<h2>Practice points</h2><ul><li>Psyllium is a bulking agent commonly used to treat constipation and regulate stool consistency. Ensure it is taken with plenty of water</li><li>Senna, a stimulant laxative, may be effective for the short-term management of constipation</li><li>Probiotics may decrease transit time in constipated patients. Supplements are best taken with meals to enhance bacterial survival</li></ul><h2>Description</h2><ul><li>Clinically defined as less than 3 bowel movements per week1</li><li>Symptoms include stool inconsistency, feelings of incomplete emptying, straining, hard and lumpy stools and urge for defaecation1</li><li>Prevalence in the general adult population ranges from 2%–26.9%2 <ul><li>More prevalent in females and the elderly2</li></ul> </li><li>Aetiology may involve various overlapping factors including: <ul><li>Extrinsic: low fibre intake, inadequate hydration, reduced mobility, some medications3</li><li>Intrinsic: pelvic floor dysfunction, slow colon transit time3 </li></ul> </li></ul>

<h2>Management principles</h2><ul><li>Consult a GP if onset is acute or recent, associated with rectal blood loss, melaena or mucus, weight loss, fever, rectal pain, anorexia, nausea, vomiting or a family history of inflammatory bowel disease or colorectal cancer</li><li>If no clear underlying cause, recommend nondrug treatments such as increasing dietary fibre. If not effective consider treatment with bulking laxatives then osmotic laxatives</li></ul>

Management

<h2>Primary recommendations</h2><h2>PSYLLIUM HUSK (Plantago ovata)</h2>Mechanism of action<ul><li>Decreases intra-colonic pressure and accelerates transit time8</li><li>Increases stool water content, stool weight and total output9</li></ul>Research<ul><li>Randomised controlled trials demonstrate superior efficacy of psyllium over placebo for relieving constipation and improving stool consistency3</li><li> A systematic review reported moderate evidence to support psyllium in chronic constipation with improvements in colonic transit time and stool frequency relative to placebo10</li></ul>Dosage<ul><li>Typically found in powder or seed form</li><li>Dosage range: Blond psyllium seed: 12–40 g whole seeds in divided doses/d11</li></ul>Adverse effects<ul><li>May initially cause mild flatulence, bloating and abdominal discomfort which reduce with long-term use. Ensure adequate water intake as there have been rare cases of abdominal obstruction11</li></ul>Key interactions<ul><li> Concomitant use with oral drugs may decrease their absorption12</li><li>May have an additive effect with hypoglycaemic drugs12</li></ul><h2>SENNA (Cassia senna)</h2>Mechanism of action<ul><li>Acts on the myenteric plexus of the colon to stimulate peristaltic contractions which decreases gut transit time3</li><li>Decreases water and salt absorption from the colon3</li></ul>Research<ul><li>Taking senna orally may be effective for the short-term treatment of constipation, although the available clinical research is mixed. Some studies have shown that, compared to other methods (e.g. polyethylene glycol; PEG), senna may be more effective, with fewer side effects13</li><li>There is some evidence that senna may be beneficial as a laxative for patients on opioid analgesics14</li><li>Combination psyllium and senna may be more effective for relieving constipation when compared to other methods (PEG, lactulose), with few adverse effects10,14</li></ul>Dosage<ul><li>Typically found in tablet form or granules</li><li>Commonly standardised to contain sennosides A and B14</li><li>Senna is included in a number of non-prescription laxatives (e.g. Senokot)14</li><li>Dosage range should be individualised as there is variability in response</li><li>Adult dose equivalent to senna pods 500 mg–2 g/d, dried leaf 1.5–6 g/d15</li></ul>Adverse effects<ul><li>Generally well tolerated for short-term use (&lt; 7–10 days) in constipation14</li><li> May cause abdominal pain, cramping, flatulence, nausea, bloating, diarrhoea, and vomiting14</li><li>Use cautiously in patients who have had a GI obstruction or gallstones and in patients with haemorrhoids, stomach ulcers and inflammatory bowel conditions14</li><li>Avoid long-term use (&gt;10 days). Chronic use may cause ‘lazy-bowel syndrome’14</li><li>Insufficient evidence for use in pregnancy. Trials have not found adverse effects when used in lactation14</li></ul>Key interactions<ul><li>Use cautiously in patients taking digoxin, diuretics and other laxatives14</li></ul> For more information on key interactions visit: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a>

