Review: Constipation Diagnosis and Treatments
When choosing a treatment for chronic idiopathic constipation (CIC) or opioid-induced constipation (OIC), it should be based on cost and efficacy, a review published in JAMA described. The small subgroup of patients that do not respond to currently existing laxatives should undergo additional testing at centers capable of performing studies of defecation and colonic transit.
Arnold Wald, MD, from the University of Wisconsin School of Medicine and Public Health, and colleagues, reviewed recent developments in the management of constipation, including (1) updates of newer and established laxative and promotility agents for CIC, (2) new approaches to the treatment of OIC, and (3) identification of functional defecation disorders in patients who are unresponsive to standard laxatives.
Study authors searched MEDLINE, EMBASE, and Cochrane Reviews and found a total of 21 peer-reviewed studies and 12 reviews/meta-analyses to support their conclusion. Study data revealed a significant cost difference among the available laxatives presumed to be safe and effective. Cost-benefit ratio calculations were favorable to traditional, non-prescription laxatives. The more expensive laxatives should be reserved as second- to third-tier choices for CIC, they stated.
The paper includes a CIC treatment algorithm based on treatment initiation with common and relatively inexpensive laxatives, which progress depending on treatment response. Researchers also recommend that use of multiple agents should come from different categories. Also, novel secretory drugs and high-affinity serotonin agonists may play a more primary role in irritable bowel syndrome with constipation.
Regarding OIC, the development of peripherally restricted mu-opiate receptor antagonists is "a major advancement in the treatment of OIC." A review on available therapies showed that combining opioid antagonists with other existing laxatives may improve outcomes, "although this has not been formally studied."
Study authors also added that patients with CIC refractory to available laxatives should be tested for a defecation disorder via balloon expulsion testing and anorectal manometry prior to measuring colonic transit times, as functional defecatory disorders can usually be treated with biofeedback techniques.
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