Chronic idiopathic constipation: which treatment works best?

  • Luthra P & al.
  • Lancet Gastroenterol Hepatol
  • 1 Nov 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • In chronic idiopathic constipation (CIC), almost all drugs and dosages were found to be superior to placebo, in terms of either failure to achieve ≥3 complete spontaneous bowel movements (CSBMs) per week or failure to achieve an increase of ≥1 CSBM per week over baseline at 4 weeks and at 8-12 weeks.
  • At 4 weeks, stimulant laxatives bisacodyl and sodium picosulfate were ranked first, and were superior to almost all other drugs, including prucalopride, which was ranked first at 12 weeks.

Why this matters

  • Randomised controlled trials (RCTs) show that laxatives and other newer pharmacological therapies are efficacious for CIC. However, information about their relative efficacy is limited.

Study design

  • A meta-analysis of 33 RCTs assessed the efficacy of osmotic or stimulant laxatives, elobixibat, linaclotide, lubiprostone, mizagliflozin, naronapride, plecanatide, prucalopride, tegaserod, tenapanor or velusetrag in adults with constipation (n=17214).
  • Funding: None disclosed.

Key results

  • Stimulant diphenyl methane laxatives bisacodyl and sodium picosulfate 10 mg once daily at 4 weeks: (relative risk [RR], 0.55; 95% CI, 0.48-0.63; P=.99), and prucalopride 2 mg once daily at 12 weeks (RR, 0.82; 95% CI, 0.78-0.86; P-score=.96) were ranked first based on an endpoint of failure to achieve ≥3 CSBMs per week.
  • Following drugs were ranked first in terms of response to therapy, i.e., failure to achieve an increase of ≥1 CSBMs per week from baseline:
    • Diphenyl methane laxatives 10 mg once daily at 4 weeks (RR, 0.44, 95% CI, 0.37-0.54; P-score=.99).
    • Prucalopride 4 mg once daily at 12 weeks (RR, 0.74, 95% CI, 0.66-0.83; P=.79), although linaclotide 290 μg once daily (P-score=.76) and prucalopride 2 mg once daily (P-score=.71) had similar efficacy.
  • Plecanatide ranked first and bisacodyl ranked last in terms of adverse events (P-scores=.95 and P-scores=.08, respectively).

Limitations

  • Head-to-head trials of 1 active drug vs another lacking; therefore, estimates of relative efficacy are based on indirect comparisons.