Constipation: New Approaches to a Common but Treatable Condition

Did you know that constipation is responsible for 8 million ambulatory visits per year?1 If you are a primary care provider, this statistic will not catch you by surprise. This Top Paper1 reminds us that there have been recent and significant changes in both the diagnostic approach to and the treatment of constipation.

The Top Paper and its accompanying guidelines2 include the following valuable information:

  • An algorithm for treatment is provided:
  1. Add fiber or a bulking agent to start treatment.
  2. If constipation is no better after step 1 above, treat with polyethylene glycol 3350 (an osmotic agent), or with bisacodyl or senna.
  3. If the patient’s constipation still does not improve, use a secretory agent such as linaclotide.
  4. Continued failure leads to consultation for additional testing.
  • What test is recommended to uncover a medical cause of constipation? Only a complete blood cell count is suggested.2 The presence of iron-deficiency anemia prompts additional testing.
  • More workup is indicated when these alarm symptoms and signs are present1:
  1. A sudden change in bowel habits
  2. Blood mixed with stool
  3. Unexpected weight loss
  4. A strong family history of colon cancer
  • Stimulant laxatives (senna and bisacodyl) are not dangerous.1
  • A new constipation epidemic is occurring among patients taking opioids. Three newer µ-opioid receptor antagonists have been identified (but not all have been approved by the Food and Drug Administration [FDA]) to help those with opioid-induced constipation.1 Methylnaltrexone, naloxone, and alvimopan were all superior to placebo in studies directed at constipation treatment. Methylnaltrexone has been FDA-approved, but that approval is limited to patients with constipation and medically advanced illnesses. Alvimopan is not FDA-approved, and because of significant adverse effects, it may not ever be approved for this indication.
  • Colonoscopy is indicated if it is prescribed either by Health Maintenance Guidelines or when alarm symptoms are present.
  • In the future, combining an opioid agent with a receptor antagonist in a single formulation may obviate constipation in people requiring opioids for pain relief.1

Primary care providers know as well as anyone else that constipation is a frequent chief complaint. This Top Paper and its accompanying guidelines furnish a simplified diagnostic and treatment approach that works and saves money by avoiding unnecessary testing. n

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the Consultant editorial board.

References:

  1. Wald A. Constipation: advances in diagnosis and treatment. JAMA. 2016;315(2):185-191.
  2. Stern T, Davis AM. Evaluation and treatment of patients with constipation. JAMA. 2016;315(2):192-193.