1
|
Abe T, Kunimoto M, Hachiro Y, Ohara K, Inagaki M, Hishiyama H, Murakami M. Tolerance and Efficacy of Polyethylene Glycol 4000 in Elderly Patients with Chronic Constipation: A Retrospective, Single-center, Observational Study. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:291-296. [PMID: 34395942 PMCID: PMC8321590 DOI: 10.23922/jarc.2020-104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022]
Abstract
Objectives: This retrospective, observational study aimed to evaluate the tolerance and efficacy of polyethylene glycol 4000 plus electrolytes (PEG 4000) in elderly patients with chronic constipation. Methods: PEG 4000 powder was orally administered once daily at a dose of one or two 6.9 g sachets as the initial dose. The outcome measures were changes in the Cleveland Clinic Constipation Score (CCCS) and the Bristol Stool Form Scale (BSFS) value before and 2 weeks after drug administration. Results: This study included 324 patients aged ≥65 years (mean age: 78.6 ± 7.6 years, range: 65-100 years) with chronic constipation. The total CCCS was noted to significantly improve from 11.5 ± 4.6 at baseline to 7.4 ± 5.2 after drug administration. All CCCS sub-scores also improved significantly. The average BSFS value at baseline (2.5 ± 1.6) significantly improved to 4.3 ± 1.1 after treatment. Side effects (16 events) were observed in 13 patients (4.0%), with the most common being diarrhea (6 patients, 1.9%). All events were mild in severity, with none of the symptoms being serious. The cumulative treatment continuation rate at 1 year was 83.1%. Conclusions: PEG 4000 treatment was safe, effective, and well tolerated in elderly patients with chronic constipation. Thus, it appears to be a promising drug that can be continued for a long time.
Collapse
Affiliation(s)
- Tatsuya Abe
- Department of Proctology, Kunimoto Hospital, Asahikawa, Japan
| | - Masao Kunimoto
- Department of Proctology, Kunimoto Hospital, Asahikawa, Japan
| | | | - Kei Ohara
- Department of Proctology, Kunimoto Hospital, Asahikawa, Japan
| | | | | | | |
Collapse
|
2
|
Han D, Iragorri N, Clement F, Lorenzetti D, Spackman E. Cost Effectiveness of Treatments for Chronic Constipation: A Systematic Review. PHARMACOECONOMICS 2018; 36:435-449. [PMID: 29352437 DOI: 10.1007/s40273-018-0609-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Chronic constipation (CC) has a significant impact on patients' quality of life and imposes an economic burden on individuals and the healthcare system. Treatment options include dietary changes, lifestyle modifications, fibre supplements, stool softeners, and laxatives. OBJECTIVE We undertook this systematic review to comprehensively evaluate the cost effectiveness of treatments for CC. METHODS We searched ten common databases to identify economic evaluations published to 13 June 2017. Abstract and full-text review were completed in duplicate. The quality of the included studies was assessed using the Consensus on Health Economic Criteria. Data extracted included costs and outcomes of treatments for CC and cost-effectiveness methods. A narrative synthesis was completed. RESULTS From the 4338 unique citations identified, 79 proceeded to full-text review, with 10 studies forming the final dataset. Eight different definitions of CC were used to define the study populations. Study designs used were decision-tree models (4), Markov model (1), and retrospective (1) and prospective (4) studies. Quality-adjusted life-years (QALY) were reported in five studies; other outcomes included, discontinuation of laxative treatment and frequency of bowel movements. The majority of studies stated that their results were from a payer perspective; however, some of these studies only considered treatment costs, a subset of costs included in the payer perspective. Lifestyle advice, dietary treatments and abdominal massage were each compared with current care with laxatives, while polyethylene glycol (PEG) and senna-fibre combination were each compared with lactulose. Two studies compared newer treatments in patients who had not responded to laxatives: prucalopride was compared with continuing laxatives, and linaclotide was compared with lubiprostone. All of the interventions were reported by the study authors to be cost effective, with the exception of abdominal massage. CONCLUSIONS A consistent definition of CC is needed and the QALY should be used to capture the diverse symptoms of CC. Further analysis is needed comparing all available treatments for patients who have not responded to laxatives. Overall, results from economic evaluations appear to align with stepwise practice guidelines.
