Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Constipation Medication

  • Author: Marc D Basson, MD, PhD, MBA, FACS; Chief Editor: BS Anand, MD  more...
 
Updated: Sep 29, 2015
 

Medication Summary

Medications to treat constipation include bulk-forming agents (fibers), emollient stool softeners, rapidly acting lubricants, prokinetics, laxatives, osmotic agents, and prosecretory drugs. Fiber is arguably the best and least expensive medication for long-term treatment, although enthusiasm for the use of polyethylene glycol as first-line therapy in chronic constipation is increasing.

NOTE:  In January 2014, the FDA issued a warning that exceeding 1 dose of OTC sodium phosphate products for constipation over a course of 24 hours may cause serious harm to the kidneys and heart and, in rare cases, may be fatal.[13, 14] Using more than the recommended dose of these products can cause severe dehydration and changes in serum electrolyte levels. Individuals who may be at higher risk for potential adverse events include young children; patients older than 55 years; patients who are dehydrated; patients with kidney disease, bowel obstruction, or inflammation of the bowel; and patients who are using medications that may affect kidney function.[13, 14]

Emollient stool softeners are easier to use, but they lose their effectiveness with chronic administration. These drugs are best used for prophylaxis in a short-term setting, such as in patients receiving a postoperative narcotic prescription.

Rapidly acting lubricants and laxatives, including over-the-counter products, are often used to treat acute and chronic constipation.

Polyethylene glycol is simple to use and is more effective than placebo in the management of chronic constipation; however, the effects of chronic therapy with polyethylene glycol over decades are still not well studied.

Newer therapies for constipation include the prokinetic agent prucalopride (not approved in the United States), the osmotic agent lubiprostone, and the guanylate cyclase C (GC-C) agonist linaclotide.

Next

Laxatives, Bulk-Producing

Class Summary

Bulk-forming agents are used for long-term prophylaxis, treatment of constipation, or both in patients without anatomic outlet obstruction.

Psyllium (Metamucil, Fiberall, Bulk-K, Fibro-XL)

 

Psyllium dosages vary depending on whether the preparations contain sugar or are sugar-free (the former are 50% sugar). These preparations must be taken with water, or they may cause obstruction.

Methylcellulose (Citrucel)

 

Theoretically, nonfermentable products such as methylcellulose, which produce less gas, are better tolerated than psyllium. Occasionally, patients who cannot tolerate one preparation may do well with another product.

Previous
Next

Laxatives, Stool Softener

Class Summary

Emollient stool softeners are used for prophylaxis against constipation in acute and subacute settings.

Docusate (Colace, Correctol, Docu-Soft, Dok)

 

Docusate is indicated for patients who should avoid straining during defecation. It allows incorporation of water and fat into stools, causing stools to soften. Tachyphylaxis develops with long-term use. Docusate is effective acutely. It does not induce defecation.

Previous
Next

Laxative, Stimulant; Laxative, Stool Softener

Class Summary

Emollient stool softeners cause stool to soften; stimulants increase the peristaltic activity in the gastrointestinal (GI) system.

Senna concentrate/docusate (Peri-Colace, Dok Plus, Senokot-S)

 

Docusate sodium allows incorporation of water and fat into stool, causing stool to soften. Sennosides induce defecation by acting directly on the intestinal mucosa or the nerve plexus, which stimulates peristaltic activity, increasing intestinal motility. The combination usually produces action 8-12 hours after administration.

Previous
Next

Laxatives, Saline

Class Summary

Saline laxatives are used for acute treatment of constipation in the absence of bowel obstruction.

Magnesium hydroxide (Phillips Milk of Magnesia, Fleet Pedia-Lax Chewable)

 

Magnesium hydroxide causes osmotic retention of fluid, which distends the colon and increases peristaltic activity; it also promotes emptying of the bowel.

Magnesium citrate (Citroma)

 

Magnesium citrate causes osmotic retention of fluid, distending the colon and increasing peristaltic activity; it promotes emptying of the bowel. The drug works within 3 hours given orally (PO) or 15 minutes given rectally (PR). It may cause electrolyte imbalance, especially in young children or patients with renal insufficiency.

