Management of Chronic Constipation

Guideline-Recommended Treatment Algorithm

• The American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) recommend polyethylene glycol (PEG) as a first-line therapy, starting at 17g daily, with a strong recommendation and moderate certainty evidence 1, 2, 3
• The AGA and ACG recommend fiber supplementation as a first-line therapy with a conditional recommendation 1, 2, 3
• The AGA and ACG recommend bisacodyl or sodium picosulfate for short-term use (≤4 weeks) or rescue therapy as a second-line therapy with a strong recommendation 1, 4
• The AGA and ACG recommend linaclotide and plecanatide (secretagogues) as a second-line therapy with a strong recommendation 1, 2, 3
• The AGA and ACG recommend prucalopride (5-HT4 agonist) as a second-line therapy with a strong recommendation 1, 2, 3

Rationale for Non-Standard Therapy

• The absence of elobixibat from the 2023 AGA-ACG guidelines reflects its limited availability and evidence base in Western populations, despite being approved in Japan 1, 2, 3
• The AGA and ACG guidelines do not recommend elobixibat as a standard therapy due to its limited evidence base and availability 1, 2, 3

First‑Line Therapy Recommendation for Chronic Constipation

Recommendation Strength

Preferred Initial Agent

Situations Where Lactulose May Be Considered

Distinction Among Osmotic Laxatives