Collapse
Affiliation(s)
- Dolly Han
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, Canada
- Health Technology Assessment Unit, Community Health Sciences and O'Brien Institute of Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Nicolas Iragorri
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, Canada
- Health Technology Assessment Unit, Community Health Sciences and O'Brien Institute of Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Fiona Clement
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, Canada
- Health Technology Assessment Unit, Community Health Sciences and O'Brien Institute of Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Diane Lorenzetti
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, Canada
- Health Technology Assessment Unit, Community Health Sciences and O'Brien Institute of Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Eldon Spackman
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, Canada.
- Health Technology Assessment Unit, Community Health Sciences and O'Brien Institute of Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| |
Collapse
|
3
|
Nelson AD, Camilleri M, Chirapongsathorn S, Vijayvargiya P, Valentin N, Shin A, Erwin PJ, Wang Z, Murad MH. Comparison of efficacy of pharmacological treatments for chronic idiopathic constipation: a systematic review and network meta-analysis. Gut 2017; 66:1611-1622. [PMID: 27287486 DOI: 10.1136/gutjnl-2016-311835] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/15/2016] [Accepted: 05/17/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare efficacy of pharmacotherapies for chronic idiopathic constipation (CIC) based on comparisons to placebo using Bayesian network meta-analysis. DATA SOURCES We conducted searches (inception to May 2015) of MEDLINE, EMBASE, Scopus and Cochrane Central, as well as original data from authors or drug companies for the medications used for CIC. STUDY SELECTION Phase IIB and phase III randomised, placebo-controlled trials (RCT) of ≥4 weeks' treatment for CIC in adults with Rome II or III criteria for functional constipation; trials included at least one of four end points. DATA EXTRACTION AND SYNTHESIS Two investigators independently evaluated all full-text articles that met inclusion criteria and extracted data for primary and secondary end points, risk of bias and quality of evidence. OUTCOMES Primary end points were ≥3 complete spontaneous bowel movements (CSBM)/week and increase over baseline by ≥1 CSBM/week. Secondary end points were change from baseline (Δb) in the number of SBM/week and Δb CSBM/week. RESULTS Twenty-one RCTs (9189 patients) met inclusion and end point criteria: 9 prucalopride, 3 lubiprostone, 3 linaclotide, 2 tegaserod, 1 each velusetrag, elobixibat, bisacodyl and sodium picosulphate (NaP). All prespecified end points were unavailable in four polyethylene glycol studies. Bisacodyl, NaP, prucalopride and velusetrag were superior to placebo for the ≥3 CSBM/week end point. No drug was superior at improving the primary end points on network meta-analysis. Bisacodyl appeared superior to the other drugs for the secondary end point, Δb in number of SBM/week. CONCLUSIONS Current drugs for CIC show similar efficacy. Bisacodyl may be superior to prescription medications for Δb in the number of SBM/week in CIC.
Collapse
Affiliation(s)
- Alfred D Nelson
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
| | - Sakkarin Chirapongsathorn
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
| | - Priya Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Valentin
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Shin
- Indiana University, Indianapolis, Indiana, USA
| | - Patricia J Erwin
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
4
|
Emmanuel A, Mattace-Raso F, Neri MC, Petersen KU, Rey E, Rogers J. Constipation in older people: A consensus statement. Int J Clin Pract 2017; 71. [PMID: 27933718 DOI: 10.1111/ijcp.12920] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/13/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND AIMS Chronic constipation is a serious medical condition that affects 30%-40% of people over 60 years old. Although not normally life threatening, constipation reduces quality of life by the same extent as diabetes and osteoarthritis. There are currently no Europe-wide guidelines for treating constipation in older people, although there is some country-level guidance for the general population. We have evaluated the existing guidance and best clinical practice to improve the care of older people with constipation. METHOD European healthcare professionals working in gastroenterology, geriatrics, nursing and pharmacology discussed the treatment of constipation in older people and reviewed existing guidance on the treatment of constipation in the general population. This manuscript represents the consensus of all authors. DISCUSSION Most general guidance for constipation treatment recommends increased dietary fibre, fluid intake and exercise; however, this is not always possible in older patients. Although a common first-line treatment, bulk-forming laxatives are unsuitable for older people because of an associated need to increase fluid intake, osmotic laxatives are likely to be the most suitable laxative type for older patients. Treatment is often hampered by reluctance to talk about bowel problems so healthcare providers should proactively identify older constipated patients who are self-medicating or not receiving treatment. CONCLUSIONS With certain modifications, general treatment guidelines can be applied to older people with constipation, although specific guidelines are still required for this age group. Awareness of constipation, its complications and treatment options need to be increased among healthcare providers, patients and carers.
