New practice guidelines aim to help clinicians navigate the increasingly crowded field of over-the-counter and prescription treatment options for chronic idiopathic conditions. constipation For otherwise healthy people.
The guidelines published in American Journal of Gastroenterologywas jointly developed by the American College of Gastroenterology and the American College of Gastroenterology. This is the AGA’s first update on chronic idiopathic constipation (CIC), also known as functional constipation, in 10 years.
Guideline lead author in interview Dr. Lin Chan, Researchers at the University of California, Los Angeles, noted that CIC is defined as constipation that lasts at least three months without a malignant tumor, obstruction, or drug side effects. inflammatory bowel disease — It is common, affecting 8% to 12% of all U.S. adults. Most will be treated by family doctors rather than specialists, Chan said. And most doctors will have already tried various over-the-counter treatments.
“The criteria for CIC, or functional constipation, haven’t really changed since the most recent AGA guidelines were published in 2013,” Chang said, adding that the diagnostic criteria currently in use are Rome’s criteria for functional constipation. It added that it is an IV standard. “There are more drugs now than there were 10 years ago.”
The new guidelines synthesize evidence from 28 studies and provide recommendations for different types of fibers.osmotic pressure laxative polyethylene glycol, magnesium oxideand Lactulose; and that stimulation laxative Bisacodylsodium picosulfate, and Senna.We also evaluate secretagogues. Lubiprostone, linaclotide, Plecanatideserotonin type 4 agonist prucalopride.
Stool softeners are one of the drugs commonly used in clinical practice. document Chan said sodium is not included in the guidelines because there is too little data to evaluate it. Fruit-based laxatives were excluded as they were the subject of a recent evidence review. Lifestyle modifications such as exercise, surgical intervention, and probiotics were not evaluated.
The guidelines most strongly recommend polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride, with conditional recommendations for fiber, lactulose, senna, magnesium oxide, and lubiprostone.
Because the cost of recommended treatments ranges from less than $10 per month to more than $500 per month, the authors include pricing information and consider “patient values, cost, and health equity considerations” when choosing treatments. He pointed out that this needs to be taken into consideration when making a selection. “For polyethylene glycol, there is a medium certainty of evidence but a strong recommendation,” Chan said. “And while we only made a conditional recommendation for fiber based on the evidence, our statement and algorithm make it clear that it should be considered as a first-line treatment. .”
In general, “if your symptoms are mild, you should eat more fiber or increase your fiber intake in your diet,” Zhang commented. “If that doesn’t work, try over-the-counter medications, such as polyethylene glycol. If your symptoms become more severe after that, or if your first-line treatment doesn’t work, seek prescription medication. It will be.”
In clinical practice, “there are always other considerations besides scientific evidence of safety and efficacy,” Zhang emphasized. “Treatment must be tailored to the patient.” It may be that the patient has already failed with dietary fiber, is unwilling to use magnesium, or is unable to afford more expensive medications. there is.
The guidelines include practical advice to guide selection of treatments and dosages. For example, with lactulose, a prescription osmotic laxative, “bloating and bloating are so common that you might not want to use it as a first-line treatment,” Chan says. “Our implementation advice makes that clear.” There is limited high-quality evidence for senna, a stimulant laxative derived from the leaves of the senna plant, so guideline authors believe that patients should avoid convulsions. He emphasized that patients should start at low doses to avoid this.
Chang said that while the new guidelines cover drug treatment options for otherwise healthy adults, clinicians should keep in mind that patients presenting with CIC may still have bowel dysfunction. He said that. “There may also be pelvic floor dysfunction as a primary cause or contributing factor. If fiber or polyethylene glycol fails, consider a digital rectal exam as part of the physical exam. If this is abnormal , consider referring anorectal manometry.”
Although there are risks to untreated constipation, “sometimes people with troublesome symptoms go untreated because they’re worried they’ll become dependent on the treatment.” It’s an addiction in the sense that you have to do it,” Chan points out. Hypertension and diabetes are possible, but the treatments are not addictive, except for some stimulant laxatives to which tolerance can be developed. ”
Over time, straining can cause hemorrhoids and bowel problems, Zhang said. “The pelvic wall can also become very loose, which is difficult to fix, or the pelvic wall can become very loose. rectal prolapse. If you have been constipated for many years, you may begin to lose the urge to defecate. ”
The development of this guideline received no support from industry and was funded by AGA and ACG. Authors with conflicts of interest regarding specific interventions or drugs were not permitted to review those interventions.
This story was originally MDedge.compart of the Medscape Professional Network.