3/14/24, 4:32 PM Summarizing the 2023 Chronic Idiopathic Constipation Guideline ​

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PUBLISHED DECEMBER 19, 2023

Summarizing the 2023 Chronic Idiopathic Constipation

Guideline ​

Ellie Ouellette, PharmD Candidate 2024

Western New England University College of Pharmacy & Health Sciences
Springfield, Massachusetts

Autumn Kelley, PharmD Candidate 2025

Western New England University College of Pharmacy & Health Sciences
Springfield, Massachusetts

Marissa L. Ostroff, PharmD, BCPS, BCGP

Clinical Associate Professor
Department of Pharmacy Practice
Western New England University College of Pharmacy & Health Sciences
Springfield, Massachusetts

Jared L. Ostroff, PharmD, MBA, BCACP, BCGP

Program Manager, Ambulatory Care
Baystate Health
Springfield, Massachusetts

US Pharm. 2023;48(12):17-22.

ABSTRACT: Chronic idiopathic constipation (CIC) is a common, yet significant,

disorder that can lead to impairment in a patient’s quality of life. Treatment for
CIC includes dietary interventions and OTC and prescrip-tion agents to reduce
worsening of the disease and to treat symptoms. Some patients may utilize OTC

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monotherapy, seek prescription options, or try a combination of the two before

they see any improvement in symptoms. Pharmacists can help patients by
providing consultation on the recommended use of each available agent.

Functional constipation describes a type of chronic constipation that does not

arise from an identifiable cause or illness. Chronic idiopathic constipation (CIC)
is a form of functional constipation wherein the constipation occurs
spontaneously.1 CIC is a common disorder that leads to physician visits and
impairment in quality of life. The diagnosis for CIC should be distinct from other
gastrointestinal disorders, such as irritable bowel syndrome (IBS), opioid-
induced constipation, or constipation due to dietary changes or changes in
physical activity.

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Diagnosis of CIC is made based on a history and physical exam of the patient.2
The Rome IV criteria provide indications for diagnosing patients with functional
gastrointestinal disorders. Patients must have symptoms present for at least 3
months with an onset at least 6 months prior to diagnosis. The Rome IV criteria
define a diagnosis of functional constipation with at least two or more of the
following diagnostic criteria: straining, lumpy or hard stools, sensation of
incomplete evacuation, sensation of anorectal obstruction/blockage, manual
maneuvers to facilitate defecations, fewer than three bowel movements per
week, loose stools that are rarely present without the use of laxatives, and
insufficient criteria for IBS.3 Diagnosis can be confirmed through imaging
studies such as colonoscopy.2

Risk factors for CIC include increased age, female gender, low-caloric diets,
sedentary lifestyle, and low fiber and water intake.4 The American
Gastroenterological Association and the American College of Gastroenterology
(AGA/ACG) 2023 guideline on the pharmacologic management of chronic
idiopathic constipation aim to provide guidance to healthcare providers on
appropriate pharmacologic management in adult patients. This article will focus
on the evidence-based recommendations for the management of CIC in adults
and the information in the 2023 AGA/ACG guideline.5

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Overview of the Guideline Updates

The 2023 American Gastroenterological Association–American College of
Gastroenterology Clinical Practice Guideline: Pharmacological Management of
Chronic Idiopathic Constipation provides official recommendations on the
treatment options available for CIC, a type of functional constipation. The
guideline was generated based on systematic reviews of the various OTC and
prescription options, and recommendations were presented after a literature
search. The recommendations were developed using the Grading of
Recommendations Assessment, Development, and Evaluation (GRADE)
approach. Ten recommendations were made, and these are classified based on
the strength of the recommendation and certainty of evidence.5 The
medications that hold strong recommendations include polyethylene glycol,
bisacodyl, sodium picosulfate, lubiprostone, linaclotide, prucalopride, and
plecanatide. The medications that hold conditional recommendations include
fiber, magnesium oxide, lactulose, and senna.

The 2023 AGA/ACG guideline on CIC is an update to the 2013 American

Gastroenterological Association Medical Position Statement on Constipation.6
The 2023 AGA/ACG guideline provides the following updated information:

• Recommendations are given for CIC rather than recommendations for

generalized chronic constipation.