Collapse
Affiliation(s)
- Anton Emmanuel
- GI Physiology Unit, University College London, London, UK
| | | | | | | | - Enrique Rey
- Division of Digestive Diseases, Department of Medicine, Instituo de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | |
Collapse
|
5
|
Corsetti M, Tack J. New pharmacological treatment options for chronic constipation. Expert Opin Pharmacother 2014; 15:927-41. [PMID: 24661106 DOI: 10.1517/14656566.2014.900543] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION A number of new medications were recently demonstrated to be more effective than placebo in treating chronic constipation, including the intestinal chloride channel activator lubiprostone, the prokinetic selective 5-HT4 receptor agonist prucalopride and the guanylate cyclase-C agonist linaclotide. Recent publications have also revisited traditional laxatives like PEG. Moreover, a number of pharmacological treatments are in development and these include another guanylate cyclase-C agonist, plecanatide and an ileal bile acid transporter inhibitor, elobixibat. AREAS COVERED This review focuses on the pharmacology, efficacy and safety profile of prucalopride, linaclotide, plecanatide and elobixibat. EXPERT OPINION The possible present or future clinical application of prucalopride, linaclotide, plecanatide and elobixibat in both chronic constipation and irritable bowel syndrome with constipation is reported, and some considerations on the possible role of PEG taking into account recent literature are advanced.
Collapse
Affiliation(s)
- Maura Corsetti
- University of Leuven, Translational Research Center for Gastrointestinal Disorders , Herestraat 49, 3000 Leuven , Belgium
| | | |
Collapse
|
6
|
Comparison of a Chinese Herbal Medicine (CCH1) and Lactulose as First-Line Treatment of Constipation in Long-Term Care: A Randomized, Double-Blind, Double-Dummy, and Placebo-Controlled Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:923190. [PMID: 22474530 PMCID: PMC3313604 DOI: 10.1155/2012/923190] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/21/2011] [Accepted: 11/22/2011] [Indexed: 12/15/2022]
Abstract
Many institutionalized patients and their healthcare providers are dissatisfied with current laxative therapy. This study compared therapeutic efficacy, safety, and laxative cost of an herbal formula (CCH1) and lactulose for long stay patients with constipation. In this double-blind, double-dummy, and placebo-controlled trial, we randomized 93 residents with chronic constipation from two long-term care facilities in Taiwan to receive either CCH1 with lactulose placebo or CCH1 placebo with lactulose for 8 weeks, then followed up for 4 weeks without study medication. Both treatments were effective and well tolerated for patients, but CCH1 produced more spontaneous bowel movements, less rectal treatments, less amount of rescue laxative, and lower laxative cost than lactulose during treatment. No significant differences were found in stool consistency, stool amount, global assessment, and safety concerns. In conclusion, our results suggest that CCH1 may have better efficacy and could be used as an alternative option to lactulose in the treatment of constipation in long-term care.
Collapse
|
7
|
Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Cochrane Review: Lactulose versus Polyethylene Glycol for Chronic Constipation. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.741] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
8
|
Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus Polyethylene Glycol for Chronic Constipation. Cochrane Database Syst Rev 2010:CD007570. [PMID: 20614462 DOI: 10.1002/14651858.cd007570.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Constipation is a common clinical problem. Lactulose and Polyethylene Glycol (PEG) are both commonly used osmotic laxatives that have been shown to be effective and safe treatments for chronic constipation. However, there is no definitive data as to which provides the best treatment. OBJECTIVES To identify and review all relevant data in order to determine whether Lactulose or Polyethylene Glycol is more effective at treating chronic constipation and faecal impaction. SEARCH STRATEGY We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of lactulose and polyethylene glycol in the management of faecal impaction and chronic constipation. SELECTION CRITERIA Studies were included if they were randomised controlled trials which compared lactulose with polyethylene glycol in the management of chronic constipation. DATA COLLECTION AND ANALYSIS Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0) and analysed using Cochrane MetaView. MAIN RESULTS In the present meta-analysis, we considered for the first time all ten randomised controlled trials so far performed. The findings of our work indicate that Polyethylene glycol is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products. On subgroup analysis, this is seen in both adults and children, except for relief of abdominal pain. AUTHORS' CONCLUSIONS Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation.
