Table 4.

Overview of interventions for the pharmacological management of chronic idiopathic constipation

What medications can be used to treat chronic idiopathic constipation?	Mechanism of action	Recommended initial dose	Guidance for dose titration	Maximum dose	Estimated monthly cost, USDa	Additional comments
Fiber	Soluble fiber traps water in the intestine and softens stool Insoluble fiber increases stool bulk	The Academy of Nutrition and Dieteticsa recommends 14 g/1,000 kcal intake per day Total daily fiber intake (dietary + supplement) 20–30 g/d	Per response to symptoms and side effects Common side effects include bloating and abdominal discomfort	Usually no benefit to increasing total fiber intake over 25–30 g	<$50	Ensure adequate hydration as fiber intake increases No clear evidence that soluble or insoluble fiber is more effective Soluble fiber includes psyllium, inulin, oats, fruit, barley, and legumes Insoluble fiber includes wheat bran, methylcellulose, wheat, rye, and other grains
Polyethylene glycol	Osmotic laxative	17 g daily	Per symptom response and side effects Common side effects include bloating, abdominal discomfort, and cramping	No clear maximum dose	$10-$45	Response to PEG has been shown to be durable over 6 mo
Magnesium oxide	Osmotic laxative	400–500 mg daily	Per symptom and response and side effects	No clear maximum dose. Prior studies used 1,000–1,500 mg daily	<$50	Use with caution in patients with renal insufficiency and in pregnancy
Lactulose	Osmotic laxative	15 g daily	Per symptom response and side effects Bloating and flatulence may be limiting if preexisting symptoms or at higher doses	No clear maximum dose. May cause hypernatremia and hypokalemia if patients experience significant diarrhea	<$50	Only osmotic agent studied in pregnancy
Bisadocyl and picosulfate	Stimulant laxative	Bisacodyl 5 mg daily	Per symptom response and side effects Side effects limited by cramping and abdominal discomfort	10 mg orally daily	<$50	Recommended for short-term use or rescue therapy Prolonged or excessive use can cause diarrhea and electrolyte imbalance Long-term safety and efficacy unknown
Senna	Stimulant laxative	8.6–17.2 mg daily	Per symptom response and side effects Side effects most commonly cramping and abdominal discomfort	No clear maximum dose. Often recommended maximum is 4 tablets twice per day	<$50	Also present in many laxative teas, where dose may be difficult to calculate Long-term safety and efficacy unknown
Lubiprostone	Intestinal secretagogue acting on chloride channel type 2 in the gut that increases chloride secretion	24 μg BID	Per symptom response Diarrhea may occur in a subset of patients, leading to discontinuation	24 μg BID	$374	May have benefit for abdominal pain. Also approved for the treatment of IBS-C at a dose of 8 μg BID
Linaclotide	Intestinal secretagogue acting on guanylate cyclase-C, which activates CFTR in the gut to increase chloride secretion	72–145 μg daily	Per symptom response Diarrhea may occur in a subset of patients, leading to discontinuation	290 μg daily	$523	May have benefit for abdominal pain. Also approved for the treatment of IBS-C
Plecanatide	Intestinal secretagogue acting on guanylate cyclase-C, which activates CFTR in the gut to increase chloride secretion	3 mg daily	Per symptom response Diarrhea may occur in a subset of patients, leading to discontinuation	3 mg daily	$526	Also approved for the treatment of IBS-C
Prucalopride	5-HT4 agonist	1 –2 mg daily	Per symptom response Headaches and diarrhea may occur in a subset of patients, leading to discontinuation	2 mg daily	$563	May have additional benefit for abdominal pain

5-HT₄, serotonin type 4; BID, twice a day; IBS-C, irritable bowel syndrome with constipation; PEG, polyethylene glycol; USD, US dollar.

^aThe given cost accommodates the extent of generic and prescription medications and may not be the exact cost. In addition, the given cost is not the cost-effectiveness of the medication, but a probable cost per month.