The health-related quality of life and economic burden of constipation

High-dose linaclotide is effective and safe in patients with chronic constipation: A phase III randomized, double-blind, placebo-controlled study with a long-term open-label extension study in Japan

BACKGROUND

A previous phase II dose-ranging study of linaclotide in a Japanese chronic constipation (CC) population showed that 0.5 mg was the most effective dose. This study aimed to verify the hypothesis that 0.5 mg of linaclotide is effective and safe in Japanese CC patients.

METHODS

This was a Japanese phase III randomized, double-blind, placebo-controlled (part 1), and long-term, open-label extension (part 2) study of linaclotide. CC patients (n = 186) diagnosed using the Rome III criteria were randomly assigned to linaclotide 0.5 mg (n = 95) or placebo (n = 91) for a 4-week double-blind treatment period in part 1, followed by an additional 52 weeks of open-label treatment with linaclotide in part 2. The primary efficacy endpoint was the change from baseline in weekly spontaneous bowel movement (SBM) frequency at the first week. Secondary endpoints included responder rate for complete SBM (CSBM), changes in stool consistency, and severity of straining.

KEY RESULTS

Part 1: Change in weekly mean SBM frequency in the first week of treatment with linaclotide (4.02) was significantly greater than that with placebo (1.48, P < 0.001). Linaclotide produced a higher CSBM responder rate (52.7%) compared to placebo (26.1%, P < 0.001). Part 2: Patients continued to show improved SBM frequency with linaclotide. Through parts 1 and 2, the most common drug-related adverse event was mild and occasionally moderate diarrhea.

CONCLUSIONS AND INFERENCES

The results of this study indicate that a linaclotide dose of 0.5 mg/day is effective and safe in Japanese CC patients.

Constipation and risk of death and cardiovascular events

BACKGROUND AND AIMS

Constipation is one of the most frequent symptoms encountered in daily clinical practice and is implicated in the development of atherosclerosis, potentially through altered gut microbiota. However, little is known about its association with incident cardiovascular events.

METHODS

In a nationally representative cohort of 3,359,653 US veterans with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m² between October 1, 2004 and September 30, 2006 (baseline period), with follow-up through 2013, we examined the association of constipation status (absence or presence; defined using diagnostic codes and laxative use) and laxative use (none, one, or ≥2 types of laxatives) with all-cause mortality, incident coronary heart disease (CHD), and incident ischemic stroke.

RESULTS

Among 3,359,653 patients, 237,855 (7.1%) were identified as having constipation. After multivariable adjustments for demographics, prevalent comorbidities, medications, and socioeconomic status, patients with (versus without) constipation had 12% higher all-cause mortality (hazard ratio [HR], 1.12; 95% CI, 1.11-1.13), 11% higher incidence of CHD (HR, 1.11; 95% CI, 1.08-1.14), and 19% higher incidence of ischemic stroke (HR, 1.19; 95% CI, 1.15-1.22). Patients with one and ≥2 (versus none) types of laxatives experienced a similarly higher risk of all-cause mortality (HRs [95% CI], 1.15 [1.13-1.16] and 1.14 [1.12-1.15], respectively), incident CHD (HRs [95% CI], 1.11 [1.07-1.15] and 1.10 [1.05-1.15], respectively) and incident ischemic stroke (HRs [95% CI], 1.19 [1.14-1.23] and 1.21 [1.16-1.26], respectively).

CONCLUSIONS

Constipation status and laxative use are independently associated with higher risk of all-cause mortality and incident CHD and ischemic stroke.

Alleviation of low-fiber diet-induced constipation by probiotic Bifidobacterium bifidum G9-1 is based on correction of gut microbiota dysbiosis

Constipation, a functional disorder of the digestive system, is common in children and adults and may compromise patient quality of life. Because many patients are not satisfied with the efficacy of existing therapies, in this study, we investigated the efficacy of the probiotic Bifidobacterium bifidum G9-1 (BBG9-1) in constipation induced by a low-fiber diet. After inducing constipation in rats by feeding a low-fiber diet, rats were fed a low-fiber diet mixed with BBG9-1 in 14 days to determine the efficacy of BBG9-1 for alleviating constipation. BBG9-1 significantly alleviated the dysbiosis induced by a low-fiber diet and improved the fecal counts, fecal weights, and fecal water contents. Moreover, it also improved organic acid concentrations in the cecal contents. These results suggested that in low-fiber diet-induced constipation, BBG9-1 could alleviate dysbiosis and constipation and may improve the intestinal environment, supporting its potential application in the treatment of constipation.

Efficacy and safety of laxatives for chronic constipation in long-term care settings: A systematic review

WHAT IS KNOWN AND OBJECTIVE

Constipation is a common disorder among long-term care (LTC) patients due to several factors. However, there are no systematic reviews investigating the use of laxatives for chronic constipation in LTC settings. This study aims to explore the safety and efficacy of laxatives in LTC patients.

METHODS

A systematic review of randomized controlled trials (RCTs) describing the efficacy and safety of laxatives for chronic constipation in LTC patients was conducted using the following databases and search engines: MEDLINE, Cochrane Database of Systematic Reviews, ScienceDirect, ProQuest and Google Scholar. Two of the investigators independently performed the searches, and the data were extracted using a standardized data abstraction tool.

RESULTS AND DISCUSSION

Seven RCTs involving 444 patients were included in the review. These studies included senna (with or without fibre, ie Plantago ovata), lactulose, sodium picosulphate, docusate sodium, docusate calcium, isotonic and hypotonic polyethylene glycol and Chinese herbal medicine. Senna and lactulose were the most studied laxatives in LTC patients, and senna was found to be superior to or as effective as other laxatives. Generally, the frequency and severity of adverse drug reactions (ADRs) were similar between the arms of the studies, and no serious ADRs were reported.

WHAT IS NEW AND CONCLUSION

Considering the short duration of the trials, the lack of trials including newer laxatives and the low quality of some of the included trials, the long-term efficacy and safety of these laxatives are not conclusive. There is a need to conduct more robust RCTs that include newer agents to evaluate long-term outcomes.

Relationship between functional constipation and anal-retentive behavior features

Objectives

Constipation is the most commonly seen defecation problem related to several environmental factors. Defecation is learned in the childhood anal period in which anal characteristic features appear. Problems in the childhood anal period may affect not only characters but also defecation function. This study aimed to evaluate the relationship between constipation and anal characteristic features of participants with functional constipation.

Material and Methods

Patients with functional constipation were included into the study according to the ROME III criteria. Patients with irritable bowel disease, slow transit constipation, outlet obstruction constipation, malignancy, and psychiatric diseases were excluded from the study. Patients filled out Personality Belief Questionnaire, Hospital Anxiety and Depression Scale, and Obsessive Belief Questionnaire. The results were compared with healthy individuals.

Results

A total of 47 patients with functional constipation were included in the study. Avoidant, obsessive-compulsive, antisocial, narcissistic, and paranoid personality traits were found to be higher in patients with constipation than in the control group. Perfectionism/certainty, importance and control, and hospital anxiety scores were found to be higher in patients with constipation than in the control group.

Conclusion

Constipation may be related to several factors, such as socioeconomic environment, emotional stress, age, and diet, among others. Here, it was found that anal-retentive behavior features are prominent in functional constipation. Biofeedback, which can be regarded as psychotherapy of defecation control, can be used for treatment.

Effect of acupuncture for constipation after ischemic stroke: study protocol for a randomized controlled trial

BACKGROUND

Constipation is a common complication after stroke that can severely influence a patient's quality of life and rehabilitation. Treatments for constipation after stroke vary. Acupuncture may improve spontaneous bowel movements, quality of life, and clinical symptoms. The study seeks to assess the preliminary effects of acupuncture on constipation after an ischemic stroke.

