Constipation in MSA

Symptoms and Treatments

Autonomic dysfunction may slow the normal, rhythmic movement of the digestive tract, known as peristalsis, resulting in bloating, decreased appetite, and constipation. Certain drugs also inhibit peristalsis. As a result, constipation is a common problem for patients with Parkinsonian conditions.

 

Non-Pharmacological Treatment Options

 

Exercise

Physical exercise helps activate peristalsis, improves stomach emptying, and is protective against colon cancer, which is more prevalent in people who experience chronic constipation3. Stay as active as possible by walking daily, participating in group exercise classes, and enlisting the services of a physical therapist who can design an exercise program tailored to your needs and abilities.

Hydration

Drink at least 8 glasses, about 2 quarts, of water per day – more in warm weather or if you exercise vigorously – to ensure proper hydration of the bowel contents. A convenient way to keep track of how much water you drink is to measure out your daily allotment in the morning and use that as your drinking water throughout the day. Warm liquids will promote peristalsis, while cold liquids may inhibit proper bowel function and cause uncomfortable muscle cramping. Also, bear in mind that coffee, tea, and some herbal teas act as diuretics, drawing water out of your system that can lead to dehydration. To avoid the dehydrating effects of these beverages, drink decaffeinated coffees and teas. Alternatively, you can offset their diuretic effects by consuming extra water.

Fiber

A high-fiber diet is essential for promoting healthy gut function and preventing constipation. Eat plenty of whole grains, beans, fresh or dried fruit, and vegetables. Fiber supplements, such as psyllium, may help, but they could also further slow peristalsis and worsen constipation. If you use a fiber supplement, be sure to consume sufficient water to allow for the hydration and expansion of the fiber.

Bulk-Forming Laxatives

Psyllium, the seeds of plants in the genus Plantago, was found in a research review to be the most effective remedy for chronic constipation in older adults4. High levels of soluble fiber in psyllium absorb water and swell, forming a gel that adds bulk to the contents of the intestinal tract, which stimulates peristalsis, the rhythmic muscular contractions of the colon. Psyllium is the active ingredient in the over-the-counter laxative Metamucil. When taking psyllium or other bulk-forming laxatives, it is important to consume sufficient fluids or the soluble fiber will form a hard mass, which can cause intestinal blockage. If you have swallowing difficulty, it may be easier to take psyllium in capsules rather than consuming it in a loose form mixed with water. Other, natural bulk-forming laxatives that you can incorporate into your diet include flaxseed and fenugreek5.

Calcium polycarbophil, brand name FiberCon, a synthetic, bulk-forming laxative, has been found to be nearly as effective as psyllium4. Calcium polycarbophil significantly decreases inflammation in the lining of the colon caused by chronic constipation6 and has been shown to shorten transit time through the colon and increase frequency of bowel movements in MSA patients7. Potential minor side effects of calcium polycarbophil include stomach pain, bloating, and gas8. Serious, though less common side effects include vomiting, difficulty swallowing, chest pain, and rectal bleeding8. If these occur, seek medical attention.

Stool Softeners

Docusate sodium and docusate calcium coat the surface of the stool to soften it and allow for easier passage9. However, they do not promote peristalsis, the muscular intestinal action that moves contents through the colon, so these compounds are often combined with stimulant or bulking laxatives9. Docusate is generally safe and well-tolerated10. Reported side effects include intestinal cramping, skin rash, and depletion of magnesium10.

Non-Absorbable Sugars

Polyethylene glycol, brand name Miralax, and lactulose, brand name Cephulac, are non-absorbable sugars that work by promoting secretion of water into the intestinal tract11. Polyethylene glycol tends to be more effective than lactulose for chronic constipation. These can occasionally cause electrolyte imbalance that can impact heart and kidney function11. Less serious side effects include abdominal cramping, nausea, bloating, and flatulence11.

Stimulants

Anthraquinone, the active ingredient in the herbs senna, aloe, and cascara segrada, stimulate peristalsis by irritating the lining of the colon. They work quickly, usually within hours, but may cause abdominal cramping. They are best used on a short-term basis, as long-term use of these drugs can cause dehydration, deplete sodium and potassium levels, and damage the nerves and muscle of the intestinal tract. As a result of these dangerous side effects, the Food and Drug Administration (FDA) has banned their use in over-the-counter laxatives12.

Pharmacological Treatment Options

Serotonin-Promoting Drugs

Serotonin-promoting drugs that have been found helpful in patients with chronic constipation include mosapride citrate, name brand Mosapride, and prucalopride, name brand Resolor (not currently available in the US) 15. Mosapride citrate has been found to increase transit speed of the small intestine, increase frequency of bowel movements, and decrease abdominal pain in patients with chronic constipation16. Mosapride citrate has been found to be helpful in patients with chronic constipation due to irritable bowel syndrome (IBS) 15, 16 and causes few or no side effects13.

Fatty Acids

Lubiprostone, trade name Amitiza, a fatty-acid compound, is the most recent drug to receive FDA approval for treating chronic constipation14. It draws water into the colon, speeding the passage of stool. Lubiprostone takes effect within 24 hours in more than half of patients and does not cause rebound constipation if the drug is stopped14. A third of participants in one trial reported a side effect of nausea, which decreased if the drug was taken with food. Other side effects of lubiprostone include headache, diarrhea, abdominal distention, abdominal pain, and gassiness14. In a review of laxatives for older adults with chronic constipation, lubiprostone was 39% more effective than placebo19.

Linaclotide, trade name Linzess, also has been shown to be effective for constipation. Diarrhea is the most common side effect of this medication. Linaclotide begins to take effect within the first 24 hours and also relieves symptoms of cramping and bloating. In clinical trials, there was no evidence of rebound constipation upon withdrawal from linaclotide20.

Pain Management

Gabapentin (Neurontin) and pregabalin (Lyrica), drugs that promote activity of the calming neurotransmitter GABA, have been used to help reduce pain and hypersensitivity of the intestinal tract11.

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