Constipation: Therapy

From: 5 minutes consult

Medication (Drugs)

In patients with no known secondary causes of constipation, conservative nonpharmacologic treatment measures generally are recommended including:
Regular exercise
Increased fluid intake
Bowel habit training
Other nonpharmacologic therapies include:
Biofeedback therapy
Behavior therapy
Electric stimulation

First Line
Hydrophilic colloids (bulk-forming agents):
Psyllium (Konsyl, Metamucil, Perdiem Fiber): 1 rounded tsp in liquid PO daily up to t.i.d.
Methylcellulose (Citrucel): 1 rounded tsp in 8 oz cold water PO daily up to t.i.d.
Polycarbophil (Mitrolan, FiberCon): 1 g PO q.i.d.
Osmotic laxatives: Appropriate for short-term use. The usual dosage is 15–30 mL daily to b.i.d.:
Milk of magnesia
Magnesium citrate
Phosphate of soda
Lactulose (Chronulac)
Sorbitol
Alumina-magnesium (Maalox, Mylanta)
Polyethylene glycol (MiraLax) (0.8 mg/kg/d): Max is 17 g
Stool softeners:
Docusate sodium (Colace): 100 mg b.i.d.
Contraindications:
Any impediment to bowel transit, such as an obstructing lesion or ileus. Osmotic laxatives may result in overdistension or bowel perforation.
Any acute intra-abdominal inflammatory condition
Renal failure/disease and heart failure are relative contraindications.
Precautions: Advise patient against chronic use of irritant and osmotic laxatives.
Significant possible interactions:
Laxatives that contain magnesium:
Bind tetracyclines and prevent their absorption
Reduce effectiveness of digitalis and phenothiazines
Sodium polystyrene sulfonate (Kayexalate) binds and prevents neutralization of bicarbonate, leading to systemic alkalosis, which may be severe.

Second Line
Lubricants (e.g., mineral oil) are unpalatable to many patients, subject to leakage, and impose the risk of aspiration.
Emollient suppositories are useful and may be helpful in alleviating or palliating anorectal pain.
Irritant cathartics (stimulants):
Ricinoleic acid or castor oil (Neoloid): 30–60 mL/d
Bisacodyl (Dulcolax, Modane): 2–3 tablets PO or 1 suppository b.i.d.
Motor and secretory properties:
Anthraquinones: Senna (Ex-Lax in various formulations, Senokot): 1–2 capsules or 15–30 mL at bedtime
Enemas (avoid soap suds, which may lead to colitis):
Sodium phosphate (Fleet enema)
Suppositories:
Osmotic: Sodium phosphate
Lubricant: Glycerin
Stimulatory: Bisacodyl
Prokinetic agents

Additional Treatment

General Measures

Attempt to eliminate medications that may cause or worsen constipation
Increase fluid intake.
Increase fiber in diet.
Enemas if other methods fail