Guidelines for the Treatment of Constipation

Moo In Park; Jeong Eun Shin; Seung-Jae Myung; Kyu Chan Huh; Chang Hwan Choi; Sung-Ae Jung; Suck Chei Choi; Chong-II Sohn; Myung-Gyu Choi

doi:10.4166/kjg.2011.57.2.100

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Park, Shin, Myung, Huh, Choi, Jung, Choi, Sohn, Choi, and The Korean Society of Neurogastroenterology and Motility: Guidelines for the Treatment of Constipation

Special Review

Korean J Gastroenterol 2011;57(2):100-114.

Published online: 4 October 2011

DOI: https://doi.org/10.4166/kjg.2011.57.2.100

Guidelines for the Treatment of Constipation

Moo In Park, Jeong Eun Shin¹, Seung-Jae Myung², Kyu Chan Huh³, Chang Hwan Choi⁴, Sung-Ae Jung⁵, Suck Chei Choi⁶, Chong-II Sohn⁷, Myung-Gyu Choi⁸; The Korean Society of Neurogastroenterology and Motility

Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea

¹Department of Internal Medicine, Kosin University College of Medicine, Busan, Dankook University College of Medicine, Cheonan, Korea

²University of Ulsan College of Medicine, Seoul, Korea

³Konyang University College of Medicine, Daejeon, Korea

⁴Chung-Ang University College of Medicine, Seoul, Korea

⁵Ewha Womans Unniversity School of Medicine, Seoul, Korea

⁶Wonkwang University School of Medicine, Iksan, Korea

⁷Sungkyunkwan University, School of Medicine, Seoul, Korea

⁸The Catholic University of Korea School of Medicine, Seoul, Korea

Correspondence to: Suck Chei Choi, Department of Internal Medicine, Wonkwang University School of Medicine, 344-2, Shinyong-dong, Iksan 570-711, Korea. Tel: +82-63-859-2563, Fax: +82-63-855-2025, E-mail: medcsc@wmc.wonkwang.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

While constipation is a common symptom in Korea, there are no existing treatment guidelines. Although constipation may occur as a result of organic cause, there is no obstructive mucosal or structural cause in the vast majority of patients with constipation. The present paper deals with only the management of functional constipation: lifestyle changes; bulking agents and stool softeners; osmotic agents; stimulant laxatives; prokinetics; biofeedback and surgical treatments. Exercise and dietary fiber are helpful in some patients with constipation. Laxatives including bulking agents, stool softeners, osmotic agents, and stimulant laxatives have been found to be more effective than placebo at relieving symptoms of constipation. New enterokinetic agents that affect peristalsis through selective interaction with 5-hydroxytryptamine-4 receptors can be effective in patients with constipation who cannot get adequate relief from current laxatives. Biofeedback can relieve symptoms in selected patients with pelvic floor dyssynergia. Surgical treatments can be helpful in some patients with refractory constipation.

Keywords: Constipation, Treatment, Guideline

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Fig. 1.

Flow chart for searching strategy.

Table 1.

Grading Recommendations⁷

Grade of recommendation/description	Benefit vs. risk and burdens	Methodological quality of supporting evidence	Implications
1A. Strong recommendation, high-quality evidence	Benefits clearly outweigh risk and burden, or vice versa	RCTs without important limitations or overwhelming evidence from observational studies	Strong recommendation, can apply to most patients in most circumstances. Further evidence is unlikely to change our confidence in the estimate of effect
1B. Strong recommendation, moderate-quality evidence	Benefits clearly outweigh risk and burden, or vice versa	RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies	Strong recommendation, can apply to most patients in most circumstances. Higher quality evidence may well change our confidence in the estimate of effect
1C. Strong recommendation, low-quality or very low-quality evidence	Benefits clearly outweigh risk and burden, or vice versa	Observational studies or case series	Strong recommendation, can apply to most patients in most circumstances. Higher quality evidence is very likely to change our confidence in the estimate of effect
2A. Weak recommendation, high-quality evidence	Benefits closely balanced with risk and burden	RCTs without important limitations or overwhelming evidence from observational studies	Weak recommendation, best action may differ depending on circumstances or patients' or societal values. Further evidence is unlikely to change our confidence in the estimate of effect
2B. Weak recommendation, moderate-quality evidence	Benefits closely balanced with risk and burden	RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies	Weak recommendation, best action may differ depending on circumstances or patients' or societal values. Higher quality evidence may well change our confidence in the estimate of effect
2C. Weak recommendation, low-quality or very low-quality evidence	Uncertainty in the estimates of benefits, risks and burden; benefits, risk and burden may be closely balanced	Observational studies or case series	Very weak recommendations; other alternatives may be equally reasonable. High quality evidence is very likely to change our confidence in the estimate of effect

RCT, randomized controlled trial.

Table 2.

Summary of Clinical Trials for Prucalopride in Patients with Chronic Constipation

Reference	Design	Patients	Treatment	Efficacy measures	Results	ADRs
Camilleri et al.⁹⁵	Phase III, multicenter, RCT, parallel group	N=620	Placebo 2, 4 mg/day 12 weeks	Primary endpoint: ≥3 CSBM Secondary endpoint: ≥1 CSBM time to first CSBM pt's satisfaction	Significant increase of ≥3 CSBM/week with 2 and 4 mg/day vs. placebo (30.9%, 28.4% vs. 12.0%, p＜0.001) Increase in number of ≥1 CSBM/week (47.3%, 46.6% vs. 25.8%, p＜0.001) Time to first CSBM (1.3, 1.0 vs. 12.6 hrs, p＜0.001)	Headache, nausea, abdominal pain
					Reduced the severity of constipation symptoms (p＜0.001)
Tack et al.⁹⁶	Phase III, multicenter, RCT, parallel group	N=713	Placebo 2, 4 mg/day 12 weeks	Primary endpoint: ≥3 CSBM Secondary endpoint: ≥1 CSBM time to first CSBM pt's satisfaction	Significant increase of ≥3 CSBM/week with 2 and 4 mg/day vs. placebo (19.5%, 23.6% vs. 9.6%, p＜0.01, p＜0.001) Increase in number of ≥1 CSBM/week (38.1%, 44.1% vs. 20.9%, p＜0.001) Time to first CSBM (4.7, 2.1 vs. 20.5 hrs, p＜0.001)	Headache, nausea, abdominal pain
					Reduced the severity of constipation symptoms (p＜0.001)
Quigley, et al.⁹⁷	Phase III, multicenter, RCT, parallel group	N=641	Placebo 2, 4 mg/day 12 weeks	Primary endpoint: ≥3 CSBM Secondary endpoint: ≥1 CSBM time to first CSBM pt's satisfaction QOL	Significant increase of ≥3 CSBM/week with 2 and 4 mg/day vs. placebo (23.9%, 23.5% vs. 12.0%, p＜0.01) Increase in number of ≥1 CSBM/week (42.6%, 46.6% vs. 27.5%, p＜0.001) Time to first CSBM (2.3, 1.9 vs. 13.0 hrs, p＜0.001)	Headache, nausea, abdominal pain
					Reduced the severity of constipation symptoms (p＜0.001)
					Improved constipation-related QOL

ADR, adverse drug reactions; SBM, spontaneous bowel movement; CSBM, complete, spontaneous bowel movement; RCT, randomized controlled trial; QOL, quality of life.

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ORCID iDs: Seung-Jae Myung
https://orcid.org/http://orcid.org/0000-0003-0585-4016
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