Table 3.

Medical Management of Chronic Constipation

Treatment and frequency	Dose	Number needed to treat for CC and IBS-C	Cost/mo, US$ (2019)	Comments
Bulking agents, psyllium, daily	CC: Variable dose IBS-C: Variable dose	CC: 2 (95% CI, 1–3)79 IBS-C: 10 (95% CI, 6–33)79	8.34	Start with low dose and increase gradually.
PEG, daily	CC: 17 g IBS-C: 17 g	CC: 3 (95% CI, 2–4)2 IBS-C: NA	30.90	More evidence from studies of CC than IBS-C. Improved bowel symptoms but not abdominal pain in patients with IBS-C.80
Lactulose, daily	20 g	NA	11.20	Can produce bloating and distension.
Bisacodyl, daily	CC: 10 mg IBS-C: 10 mg	CC: 4 (95% CI, NA)81 IBS-C: NA	5.17	Available as suppository, preferably administered 30 min after breakfast.
Senna, daily	17.2–34.4 mg	—	5.90	Widely used anthraquinone laxative
Prucalopride, daily	CC: 2 mg IBS-C: NA	CC: 6 (95% CI, 5–9)2 IBS-C: NA	395.67	Approved in the United States; available in Mexico, Canada, and Europe.
Linaclotide, daily	CC: 72 μg IBS-C: 290 μg	CC: 72 μg, 12 (95% CI, 6–29); 145 μg, 10 (95% CI, 6–19)78 IBS-C: 290 μg, 6 (95% CI, 4–16)	395.41	Reduces abdominal pain, bloating, and overall symptoms of IBS in patients with IBS-C.
Lubiprostone, twice daily	CC: 24 μg IBS-C: 8 μg	CC: 24 μg, 4 (95% CI, 3–6)79 IBS-C: 8 μg, 12 (95% CI, 8–25)	342.92	Also reduces abdominal bloating, discomfort, and severity of constipation in patients with opioid-induced constipation.82
Plecanatide, daily	CC: 3 mg or 6 mg IBS-C: 6 mga	CC: 3 mg, 11 (95% CI, 8–19) 6 mg, 12 (95% CI, 8–23)78 IBS-C: 3 mg, 9 (95% CI, 6–16) 6 mg, 9 (95% CI, 6–17)	384.36	Similar to linaclotide.
Tenapanor, twice daily	CC: NA IBS-C: 50 mg	IBS-C: NA	NA	Only studied in patients with IBS-C and only approved in the United States. Diarrhea is the most frequent side effect. Safety analysis underway in 2 phase 3 trials

NOTE. Modified from Bharucha and Wald,⁷² with permission.

CI, confidence interval; NA, not available.

^aFDA-approved dose for CC and IBS-C is 3 mg daily.