Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

opioid-induced

1st line – review opioid use + osmotic or stimulant laxative

Back
ACUTE
|
opioid-induced
1st line – 

review opioid use + osmotic or stimulant laxative

Opioid use should be reviewed as appropriate. Other underlying causes or factors that may contribute to constipation should also be considered and excluded.[81]

Traditional laxatives are recommended as first-line therapy for opioid-induced constipation. Osmotic laxatives (e.g., lactulose, polyethylene glycol [macrogols], magnesium-containing laxatives) or stimulant laxatives (e.g., bisacodyl, senna) are preferred.[52][81]​​​ If response to a single agent is inadequate, some guidelines recommend combining an osmotic and stimulant laxative before escalating therapy.[52][81]​​

The main adverse effects of osmotic laxatives include bloating, diarrhoea, epigastric pain, flatulence, nausea, vomiting, and, rarely, hypernatraemia and hypokalaemia. Common adverse effects of magnesium-containing laxatives include nausea, diarrhoea, and hypermagnesaemia.

Systematic reviews have found that while stimulant laxatives are effective, diarrhoea and abdominal pain are common, which may impact their tolerability.[59][64]​​​​

Primary options

lactulose: 10-20 g/day orally, maximum 40 g/day

OR

macrogols: consult product literature for guidance on dose

OR

magnesium citrate: consult product literature for guidance on dose

OR

magnesium gluconate: consult product literature for guidance on dose

OR

magnesium hydroxide: consult product literature for guidance on dose

OR

bisacodyl: 5-15 mg orally once daily

OR

senna: consult product literature for guidance on dose

Plus – diet + lifestyle advice

Back
ACUTE
|
opioid-induced
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Patients with opioid-induced constipation should also be advised on appropriate dietary and lifestyle modifications, adjusted according to the clinical setting and underlying conditions.[52][81]​​​​

Fibre (including bulk laxatives like psyllium) may be helpful in patients with a fibre-deficient diet.[51][81]​​​​ In people with a low calorie intake, an increased daily calorie intake is advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

2nd line – peripherally acting mu-opioid receptor antagonist

Back
ACUTE
|
opioid-induced
2nd line – 

peripherally acting mu-opioid receptor antagonist

Peripherally acting mu-opioid receptor antagonists such as naldemedine, naloxegol, and methylnaltrexone are recommended for laxative-refractory opioid-induced constipation.[18][81]​ They can be used as monotherapy, but they are often used in combination with an osmotic or stimulant laxative.[82]

Data to support naldemedine come from one phase 2 and three phase 3 trials.[83][84][85]​​

The efficacy of naloxegol was shown in one phase 2 trial and two phase 3 RCTs.[86][87][88]

The quality of evidence supporting methylnaltrexone is not as robust.[81] Out of five RCTs, only three examined an outcome of ≥3 spontaneous bowel movements per week, and most studies were in patients with cancer. However, the subcutaneous formulation of methylnaltrexone is an advantage for patients who cannot tolerate oral drugs.[81] Regardless, a pooled analysis showed reduced all-cause mortality in cancer and non-cancer patients with opioid-induced constipation who took methylnaltrexone compared to placebo.[90]

The most common adverse effects of methylnaltrexone are abdominal cramping and flatulence. Concerns have been raised about severe abdominal pain and bowel perforation in patients with advanced cancer who were receiving methylnaltrexone for opioid-induced constipation. These concerns led the FDA to issue a warning for physicians in the US to use caution in administering methylnaltrexone to patients with known or suspected lesions in the intestinal wall, and to discontinue treatment with methylnaltrexone immediately if gastrointestinal symptoms worsen.[89]​ Regardless, a pooled analysis showed reduced all-cause mortality in cancer and non-cancer patients with opioid-induced constipation who took methylnaltrexone compared to placebo.[90]

One Cochrane review on peripherally acting mu-opioid receptor antagonists for opioid-induced bowel dysfunction concluded that moderate-certainty evidence supports the efficacy of naldemedine for people with cancer and subcutaneous methylnaltrexone for people receiving palliative care.[91]

Primary options

naldemedine: 0.2 mg orally once daily

OR

naloxegol: 25 mg orally once daily in the morning

OR

methylnaltrexone: 450 mg orally once daily in the morning; subcutaneous dose depends on body weight and indication, consult specialist for guidance on dose

Plus – diet + lifestyle advice

Back
ACUTE
|
opioid-induced
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Patients with opioid-induced constipation should also be advised on appropriate dietary and lifestyle modifications, adjusted according to the clinical setting and underlying conditions.[52][81]​​

Fibre (including bulk laxatives like psyllium) may be helpful in patients with a fibre-deficient diet.[51][81]​​​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

Consider – osmotic or stimulant laxative

Back
ACUTE
|
opioid-induced
Consider – 

osmotic or stimulant laxative

Additional treatment recommended for SOME patients in selected patient group

May be used in combination with peripherally acting mu-opioid receptor antagonists if necessary.