Collapse
Affiliation(s)
- Heather Lee-Robichaud
- Department of General Surgery, Northern General Hospital, Herries Road, Sheffield, England, UK, S5 7AU
| | | | | | | |
Collapse
|
9
|
Lämås K, Lindholm L, Engström B, Jacobsson C. Abdominal massage for people with constipation: a cost utility analysis. J Adv Nurs 2010; 66:1719-29. [DOI: 10.1111/j.1365-2648.2010.05339.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
10
|
Belsey JD, Geraint M, Dixon TA. Systematic review and meta analysis: polyethylene glycol in adults with non-organic constipation. Int J Clin Pract 2010; 64:944-55. [PMID: 20584228 DOI: 10.1111/j.1742-1241.2010.02397.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
It is unclear how polyethylene glycol (PEG) laxatives compare with other classes of laxative in terms of efficacy. To assess efficacy of PEG vs. placebo and active comparators in adults with non-organic constipation. Text Word searches were carried out on MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Clinical Trials and Google Scholar databases covering the period January 1970 to October 2009. Search terms were (constipation) AND (randomised OR randomized) AND (PEG OR polyethylene OR macrogol OR movicol OR idrolax OR miralax OR transipeg OR forlax OR colyte OR golytely OR isocolan OR nulytely) NOT colonoscopy. Only published randomised controlled trials, with a parallel-group or cross-over design, comparing oral PEG with placebo or a comparator laxative in adults with a history of non-organic constipation, were included. The frequency of defaecation in each arm, on completion of the protocol-defined treatment duration was extracted. All pooled analyses were based on random effect models. Of the 20 qualifying studies, 10 were vs. placebo, seven were vs. lactulose, and four were vs. other agents. One study compared PEG, placebo and lactulose. PEG treatment resulted in a highly significant increase in defaecations/week over placebo (all studies: additional 1.98 stools/week; p = 0.0003, high-quality studies: additional 2.34 stools/week; p = 0.0001) and over lactulose (all studies: additional 1 stool/week; p = 0.0017, high-quality studies: additional 1.65 stools/week; p = 0.021). This meta analysis is the only quantitative statistical analysis to have been published in the field. PEG was found to be a more effective laxative than lactulose in adult patients with constipation.
Collapse
Affiliation(s)
- J D Belsey
- JB Medical Ltd, The Old Brickworks, Chapel Lane, Little Cornard, Sudbury, UK.
| | | | | |
Collapse
|
11
|
Spinzi G, Amato A, Imperiali G, Lenoci N, Mandelli G, Paggi S, Radaelli F, Terreni N, Terruzzi V. Constipation in the elderly: management strategies. Drugs Aging 2009. [PMID: 19591521 DOI: 10.2165/00002512-200926060-00003.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2022]
Abstract
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified. Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life. There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation. The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation. The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.
Collapse
|
12
|
Spinzi G, Amato A, Imperiali G, Lenoci N, Mandelli G, Paggi S, Radaelli F, Terreni N, Terruzzi V. Constipation in the elderly: management strategies. Drugs Aging 2009; 26:469-74. [PMID: 19591521 DOI: 10.2165/00002512-200926060-00003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified. Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life. There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation. The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation. The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.
Collapse
|
13
|
Guest JF, Clegg JP, Helter MT. Cost-effectiveness of macrogol 4000 compared to lactulose in the treatment of chronic functional constipation in the UK. Curr Med Res Opin 2008; 24:1841-52. [PMID: 18558017 DOI: 10.1185/03007990802102349] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of macrogol 4000 compared to lactulose in the treatment of chronic functional constipation, from the perspective of the National Health Service (NHS) in the UK. METHODS A decision model depicting the management of chronic functional constipation was constructed using clinical outcomes and resource use values derived from patients suffering from chronic functional constipation in The Health Improvement Network (THIN) Database. The model was used to estimate the cost-effectiveness of a general practitioner (GP) prescribing macrogol 4000 relative to lactulose to treat adults >/=18 years of age suffering from chronic functional constipation. RESULTS Forty-two per cent (95% confidence interval [CI]: 38%; 46%) of macrogol 4000-treated patients are expected to be successfully treated within 3 months after starting treatment, compared to 31% (95% CI: 27%; 37%) of lactulose-treated patients. Patients' health status at 3 months was estimated to be 0.213 (95% CI: 0.200; 0.223) and 0.210 (95% CI: 0.197; 0.220) quality-adjusted life years (QALYs) in the macrogol 4000 and lactulose groups, respectively. The total 3-monthly NHS cost of treating patients with macrogol 4000 or lactulose was estimated to be pound115 (95% CI: pound98; pound132) and pound102 (95% CI: pound86; pound119), respectively. Hence, the cost per QALY gained with macrogol 4000 was estimated to be pound4333. CONCLUSION Within the limitations of the model, treatment with macrogol 4000 relative to lactulose is expected to increase the probability of being successfully treated by 35% at 3 months (p<0.0001), although this yields only a 1% improvement in health gain. Nevertheless, macrogol 4000 affords a cost-effective addition to the range of laxatives available for this potentially resource-intensive condition, since it is clinically more effective than lactulose and the cost-effective strategy from the perspective of the NHS.
