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.¹ 

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.