Management Of Chronic Idiopathic Constipation Research Articles

S833 How Valuable is an Electronic Stool Diary App in the Management of Chronic Idiopathic Constipation (CIC) When Using the Vibrating Capsule (VC)

S833 How Valuable is an Electronic Stool Diary App in the Management of Chronic Idiopathic Constipation (CIC) When Using the Vibrating Capsule (VC)

Continuing Medical Education Questions: June 2023.

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

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

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. 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. 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. 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.

CME Exam 2: American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

CME Exam 2: American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

Role of 3D high resolution anorectal manometry compared to conventional technique in management of constipation and fecal incontinence in children

BackgroundAnorectal manometry is a valuable tool for objective assessment of motility motor and sensory function of the anorectum. The aim of this study was to investigate role of water-perfused (WP) three dimensional high-resolution anorectal manometry (3D-HRARM) compared to WP conventional manometry (CM) in the management of chronic idiopathic constipation (CIC) and faecal incontinence (FI) in children. MethodsThis was a retrospective review of 122 consecutive children, who had WP 8-channel CM or 24 channel 3D-HRARM and endosonography under ketamine anaesthesia from September 2012 to February 2019. All patients had a validated symptom severity score questionnaire ranging from 0 (best) to 65 (worst). Mann-Whitney-U test and Spearman rank test were used and p<0.05 was considered significant. ResultsSubjects were divided according to investigation: CM group (n = 75) and 3D-HRAM (n = 47), who were otherwise comparable. Median anal resting pressure was 50 mmHg and rectoanal inhibitory reflex (RAIR) threshold volume was 10mls across the entire cohort. There were no significant differences in resting pressure or RAIR threshold when using conventional or 3D-HRARM. Rectal capacity was significantly higher in the CM group (p = 0.002). Rectal capacity and internal anal sphincter (IAS) thickness positively correlated with symptom severity, duration and patient age. 3D-HRARM provided a more detailed depiction of the anorectal pressure profile. Botulinum toxin was injected into the external anal sphincter (EAS) muscle (n = 75, 61%) and an anterograde colonic enema (ACE) stoma was needed subsequently in 19 (16%) to treat recurrent constipation and soiling symptoms. Rectal biopsy was done in 43(35%) patients, if RAIR was absent or inconclusive. ConclusionCM and 3D-HRARM are comparable in terms of resting pressure and RAIR threshold. 3D-HRAM is safe and provides detailed functional morphology of anal sphincters and it is useful to understand underlying pathophysiology of constipation and faecal incontinence in children and plan further treatment. Level of EvidenceLevel I

Best Practices for the Management of Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation: A Roundtable Discussion and Review.

Chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) are highly prevalent conditions that affect a significant proportion of the US population. Pathogenic, diagnostic, and treatment paradigms for patients with constipation have changed considerably over time. A clinical roundtable consisting of experts from across the United States was convened (virtually) to discuss the burden of constipation and current evidence-based diagnostic and management tools at a mechanistic level, with a primary goal of determining realistic clinical strategies to improve outcomes in patients with CIC or IBS-C. This 4-part supplement provides a critical review and discussion of the burden of illness and strategies for the diagnosis and management of CIC and IBS-C. These common and bothersome disorders of gut–brain interaction present a spectrum of stool-related symptoms such as infrequent bowel movements, hard stools, excessive straining, and an overall sensation of incomplete evacuation or obstruction. In addition, patients commonly report a variety of non‒stool-related abdominal symptoms that are often directly related to the patients' severity of CIC or IBS-C. The overlapping symptomatology of CIC and IBS-C have a significant impact on health-related quality of life, with individuals reporting frustration, shame, and embarrassment, along with an overall sense of helplessness. Many patients cycle through multiple treatment options in an attempt to manage their abdominal symptoms and to regulate bowel frequency and stool consistency. For healthcare providers, central to the management of patients with CIC or IBS-C is the utilization of a patient-centered communication approach that ensures understanding of symptom type and intensity, accurate symptom reporting, and compliance to treatment. Although treatment strategies for patients with CIC and IBS-C can often be challenging—with many patients unaware of available treatment options and instead choosing to self-medicate with diet or over-the-counter strategies—it is vital that patients are educated about symptomatology and available treatments, actively monitored for changes in symptom severity and response to treatment, and appropriately managed to maximize clinical outcomes such as patient adherence and cost benefit. My colleagues and I hope that this supplement provides practitioners, such as gastroenterologists, and the medical community at-large with a better understanding of the burden and unmet needs of patients with CIC or IBS-C. With this recognition, we hope to improve management outcomes. CONFLICTS OF INTEREST Guarantor of the article: Darren M. Brenner, MD. Specific author contributions: Darren M. Brenner moderated and participated in the advisory board discussions, contributed to the drafting of the manuscript, provided critical revision of all manuscript drafts for important intellectual content, and approved the final version for publication. Financial support: This supplement was funded by Salix Pharmaceuticals, Inc. Potential competing interests: D.M.B. is a consultant, advisor, and/or speaker for Salix, AbbVie (Allergan), Ironwood, Takeda, RedHill, Alnylam, AlphaSigma, Bayer, Arena Pharmaceuticals, GI Health Foundation, IFFGD, and the Rome Foundation. His research is sponsored by an unrestricted grant from the Irene D. Pritzker Foundation.

