January 2023 ~ Resource #390108

Management of Constipation
This FAQ reviews the management of constipation in nonpregnant adults and children. The charts following the FAQ outline OTC meds (dosing,
onset, adverse effects, etc) for children and adults, and then prescription meds (indications, cost, prescribing considerations) for adults. For specific
information on meds useful for constipation-predominant IBS (IBS-C), see our chart, Irritable Bowel Syndrome (IBS) Drug Comparison.
Question Answer/Pertinent Information
What are the symptoms of  Normal bowel movements vary between individuals. Generally, symptoms of constipation can include:1-3
constipation? o difficulty or pain with bowel movements.
o incomplete passage of stool.
o reduced frequency of bowel movements (e.g., less than three times per week).
o feeling bloated or uncomfortable.
o abdominal pain.
 Functional constipation is constipation without an organic cause.
o More than 95% of children over the age of one year with constipation have functional constipation.4
o Commonly seen in preschool-aged children, especially around the time of toilet training.4
o Contributing factors can include withholding behaviors, environmental conditions (e.g., unfamiliar restrooms),
stress (e.g., starting school), diet, coping skills, and social supports.4
 A small percentage of infants and children may have a more serious illness such as gastrointestinal diseases
(e.g., Hirschsprung’s disease), metabolic causes (e.g., electrolyte abnormalities), diabetes mellitus or insipidus,
cystic fibrosis, or neurological diseases.5
When should adult  Recommend colon cancer screening for patients with alarm signs and symptoms, such as:1,6,7
patients with constipation o anemia.
be screened for colon o blood in stool.
cancer? o change in bowel habits after 50 years of age.
o family history of colon cancer.
o refractory constipation.
o unexplained weight loss of 5 kg (~10 pounds) or more in past three to six months.
Which medications can  Evaluate for medications that can cause constipation, including:1,6-9 antacids with aluminum or calcium,
cause constipation? anticholinergics (e.g., tricyclic antidepressants [TCAs], antihistamines, antipsychotics), antidiarrheals, beta-
blockers, calcium channel blockers, calcium supplements, non-potassium sparing diuretics, nonsteroidal anti-
inflammatory drugs (NSAIDs), oral iron supplements, opioids, 5-HT3 receptor antagonists (e.g., ondansetron).
 Consider reducing the dose or switching to another medication if risks of the med outweigh its benefits.

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Question Answer/Pertinent Information

Which disease states or  Many conditions can contribute to constipation, including: anxiety, autonomic neuropathy, chronic kidney disease
metabolic abnormalities (CKD), colorectal cancer, dementia, depression, diabetes, diverticulitis, hemorrhoids, hypercalcemia,
that can cause hypokalemia, hypothyroidism, irritable bowel syndrome (IBS), multiple sclerosis (MS), Parkinson’s disease,
constipation? rectal prolapse, stroke, systemic sclerosis (scleroderma).1,6-9
 Patients should be assessed and treated as indicated.