Magnesium sulfate

 

Magnesium sulfate causes osmotic retention of fluid, which distends the colon and increases peristaltic activity; it promotes emptying of the bowel.

Previous
Next

Laxatives, Lubricant

Class Summary

Lubricant laxatives are used for acute or subacute management of constipation. They lubricate the intestine and facilitate passage of stool by decreasing water absorption from the intestine.

Mineral oil (Fleet, Kondremul)

 

Mineral oil is more gentle than some other rapidly acting laxatives. It generally works within 8 hours. Long-term use is accompanied by concerns about lipid pneumonia, lymphoid hyperplasia, and foreign body reactions.

Previous
Next

Laxatives, Other

Class Summary

These agents elicit various pharmacologic effects resulting in increased intestinal fluid and thereby decrease constipation symptoms.

Lubiprostone (Amitiza)

 

Lubiprostone is a locally acting chloride channel activator that enhances a chloride-rich intestinal fluid secretion without altering sodium and potassium concentrations in the serum. It specifically activates C1C-2, an apical membrane in the human intestine. It increases intestinal fluid secretion to assist in GI motility, thereby decreasing symptoms of constipation (eg, abdominal pain, bloating, straining, hard stools). It is approved to treat chronic idiopathic constipation; opioid-induced constipation in patients with chronic, noncancer pain; and for women with constipation caused by irritable bowel syndrome.

Linaclotide (Linzess)

 

GC-C agonist; activation of GC-C receptors in the intestinal neurons leads to increased cyclic guanosine monophosphate (cGMP), anion secretion, fluid secretion, and intestinal transit; appears to work topically rather than systemically; when administered PO, linaclotide activates chloride channels in intestinal epithelial cells to increase intestinal fluid secretion; it is indicated to treat chronic idiopathic constipation and for IBS-C in adults.

Previous
Next

Laxatives, Osmotic

Class Summary

Osmotic agents are useful for long-term treatment of constipated patients with slow colonic transit who are refractory to dietary fiber supplementation.

Lactulose (Constulose, Enulose, Generlac, Kristalose)

 

Lactulose produces an osmotic effect in the colon, resulting in bowel distention and stimulation of peristalsis.

Sorbitol

 

Sorbitol is a hyperosmotic laxative that has a cathartic action in the GI tract.

Polyethylene glycol solution (Miralax)

 

Polyethylene glycol solution (Miralax)

Polyethylene glycol is typically used in large volumes for bowel preparation and washout before surgical or endoscopic procedures. It is now being used in smaller volumes as an osmotic (but not hyperosmotic) agent.

In theory, there is a lower risk of dehydration or electrolyte imbalance with isotonic polyethylene glycol than with hypertonic sugar solutions. The laxative effect is generated because polyethylene glycol is not absorbed and continues to hold water by osmotic action through the small bowel and the colon, resulting in mechanical cleansing.

Previous
Next

Stimulant Laxatives

Class Summary

Stimulant laxatives are commonly employed to treat acute constipation and are the most common class of laxatives used over the long term by individuals taking over-the-counter products. The latter represents an inappropriate choice, at least as first- or second-line therapy, given concerns about development of tolerance.

Senna (Senokot, Ex-Lax, Senexon, Senna-Gen)

 

Sennosides induce defecation by acting directly on the intestinal mucosa or nerve plexus, which stimulates peristaltic activity, by increasing intestinal motility. Senna usually produces its action 8-12 hours after administration.

Bisacodyl (Bisac-Evac, Biscolax, Dulcolax, Dacodyl)

 

Bisacodyl stimulates peristalsis by possibly stimulating the colonic intramural neuronal plexus. It alters water and electrolyte secretion, resulting in net intestinal fluid accumulation and laxation. It provokes defecation within 24 hours and may cause abdominal cramping.

Cascara sagrada

 

Cascara sagrada irritates the intestinal mucosa, resulting in increased colonic motility and altered fluid and electrolyte secretion.