Collapse
Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex, UK.
| | | | | |
Collapse
|
14
|
Ternent CA, Bastawrous AL, Morin NA, Ellis CN, Hyman NH, Buie WD. Practice parameters for the evaluation and management of constipation. Dis Colon Rectum 2007; 50:2013-22. [PMID: 17665250 DOI: 10.1007/s10350-007-9000-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Charles A Ternent
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
| | | | | | | | | | | |
Collapse
|
15
|
Piche T, Dapoigny M, Bouteloup C, Chassagne P, Coffin B, Desfourneaux V, Fabiani P, Fatton B, Flammenbaum M, Jacquet A, Luneau F, Mion F, Moore F, Riou D, Senejoux A. [Recommendations for the clinical management and treatment of chronic constipation in adults]. ACTA ACUST UNITED AC 2007; 31:125-35. [PMID: 17347618 DOI: 10.1016/s0399-8320(07)89342-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Thierry Piche
- Service d'Hépato-Gastroentérologie et Nutrition Clinique, Nice
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Greiner W, Lehmann K, Earnshaw S, Bug C, Sabatowski R. Economic evaluation of Durogesic in moderate to severe, nonmalignant, chronic pain in Germany. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2006; 7:290-6. [PMID: 16983521 DOI: 10.1007/s10198-006-0376-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
We carried out a cost-effectiveness evaluation of transdermal fentanyl compared to three other widely used opioids: transdermal buprenorphine, sustained-release morphine, and controlled-release oxycodone from a third-party-payers perspective. A decision analytic model with data from a structured database search and from panel data and assumptions was used to derive both cost and utility results. Probabilistic sensitivity analysis was performed to ensure the findings. Transdermal fentanyl patients gain more quality adjusted life-days or quality-adjusted life-years per euro. The incremental cost per quality-adjusted life-year is 1,625.65 euro for transdermal fentanyl compared to sustained-release morphine and 1,003.03 euro compared to CO, and it is cost-saving compared to transdermal buprenorphine (-203.38 euro per patient). Transdermal fentanyl is thus cost-effective compared to both sustained-release morphine and CO and dominant compared to transdermal buprenorphine in the treatment of adults with nonmalignant moderate to severe chronic pain.
Collapse
Affiliation(s)
- W Greiner
- Department of Health Economics and Health Management, University of Bielefeld, Germany.
| | | | | | | | | |
Collapse
|
17
|
Ramkumar D, Rao SSC. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol 2005; 100:936-71. [PMID: 15784043 DOI: 10.1111/j.1572-0241.2005.40925.x] [Citation(s) in RCA: 301] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Constipation is common, and its treatment is unsatisfactory. Although many agents have been tried, there are limited data to support their use. Our aim was to undertake a systematic review of the efficacy and safety of traditional medical therapies for chronic constipation and to make evidence-based recommendations. METHODS We searched the English literature for drug trials evaluating treatment of constipation by using MEDLINE and PUBMED databases from 1966 to 2003. Only studies that were randomized, conducted on adult subjects, and published as full manuscripts were included. Studies were assigned a quality score based on published methodology. Standard forms were used to abstract data regarding study design, duration, outcome measures, and adverse events. By using the cumulative evidence of published data for each agent, recommendations were made regarding their use following the United States Preventive Services Task Force guidelines. RESULTS Good evidence (Grade A) was found to support the use of polyethylene glycol (PEG) and tegaserod. Moderate evidence (Grade B) was found to support the use of psyllium, and lactulose. There was a paucity of quality data regarding many commonly used agents including milk of magnesia, senna, bisacodyl, and stool softeners. CONCLUSIONS There is good evidence to support the use of PEG, tegaserod, lactulose, and psyllium. Surprisingly, there is a paucity of trials for many commonly used agents. These aspects should be considered when designing trials comparing new agents with traditional therapies because their use may not be well validated.
