Chronic constipation
Constipation lasting over 3 months per Rome IV criteria: straining, hard stools, sensation of incomplete evacuation. Baseline management — fluid, fiber, physical activity; if insufficient — osmotic laxatives, then stimulants.
ICD-10 K59.06 drugs
Also known as: Functional constipation
Drugs used for this condition
- APsyllium (Plantago ovata, ispaghula husk)First line · Soluble and insoluble fibre from seed husk. AEMPS registered Plantaben and Cenat as medicinal products for chronic constipation and maintenance of normal defecation. ACG 2014 and NICE NG61 IBS 2017 list psyllium as the primary soluble fibrePsyllium is the first-line soluble fibre in chronic functional constipation per ACG 2014 monograph and NICE recommendations. AEMPS registered Plantaben and Cenat with the indication of functional constipation and maintenance of normal defecation. Christodoulides 2016 meta-analysis (7 RCTs, 405 patients) showed increased stool frequency and improved consistency on psyllium 10–20 g/day × 4 weeks. EFSA 2013 approved a health claim for psyllium on increased stool bulk at minimum 7 g/day. ACG 2014 in chronic constipation lists first-line: soluble psyllium fibre 7–10 g/day with ample water, osmotic laxatives (PEG/macrogol) if insufficient, stimulant laxatives (bisacodyl, sennosides) for persistent constipation, novel drugs (linaclotide, prucalopride, lubiprostone) for refractory constipation. Dose: start at 3.5 g 1–2 times daily, gradually increase to 7–10 g/day with minimum 250 mL of water per dose.
- BBisacodylSecond line · Stimulant laxativesPer AGA 2023 and ACG 2014, stimulant laxatives are second-line for chronic constipation in adults after baseline measures (adequate hydration, fiber, physical activity) and osmotic laxatives (PEG, lactulose). Bisacodyl 5–10 mg at bedtime. Efficacy confirmed by meta-analyses. Continuous use beyond 1–2 weeks is linked to hypokalemia and 'colonic conditioning' – the clinical significance of melanosis coli and dependence is now debated in guidelines, but long-term self-medication is not recommended.
- CInulin (chicory/agave/Jerusalem artichoke prebiotic)Add-on therapy · Soluble fructan fibre, prebiotic. Supplement in Russia and Spain. EFSA approved health claim for chicory inulin on maintenance of normal defecation (2015). AEMPS does not register it as a medicineChicory root inulin is the only variant with an EFSA 2015 approved health claim on maintenance of normal defecation at minimum 12 g/day. RCTs showed moderate stool frequency increase in adult chronic constipation at 10–20 g/day × 4 weeks. ACG 2014 monograph on chronic constipation lists dietary fibre increase 25–30 g/day (soluble psyllium preferable to insoluble wheat bran) first-line, osmotic laxatives (PEG/macrogol, lactulose); if ineffective – linaclotide, prucalopride. Inulin may be a useful adjunct but is not a priority option: causes marked bloating at doses >10–15 g/day and is poorly tolerated in IBS-C patients. If inulin was recommended for chronic constipation lasting more than 6 months without workup for pelvic floor dysfunction, hypothyroidism and red flags (weight loss, bloody stool, onset after 50), consider seeking a second opinion from a gastroenterologist.
- CSodium picosulfateAdd-on therapy · Local stimulant laxative, triarylmethane derivativeIn chronic constipation stimulant laxatives do help, but their role is supporting. The AEMPS ficha técnica states the limit directly: picosulfate is not taken daily and long-term without establishing the cause of constipation. The causes are many – from drugs, hypothyroidism and diabetes to irritable bowel syndrome and, less often, colon cancer. The ficha names an alarm sign separately: a sudden change in bowel habit lasting beyond two weeks is a contraindication to self-treatment. The standard sequence looks different: fibre and water first, then osmotic agents such as macrogol, with a stimulant laxative for short episodes or on prescription. If picosulfate was prescribed as a permanent daily remedy without investigation, consider seeking a second opinion.
- DGlucomannan (Amorphophallus konjac)Add-on therapy · Water-soluble dietary fibre from konjac root (Amorphophallus konjac); the only weight-loss supplement with an EFSA-approved health claim under Regulation 432/2012On iHerb and marketplaces glucomannan is often sold «for constipation» as a natural laxative. EFSA has not approved a separate bowel-function health claim – outside the weight-loss indication this is off-label use. Glucomannan increases stool bulk by retaining water, similar in theory to other soluble fibres, but quality RCTs with stool-frequency endpoints are sparse. In some patients concentrated glucomannan worsens constipation and causes bloating. AGA 2024 and SEPD recommend dietary fibre, adequate fluids and physical activity for chronic constipation, with macrogol, lactulose or prucalopride as needed by physician prescription.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit