Gastroenterology Guidelines Suggest 2 New Treatments for Chronic Constipation

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The American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) recently published new practice guidelines for how to treat chronic idiopathic constipation in adults.

These updated recommendations include 10 evidence-based ways to treat chronic constipation—two of which are included for the first time. Now, the guidelines also include using magnesium oxide and senna as treatment options for chronic constipation, as well as eight other options.

“The recent AGA-ACG clinical practice guideline on the pharmacologic management of chronic idiopathic constipation (CIC) reviewed multiple different treatments for CIC including magnesium and senna-based laxatives,” Lin Chang, MD, AGAF, FACG, one of the authors of the recommendations told Health.

“Randomized, placebo-controlled clinical trials were evaluated using GRADE methodology [Grading of Recommendations Assessment, Development, and Evaluations] and certainty of the evidence was rated and recommendations made regarding the use of these treatments,” she said.

Expanding the number of treatment options can be useful for physicians who are treating patients with this type of constipation, especially since this condition affects between 8% and 12% of people in the U.S. Symptoms of CIC can include infrequent bowel movements, incomplete bowel movements, and bowel movements that are hard to pass. But unlike other types of constipation, the cause of CIC is unknown.

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Magnesium oxide is a magnesium supplement that can be purchased at a grocery store or pharmacy, William D. Chey, MD, AGAF, FACG, an author of the updated recommendations told Health.

“At usual doses, it is very safe and offers benefits for chronic constipation by causing a release of the body’s own fluid into the lumen of the bowel,” he said. “This tends to soften the stool and can indirectly stimulate the bowel to contract, helping stool to move through the GI tract.”

According to Dr. Chey, there are several studies from Japan supporting the benefits of magnesium oxide for chronic constipation when used at doses up to 1,500 mg per day. “Typically, we recommend starting at 400 mg to 500 mg per day and increasing the dose as needed to no more than 1,500 mg per day.”

Senna, which comes from the herb Senna alexandrina, has been used for centuries to treat chronic constipation, Dr. Chey said. “It is natural and derived from a plant. It stimulates the colon to contract and in that way, helps with constipation.”

Because it can cause cramping at higher doses, Dr. Chey noted they recommend using it intermittently when people feel more constipated as opposed to every day. “There is one trial from Japan showing that senna and magnesium oxide are similarly effective for chronic constipation.”

In addition to magnesium oxide and senna, the ACG and AGA also list other non-pharmacological options for treating chronic constipation. According to Dr. Chang, these include both recommendations and suggestions.

“In patients with CIC, the AGA and ACG recommend the use of the osmotic laxative polyethylene glycol, stimulant laxatives bisacodyl and sodium picosulfate, guanylate cyclase-C agonists linaclotide and plecanatide, and 5HT4 agonist prucalopride in patients with CIC,” she said. “These treatments were given a strong recommendation with a moderate certainty of evidence.”

Meanwhile, the AGA and ACG suggestthe use of fiber, osmotic laxatives magnesium oxide and lactulose, stimulant laxative senna, and ClC-2 activator lubiprostone in the treatment of patients with CIC, Dr. Chang added. “These medications were given a conditional recommendation with low (fiber, senna, lubiprostone) to very low (magnesium oxide and lactulose) certainty of evidence.”

The panel also takes into consideration other factors as well, said Michelle Pearlman, MD, a physician nutrition specialist board certified in gastroenterology and CEO and co-founder of Prime Institute. These factors include shared decision-making between the provider and the patient as well as the patient’s preferences, medication costs, and medication availability.

According to Trish Gomez, RD, CPT, a registered dietitian with Vanderbilt Stallworth Rehabilitation Hospital, there are a number of other things you can do to treat chronic constipation. These options can be used in combination with the treatment plan your healthcare provider recommends.

  • Drink adequate amounts of fluids: People who drink the least are more likely to be constipated, Gomez said. “A good goal is eight 8-ounce glasses (or 2 liters) per day, of non-caffeinated, unsweetened beverages.”
  • Ensure adequate dietary fiber intake: Gomez recommended getting at least 25 grams of fiber a day. Focus on getting your fiber from a large variety of sources, including whole grains, legumes, fruits, and vegetables and increase the amount slowly, she said. Too much fiber can lead to excessive bloating and gas, though, which can either worse constipation or cause diarrhea, added Dr. Pearlman.
  • Get regular physical activity: The Centers for Disease Control and Prevention recommends 150 minutes of moderate physical activity a week, so try to aim for 30 minutes a day, she said. “Exercise improves your gut motility [or] how well food waste moves through our bowels. Walking, jogging, biking, stretching, and weight training are all great ways to help improve constipation.”
  • Try pelvic floor therapy: A number of people with chronic constipation have pelvic floor dysfunction or impaired relaxation and coordination of pelvic floor and abdominal muscles during evacuation, Gomez said. “Pelvic floor retraining exercises have been shown to significantly improve symptoms for those with pelvic floor dysfunction.”
  • Manage stress: According to Gomez, unmanaged stress can trigger or exacerbate constipation. “Finding ways to manage your stress on a daily basis can improve bowel habits. Try a meditation app, take a yoga class, listen to music, laugh with friends, or sip on a calming herbal tea.”
  • Utilize abdominal massage: Massaging your lower abdomen, along the tract of your large intestine, can help improve gut motility, Gomez explained. “Start at your lower right abdomen just inside your right hip, massage in small circles. Move upward to just under your ribs, then to the left side, and massage down towards your left hip.”

If you are experiencing ongoing constipation, it is important to see a healthcare provider, especially if you cannot resolve the issue at home with increased fluids, exercise, and dietary changes, said Mark Pimentel, MD, gastroenterologist and executive director of the Medically Associated Science and Technology (MAST) Program at Cedars-Sinai.

“Many non-gastrointestinal conditions such as hypothyroidism can be a cause of constipation,” Dr. Pimentel explained. “In addition, medications are a common cause. For example, commonly used anti-depressants can cause constipation.”

Likewise, if your constipation is a new symptom for you, this also could be a reason to be evaluated as well, he added. “If you are over the age of 45 years of age, new onset constipation could be a symptom of colon cancer. Be sure you are up to date on colonoscopy for cancer screening.”

He noted that other important red flags to alert a healthcare provider about are blood in the stool, unexpected weight loss, and a family history of colon cancer.

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