METHODS/DESIGN

This is a prospective randomized controlled pilot trial design in which 120 eligible patients will be randomly allocated to one of three groups. The acupuncture group (n = 40) will receive acupuncture and routine care, the medication group (n = 40) will receive mosapride citrate and routine care, and the control group (n = 40) will receive only routine care for ischemic stroke. Patients will be recruited 2 weeks to 6 months after stroke onset and will receive the intervention continuously over 4 weeks, with a follow-up period of 4 additional weeks. Adverse events will be recorded to assess the safety and tolerability of acupuncture for constipation after an ischemic stroke. The primary outcome will be the change in the weekly mean number of complete spontaneous bowel movements. Secondary outcomes will include any change in the weekly mean number of spontaneous bowel movements, mean stool consistency scores, mean straining scores during defecation, and frequency of laxative use. All outcome measures will be assessed at inception, after the intervention (4 weeks), and at the follow-up (8 weeks).

DISCUSSION

This study will provide evidence of the preliminary effects and inform future sample size calculations for studies of acupuncture for constipation following an ischemic stroke. These findings will inform subsequent large-scale randomized controlled trials.

TRIAL REGISTRATION

ISRCTN, 22214747 . Registered on 17 August 2015.

Effects of Synbiotics among Constipated Adults in Serdang, Selangor, Malaysia-A Randomised, Double-Blind, Placebo-Controlled Trial

Synbiotics approach complementarily and synergistically toward the balance of gastrointestinal microbiota and improvement in bowel functions. A randomised, double-blind, placebo-controlled study was conducted to examine the effects of a synbiotics supplement among constipated adults. A total of 85 constipated adults, diagnosed by Rome III criteria for functional constipation were randomised to receive either synbiotics (n = 43) or placebo (n = 42) once daily (2.5 g) in the morning for 12 weeks. Eight times of follow-up was conducted every fortnightly with treatment response based on a questionnaire that included a record of evacuation (stool frequency, stool type according to Bristol Stool Form Scale), Patients Assessment on Constipation Symptoms (PAC-SYM), and Patients Assessment on Constipation Quality of Life (PAC-QOL). There were no significant differences in stool evacuation, but defecation frequency and stool type in treatment group were improved tremendously than in placebo group. While the treatment group was reported to have higher reduction in severity of functional constipation symptoms, the differences were not statistically significant. Dietary supplementation of synbiotics in this study suggested that the combination of probiotics and prebiotics improved the functional constipation symptoms and quality of life although not significant. This was due to the high placebo effect which synbiotics failed to demonstrate benefit over the controls.

Efficacy and safety of acupuncture for functional constipation: a randomised, sham-controlled pilot trial

Background

The prevalence of functional constipation (FC) is 3–27%, and FC has been reported to cause discomfort in daily life and various complications. The treatment for FC depends on laxatives, and thus, effective and non-toxic alternative treatments are needed.

Methods

We conducted a randomised, sham-controlled parallel-design, pilot trial. Participants with FC were randomly assigned to either the real acupuncture (RA) or sham acupuncture (SA) group. The RA consisted of eight fixed acupuncture points (bilateral ST25, ST27, BL52 and BL25) and four additional points targeted to the individual based on Traditional Korean medicine (TKM). SA consisted of shallow acupuncture insertion at 12 non-acupuncture points. Twelve sessions were provided over 4 weeks. The outcome measures were weekly defecation frequency (DF), spontaneous complete bowel movement (SCBM), Bristol stool scale (BSS) score and constipation assessment scale (CAS) score. The participants were followed for 4 weeks after the treatment.

Results

Thirty participants were enrolled (15:15). The mean DF were 5.86 ± 5.62, 5.43 ± 3.39 and 5.79 ± 3.64 in the RA group and 3.73 ± 1.62, 5.00 ± 1.77 and 5.40 ± 1.96 in the SA group at weeks 1, 5, and 9, respectively. The increases in weekly SCBMs were 2.50 ± 3.86 and 2.71 ± 4.01 with RA and 2.33 ± 2.74 and 1.93 ± 2.25 with SA at weeks 5 and 9, respectively (mean difference [MD] 0.78). The BSS scores were 0.57 ± 1.72 and 1.09 ± 1.30 with RA and 0.15 ± 1.06 and 0.14 ± 0.88 with SA at weeks 5 and 9, respectively (MD 0.95). The CAS score changes were − 3.21 ± 2.91 and − 3.50 ± 3.98 with RA and − 2.67 + ±2.82 and − 2.87 ± 2.95 with SA at weeks 5 and 9, respectively. Greater improvements were observed in subgroup analysis of participants with hard stool. The numbers of participants who developed adverse events (AEs) were equal in both groups (four in each group), and the AEs were not directly related to the intervention.

Conclusions

This clinical trial shows feasibility with minor modifications to the primary outcome measure and comparator. Acupuncture showed clinically meaningful improvements in terms of SCBMs occurring more than 3 times per week and in these improvements being maintained for 4 weeks after treatment completion. As this is a pilot trial, future studies are warranted to confirm the efficacy and safety.

Trial registration

KCT0000926 (Registered on 14 November 2013).

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2243-4) contains supplementary material, which is available to authorized users.

Chronic constipation: A review of literature

BACKGROUND

Chronic constipation is described as a common complication determined by difficult and/or rare passage of stool or both. The difference in definition of constipation has led to a wide range of reported prevalence (i.e., between 1% and 80%). Various factors are involved in the pathogenesis of the disease, including type of diet, genetic predisposition, colonic motility, absorption, social economic status, daily behaviors, and biological and pharmaceutical factors. Diagnostic and therapeutic options play a key role in the treatment of chronic constipation. There are still debates about the timing of these diagnostic and therapeutic algorithms.

METHODS

A systematic and comprehensive search will be performed using MEDLINE, PubMed, EMBASE, AMED, the Cochrane Library and Google Scholar. Better understanding of the pathophysiology of chronic constipation and efficacy of pharmacological agent can help physicians for treating and managing symptoms.In this study, some of the old and new therapies in the treatment of chronic constipation have been studied based on the controlled studies and strong evidence. We are trying to address some of the controversial issues to manage the disease and to provide appropriate diagnostic options in an efficient and cost-effective way.

RESULTS

The results of this systematic review will be published in a peer-reviewed journal.

CONCLUSION

To our knowledge, our study will provide an overall estimate of chronic constipation to assess controversial issues, available diagnostic and therapeutic strategies of chronic constipation.

ETHICS AND DISSEMINATION

Ethical approval and informed consent are not required, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care.

Cost Effectiveness of Treatments for Chronic Constipation: A Systematic Review

BACKGROUND

Chronic constipation (CC) has a significant impact on patients' quality of life and imposes an economic burden on individuals and the healthcare system. Treatment options include dietary changes, lifestyle modifications, fibre supplements, stool softeners, and laxatives.

OBJECTIVE

We undertook this systematic review to comprehensively evaluate the cost effectiveness of treatments for CC.

METHODS

We searched ten common databases to identify economic evaluations published to 13 June 2017. Abstract and full-text review were completed in duplicate. The quality of the included studies was assessed using the Consensus on Health Economic Criteria. Data extracted included costs and outcomes of treatments for CC and cost-effectiveness methods. A narrative synthesis was completed.

RESULTS

From the 4338 unique citations identified, 79 proceeded to full-text review, with 10 studies forming the final dataset. Eight different definitions of CC were used to define the study populations. Study designs used were decision-tree models (4), Markov model (1), and retrospective (1) and prospective (4) studies. Quality-adjusted life-years (QALY) were reported in five studies; other outcomes included, discontinuation of laxative treatment and frequency of bowel movements. The majority of studies stated that their results were from a payer perspective; however, some of these studies only considered treatment costs, a subset of costs included in the payer perspective. Lifestyle advice, dietary treatments and abdominal massage were each compared with current care with laxatives, while polyethylene glycol (PEG) and senna-fibre combination were each compared with lactulose. Two studies compared newer treatments in patients who had not responded to laxatives: prucalopride was compared with continuing laxatives, and linaclotide was compared with lubiprostone. All of the interventions were reported by the study authors to be cost effective, with the exception of abdominal massage.

