How community pharmacists facilitate optimal constipation self-management

While frequently underestimated, the impact of constipation on quality of life is significant [2], emphasizing the need for interventions and proper guidance. Interactions with pharmacists offer the opportunity not only to correct prevalent misconceptions about constipation but also to guide patients towards the most suitable treatment option.

The developed guide (Fig. 1) aims to empower pharmacy staff with essential knowledge and an efficient decision tool to make informed decisions, i.e., when and when not to offer OTC solutions and how to recognize when a more detailed medical consultation is required [1]. 

Before recommending treatments, pharmacists should consider the patient's overall health, focusing on general well-being and specific concerns. Central to this are two screening questions (SQ) to identify potential alarm symptoms that might indicate a more severe underlying disease [1]:

1. “Do you have severe abdominal pain, possibly with vomiting or fever?”
2. “Is there blood in your stool (in the absence of a known cause, i.e., hemorrhoids) or recent significant unexpected weight loss?”

By posing these questions, the algorithm provides the following insights and guiding pathways [1]:

Severe alarm symptoms that prevent laxative use:A positive response to SQ1 regarding severe abdominal pain (with or without vomiting or fever) indicates potential severe gastrointestinal issues requiring an immediate medical consultation within three days, during which no laxatives should be dispensed. Based on severity of the symptoms, antispasmodics or analgesics can be recommended until physician visit. 

Moderate alarm symptoms: Implications of SQ1: If abdominal pain is not severe, OTC medications can be dispensed until physician visit (within 2–4 weeks). In the case of vomiting, laxatives can be dispensed up to three days until physician visit. Implications of SQ2: While both unexpected weight loss (> 5%) and the presence of blood in the stool in the absence of a known cause necessitate clinical evaluation, OTC laxatives are permissible as an interim solution until physician consultation. Specifically, new onset of blood in stool in the absence of a known cause requires immediate medical attention within three days, while weight loss mandates consultation within two to four weeks.

Straightforward cases:When no alarm symptoms are present, and the patient's overall condition is stable, OTC solutions can be confidently recommended for both acute and chronic constipation. Patients with acute or occasional constipation should consult a physician if symptoms persist for two to three months. Chronic symptoms, especially without any prior diagnosis, warrant a physician consultation within two to four weeks, with a potential colonoscopy, particularly for those over 50. Overall, situations signaling a sudden exacerbation in constipation or unsatisfactory symptom relief despite treatment necessitate a timely medical evaluation (2–4 weeks).

The choice of laxative should also consider patients preferences like onset time, taste and application form. Macrogols, bisacodyl, and sodium picosulfate stand out as first-line choices, with evidence backing their safety and efficacy [3]. As stimulant laxatives warrant a faster action and symptom relief (onset time: 6–12 hours), they are particularly suitable as on-demand medication, e.g., in acute or intermittent constipation. For optimal efficacy, macrogols should be taken continuously (onset time: 24–48 hours). Since ensuring regular bowel movements is of greater relevance in chronic constipation rather than prompt relief, macrogols are favorably used in cases of continuous treatment. If a patient does not respond favorably to either of the OTC laxatives, pharmacists can suggest an alternate first-line treatment or even a different drug class. Importantly, contrary to prevalent myths, studies affirm that long-term laxative use remains safe.

The responsibility of a pharmacist goes beyond dispensing medications. Bridging the gap between self-management and medical care, they serve as essential facilitators in patient’s self-care. The provided algorithm further empowers pharmacists in this pivotal role. 

^{Acknowledgements: The authors thank Paula Fontanilla, PhD, an employee of Sanofi, for critically reviewing the manuscript for scientific content and Sima Manmode, an employee of Sanofi, for figure recreation.}

^{Conflict of interest: C. Ude has acted as a consultant/speaker for Bionorica, Infectopharm Arzneimittel, Consilium, and Sanofi. E. Martin worked as a consultant for AstraZeneca, Berlin-Chemie, GSK, Infectopharm, Pfizer, and Sanofi, and gave lectures/seminars for Berlin-Chemie, GSK, and Infectopharm. E. Martin received author’s fees from Avoxa, DAV, WVG, Helmholtz Zentrum and PNN Pharma Nation Network. D. Esen is an employee of Sanofi.  D. Pohl has acted as a consultant for Sanofi and as a consultant/speaker for Schwabe Pharma, Permamed, and Medtronic.} 

^{Disclosure: Publication funded by Sanofi.}