USA: The American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) have jointly released a clinical practice guideline on the pharmacological management of chronic idiopathic constipation (CIC).
Chronic idiopathic constipation is a common disorder associated with significantly impaired quality of life. The clinical practice guideline, published in The American Journal of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults.

For developing the guideline, the AGA and ACG formed a multidisciplinary guideline panel to conduct systematic reviews of the following agents: fibre, osmotic laxatives, stimulant laxatives, secretagogues, and serotonin type 4 agonist prucalopride. To assess the certainty of the evidence for each intervention, the panel prioritized clinical questions and outcomes and used the GRADE framework.
The recommendations are stated below:
Recommendation 1
In adults with CIC, the panel suggests using fibre supplementation over management without fibre supplements.
Implementation considerations
Dietary assessment is important to determine total fibre intake from diet and supplements
Fibre supplements can be used as first-line therapy for CIC, particularly for individuals with low dietary fibre intake
Adequate hydration should be encouraged with the use of fibre
Flatulence is a commonly observed side effect of the use of fibre
Among the evaluated fibre supplements, only psyllium appears to be effective
Recommendation 2
The panel recommends using PEG (polyethene glycol) in adults with CIC compared with management without PEG.
Implementation considerations
A trial of fibre supplement can be considered for mild constipation before PEG use or in combination with PEG
Response to PEG is durable over six months
Side effects include abdominal distension, loose stool, flatulence, and nausea
Recommendation 3
In adults with CIC, the panel suggests the use of magnesium oxide over management without magnesium oxide
Implementation considerations
The trials were conducted for 4 wk, although longer-term use is probably appropriate
The panel suggests starting at a lower dose, which may be increased if necessary
Avoid use in patients with renal insufficiency due to risk of hypermagnesemia
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
Implementation considerations
Bloating and flatulence are dose-dependent and common side effects, which may limit their use in clinical practice
Recommendation 5
In adults with CIC, the panel recommends the use of bisacodyl or sodium picosulphate short-term or as rescue therapy over management without bisacodyl or sodium picosulphate
Implementation considerations
Short-term use is defined as daily use for 4 wk or less. While long-term use is probably appropriate, data are needed to understand tolerance and side effects better
This is a good option for occasional use or rescue therapy in combination with other pharmacological agents for CIC
The most common side effects are abdominal pain, cramping and diarrhoea. The panel suggests starting at a lower dose and increasing the dose as tolerated
Recommendation 6
In adults with CIC, the panel suggests using senna over management without senna.
Implementation Considerations
While the trials were conducted for four weeks, longer-term use is probably appropriate, but data are needed to understand tolerance and side effects better
Abdominal pain and cramping may occur with a higher dose of senna
Recommendation 7
In adults with CIC who do not respond to OTC agents, the panel suggests the use of lubiprostone over management without lubiprostone.
Recommendation 8
In adults with CIC who do not respond to OTC agents, the panel recommends using linaclotide over management without linaclotide.
Recommendation 9
In adults with CIC who do not respond to OTC agents, the panel recommends the use of plecanatide over management without plecanatide
Implementation Considerations
It can be used as a replacement or as an adjunct to OTC agents
Duration of treatment in trials was 12 wk, but the drug label does not provide a limit
May be associated with side effects of diarrhoea leading to discontinuation of treatment
Recommendation 10
In adults with CIC who do not respond to OTC agents, the panel recommends the use of prucalopride over management without prucalopride
Implementation Considerations
Duration of treatment in trials was 4–24 wk but the drug label does not provide a limit
Can be used as a replacement or as an adjunct to OTC agents
May be associated with side effects of headache, abdominal pain, nausea, and diarrhoea
The authors noted one important limitation of this body of evidence: clinical trials did not uniformly evaluate interventions for patients' important outcomes on efficacy, adverse effects, and tolerability.
"The guidelines are meant to provide a template for an approach to management, and practitioners should engage in shared decision-making based on the preference of patients and cost and availability of the medications," the authors wrote. "Although the recommendations in this guideline were based on available evidence, the implementation considerations included suggestions from the collective experience of the expert panel and may not be based on evidence."
.Reference:
Chang, Lin MD, AGAF, FACG1,*; Chey, William D. MD, FACG2,*; Imdad, Aamer MBBS, MPH3,*; Almario, Christopher V. MD, MSHPM, FACG4; Bharucha, Adil E. MD5; Diem, Susan MD, MPH6,7; Greer, Katarina B. MD, MS Epi8,9; Hanson, Brian MD6,10; Harris, Lucinda A. MD, FACG11; Ko, Cynthia MD12; Murad, M. Hassan MD13; Patel, Amit MD, FACG14; Shah, Eric D. MD, MBA, FACG2,15; Lembo, Anthony J. MD, FACG16,†; Sultan, Shahnaz MD, MHSc, FACG6,17,†. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. The American Journal of Gastroenterology ():10.14309/ajg.0000000000002227, May 19, 2023. | DOI: 10.14309/ajg.0000000000002227