Comparative efficacy of pharmacological and nonpharmacological treatments for chronic idiopathic constipation in China: a Bayesian network meta-analysis

BackgroundTo provide evidence for medical management of chronic idiopathic constipation (CIC) in China based on comparisons of all clinical practical interventions using Bayesian network meta-analysis.MethodsWe conducted a systematic literature review by searching PubMed, Embase, Cochrane Central, the China National Knowledge Infrastructure (CNKI), and the Wanfang Database (inception to May 2019) for randomized controlled trials (RCTs) for CIC in Chinese people. Only RCTs that recruited participants aged over 18 and diagnosed with CIC by the Rome II, III or IV criteria were included. We used three outcomes to examine efficacy. The risk ratio (RR) of the responder rate, based on ≥3 spontaneous bowel movements (SBMs) per week after treatment, was the primary outcome, and the SBM count per week and the Bristol score (BS) were secondary outcomes. In addition, adverse effects (AEs) were also considered a secondary outcome to evaluate safety. We conducted Bayesian network meta-analysis with random effects, and the RR or mean difference with its 95% credible interval was calculated. In addition, we ranked all treatments via their cumulative curves (SUCRA) and assessed the quality of evidence according to the GRADE criteria.ResultsWe included a total of 42 trials (6820 participants) of 20 grouped interventions that included pharmacological and nonpharmacological treatments. For the primary outcome, fourteen interventions were significantly better than placebo, and Probiotics plus Mosapride (PB + MP) appeared superior to others (GRADE quality of evidence: Moderate to Low), followed by Prucalopride (PP) (High to Low) and Electroacupuncture (EA) (High to Low). For SBM, Compound sodium bicarbonate suppository (CSBS) appeared to be best, with an SUCRA value of 90% (High to Low). For BS, Lactulose plus Probiotics (LT + PB) was superior to others (Moderate to Low), followed by Polyethylene glycol (PEG) (High to Moderate). Although all interventions appeared non-significant when compared with placebo in terms of adverse effects, Lactulose plus Mosapride showed greater risk than others on ranking probability.ConclusionsGiven the GRADE assessment, PB + MP, PP and EA may be the priory options with moderate certainty in the quality of evidence for the primary outcome. For SBM, a CSBS may be the best option with moderate certainty in the quality of evidence. For BS, PEG may be the priory option with high certainty in the quality of evidence. However, due to a lack of high certainty in the quality of evidence, caution is needed when recommending the interventions. Because of the limitations, an increased number of trials are required for more accurate results.

Current treatment paradigm and landscape for the management of chronic idiopathic constipation in adults: Focus on plecanatide

Chronic idiopathic constipation (CIC) is a prevalent disorder affecting productivity, quality of life, and health care resource utilization. Nurse practitioners (NPs) play a critical function in managing patients presenting with CIC, with roles including evaluation, diagnosis, treatment decisions, and patient education. For adults with inadequate response or tolerability issues using over-the-counter treatments, three prescription agents (plecanatide, linaclotide, and lubiprostone) are available in the United States to treat CIC, of which plecanatide was mostly recently approved. This review provides NPs with a current overview and summary of plecanatide in the current treatment landscape for CIC. PubMed was searched for the literature regarding clinical practice guidelines and published trial data for lubiprostone, linaclotide, and plecanatide in CIC. Efficacy and safety comparisons between prescription agents are limited beacause of the differences in trial duration and primary end points (all different). Generally, plecanatide and linaclotide demonstrated similar efficacy, with plecanatide demonstrating lower rates of adverse events. The success of CIC treatment can be affected by patient adherence to the regimen, which is dependent on the efficacy and tolerability of treatment. Plecanatide is a promising option for patients whose CIC symptoms are not adequately controlled using their current treatment approach.

An update on prucalopride in the treatment of chronic constipation.

