ACG and AGA Joint Guideline on Chronic Constipation Management

New guidelines for the pharmacological treatment of chronic idiopathic constipation (CIC) in adults are the first to recommend magnesium oxide and senna as evidence-based treatments. The first joint clinical practice guideline developed by the American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA) published today in both societies’ scientific journals, ACG’s The American Journal of Gastroenterology and AGA’s Gastroenterology. An accompanying Clinical Support Decision Tool is available in Gastroenterology.

Under the leadership of Lin Chang, MD, AGAF, FACG, and William D. Chey, MD, AGAF, FACG, a multidisciplinary guideline panel conducted systematic reviews of various over-the-counter and prescription pharmacological agents available for the treatment of CIC: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride).

The authors hope the implementation of these recommendations will be of great practical value to clinicians. Among their 10 recommendations for the pharmacological management of CIC in adults, based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone.

“The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability,” commented Dr. Lin Chang, Vice-Chief of the Vatche and Tamar Manoukian Division of Digestive Diseases at David Geffen School of Medicine at UCLA.

“Most of the medications assessed in this guideline are readily available; however, some of them are still available only in brand name formulations because generic formulations do not exist. As a result, it is important to consider the out-of-pocket expenses for patients that may depend on prescription coverage with various insurance plans. Prior authorization might be required for some of the medications,” explained Dr. William Chey, Chief of the Division of Gastroenterology & Hepatology at the University of Michigan Medical School.

About Chronic Idiopathic Constipation

Chronic idiopathic constipation (CIC) is a common clinical diagnosis associated with significant impairment in quality of life that affects approximately 8 percent to 12 percent of the U.S. population. CIC is a lower gastrointestinal tract disorder of gut-brain interaction and can be associated with symptoms such as infrequent and incomplete defecation in the absence of mucosal or structural abnormalities. The medical costs related to the management of constipation are estimated to be between approximately $2,000 and $7,500 U.S. dollars per patient per year, and the effects on quality of life can be similar to those associated with conditions such as chronic obstructive pulmonary disease, diabetes, and depression.

Nonpharmacological therapies often represent the initial steps in management and may include dietary recommendations (such as increased fluid intake and increased dietary fiber) and behavioral changes (such as exercise). Pharmacological treatment may include the use of over-the-counter (OTC) or prescription medications, such as polyethylene glycol, secretagogues, or prokinetic agents. Overall, a significant proportion of patients with CIC are not satisfied with their treatment and may use multiple OTC medications, followed by prescription medications before they have improvement in their symptoms.

Evidence-Based Recommendations

Fiber

• Recommendation 1: In adults with CIC, the panel suggests the use of fiber supplementation over management without fiber supplements including bran, inulin and psyllium (conditional recommendation, low certainty of evidence).

Osmotic Laxatives

• Recommendation 2: In adults with CIC, the panel recommends the use of PEG compared with management without PEG (strong recommendation, moderate certainty of evidence).
• Recommendation 3: In adults with CIC, the panel suggests the use of magnesium oxide (MgO) over management without MgO (conditional recommendation, very low certainty of evidence certainty).
• Recommendation 4: In adults with CIC who fail or are intolerant to OTC therapies, the panel suggests the use of lactulose over management without lactulose (conditional recommendation, very low certainty of evidence).

Stimulant Laxatives

• Recommendation 5: In adults with CIC, the panel recommends the use of bisacodyl or sodium picosulfate (SPS) short term or as rescue therapy over management without bisacodyl or SPS (strong recommendation, moderate certainty of evidence).
• Recommendation 6: In adults with CIC, the panel suggests the use of senna over management without senna (conditional recommendation, low certainty of evidence).

Secretagogues (lubiprostone, linaclotide, plecanatide)

• Recommendation 7: In adults with CIC who do not respond to OTC agents, the panel suggests the use of lubiprostone over management without lubiprostone (conditional recommendation, low certainty of evidence).
• Recommendation 8: In adults with CIC who do not respond to OTC agents, the panel recommends the use of linaclotide over management without linaclotide (strong recommendation, moderate certainty of evidence).
• Recommendation 9: In adults with CIC who do not respond to OTC agents, the panel recommends the use of plecanatide over management without plecanatide (strong recommendation, moderate certainty of evidence).

5-HT4 agonist (prucalopride)

• Recommendation 10: In adults with CIC who do not respond to OTC agents, the panel recommends the use of prucalopride over management without prucalopride (strong recommendation, moderate certainty of evidence).

Read the Guideline

The American Journal of Gastroenterology

https://journals.lww.com/ajg/Fulltext/9900/American_Gastroenterological_Association_American.697.aspx

Gastroenterology

https://www.gastrojournal.org/article/S0016-5085(23)00513-9/fulltext

Clinical Decision Support Tool

https://www.gastrojournal.org/article/S0016-5085(23)00638-8/fulltext

About the American College of Gastroenterology Founded in 1932, the American College of Gastroenterology (ACG) is an organization with a membership of over 18,000 individuals from 86 countries. The College’s vision is to be the preeminent professional organization that champions the prevention, diagnosis, and treatment of digestive disorders, serving as a beacon to guide the delivery of the highest quality, compassionate, and evidence-based patient care. The mission of the College is to enhance the ability of our members to provide world-class care to patients with digestive disorders and advance the profession through excellence and innovation based upon the pillars of Patient Care, Education, Scientific Investigation, Advocacy and Practice Management. Website | Twitter

About the American Gastroenterological Association

The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, AGA has grown to more than 16,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. Website | Twitter

Media Contacts

• ACG: Anne-Louise Oliphant, [email protected], 301.263.9000 
• AGA: Courtney Reed, [email protected], 301.272.0025

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