CONCLUSIONS

A consistent definition of CC is needed and the QALY should be used to capture the diverse symptoms of CC. Further analysis is needed comparing all available treatments for patients who have not responded to laxatives. Overall, results from economic evaluations appear to align with stepwise practice guidelines.

Nonclinical Cardiovascular Studies of Prucalopride, a Highly Selective 5-Hydroxytryptamine 4 Receptor Agonist

Patients with chronic constipation benefit from treatment with 5-hydroxytryptamine 4 (5-HT4) receptor agonists. However, the first-generation 5-HT4 receptor agonists cisapride and tegaserod were withdrawn from the market owing to rare cardiovascular adverse events that were not 5-HT4-receptor-related but due to the lack of selectivity of these drugs. Here we report the nonclinical cardiovascular profile of the selective 5-HT4 receptor agonist prucalopride. To assess its non-5-HT4 receptor-mediated effects on cardiovascular electrophysiological parameters, in vitro studies were performed in human ether-à-go-go-related gene-transfected cells, guinea pig ventricular myocytes and papillary muscle preparations, rabbit and dog Purkinje fibers, and the Langendorff rabbit heart. In vivo experiments were performed in a rabbit model for drug-induced proarrhythmogenesis, in anesthetized guinea pigs, and anesthetized and conscious dogs. In addition, human platelet aggregation and coronary artery contraction were studied to exclude interactions that have been suggested to mediate the cardiovascular effects of tegaserod. Effects at 5-HT4 receptors were evaluated in piglet and human atrial myocardium, and in anesthetized pigs. Finally, cardiovascular endpoints were investigated in chronic, repeated-dose toxicology studies at very high prucalopride doses in rats and dogs. No relevant effects were observed in any of the cardiovascular studies at concentrations at least 50 times the therapeutic plasma level. Only in pigs were minor and transient increases in heart rate and blood pressure noted upon first exposure to prucalopride, at plasma levels at least 10 times higher than human therapeutic plasma levels. Prucalopride may thus provide therapeutic benefit without the cardiovascular risks reported for other 5-HT4 receptor agonists.

Drug burden index to define the burden of medicines in older adults with intellectual disabilities: An observational cross-sectional study

AIMS

The drug burden index (DBI) is a dose-related measure of anticholinergic and sedative drug exposure. This cross-sectional study described DBI in older adults with intellectual disabilities (ID) and the most frequently reported therapeutic classes contributing to DBI and examined associations between higher DBI scores and potential adverse effects as well as physical function.

METHODS

This study analysed data from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a representative study on the ageing of people with ID in Ireland. Self- and objectively-reported data were collected on medication use and physical health, including health conditions. The Barthel index was the physical function measure.

RESULTS

The study examined 677 individuals with ID, of whom 644 (95.1%) reported taking medication and 78.6% (n = 532) were exposed to medication with anticholinergic and/or sedative activity. 54.2% (n = 367) were exposed to high DBI score (≥1). Adjusted multivariate regression analysis revealed no significant association between DBI score and daytime dozing, constipation or falls. After adjusting for confounders (sex, age, level of ID, comorbidities, behaviours that challenge, history of falls), DBI was associated with significantly higher dependence in the Barthel index (P = 0.002).

CONCLUSIONS

This is the first time DBI has been described in older adults with ID. Scores were much higher than those observed in the general population and higher scores were associated with higher dependence in Barthel index activities of daily living.

Inappropriate anticholinergic drugs prescriptions in older patients: analysing a hospital database

Background Although many anticholinergics are inappropriate in older patients, the prescription of these drugs in a hospital setting has not been extensively studied. Objective To describe prescriptions of anticholinergic drugs in terms of frequency, at risk situations and constipation in hospitalized, older adults. Setting Using a database from a French general hospital (period 2009-2013), we extracted information on 14,090 hospital stays by patients aged 75 and over. Methods Anticholinergic drug prescriptions were automatically detected, with a focus on prescriptions in three well-known at-risk situations: falls, dementia, and benign prostatic hyperplasia. Cases of constipation that might have been causally related to the administration of anticholinergic drugs were screened for and reviewed. Main outcome measure Prescriptions with a high associated risk of anticholinergic related adverse reactions. Results Administration of an anticholinergic drug was detected in 1412 (10.0%) of the hospital stays by older patients. At-risk situations were identified in 413 (36.5%) of these stays: 137 (9.7%) for falls, 243 (17.2%) for dementia, and 114 (8.1%) for benign prostatic hyperplasia; 78 (18.9%) of these 413 stays featured a combination of two or three at-risk situations. Cases of constipation induced by anticholinergic drug administration were identified in 188 (13.3%) patient stays by using validated adjudication rules for adverse drug reactions: 85 and 103 cases were respectively evaluated as "possible" or "probable" adverse drug reactions. Conclusions Anticholinergic drugs prescription was found in 10.0% of hospitalized, older patients. More than one third of these prescriptions occurred in at-risk situations and more than one in ten prescriptions induced constipation.

Outcomes and prognostic factors of fecal microbiota transplantation in patients with slow transit constipation: results from a prospective study with long-term follow-up

Background and aim

Gut microbiota may contribute to regulate colonic motility, which is involved in the etiology of constipation. Fecal microbiota transplantation (FMT) has been demonstrated to restore intestinal homeostasis. The aim of this study was to evaluate the clinical outcomes and prognostic factors of FMT for the treatment of slow transit constipation (STC).

Methods

Fifty-two patients with STC received standardized FMT and were followed up for 6 months. Bowel habit, colonic transit time, constipation-related symptoms (PAC-SYM score), quality of life (PAC-QOL score), treatment satisfaction scores and adverse events were monitored. The primary efficacy endpoint was the proportion of patients having on average three or more complete spontaneous bowel movements (CSBMs) per week.

Results

The primary efficacy endpoint was achieved in 50.0%, 38.5% and 32.7% of patients over week intervals 3-4, 9-12 and 21-24, respectively (P < 0.01 for all comparisons). Significant improvements were also observed in other bowel movement assessments, colonic transit time, constipation-related symptoms and quality of life; but all improvements diminished at weeks 12 and 24. Incompleteness of evacuation served as the only factor associated with efficacy. No serious treatment-related adverse events were observed.

Conclusion

This study suggested FMT was effective and safe for STC, while a late loss of efficacy was also observed. A lower degree of sensation of incompleteness predicted a better outcome.

Efficacy of Biofeedback Therapy in the Treatment of Dyssynergic Defecation in Community-Dwelling Elderly Women

AIM OF THE STUDY

The aim of this study was to evaluate the efficacy of biofeedback therapy in the treatment of dyssynergic defecation in chronically constipated community-dwelling elderly women.

MATERIALS AND METHODS

After an initial assessment phase carried out during 1 month, 20 chronically constipated women with dyssynergic defecation were randomly assigned to either electromyographic biofeedback (EMG-BF) group (n=10) or control group (n=10). Outcome measures used to evaluate the efficacy of treatment were weekly stool frequency, sensation of incomplete evacuation, difficulty evacuation level, mean EMG-activity (μV) of the external anal sphincter during straining to defecate and Anismus index.

RESULTS

The results obtained in this randomized controlled trial showed significant differences between the groups in all the dependent variables after 1 month of treatment. Moreover, there was no difference between the groups neither in age nor in the duration of chronic constipation symptoms. At the follow-up, 3 months later, clinical gains were maintained.

CONCLUSIONS

This study demonstrates that the EMG-BF is an effective behavioral therapy for the treatment of dyssynergic defecation in community-dwelling elderly women.

Cost-effectiveness of sacral neuromodulation for chronic refractory constipation in children and adolescents: a Markov model analysis

AIM

This study aimed to assess the cost-effectiveness of sacral neuromodulation (SNM) compared with conservative treatment in children and adolescents with constipation refractory to conservative management.

