Get Up to Date on Constipation Treatments

Pharmacy Times, October 2020, Volume 88, Issue 10

Pharmacists should learn about alternative solutions to this common digestive problem.

Most people experience constipation within their lifetimes, especially as they age, and more than 4 million Americans suffer from it frequently, surveys show.1

Most pharmacists are familiar with common OTC and prescription products that treat this common ailment, but they may not be aware of niche treatments or agents in development.

For example, many inpatient settings use milk and molasses enemas (M&M) for pediatric constipation.2 The exact recipe varies, but these generally low-volume (300 mL or less) enemas are inserted 12 inches into the rectum and held for 20 minutes.2 Investigators think that the sugars within the milk and molasses irritate the intestinal lining, producing gas and intestinal distension, which then increases peristalsis and eventually defecation.2

When assessed against a traditional oral laxative, polyethylene glycol 3350 (PEG 3350), M&M enemas have surprising efficacy.2 A head-to-head comparison of the 2 methods with pediatric patients assessed differences in consistency, ease of passage, stool frequency, symptom improvement, and treatment failure. At day 1, patients in the M&M group had higher rates of symptom improvement, and at day 3, they were twice as likely to have ideal stool consistency. However, 54% of the M&M recipients reported being upset by the process; none of the PEG 3350 recipients was upset.2

The University of California’s Department of Emergency Medicine conducted an 8-year, retrospective analysis to examine M&M’s efficacy and safety. They enrolled 2013 patients.3 From the analysis, M&M’s success rates were 87.9% when given alone and 82.4% when used after other treatments had failed.3 However, 3.1% of patients had complications, such as increased heart rate or pain.3

Often end-of-life and palliative care creates challenging issues for patients, family members, and prescribers. A common, and often uncomfortable, issue is constipation, with 22% of hospice patients reporting this issue during their stay.4 Congruent with the goal of minimizing medication use at end of life, health care professionals sometimes use frozen petroleum jelly balls as a laxative in this population (see figure). It works similarly to another lubricant laxative, mineral oil.4 The oil coats the intestines, decreasing water reabsorption and easing the release of bowel contents.4

In a 2013 survey of hospice and palliative professionals, 87% defined the treatment as “effective” or “very effective.”. Furthermore, 94.9% said that they would recommend using oral petroleum jelly to a patient.4

A similar constipation relief strategy, liquid paraffin, has been used to treat constipation since 1913.5 When compared with senna as a maintenance treatment for constipation, recent study results showed that 57.9% of participants using liquid paraffin achieved relief from constipation, while 22.2% of those using senna did.5

Acupuncture’s popularity has grown in recent years, including for the treatment of chronic constipation. Investigators have observed that pinning certain pressure points in constipated rats activates M3 receptors and somatic afferent C-fibers. This increases intestinal movement.6 In a meta-analysis comparing acupuncture with lactulose, linaclotide, and PEG 3350, acupuncture proved effective for chronic constipation with significant improvement in symptoms compared with the placebo.6 Furthermore, a randomized trial in 15 Chinese hospitals compared traditional acupuncture’s effects with sham acupuncture for those with chronic constipation over an 8-week period.7 The investigators observed 1075 participants for changes in complete spontaneous bowel movements and the proportion of patients who had 3 or more weekly spontaneous bowel movements. The change in weekly bowel movements was 1.76 in the traditional group and 0.87 in the sham group, and the proportion of those having 3 or more spontaneous bowel movements in a week was 37.7% versus 14.1%, respectively. Additionally, there were few, if any, adverse effects experienced, aside from pain from the needles.

ON THE HORIZON

Although many people joke about constipation, it can have serious consequences. Investigators constantly seek newer, better remedies. The medical community has come a long way in its understanding of constipation and how to handle it since 1913 when the gold standard treatment was liquid paraffin wax. The table8-13 summarizes treatments being studied, some of which are FDA approved for gastrointestinal motility conditions but considered for new indications.

CONCLUSION

A final note is that constipation is not just 1 condition. It has numerous causes and presents differently in different people. New effective and safe interventions are needed. Thankfully, investigators are on the job.

Canyon Hopkins is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

  • Sonnenberg A, Koch TR. Epidemiology of constipation in the United States. Dis Colon Rectum. 1989;32(1):1-8. doi:10.1007/bf02554713
  • Miller MK, Dowd MD, Friesen CA, Walsh-Kelly CM. A randomized trial of enema versus polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency department. Pediatr Emerg Care. 2012;28(2):115-119. doi:10.1097/PEC.0b013e3182442c0a
  • Vilke GM, DeMers G, Patel N, Castillo EM. Safety and efficacy of milk and molasses enemas in the emergency department. J Emerg Med. 2015;48(6):667-670. doi:10.1016/j.jemermed.2015.01.035
  • Tavares CN, Kimbrel JM, Protus BM, Grauer PA. Petroleum jelly (Vaseline balls) for the treatment of constipation: a survey of hospice and palliative care practitioners. Am J Hosp Palliat Care. 2014;31(8):797-803. doi:10.1177/1049909113502578
  • Sharif F, Crushell E, O’Driscoll K, Bourke B. Liquid paraffin: a reappraisal of its role in the treatment of constipation. Arch Dis Child. 2001;85(2):121-124. doi:10.1136/adc.85.2.121
  • Luo D, Liu S, Xie X, Hou X. Electroacupuncture at acupoint ST-36 promotes contractility of distal colon via a cholinergic pathway in conscious rats. Dig Dis Sci. 2008;53(3):689-693. doi:10.1007/s10620-007-9929-7
  • Liu Z, Yan S, Wu J, et al. Acupuncture for chronic severe functional constipation: a randomized trial. Ann Intern Med. 2016;165(11):761-769. doi:10.7326/M15-3118
  • Prichard DO, Bharucha AE. Recent advances in understanding and managing chronic constipation. F1000Res. 2018;7:F1000 Faculty Rev-1640. doi:10.12688/f1000research.15900.1
  • Gwynne RM, Bornstein JC. Luminal 5-HT4 receptors—a successful target for prokinetic actions. Neurogastroenterol Motil. 2019;31(10):e13708. doi:10.1111/nmo.13708
  • Quigley EMM, Neshatian L. Advancing treatment options for chronic idiopathic constipation. Expert Opin Pharmacother. 2016;17(4):501-511. doi:10.1517/14656566.2016.1127356
  • Abe T, Kunimoto M, Hachiro Y, Ohara K, Inagaki M, Murkami M. Efficacy and safety of elobixibat in elderly patients with chronic constipation: a single-center, observational study. J Anus Rectum Colon. 2020;4(3):122-127. doi:10.23922/jarc.2020-0
  • Camilleri M. What’s in the pipeline for lower functional gastrointestinal disorders in the next 5 years? Am J Physiol: Gastrointest Liver Physiol. 2019;317(5):G640-G650. doi:10.1152/ajpgi.00205.2019
  • Siddiqui S, Cash BD. Tenapanor for constipation-predominant irritable bowel syndrome. Drugs Today (Barc). 2020;56(3):203-210. doi:10.1358/dot.2020.56.3.3115214