Castor oil

 

Castor oil is reduced to ricinoleic acid. It decreases net absorption of fluid and electrolytes and stimulates peristalsis. It acts on the small intestine.

Previous
Next

Prokinetic Agents

Class Summary

Prokinetics are promotility agents proposed for use in patients with severe constipation-predominant symptoms.

Tegaserod (Zelnorm)

 

Description Tegaserod is available in the United States only by an emergency treatment investigational new drug (IND) protocol obtained from the FDA for irritable bowel syndrome (IBS) and IBS with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. It is indicated for the treatment of chronic idiopathic constipation. It is also indicated for short-term treatment of women with IBS in whom constipation is the predominant symptom.

Tegaserod is a serotonin type 4 (5-HT4) receptor partial agonist with no affinity for 5-HT3 receptors. It may trigger peristaltic reflex via 5-HT4 activation, which enhances basal motor activity and normalizes impaired GI motility. Research studies have shown inhibitory activity of the drug on visceral activity in the GI tract.

Previous
Next

Opioid Antagonist, Peripherally-Acting

Class Summary

Peripherally acting mu-opioid receptor antagonists (PAMORAs) may provide relief from GI adverse effects such as constipation associated with chronic opioid use.

Methylnaltrexone (Relistor)

 

Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist. It selectively displaces opioids from mu-opioid receptors outside the central nervous system (CNS), including those located in the GI tract, thereby decreasing the constipating effects of opioids. It is indicated for opioid-induced constipation in patients with advanced illness receiving palliative care when response to laxatives has not been sufficient. It is also indicated for opioid-induced constipation in patients with chronic noncancer pain who are treated with opioids. It is available as an injectable solution for subcutaneous use.

Naloxegol (Movantik)

 

Naloxegol is a PAMORA indicated for opioid-induced constipation in adults with chronic noncancer pain. Antagonism of gastrointestinal mu-opioid receptors by naloxegol inhibits the opioid-induced delay of GI transit time.

Alvimopan (Entereg)

 

Alvimopan is a peripherally acting mu-opioid receptor antagonist. It binds mu-opioid receptors in the gut, thereby selectively inhibiting negative opioid effects on GI function and motility. It is indicated for postoperative ileus after bowel resection with primary anastomosis.

In 5 clinical studies that enrolled more than 2500 patients, alvimopan demonstrated accelerated recovery time of upper and lower tract GI function compared with placebo. A decrease in the hospital days was also observed in the alvimopan group.

Alvimopan is only available to hospitals after they complete a registration process designed to maintain the benefits associated with short-term use and prevent long-term outpatient use (Entereg Access Support and Education [EASE] program).

Previous
 
Contributor Information and Disclosures
Author

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy ofSciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ronnie Fass, MD, FACP, FACG Chief of Gastroenterology, Head of Neuroenteric Clinical Research Group, Southern Arizona Veterans Affairs Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine

Ronnie Fass, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Motility Society, American Society for Gastrointestinal Endoscopy, and Israel Medical Association

Disclosure: Takeda Pharmaceuticals Grant/research funds Conducting research; Takeda Pharmaceuticals Consulting fee Consulting; Takeda Pharmaceuticals Honoraria Speaking and teaching; Vecta Consulting fee Consulting; XenoPort Consulting fee Consulting; Eisai Honoraria Speaking and teaching; Wyeth Pharmaceuticals Conducting research; AstraZeneca Grant/research funds Conducting research; Eisai Consulting fee Consulting

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Dave A Holson, MD, MBBS, MPH Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine; Director, Department of Emergency Medicine, Queens Hospital Center

Dave A Holson, MD, MBBS, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Pharmaceutical Business Review. Ironwood Pharma, Forest Labs Present Linaclotide Phase 3 Trial Results. pharmaceutical-business-review.com. Available at http://clinicaltrials.pharmaceutical-business-review.com/news/ironwood_pharma_forest_labs_present_linaclotide_phase_3_trial_results_100504/. Accessed: May 4, 2010.

