Constipation Relief In Adults Who Battle Comorbid Conditions
Overview
Chronic idiopathic constipation (CIC) is a disorder involving complex gut-brain interactions, manifesting through various bowel movement-related and abdominal symptoms. To enhance patient care, this study aimed to gain a deeper understanding of medication use and satisfaction with symptom management in adults diagnosed with CIC. The research analyzed data from a comprehensive nationwide survey conducted in the United States, which included information on demographics, clinical characteristics, comorbid conditions, medication usage, healthcare-seeking behaviors, and satisfaction with symptom control. Participants were categorized into the CIC cohort if they met the Rome IV criteria, with a control group matched 1:1 based on age, sex, race, region, and Charlson Comorbidity Index score. All data were self-reported by the participants.
Introduction
Chronic idiopathic constipation (CIC), also referred to as functional constipation, is a widespread condition characterized by difficult, infrequent, or incomplete bowel movements. It is classified as a disorder of gut-brain interaction, previously known as a functional bowel disorder. While CIC shares certain symptoms and treatment approaches with irritable bowel syndrome with constipation (IBS-C), the two conditions are distinct according to the Rome IV criteria. In the United States, CIC affects approximately 8.7% of the population, with a higher prevalence among women and the elderly.
Despite the existence of formal diagnostic criteria, diagnosing CIC can be challenging. Studies have shown that only about 60% of general practitioners and 70% of specialists can accurately identify CIC when presented with case studies. This difficulty in diagnosis is partly due to the lack of correlation between objective measures, such as bowel movement frequency, and patient-reported symptoms. As a result, CIC is often underdiagnosed, leading to inadequate treatment and management in the general population.
CIC has a profound impact on a patient’s quality of life (QoL) and daily productivity. The negative effects of CIC are comparable to those seen in patients with other chronic conditions, such as chronic obstructive pulmonary disease (COPD), diabetes mellitus, or depression. Patients with CIC often experience significant disruptions in their daily activities, with the condition causing considerable discomfort and stress. The burden of CIC extends beyond the individual, leading to an economic strain on healthcare systems due to increased physician visits, medication use, and reduced patient productivity.
Managing CIC is particularly challenging because there is no definitive cure. Healthcare providers focus on symptom management to alleviate the condition’s burden on patients. Untreated CIC can result in persistent symptoms, including abdominal pain, bloating, fecal impaction, and occasional overflow incontinence. These symptoms can lead to increased emergency room visits and hospitalizations, further exacerbating the burden on both patients and healthcare systems.
Initial treatment for CIC typically involves lifestyle modifications. These may include increasing dietary fiber intake, engaging in regular exercise, and establishing a routine for bowel movements. Over-the-counter (OTC) agents, such as fiber supplements, probiotics, laxatives, and osmotic agents, are also commonly recommended. However, these treatments are not always effective, leading to patient dissatisfaction. As a result, many patients eventually seek prescription therapies. Despite active treatment, whether with OTC or prescription medications, many patients continue to experience constipation, underscoring the complexity of managing this condition. A large 12-month study found that 54.9% of patients with chronic constipation experienced treatment failure, which was defined as a switch in medication, a constipation-related inpatient stay or emergency department visit, or the occurrence of fecal impaction.
The persistent nature of CIC, combined with the challenges of effective treatment, highlights significant gaps in knowledge regarding patient care-seeking behavior and satisfaction with medical therapies. There is a need for further research to better understand how patients use medications and their satisfaction with symptom control. Such insights could lead to more effective treatment strategies and improved patient outcomes.
Also read Chronic Constipation In Adults : A Systematic Study
This study, which involved a large nationwide survey of adults in the United States who met the Rome IV criteria for CIC, aimed to explore the symptom burden, care-seeking behaviors, medication use, and overall satisfaction with symptom control. By examining these factors, the study sought to provide a deeper understanding of the challenges faced by patients with CIC and to identify potential areas for optimizing patient care. The findings of this study could inform the development of more targeted and effective treatment approaches, ultimately improving the quality of life for individuals living with CIC.
Methods
This observational cross-sectional study utilized data from an online survey administered to U.S. adults between August 2020 and December 2021. The survey was designed to represent the national population according to the U.S. Census Bureau’s 2015-2019 American Community Survey 5-Year Estimate. To reduce the impact of seasonal variations, the survey was conducted monthly and was enriched with responses from a population prequalified as having irritable bowel syndrome (IBS) to increase the sample size for comparative analyses. Participants were recruited from the American Health Research Institute’s research panel and received a predetermined reward for completing the survey.
The survey was part of the Acumen Health Research Institute National Health Survey and included a specialized IBS/Chronic Idiopathic Constipation (CIC) module developed with input from clinicians and patient representatives. The survey and its modules underwent institutional review board (IRB) review and user-acceptability testing before data collection. Participants who indicated having IBS, chronic or frequent constipation, or chronic or frequent diarrhea in the comorbid condition checklist were directed to the IBS/CIC module. Those who did not report these conditions continued with the general survey.
The study focused on respondents who met the Rome IV criteria for CIC, while excluding those who met the Rome IV criteria for IBS-C. Quality control measures ensured the validity of survey responses, preventing duplicate participation and identifying fraudulent entries.
Survey participants were required to be at least 18 years old and residents of the United States. Those who self-reported IBS, constipation, or diarrhea in the comorbid conditions checklist were excluded from the control cohort. The CIC cohort was defined based on the Rome IV criteria for CIC. Participants meeting these criteria were referred to as respondents, while control participants were explicitly referred to as the control cohort.
