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CME / ABIM MOC / CE

Managing Constipation in Primary Care: Cases From the Community

  • Authors: Joel Heidelbaugh, MD, FAAFP, FACG; Brian E. Lacy, MD, PhD, FACG; Nicole G. Rockey, PharmD, BCACP
  • CME / ABIM MOC / CE Released: 9/28/2022
  • Valid for credit through: 9/28/2023
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  • Credits Available

    Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.50 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for primary care physicians, gastroenterologists, nurses, and pharmacists.

The goal of this activity is that learners will be better able to identify and manage occasional constipation in their patients using best available evidence.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Evidence-based recommendations for managing occasional constipation
    • Characteristics of different over-the-counter (OTC) constipation medications
  • Have greater competence related to
    • Tailoring OTC treatments for constipation based on patient-specific factors


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Moderator

  • Joel Heidelbaugh, MD, FAAFP, FACG

    Professor, Family Medicine and Urology
    Director, Medical Student Education
    Department of Family Medicine
    University of Michigan Medical School
    Ann Arbor, Michigan

    Disclosures

    Joel J. Heidelbaugh, MD, has no relevant financial relationships.

Faculty

  • Brian E. Lacy, MD, PhD, FACG

    Professor of Medicine
    Division of Gastroenterology and Hepatology
    Mayo Clinic
    Jacksonville, Florida

    Disclosures

    Brian E. Lacy, PhD, MD, FACG, has the following relevant financial relationships:
    Consultant or advisor for: Gemelli; Ironwood; Salix; Sanofi; Takeda
    Research funding from: Bausch

  • Nicole G. Rockey, PharmD, BCACP

    Clinical Pharmacist Specialist in Ambulatory Care
    Adjunct Clinical Professor in Pharmacy
    Michigan Medicine
    Ann Arbor, Michigan

    Disclosures

    Nicole G. Rockey, PharmD, BCACP, has no relevant financial relationships.

Editors

  • Roderick Smith, MS

    Senior Medical Education Director, Medscape, LLC

    Disclosures

    Roderick Smith, MS, has no relevant financial relationships.

  • Renata Feldman, PharmD

    Scientific Content Manager, Medscape, LLC

    Disclosures

    Renata Feldman, PharmD, has no relevant financial relationships.

Compliance Reviewer/Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.


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CME / ABIM MOC / CE

Managing Constipation in Primary Care: Cases From the Community

Authors: Joel Heidelbaugh, MD, FAAFP, FACG; Brian E. Lacy, MD, PhD, FACG; Nicole G. Rockey, PharmD, BCACPFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/28/2022

Valid for credit through: 9/28/2023

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Activity Transcript

Joel Heidelbaugh, MD: Hello, I'm Dr Joel Heidelbaugh. I'm a Professor of Family medicine and the Director of Medical Student Education at the University of Michigan in Ann Arbor. Welcome to this Medscape program titled “Managing Constipation in Primary Care: Cases From the Community”. I'm very pleased to be joined today by my colleague, Dr Brian Lacey, who's a Professor of Medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic in Jacksonville, Florida. I'm also very pleased to be joined today by my colleague, Dr Nicole Rockey, who is a Clinical Pharmacist, an Adjunct Clinical Professor of Pharmacy at Michigan Medicine in Ann Arbor. Welcome, Brian and Nicole.

Let's start with a brief overview of constipation. We know that constipation is one of the most common GI complaints seen in our primary care practices, and the prevalence among adults is estimated at about 15%. It's most often described in the literature as being chronic with the onset greater than six months ago, such as with chronic idiopathic constipation and the predominant constipation form of irritable bowel syndrome. However, we know that many people experience less frequent constipation, which doesn't fall under one of these current definitions. And that's the focus of this particular program today.

Primary care providers need to be aware of the different types and causes of constipation. They need to be able to do an adequate evaluation and recommend appropriate therapy. They also need to know when a patient should be considered, perhaps complex enough to be referred to a GI specialist.

