Constipation Considerations from DDW 2018. Many presentations and poster sessions at Digestive Disease Week 2018 explored new findings on diagnosis and disease management of functional causes of constipation. Veronica Hackethal, MD, was on site and provided the 5 study summaries in the slide show above.
Functional constipation is divided into irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC, or constipation without known anatomical or physiological cause) and affects about 1 in 7 Americans.
The impact on quality of life is significant - approximately 12% of patients report missed work or school - and direct costs are estimated to be around $1.6 billion (mean annual cost of $3000/patient).
Mean costs, ED visits, and hospitalizations are increasing.
Rehospitalization for Constipation. The first study to assess readmission rates for constipation nationwide found that male sex, Medicare/Medicaid status, hospital stays of more than 2 days, d/c to a skilled nursing facility, 3 or more comorbidities, and bipolar disorder were associated with return to hosptial. DDW 2018 Abstract.
Don't Forget the Pelvic Floor. Often overlooked as a cause of constipation in women, symptoms of pelvic floor dysfunction can include a feeling of incomplete bowel movements, frequent urge to have a bowel movement, low back or pelvic/genital pain, urinary frequency as well as pain during sexual intercourse.
IBS-C, Vaginal Delivery Predict Pelvic Floor Dysfunction. Prashant Singh, MD, of Beth Israel Deaconess Medical Center in Boston found that overall pelvic floor distress and GI symptom distress were significantly higher in IBS-C compared to CIC. IBS-C, severity of constipation, and vaginal delivery were independent predictors of overall pelvic floor dysfunction. DDW 2018 Abstract.
The Quest for Effective Rx Contintues. Despite progress in diagnosing IBS-C and CIC, effective treatments remain elusive. Diet, biofeedback training, and over-the-counter agents such as laxatives are variably successful.
Prosecretory Agents: Adherence is Low. An administrative claims study by Bornheimer et al, included 43,164 patients who initially received linaclotide and 17,743 who initially received lubiprostone from Jan 2013 through Dec 2015. Results showed that only 22% continued linaclotide for more than a year, while only 11.8% continued lubiprostone.3 DDW 2018 Abstract.
Enter Plecanatide, a Guanylate Cyclase-C Agonist. A pooled analysis of plecanatide registration trials by Sayuk et al, showed that plecanatide 3 mg and 6 mg were associated with significant improvement in most bowel symptoms vs placebo. Further analysis supported a maximal dose of plecanatide 3 mg QD for treating CIC.4DDW 2018 Abstract.
sNDA for Alfuzosin? FDA-approved in the US for BPH, results from a preliminary, single center placebo-controlled double blind parallel group study found that immediate release alfuzosin (not available in the US) resulted in significant decrease in anal pressure during evacuation in women with CIC or IBS-C. But 2 weeks of the extended release formualtion was not superior vs placebo.5DDW 2018 Abstract.
Constipation Considerations-Take Home Points
Male sex, Medicare/Medicaid recipients, hospital stays over two days, discharge to a skilled nursing facility, three or more comorbidities, and bipolar disorder are associated with hospital re-admission for constipation.
IBS-C, severity of constipation, and vaginal delivery are independent predictors of pelvic floor dysfunction; providers should ask patients with constipation about symptoms of pelvic floor dysfunction, especially women.
Linaclotide and lubiprostone have high discontinuation rates.
A pooled analysis of phase III RCTs supports a maximal dose of plecanatide 3 mg daily for treating CIC.
Immediate-release alfuzosin shows significant decrease in anal pressure during evacuation in women with CIC or IBS-C; extended-release alfuzosin shows lack of effect.