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Drugs for chronic idiopathic constipation are similarly effective
Clinical Question
What is the most effective drug treatment for chronic idiopathic constipation?
Bottom line
If nondrug measures are unsuccessful for chronic idiopathic constipation, the choice of a pharmacologic agent should be based on cost, tolerability, and long-term adherence rather than efficacy, as the efficacy is similar among drugs and drug classes. Bisacodyl increases the number of spontaneous bowel movements more than other drugs. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Government
Setting: Various (meta-analysis)
Synopsis
There are many treatment options for patients with chronic idiopathic constipation, including osmotic and stimulant laxatives; 5-hydroxytryptamine receptor 4 agonists, such as prucalopride, tegaserod, and velusetrag; linaclotide; lubiprostone; and elobixibat (the latter not approved in the United States). This study was a network meta-analysis that performed both direct comparisons (where possible) and indirect comparisons of trials of different drugs compared with a common control drug or placebo. This was a methodologically rigorous meta-analysis, with a thorough search of multiple databases, data abstraction by 2 independent investigators, and careful assessment of study quality. The authors identified 21 studies with a total of 9189 patients that compared 9 different drugs with placebo.The primary outcomes that defined a clinical response were having at least 3 more complete spontaneous bowel movements (CSBMs) per week or an increase from baseline of 1 or more CSBMs per week. Most studies were set in the United States or Europe, were adequately powered, and enrolled patients with a mean age in their late 40s or 50s. Most studies defined constipation as less than 2 or 3 CSBMs per week. The overall quality of most included studies was judged to be moderate or high. The results for several drugs (including bisacodyl, tegaserod, linaclotide, and sodium picosulphate) came from a single trial. In direct comparisons with placebo, the drugs roughly doubled the likelihood of having more 3 or more CSBMs per week, with an average increase overall of slightly more than 1 CSBM per week. These improvements were statistically significant for bisacodyl, sodium picosulphate, prucalopride, and velusetrag. Although velusetrag had the largest effect, there was a wide confidence interval around the results from its single study, and it was not significantly better than the other drugs. For the secondary outcome of the increase in the number of any (not only complete) spontaneous bowel movements, bisacodyl was more effective, with an increase in 4.9 spontaneous bowel movements compared with 1.9 to 3.2 for the other drugs.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
The question is long term efficacy of the same drug and safety as well as the concept of dependency that bothers the patients most.
This is a younger group of patients than I have.
We don't have a lot of availability of these fancy drugs in my area of Canada.
I tend to stick to the simple measures and tend to have success as do the authors - the basic simple ones worked about as well as the more complex drugs.
I think what is interesting here is looking at whether or not the patient went through thorough testing to be sure there were not diet or medication reasons for the issues with their bowels...
I think there is also a wide range of normal in the area of this bodily function.
good poem
Just coming at the right time for me.
"meta-analysis" , another word for trying to get good , reliable results out of poor quality "studies".