What lifestyle  Increase dietary fiber to a total of 20 to 25 g per day (adults) via fiber-rich foods such as whole grains, wheat bran,
recommendations are or vegetables. Start slowly and titrate up over one to two weeks to improve tolerance.7,10,11
appropriate for patients o The role of fiber supplementation in the treatment of constipation in children is limited and conflicting.
with constipation? (Note Infants and children who are consuming solid foods should consume a well-balanced diet including foods with
that it may take days to fiber (e.g., cereals, apricots, prunes, peaches, pears, plums, beans, and peas). For older children, raw fruits and
weeks for results.) other foods such as figs, dates, raisins, celery, cauliflower, broccoli, and cabbage are good sources of fiber.12,13
o A general rule for the daily amount of fiber for all children is 5 grams plus the child’s age, although some
experts recommend that for children who have had constipation in the past, the amount should be increased to
10 grams plus the child’s age. Others recommend 0.5 g/kg/day (35 g/day maximum).12,13
 Ensure adequate fluid intake. Encourage a target fluid intake of 1.5 to 2 L per day (adults). In general, for
children, two ounces (60 mL) of nondairy fluids are recommended for each gram of fiber intake.
o Water is the best choice for hydration.
o Fruit juices, such as apple, pear, or prune juice, may be helpful due to sorbitol content. Each day, young
children can have up to ½ cup (120 mL) of fruit juice or up to one cup (240 mL) for older children.12,13
 Do not give brown sugar or corn syrup to treat constipation.
 Avoid excessive amounts of constipating foods such as dairy products. However, foods should not be removed
from a child’s diet (cow’s milk, iron-fortified formula, etc) without talking to the child’s prescriber.
 Consider increased physical activity, if possible.11
 Counsel on toileting habits such as not “holding it,” not rushing on the toilet, sitting on the toilet about 30 minutes
after breakfast, and sitting on the toilet in a position where the knees are at least as high as the hips.1,10
o Children should sit on the toilet for 5 to 10 minutes at the same time each day. Do this about 20 to 30 minutes
after a meal. Give rewards for sitting, not for having a bowel movement.12,13
o It can be helpful to give children a stool to put their feet on while sitting on the toilet. This helps them push.

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Question Answer/Pertinent Information

What OTC meds can be  Recommend OTC meds if necessary, titrating dose to soft stools:
recommended for patients 1. Consider a two- to four-week trial of a laxative the patient previously found to be effective.1
with constipation? 2. Consider a two- to four-week trial of fiber (e.g., psyllium, methylcellulose) or an osmotic laxative, such as
PEG 3350 (preferred because of good evidence and good tolerability), sorbitol, lactulose (Rx [US]), or
magnesium hydroxide.1,17
3. Consider switching to or adding a stimulant laxative (e.g., bisacodyl, senna) if additional effects are needed.7,17
4. Consider a stimulant laxative as a rescue method with other laxatives if the patient has not had a bowel
movement for two days or longer.6
 See below for a chart of OTC med options, including onset and adverse effects.

What are some  Treatment of constipation should be individualized based on patient characteristics and special considerations.
considerations to help For example:
individualize OTC med o Avoid bulk laxatives in patients who are immobile, on fluid restriction, or have difficulty swallowing.10
management of o Avoid oral laxatives in patients with an intestinal obstruction.10,14
constipation? o Use enemas or suppositories for patients with fecal impaction.10,14
o Use a bowel regimen with an osmotic laxative (e.g., polyethylene glycol [PEG] 3350) or a stimulant laxative
(e.g., bisacodyl) for patients who take opioids (initiate bowel regimen at start of opioid therapy).10
o Adding a stool softener (e.g., docusate) to a stimulant laxative is widely recommended, although small studies
show that adding docusate is not beneficial.15
o Use an osmotic laxative (e.g., PEG 3350) for patients who should avoid straining such as after surgery or a
heart attack.16
o Avoid osmotic saline laxatives (e.g., magnesium-containing, oral sodium phosphate) in patients at risk for
electrolyte abnormalities (e.g., concomitant diuretics, elderly, heart or kidney failure).1,10
o Do not give mineral oil to infants to treat constipation.12

What is recommended if  If lifestyle changes and OTC options are not effective after a trial period, consider diagnostic tests (e.g., anorectal
lifestyle changes and manometry, rectal balloon expulsion) to determine cause of constipation.17
OTC options are not  For adults, consider therapies targeted to specific diagnoses, including prescription medications, as indicated. See
effective for constipation? chart below for prescription options for specific constipation indications.

