AGA-ACG Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

[Jeffrey Roberts]

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

Chang, Lin MD, AGAF, FACG^1,*; Chey, William D. MD, FACG^2,*; Imdad, Aamer MBBS, MPH^3,*; Almario, Christopher V. MD, MSHPM, FACG⁴; Bharucha, Adil E. MD⁵; Diem, Susan MD, MPH^6,7; Greer, Katarina B. MD, MS Epi^8,9; Hanson, Brian MD^6,10; Harris, Lucinda A. MD, FACG¹¹; Ko, Cynthia MD¹²; Murad, M. Hassan MD¹³; Patel, Amit MD, FACG¹⁴; Shah, Eric D. MD, MBA, FACG^2,15; Lembo, Anthony J. MD, FACG^16,†; Sultan, Shahnaz MD, MHSc, FACG^6,17,†

Author Information 

The American Journal of Gastroenterology ():10.14309/ajg.0000000000002227, May 19, 2023. | DOI: 10.14309/ajg.0000000000002227

Abstract

INTRODUCTION: 

Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults.

METHODS: 

The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: 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 panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations.

RESULTS: 

The panel agreed on 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.

DISCUSSION: 

This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. 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. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.

EXECUTIVE SUMMARY

Chronic idiopathic constipation (CIC) is a common clinical diagnosis that affects approximately 8%–12% of the US population (¹). 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 (PEG), secretagogues, or prokinetic agents (²). This joint evidence-based guideline from the American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) aims to provide recommendations for the pharmacological management of CIC in adults.

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© 2023 by The American College of Gastroenterology and the American Gastroenterological Association