Primary

<h2>Secondary recommendations</h2><h2>PROBIOTICS</h2><ul><li>Gut microbiota are significantly different in healthy individuals than those with chronic constipation.16 Probiotics lower colon pH which may enhance peristalsis and decrease colonic transit time16 </li><li>2 meta-analyses of randomised trials found supplementation decreased transit time in constipated adults with greatest improvements using Bifidobacterium lactis (strains HN019 and DN-173) 17,18 </li><li> In individual RCTs, a number of strains have been found to improve constipation and stool quality including Lactobacillus casei strain Shirota19, B. lactis DN-1730101820 and a multistrain Lactobacillus and Bifidobacterium combination VSL#321</li></ul>Dosage information<ul><li>Typically found in tablet/capsule or powder form</li><li>Strength of probiotic preparations is quantified by number of colony forming units (CFUs)/g: therapeutic effects: between 109 (1 billion)–1011 (150 billion) CFUs/d11</li></ul><h2>FLAXSEED (Linum usitatissimum)</h2><ul><li>Constipated mice treated with flaxseed meal demonstrated increased stool frequency and weight22</li><li>A small study found flaxseed supplementation may be associated with increased faecal weight similar to that found with psyllium23</li></ul>

Secondary

<h2>Diet and lifestyle recommendations</h2><ul><li>Increased dietary fibre is associated with an increased number of bowel movements5</li><li>Consumption of prunes may improve stool frequency and consistency6</li><li>Exercise: There is a positive association between the amount of vigorous physical exercise and the number of bowel movements5</li><li> Drink more water: Insufficient fluid intake may be linked to constipation7</li><li> Massage and acupuncture may help relieve constipation2</li></ul>

Diet & lifestyle

<h2>References</h2>1. Rome Foundation, “Guidelines—Rome III diagnostic criteria for functional gastrointestinal disorders,” J Gastrointest Liver Dis 2006;15(3):307-12 2. Wang X, Yin J. Complementary and alternative therapies for chronic constipation. Evid Based Complement Altern Med. 2015; 2015:396396. 3. Leung L, Riutta T, Kotecha J, et al. Chronic constipation: an evidence-based review. J Am Board Fam Med 2011;24(4):436-51. 4. Selby W, Corte C. Managing Constipation in adults. Aust Prescriber 2010;33:116-9 5. Sanjoaquin MA, Appleby PN, Spencer EA, Key TJ. Nutrition and lifestyle in relation to bowel movement frequency: a cross-sectional study of 20 630 men and women in EPIC–Oxford. Pub health Nutr 2004;7(1):77-83 6. Attaluri A, Donahoe R, Valestin J, et al. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther 2011; 33(7):822-8. 7. Robson KM, Kiely DK, Lembo T. Development of constipation in nursing home residents. Dis Colon Rectum 2000; 43(7):940-3. 8. Hammerle C, Surawicz C. Updates on treatment of irritable bowel syndrome. World J Gastroenterol 2008; 14(17):2639-49. 9. Paré P, Fedorak RN. Systematic review of stimulant and nonstimulant laxatives for the treatment of functional constipation. Can J Gastroenterol Hepatol 2014; 28(10): 549-57. 10. Ramkumar D, Rao SS. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol 2005; 100(4):936-71. 11. Braun L, Cohen M. Herbs &amp; Natural Supplements. 3rd ed. Chatswood: Elsevier; 2010. 12. Blackmores Institute Complementary Medicines Interaction Guide; 2016. 13. Natural Medicines 2016. Senna professional monograph 14. Ulbricht C, Conquer J, Costa D, et al. An Evidence-based systematic review of senna (Cassia senna) by the Natural Standard Research Collaboration. J Diet Suppl. 2011; 8(2):189-238. 15. Mills S, Bone K. The Essential Guide to Herbal Safety. Elsevier 2005 16. Chmielewska A, Szajewska H. Systematic review of randomised controlled trials: probiotics for functional constipation. World J Gastroenterol 2010; 16(1): 69-75. 17. Miller LE, Ouwehand AC. Probiotic supplementation decreases intestinal transit time: meta-analysis of randomized controlled trials. World J Gastroenterol 2013;19(29):4718-25. 18. Dimidi E, Christodoulides S, Fragkos KC, et al. The effect of probiotics on functional constipation in adults: a systematic review and metaanalysis of randomized controlled trials. Am J Clin Nutr. 2014; 100(4):1075-84. 19. Sakai T, Makino H, Ishikawa E, et al. Fermented milk containing Lactobacillus casei strain Shirota reduces incidence of hard or lumpy stools in healthy population. Int J Food Sci Nutr 2011; 62(4):423-30.20. Yang YX, He M, Hu G, et al. Effect of a fermented milk containing Bifi dobacterium lactis DN-173010 on Chinese constipated women. World J Gastroenterol 2008; 14(40):6237-321. 21. Kim SE, Choi SC, Park KS, et al. Change of fecal flora and effectiveness of the short-term VSL#3 probiotic treatment in patients with functional constipation. J Neurogastroenterol Motil 2015; 21(1):111-20. 22. Xu J, Zhou X, Chen C, et al. Laxative effects of partially defatted flaxseed meal on normal and experimental constipated mice. BMC Complement Altern Med 2012; 12:14. 23. Dahl WJ, Lockert EA, Cammer AL, et al. Effects of fl ax fiber on laxation and glycemic response in healthy volunteers. J Med Food 2005; 8(4):508-11.

Constipation

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