Guidance issued on pharmacologic treatment of chronic idiopathic constipation

The American Gastroenterological Association and the American College of Gastroenterology recently issued a joint clinical practice guideline on pharmacologic management of chronic idiopathic constipation in adults.

The guideline was developed by a multidisciplinary panel that conducted systematic reviews of evidence on fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and a serotonin type 4 agonist (prucalopride). The panel used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess certainty of evidence for each intervention and used the Evidence to Decision framework to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. The guideline was published May 19 by the American Journal of Gastroenterology and Gastroenterology.

The guideline panel suggested the use of fiber supplementation (conditional recommendation, low certainty of evidence) and said it could be used as first-line therapy, particularly for patients whose dietary fiber intake is low. Among the evaluated fiber supplements, only psyllium appeared to be effective; data on bran and inulin were very limited and uncertain, the panel said. It noted that patients using fiber should be encouraged to hydrate adequately and that flatulence is a common side effect.

For osmotic laxatives, the panel recommended polyethylene glycol (strong recommendation, moderate certainty of evidence) and suggested magnesium oxide (conditional recommendation, very low certainty of evidence). Patients with renal insufficiency should avoid the latter due to risk of hypermagnesemia, the panel said. It also suggested lactulose (conditional recommendation, very low certainty of evidence) for patients who do not respond to or are intolerant of over-the-counter therapies.

For stimulant laxatives, the panel recommended bisacodyl or sodium picosulfate in the short term or as rescue therapy (strong recommendation, moderate certainty of evidence). It defined short-term use as daily use for up to four weeks. The panel said that long-term use is probably appropriate but noted that more data are needed on tolerance and side effects. The panel also suggested senna (conditional recommendation, low certainty of evidence), noting that the dose evaluated in trials is higher than commonly used in practice and suggesting that clinicians start at a lower dose and increase it if the patient does not respond.

Among patients who do not respond to over-the-counter agents, the panel recommended linaclotide (strong recommendation, moderate certainty of evidence), plecanatide (strong recommendation, moderate certainty of evidence), and prucalopride (strong recommendation, moderate certainty of evidence) and suggested lubiprostone (conditional recommendation, low certainty of evidence).

The panel noted that clinical trials did not uniformly evaluate the effect of interventions on such outcomes as efficacy, adverse effects, and tolerability and said that data were lacking on the most common treatments for chronic idiopathic constipation, such as fiber, lactulose, senna, and docusate. The authors called for future research to evaluate the long-term safety and tolerance of medications for this condition.

“This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC [chronic idiopathic constipation],” the panel authors wrote. “The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability.”