The main adverse effects of osmotic laxatives include bloating, diarrhoea, epigastric pain, flatulence, nausea, vomiting, and, rarely, hypernatraemia and hypokalaemia. Common adverse effects of magnesium-containing osmotic laxatives include nausea, diarrhoea, and hypermagnesaemia.

Systematic reviews have found that while stimulant laxatives are effective, diarrhoea and abdominal pain are common, which may impact their tolerability.[59][64]​​

Primary options

lactulose: 10-20 g/day orally, maximum 40 g/day

OR

macrogols: consult product literature for guidance on dose

OR

magnesium citrate: consult product literature for guidance on dose

OR

magnesium gluconate: consult product literature for guidance on dose

OR

magnesium hydroxide: consult product literature for guidance on dose

OR

bisacodyl: 5-15 mg orally once daily

OR

senna: consult product literature for guidance on dose

3rd line – lubiprostone

Back
ACUTE
|
opioid-induced
3rd line – 

lubiprostone

Lubiprostone is approved for the treatment of opioid-induced constipation in adults with chronic non-cancer pain. Phase 3 trials found that lubiprostone was more effective than placebo for opioid-induced constipation.[92]

Primary options

lubiprostone: 24 micrograms orally twice daily

Plus – diet + lifestyle advice

Back
ACUTE
|
opioid-induced
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Patients with opioid-induced constipation should also be advised on appropriate dietary and lifestyle modifications, adjusted according to the clinical setting and underlying conditions.[52][81]​​

Fibre (including bulk laxatives like psyllium) may be helpful in patients with a fibre-deficient diet.[51][81]​​​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

Plus – evacuation measures

Back
ACUTE
|
opioid-induced
|
with faecal impaction
Plus – 

evacuation measures

Treatment recommended for ALL patients in selected patient group

Enemas, suppositories, large volume polyethylene glycol solution (macrogols), stimulant laxatives, or disimpaction with sedation may be required if there is faecal impaction.[51][52][81]​​​​

The type of enemas or drugs, and the need for sedation/anaesthesia, are all variables and depend on the clinical setting and individual patient characteristics (e.g., patient age, anxiety, first or recurrent episode).

Enemas are contraindicated in patients with neutropenia, thrombocytopenia, intestinal obstruction, recent colorectal or gynecological surgery, inflammatory colitis, toxic megacolon, abdominal infection or inflammation, recent anal or rectal trauma, undiagnosed abdominal pain, or recent pelvic radiotherapy.[52][51]​​

Dosage regimens and types of sedation are beyond the scope of this topic. Referral to a specialist unit for management is advised.

not opioid-induced: symptoms <3 months

1st line – treatment of any identified underlying cause

Back
ACUTE
|
not opioid-induced: symptoms <3 months
1st line – 

treatment of any identified underlying cause

When constipation presents acutely, it is important to consider possible secondary causes, including colorectal cancer. Secondary causes are treated appropriately.

The initial step with drug-induced constipation is to withdraw the drug (e.g., calcium-channel blockers, antipsychotics, tricyclic antidepressants) if possible. Opioids are a common cause of drug-induced constipation. However, management of these patients differs - see opioid-induced below.

Constipation in pregnant women is managed with fibre and laxatives, with consideration for the withdrawal of iron supplements.[21][22]

Plus – diet + lifestyle advice

Back
ACUTE
|
not opioid-induced: symptoms <3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Dietary and lifestyle changes may be helpful, and evidence suggests they may be most effective when combined.[18]

Patients are advised to increase their daily dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

Consider – bulk or fruit-based laxatives and/or stool softener

Back
ACUTE
|
not opioid-induced: symptoms <3 months
Consider – 

bulk or fruit-based laxatives and/or stool softener

Additional treatment recommended for SOME patients in selected patient group

Bulk laxatives (fibre supplements), prunes, or fruit-based laxatives are the preferred first-line laxatives. In patients who complain of hard stool and straining at stool, stool softeners (e.g., docusate) may be used.