--Continue to the next section for OTC Management of Constipation--

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OTC Management of Constipation: Pharmacological treatment for constipation can be divided into disimpaction and maintenance treatment.
Disimpaction, if necessary, can be performed manually (physical removal of stool) or pharmacologically. In children, disimpaction is most often performed
with medication to avoid traumatizing the child. The below chart summarizes the (mostly) OTC pharmacologic agents commonly used in the treatment
(disimpaction and maintenance) of children and adults with constipation. Dosing information in the chart below is based on pediatric guidelines and other
references, as indicated.1,4,18 Alternate dosing may also be available from other sources. Doses may differ from product labeling. Of note, there are only a
limited number of trials evaluating the use of laxatives in infants and children.
Druga,c Dose (per guidelines unless Side effects12,18 Onset7,18 Comments
otherwise indicated)12,13,b
Bisacodyl RECTAL Nausea, vomiting, 6 to 10 hours  Considered as an alternative or second-line
(Dulcolax,  Younger than 2 years: 5 mg/day PR abdominal cramps (PO); agent by US pediatric guideline.12
others) (Canada). 15 to 60 minutes  Stimulant laxatives (bisacodyl, senna) may be
 2 to 10 years: 5 mg PR once daily (PR) required long-term for some patients (e.g.,
(US). (Canada: 5 to 10 mg/day for ages patients taking a chronic constipating med).
2 to 11 years). Evidence does not support laxative
 11 years or older: 5 to 10 mg PR once dependence or harm to the colon with long-
daily (US). term use in adults.
 Adults: 10 mg PR once daily, OR  Should not be used in newborns.18
single dose up to 3 times per week.18  Enteric-coated tablets should not be crushed
ORAL or chewed due to gastric irritation.18
 3 to 10 years: 5 mg/day PO (US).  Do not take oral bisacodyl within one hour
(Canada: 5 to 20 mg [no frequency after milk or antacids.18
specified] for ages 3 to 12 years).
 11 years or older: 5 to 10 mg/day PO
(US).18
 Adults: 5 to 15 mg PO once daily, OR
single dose up to 3 times per week.
Docusate ORAL (Canada): 5 mg/kg/day PO given Oral liquid is 1 to 3 days  Oral docusate not included in the US pediatric
sodium as a single dose or in up to three divided bitter.19 guideline.12
(Colace, doses.  Not recommended to treat or prevent
others) RECTAL (US): constipation. There is no good evidence that
 <6 years: 60 mL. docusate is effective for constipation.13
 >6 years: 120 mL.  Give oral liquid with 6 to 8 ounces of milk,
 Adults: 50 to 300 mg/day PO in single fruit juice, or formula to mask taste of liquid
or divided doses.18 and prevent throat irritation.18

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Druga,c Dose (per guidelines unless Side effects12,18 Onset7,18 Comments

otherwise indicated)12,13,b
Glycerin  Infants to up to 6 years: 1/2 infant Can irritate the 15 to 60 minutes8  Not included in the US pediatric guideline.12
suppository PR once daily prn. 20 anus or rectal  Insert suppository high into the rectum and
5
 2 to 5 years: 1 pediatric suppository PR mucosa. retain for 15 minutes.18
18
once daily prn.
 6 years to adult: 1 adult suppository
PR once daily prn.18

Lactulose Pediatric: Flatulence, 1 to 2 days  Preferred agent if PEG solutions not

(10 g/15 mL)  1 to 2 g/kg PO once or twice daily (US). abdominal cramps available.12
 1 mL/kg/day to 3 mL/kg/day (of 70%  Interpret units carefully as lactulose can be
solution) PO divided twice daily (max dosed in volume (mL) or weight (g).
60 mL/day) (Canada).  Can mix with fruit juice, milk, or water.18
Adults: 15 to 30 mL PO once daily, as
needed.18

Magnesium  2 to 5 years: 1 to 3 mL/kg/day as a Hypermagnesemia 0.5 to 3 hours  Not included in the pediatric US or Canadian
citrate single or divided dose.18 leading to muscle guidelines.12,13
 6 to 11 years: 100 to 150 mL (OR 90 weakness,  Use with caution in kidney insufficiency.18
to 210 mL) given as a single dose or hypotension, or  Up to 30% of the dose may be absorbed.18
divided doses.18 respiratory (See hypermagnesemia caution under Side
 12 years to adult: 150 to 300 mL given depression Effects.)
as a single dose or divided doses.18

