Prescription Medications for Constipation

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Constipation is an incredibly common problem-by some estimates affecting 27% of the population. One review found that 63 million people in North America are affected. Definitions of constipation vary, but most include the criteria of less than 3 bowel movements per week.

Patients who see me in the office often- in addition to decreased bowel movement frequency-complain of hard stools, straining, of sensation of incomplete bowel movements.

While patients often self-medicate for constipation, it is wise to seek professional medical advice, since constipation can be the result of an underlying serious medical problem, and can even be a sign of colon cancer. When I see a patient with constipation, I generally review their dietary habits, review their medication list looking for medications that may be contributing to their constipation,  and perform a thorough physical exam. Depending on the situation, I may order blood tests looking for such issues as an underachieve thyroid-which can lead to constipation. I may also order x-ray studies, check for blood in the stool, or suggest a colonoscopy.

Once I have determined that the patient has "idiopathic" constipation-which basically means that there is no obvious underlying correctable cause( such as an underachieve thyroid, constipating medications, etc) I usually suggest some simple interventions-such as encouraging adequate dietary fiber, adequate fluid intake, and adequate physical activity-simple, natural measures that often work.

My next step is usually to consider Miralax(polyethylene glycol). This is a powder laxative, that is mixed with water. While it is not a "natural" substance, I believe it to be safe, and is generally effective. Some patients are able to take it on occasion "as needed", while others find that they need to use it on a regular basis.

If lifestyle changes and miralax are not getting the job done, I sometimes recommend a prescription laxative. The three prescription laxatives that I generally consider for my patients are: 1) Amitiza (lubiprostone) 2) Linzess(linaclotide) 3) Trulance (plecanitide)

Amitiza was approved by the Food and Drug Administration(FDA) in 2007. It is current FDA approved for the treatment of Chronic Idiopathic Constipation, Irritable Bowel Syndrome with Constipation, and Constipation Caused by Opioids. Nausea is the most common side effect of the medication-though there are other potential side effects that you should discuss with your doctor if this is prescribed to you. It is a twice per day medication. Nausea can be reduced by taking it with food and water.

Linzess was FDA approved in 2012. It is FDA approved for Chronic Idiopathic Constipation, and Irritable Bowel Syndrome with Constipation. Linzess is taken once daily. The most common side effect is diarrhea, though, again, there are other potential side effects that should be reviewed with the prescribing physician.

Finally, the most recent addition is Trulance, which was FDA approved in January of 2017. It is also a once daily product. It is FDA approved for Chronic Idiopathic Constipation. Like Linzess, the most common side effect is diarrhea.

I will share some thoughts on use of these medications from my experience with my patients. This is not intended as a comprehensive review of these products, nor should it be interpreted as specific advice. Every patient's situation is unique, and-as stated above-you should seek professional medical advice for your particular situation.

I feel that these medications are generally safe, generally well tolerated, and have a convenient dosing schedule. They don't work for everybody. On the other hand, sometimes they work too well! By that I mean that they can cause diarrhea. Sometimes the diarrhea can be severe, and even cause dangerous dehydration, requiring discontinuation of the medication. I usually caution patients to watch out for diarrhea, and even plan to stay close to their home for several days after starting the medication. Often times if diarrhea occurs initially, it may resolve after a few days. I encourage patients to "hang in there", drink plenty of fluids to stay hydrated, and if the initial diarrhea resolves, then they may be able to continue the medication. But, of course, if the diarrhea is severe or persistent the medication may need to be discontinued.

In addition to the above, it has been my experience that sometimes patients have an excellent response, but at some point lose the response and the medication stops working. My approach to those patients is usually to try another medication in place of the one that stopped working. However, at some point, I suggest re-starting the original medication, since often after a "drug holiday" the original medication may work once again. Other physicians may approach these medications differently.

While lifestyle and diet modifications are often adequate to treat constipation, the prescription products mentioned above have added significantly to our ability to help patients with constipation.