  2. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006 Apr. 130(5):1480-91. [Medline].

  3. Uher R, Farmer A, Henigsberg N, et al. Adverse reactions to antidepressants. Br J Psychiatry. 2009 Sep. 195(3):202-10. [Medline].

  4. Staats PS, Markowitz J, Schein J. Incidence of constipation associated with long-acting opioid therapy: a comparative study. South Med J. 2004 Feb. 97(2):129-34. [Medline].

  5. Martin BC, Barghout V, Cerulli A. Direct medical costs of constipation in the United States. Manag Care Interface. 2006 Dec. 19(12):43-9. [Medline].

  6. Peppas G, Alexiou VG, Mourtzoukou E, et al. Epidemiology of constipation in Europe and Oceania: a systematic review. BMC Gastroenterol. 2008 Feb 12. 8:5. [Medline].

  7. Sonnenberg A, Koch TR. Epidemiology of constipation in the United States. Dis Colon Rectum. 1989 Jan. 32(1):1-8. [Medline].

  8. Bouras EP, Tangalos EG. Chronic constipation in the elderly. Gastroenterol Clin North Am. 2009 Sep. 38(3):463-80. [Medline].

  9. Amselem C, Puigdollers A, Azpiroz F, et al. Constipation: a potential cause of pelvic floor damage?. Neurogastroenterol Motil. 2010 Feb. 22(2):150-3, e48. [Medline].

  10. Noguera A, Centeno C, Librada S, Nabal M. Screening for constipation in palliative care patients. J Palliat Med. 2009 Oct. 12(10):915-20. [Medline].

  11. Taghavi SA, Shabani S, Mehramiri A, et al. Colchicine is effective for short-term treatment of slow transit constipation: a double-blind placebo-controlled clinical trial. Int J Colorectal Dis. 2010 Mar. 25(3):389-94. [Medline].

  12. Gladman MA, Knowles CH. Novel concepts in the diagnosis, pathophysiology and management of idiopathic megabowel. Colorectal Dis. 2008 Jul. 10(6):531-8; discussion 538-40. [Medline].

  13. Brooks M. FDA Issues Safety Warning for Sodium Phosphate for Constipation. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/818859. Accessed: January 13, 2014.

  14. FDA Safety Announcement. FDA warns of possible harm from exceeding recommended dose of over-the-counter sodium phosphate products to treat constipation. US Food and Drug Administration. Available at http://www.fda.gov/Drugs/DrugSafety/ucm380757.htm. Accessed: January 13, 2014.

  15. Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut. 2011 Feb. 60(2):209-18. [Medline].

  16. Melville NA. Long-Term Efficacy With Lubiprostone in Opioid Constipation. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/810646. Accessed: September 16, 2013.

  17. Lembo AJ, Kurtz CB, Macdougall JE, et al. Efficacy of linaclotide for patients with chronic constipation. Gastroenterology. 2010 Mar. 138(3):886-95.e1. [Medline].

  18. Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med. 2011 Aug 11. 365(6):527-36. [Medline]. [Full Text].

  19. Rao S, Lembo AJ, Shiff SJ, et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012 Nov. 107(11):1714-24; quiz p.1725. [Medline].

  20. Brown SR. Tegaserod for chronic constipation. J Fam Pract. 2005 Dec. 54(12):1060, 1063. [Medline].

  21. Di Palma JA. Expert commentary--new developments in the treatment of constipation. MedGenMed. 2005 Jan 1. 7(1):17. [Medline].

  22. Layer P, Keller J, Loeffler H, et al. Tegaserod in the treatment of irritable bowel syndrome (IBS) with constipation as the prime symptom. Ther Clin Risk Manag. 2007 Mar. 3(1):107-18. [Medline].

  23. Zelnorm (tegaserod) emergency treatment IND program. Novartis Pharmaceuticals Corp. July 16, 2014.

  24. Johanson JF. Review of the treatment options for chronic constipation. MedGenMed [serial online]. May 2, 2007;9 (2):25-40. Available at http://www.medscape.com/viewarticle/550956. Accessed: April 26, 2010.

