Medical Therapy of Constipation: Current Standards and Beyond

Abstract

Chronic constipation is a very common medical problem with relevant impact on the patients' quality of life. Modern definitions recognize constipation as a polysymptomatic disorder, including various aspects of disturbed defecation. Current guidelines recommend a stepwise approach in the management of chronic constipation. Isolated or concomitant evacuation disorders should be identified and may need differential/additional treatment. Baseline measures include lifestyle components and bulking agents. The next step recommends treatment with conventional laxatives. In refractory patients, modern medical therapies, such as the prokinetic prucalopride or the secretagogues linalotide or lubiprostone, may be used effectively. For patients with opioid-induced constipation, the modern concept of peripherally acting µ-opioid antagonists has shown to successfully improve this increasing medical problem and even to potentially increase survival time in terminally ill patients on opioid therapy. Prolonged-released oral naloxone (in fixed combination with oxycodone), oral naloxegol or naldemedine, and subcutaneous methylnaltrexone have all demonstrated good efficacy and tolerability in the treatment of opioid-induced constipation. To adequately apply stepwise treatment algorithms, a simple tool to identify treatment failure may improve patient care.

Keywords: Laxatives; Linaclotide; OIC; PAMORA; Prucalopride.

Fig. 1

Stepwise approach in the management of chronic constipation (modified from [3]).

Fig. 2

Significant effect of prucalopride on normalization of stool frequency in patients with severe constipation (modified from [15]).

Fig. 3

Effects of linaclotide on stool frequency in patients with constipation-predominant irritable bowel syndrome (phase III study, 12 + 4 weeks, n = 800 patients, CSBM = complete spontaneous bowel movement) (modified from [38]).