The survey assessed various measures, including demographics, clinical characteristics, comorbid conditions (using the Charlson Comorbidity Index score), generalized anxiety disorder (GAD-7), depression (PHQ-9), and work productivity (measured by presenteeism and absenteeism using the Work Productivity and Activity Impairment questionnaire). Absenteeism reflected the percentage of work time missed due to health problems in the past seven days, while presenteeism indicated the percentage of impairment experienced at work during the same period. Higher WPAI scores indicated greater impairment and reduced productivity.
The IBS/CIC module specifically evaluated bowel movement-related symptoms and abdominal symptoms. These symptoms included incomplete bowel movements, straining, painful bowel movements, changes in the frequency and consistency of bowel movements, bowel urgency, and incontinence. Abdominal symptoms assessed included discomfort, pain, and bloating. Symptom severity was measured on a scale from 0 (not severe) to 10 (extremely severe), and symptom frequency was rated on a five-point scale. Participants ranked the top five most bothersome symptoms from a list that included abdominal pain, discomfort, bloating, distension, straining, painful bowel movements, bowel movement frequency, urgency, stool consistency, incomplete bowel movements, and incontinence.
The study also explored medication use, care-seeking behaviors (including healthcare visits, emergency department visits, and hospital admissions), and satisfaction with symptom control. Respondents were asked if they had ever visited an emergency room or been hospitalized for their symptoms and whether they had accessed these resources within the past 12 months. Satisfaction with symptom control was rated on a seven-point scale ranging from “extremely dissatisfied” to “extremely satisfied.” All data collected were self-reported.
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Key findings from the study include that respondents with chronic idiopathic constipation identified abdominal pain as the most bothersome symptom, with abdominal discomfort and pain being the primary drivers for seeking medical care. The study also suggested that respondents using prescription medications, with or without over-the-counter (OTC) medications, experienced higher satisfaction with symptom control than those relying solely on OTC treatments. The findings highlight the importance of educating patients about prescription medications to help them manage their symptoms more effectively, potentially improving their quality of life.
Analysis
In the study, participants in the Chronic Idiopathic Constipation (CIC) cohort were matched one-to-one with controls based on age, sex, race, region, and Charlson Comorbidity Index (CCI) score. Descriptive statistics were utilized to present demographics and characteristics, with means and standard deviations reported for continuous variables, and percentages for categorical variables. Comparisons between the CIC cohort and their matched controls were performed using chi-square tests for categorical data and analyses of variance (ANOVA) for continuous data. Statistical significance was determined using two-sided tests, with a p-value of less than 0.05 indicating significance. All analyses were conducted using unweighted data and were performed with SPSS® Statistics for Windows, version 28.0 (IBM®, Armonk, New York).
Results
In this observational study, 35,182 participants were enrolled, with 29,359 (83.4%) completing the survey. Among them, 7,435 (25.3%) reported constipation symptoms, and 2,696 (9.2%) met the Rome IV criteria for Chronic Idiopathic Constipation (CIC). Of these, 2,533 respondents were successfully matched with controls.
Demographically, both the CIC cohort and the control group were similar, with the majority being women (68.2%) and White (82.0%), and a mean age of 44.6 years. Regarding medication use, abdominal pain was the most frequent symptom prompting the use of medications, reported by 63.4% of respondents using either prescription or over-the-counter (OTC) medications. Additionally, 15.9% of respondents used both prescription and OTC medications, while 13.3% used prescription medication alone, and 44.6% relied solely on OTC medications.
Common OTC treatments included polyethylene glycol (55.7%), bisacodyl laxatives (39.2%), sennosides (38.2%), and psyllium husk (34.1%). Among prescription treatments, linaclotide (34.6%) and selective serotonin reuptake inhibitors (27.8%) were the most prevalent. Those not using medications often cited mild symptoms (34.6%) or uncertainty about which medication to take (30.4%).
Satisfaction with symptom control varied, with 33.9% of the CIC cohort satisfied with bowel movement control, while 37.6% expressed dissatisfaction. Satisfaction was higher among those using prescription medications (51.7%) compared to those using OTC treatments alone (28.1%).
Symptomatically, more than half of CIC respondents experienced abdominal discomfort (57.6%) and straining during bowel movements (56.4%) within the past week. A significant number reported abdominal pain (49.3%) and bloating (48.8%), and over one-third experienced a sense of incomplete evacuation (36.7%). A notable proportion (31.5%) had been hospitalized or visited the emergency room for bowel or abdominal symptoms, primarily due to abdominal pain (84.4%).
The CIC cohort also reported higher rates of comorbidities, such as chronic pain (62.6%), anxiety (58.4%), and depression (49.9%). Moreover, CIC respondents had significantly higher work productivity losses, increased absenteeism, and greater impairment in daily activities compared to the control group.
Conclusion
This study highlights the significant burden of Chronic Idiopathic Constipation (CIC) on patients, affecting their quality of life, work productivity, and overall well-being. Despite the use of both prescription and over-the-counter medications, many patients remain dissatisfied with their symptom control, particularly for abdominal discomfort and bowel movement issues. The high prevalence of comorbidities, such as anxiety and depression, further underscores the need for comprehensive management strategies to improve patient outcomes. Enhanced education and targeted treatments could lead to better symptom control and improved quality of life for those affected by CIC.
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