In patients who have occasional loose stool in between episodes of constipation, a bulk laxative may be preferred. In one meta-analysis of 16 randomised controlled trials, fibre supplements were shown to be effective at improving chronic constipation (RR 1.48, 95% CI 1.17 to 1.88), with significant effects from psyllium and pectin supplements at higher doses (>10 g/day) for longer treatment durations (≥4 weeks).[32]​ Bulk laxatives do not get absorbed systemically and are considered safe for administration during pregnancy.[22]​ Bulk laxatives can produce excessive gas, leading to flatulence and bloating, which may deter patients from continuing treatment.[55] Adverse effects of stool softeners include a bitter taste in the mouth, nausea, diarrhoea, and cramping.

Prunes (dried plums) are a natural alternative to laxatives and have been shown in a blinded randomised controlled study to be as effective as psyllium in improving symptoms of constipation.[56]​ Kiwifruit may also be effective and associated with less patient dissatisfaction than prunes or psyllium, but one systematic review reported evidence is low to very low certainty.[57][58]​ Fruit-based laxatives include preparations (e.g., powder, paste) of kiwi, mango, prunes, or fig; they are supported by moderate evidence according to one systematic review.[59]​ Studies suggest they are well tolerated with few or no mild gastrointestinal adverse effects reported.

Stool softeners such as docusate are one of the most commonly used non-prescription drugs for treatment of constipation.[59] However, clinical data have remained inconsistent and there have been no new efficacy studies since 2004. In one study, docusate was found to be no more effective than placebo and significantly inferior to psyllium.[60]​ Adverse effects of stool softeners include a bitter taste in the mouth, nausea, diarrhoea, and cramping.

Primary options

docusate sodium: 100 mg orally once or twice daily

Plus – evacuation measures

Back
ACUTE
|
not opioid-induced: symptoms <3 months
|
with faecal impaction
Plus – 

evacuation measures

Treatment recommended for ALL patients in selected patient group

Enemas, suppositories, large volume polyethylene glycol (PEG) solution (macrogols), stimulant laxatives, or disimpaction with sedation may be required if there is faecal impaction.

The type of enemas or drugs, and the need for sedation/anaesthesia, are all variables and depend on the clinical setting and individual patient characteristics (e.g., patient age, anxiety, first or recurrent episode). Enemas are contraindicated in patients with neutropenia, thrombocytopenia, intestinal obstruction, recent colorectal or gynecological surgery, inflammatory colitis, toxic megacolon, abdominal infection or inflammation, recent anal or rectal trauma, undiagnosed abdominal pain, or recent pelvic radiotherapy.[51][52]​​

Dosage regimens and types of sedation are beyond the scope of this topic. Referral to a specialist unit for management is advised.

ONGOING

not opioid-induced: symptoms ≥3 months

1st line – treatment of any identified underlying cause

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
1st line – 

treatment of any identified underlying cause

The approach to treatment depends on whether the constipation is diagnosed as a primary or a secondary condition (e.g., drug-induced constipation, pregnancy, Parkinson's disease).

The initial step with drug-induced constipation is to withdraw the drug (e.g., calcium-channel blockers, antipsychotics, tricyclic antidepressants) if possible. Opioids are a common cause of drug-induced constipation. However, management of these patients differs - see opioid-induced above.

Constipation in pregnant women is managed with fibre and laxatives, with consideration for the withdrawal of iron supplements.[21][22]

Plus – diet + lifestyle advice

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Dietary and lifestyle changes may be helpful, and evidence suggests they may be most effective when combined.[18]

Patients are advised to increase their daily dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​​ The American Gastroenterological Association-American College of Gastroenterology (AGA-ACG) suggests use of fibre supplements for the management of chronic idiopathic constipation.[54]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

Consider – bulk or fruit-based laxative and/or stool softener

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Consider – 

bulk or fruit-based laxative and/or stool softener

Additional treatment recommended for SOME patients in selected patient group

Bulk laxatives (fibre supplements), prunes, or fruit-based laxatives are the preferred first-line laxatives. In patients who complain of hard stool and straining at stool, stool softeners (e.g., docusate) may be used.