Let's start today with a case presentation that is common to many of our practices. Arlene is our patient who's a 24-year-old female, and she presents to her PCP with a primary concern of feeling constipated several times per month over the last year. Recently, she started a new job, and she finds that somewhat stressful. Otherwise, Arlene's a very healthy young lady. She takes no medications except for low-dose oral contraceptives. She tells you that she's concerned because she thinks that constipation is something that older people get. She comes today seeking advice on what to do.

So, Brian, we know this is a very common presentation in our practices, and we see a lot of this in primary care. Why is it important to differentiate occasional or what, I might say, normal constipation from chronic forms of constipation?

Brian Lacy, MD, PhD: Joel, great question. I think there are three good reasons. One is that I think it's important we all use the same language and define occasional constipation, which is different than chronic constipation. We define occasional constipation as a bothersome reduction in bowel movement frequency or difficulty with passage of stool. So now we speak the same language.

Number two, chronic constipation and IBS with constipation has been extensively studied, but there's actually very little research about occasional constipation, which is still very prevalent and very bothersome. The third important reason is that that treatment is very different. When we think about chronic idiopathic constipation or IBS with constipation, you can imagine that treatments are usually prescription medications. In contrast, and as we'll learn more about later, occasional constipation, a couple of days with no bowel movement, and then going back to your normal routine is typically treated with lifestyle modifications or over-the-counter medications.

Highlighting some of these differences, I think it's nice to go back a little bit and remind all of our listeners and viewers today about the Rome criteria for functional constipation.

When we think about chronic idiopathic constipation or functional constipation, one when we use the Rome criteria. Remember, patients must have had symptoms that developed at least six months earlier and have been active within the last three months. Occasional constipation, of course, may just mean a few days of symptoms and then weeks or sometimes even months of no symptoms. In addition, for functional constipation, adults should have at least two of the three following criteria. They have fewer than two bowel movements per week. They describe harder, lumpy stool at least 25% of the time having a bowel movement. They describe a lot of straining at least 25% of the time.

They describe a feeling of incomplete evacuation when having a bowel moment, "If I could just go a little bit more, I'd feel better." Or they have a feeling that there's some mechanical blockage preventing proper evacuation of stool. And sometimes, they use what we call manual maneuvers, where they may press on the perineal body to support themselves or even use digital stimulation. So, a lot of key differences between occasional constipation and chronic idiopathic constipation.

Thinking about these two big issues, Joel, I'm going to turn the table back to you. Thinking about medications that clinicians might be able to use to treat chronic constipation, how about some of the side effects of medications that may cause occasional or chronic constipation?

Dr Heidelbaugh: Yes, Brian, I'd say this is really important. I think certainly in primary care practices, as you know, we treat a variety of conditions, and we prescribe a variety of different medications and medication classes. It's hard to often think about constipation as a potential side effect until it happens.

A lot of pain medications are going to cause chronic constipation. Certainly, the opioids: certainly Tramadol is included in that. It's important to take a thorough history of what medications patients may already be taking over-the-counter, including antidiarrhea agents. Other common medications I see that we prescribe in primary care and certainly chronic medications that we use include anticholinergic medications, and antimuscarinic medications. These are common, also again, for pain indications, treating migraines, and urinary incontinence certainly, these medications can cause that. Many antipsychotic medications can cause chronic constipation. High-dose calcium channel blockers that we may use for the treatment of hypertension, atrial fibrillation, or other conditions that we need to control our heart rate. And tricyclic antidepressants, again, for a variety of different indications ranging from insomnia to chronic pain and certainly visceral hypersensitivity.

Let's now transition to talk about the management of constipation in the primary care setting, and in primary care practices, what we often recommend for our patients. Nicole, can you give us an overview of how we might best approach and manage a patient with occasional constipation and what options are available in primary care practices?

Nicole Rockey, PharmD: Yes. Happy to talk about that. Just like Dr Lacey mentioned, we have a fair bit of peer-reviewed studies as well as guidelines and recommendations for managing chronic constipation, but there isn't really a published algorithm regarding the management of occasional constipation. I think that we can take some of the literature that we have on managing chronic constipation as well as clinical experience to try to describe the best way to go about this. I think that with chronic constipation, we often use a stepwise approach, but with occasional constipation, you probably can combine multiple methods at once.

