Managing Occasional Constipation with Osmotic Laxatives

Announcer:
You’re listening to GI Insights on ReachMD, and this episode is brought to you by MiraLAX. And now, here’s your host, Dr. Charles Turck.

Dr. Turck:
For many patients, occasional constipation is disruptive enough to seek relief, and that's where polyethylene glycol, or PEG, osmotic laxatives come into focus. This is GI Insights on ReachMD, and I'm Dr. Charles Turck. Joining me to review best practices for treating occasional constipation is Dr. Jeffrey Crespin. He's a Clinical Assistant Professor in the Department of Medicine at NYU Grossman School of Medicine. Dr. Crespin, welcome to the program.

Dr. Crespin:
Thank you for having me today.

Dr. Turck:
Well, to start us off, Dr. Crespin, how would you describe the clinical or real-world relevance of PEG osmotic laxatives in managing occasional constipation today?

Dr. Crespin: 
Well, as you know, PEG has been around for a long time—decades. I trained in the nineties, so I was using it during my fellowship and continue to use it to this day. It has a long track record, both in terms of efficacy, safety, and tolerability And frequently, I'll have both male and female patients that will come to me with symptoms of constipation, and I'll discuss with them, what have they tried? What are their symptoms? And for me, PEG 3350 is sort of my go-to first choice.

So we'll talk to, let's say, the last patient I saw, a hypothetical woman who sought help at both the urgent care and primary but did not get the answer she was seeking. She’s had constipation for less than three months. And she may say, ‘I tried some fiber. What else do you have to offer me?’ And so I'll say, have you tried PEG 3350? What have you heard about it? And I’d say there is some awareness, but not everybody knows about PEG 3350—certainly, most people do not know how it works.

So PEG 3350 really works by osmosis. What it does is it draws water back into the colon, but it makes the stool softer and helps people to go to the bathroom. I do talk to patients and ask about how much water they consume on the average day. And I do stress with them that, ideally, they should be consuming 64 ounces of water a day, and that if they don't drink enough water, the PEG 3350 will not work as well. And so I'll say, look, ideally, you're going to try to have three meals and a snack and drink at least 16 ounces of water with each of these meals. And usually, patients will see a response within one to three days when they take it.

Dr. Turck:
And what does the clinical evidence tell us about the efficacy and tolerability of PEG for occasional constipation?

Dr. Crespin: 
I'd say that for the majority of patients, PEG does work. And normally they will see results within one to three days. So oftentimes, patients will say, ‘Is this going to work tonight? Will I have explosive diarrhea?’ And I say, no, you're not going to have explosive diarrhea by taking this medication. Sometimes it takes a little bit with patients. But in the majority of patients, it will work. And we have scientific data for many decades showing proven efficacy where people will have increased bowel movements weekly by going on it.

Dr. Turck: 
And what should healthcare providers consider when guiding patients on how to use PEG safely and effectively for occasional constipation?

Dr. Crespin: 
I think you have to ask the patients and take an accurate history and physical. You have to ask them, are there any new medications, probiotics, or supplements they've taken? Oftentimes, patients will not think of probiotics as medicine. They need to tease out that history. So you need to take the accurate history, discuss with a patient what has worked, what has not, and what their expectation is. It's okay to not have a bowel movement every day. It's not okay to go once a month. And so for some patients, their norm is going every other day, and that's acceptable.

There was a study, I want to say a decade ago in the UK, where they surveyed patients, saying, how often do you have a bowel movement? And it could be as frequently as three times a week to three times a day. But there are patients that present to me with constipation, saying, ‘I'm only going once every four or five days,’ and I go, that's not normal. And I go, we have something that can help you with your constipation and to get you closer to what is normal.

Dr. Turck: 
For those just tuning in, you're listening to GI Insights on ReachMD. I'm Dr Charles Turck, and I'm speaking with Dr. Jeffrey Crespin about using polyethylene glycol, or PEG, osmotic laxatives to treat occasional constipation.

So Dr. Crespin, let's turn to the patient experience. How do you typically approach patient counseling when initiating PEG for occasional constipation?

Dr. Crespin: 
Being a gastroenterologist, they're coming to me with GI symptoms. And those GI symptoms can be bloating, pain, or constipation. They may not elaborate a lot about that constipation. They may just say, ‘Well, I'm constipated.’ And then you sort of tease it out further and say, well, when you say constipated, how many times are you going per week? How much time are you spending in the bathroom? Are you having pain going to the bathroom? Are you having bleeding when you're going to the bathroom? Have you had sort of atypical symptoms? Constipation should not cause weight loss. Bleeding, I tell patients, is not a normal symptom. It could be from internal hemorrhoids, but it could be a sign of something more serious.

So as a clinician, we have to take the history. We have to. Now it’s presumed just because they didn't tell you, it didn't happen, so we do have to ask them. And sometimes it does take a couple of times asking during the history to really tease out sort of the full profile. And some patients, as you said, will volunteer a little bit more readily and sort of say, ‘Yeah, I'm in my sixties and I was like clockwork until my fifties.’ Or, ‘I just cut out coffee three weeks ago, and I don't understand what's going on.’ Well, coffee is a diuretic, but it can also help you go the bathroom more often. So I'm not saying you need to go back on the coffee. But on the other hand, I say, this is one reason why you may now have constipation. And then there are certain life stressors that can cause some people to get constipated. So we need to take an accurate history.

So I can feel pretty comfortable making PEG 3350 my go-to first choice for patients that come to me with constipation. Usually I discuss with them that we have a plan here. You can go to your local pharmacy and get the two-week bottle or the 30-day bottle. Or if you're traveling to the Hamptons, you can get the packets and take them with you. And you can feel safe that you're not going to have an accident taking this on your car ride to your summer home, or on your cross country drive to Florida.

And so I discuss with patients that you should see normally a response, really, within the first one to three days We have decades’ worth of data showing that it’s safe and has no cardiac effects, no diabetes effects, no weight gain or weight loss effects. And we can't say that about a lot of other medicines.

Dr. Turck:
Now, before we wrap up, Dr. Crespin, what are some key takeaways you'd like to share with colleagues concerning the role of PEG in supporting patients with occasional constipation?

Dr. Crespin:
I think some of the key takeaways are that PEG has a long track record of efficacy, safety, and tolerability. We don't see any dependence or withdrawal on this medication, unlike some other medications. And I think it's important for clinicians to educate their patients.

Dr. Turck: 
Well, with those final comments in mind, I want to thank my guest, Dr. Jeffrey Crespin, for joining me to discuss how polyethylene glycol osmotic laxatives can help treat occasional constipation. Dr. Crespin, it was great having you on the program.

Dr. Crespin: 
Well, thank you for having me today.

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