In patients who have occasional loose stool in between episodes of constipation, a bulk laxative may be preferred. In one meta-analysis of 16 randomised controlled trials, fibre supplements were shown to be effective at improving chronic constipation (RR 1.48, 95% CI 1.17 to 1.88), with significant effects from psyllium and pectin supplements at higher doses (>10 g/day) for longer treatment durations (≥4 weeks).[32]​ Bulk laxatives do not get absorbed systemically and are considered safe for administration during pregnancy.[22]​ Bulk laxatives can produce excessive gas, leading to flatulence and bloating, which may deter patients from continuing treatment.[55]

Prunes (dried plums) are a natural alternative to laxatives and have been shown in a blinded randomised controlled study to be as effective as psyllium (ispaghula husk) in improving symptoms of constipation.[56]​ Kiwifruit may also be effective and associated with less patient dissatisfaction than prunes or psyllium, but one systematic review reported evidence is low to very low certainty.[57][58]​ Fruit-based laxatives include preparations (e.g., powder, paste) of kiwi, mango, prunes, or fig; they are supported by moderate evidence according to one systematic review.[59]​ Studies suggest they are well tolerated with few or no mild gastrointestinal adverse effects reported. 

Stool softeners such as docusate are one of the most commonly used non-prescription drugs for treatment of constipation.[59] However, clinical data have remained inconsistent and there have been no new efficacy studies since 2004. In one study, docusate was found to be no more effective than placebo and significantly inferior to psyllium.[60]​ Adverse effects of stool softeners include a bitter taste in the mouth, nausea, diarrhoea, and cramping.

Primary options

docusate sodium: 100 mg orally once or twice daily

2nd line – osmotic and/or stimulant laxative

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
2nd line – 

osmotic and/or stimulant laxative

If there is no clinical response (defined as patient satisfaction with bowel habits and associated symptoms) after at least 6 weeks of therapy, and no suspicion of dyssynergia, osmotic laxatives, such as lactulose, polyethylene glycol (PEG) solution (macrogols), or magnesium-containing laxatives are considered.[61][62]​​​​​​ AGA-ACG recommend use of PEG and suggest use of lactulose or magnesium oxide for the management of chronic idiopathic constipation.[54]​ One meta-analysis has shown that PEG (macrogols) is better than lactulose in improving outcome measures of stool frequency per week, form of stool, relief of abdominal pain, and the need for additional products.[61] Lactulose and PEG are considered safe for administration during pregnancy.[22]​

The main adverse effects of osmotic laxatives include bloating, diarrhoea, epigastric pain, flatulence, nausea, vomiting, and, rarely, hypernatraemia and hypokalaemia. Common adverse effects of magnesium-containing laxatives include nausea, diarrhoea, and hypermagnesaemia.

Stimulant laxatives, such as bisacodyl and senna, are another option at this stage. They may also be used as rescue laxatives in patients using another class of laxatives (to be used if the patient does not have a bowel movement for 3 days).[63]​ Systematic reviews have found that while stimulant laxatives are effective, diarrhoea and abdominal pain are common, which may impact their tolerability.[59][64]​​​​ AGA-ACG recommend bisacodyl for daily use up to 4 weeks or as a rescue therapy. A gradual increase in dose is suggested to improve tolerability. They also suggest use of senna for the management of chronic idiopathic constipation.[54]​ Stimulant laxatives are generally not recommended for pregnant women.[21]

Often a single class of laxative is used as much as possible.

Primary options

lactulose: 10-20 g/day orally, maximum 40 g/day

or

macrogols: consult product literature for guidance on dose

or

magnesium citrate: consult product literature for guidance on dose

or

magnesium gluconate: consult product literature for guidance on dose

or

magnesium hydroxide: consult product literature for guidance on dose

or

magnesium oxide: consult product literature for guidance on dose

-- AND / OR --

bisacodyl: 5-15 mg orally once daily

or

senna: consult product literature for guidance on dose

Plus – diet + lifestyle advice

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Dietary and lifestyle changes may be helpful, and evidence suggests they may be most effective when combined.[18]

Patients are advised to increase their daily dietary fibre. A diet-deficient fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​​ AGA-ACG suggest use of fibre supplements for the management of chronic idiopathic constipation.[54]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

3rd line – guanylate cyclase-C agonist

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
3rd line – 

guanylate cyclase-C agonist

An option if symptoms persist after at least 6 weeks of traditional laxatives and there is no suspicion of dyssynergia.