Chronic constipation (CC) is a highly prevalent and often under-appreciated gastrointestinal disorder associated with significant impairment in quality of life. Symptoms of constipation are typically present for a number of years prior to a patient seeking help. Lifestyle modifications followed by, or coupled with, over-the-counter laxatives represent the initial treatment option; however, relief for many is limited and dissatisfaction rates for these approaches remain high. Over recent years, therefore, considerable effort has been exerted on the development of novel pharmacological approaches. Two major targets have emerged, motility and secretion. Research on the former led to the development of a number of prokinetic agents capable of stimulating colonic motility and, thus, accelerating colonic transit. Of these, earlier prototypes such as cisapride and tegaserod, though effective, were ultimately withdrawn due to cardiovascular adverse events due in part to receptor non-selectivity. Highly selective serotonergic receptor agonists have since emerged which appear to be equally effective in stimulating gut motility but are devoid of cardiac side effects. One such agent is prucalopride, which has now been approved for the management of chronic idiopathic constipation in several countries, but not in the United States. Multiple multicenter, randomized placebo-controlled clinical trials have demonstrated superiority for prucalopride compared to placebo in the short to medium term in relieving the major symptoms of constipation in both men and women across a broad spectrum of ages, ethnicities and geographic locations. To date, prucalopride has enjoyed a favorable safety profile and there have been no signals to suggest arrythmogenicity. Efficacy over longer periods of treatment remains to be confirmed. Evidence for efficacy in other forms of constipation, such as opioid-induced constipation and that related to Parkinson's disease is beginning to emerge; its status in the management of constipation-predominant irritable bowel syndrome or foregut motility disorders, such as gastroparesis, remains to be established.

A Comparison of the Efficacy and Safety of 2 Dosing Regimens, 2 and 5 Times per Week, of an Intraluminal Vibrating Capsule in the Management of Chronic Idiopathic Constipation

A Comparison of the Efficacy and Safety of 2 Dosing Regimens, 2 and 5 Times per Week, of an Intraluminal Vibrating Capsule in the Management of Chronic Idiopathic Constipation

Durability of Response of Linaclotide in the Management of Chronic Idiopathic Constipation

Introduction: Linaclotide is approved for the treatment of chronic idiopathic constipation (CIC) and IBS-C. It activates guanylate-cyclase C (GC-C) receptors on the luminal surface of enterocytes resulting in increased intestinal secretion and decreased transit time. Two phase 3 studies demonstrated that 21 days of linaclotide therapy resulted in as least 3 complete and spontaneous bowel movements (CSBM) per week and an increase of 1 CSBM per week. Since recurrence of constipation is common, the purpose of this study was to describe durability of response to linaclotide in patients with an initial response. Methods: Electronic medical records of 167 patients who began linaclotide for the management of CIC were reviewed retrospectively. To be eligible for inclusion, patients must have responded to standard dosing (145 mcg daily) for at least 4 months with appropriate follow up and documentation. Response was defined as ≥3 CSBM/week and 1 additional BM/week and a Bristol stool score (BSS) of 3-4. Patients who required dose adjustment within the first 4 months or experienced an adverse effect (AE) of treatment during initial therapy were excluded. Variables including age, gender, duration of therapy, time to follow up, response to therapy, BSS, dose and frequency of linaclotide, and AE were all recorded. Data were summarized with Microsoft excel 14.6. Paired t-test was used to compare initial and final BSS. Results: 32 of 167 patients met criteria for review. 5 were men and 27 were women. Mean age was 57 ± 18 (range 19-93). 28 patients (87.5%) exhibited sustained response with a mean follow up time of 15.3 months (range 4-36 months). BSS at the time of inclusion was 3.5 ± 0.6. BSS at the last follow up time was unchanged at 3.4 ± 0.8 (range 2-5, p = 0.55). AE were observed in 6 patients (18.7%). Three had diarrhea and 3 had discomfort or bloating. The mean time to first reported AE was 12 months (range 6-36 months). In all cases, minimal alterations in dose or frequency resulted in improvement of AE. Conclusion: CONCLUSIONS 1. 87.5% of patients in this cohort of initial responders to standard dose linaclotide demonstrated durable reponse with a mean duration of 15.3 months. 2. BSS was stable over an extended period of therapy. 3. AE occurred in 18.7% of patients, on average 12 months after starting therapy. 4. Most patients with AE responded well to changes in dose and/ or frequency of administration of linaclotide or minimal adjunctive therapy.

