Which is the best over-the-counter drug for the treatment of constipation?

Constipation is a common type of gastrointestinal disease, which is mainly manifested as decreased stool frequency, dry stool and/or difficulty in defecation.
It has a significant impact on clinical, economic and quality of life (QoL), and is associated with higher psychological problems.
Rate related
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Constipation is usually treated with over-the-counter (OTC) drugs, but its efficacy and safety are still unclear
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The researchers conducted an updated evidence-based systematic review of OTC treatment options for chronic constipation
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The systematic review of new data published in the past 15 years aims to update the classification of drugs and provide new treatment recommendations based on the level and strength of evidence
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Research methods Researchers searched for randomized controlled trials with duration ≥ 4 weeks in PubMed and Embase, and evaluated OTC preparations between 2004 and 2020
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Use the US Preventive Medicine Task Force standards (0-5 levels) for scoring, including randomization, blinding, and drug withdrawal
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In each treatment category, judge the strength of the evidence, and grade the recommendations (A, B, C, D, and I) according to the level of evidence (level I, good; II, fair; III, poor)
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Research results Penetrant laxative polyethylene glycol (PEG) and stimulant senna (Senna) (recommended grade: A; level of evidence) PEG is a penetrant, approved by the US Food and Drug Administration (US FDA) Used to treat occasional constipation
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PEG is poorly absorbed (<0.
28%), almost 100% will be excreted through feces
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Due to the lack of significant systemic absorption and low metabolic rate, PEG preparations are well tolerated and have a low incidence of adverse events
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Most events are gastrointestinal and mild to moderate events, including abdominal distension, diarrhea, loose stools, flatulence, and nausea
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Two studies also evaluated Senna
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First, according to the assessment of complete remission rate [ie increase of ≥1 mean complete spontaneous bowel movement (CSBMs)/week], Senna is superior to placebo and has similar efficacy to Chinese herbal preparations used for constipation
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Senna also outperformed placebo in secondary endpoints, including the frequency of CSBM and spontaneous BM (SBM), severity of constipation, and tension
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In a recently published study in Asia, Senna (starting at 1 g/d, which can be reduced later) was superior to placebo in improving overall symptoms (primary endpoint), stool frequency, and QoL; however, the consumed Senna dose Significantly higher than the dose used in clinical practice in the United States
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Stimulants (bisacodyl and sodium picosulfate), magnesium-containing preparations (grade of recommendation: B; level of evidence).
Due to the irritation of stimulants, most adverse events are essentially gastrointestinal symptoms
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Compared with placebo, the increased incidence of diarrhea (32%-53%vs2%-5%) and abdominal pain (6%-25%vs2%-3%) may limit the resistance of bisacodyl and sodium picosulfate Medicinal properties
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Overall, these data indicate that although bisacodyl and sodium picosulfate are associated with dose reduction or increased likelihood of intolerance, they are effective in treating chronic constipation
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In the study of magnesium-containing preparations, compared with placebo, the overall improvement of subjects' constipation, stool frequency (SBM, CSBM) and QoL was significant, but there was no difference compared with Senna
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Plantain, SupraFiber, fruit laxatives (mango, prunes, and figs), and yogurt with galactooligosaccharide/prunes/linseed oil (recommended grade: B; level of evidence) SupraFiber increases stool weight and water absorption To increase the volume of feces and soften the consistency of feces
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Current data show that soluble fiber, plantain and SupraFiber all have moderate efficacy in the treatment of constipation
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The data of plantain is the most reliable
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However, it is worth noting that the highest-ranking placebo-controlled plantain study showed that plantain had no significant benefits compared to placebo, while head-to-head trials showed that plantain was not as effective as comparison agents (e.
g.
, PEG, Lactulose and fruit)
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A current study found that in elderly patients with mild constipation, compared with control yogurt, yogurt containing galactooligosaccharides, prunes and flaxseed oil was associated with a significant increase in stool frequency, easier bowel movements, and softer stools.

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Another study showed that compared with low-fiber toast, the intestinal transit time of the rye-bread yogurt group was shortened, the frequency of bowel movements increased, the stool became soft, and the bowel movement was easier, but it was related to gastrointestinal side effects (flatulence and bloating).
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There is insufficient evidence for polydextrose, inulin and oligofructose (grade of recommendation: level I)
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Conclusion The OTC drugs analyzed in this study are safe and well tolerated.
Diarrhea, nausea, abdominal distension and abdominal pain are common adverse events, but no serious adverse events have been reported
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Based on the above studies, the scope of OTC drugs has increased and the quality of evidence has improved, but methodological problems still exist (including variability in study design, measurement of main results, trial duration, and small sample size)
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This study shows that there is good evidence to recommend PEG or Senna as a first-line laxative, as well as moderate evidence to support SupraFiber, fruit laxatives, stimulant laxatives, and magnesium-containing preparations
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For other over-the-counter preparations, further research is needed for verification
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Yimaitong compiled and compiled from: Rao SSC, Brenner DM.
Efficacy and Safety of Over-the-Counter Therapies for Chronic Constipation: An Updated Systematic Review, AM J GASTROENTEROL 2021 Jun 1; 116 (6): 1156-1181