Table 1.

Summary of recommendations and implementation considerations

Recommendations	Strength of recommendation	Certainty of evidence
Fiber
Recommendation 1: In adults with CIC, the panel suggests the use of fiber supplementation over management without fiber supplements Implementation considerations • Dietary assessment is important to determine total fiber intake from diet and supplements • Fiber supplements can be used as first-line therapy for CIC, particularly for individuals with low dietary fiber intake • Among the evaluated fiber supplements, only psyllium appears to be effective (with very limited and uncertain data on bran and inulin) • Adequate hydration should be encouraged with the use of fiber • Flatulence is a commonly observed side effect with the use of fiber	Conditional	Low
Osmotic laxatives
Recommendation 2: In adults with CIC, the panel recommends the use of PEG compared with management without PEG Implementation considerations • A trial of fiber supplement can be considered for mild constipation before PEG use or in combination with PEG • Response to PEG has been shown to be durable over 6 mo • Side effects include abdominal distension, loose stool, flatulence, and nausea	Strong	Moderate
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	Conditional	Very low
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 its use in clinical practice	Conditional	Very low
Stimulant laxatives
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 better understand tolerance and side effects • 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 diarrhea. The panel suggests starting at a lower dose and increasing the dose as tolerated	Strong	Moderate
Recommendation 6: In adults with CIC, the panel suggests the use of senna over management without senna Implementation considerations • While the trials were conducted for 4 wk, longer term use is probably appropriate, but data are needed to better understand tolerance and side effects • The dose evaluated in trials is higher than commonly used doses in practice. The panel suggests starting at lower dose and increase if no response • Abdominal pain and cramping may occur with a higher dose of senna	Conditional	Low
Secretagogues
Recommendation 7: In adults with CIC who do not respond to OTC agents, the panel suggests the use of lubiprostone over management without lubiprostone Implementation considerations • Can be used as a replacement or as an adjunct to OTC agents • Duration of treatment in trials was 4 wk, but the drug label does not provide a limit • Nausea may occur; however, the risk of nausea is dose-dependent and seems to be lower when taken with food and water	Conditional	Low
Recommendation 8: In adults with CIC who do not respond to OTC agents, the panel recommends the use of linaclotide over management without linaclotide Implementation considerations • 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 diarrhea leading to discontinuation of treatment	Strong	Moderate
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 • 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 diarrhea leading to discontinuation of treatment	Strong	Moderate
5-HT4 agonist
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 diarrhea	Strong	Moderate

The implementation considerations are based on the collective experience of the panel members, and evidence may not be available for each of the implementation considerations.

5-HT₄, serotonin type 4; CIC, chronic idiopathic constipation; OTC, Over-the-counter; PEG, polyethylene glycol.