Systematic review: the effects of fibre in the management of chronic idiopathic constipation

Patients with chronic idiopathic constipation are often told to increase dietary fibre intake. Whether this is of any benefit remains unclear. To conduct a systematic review of the efficacy of soluble and insoluble fibre supplementation in the management of chronic idiopathic constipation. MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched to identify randomised controlled trials (RCTs) comparing fibre with placebo or no therapy in adult chronic idiopathic constipation patients. Studies had to report dichotomous data assessing response to therapy, or continuous data examining either effect of therapy on mean number of stools per week, or mean symptom scores. Adverse events data were extracted where reported. Six RCTs were eligible. Four used soluble fibre and two used insoluble fibre. Formal meta-analysis was not undertaken due to concern about methodological quality of identified studies. Compared with placebo, soluble fibre led to improvements in global symptoms (86.5% vs. 47.4%), straining (55.6% vs. 28.6%), pain on defaecation, and stool consistency, an increase in the mean number of stools per week (3.8 stools per week after therapy compared with 2.9 stools per week at baseline), and a reduction in the number of days between stools. Evidence for any benefit of insoluble fibre was conflicting. Adverse events data were limited, with no RCT reporting total numbers. Soluble fibre may be of benefit in chronic idiopathic constipation, but data for insoluble fibre are conflicting. More data from high quality RCTs are required before the true efficacy of either fibre type in the treatment of chronic idiopathic constipation is known.

Constipation in adults: an update

Constipation affects 2% to 27% of individuals. It is associated to irritable bowel syndrome in 59% of cases, to a pelvic floor dysfunction in 29% and to a low transit time in 13%. During assessment of patients with constipation the effects of medications and chronic diseases must be discarded and the ideal is to determine which type of functional disorder it present. An algorithm for the management of chronic idiopathic constipation, that includes a recommendation to increase fiber and liquid intake as an initial approach and an orientation to the use of different laxatives, is presented. The usefulness of biofeedback in patients with pelvic floor dysfunction and without organic cause of constipation, is also discussed.

Manejo de la constipación crónica del adulto: Actualización

Constipation affects 2% to 27% of individuals. It is associated to irritable bowel syndrome in 59% of cases, to a pelvic floor dysfunction in 29% and to a low transit time in 13%. During assessment of patients with constipation the effects of medications and chronic diseases must be discarded and the ideal is to determine which type of functional disorder it present. An algorithm for the management of chronic idiopathic constipation, that includes a recommendation to increase fiber and liquid intake as an initial approach and an orientation to the use of different laxatives, is presented. The usefulness of biofeedback in patients with pelvic floor dysfunction and without organic cause of constipation, is also discussed.

Pharmacoeconomic Impact of Low-Dose Macrogol 3350 plus Electrolytes Compared with Lactulose in the Management of Chronic Idiopathic Constipation among Ambulant Patients in Belgium

To estimate the economic impact of using low-dose macrogol 3350 plus electrolytes (macrogol 3350; Movicol((R))) compared with lactulose in the treatment of chronic idiopathic constipation among ambulant patients in Belgium, from the perspectives of the Sick Fund and patients. The analysis considered separately the economic impact of (a) a specialist and (b) a general practitioner (GP) initiating treatment. This was a modelling study performed from the perspective of Belgium's Sick Fund and patients. Estimates of healthcare resource utilisation in a previously reported UK model depicting the management of chronic idiopathic constipation with either macrogol 3350 and lactulose over 3 months were replaced with Belgian estimates derived from a panel of 11 gastroenterologists and 11 GPs. The model was used to estimate the expected 3-monthly Sick Fund cost and direct cost to patients of using either laxative to manage chronic idiopathic constipation in Belgium. According to our model, 53% and 24% of patients are expected to be successfully treated with macrogol 3350 and lactulose, respectively. Additionally, using macrogol 3350 instead of lactulose is expected to reduce the 3-monthly Sick Fund cost in approximately 55% of patients and afford a cost-effective treatment in the remaining patients. Furthermore, the 3-monthly Sick Fund cost of managing chronic idiopathic constipation among ambulant patients is expected to be reduced by approximately 50% if patients were initially treated by a GP instead of a specialist. In Belgium, laxatives are paid for by patients. Despite the difference in their acquisition cost, treating chronic idiopathic constipation with either macrogol 3350 or lactulose was found to be cost neutral from a patient's perspective. The true cost of managing chronic idiopathic constipation is impacted on by a broad range of resources and not only laxative acquisition costs. This study indicated that managing ambulant patients with chronic idiopathic constipation with macrogol 3350 instead of lactulose is a cost-effective treatment from the Sick Fund's perspective and cost neutral from a patient's perspective.