Advancing treatment options for chronic idiopathic constipation

ABSTRACT

Introduction: Chronic constipation is a global problem affecting all ages and associated with considerable morbidity and significant financial burden for society. Though formerly defined on the basis of a single symptom, infrequent defecation; constipation is now viewed as a syndrome encompassing several complaints such as difficulty with defecation, a sense of incomplete evacuation, hard stools, abdominal discomfort and bloating.

Areas covered: The expanded concept of constipation has inevitably led to a significant change in outcomes in clinical trials, as well as in patient expectations from new therapeutic interventions. The past decades have also witnessed a proliferation in therapeutic targets for new agents. Foremost among these have been novel prokinetics, a new category, prosecretory agents and innovative approaches such as inhibitors of bile salt transport. In contrast, relatively few effective therapies exist for the management of those anorectal and pelvic floor problems that result in difficult defecation.

Expert opinion: Though constipation is a common and often troublesome disorder, many of those affected can resolve their symptoms with relatively simple measures. For those with more resistant symptoms a number of novel, effective and safe options now exist. Those with defecatory difficulty (anismus, pelvic floor dysfunction) continue to represent a significant management challenge.

KEYWORDS:

• Chronic constipation
• irritable bowel syndrome
• prokinetic
• prucalopride
• velusetrag
• prosecretory agent
• lubiprostone
• linactolide
• plecanatide
• bile salt transporter inhibitor
• elobixibat
• biofeedback
• colectomy
• botulinum toxin

Article highlights.

• Constipation is a syndrome not a single symptom.

• Chronic constipation (CC) can impair quality of life and inflict significant societal costs.

• The evidence base supporting the efficacy of dietary approaches and life style changes in CC is slim.

• While many are not supported by high quality evidence, some ‘traditional’ laxatives can now boast data derived from high quality RCTs.

• New prokinetic agents (prucalopride, velusetrag, mosapride and naronapride) are highly selective for the 5-HT4 receptor and should be free from cardiotoxicity.

• Pro-secretory agents (lubiprostone, linaclotide and plecanatide) and bile salt uptake inhibitors are active luminally, effective in CC and have minimal systemic bioavailability.

• Biofeedback delivered by experienced therapists is effective for difficult defecation; the status of more invasive approaches remains unclear.

This box summarizes key points contained in the article.

Declarations of Interest

EMM Quigley is a consultant to Alimentary Health, Commonwealth, Forest, Ironwood, Movetis, Rhythm, Shire, Valeant and Vibrant. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Disclosure statement

No potential conflict of interest was reported by the authors.