Magnesium Doses are based on 400 mg/5 mL Hypermagnesemia 0.5 to 6 hours  Considered as an alternative or second-line
hydroxide (80 mg/mL) liquid: leading to muscle agent by the US pediatric guideline.12
(Milk of  2 to 5 years: 0.4 to 1.2 g PO once daily weakness,  Use caution as products of different strengths
Magnesia, or in divided doses (US). hypotension, or are available (400 mg/5 mL,
others)  6 to 11 years: 1.2 to 2.4 g PO once respiratory 800 mg/5 mL).18
daily or in divided doses (US). depression  Infants are susceptible to magnesium
OR poisoning which can result in
 Less than 12 years: 1 to 3 mL/kg/day hypermagnesemia, hypophosphatemia, and
(Canada). hypocalcemia.12
OR
Continued…

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Druga,c Dose (per guidelines unless Side effects12,18 Onset7,18 Comments

otherwise indicated)12,13,b
Magnesium  Less than 2 years: 0.5 mL/kg/day x  Use with caution on kidney insufficiency.13
hydroxide, one dose, with prescriber supervision.18  Usual administration time is bedtime.18
continued  2 to 5 years: 5 to 15 mL PO once daily  Chew tablets thoroughly and administer each
or in divided doses.18 dose with eight ounces of liquid.18
 6 to 11 years: 15 to 30 mL PO in a
single daily dose or in divided doses.18
 12 years to adult: 15 to 60 mL PO
once daily or in divided doses.18

Mineral oil  1 to 18 years: 1 to 3 mL/kg/day PO in Cramps, lipoid 6 to 8 hours (PO)  Considered as an alternative or second-line
one daily dose or in divided doses (max pneumonitis, if 2 to 15 min (PR) agent by the US guideline.12
Available as: 90 mL/day) (US and Canada). aspirated  Canadian pediatric guidelines suggest an oral
Oral liquid  2 to 11 years: 30 to 60 mL PR once dose of 15 mL/year of age to
(plain mineral daily (US). 30 mL/year of age (up to 240 mL/day) as the
oil) OR Oral
 12 to 18 years: 60 to 150 mL PR once dose for disimpaction.13
emulsion (e.g.,
daily (US).  Do not use in children less than 1 year due to
Kondremul;
OR risk of aspiration pneumonitis. 12,13
2.5 mL
 12 years to adult: 30 to 90 mL PO as  Do not administer at bedtime to minimize the
mineral oil/
needed.18 risk of aspiration.18
5 mL)
*See Comments for disimpaction dose.
Polyethylene Pediatric: Flatulence, 48 hours  Preferred agent for disimpaction and
glycol (PEG)  Disimpaction: 1 to 1.5 g/kg/day PO abdominal pain maintenance therapy.12
3350 (Miralax (up to 6 days [US] or 3 days [Canada]).  Doses should be rounded to a measurable
[US],  Maintenance: 0.2 to 0.8 g/kg/day PO dose: 1 capful (17 g) = 1 heaping tablespoon.
RestoraLAX once daily (US) or 0.4 to 1 g/kg/day PO Therefore 1 heaping teaspoonful: ~5.5 g and
[Canada], once daily (Canada). 2 heaping teaspoonfuls: ~11 g.
others) (Some experts suggest starting at a dose Alternatively:
of 1 g/kg/day and decrease as o ¼ capful: ~4 g
necessary.13) o ½ capful: ~8.5 g
Adults: 17 g PO once daily.18 o ¾ capful: ~13 g
 Rare reports of neuropsychiatric adverse
effects in children such as tics, tremors,
obsessive-compulsive behavior, etc.21