Many patients with occasional constipation will self-manage and will use OTC medications without asking for advice. Some patients certainly will ask their pharmacist when they're at the pharmacy to try to help them pick something, and other patients will call their primary care physician for a recommendation. But really, I think management of occasional constipation should be patient-focused. We really need to remember that lifestyle changes can take time to have an effect. And so, many patients are going to need an OTC medication to go along with that.

In general, we should consider diet and lifestyle modifications, which include physical activity probably as well as an OTC medication for the management of occasional constipation. We should encourage patients to get plenty of soluble fiber, either through their diet or a supplement and also adequate hydration along with that. Hydration is particularly important because of the mechanism of action of fiber supplements, which I'll talk about here shortly. The benefits of physical activity are less clear in managing constipation, and we'll talk more about that again later. Then I think remembering that soluble fiber sometimes takes some time to have an effect on constipation, and so if patients are uncomfortable, they probably need an OTC laxative or stool softener to help out.

Dr Heidelbaugh: Thanks, Nicole. That's a really great overview to get us started here. Let's actually start with fiber. In every grocery store and in every pharmacy, it seems like there's an entire aisle dedicated to fiber. We know that most Americans probably don't get enough dietary fiber, and most people know that there are fiber supplements. So as a cornerstone treatment for occasional constipation, what are the options? And what's the evidence?

Dr Rockey: We have soluble fiber supplements like psyllium, polydextrose, and inulin, and then there are insoluble fibers like bran and methylcellulose. Insoluble fiber supplements really don't have good data to support their use in constipation. There was a review article published in the American Journal of Gastroenterology last year that reviewed the data that we have for different fiber supplements, and they really found modest evidence supporting the efficacy of psyllium fiber, but actually, inadequate evidence supporting polydextrose or inulin fibers.

I think it's also important to remember that fiber supplements have side effects. They can cause mild to moderate flatulence as well as abdominal pain or bloating. We have to consider that and make sure patients are aware that is a possible side effect.

There was also a meta-analysis published a couple of years ago that looked at soluble fibers vs insoluble fibers, specifically psyllium vs wheat bran. And they compared the effects on stool output. They found that both psyllium and wheat bran did increase stool output, but the psyllium was significantly more effective. It was 3.4 times more effective than a wheat brand for increasing stool weight.

Then I think it's also important to consider fruit-based laxatives. Fruits contain varying proportions of both soluble and insoluble fibers, and there have been small studies involving Kiwi, mango, figs, and prunes that generally showed improvements in constipation symptoms. I think what's really important to know is that these fruit-based laxatives tend to be well tolerated and have a low rate of adverse effects. There are some patients that are going to prefer this method vs a psyllium fiber supplement. We really do need more well-designed studies with these because it's hard to make evidence-based recommendations with the data that we have.

Dr Heidelbaugh: Thanks, Nicole. That's really helpful and really enlightening as well. Going back to our case, what kind of advice might you give our patient regarding fiber intake or supplementation?

Dr Rockey: If our patient is interested in a fiber supplement, I will encourage her to consider a psyllium fiber supplement simply because we have the best evidence of efficacy with the psyllium fibers. I would encourage her to look for one of those. Then I would give her a heads up about side effects. She could experience bloating, abdominal pain, and flatulence. Those are probably the most common adverse effects. I would encourage her to start with a low dose and slowly increase to try to minimize those side effects. I would also encourage adequate hydration. Again, because of the way fiber works, fiber increases the water absorption of the stool, and so having adequate hydration is going to make it work better.

Then lastly, I think with any recommendation for laxatives or fiber supplements, it's good to give patients a heads up on what the onset of action is of these things. Some patients are worried about taking these products because they're worried about fecal urgency or having real watery diarrhea. I think with psyllium, you can expect an onset of action of about 12 to 72 hours and give them an expectancy that most patients are going to experience a soft bowel movement but not watery diarrhea after they start using psyllium fiber.