Collapse
Affiliation(s)
- Davendra Ramkumar
- Division of Gastroenterology, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, USA
| | | |
Collapse
|
18
|
Bosshard W, Dreher R, Schnegg JF, Büla CJ. The treatment of chronic constipation in elderly people: an update. Drugs Aging 2005; 21:911-30. [PMID: 15554750 DOI: 10.2165/00002512-200421140-00002] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition. Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives. Several promising compounds such as the new serotonin 5-HT4 receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified. Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.
Collapse
Affiliation(s)
- Wanda Bosshard
- Division of Geriatric Medicine and Geriatric Rehabilitation, Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | | |
Collapse
|
19
|
Dennison C, Prasad M, Lloyd A, Bhattacharyya SK, Dhawan R, Coyne K. The health-related quality of life and economic burden of constipation. PHARMACOECONOMICS 2005; 23:461-76. [PMID: 15896098 DOI: 10.2165/00019053-200523050-00006] [Citation(s) in RCA: 260] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Constipation is a prevalent condition that disproportionately affects women and older adults and leads to self-medication and/or medical consultation. It occurs as a result of functional idiopathic causes or secondarily as a result of a variety of factors including dietary and exercise patterns, adverse effects of medication and disease processes. Constipation is often perceived to be a benign, easily treated condition with short-term treatment being relatively straightforward; however, chronic constipation is associated with mild complications that, left untreated, can develop into more serious bowel complaints (faecal impaction, incontinence and bowel perforations) with further implications for healthcare costs and the patient's health-related quality of life (HR-QOL). This review summarises the evidence of the HR-QOL impact and economic burden of constipation on patients. Relatively few studies have systematically explored the HR-QOL and economic impact of constipation; however, the existing evidence suggests that HR-QOL is lower in patients with constipation than in non-constipated individuals, and treatments for constipation improve HR-QOL. Additionally, constipation represents an economic burden for the patient and healthcare provider. Resource utilisation associated with the diagnosis and management of constipation is a significant cost driver, whereas constipation prevention programmes have demonstrated cost savings.
Collapse
|
20
|
Guest JF, Varney SJ. Pharmacoeconomic Impact of Low-Dose Macrogol 3350 plus Electrolytes Compared with Lactulose in the Management of Chronic Idiopathic Constipation among Ambulant Patients in Belgium. Clin Drug Investig 2004; 24:719-29. [PMID: 17523735 DOI: 10.2165/00044011-200424120-00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To estimate the economic impact of using low-dose macrogol 3350 plus electrolytes (macrogol 3350; Movicol((R))) compared with lactulose in the treatment of chronic idiopathic constipation among ambulant patients in Belgium, from the perspectives of the Sick Fund and patients. The analysis considered separately the economic impact of (a) a specialist and (b) a general practitioner (GP) initiating treatment. DESIGN AND SETTING This was a modelling study performed from the perspective of Belgium's Sick Fund and patients. METHODS Estimates of healthcare resource utilisation in a previously reported UK model depicting the management of chronic idiopathic constipation with either macrogol 3350 and lactulose over 3 months were replaced with Belgian estimates derived from a panel of 11 gastroenterologists and 11 GPs. The model was used to estimate the expected 3-monthly Sick Fund cost and direct cost to patients of using either laxative to manage chronic idiopathic constipation in Belgium. MAIN OUTCOME MEASURES AND RESULTS According to our model, 53% and 24% of patients are expected to be successfully treated with macrogol 3350 and lactulose, respectively. Additionally, using macrogol 3350 instead of lactulose is expected to reduce the 3-monthly Sick Fund cost in approximately 55% of patients and afford a cost-effective treatment in the remaining patients. Furthermore, the 3-monthly Sick Fund cost of managing chronic idiopathic constipation among ambulant patients is expected to be reduced by approximately 50% if patients were initially treated by a GP instead of a specialist. In Belgium, laxatives are paid for by patients. Despite the difference in their acquisition cost, treating chronic idiopathic constipation with either macrogol 3350 or lactulose was found to be cost neutral from a patient's perspective. CONCLUSIONS The true cost of managing chronic idiopathic constipation is impacted on by a broad range of resources and not only laxative acquisition costs. This study indicated that managing ambulant patients with chronic idiopathic constipation with macrogol 3350 instead of lactulose is a cost-effective treatment from the Sick Fund's perspective and cost neutral from a patient's perspective.