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Druga,c Dose (per guidelines unless Side effects12,18 Onset7,18 Comments

otherwise indicated)12,13,b
Psyllium  Various products and dosage Abdominal 12 to 72 hours  Not included in pediatric US or Canadian
(Metamucil, formulations are available. Follow cramps, esophageal guidelines.12,13
Fiberall, labeling for dose. or bowel  Take at least two hours before or two hours
others) obstruction after other oral medications.
General dosing:  Dose must be mixed in full glass of water or
 6 to 11 years: 1.2 g of soluble juice. It is advised for patients to drink
fiber/dose PO 1 to 3 times/day.18 another glass of water following the dose.18
 12 years to adult: 2.4 g of soluble
fiber/dose PO 1 to 3 times/day.18

Senna (as Doses are based on Nausea, vomiting, 6 to 24 hours  Considered as an alternative or second-line
sennosides) 8.8 mg sennosides/5 mL liquid: abdominal agent by the US pediatric guideline.12
(Senokot, cramping,  Stimulant laxatives (bisacodyl, senna) may be
others, various  2 to 6 years: 2.5 to 5 mg PO once or idiosyncratic required long-term for some patients (e.g.,
formulations) twice daily (US guidelines) OR hepatitis patients taking a chronic constipating med).
2.5 to 7.5 mL/day PO (Canada). Evidence does not support laxative
 6 to 12 years: 7.5 to 10 mg/day PO dependence or harm to the colon with long-
(US) OR term use in adults.
5 to 15 mL/day PO (Canada).  Interpret units carefully as senna can be dosed
OR in volume (mL) or weight (mg).
 Less than 2 years: 2.2 to 4.4 mg PO at  Syrup may be given with juice or milk or
bedtime.20 mixed with ice cream to mask taste.18
 2 to 5 years: 4.4 to 6.6 mg PO at
bedtime.5,18
 6 to 11 years: 8.8 to 13.2 mg PO at
bedtime.18
 12 years to adult: 17.6 to 26.4 mg PO
at bedtime.18

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Druga,c Dose (per guidelines unless Side effects12,18 Onset7,18 Comments

otherwise indicated)12,13,b
Sodium  Not for <2 years (Canada). Risk of trauma to 2 to 5 minutes18  Most side effects occur in children with
phosphate  >2 years: 6 mL/kg (up to 135 mL) PR rectal wall, kidney insufficiency.13
enemas (Canada). abdominal  Contraindicated in hypocalcemia,
 1 to 18 years: 2.5 mL/kg PR (max distension, hyperphosphatemia, hypernatremia, kidney
133 mL/dose) (US). vomiting, hyper- failure, toxic megacolon, and bowel
OR phosphatemia, obstruction or perforation.18
 2 to 4 years: 33 mL (1/2 pediatric hypocalcemia,
enema) PR once. 18 nausea, abdominal
 5 to 11 years: 66 mL (1 pediatric pain, hypokalemia
18
enema) PR once.
 12 years to adult: 133 mL (1 adult
enema) PR once.18
Sorbitol 70%  1 to 11 years: 1 mL/kg/day PO once or Flatulence, 24 to 48 hours  Not included in the US pediatric guideline.12,13
5
twice a day OR 30 to 60 mL PR of a abdominal
25% to 30% solution as a rectal cramping
enema.18
 12 years to adult:
30 to 45 mL PO once daily18 OR
120 mL PR of a 25% to 30% solution as
a rectal enema.18
Abbreviations: OTC = over-the-counter; PO = Orally; PR = Rectally; prn = as needed.
a. Be aware of possible confusion due to brand name extensions. Generally recommend choosing products based on the generic rather than brand name.
b. If using weight-based dosing, do not exceed the adult dose.
c. Mechanisms of OTC (unless otherwise indicated) laxatives:
 Osmotic agents (lactulose [Rx in US], PEG 3350, sorbitol, and saline laxatives [see below]) promote secretion of water into the lumen of the colon
and stimulate movement of the bowel.1,10
 Fiber/bulk agents (methylcellulose, calcium polycarbophil, and psyllium) hold water in stool, increase stool weight, increase colonic distension, and
improve frequency of bowel movements.1
 Stimulant laxatives (bisacodyl and sennoside) increase intestinal motility and colonic secretions.1,7
 Stool softeners (docusate) may improve the interaction of water and solid stool.1
 Saline laxatives (magnesium hydroxide, magnesium citrate, and oral sodium phosphate liquid) are a type of osmotic laxative. Saline laxatives draw
water into intestines and colon by osmosis to increase motility.6,10

