Management of Chronic Constipation

Introduction to Constipation Management

For a 69-year-old diabetic patient with coronary artery disease (CAD) and post-coronary artery bypass grafting (CABG) experiencing chronic constipation, the American Gastroenterological Association recommends adding polyethylene glycol (PEG) as the next therapeutic option, followed by stimulant laxatives if needed 1, 2
The patient is already on isabgol (psyllium fiber) twice daily, which is an appropriate first-line therapy for mild constipation, as recommended by the American Gastroenterological Association 1
The patient is also on lactulose twice daily, which is a reasonable osmotic laxative but has limited efficacy and significant side effects like bloating and flatulence, according to the American Gastroenterological Association 3, 4

The American Gastroenterological Association strongly recommends adding polyethylene glycol (PEG) with moderate quality evidence, with an initial dose of 17g daily that can be titrated based on response 1, 2, 5
Response to PEG has been shown to be durable over 6 months, as reported by the American Gastroenterological Association 2
If PEG is ineffective or poorly tolerated, the American Gastroenterological Association recommends adding bisacodyl with strong recommendation and moderate quality evidence, starting with 5 mg daily and increasing to a maximum of 10 mg daily 1, 6, 7
The American Gastroenterological Association conditionally recommends considering adding senna 8.6-17.2 mg daily with low quality evidence if constipation persists 8, 9

For patients with CAD and post-CABG, the American Heart Association recommends avoiding straining during defecation as it increases cardiovascular risk, and ensuring adequate hydration unless fluid restriction is required for cardiac reasons 8
The American Geriatrics Society suggests considering magnesium oxide (400-500 mg daily) unless renal function is impaired, for elderly constipated patients 2

The American Gastroenterological Association recommends ruling out impaction if diarrhea accompanies constipation, discontinuing any non-essential constipating medications, setting realistic goals, ensuring adequate hydration and physical activity if appropriate for cardiac status, considering combination therapy, and monitoring for adverse effects 6, 8, 2