Dr Heidelbaugh: That's great, Nicole. Thank you very much. I want to go back and focus a little bit on two things that you mentioned, exercise and drinking more fluids or drinking more water. It seems kind of intuitive that if patients have constipation, they should exercise more, and their bowels will move more. Or if they're not drinking enough water or not getting enough fluid and their stools are hard, then they should drink more water and drink more fluid, and then their stools won't be as hard.

So, Brian, we hear this all the time, and I think this is important for primary care providers to really acknowledge, but is there evidence to really support these claims when we're discussing these issues with our patients?

Dr Lacey: Yes. Two great questions. The way I like to think about this, Joel, is the myths and misconceptions about constipation, whether occasional or chronic. Two questions are buried there. Let's think about exercise first. And you're right, you would think that if you exercise more, that should stimulate the GI tract and, therefore, that should solve or resolve or improve symptoms of constipation. That said, if we really look at the evidence, there's not a lot of evidence to support that. There is some evidence, and I'm looking at this slide here now, looking at one study comparing the level of physical activity.

We know that some level of physical activity does improve stool frequency to some degree. And certainly, for somebody who exercises to some degree, whether it's running, cycling, or even going to the gym and lifting weights, you are less likely to suffer from constipation than if you don't exercise at all.

But we really don't have great data looking at large numbers of people and looking at the number of exercise events and the duration of exercise activity. Thinking about water, there's even less data. And so, you're right, you think it would make sense, if I drink more water, I could just solve my constipation symptom. It doesn't work that way. Drinking water, there's a lot of myths about water. One of them is you need to drink eight glasses of water per day to stay healthy. That's an absolute myth, and that's been disproven.

But remember, think about what your GI tract does. It acts like a sponge to absorb fluid. In fact, your small intestine can absorb up to 14 to 15 liters of water per day. So when you think about that, trying to drink even two liters of water or three liters of water per day, it never even reaches the colon to help symptoms of constipation. So drinking water by itself will never solve constipation.

However, I do want to go back to Nicole's very good point. If you're using a fiber supplement, mixing with water, if it's a powder, or taking the pills with water, does make a difference because those products are hydrophilic and will absorb the water you're drinking at the time.

Dr Heidelbaugh: Thanks, Brian. This was very helpful. So ironically, during our webinar, our patient sent me a message through her patient portal. She says that she tried a psyllium fiber supplement for about three weeks. She didn't say exactly how much, but she found that it made her very bloated, and her constipation really hasn't improved all that much.

So now she's inquiring: should she take any laxatives? She has a lot of questions about those, but she's confused because she actually went to her pharmacy and saw so many choices she didn't know where to start. I'm wondering if you could shed some light on the different laxatives that are available over-the-counter, perhaps starting with polyethylene glycol or PEG as we call it.

Dr Lacey: Great. Several great teaching points here. As you and Nicole have both mentioned that fiber products could help constipation, but frequently in 50 to 60% of patients, it may be because of some gas or bloating. And then Joel, as you mentioned earlier, you walk down any grocery store aisle or pharma aisle, and you're overwhelmed with treatment options.

Let's look at some of these treatment options, and polyethylene glycol is a very reasonable treatment option. This is FDA approved to treat chronic constipation and occasional constipation. I like to think of polyethylene glycol when I explain to my patients, it acts like a sponge, and it absorbs and holds onto fluid already in the GI tract. It's very poorly absorbed, very little gets into the body. I think it's very safe. Nearly 100% is excreted in stool. We have very good data from the literature, looking at both short-term studies and long-term studies showing that it's efficacious and it's safe. Generally, I recommend that patients start at about 17 grams per day and about six to eight ounces of water. If you have your patients buy the big bottle, unscrew the cap, and there's a line about halfway up.

