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Practice Guideline
. 2023 Jun;164(7):1086-1106.
doi: 10.1053/j.gastro.2023.03.214.

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

Lin Chang  1 , William D Chey  2 , Aamer Imdad  3 , Christopher V Almario  4 , Adil E Bharucha  5 , Susan Diem  6 , Katarina B Greer  7 , Brian Hanson  8 , Lucinda A Harris  9 , Cynthia Ko  10 , M Hassan Murad  11 , Amit Patel  12 , Eric D Shah  13 , Anthony J Lembo  14 , Shahnaz Sultan  15
Affiliations
Practice Guideline

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

Lin Chang et al. Gastroenterology. 2023 Jun.

Abstract

Introduction: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults.

Methods: The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations.

Results: The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone.

Discussion: This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.

Keywords: Bisacodyl; Docusate; Fiber; Lactulose; Linaclotide; Lubiprostone; Magnesium Oxide; Plecanatide; Polyethylene Glycol; Prucalopride; Senna; Sodium Picosulfate.

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Conflict of interest statement

Panel members disclosed all potential conflicts of interest. Conflicts were managed according to AGA and ACG policies, the National Academy of Medicine, and Guidelines International Network standards.- Panel members determined to have a potential conflict of interest with a specific intervention or agent were allocated to a subcommittee that did not include the specific intervention(s). Development of this guideline was wholly funded by the AGA and ACG with no support from the industry.

Conflicts of interest

Potential competing interests: These authors disclose the following: L.C. has served as a member of the scientific advisory boards for Ardelyx, Atmo, Immunic, Ironwood, and Mauna Kea Technologies; has served as a consultant for Bausch Health and Trellus Health and a speaker for Ironwood; has received research support from the National Institute of Health, Arena, AnX Robotica, Ironwood, and Vanda Pharmaceuticals; and has stock options with ModifyHealth and Trellus Health. W.D.C. has served as a consultant for AbbVie, Ardelyx, Biomerica, Ironwood, Isothrive, QOL Medical, Nestle, Phathom Pharmaceuticals, Redhill, Salix/Valeant, Takeda, and Vibrant; has received research grants from FDA, NIH, Commonwealth Diagnostics, QOL Medical, and Salix; has board membership at ACG, GI on Demand, International Foundation for Functional Gastrointestinal Disorders (IFFGD), and the Rome Foundation; holds patents for Digital Manometry and the Rectal Expulsion Device; and has stock options in Coprata, Dieta, Kiwi Bioscience, ISOThrive, and Modify Health. C.V.A. has served as a consultant for Owlstone Medical; and has stock options in My Total Health and Owlstone Medical. A.E.B. receives royalties from a patent created for Medispira Medical Technologies. L.A.H. has consulted for AbbVie/Ironwood, Alyman, and Takeda. E.D.S has served as a consultant for Salix, Mahana, Ardelyx, Takeda, GI Supply and Neuraxis outside the scope of the current work. He holds a patent on the Rectal Expulsion Device. A.J.L. has consulted for Vibrant and Mylan; owns equity in Johnson & Johnson and Bristol Meier & Squibb; and has received research support from Takeda, Vanda, Shire, and Biomerica. The remaining authors disclose no conflicts.

Figures

Figure 1.
Figure 1.
PRISMA flow diagram. Six studies on fiber supplements included studies on the use of insulin (1 study), bran (1 study), and psyllium (3 studies). One study addressed magnesium oxide and senna in the same trial, so the total number of included studies is 28 and not 29. PEG, polyethylene glycol.
See this image and copyright information in PMC

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