Constipation Frustrates Patients and Providers

About 30% of Americans experience constipation at least once a month,¹ but about 13% indicate that they are constipated more often, and 12% to 19% consider the condition chronic (see Table 1²), according to a survey of 2000 people.¹ Most people experience constipation sporadically. But if constipation is frequent with no identifiable cause or is long-lasting, it is considered chronic idiopathic constipation (CIC). CIC is a very common chronic functional gastrointestinal disorder, and elderly individuals are more likely to be affected.³ Lower socioeconomic status, reduced caloric and dietary fiber intake, and a sedentary lifestyle elevate the risk.^4-6

CIC costs the American health care system between $1912 and $7522 per patient per year in 2007 US dollars and is also associated with significant rates of absenteeism and presenteeism at work.⁷ Experts indicate that reducing constipation’s severity by 20% can save between $641 and $2437 per patient.⁸

A STRESSFUL SEARCH FOR RELIEF

The average patient with CIC tries about 4 OTC and 2 prescription medications before finding relief, according to a Harris Poll. Just 22% of Americans who have constipation seek help from a health care provider, and 14% of patients with CIC report at least 1 emergency department visit annually. The Harris Poll surveyed 881 patients with CIC and gastroenterologists in spring 2018 as part of the Current Insights About Constipation Survey,⁹ which confirmed that patients experience considerable frustration and stress. Table 2⁹ lists additional findings.

SELECTING TREATMENT

Guideline-directed treatment generally recommends moving from lifestyle modifications to OTC products and prescription laxatives and stool softeners. Most patients report that these steps are inadequate, however. Pharmacists need to manage patients’ expectations about the effectiveness of common treatments when they recommend approaches. For example, most health care practitioners recommend increasing fiber as the first step. Two systematic reviews report that although fiber is more effective than a placebo, it has limited benefit overall in CIC¹⁰ and a propensity to cause unwanted gastrointestinal adverse effects, including flatulence.¹¹ Increasing water intake is also a frequent concurrent recommendation. Unless the patient is dehydrated, however, this intervention is unlikely to help appreciably.^12,13

Bisacodyl, linaclotide, lubiprostone, polyethylene glycol, prucalopride, and sodium picosulfate are all more effective than a placebo for CIC, but data on lactulose are limited. Pharmacists should note that patients taking laxatives and pharmacologic therapies are significantly more likely to experience diarrhea.¹⁴

Substantial evidence indicates that the newer prescription drugs provide better symptom relief than traditional approaches. Effective treatment depends on consideration of cost, a rational approach, and use of effective interventions. In addition, patient commitment and satisfaction are critical to successful outcomes.

Four prescription drugs are available: the prosecretory drugs linaclotide, lubiprostone, and plecanatide, as well as the selective 5-HT4 receptor agonist prucalopride (see table 3^15-18).

CONCLUSION

Many treatment recommendations that clinicians have used for decades fail to deliver results. Earlier consideration of pharmacologic intervention can help patients avoid adverse outcomes and improve their quality of life.

Jeannette Y. Wick, MBA, RPh, FASCP, is an assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

• American gut check. Healthline.com website. healthline.com/health/ american-gut-check#6. Accessed May 7, 2019.
• National Institute of Diabetes and Digestive and Kidney Diseases. Constipation. National Institutes of Health website. niddk.nih.gov/health-information/digestivediseases/ constipation. Accessed May 7, 2019.
• Choung RS, Locke GR III, Schleck CD, Zinsmeister AR, Talley NJ. Cumulative incidence of chronic constipation: a population-based study 1988-2003. Aliment Pharmacol Ther. 2007;26(11-12):1521-1528. doi: 10.1111/j.1365-2036.2007.03540.x.
• Nellesen D, Chawla A, Oh DL, Weissman T, Lavins BJ, Murray CW. Comorbidities in patients with irritable bowel syndrome with constipation or chronic idiopathic constipation: a review of the literature from the past decade. Postgrad Med. 2013;125(2):40-50. doi: 10.3810/pgm.2013.03.2640.
• Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P, Talley NJ. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005;100(suppl 1):S5-S21. doi: 10.1111/j.1572-0241.2005.50613_2.x.
• Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterol. 2003;98(8):1790-1796. doi: 10.1111/j.1572-0241.2003.07591.x.
• Nellesen D, Yee K, Chawla A, Lewis BE, Carson RT. A systematic review of the economic and humanistic burden of illness in irritable bowel syndrome and chronic constipation. J Manag Care Pharm. 2013;19(9):755-764. doi: 10.18553/ jmcp.2013.19.9.755.
• Neri L, Basilisco G, Corazziari E, et al; LIRS Study Group. Constipation severity is associated with productivity losses and healthcare utilization in patients with chronic constipation. United European Gastroenterol J. 2014;2(2):138-147. doi: 10.1177/2050640614528175.
• 9. Current insights about constipation [news release]. Cambridge, MA: Shire US Inc; December 7, 2018. multivu.com/players/English/8374951-national-cic-chronicidiopathic- constipation-survey/. Accessed May 7, 2019. 10. Suares NC, Ford AC. Systematic review: the effects of fibre in the management of chronic idiopathic constipation. Aliment Pharmacol Ther. 2011;33(8):895-901. doi: 10.1111/j.1365-2036.2011.04602.x. 11. Christodoulides S, Dimidi E, Fragkos KC, Farmer AD, Whelan K, Scott SM. Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults. Aliment Pharmacol Ther. 2016;44(2):103-116. doi: 10.1111/apt.13662. 12. Anti M, Pignataro G, Armuzzi A, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. 1998;45(21):727-732. 13. Ziegenhagen DJ, Tewinkel G, Kruis W, Herrmann F. Adding more fluid to wheat bran has no significant effects on intestinal functions of healthy subjects. J Clin Gastroenterol. 1991;13(5):525-530. 14. Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut. 2011;60(2):209- 218. doi: 10.1136/gut.2010.227132. 15. Trulance [prescribing information]. New York, NY: Synergy Pharmaceuticals Inc; 2017. www.accessdata.fda.gov/drugsatfda_docs/label/2017/208745lbl.pdf. Accessed June 11, 2019. 16. Motegrity [prescribing information]. Lexington, MA: Shire US Inc; 2018. www.accessdata.fda.gov/drugsatfda_docs/label/2018/210166s000lbl.pdf. Accessed June 11, 2019. 17. Linzess [prescribing information]. Madison, NJ: Allergan USA Inc; 2018. allergan. com/assets/pdf/linzess_pi. Accessed June 11, 2019. 18. Amitiza [prescribing information]. Deerfield, IL: Takeda Pharmaceuticals America Inc; 2018. www.accessdata.fda.gov/drugsatfda_docs/label/2012/021908s010lbl.pdf. Accessed June 11, 2019.