  25. Hsiao KC, Jao SW, Wu CC, et al. Hand-assisted laparoscopic total colectomy for slow transit constipation. Int J Colorectal Dis. 2008 Apr. 23(4):419-24. [Medline].

  26. Tomita R, Fujisak S. Minilaparotomy with a gasless laparoscopic-assisted procedure by abdominal wall lifting for ileorectal anastomosis in patients with slow transit constipation. Hepatogastroenterology. 2009 Jul-Aug. 56(93):1022-7. [Medline].

  27. Frascio M, Stabilini C, Ricci B, et al. Stapled transanal rectal resection for outlet obstruction syndrome: results and follow-up. World J Surg. 2008 Jun. 32(6):1110-5. [Medline].

  28. Bona S, Battafarano F, Fumagalli Romario U, et al. Stapled anopexy: postoperative course and functional outcome in 400 patients. Dis Colon Rectum. 2008 Jun. 51(6):950-5. [Medline].

  29. van den Esschert JW, van Geloven AA, Vermulst N, Groenedijk AG, de Wit LT, Gerhards MF. Laparoscopic ventral rectopexy for obstructed defecation syndrome. Surg Endosc. 2008 Dec. 22(12):2728-32. [Medline].

  30. Mowatt G, Glazener C, Jarrett M. Sacral nerve stimulation for fecal incontinence and constipation in adults: a short version Cochrane review. Neurourol Urodyn. 2008. 27(3):155-61. [Medline].

  31. Holzer B, Rosen HR, Novi G, et al. Sacral nerve stimulation in patients with severe constipation. Dis Colon Rectum. 2008 May. 51(5):524-29; discussion 529-30. [Medline].

  32. Biggs WS, Dery WH. Evaluation and treatment of constipation in infants and children. Am Fam Physician. 2006 Feb 1. 73(3):469-77. [Medline].

  33. Cryer B, Katz S, Vallejo R, Popescu A, Ueno R. A randomized study of lubiprostone for opioid-induced constipation in patients with chronic noncancer pain. Pain Med. 2014 Nov. 15(11):1825-34. [Medline].

  34. Jeffrey S. FDA Approves Amitiza for Opioid-Induced Constipation. Medscape Medical News. April 23, 2013. Available at http://www.medscape.com/viewarticle/802953. Accessed: April 30, 2013.

  35. Anderson P. FDA okays naloxegol (Movantik) in opioid-induced constipation. Medscape Medical News. September 16, 2014. [Full Text].

  36. Chey WD, Webster L, Sostek M, Lappalainen J, Barker PN, Tack J. Naloxegol for opioid-induced constipation in patients with noncancer pain. N Engl J Med. 2014 Jun 19. 370(25):2387-96. [Medline].

  37. Webster L, Chey WD, Tack J, Lappalainen J, Diva U, Sostek M. Randomised clinical trial: the long-term safety and tolerability of naloxegol in patients with pain and opioid-induced constipation. Aliment Pharmacol Ther. 2014 Oct. 40(7):771-9. [Medline].

  38. Relistor (methylnaltrexone bromide) subcutaneous injection [package insert]. Tarrytown, NY: Progenics Pharmaceuticals, Inc. September, 2014. Available at [Full Text].

  39. Camilleri M, Beyens G, Kerstens R, Robinson P, Vandeplassche L. Safety assessment of prucalopride in elderly patients with constipation: a double-blind, placebo-controlled study. Neurogastroenterol Motil. 2009 Dec. 21(12):1256-e117. [Medline].

  40. US Food and Drug Administration. FDA approves Movantik for opioid-induced constipation. 2014 Sept 16. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm414620.htm. Accessed: September 16, 2014.

 
Previous
Next
 
Large amount of stool throughout colon.
Large stool mass in hepatic flexure of colon.
Colon distention secondary to fecal impaction.
Pseudo-obstruction secondary to fecal impaction.
Distended transverse colon.
Distended rectum.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.