METHOD

A Markov probabilistic model was used, comparing costs and effectiveness of SNM and conservative treatment in children and adolescents aged 10-18 years with constipation refractory to conservative management. Input for the model regarding transition probabilities, utilities and healthcare costs was based on data from a cohort of patients treated in our centre. This cohort consisted of 30 female patients (mean age 16 years) with functional constipation refractory to conservative management. The mean duration of laxative use in this group was 5.9 years. All patients had a test SNM, followed by a permanent SNM in 27/30. Median follow-up was 22.1 months (range 12.2-36.8). The model was run to simulate a follow-up period of 3 years.

RESULTS

The mean cumulative costs for the SNM group and the conservative treatment group were €17 789 (SD €2492) and €7574 (SD €4332) per patient, respectively. The mean quality adjusted life years (QALYs) in the SNM group was 1.74 (SD 0.19), compared with 0.86 (SD 0.14) in the conservatively managed group. The mean incremental cost-effectiveness ratio was €12 328 per QALY (SD €4788). Sensitivity analysis showed that the outcomes were robust to a wide range of model assumptions.

CONCLUSION

Chronic constipation seriously affects the quality of life of children and adolescents. Preliminary evidence suggests that SNM can improve symptoms and quality of life at a reasonable cost.

Comparison of efficacy of pharmacological treatments for chronic idiopathic constipation: a systematic review and network meta-analysis

OBJECTIVE

To compare efficacy of pharmacotherapies for chronic idiopathic constipation (CIC) based on comparisons to placebo using Bayesian network meta-analysis.

DATA SOURCES

We conducted searches (inception to May 2015) of MEDLINE, EMBASE, Scopus and Cochrane Central, as well as original data from authors or drug companies for the medications used for CIC.

STUDY SELECTION

Phase IIB and phase III randomised, placebo-controlled trials (RCT) of ≥4 weeks' treatment for CIC in adults with Rome II or III criteria for functional constipation; trials included at least one of four end points.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently evaluated all full-text articles that met inclusion criteria and extracted data for primary and secondary end points, risk of bias and quality of evidence.

OUTCOMES

Primary end points were ≥3 complete spontaneous bowel movements (CSBM)/week and increase over baseline by ≥1 CSBM/week. Secondary end points were change from baseline (Δ_b) in the number of SBM/week and Δ_b CSBM/week.

RESULTS

Twenty-one RCTs (9189 patients) met inclusion and end point criteria: 9 prucalopride, 3 lubiprostone, 3 linaclotide, 2 tegaserod, 1 each velusetrag, elobixibat, bisacodyl and sodium picosulphate (NaP). All prespecified end points were unavailable in four polyethylene glycol studies. Bisacodyl, NaP, prucalopride and velusetrag were superior to placebo for the ≥3 CSBM/week end point. No drug was superior at improving the primary end points on network meta-analysis. Bisacodyl appeared superior to the other drugs for the secondary end point, Δ_b in number of SBM/week.

CONCLUSIONS

Current drugs for CIC show similar efficacy. Bisacodyl may be superior to prescription medications for Δ_b in the number of SBM/week in CIC.

Intractable Constipation in the Elderly

OPINION STATEMENT

Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.

Novel Effects of Traditional Wooden Toothbrush on Bowel Motility Symptoms in Spinal Cord Injury Patients; Findings from a Pilot Quasi-experimental Study

BACKGROUND

The aim of this study was to investigate the therapeutic effect of traditional wooden toothbrush usage on most severe constipation, which usually occurs in spinal cord injury (SCI) patients.

METHODS

In a quasi-experimental study, 61 SCI patients were selected who had injuries in different spinal levels (cervical, thoracic, and lumbar), and severe constipation from one defection in a few days to 3 weeks. They were recommended to use traditional wooden toothbrush for 5 min twice a day, after breakfast and dinner, over a 6 weeks period. Two proper standard scales, called neurogenic bowel dysfunction (NBD), and "Constipation Assessment Scale (CAS)," were used for evaluating the changes in patients' gastrointestinal (GI) habits during the period of using the wooden toothbrush. Through these scales (NBD and CAS), the therapeutic effects of traditional wooden toothbrush usage on the severity of constipation before and after intervention were measured.

RESULTS

The mean of NBD and CAS scores were reduced significantly, from 8.95 ± 0.78 and 3.34 ± 0.28; respectively, to 3.03 ± 0.57 and 1.74 ± 0.25, after 6 weeks using traditional wooden toothbrush (P < 0.0001). There was a significant difference in terms of NBD scores in patients with different levels of injury (P < 0.01), particularly in patients with thoracic injury, before (10.52 ± 0.88) and after (3.13 ± 0.78) treatment, respectively (P < 0.0001). Eventually, all symptoms of bowel problems improved significantly after the intervention (P < 0.05).

CONCLUSIONS

The use of traditional wooden toothbrush lead to the improvement of bowel and defecation problems in SCI patients. Yet more studies, particularly randomized control clinical trials are needed to investigate the effect of using wooden toothbrush on other GI reflexes. In addition, if some clinical trials are devised to study the effects of wooden toothbrush on both conscious and unconscious patients in ICU, best results are expected to be found on keeping their mouth and teeth hygiene, as well as, getting rid of their constipations.

Prevalence and Risk Factors of Chronic Constipation Among Women Aged 50 Years and Older in Shanghai, China

BACKGROUND Chronic constipation (CC) is a major public health problem worldwide, especially in elderly women. This study aimed to investigate the prevalence and risk factors of CC among women aged 50 years and older in Shanghai, China. MATERIAL AND METHODS A cross-sectional survey was conducted on 1950 women aged 50 years and older, randomly sampled in Yangpu District of Shanghai from April to October 2015. Information on demographic characteristics, lifestyle habits, medical history, and defecation situation was collected through in-person interviews. CC was defined according to Rome III criteria. The data were analyzed by chi-square test and multiple logistic regression analysis. RESULTS The response rate to the survey was 80.4%. Of the 1568 participants, 77 were diagnosed with CC, with a prevalence of 4.9%. Moreover, the prevalence increased with advancing age. Multiple logistic analyses showed that body mass index (BMI) ≥25.0 kg/m², non-manual occupation, premenopausal period, no delivery history, poor sleep quality, meat-based diet, and less physical exercise were significant risk factors for CC in the population of women aged 50 years and older. CONCLUSIONS CC was a common health problem among women aged 50 years and older in Shanghai, and the prevalence was positively associated with BMI ≥25.0 kg/m², non-manual occupation, premenopausal period, no delivery history, poor sleep quality, meat-based diet, and less physical exercise. Further studies are needed to identify the risk factors and potential interventions for CC.

INFLUENCE OF DRINKING A PROBIOTIC FERMENTED MILK BEVERAGE CONTAINING BIFIDOBACTERIUM ANIMALIS ON THE SYMPTOMS OF CONSTIPATION

ABSTRACT BACKGROUND Constipation is a chronic problem in many patients all over the world. OBJECTIVE - To evaluate the effect of consumption of a probiotic fermented milk beverage containing Bifidobacterium animalis on the symptoms of constipation. METHODS - This randomized, double-blind controlled trial included 49 female patients aged 20 to 50 years and diagnosed with constipation according to the ROME III criteria (Diagnostic Criteria for Functional Gastrointestinal Disorders) and the Bristol Stool Form Scale. The patients were randomized into two groups: the intervention group received the probiotic fermented milk beverage and the control group received non-probiotic milk. Participants were instructed to ingest 150 mL of the beverages during 60 days. At the end of this period, patients were assessed again by the ROME III criteria and Bristol scale. The Wilcoxon test was used to evaluate pre and post-intervention results of the ROME III criteria and Bristol scale. The statistical significance level was considered as 5% ( P ≤0.05). RESULTS - The intervention group showed improvement in the following criteria: straining during a bowel movement ( P <0.001), feeling of incomplete evacuation ( P <0.001) and difficulty in passing stool ( P <0.014), in addition to Bristol scale results ( P <0.001). In the control group, improvements were observed in the following criteria: straining during a bowel movement ( P <0.001), feeling of incomplete evacuation ( P <0.001) and difficulty in passing stool ( P <0.025), in addition to Bristol scale results ( P <0.001). No statistically significant post-intervention differences were observed between the two groups for the Rome III criteria and Bristol scale. CONCLUSION - The results show that the consumption of milk resulted in the improvement of constipation symptoms, regardless of the probiotic culture.

