Gastroenterologists recommend 2 new treatments for chronic constipation

The American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA) recently released new clinical practice guidelines for the use of medications to treat chronic idiopathic constipation (CIC) in adults. The effort is intended to provide healthcare professionals with clear and practical tips to effectively manage the common condition.

The updated guidelines include 10 evidence-based recommendations for the treatment of CIC. Two treatments, magnesium oxide and senna, are included in the recommendations for the first time.

Here’s what experts want you to know about managing CIC, including when to talk to your provider about medications that can help.

What are magnesium oxide and senna?

Magnesium oxide is a type of magnesium supplement that can be used to relieve gastrointestinal symptoms such as heartburn and acid indigestion.

Ekta Gupta, MD, assistant professor of medicine in the Department of Gastroenterology and Hepatology at Johns Hopkins University School of Medicine, told Verywell that magnesium oxide can also be used as an osmotic laxative to soften stools.

Unabsorbed magnesium creates an osmotic gradient, which draws more water into the colon, making it softer and easier to pass, Gupta said.

Senna comes from grass Senna Alexandria and acts as a stimulant laxative, making it different from magnesium oxide.

Megan Gerber, RD, LDN, a functional and integrative dietitian/nutritionist and founder of Grounded Nourishment, told Verywell that senna works by actively activating contractions in the muscles of the intestines to stimulate bowel movements.

Gerber said both options are available over-the-counter (OTC) in capsule, pill or tablet form. Magnesium oxide also comes in powder form and senna can be made into tea.

Why are experts recommending these treatments now?

According to Gupta, the ACG and AGA cited two studies to support the updated recommendation that includes magnesium oxide and senna as treatment options for CIC.

For example, studies have shown that patients who have used magnesium oxide had complete, more spontaneous bowel movements per week and also reported improved quality of life. As for senna, research has shown that it can increase spontaneous and complete bowel movements and also improve the quality of life of patients.

Despite the findings, Gupta said the research has major limitations to think about, for example, the studies lasted just four weeks and didn’t look at the long-term effects of these treatments.

Given the short duration of the study, this is a conditional recommendation with very low certainty of the evidence, Gupta said, adding that data on long-term use is also not available for these treatments.

What does this mean for providers and patients? While there is some research supporting the inclusion of magnesium oxide and senna as recommended CIC treatments, we still need more research, preferably with more people and longer time frames, to know for sure how safe and effective they are.

Why did the experts make the recommendation if the evidence is limited?

While there are limitations to the research available, other experts say magnesium oxide and senna have made the list of recommended treatments for CIC because they have shown efficacy in the studies that have been done.

We’re still learning a lot about constipation and what causes it beyond dietary changes that can be modified, Natasha Chhabra, MD, a gastroenterologist at Gastroenterology Associates of New Jersey, told Verywell. This is still something being studied how it can be tested and improved, [but] all of these drugs work to improve motility.

Chhabra added that another potential reason both treatments are being recommended now is that they are considered more accessible and convenient for patients because they are sold OTC and are relatively low-cost.

The cost of managing constipation can be very high, she said. While there are prescription drugs for constipation available, some of which are mentioned in the guidelines, many of these are not yet available in generic form, so they may cost more depending on the person’s insurance plan.

What other evidence-based treatments for constipation are there?

In addition to magnesium oxide and senna, the ACG and AGA also list other nondrug therapies for CIC, including over-the-counter and prescription drugs that providers and patients may consider.

• Fiber: In adults with CIC, the panel recommends fiber supplements such as bran, inulin and psyllium. These options contain dietary fiber that can help regulate bowel movements and prevent constipation.
• Osmotic laxatives: The panel suggests that adults with CIC use polyethylene glycol (PEG), which is an osmotic laxative. It works by causing water to be retained in the stool. Miralax is a well-known brand of PEG. It increases bowel movements and softens stool, so it’s easier to pass. Experts also recommend lactulose, a man-made sugar that helps with constipation by increasing the number of bowel movements per day.
• Stimulant laxatives: In the short term, adults with CIC can also use bisacodyl or sodium picosulfate (SPS), which are stimulant laxatives that work by stimulating the muscles in the intestines. Stimulant laxatives increase bowel movement to help with the passage of stool to relieve constipation.
• Secretagogues: The panel recommends lubiprostone, linaclotide, and plecanatide for CIC patients who have not been helped by OTC treatments. These medications are used to treat certain digestive disorders and help loosen stools and promote bowel movements.
• 5-HT4 agonists: The panel also suggests that adults with CIC who have not responded to OTC treatments consider prucalopride, a drug used to treat chronic constipation. It works by stimulating the muscles in intensives to promote bowel movements and relieve constipation as well as facilitate regular bowel movements.

While there are several evidence-based options in the guidelines that can help treat constipation in adults, Chhabra said they’re only recommendations. It’s important for patients with symptoms of CIC to talk with their providers or gastrointestinal specialists to figure out the best option for them, including how much and how often they should take a recommended medication.

The guidelines are there to guide us, they don’t dictate how we practice, Chhabra said. It’s really about understanding the patient and what works best for them and their preferences.

Natural ways to treat constipation

If you’re looking for natural ways to treat constipation, experts say there are many strategies you can try on your own at home:

• Drink plenty of water throughout the day. Aim to get up to 64 ounces (or 8 cups) of water each day.
• Increase your physical activity and exercise to help with colon motility.
• Eat foods high in fiber, such as whole grain breads, bran cereals, and nuts. Other foods that help with constipation include green vegetables, prunes, kiwis, avocados, berries, olive and flaxseed oils, and legumes.

If you’ve tried strategies like increasing your fiber and water intake with no relief, Chhabra said to see a gastroenterologist. These gastrointestinal specialists can help people with chronic constipation by examining how to use over-the-counter laxatives and how long to try them for before determining if they need something stronger like prescription drugs, she said.

If you’ve tried making some changes to your lifestyle and diet but still have symptoms of constipation, Gupta recommends seeing a provider to understand the underlying cause and ensure there’s no other organic etiology behind your constipation. If OTC medicine doesn’t help or you have side effects, Gupta said that’s also another reason to talk to a specialist.