In a recent publication in The American Journal of Gastroenterology, a panel of experts from the AGA and the American College of Gastroenterology issued a clinical practice guideline that provided evidence-based practice recommendations for the pharmacologic treatment of CIC in adults. This update is the AGA’s first update on CIC, also called functional constipation, in a decade.
Under the leadership of Lin Chang, MD, AGAF, FACG, and William D. Chey, MD, AGAF, FACG, a multidisciplinary guideline panel conducted systematic reviews of various OTC and prescription pharmacologic agents available for the treatment of CIC, including the following: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose); stimulant laxatives (bisacodyl, sodium picosulfate, senna); secretagogues (lubiprostone, linaclotide, plecanatide); and serotonin type 4 agonist (prucalopride).
The panel prioritized clinical questions and outcomes and employed the Grading of Recommendations Assessment, Development, and Evaluation framework to measure the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations established on the balance between the desirable and undesirable adverse effects, patient values, costs, and health equity considerations.
After completing the systematic review, the panel agreed on 10 recommendations for the pharmacologic management of CIC in adults. Established on existing evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations for using fiber, lactulose, senna, magnesium oxide, and lubiprostone were noted.
The authors wrote, “Most of the medications assessed in this guideline document are readily available; however, some of them are still available only in brand name formulations because generic formulations do not exist. As a result, it is important to consider the out-of-pocket expenses for patients that may depend on prescription coverage with various insurance plans.”
The experts concluded, “This document provides a comprehensive outline of the various OTC and prescription pharmacological agents available for treating CIC. The guidelines are meant to provide a template for an approach to management, and practitioners should engage in shared decision making based on the preference of patients and cost and availability of the medications.”
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