Nurse-Led Self-Management Educational Intervention Improves Symptoms of Patients With Functional Constipation

This study aimed to evaluate the effects of self-management educational intervention on the symptoms of patients with functional constipation. From January 2014 to April 2015, 66 patients with functional constipation were randomly assigned into intervention group receiving intensive educational interventions and control group receiving routine nursing care. The constipation score of all clinical symptoms (Bristol stool form scale, defecation interval, incomplete evacuation, evacuatory difficulty) at 1 month postdischarge were all significantly lower in the intervention group than in the control group (all, p < .05). At 1 month postdischarge, the intervention group had a significantly higher proportion of patients with good health habits (reasonable diet, regular exercise, good defecation habits, proper use of laxatives) as compared with the control group (all, p < .05). These data suggest educational intervention can effectively improve constipation symptoms and compliance with treatment of patients, and lead to the development of good health habits.

Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult

In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.

Electroacupuncture for Functional Constipation: A Multicenter, Randomized, Control Trial

Background and Aim. To investigate the efficacy and safety of electroacupuncture (EA) with different current intensities for functional constipation (FC) and to assess whether the effects of EA with different current intensities are superior to the mosapride. Methods. Patients with FC were randomly divided into low current intensity group (LCI), high current intensity group (HCI), and mosapride group (MC). The primary outcome was three or more spontaneous bowel movements (SBMs) per week and an increase of one or more SBMs from baseline during at least 3 of the 4 weeks. Results. The primary outcome was reached by 53.45%, 66.15%, and 52.24% of the patients who received LCI, HCI, and mosapride, respectively. EA can significantly improve the weekly SBMs and stool consistency and reduce straining severity (p < 0.0001, all). HCI improved the quality of life better than mosapride (p < 0.05) and reduced the proportion of severe constipation more than LCI and mosapride (p < 0.05, both). Conclusions. EA is effective and safe at both current intensities for FC; therapeutic effects of LCI and HCI are not superior to mosapride. EA is superior to mosapride in improving patients' life quality and satisfaction level of treatment; EA has fewer adverse events than mosapride.

Pharmacological treatment for antipsychotic-related constipation

BACKGROUND

Antipsychotic-related constipation is a common and serious adverse effect, especially for people taking clozapine. Clozapine has been shown to impede gastrointestinal motility, leading to constipation, and has been reported in up to 60% of patients receiving clozapine. In rare cases, complications can be fatal. Appropriate laxatives should be prescribed to treat constipation in people taking antipsychotics, but there is a lack of guidance on the comparative effectiveness and harms of different agents in this population. An understanding of the effectiveness and safety of treatment for antipsychotic-related constipation is important for clinicians and patients alike.

OBJECTIVES

To evaluate the effectiveness and safety of pharmacologic treatment (versus placebo or compared against another treatment) for antipsychotic-related constipation (defined as constipated patients of any age, who are treated with antipsychotics, regardless of dose, in which constipation is considered to be an antipsychotic-related side effect).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (15 June 2015), which is based on regular searches of MEDLINE, Embase, CINAHL, BIOSIS, AMED, PubMed, PsycINFO, and registries of clinical trials, grey literature, and conference proceedings. There are no language, date, document type, or publication status limitations for inclusion of records in this register. We also handsearched bibliographies and contacted relevant authors for additional information.

SELECTION CRITERIA

We included all published and unpublished randomised controlled trials (RCTs) investigating the efficacy of pharmacological treatments in patients with antipsychotic-related constipation. Pharmacological treatments included laxatives and other medicines that could reasonably be used to combat constipation in this population (e.g. anticholinergic agents, like bethanecol).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from all included studies and assessed trials for risk of bias. A third author reviewed 20% of trials. We analysed dichotomous data using relative risks (RR) and the 95% confidence intervals (CI). We assessed risk of bias for included studies and used GRADE to create a 'Summary of findings' table. We discussed any disagreement, documented decisions, and attempted to contact study authors when necessary.

MAIN RESULTS

We identified two relevant Chinese studies (N = 480) that contributed data to this review. Both studies were over ten years old and poorly reported, lacking descriptions of contemporary CONSORT reporting prerequisites, such as sequence generation, allocation concealment, blinding, participant flow, how the sample size was determined, or how outcomes were measured. The studies also did not report trial registration, pre-specified protocols, consent processes, ethical review, or funding source. We were unsuccessful in making contact with the authors to clarify the missing details. We classified both studies as having an overall high risk of bias.One study compared glycerol suppository with the traditional Chinese medicine (TCM) approaches of tuina massage and acupuncture. Compared to tuina massage, glycerol laxative was less effective in relieving constipation at both two days after treatment (1 RCT; N = 120; RR 2.88, 95% CI 1.89 to 4.39; very low-quality evidence), and three days (1 RCT; N = 120; RR 4.80, CI 1.96 to 11.74, very low-quality evidence). Favourable results were also seen for acupuncture at two days (1 RCT; N = 120; RR 3.50; 95% CI 2.18 to 5.62; very low-quality evidence), and at three days (1 RCT; N = 120; RR 8.00, 95% CI 2.54 to 25.16; very low-quality evidence).The other study compared mannitol, an osmotic laxative, with rhubarb soda or phenolphthalein. Mannitol was more effective than rhubarb soda or phenolphthalein in trelieving constipation within 24 hours of treatment (1 RCT; N = 240; RR 0.07; 95% CI 0.02 to 0.27, very low-quality evidence).No data were reported for our other important outcomes: need for rescue medication, bowel obstruction (a complication of antipsychotic-related constipation), quality of life, adverse events, leaving the study early, and economic costs.

AUTHORS' CONCLUSIONS

We had hoped to find clinically useful evidence appraising the relative merits of the interventions routinely used to manage antipsychotic-related constipation, a common and potentially serious adverse effect of the use of these drugs. The results were disappointing. There were no data comparing the common pharmacological interventions for constipation, such as lactulose, polyethylene glycol, stool softeners, lubricant laxatives, or of novel treatments such as linaclotide. Data available were very poor quality and the trials had a high risk of bias. Data from these biased studies suggested that mannitol, an osmotic laxative, was more effective than rhubarb soda and phenolphthalein in relieving constipation, and a two-week course of glycerol suppositories was less effective than the TCM approaches of tuina massage and acupuncture.Overall, there is insufficient trial-based evidence to assess the effectiveness and safety of pharmacological interventions for treating antipsychotic-related constipation, due to limited, poor quality data (few studies with high risk of bias and no meta-analyses). The methodological limitations in the included studies were obvious, and any conclusions based on their results should be made with caution. Methodologically rigorous RCTs evaluating interventions for treating antipsychotic-related constipation are needed.

[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]

In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.

Constipation in older people: A consensus statement

BACKGROUND AND AIMS

Chronic constipation is a serious medical condition that affects 30%-40% of people over 60 years old. Although not normally life threatening, constipation reduces quality of life by the same extent as diabetes and osteoarthritis. There are currently no Europe-wide guidelines for treating constipation in older people, although there is some country-level guidance for the general population. We have evaluated the existing guidance and best clinical practice to improve the care of older people with constipation.

METHOD

European healthcare professionals working in gastroenterology, geriatrics, nursing and pharmacology discussed the treatment of constipation in older people and reviewed existing guidance on the treatment of constipation in the general population. This manuscript represents the consensus of all authors.