Linaclotide has been shown to accelerate gut transit in healthy people and in female patients with irritable bowel syndrome-constipation.[72][73]

Plecanatide has similarly demonstrated to increase intracellular cyclic guanosine monophosphate (cGMP) and promote luminal secretion through the CFTR receptor to facilitate bowel movements.[71]

This class of drugs has been shown to be more effective than placebo in clinical trials, where it has demonstrated rapid and sustained improvements of bowel habits, bowel and abdominal symptoms, and quality of life in patients with chronic constipation.[69][70][71]​​​​​​​ Furthermore, both linaclotide and plecanatide appear to have few adverse effects. AGA-ACG recommend linaclotide or plecanatide for patients with chronic idiopathic constipation that does not respond to non-prescription agents.[54]

These drugs are generally not recommended for pregnant women due to a lack of safety data.

They are usually used as monotherapy and not in combination with other laxatives.

Primary options

linaclotide: chronic idiopathic constipation: 72-145 micrograms orally once daily; constipation-predominant irritable bowel syndrome: 290 micrograms orally once daily

OR

plecanatide: chronic idiopathic constipation or constipation-predominant irritable bowel syndrome: 3 mg orally once daily

Plus – diet + lifestyle advice

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Dietary and lifestyle changes may be helpful, and evidence suggests they may be most effective when combined.[18]

Patients are advised to increase their daily dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​​ AGA-ACG suggest use of fibre supplements for the management of chronic idiopathic constipation.[54]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

3rd line – lubiprostone

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
3rd line – 

lubiprostone

An option if symptoms persist after at least 6 weeks of traditional laxatives and there is no suspicion of dyssynergia.

Lubiprostone (a chloride channel activator) has been shown to be more effective than placebo in increasing the number of spontaneous bowel movements, decreasing straining, improving stool consistency, and relieving symptoms of chronic constipation.[65][66][67][68]​​​

The most common adverse events include nausea (31%), headache (13%), diarrhoea (13%), abdominal pain (7%), and distension (7%). AGA-ACG suggest lubiprostone for patients with chronic idiopathic constipation that does not respond to non-prescription agents.[54]

It is not recommended for pregnant women due to a lack of safety data.

It is usually used as monotherapy and not in combination with other laxatives.

Lubiprostone has been withdrawn from the UK market for commercial reasons.

Primary options

lubiprostone: 24 micrograms orally twice daily

Plus – diet + lifestyle advice

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Dietary and lifestyle changes may be helpful, and evidence suggests they may be most effective when combined.[18]

Patients are advised to increase their daily dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​​ AGA-ACG suggest use of fibre supplements for the management of chronic idiopathic constipation.[54]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

3rd line – prucalopride

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
3rd line – 

prucalopride

An option if symptoms persist after at least 6 weeks of traditional laxatives and there is no suspicion of dyssynergia.

Prucalopride is a 5-HT4 receptor agonist with prokinetic properties. Prucalopride was the most effective laxative at 12 weeks according to one meta-analysis.[64]​ ​​​​ Headache, nausea, abdominal pain, and diarrhoea were reported by over 10% of the 4000 patients in the three phase 3 trials.[74][75]​​​​[76]​ No clinically relevant cardiac adverse effects were reported. AGA-ACG recommend prucalopride for patients with chronic idiopathic constipation that does not respond to non-prescription agents.[54]

It is not recommended for pregnant women due to a lack of safety data.

Primary options

prucalopride: 2 mg orally once daily

Plus – diet + lifestyle advice

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Dietary and lifestyle changes may be helpful, and evidence suggests they may be most effective when combined.[18]

Patients are advised to increase their daily dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​​ AGA-ACG suggest use of fibre supplements for the management of chronic idiopathic constipation.[54]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be advised on adequate fluid intake, encouraged to get regular non-strenuous exercise, and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

3rd line – vibrating capsule

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
3rd line – 

vibrating capsule

​In some countries (e.g., the US), a vibrating capsule is available for the treatment of chronic constipation in adults who have not experienced symptom improvement from laxatives after at least 1 month. The vibrating capsule is a non-pharmacological device that mechanically induces colonic contractions.[78]​ In a double-blind phase 3 trial of patients with chronic constipation, a significantly higher proportion of patients who received the vibrating capsule experienced ≥1 complete spontaneous bowel movements per week compared with those who received the sham placebo capsule (39.3% versus 22.1%).[79]​ Studies also reported improvements in quality of life, and mild gastrointestinal adverse effects.[79][80] If there has been no bowel movement within ≥3 consecutive days of using the vibrating capsule, consider adjunctive laxative therapy.