--Continue to the next section for Prescription Management of Constipation—

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Prescription Management of Constipation

Drug/Costa Adult Indicationsb Therapeutic Considerationsb
Linaclotide  Chronic idiopathic  Do not crush or chew capsules or contents (beads). Contents of capsules can be sprinkled
(Linzess [US]; constipation on applesauce or water (can give via nasogastric tube; see labeling for more information).
Constella  IBS-C o The drug is coated on the outside of the beads and, when mixed with water, will
[Canada]) dissolve. It is not necessary to consume all the beads to get the full dose.
US: $490  Take on an empty stomach at least 30 minutes before the first meal of the day.
Canada:  Minimal absorption, interactions unlikely.
$115 (72 and  Expect improvement in week one for bowel symptoms; longer onset for abdominal
145 mcg), symptoms. Keep this in mind if treatment is delayed (e.g., during transitions of care).
$185 (290 mcg)  No adjustments needed for kidney or liver impairment
 Protect from moisture; keep in original container with supplied desiccant.
Lubiprostone  Chronic idiopathic  Swallow whole, do not break or chew. Take with food and water.
(Amitiza, constipation  No known drug interactions.
generics; US  IBS-C (females)  Reduce dose for moderate (when using for CIC or OIC) and severe liver impairment.
only)  OIC in patients with  May not be effective in patients taking methadone. In vitro and preliminary data suggest
$300 chronic non-cancer pain methadone may interfere with lubiprostone’s activation of GI chloride channels.22
Methylnaltrexone  OIC in patients with  Advise patients to stay close to the toilet due to quick onset (within four hours).
(Relistor) chronic non-cancer pain  Avoid with other opioid antagonists, due to additive effects and increased risk of opioid
(US) withdrawal (US).
US:  Reduce dose for moderate (US) and severe kidney impairment.
$2,180 (oral) Injection only: OIC in  Reduce dose for moderate or severe liver impairment (US) (not recommended in severe
$970 (injectable, patients with advanced illness liver impairment per Canadian labeling).
12 mg once daily) or pain caused by active  Stop other laxatives; can restart if needed after three days (US).
cancer, who are receiving  May see less response if on opioids for less than four weeks.
Canada: opioid-escalation for  Monitor for symptoms of opioid withdrawal.
$1,329 palliative care.  Oral: Give on an empty stomach, at least 30 minutes prior to first meal.
(injectable,
12 mg once daily)  Subcutaneous injection:
*oral not o weight-based dosing.
o give injection while seated or lying down.
available in
Canada o protect from light.
o consider stopping if no response after four doses (Canada).
o can be considered second-line, AFTER a trial of laxatives.23

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Drug/Costa Adult Indicationsb Therapeutic Considerationsb

Naldemedine  OIC in patients with  Take with or without food.
(Symproic, US chronic non-cancer pain  Avoid with strong CYP3A inducers and other opioid antagonists; monitor for adverse
only) reactions with moderate and strong CYP3A4 inhibitors and P-glycoprotein inhibitors.
 Avoid with severe liver impairment.
$420  May see less response in those on opioids for less than four weeks.
 Monitor for symptoms of opioid withdrawal.
 Recommended as a second-line option, AFTER a trial of laxatives.23