Patients do like to know when it works. Generally, this seems to kick in about 24 hours later. Of course, it's different in different people based on the severity of their constipation symptoms. Side effects, sometimes the timing's a little tricky. Sometimes it causes too loose stools, just to have your patients back off. And sometimes because it does hold onto all that water, it may create some symptoms of gurgling and churning and some symptoms of gas and bloating. Most patients get used to that.

Importantly too, in contrast to many other medications, polyethylene glycol has been compared to not just placebo, but also to psyllium products and some prescription medications like prucalopride, tegaserod, and lactulose. In those head-to-head comparisons, polyethylene glycol was found to be both effective and safe. One study did look at whether adding electrolytes to polyethylene glycol formulations would be more effective or efficient. The answer was no. And we do know too that in terms of something like lactulose, which can cause a lot of gas and bloating, I think that polyethylene glycol is a better product.

Now, what other options are available? We can think about the class of stimulant laxatives, which includes senna, bisacodyl, and picosulfate. So as a group, stimulant laxatives work on nerves in the intestinal GI tract within the muscle to stimulate colon motility; they do stimulate GI motility. And that can either be good or when we talk about side effects, maybe not so good. The best evidence for stimulant laxatives is for senna. One of the side effects of all these agents within this class is that sometimes the stimulation is too significant, leading to cramps, pain, spasms, and diarrhea. Generally, those can be managed by reducing the dose.

Thinking about senna, this can come alone as an individual product. Sometimes it's sold in combination with a stool softener, such as docusate. When does it act? Well, typically, senna products seem to act within a very short period of time, within about 6 to 12 hours. Recommendations are you could start with two tablets. They're about 8.6 milligrams, two tablets, once daily. You can go up to as many as four tablets twice daily, which can be effective for many patients. What we do know from a 4-week study is that as the doses increase, many patients need a dose reduction because of some symptoms of pain, spasms, cramps, or diarrhea. And that can be easily accomplished through email or phone calls.

What about bisacodyl? Bisacodyl is a very effective stimulant laxative used to treat occasional constipation. And for many research studies looking at chronic constipation, bisacodyl is the rescue medication because it works so well. Generally, once again, it seems to induce a bowel movement within about six to 12 hours. A typical adult dose is one to two or three tablets in a single dose. Sometimes we use it to help with colon preps, and we have patients take two tablets the evening before they start the colon prep.

The level of evidence for bisacodyl is good but not great. It's not quite as good as senna. We don't have as many studies to look at. And once again, what are some of the most common side effects? Spasms, pain, cramps, and diarrhea. Just have patients reduce their dose. By the way, another misconception we mentioned earlier is this is not addictive and does not injure the nerves of the colon.

Dr Heidelbaugh: Many thanks, Brian. That was really informative. I do have a question, though. And Nicole, I'm going to ask your perspective on this because I know there are options for both oral and suppository forms of bisacodyl. And certainly, I think this comes down to patient preference, but do you see any benefit to one over the other?

Dr Rockey: It's a good question. And I agree that patient preference probably plays a big role in this and whether we use tablets or suppositories, many patients are going to prefer tablets just because they're probably easier to use. However, you can certainly see more side effects from the tablets because they're moving through the entire GI tract. You may get a more complete evacuation from that because of where the tablet is moving. But if a patient prefers fewer side effects, they certainly could use a bisacodyl suppository.

Dr Heidelbaugh: Great. That’s very helpful. What are your thoughts about saline laxatives?

Dr Rockey: Saline laxatives work by extracting fluid into the intestines to soften stools and produce bulkier stools. Magnesium citrate, magnesium oxide, and magnesium-rich water have all been studied and have modest efficacy or modest evidence of efficacy, I should say. These products typically work quickly. We're talking 30 minutes to maybe up to three hours, but they tend to produce more watery stools as well as some fecal urgency. So I think that if you're going to recommend a saline laxative, it's really important to give patients that heads-up, that this is going to work quickly and can cause some fecal urgency so that they're prepared for that.

Certainly, these can also because abdominal pain and diarrhea. Then also, we really have to use caution in patients with renal impairment because they can cause hypermagnesemia in patients with renal impairment.

