AGA Journals (Gastroenterology): June, 2023

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.

The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults.

Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone.

The American Journal of Gastroenterology Recommendations

FIBER

Recommendation 1: 

In adults with CIC, the panel suggests the use of fiber supplementation over management without fiber supplements.

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.

OSMOTIC LAXATIVES

Recommendation 2: 

In adults with CIC, the panel recommends the use of Polyethylene glycol (PEG) compared with management without PEG.

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 months.

Side effects include abdominal distension, loose stool, flatulence, and nausea.

Recommendation 3: 

In adults with CIC, the panel suggests the use of Magnesium oxide (MgO) over management without MgO.

Implementation considerations

The trials were conducted for 4 weeks, 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.

Recommendation 4: 

In adults with CIC who fail or are intolerant to OTC therapies, the panel suggests the use of lactulose over management without lactulose.

Implementation considerations

Bloating and flatulence are dose-dependent and common side effects, which may limit its use in clinical practice.

STIMULANT LAXATIVES

Recommendation 5: 

In adults with CIC, the panel recommends the use of bisacodyl or sodium picosulfate (SPS) short term or as rescue therapy over management without bisacodyl or SPS.

Implementation considerations

Short-term use is defined as daily use for 4 weeks 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.

Recommendation 6: 

In adults with CIC, the panel suggests the use of senna over management without senna.

Implementation considerations

While the trials were conducted for 4 weeks, 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 a lower dose and increase if there is no response.

Abdominal pain and cramping may occur with a higher dose of senna.

SECRETAGOGUES

Recommendation 7: 

In adults with CIC who do not respond to OTC agents, the panel suggests the use of lubiprostone over management without lubiprostone.

Implementation considerations

Can be used as a replacement or as an adjunct to OTC agents.

Duration of treatment in trials was 4 weeks, 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.

Recommendation 8: 

In adults with CIC who do not respond to OTC agents, the panel recommends the use of linaclotide over management without linaclotide.

Implementation considerations

Can be used as a replacement or as an adjunct to OTC agents

Duration of treatment in trials was 12 weeks, but the drug label does not provide a limit.

May be associated with side effects of diarrhea leading to discontinuation of treatment

Recommendation 9: 

In adults with CIC who do not respond to OTC agents, the panel recommends the use of plecanatide over management without plecanatide.

Implementation considerations

Can be used as a replacement or as an adjunct to OTC agents

Duration of treatment in trials was 12 weeks, but the drug label does not provide a limit.

May be associated with side effects of diarrhea leading to discontinuation of treatment

5-HT₄ AGONIST

Recommendation 10: 

In adults with CIC who do not respond to OTC agents, the panel recommends the use of prucalopride over management without prucalopride.

Implementation considerations

Duration of treatment in trials was 4–24 weeks, 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