Plus – diet + lifestyle advice

Back
ONGOING
|
not opioid-induced: symptoms ≥3 months
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Lifestyle and dietary changes are advised, including adequate daily fluids and increased dietary fibre. A high-fibre diet increases stool weight and accelerates colonic transit time.[32]​ By contrast, diet that is deficient of fibre may lead to constipation.[33]​ AGA-ACG suggest use of fibre supplements for the management of chronic idiopathic constipation.[54]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Regular non-strenuous exercise is recommended. Patients are advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

suspicion for dyssynergia or refractory to pharmacotherapy

1st line – biofeedback

Back
ONGOING
|
suspicion for dyssynergia or refractory to pharmacotherapy
|
positive test for dyssynergia
1st line – 

biofeedback

Symptoms associated with dyssynergia include the sensation of anal blockage, straining, and the use of digital manoeuvres to assist defecation. The diagnosis is confirmed with physiological testing. See Diagnosis approach.

Biofeedback (bowel retraining) has been found to be effective in treating dyssynergia.​[93][94][95][96]

Three biofeedback techniques used to improve coordination of abdominal and anorectal muscles are: diaphragmatic muscle training with simulated defecation; manometric guided pelvic floor retraining; and simulated defecation training.

Home biofeedback therapy has been shown to be as effective as office-based therapy.[97]

Sixty per cent of patients with dyssynergic defecation have impaired rectal sensation, and rectal sensory conditioning provides additional therapeutic benefit.[94][98][103]​ One RCT found that barostat-assisted sensory training was superior to syringe-assisted sensory training.[99]

Plus – diet + lifestyle advice

Back
ONGOING
|
suspicion for dyssynergia or refractory to pharmacotherapy
|
positive test for dyssynergia
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Patients are gradually weaned off laxatives. Lifestyle and dietary changes are continued, including adequate daily fluids and increased dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]

Patients should also be encouraged to get regular non-strenuous exercise and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

1st line – referral to specialised centre

Back
ONGOING
|
suspicion for dyssynergia or refractory to pharmacotherapy
|
negative test for dyssynergia: chronic refractory symptoms
1st line – 

referral to specialised centre

Patients with persistent symptoms (lasting several months to years) that are unresponsive to medical treatment can be referred to a specialised centre. Patients undergo evaluation of upper gut and small bowel motility, plus a detailed assessment of colonic motility with colonic manometry.

Surgery is reserved for refractory patients with severe colonic neuropathy and relatively preserved gastric and small bowel motility. Caecostomy is generally preferred in institutionalised patients, and in patients with neurological lesions, in whom there seems to be a high success rate; satisfactory results range from 40% to 78%.[100]

Several colectomy techniques have been advocated, which include segmental colectomy, ileorectal anastomosis, ileosigmoid anastomosis, caecorectal anastomosis, ileoanal anastomosis with proctocolectomy, and pouch formation or ileostomy.[101] Most of these can be done laparoscopically.

Surgery is unlikely to be of benefit in patients who fail all therapies and have evidence for motility dysfunction not limited to the colon. A multi-disciplinary approach may be tried, including addressing nutrition, behavioural therapy, biofeedback, psychotherapy, and cyclical laxatives. The evidence for this type of therapy is mostly anecdotal.

Plus – diet + lifestyle advice

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ONGOING
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suspicion for dyssynergia or refractory to pharmacotherapy
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negative test for dyssynergia: chronic refractory symptoms
Plus – 

diet + lifestyle advice

Treatment recommended for ALL patients in selected patient group

Patients are gradually weaned off laxatives. Lifestyle and dietary changes are continued, including adequate daily fluids and increased dietary fibre. A diet deficient in fibre may lead to constipation, while a high-fibre diet increases stool weight and accelerates colonic transit time.[32][33]​ In people with a low calorie intake, an increased daily calorie intake is also advised. It has been shown that inadequate calorie intake can cause constipation.[35]​ Patients should also be encouraged to get regular non-strenuous exercise and advised to dedicate time for bowel movements and to avoid postponing bowel movements when an urge for defecation is felt.[34]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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