New U.S. guidelines on the pharmacologic management of chronic idiopathic constipation

The American Gastroenterological Association and the American College of Gastroenterology have jointly developed evidence-based guidelines that outline recommendations for the pharmacologic management of chronic idiopathic constipation in adults. The guidelines are intended to provide a framework for approaching the management of chronic idiopathic constipation, with healthcare providers engaging in shared decision making with patients based on patient preferences, medication cost and availability. Chronic idiopathic constipation affects approximately 8%–12% of the US population. It is described as a lower gastrointestinal tract disorder of gut–brain interaction and can be associated with symptoms such as infrequent and incomplete defecation in the absence of mucosal or structural abnormalities. The effects of chronic idiopathic constipation on quality of life can be similar to those associated with conditions such as chronic obstructive pulmonary disease, diabetes and depression. Summary of guideline recommendations and implementation considerations (all recommendations apply only to adults with chronic idiopathic constipation) 1. Fibre The use of fibre supplementation is suggested over management without fibre supplements (Conditional recommendation; low certainty of evidence). Implementation considerations: Dietary assessment is important to determine total fibre intake from diet and supplements. Fibre supplements can be used as first-line therapy, particularly for adults with low dietary fibre intake. Among fibre 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 fibre. Flatulence is a commonly observed side effect. 2. Osmotic laxatives The use of polyethylene glycol (PEG) is recommended over management without PEG (Strong recommendation; moderate certainty of evidence). Implementation considerations: A trial of fibre supplementation can be considered for mild constipation before PEG use or in combination with PEG. Response to PEG is durable over six months. Side effects include abdominal distension, loose stool, flatulence and nausea. 3. Magnesium oxide The use of magnesium oxide is suggested over management without magnesium oxide (Conditional recommendation; very low certainty of evidence). Implementation considerations: Trials were conducted for four weeks, although longer term use is probably appropriate. Starting at a lower dose is suggested, and increasing the dose if necessary. Avoid use in patients with renal insufficiency due to risk of hypermagnesemia. 4. Lactulose In adults who fail or are intolerant to OTC therapies, the use of lactulose is suggested over management without lactulose (Conditional recommendation; very low quality of evidence). Implementation consideration Bloating and flatulence are dose-dependent and common side effects, which may limit its use in clinical practice. 5. Stimulant laxatives The use of bisacodyl short term or as rescue therapy is recommended over management without bisacodyl (Strong recommendation; moderate quality of evidence). Implementation considerations Short-term use is defined as daily use for ≤ 4 weeks. 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 chronic idiopathic constipation. The most common side effects are abdominal pain, cramping and diarrhea. Starting at a lower dose and increasing the dose as tolerated is suggested. 6. Stimulant laxatives The use of senna is suggested over management without senna (Conditional recommendation; low quality of evidence). Implementation considerations Trials were conducted for four weeks. Longer-term use is probably appropriate, but data are needed to better understand tolerance and side effects. The dose evaluated in trials was higher than commonly used doses in practice. Starting at a lower dose is suggested and increasing if there is no response. Abdominal pain and cramping may occur with a higher dose. 7. Secretagogues In adults who do not respond to OTC agents, the use of linaclotide (Constella) is recommended over management without linaclotide (Strong recommendation; moderate quality of evidence). 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. 8. Secretagogues In adults who do not respond to OTC agents, the use of plecanatide (Trulance) is recommended over management without plecanatide (Strong recommendation; moderate quality of evidence). 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 US drug label does not provide a limit (Note: approved in Canada only for treatment of irritable bowel syndrome with constipation). May be associated with diarrhea as a side effect, leading to discontinuation of treatment. 9. Serotonin type 4 (5-HT4) agonist In adults who do not respond to OTC agents, the use of prucalopride (Resotran, generics) is recommended over management without prucalopride (Strong recommendation; moderate quality of evidence). Implementation considerations Duration of treatment in trials was four to 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. For each of the preceding recommendations, the guidelines include a summary of the evidence, benefits and harms, certainty in evidence of effects, and a discussion. A separate table summarizes key properties of pharmacological agents used to manage chronic idiopathic constipation in adults, including mechanism of action, recommended initial dose, guidance for dose titration, maximum dose and additional comments. Reference 1. Chang L, Chey WD, Imdad A, et al. American Gastroenterological Association-American College of Gastroenterology clinical practice guideline: pharmacological management of chronic idiopathic constipation. Am J Gastroenterol 2023;118(6):p 936-54. (accessed June 15, 2023).

New U.S. guidelines on the pharmacologic management of chronic idiopathic constipation

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