Occasional Constipation Management: Optimizing Patient Communication

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:
Even though constipation is something many people experience, few actually talk about it, leading to unnecessary discomfort and delayed relief. Polyethylene glycol, or PEG for short, is one of the most commonly recommended options for occasional constipation, but patients often struggle with misconceptions about laxatives and finding the right treatment. So how can we break down these barriers and help patients get the relief they need?

This is GI Insights on ReachMD, and I'm Dr. Charles Turck. Joining me to provide strategies for optimizing PEG therapy is Dr. Kyle Staller. He's an Assistant Professor of Medicine at Harvard University and the Director of the Gastrointestinal Motility Lab at Massachusetts General Hospital. Dr. Staller, welcome to the program.

Dr. Staller:
Dr. Turck, thanks so much for having me.

Dr. Turck:
Well, let's start with some context, Dr. Staller. Why do you think occasional constipation continues to be associated with stigma and is an under-discussed topic in clinical care?

Dr. Staller:
I think a couple of reasons, right? Of course, there is the stigma that we all know when it comes to bowel movements—something that is sort of shameful or kept in secret or private—and that really translates to when patients will show up at the office and feel uncomfortable talking about them.

The second is that really, there hasn't really been a good definition for what occasional constipation is, right? We've talked about chronic constipation in the literature, and a lot of the drugs that are out there—prescription drugs, et cetera—have been studied in chronic constipation, which really has strict, understood criteria. Occasional constipation, on the other hand, which is probably more common, hasn't really had a definition until recently, and so there's recently been some consensus documents that tell us what we should look for and how we can define occasional constipation. And now, with that in hand, we may be able to better understand the scope of the problem and how we can connect patients best to treatments that are out there that could help them improve their symptoms.

Dr. Turck:
Now, in your experience, what are some practical communication strategies that can help normalize the conversation about bowel health, especially during short office visits?

Dr. Staller:
I think the truth is this happens in many topics, right? If the patient senses that you're comfortable talking about bowel movements, then they're going to be comfortable talking about bowel movements.

On a more practical level, I think it's helpful to sort of normalize what is normal. And there has been data from the NHANES study that was published a few years ago, and it sort of helped us put up some guardrails as to what we consider normal bowel habits. And that is, in general, it's normal to have between three bowel movements per day and three bowel movements per week.

And importantly, consistency, which is really a surrogate marker for colonic transit time—how fast things move from one end of the colon to the other—also has normal values. We have a seven-point Bristol stool scale with at one end, type one, which are these hard pellet-like rocks; on the other end, type seven, which is pure liquid.

Most people—90 percent of people—are going to fall somewhere in the sort of three to five range, right? And that four is the sweet spot. That's a smooth, sausage, snake-like poop, if you will—and we'll call it a poop here. Those are really what we kind of define as normal.

So by telling people what we would expect to see as normal, we can then start the conversation as to whether what they're experiencing is abnormal. Now, someone could have infrequent bowel movements and be uncomfortable. That's abnormal. But giving them some guardrails as to what the normal values are can help with that context.

Dr. Turck:
So if we're talking to our patients about the available treatment options and they come back to us with concerns about safety or efficacy, how can we best educate them on PEG and how it works?

Dr. Staller:
I think, specifically, polyethylene glycol really has one of the best safety and efficacy records out there, particularly among the over-the-counter agents that patients are likely to find in their pharmacy aisle.

In fact, if we look at recent consensus guidelines about occasional constipation, PEG is really listed as one of the top options that are out there, along with perhaps some of the stimulant laxatives, and then, as potentially second-line therapy, some of the magnesium-based laxatives.                       

So when we talk with patients about how PEG works, it's important for them to realize that PEG is not a drug that traditionally gets absorbed, goes throughout the body, and then does its thing at whatever tissue it needs to do its thing at. Instead, PEG actually draws water into the colon without really being absorbed itself, and the water that's drawn into the colon then stretches the colon out. And that causes secondary peristalsis. So that stretch of the colon from the influx of water then causes the colon to contract. And when the colon contracts, that leads to softer and more frequent bowel movements.

Dr. Turck:
So Dr. Staller, let's consider patients who start PEG therapy for occasional constipation. What are some common barriers you've seen to appropriate use of this therapy, and how can we help set clear expectations?

Dr. Staller:
Yeah, I think expectations are important here, right? One, it's a powder that needs to be mixed into a drink. That drink, though, can be anything. It doesn't have to be water. It can be your morning coffee or your morning juice. So there is some flexibility there.

There's flexibility on timing too, although traditionally, we probably would tell patients to take it in the morning. If you forget to take it in the morning and you take it later in the day, there's nothing wrong with that, because, really, polyethylene glycol is going to work over the long term of a few days. And that's going to lead to results.

Dr. Turck:
Well, with those final strategies and thoughts in mind, I want to thank my guest, Dr. Kyle Staller, for joining me to discuss how we can optimize PEG therapy for occasional constipation. Dr. Staller, it was great having you on the program.

Dr. Staller:
Thanks so much for having me.

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