Focus On the Impact of Chronic Constipation: A Managed Care Perspective
Including proceedings from a symposium held in Boston, Massachusetts
Activity Date: February 2007  — Activity Info: Volume 4, (2)
Goals & Objectives | Faculty | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)

Focus On the Impact of Chronic Constipation: A Managed Care Perspective
James C. Eoff III, PharmD*

This issue of University of Tennessee Advanced Studies in Pharmacy focuses on chronic constipation, a common condition with considerable discomfort and diminished quality of life that affects more people in the United States than coronary heart disease, asthma, diabetes, migraine, and hypertension.1

Normal colon function is characterized by extraction of water and electrolytes from the intestinal lumen, digestion of dietary fiber and other nutrients that are not digested by enzymes, propulsion of intestinal contents from the ileum to the rectum, and evacuation of feces from the rectum in a controlled and coordinated fashion.2 Sensorimotor functions of the colon are regulated by intrinsic or enteric nerves, whereas motility within the colon is modulated by extrinsic nerves, with sympathetic nerves inhibiting motility and parasympathetic nerves stimulating it.2,3 Disturbances in any of these functions can result in constipation.

Chronic constipation is more common in: women4; adults older than 65 years5; African Americans, Native Americans, Asians, and Hispanics4,6; and persons in lower socioeconomic groups.7 Chronic constipation is also present in approximately one third of patients with gastroesophageal reflux disease and dyspepsia.8,9

Patients with chronic constipation often pay significant expenditures for pharmacologic agents and dietary supplements to alleviate the condition. For example, Americans spend approximately $800 million per year on over-the-counter (OTC) laxatives.10 In fact, more prescriptions are written annually for laxatives than for birth control pills or antihypertensive agents.11

OTC products for chronic constipation include bulking agents such as bran and psyllium; surface-acting stool softeners such as docusate; osmotic agents such as magnesium salts, phosphate salts, and sorbitol; stimulant laxatives such as bisacodyl and senna; lubricants such as mineral oil; enemas; and rectal suppositories.

Against this backdrop, it is natural that pharmacists in various practice settings (eg, hospital, consultant, retail, trade, and managed care) are often called upon to manage and counsel patients with chronic constipation and other disorders of the gastrointestinal tract. Among the challenges facing healthcare professionals who manage patients with constipation is that many of these patients are uncomfortable discussing constipation. Instead, many patients prefer to handle the condition themselves with a variety of OTC agents, which can be problematic because these agents may be inappropriate or inadequate for them. Many other patients are unable to provide accurate information about the history of their condition, including the nature and frequency of their bowel movements. Therefore, before recommending treatment, careful questioning is necessary to elicit as much information as possible about the onset of constipation, accompanying symptoms, the number of bowel movements per week, and medications used to treat constipation and any other medical conditions.

Anthony J. Lembo, MD, a gastroenterologist at Beth Israel Deaconess Medical Center and Harvard Medical School, addresses several of these issues in his article. Dr Lembo's article includes highlights of his presentation at a chronic constipation seminar for pharmacists, held in Boston, Mass, on October 19, 2006.

The article begins with a review of the diagnostic features of chronic constipation, its primary and secondary causes, and its prevalence and recognized risk factors. Dr Lembo continues with a discussion of the economic impact of chronic constipation, and provides data that demonstrate what patients routinely report anecdotally—namely, a reduction in quality of life.

The major focus of Dr Lembo's presentation was treatment, beginning with an overall evaluation of the patient and the initiation of lifestyle interventions, fiber supplementation, and OTC laxatives if necessary. Additionally, he reviewed the safety, efficacy, and mechanisms of action of prescription medications that are currently available for the treatment of occasional and chronic constipation.

Also in this monograph is a case study that reflects a common pharmacist/patient scenario, which involves a patient who was self-treating with OTC laxatives but is now asking for professional advice because of worsening constipation. This case study reinforces key therapeutic points for pharmacists who counsel patients with chronic constipation and it underscores the important role of pharmacists in patient care.

The clinically oriented material presented in this issue provides useful information on the definition, etiology, and treatment of chronic constipation, in addition to practical advice that pharmacists can use in their day-to-day practice. As such, it is hoped that this monograph proves to be a valuable learning resource for pharmacists and, in turn, leads to enhanced patient care.

1.    Lethbridge-Cejku M, Schiller JS, Bernadel L. Summary health statistics for US adults: national health interview survey, 2002. Vital Health Stat 10. 2004;222:1-151.
2.    Bharucha AE. Pathophysiology of chronic constipation and IBS. Adv Stud Med. 2006;6(suppl 2A):S58-S66.
3.    Bharucha AE, Camilleri M, Zinsmeister AR, Hanson RB. Adrenergic modulation of human colonic motor and sensory function. Am J Physiol. 1997;273:G997-G1006.
4.    Stewart WF, Liberman JN, Sandler RS, et al. Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenterol. 1999;94:3530-3540.
5.    Talley NJ, Fleming KC, Evans JM, et al. Constipation in an elderly community: a study of prevalence and potential risk factors. Am J Gastroenterol. 1996;91:19-25.
6.    Johanson JF, Sonnenberg A, Koch TR. Clinical epidemiology of chronic constipation. J Clin Gastroenterol. 1989;11:525-536.
7.    Everhart JE, Go VL, Johannes RS, et al. A longitudinal survey of self-reported bowel habits in the United States. Dig Dis Sci. 1989;34:1153-1162.
8.    Corazziari E. Definition and epidemiology of functional gastrointestinal disorders. Best Pract Res Clin Gastroenterol. 2004;18:613-631.
9.    Locke GR III, Zinsmeister AR, Fett SL, et al. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil. 2005;17:19-34.
10.    Faigel DO. A clinical approach to constipation. Clin Cornerstone. 2002;4:11-21.
11.    National Center for Health Statistics. Available at: Accessed May 17, 2006.
*Executive Associate Dean, Professor of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee.
Address correspondence to: James C. Eoff III, PharmD, Executive Associate Dean, Professor of Clinical Pharmacy, University of Tennessee College of Pharmacy, 847 Monroe Avenue, Suite 226, Memphis, TN 38163.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.
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