DISCUSSION

Most general guidance for constipation treatment recommends increased dietary fibre, fluid intake and exercise; however, this is not always possible in older patients. Although a common first-line treatment, bulk-forming laxatives are unsuitable for older people because of an associated need to increase fluid intake, osmotic laxatives are likely to be the most suitable laxative type for older patients. Treatment is often hampered by reluctance to talk about bowel problems so healthcare providers should proactively identify older constipated patients who are self-medicating or not receiving treatment.

CONCLUSIONS

With certain modifications, general treatment guidelines can be applied to older people with constipation, although specific guidelines are still required for this age group. Awareness of constipation, its complications and treatment options need to be increased among healthcare providers, patients and carers.

Clozapine-Induced Gastrointestinal Hypomotility: A 22-Year Bi-National Pharmacovigilance Study of Serious or Fatal 'Slow Gut' Reactions, and Comparison with International Drug Safety Advice

INTRODUCTION

Clozapine is the preferred antipsychotic for treatment-resistant schizophrenia, but has significant adverse effects, including gastrointestinal hypomotility or 'slow gut', which may result in severe constipation, ileus, bowel obstruction, and even death. These gastrointestinal effects remain inadequately recognized.

METHODS

We reviewed all reports of serious clozapine-induced gastrointestinal hypomotility (CIGH) submitted to the Australian Therapeutic Goods Administration and New Zealand Pharmacovigilance Centre between 1992 and 2013. We extracted relevant demographic, clinical, and outcome data and derived a numerator from clozapine registries. We examined whether clozapine drug safety information in Australia, New Zealand, the US, and the UK was adequate and consistent with pharmacoepidemiologic evidence.

RESULTS

A total of 43,132 people commenced clozapine over the study period. 160 were reported as having serious gastrointestinal hypomotility with clozapine the suspected cause (37/10,000 clozapine users). Of these, 66.3% were male, age range was 17-76 years, clozapine dose range 25-1000 mg/day (mean 439 mg/day) and median duration of clozapine treatment 2.5 years. Few had received laxatives. At least 29 patients died (7/10,000 clozapine users), a reported case fatality rate of 18%. The CIGH prevalence, while similar to other smaller studies, differs significantly from clozapine prescribing information issued by regulators and pharmaceutical companies, none of which mention CIGH, and which report serious gastrointestinal complications at rates of <1/10,000, almost a 40-fold difference.

CONCLUSION

This is the largest study to date of serious CIGH. The reported prevalence of serious CIGH was 37/10,000, a likely underestimation of true prevalence. Current prescribing guidelines provide inadequate information on CIGH. This may be contributing to poor awareness and high associated morbidity and mortality. It is time regulators and manufacturers update their guidance.

[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]

In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.

Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments

Gastrointestinal (GI) side-effects of chemotherapy are a debilitating and often overlooked clinical hurdle in cancer management. Chemotherapy-induced constipation (CIC) and Diarrhea (CID) present a constant challenge in the efficient and tolerable treatment of cancer and are amongst the primary contributors to dose reductions, delays and cessation of treatment. Although prevalence of CIC is hard to estimate, it is believed to affect approximately 16% of cancer patients, whilst incidence of CID has been estimated to be as high as 80%. Despite this, the underlying mechanisms of both CID and CIC remain unclear, but are believed to result from a combination of intersecting mechanisms including inflammation, secretory dysfunctions, GI dysmotility and alterations in GI innervation. Current treatments for CIC and CID aim to reduce the severity of symptoms rather than combating the pathophysiological mechanisms of dysfunction, and often result in worsening of already chronic GI symptoms or trigger the onset of a plethora of other side-effects including respiratory depression, uneven heartbeat, seizures, and neurotoxicity. Emerging treatments including those targeting the enteric nervous system present promising avenues to alleviate CID and CIC. Identification of potential targets for novel therapies to alleviate chemotherapy-induced toxicity is essential to improve clinical outcomes and quality of life amongst cancer sufferers.

The use of conventional and complementary health services and self-prescribed treatments amongst young women with constipation: An Australian national cohort study

BACKGROUND

Little research has been conducted regarding the comprehensive health service utilisation in constipation care. This study investigates the comprehensive health service utilisation amongst Australian women with constipation.

METHODS

This study draws upon data from the Australian Longitudinal Study on Women's Health. A total of 8074 young women were asked about their frequency of constipation, measures of quality of life, and use of a range of health services and self-prescribed treatments via two postal surveys conducted in 2006 and 2009, respectively.

RESULTS

The prevalence of constipation was 18.5% amongst women in 2009. Constipated women had poorer quality of health than women without constipation. Women who sought help for constipation were more likely to visit multiple groups of conventional and complementary health practitioners compared to women who did not experience constipation (p<0.005). However, women were less likely to visit a specialist for the management of constipation over time (2006 to 2009). There was an increase in the proportion of women with constipation who self-prescribed vitamins/minerals over time (p<0.001).

CONCLUSION

Although only 4.5% of women sought help for their constipation, given the increasing use of multiple health services across time, more studies are required regarding the optimal treatment in constipation care.

"The constipation conundrum": Improving recognition of constipation on a gastroenterology ward

Constipation is a common and often overlooked problem, but it can cause serious complications for patients including pain, nausea, urinary retention, and prolonged hospital admission. There are no recognised criteria for the diagnosis of constipation in the acute hospital setting, and it is often the role of the ward doctor to identify and manage this problem.

Completion and monitoring of “stool charts” by nursing and medical staff is key to proper recognition and management of constipation. A baseline study found that while charts were completed well, they were only monitored by doctors 17.5% of the time. This quality improvement project introduced an altered “continuation sheet” to the clinical notes to prompt monitoring of stool charts and provide an area for documentation. This resulted in an increase in monitoring to 66.7%.

Randomized clinical trial: efficacy of a food supplement, TRANSITECH, on healthy individuals with mild intermittent constipation

BACKGROUND

Constipation is a common disorder in the general population and can be observed in healthy individuals. A natural product leading to an increase in bowel movements and decrease in colonic transit time (CTT), without bloating, could be useful for the patient's care.

OBJECTIVES

To investigate the effects of TRANSITECH, a food supplement composed of plants and lactic ferments, on bowel movements, CTT and bloating.

METHODS

A total of 100 healthy participants, presenting two to five stools per week, were selected and followed over a 6-day baseline period. They were randomly assigned to receive daily two tablets of TRANSITECH or placebo during 10 days. They were then followed up over 28 days after intervention. Participants daily recorded in a home questionnaire the characteristics of stools (frequency and consistency), and the importance of bloating during the preintervention period (from D-6 to D0), the intervention period (from D0 to D10) and the postintervention period (from D10 to D38). Their CTTs were also evaluated by following the propagation of radiopaque markers at D0 and D10.

RESULTS

At D10, the food supplement group showed, compared with the placebo group, higher daily stool emission (0.95±0.50, 0.70±0.20, P<0.001), softer stool consistency (2.5±0.6 vs. 3.0±0.8, P<0.001) and lower CTT (33.8±28.2 vs. 56.4±36.2 h, P=0.01). The active group also showed a sustained increase in daily stool emissions observed at D38 compared with D0 (P=0.03).

CONCLUSION

TRANSITECH is an efficient natural solution for the treatment of constipation. It increases the number of bowel movements, decreases the oroanal and segmental CTT, is well tolerated, and presents sustained effects after treatment completion.

Chronic Constipation: a Review of Current Literature

Chronic constipation is a common health condition representing a substantial proportion of primary care visits and referrals to specialist providers. Chronic constipation can have a significant negative effect on health-related quality of life and has been associated with psychological distress in severely affected patients. It has the potential to cause patients to curtail work, school, and social activities. While different pathophysiological mechanisms have been implicated in the development of chronic constipation, in some instances, the causes of chronic constipation are not easily determined. Expenditures for the evaluation and management of chronic constipation represent a significant burden on patients and payers, and it is important for clinicians to have a clear understanding of the different pathophysiological mechanisms associated with constipation, understand the different testing modalities and treatments that are available including their appropriateness and limitations, and tailor that knowledge to the management of individual patients.

Diagnosis and Treatment of Dyssynergic Defecation

Dyssynergic defecation is common and affects up to one half of patients with chronic constipation. This acquired behavioral problem is due to the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. A detailed history, prospective stool diaries, and a careful digital rectal examination will not only identify the nature of bowel dysfunction, but also raise the index of suspicion for this evacuation disorder. Anorectal physiology tests and balloon expulsion test are essential for a diagnosis. Newer techniques such as high-resolution manometry and magnetic resonance defecography can provide mechanistic insights. Recently, randomized controlled trials have shown that biofeedback therapy is more effective than laxatives and other modalities, both in the short term and long term, without side effects. Also, symptom improvements correlated with changes in underlying pathophysiology. Biofeedback therapy has been recommended as the first-line of treatment for dyssynergic defecation. Here, we provide an overview of the burden of illness and pathophysiology of dyssynergic defecation, and how to diagnose and treat this condition with biofeedback therapy.

Prevalence and Predictors of Clozapine-Associated Constipation: A Systematic Review and Meta-Analysis

Constipation is a frequently overlooked side effect of clozapine treatment that can prove fatal. We conducted a systematic review and meta-analysis to estimate the prevalence and risk factors for clozapine-associated constipation. Two authors performed a systematic search of major electronic databases from January 1990 to March 2016 for articles reporting the prevalence of constipation in adults treated with clozapine. A random effects meta-analysis was conducted. A total of 32 studies were meta-analyzed, establishing a pooled prevalence of clozapine-associated constipation of 31.2% (95% CI: 25.6-37.4) (n = 2013). People taking clozapine were significantly more likely to be constipated versus other antipsychotics (OR 3.02 (CI: 1.91-4.77), p < 0.001, n = 11 studies). Meta-regression identified two significant study-level factors associated with constipation prevalence: significantly higher (p = 0.02) rates of constipation were observed for those treated in inpatient versus outpatient or mixed settings and for those studies in which constipation was a primary or secondary outcome measure (36.9%) compared to studies in which constipation was not a specified outcome measure (24.8%, p = 0.048). Clozapine-associated constipation is common and approximately three times more likely than with other antipsychotics. Screening and preventative strategies should be established and appropriate symptomatic treatment applied when required.

Factors associated with impaired quality of life in French patients with chronic idiopathic constipation: a cross-sectional study

OBJECTIVE

Chronic idiopathic constipation can impact the health-related quality of life (QoL). We aimed to evaluate QoL in French patients with different clinical types of chronic constipation.

METHODS

In this cross-sectional study, 338 general practitioners included 1710 consecutive adult patients who fulfilled the Rome III criteria for constipation and agreed to complete Patient-Assessment of Constipation Quality of Life and Symptom questionnaires. Sociodemographic and medical data were collected. Multivariate analyses enabled identification of factors associated with poor QoL using odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

Overall, 1673 patients were eligible for analyses; 32% had infrequent evacuation (IE) of feces, 24% had difficult evacuation (DE) of feces, and 44% had both (IE+DE). The mean global Patient-Assessment of Constipation Quality of Life score was 1.9 (95% CI: 1.9-2.0), with a significantly worse QoL for IE+DE patients (mean 2.0; 95% CI: 2.0-2.1); 23% of patients reported a poor QoL, that is, a more than 2.4 (29% in IE+DE group, P<0.0001). Poor QoL was significantly associated with psychosocial parameters, associated digestive symptoms, but the main factors were the use of rectal treatment (OR 2.5; 95% CI: 1.9-3.3), one or less defecation/week (OR 3.5; 95% CI: 2.2-5.7), and weak/null perceived treatment efficiency (OR 4.3; 95% CI: 2.8-6.5).

CONCLUSION

Chronic constipation is associated with a significant decrease in QoL, especially in patients suffering from both infrequent and DE of feces and feeling unsatisfied by their treatments.

Diagnosis and management of chronic constipation in adults

Constipation is a heterogeneous, polysymptomatic, multifactorial disease. Acute or transient constipation can be due to changes in diet, travel or stress, and secondary constipation can result from drug treatment, neurological or metabolic conditions or, rarely, colon cancer. A diagnosis of primary chronic constipation is made after exclusion of secondary causes of constipation and encompasses several overlapping subtypes. Slow-transit constipation is characterized by prolonged colonic transit in the absence of pelvic floor dysfunction. This subtype of constipation can be identified using either the radio-opaque marker test or wireless motility capsule test, and is best treated with laxatives such as polyethylene glycol or newer agents such as linaclotide or lubiprostone. If unsuccessful, subspecialist referral should be considered. Dyssynergic defecation results from impaired coordination of rectoanal and pelvic floor muscles, and causes difficulty with defecation. The condition can be identified using anorectal manometry and balloon expulsion tests and is best managed with biofeedback therapy. Opioid-induced constipation is an emerging entity, and several drugs including naloxegol, methylnaltrexone and lubiprostone are approved for its treatment. In this Review, we provide an overview of the burden and pathophysiology of chronic constipation, as well as a detailed discussion of the available diagnostic tools and treatment options.

Opioid-induced constipation, use of laxatives, and health-related quality of life

Background and aims

Real-life data on laxative use in patients suffering from opioid-induced constipation (OIC) are very limited, and many OIC patients are only using over the counter laxatives to resolve their constipation. Our aim was to describe laxative utilization and quality of life in participants in Norway who ever experienced OIC.

Methods

This was a cross-sectional online survey conducted between 27th of June and 3rd of July 2014 among participants above 18 years with self-reported OIC and who had agreed to receive information from the pharmacy chain (Boots A/S, Norway). The questionnaire comprised a series of multiple choice, close-ended, and free text questions on abdominal symptoms, laxative use and health-related quality of life.

Results

A total of 417 participants met the study eligibility criteria: (1) treated with opioid for a minimum of 4 weeks, (2) actively accepted participation, and (3) confirmed ever experiencing OIC and in addition completed the survey. Among the eligible participants, 86% were females, 85% were younger than 60 years of age, and 57% were currently suffering OIC. More than half of the currently constipated participants were experiencing moderate to very severe abdominal bloating (63%), abdominal pain (55%) and/or pain during bowel movement (50%). Less than every fourth participant (23%) had consulted health care professionals (HCPs) about their constipation. Up to 39% reported that they handled their OIC by self-management, e.g., bought laxative, reduced the dose and/or changed opioid without consulting HCP or pharmacy. Less than half (48%) of the laxative users were satisfied with the laxative they were using to relieve their constipation. The EQ-5D health-related quality of life score was mean (SD): 0.587 (0.272). Although not statistically significant (p = 0.067), there was a tendency of lower quality of life among the participants who were currently constipated compared with those not currently constipated (difference of mean EQ-5D: 0.629-0.555 = 0.074). A significantly lower (p = 0.001) quality of life was found among participants who were dissatisfied with their laxative [mean (SD): 0.424 (0.350)] than among those who were satisfied or neither satisfied nor dissatisfied [mean (SD): 0.628 (0.235) and 0.673 (0.155), respectively].

Conclusions

The results suggest a high degree of moderate to very severe abdominal symptoms, a high degree of self-management of opioid-induced constipation, a low degree of satisfaction with laxative, and low health-related quality of life of patients suffering from chronic pain necessitating long-term opioid treatment, subsequent constipation and laxatives use.

Implications

Patients suffering from OIC with low quality of life and remaining symptoms despite use of two or more laxatives are a vulnerable patient group in need of optimized healthcare management, who also might benefit from more specific and innovative therapy.

Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group

Background and aims

Opioid-induced bowel dysfunction (OIBD) is an increasing problem due to the common use of opioids for pain worldwide. It manifests with different symptoms, such as dry mouth, gastro-oesophageal reflux, vomiting, bloating, abdominal pain, anorexia, hard stools, constipation and incomplete evacuation. Opioid-induced constipation (OIC) is one of its many symptoms and probably the most prevalent. The current review describes the pathophysiology, clinical implications and treatment of OIBD.