Dr Heidelbaugh: Thank you. Let's go back to our patient again, a 24-year-old woman, healthy, with occasional constipation. Nicole, the patient is producing questions about starting laxatives. She wants to know what to expect and how fast it'll work. Will it suddenly kick in when she's at the office or in the car, or on her morning jog? And from a pharmacist perspective, how do you actually counsel patients when they're starting a laxative?

Dr Rockey: Okay. With our patient, let's say we're going to recommend polyethylene glycol, certainly, I would start with how to use it, fill the cup up to the line with powder, and mix it in water. I would go through the basic instructions on how to use it. But aside from that, I think always talking about when they can expect it to work. So, if we're talking about polyethylene glycol, this is a little bit of a review, but we talked about typically, you're going to get a soft bowel movement in 24 hours. It could take up to 72 hours, but usually, in about 24 to 48 hours you'll see a soft bowel movement.

It should not, or it typically does not cause diarrhea or significant urgency. Now, if we're recommending a stimulant laxative, we talked about onset of action, probably six to 12 hours, a saline laxative, even faster, we're talking 30 minutes to three hours. So, I think definitely talking about the onset of action and what to expect in terms of soft bowel movement vs watery loose stools.

Dr Heidelbaugh: Thanks, Nicole. That's great information again. One thing that comes up a lot in our primary care practices is how can we best educate patients on what we consider an adequate trial of an OTC laxative for constipation before moving on to something else?

Dr Rockey: I think about that onset of action that we just talked about. And so if they're not getting relief on the upper end of that onset of action, then I would consider dose titration or the addition of a second agent. For example, if they're using polyethylene glycol, we might think about adding a stimulant laxative. Then certainly, as a pharmacist, if these things aren't working, I'm going to encourage them to call their physician to try to further investigate what's going on.

Dr Heidelbaugh: And Brian, do we have any evidence to support combination therapy for patients with occasional constipation?

Dr Lacey: The short answer, Joel is no, we don't have great evidence. That said, I think we have a lot of clinical experience. And so I like what Nicole said an awful lot. So if somebody is on a trial of whatever medication you think is best for them, and in this case, for occasional constipation, and they don't seem to be improving, you have to ask why. Was it not an adequate trial? Was it not an adequate dose? Were they not taking it correctly? Or maybe it helped to some degree, and then you need to layer something else on. And if you decide to layer something else on, I always think about using something with a different mechanism of action.

As an example, if somebody's having some response to polyethylene glycol but not a great or complete response, you could maybe layer on a low dose of a stimulant laxative, even maybe a bisacodyl suppository, to improve those symptoms.

So following up on that too, Joel, we've talked about an awful lot today. How do you go about developing a management plan in primary care for a patient with constipation? And at what point would you refer to a gastroenterologist? I'm really curious to know.

Dr Heidelbaugh: Sure. Starting where we started, I think every patient needs an individualized approach relative to their comorbidities, relative to what medications they take. Talking about diet, exercise, adequate hydration, and fitting in on the spectrum of where that patient falls, do they have occasional constipation, or do they have chronic idiopathic constipation or constipation-predominant irritable bowel syndrome? I'm going to develop a management plan based on all of that with close follow-up.

Certainly today, we've highlighted a great approach to not only fiber but over-the-counter laxative therapy. And I think that's a great place to start. When would I refer someone to a gastroenterologist? Certainly, after an adequate trial of all of those. If those things fail, I've got to work them up for certainly organic disorders that may be playing a role in chronic constipation or more severe forms. Certainly, looking at pelvic floor disorders. We did not dive into colorectal cancer screening or other organic issues today, but certainly, in a primary care practice, I think a thorough and careful history relative to each individual patient is going to be warranted.

So, Brian and Nicole, I'd like to sincerely thank you for joining me today. I'd like to thank our participants for joining us in this Medscape activity today. We'd like you to please continue on to answer the questions that follow and to complete this evaluation. On behalf of our team today, thank you.

This transcript has not been copyedited.

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