 mg PO daily
      • Preferred regimen (3): Milk of Magnesia 15-30 mL PO daily
      • Alternative regimen (1): Senokot 50 mg PO daily
  • 2.2 Prescription medicines
    • 2.2.1 Chloride channel activators
      • Preferred regimen (1): Lubiprostone (Amitiza) not approve for pediatrics
    • 2.2.2 Guanylate cyclase-C agonists
      • Preferred regimen (1): Linaclotide (Linzess) not approve for pediatrics

Probiotics

• Probiotics are live microorganism spores that are given orally to improve the gastrointestinal tract function. Recently, use of probiotics in food industry is growing.
• Bifidobacterium and Lactobacillus are most studied organisms as probiotics.
• It is found that probiotics significantly improve the chronic constipation symptoms in patients.

General treatment priorities in patients with constipation

Flow chart showing general treatment priorities in patient with constipation include:

Education Aknowledgement and attention to patietns' concerns Guiding and encouraging the patients to participate in the treatment and have realistic goals

Diet and physical activity Improving the previous habits

Fiber supplementation

Osmotic laxatives MoM, Lactulose, PEG

Prokinetics Prucalopride

Surgery