Methods

The Nordic Working Group was formed to provide input for Scandinavian specialists in multiple, relevant areas. Seven main topics with associated statements were defined. The working plan provided a structured format for systematic reviews and included instructions on how to evaluate the level of evidence according to the GRADE guidelines. The quality of evidence supporting the different statements was rated as high, moderate or low. At a second meeting, the group discussed and voted on each section with recommendations (weak and strong) for the statements.

Results

The literature review supported the fact that opioid receptors are expressed throughout the gastrointestinal tract. When blocked by exogenous opioids, there are changes in motility, secretion and absorption of fluids, and sphincter function that are reflected in clinical symptoms. The group supported a recent consensus statement for OIC, which takes into account the change in bowel habits for at least one week rather than focusing on the frequency of bowel movements. Many patients with pain receive opioid therapy and concomitant constipation is associated with increased morbidity and utilization of healthcare resources. Opioid treatment for acute postoperative pain will prolong the postoperative ileus and should also be considered in this context. There are no available tools to assess OIBD, but many rating scales have been developed to assess constipation, and a few specifically address OIC. A clinical treatment strategy for OIBD/OIC was proposed and presented in a flowchart. First-line treatment of OIC is conventional laxatives, lifestyle changes, tapering the opioid dosage and alternative analgesics. Whilst opioid rotation may also improve symptoms, these remain unalleviated in a substantial proportion of patients. Should conventional treatment fail, mechanism-based treatment with opioid antagonists should be considered, and they show advantages over laxatives. It should not be overlooked that many reasons for constipation other than OIBD exist, which should be taken into consideration in the individual patient.

Conclusion and implications

It is the belief of this Nordic Working Group that increased awareness of adverse effects and OIBD, particularly OIC, will lead to better pain treatment in patients on opioid therapy. Subsequently, optimised therapy will improve quality of life and, from a socio-economic perspective, may also reduce costs associated with hospitalisation, sick leave and early retirement in these patients.

Laparoscopic-assisted subtotal colectomy combined with modified Duhamel procedure for mixed constipation

Background and Objectives:

To evaluate the effects of subtotal colectomy combined with the modified Duhamel procedure on mixed constipation.

Methods:

A total of 16 female patients with mixed constipation were enrolled and underwent subtotal colectomy combined with the modified Duhamel procedure under laparoscopy from April 2010 to April 2012. Before surgery, physical examinations such as the gastrointestinal transit test, barium enema, and defecography were performed for all the patients. After surgical treatment, 2-year follow-up was performed using questionnaires to assess the effect of treatment.

Results:

All 16 cases were treated successfully, with a mean operation time of 230 minutes (range, 180–290 minutes). No intraoperative or postoperative complications were found, and no deaths occurred. Constipation and relevant symptoms were relieved, and all patients were satisfied with their quality of life. The gastrointestinal quality-of-life score was significantly increased 6 months postoperatively (mean, 102) compared with preoperatively (mean, 75).

Conclusion:

Subtotal colectomy combined with the modified Duhamel procedure under laparoscopy is effective and safe for the treatment of mixed constipation.

Self-administered acupressure for treating adult psychiatric patients with constipation: a randomized controlled trial

BACKGROUND

Constipation has a high prevalence rate (>30 %) in psychiatric patients with psychotropic drugs. Common pharmacological and non-pharmacological interventions for constipation might have longer-term negative and adverse effects that would outweigh their short-term efficacy in symptom reduction. This randomized controlled trial aims to investigate the effect of self-administered acupressure for the management of constipation, in hospitalized psychiatric patients.

METHODS

Seventy-eight patients were recruited in matched pairs in terms of gender, age and laxative use from five acute psychiatric wards in Hong Kong. Each of these matched pairs of patients was randomly assigned to either a self-administered acupressure (n = 39) or a sham group (n = 39), using computer-generated random numbers. After baseline measurement, the intervention and sham group received the same training in self-administered acupressure and supervised practice once per day for 10 days, except light pressure on non-acupoints was taught to the sham group. The acupoints chosen for acupressure included Zhongwan (RN12), right and left Tianshu (ST25), right and left Quchi (LI11). Participants' symptoms and quality of life regarding constipation were measured at baseline and immediately and 2 weeks after completion of the interventions with constipation assessment scale and patient assessment of constipation quality of life questionnaire, respectively.

RESULTS

After 2 weeks follow-up, participants who had received self-administered acupressure indicated significantly greater improvements in both symptom severity (P = 0.0003) and quality of life (P = 0.0004) when compared with the sham group.

CONCLUSION

The psychiatric patients with constipation who practiced self-administered acupressure for 10 days improved their symptom severity and perceived quality of life immediately and 2 weeks after completion of the intervention in comparison with the sham group.

TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov (Reg. No: NCT02187640).

Chronic constipation in the elderly: a primer for the gastroenterologist

Constipation is a frequently reported bowel symptom in the elderly with considerable impact on quality of life and health expenses. Disease-related morbidity and even mortality have been reported in the affected frail elderly. Although constipation is not a physiologic consequence of normal aging, decreased mobility, medications, underlying diseases, and rectal sensory-motor dysfunction may all contribute to its increased prevalence in older adults. In the elderly there is usually more than one etiologic mechanism, requiring a multifactorial treatment approach. The majority of patients would respond to diet and lifestyle modifications reinforced by bowel training measures. In those not responding to conservative treatment, the approach needs to be tailored addressing all comorbid conditions. In the adult population, the management of constipation continues to evolve as well as the understanding of its complex etiology. However, the constipated elderly have been left behind while gastroenterology consultations for this common conditions are at a rise for the worldwide age increment. Aim of this review is to provide an update on epidemiology, quality of life burden, etiology, diagnosis, current approaches and limitations in the management of constipation in the older ones to ease the gastroenterologists' clinic workload.

Differences in Symptom Severity and Quality of Life in Patients With Obstructive Defecation and Colonic Inertia

BACKGROUND

Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life.

OBJECTIVE

We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms.

DESIGN

This study was a cross-sectional analysis of a prospective database.

SETTING

Patients were enrolled at a single tertiary referral center.

PATIENTS

We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument.

MAIN OUTCOME MEASURES

The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey.

RESULTS

Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p < 0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ≤ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06).

LIMITATIONS

The use of patient self-report instruments resulted in a proportion of patients with incomplete data.

CONCLUSION

Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.

Quality of life and healthcare resource in patients receiving opioids for chronic pain: a review of the place of oxycodone/naloxone

In patients managed with opioids for chronic pain, opioid-induced bowel dysfunction—specifically, opioid-induced constipation (OIC)—is a common side effect, which has a significant impact on quality of life (QoL). The most recent developments for management of OIC are opioid antagonists, including naloxone, a competitive antagonist of peripheral opioid receptors that reverses opioid-induced peripheral gastrointestinal (GI) effects. A prolonged-release formulation of naloxone is available in combination with oxycodone (OXN PR). To review the specific role of OXN PR in the management of chronic pain and OIC and its impact on QoL and healthcare costs, a review of available relevant literature was conducted. Healthcare costs can be up to ten times higher for patients with GI events than for those without. Assessment of QoL in patients with OIC is essential, and multiple tools for its evaluation are available. The Bowel Function Index (BFI), a tool that was specifically developed and validated to measure bowel function in patients with OIC, can be an indication of QoL. In patients with moderate-to-severe chronic pain, randomized trials have demonstrated that OXN PR has equal analgesic efficacy and safety, but results in improved bowel function, compared with prolonged-release oxycodone (Oxy PR) alone. In conclusion, randomized studies using the BFI, as well as real-world clinical practice observations, have demonstrated improved QoL for patients taking OXN PR. This combination should allow more patients to benefit from the analgesic efficacy of opioid therapy and should minimize the side effects of constipation that correspond to improvements in QoL and healthcare offsets.