• No recommendations are given on physical exams before starting drug

therapy, anorectal testing if drug therapy is not adequate, or pelvic floor
retaining for defecatory disorders. Previously, these held strong
recommendations in the Medical Position Statement.

• Lubiprostone and linaclotide now hold strong recommendations to be used as

a replacement or as an adjunct to OTC agents. In the 2013 Medical Position
Statement, lubiprostone and linaclotide were weak recommendations to be
used in patients with normal-transit or slow-transit constipation.

• At the time of the 2013 Medical Position Statement, prucalopride and

plecanatide were not approved in the United States. Therefore, there were no
recommendations for prucalopride or plecanatide until the 2023 AGA/ACG
guideline, which gave them strong recommendations, after they gained approval
for use in the United States.
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Recommendations
Patients should first be evaluated for alarm features, such as gastrointestinal
bleed or weight loss, and seek appropriate diagnostic testing. For patients with
CIC who have no alarm features, fiber is recommended first line, particularly for
patients with low dietary fiber intake. If that provides an unsatisfactory
response, osmotic laxatives are recommended alone or in combination with
fiber. Patients who do not have relief with fiber or osmotic laxatives may benefit
from the addition of stimulant laxatives used as needed or as short-term
therapy in addition to fiber and osmotic laxatives. Secretagogues and 5-
hydroxytryptamine receptor 4 (5-HT4) agonist options for patients who do not
respond to OTC agents may be used as a replacement or as an adjunct to OTC
agents. FIGURE 1 provides guidance for the recommendations for CIC.5,7

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OTC and Prescription Options

TABLE 1 outlines the OTC options for the management of CIC.5,8-16 TABLE 2
outlines the prescription options for the management of CIC.5,16-21

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Evidence for Prescription Options

Compared with the 2013 American Gastroenterological Association Medical
Position Statement on Constipation, the prescription options lubiprostone,
linaclotide, plecanatide, and prucalopride have been updated to provide strong
recommendations with a moderate certainty of evidence. The 2023 AGA/ACG
guideline mentions various articles to support the current recommendations.5
TABLE 3 discusses one of the randomized, controlled trials mentioned in the
guideline for each medication to support the current strong recommendations
based on statistically significant end points.22-25

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The Role of the Pharmacist

Pharmacists play a role in counseling patients on the different treatment
options available for CIC. When patients are seeking recommendations,
pharmacists should first evaluate a patient’s symptoms and refer as appropriate
for alarm features. After identifying patients who do not require referral,
community pharmacists can assist patients in locating OTC options and
recommending an appropriate agent. Patients may try multiple treatments or a
combination of treatments before settling on a satisfactory option.

A limitation of the available prescription options may be cost. The

secretagogues, including Linzess (linaclotide) and Trulance (plecanatide), as
well as the 5-HT4 agonist Motegrity (prucalopride), are only available as brand-
name products. As a result, these options have a higher cost compared with the
OTC options. However, the secretagogue Amitizia (lubiprostone) is now
available as a generic medication and may be more cost-effective. Pharmacists
can counsel patients on the use and effectiveness of both OTC and prescription
options and further assist them in checking insurance coverage to address
financial and insurance barriers. In addition, information on adverse events is an
important point to counsel patients on when helping choose a regimen for CIC
to individualize treatment, enhance long-term outcomes, and improve patient
satisfaction.

Conclusion
The 2023 AGA/ACG guideline on the pharmacologic management of CIC aims
to provide guidance to healthcare providers on appropriate pharmacologic
management in adult patients. The treatment for CIC includes OTC and
prescription options. Patients may start with a trial of fiber supplementation
with or without osmotic laxatives. Stimulant laxatives may be used as needed or
as short-term therapy in combination with fiber or osmotic laxatives.
Prescription options are reserved if OTC agents do not provide satisfactory
relief either as monotherapy or as an adjunct to OTC agents. Pharmacists may
assist patients by providing consultation on the available options, including the
indication, benefit, and potential side effects, and help to evaluate the cost of
the various recommendations.

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The content contained in this article is for informational purposes only. The
content is not intended to be a substitute for professional advice. Reliance on any
information provided in this article is solely at your own risk.

To comment on this article, contact rdavidson@uspharmacist.com.

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