Naloxegol  OIC in patients with  Can crush tablet; then mix with water for oral or nasogastric tube use.
(Movantik) chronic non-cancer pain  Give on an empty stomach, at least one hour prior to or two hours after the first meal of the
day.
US: $390  Contraindicated with strong CYP3A4 inhibitors.
Canada: $200  Avoid with moderate CYP3A4 inhibitors (if possible), strong CYP3A4 inducers, other
opioid antagonists, and grapefruit juice or grapefruit.
 Reduce dose for moderate to severe kidney impairment, with weak CYP3A4 inhibitors
(Canada), with moderate CYP3A4 inhibitors (if use can’t be avoided), or if not tolerated
(US).
 Avoid with severe liver impairment.
 May see less response in those on opioids for less than four weeks.
 Stop other laxative therapy; may restart in three days if needed (US) or as instructed by
prescriber (Canada).
 Monitor for symptoms of opioid withdrawal. Patients taking methadone had more
abdominal pain and diarrhea, which may be related to opioid withdrawal.
 Recommended as a second-line option, AFTER a trial of laxatives.23

Oxycodone/  Oxycodone: treatment of  Controlled release; swallow whole.

naloxone severe pain (similar  High first pass metabolism of naloxone results in almost no systemic action.
(Targin, Canada pharmacokinetics to  Contraindicated in severe kidney impairment and moderate to severe liver impairment.
only) OxyContin)  Remnants of capsule matrix may appear in stool.
 Naloxone: OIC  Holding oxycodone (e.g., during transitions of care) could result in withdrawal symptoms
$50 (5/2.5mg) to and inadequate pain control.
$105 (20/10 mg)  Protect from light, heat, and humidity.

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Drug/Costa Adult Indicationsb Therapeutic Considerationsb

Plecanatide  Chronic idiopathic  Swallow whole; can crush in applesauce or water (can give via nasogastric tube).
(Trulance) constipation (US)  Take with or without food. Taking with food may increase looseness of stools and
 IBS-C abdominal pain. Reduce GI adverse effects by avoiding high-fat, high-calorie meals with
US: $510 dose.
Canada: $175  Negligible absorption; no expected drug interactions.
 Protect from moisture; keep in original bottle with desiccant.

Prucalopride  Chronic idiopathic  Take with or without food.

(Motegrity [US]; constipation (only  Reduce dose for severe kidney impairment (e.g., creatinine clearance [CrCl] <30 mL/min).
Resotran approved for females in  Contraindicated in patients with end-stage kidney disease requiring dialysis.
[Canada], Canada)  Use with caution in patients with severe liver impairment (Canada).
generics)  Monitor patients for suicidal ideation or behaviors and depression.
 Protect from moisture; keep in original container.
US: $480
Canada: $100

Abbreviations: OIC = opioid-induced constipation; IBS-C = irritable bowel syndrome with constipation; GI = gastrointestinal.

a. Pricing based on wholesale acquisition cost (WAC), for generic when available, for a one-month supply of the usual maintenance dose. US
medication pricing by Elsevier, accessed December 2022.
b. Information from the product labeling, unless otherwise noted. Differences between US and Canadian product labeling noted when significantly
different.

US product labeling used for the above chart, unless otherwise noted: Amitiza (April 2021), Linzess (August 2021), Motegrity (November 2020),
Movantik (April 2020), Relistor (April 2020), Symproic (May 2020), Trulance (April 2021).

Canadian product labeling used for the above chart, unless otherwise noted: Constella (October 2022), Movantik (December 2019), Relistor (July
2018), Resotran (February 2019), Targin (September 2020), Trulance (March 2021).

Users of this resource are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments
based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations.
Information and internet links in this article were current as of the date of publication

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Cite this document as follows: Clinical Resource, Management of Constipation. Pharmacist’s Letter/Prescriber’s
Letter. January 2023. [390108]

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