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New Help in Chronic Idiopathic Constipation

Nurse practitioners play a critical part in the management of patients who present with chronic idiopathic constipation (CIC), a prevalent disorder that affects productivity, quality of life, and health care resource utilization. NP roles include evaluation, diagnosis, treatment decisions, and patient education.

Adults with CIC may have inadequate response to or tolerability issues with over-the-counter treatments, but 3 prescription agents are available in the United States for these patients: plecanatide (Trulance, Synergy Pharmaceuticals Inc.), linaclotide (Linzess, Allergan USA and Ironwood Pharmaceuticals, Inc.), and lubiprostone (Amitiza, Sucampo Pharma Americas, LLC, and Takeda Pharmaceuticals America, Inc.).

In a review article in the Journal of the American Association of Nurse Practitioners, the authors searched PubMed for the literature on practice guidelines and trial data for these 3 agents in CIC[1].

Here are some of the key points:

  • A symptom-based GI disorder, CIC is defined by infrequent spontaneous bowel movements (SBMs), lumpy or hard stools, the sensation of incomplete evacuation, and straining during defecation.
  • More than half of 24,000 survey respondents reported that constipation affected their health-related quality of life somewhat, a lot, or a great deal. The most severe symptoms: hard stool and straining. The most bothersome: bloating, hard stool, and straining. About 70% experienced reduced productivity at school or work and reported negative effects on their personal and social life.
  • The Rome IV clinical practice criteria for diagnosis of functional constipation include infrequent SBMs (fewer than 3 per week), lumpy or hard stools, straining during defecation, and the sensation of incomplete evacuation after defecation.
  • Several extraintestinal disorders and medications may be associated with constipation and complicate the diagnosis.
  • Establishing any contribution of these illnesses or medications to a patient’s constipation is an important step in developing a treatment plan.
  • Patients should be evaluated for alarm symptoms (eg, blood in stools, anemia, unintentional weight loss, and family history of colon cancer) and, if present, referred for imaging or endoscopy.
  • Once a diagnosis of CIC has been established, lifestyle and diet changes (eg, probiotics, increased exercise, water intake, and dietary fiber) are recommended as initial treatment steps.
  • A stepwise approach to treatment, starting with a gradual increase in fiber intake, is recommended by the American Gastroenterological Association. If increased dietary fiber is deemed inadequate, over-the-counter osmotic agents, sugar-based osmotic laxatives, and magnesium salts may be added to the regimen.
  • Prescription pharmacotherapies should be considered if a patient is not experiencing a sufficient clinical response, is having tolerability issues, or is dissatisfied with conventional therapies.
  • Plecanatide, approved for CIC in 2017, is the newest of the 3 prescription agents to reach the marketplace. In 2 large randomized, double-blind, placebo-controlled, 12-week, phase 3 studies of adults with CIC, a significantly greater percentage of patients receiving plecanatide experienced a complete spontaneous bowel movement or SBM within 24 hours of the first dose of study drug compared with placebo.
  • Plecanatide treatment also significantly improved secondary symptom end points, including stool consistency and the severity of straining, abdominal bloating, and abdominal discomfort.
  • NPs have a growing number of prescription options for adult patients with CIC at their disposal. Plecanatide, an effective, well-tolerated, and simple dosing medication for patients who require prescription therapy, adds to those options.

Last updated on 9/14/19.

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