Collapse
Affiliation(s)
- Julian F Guest
- CATALYST Health Economics Consultants, Northwood, Middlesex, UK
| | | |
Collapse
|
21
|
Zhang CQ, Zhang GW, Zhang KL, Fu YQ. Clinical evaluation of polyethylene glycol 4000 in treatment of functional constipation in elderly patients. Shijie Huaren Xiaohua Zazhi 2003; 11:1399-1401. [DOI: 10.11569/wcjd.v11.i9.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the efficacy and safety of polyethylene glycol (PEG) 4000 in the treatment of elderly functional constipation in comparison with lactulose.
METHODS A total of 85 patients with functional constipation were enrolled in this randomized and comparative trial. They received either PEG 4 000 (10 g, n =41) or lactulose (15 ml, n =44) for 2-4 weeks.
RESULTS The complete remission of constipation was significantly higher in patients treated with PEG 4 000 in comparison with lactulose group (2 wk: 63.6% vs 39.0%, P <0.01; 4 wk: 69.0% vs 42.1%, P <0.01). The mean Bristol score of stool consistency during the 4 wk treatment was higher in the PEG group (4.0±0.3 vs 2.9±0.2, P <0.01). At the end of 4 wk study, PEG 4 000 normalized the stool consistency in 81.5% patients (lactulose group: 52.4%, P <0.01). Thus, PEG 4 000 was more effective in alleviating abdominal pain and difficult defecation than lactulose. The side-effect incidences were 11.7% and 16.1% in the two groups respectively (P >0.05). There was no severe side-effect in both groups.
CONCLUSION PEG 4 000 is an effective and safe agent in the treatment of elderly functional constipation.
Collapse
Affiliation(s)
- Chang-Qing Zhang
- Department of Gastroenterology, The First Hospital of Quanzhou, Quanzhou 362000, Fujian Province, China
| | - Guo-Wei Zhang
- Department of Gastroenterology, The First Hospital of Quanzhou, Quanzhou 362000, Fujian Province, China
| | - Kui-Ling Zhang
- Department of Gastroenterology, The First Hospital of Quanzhou, Quanzhou 362000, Fujian Province, China
| | - Yi-Qi Fu
- Department of Gastroenterology, The First Hospital of Quanzhou, Quanzhou 362000, Fujian Province, China
| |
Collapse
|
22
|
Tytgat GN, Heading RC, Müller-Lissner S, Kamm MA, Schölmerich J, Berstad A, Fried M, Chaussade S, Jewell D, Briggs A. Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting. Aliment Pharmacol Ther 2003; 18:291-301. [PMID: 12895213 DOI: 10.1046/j.1365-2036.2003.01679.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux disease (GERD) and constipation have a major impact on public health; however, the wide variety of treatment options presents difficulties for recommending therapy. Lack of definitive guidelines in pharmacy and general practice medicine further exacerbates the decision dilemma. AIMS To address these issues, a panel of experts discussed the principles and practice of treating GERD and constipation in the general population and in pregnancy, with the aim of developing respective treatment guidelines. RESULTS The panel recommended antacids 'on-demand' as the first-line over-the-counter treatment in reflux, and as rescue medication for immediate relief when reflux breaks through with proton pump inhibitors. Calcium/magnesium-based antacids were recommended as the treatment of choice for pregnant women because of their good safety profile. In constipation, current data do not distinguish a hierarchy between polyethylene glycol (PEG)-based laxatives and other first-line treatments, although limitations are associated with stimulant- and bulk-forming laxatives. Where data are available, PEG is superior to lactulose in terms of efficacy. In pregnancy, PEG-based laxatives meet the criteria for the ideal treatment. CONCLUSIONS The experts developed algorithms that present healthcare professionals with clear treatment options and management strategies for GERD and constipation in pharmacy and general practice medicine.
Collapse
Affiliation(s)
- G N Tytgat
- Academisch Medisch Centrum, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | |
Collapse
|