Constipation is a common and often distressing problem, but the first line of attack should not be a laxative and especially not the type of laxative that prompted warnings from the Food and Drug Administration this week, experts say.
As health conditions go, constipation — usually defined as having fewer than three bowel movements a week or having stools that are hard, dry and difficult to pass — rarely makes the news. But it's probably not news to most people that almost everyone suffers from it from time to time. Women and people over age 65 are especially affected. About 42 million people at a time, or 15% of the population, have constipation, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
Many of those people will, sooner or later, find themselves in a drugstore aisle, looking for relief and finding what can be a confusing array of products. Among those products: enemas and oral solutions containing sodium phosphate, an ingredient the FDA says can cause dehydration and electrolyte imbalances, especially when taken too often or in higher-than-recommended doses. Most at risk, the FDA says, are young children; people over age 55; those taking several common medications, including diuretics and ibuprofen; and those with kidney disease, heart problems, bowel obstructions or inflamed colons. The best known of these products are enemas made by C.B Fleet Co. Inc. in Lynchburg, Va. (which makes other kinds of laxatives as well).
Before most people reach for any laxative, they should look at their diet and lifestyle, says Eric Widera, a specialist in geriatrics at the University of California-San Francisco. "The ultimate goal is prevention," he says. Eating more fiber, from fruits, vegetables and grains, is the first step, he says, because that adds bulk to stools and helps move digestion along.
Drinking plenty of water and exercising also are recommended, though the evidence they work is not as good, says Spencer Dorn, a gastroenterologist at the University of North Carolina-Chapel Hill.
"People who are active tend to be less constipated," he says.
But the most important lifestyle change may involve taking a break — to use the toilet, Widera says. People who follow the natural rhythms of their colons will often find it's easiest to have bowel movements at the same time of day, often in the morning, after breakfast, he says. Resisting the urge, because you are busy or away from home, for instance, can make constipation worse.
If those measures don't work, the first choice from the drugstore should usually be a fiber supplement, Widera and Dorn agree. Those include products such as Metamucil and Citrucel.
People with more persistent constipation have additional choices. Those include laxatives that draw water into the colon, known as osmotic laxatives, and laxatives that work by stimulating the colon.
The sodium phosphate laxatives are osmotic laxatives, but there are others in that category that don't cause dehydration and electrolyte imbalances, Dorn says. Those include products such as Miralax and milk of magnesia.
Stimulant laxatives, such as Dulcolax and Senokot, may be needed by people with tougher constipation caused by medications such as opioid painkillers, Widera says.
Doctors sometimes recommend stool softeners, though there is not as much evidence they help, Widera says. Some prescription medications also are available.
Widera says he never recommends sodium phosphate laxatives for his elderly patients. Dorn says they may have some use for low-risk patients in whom nothing else works.
The FDA has issued warnings about higher-dose oral versions of sodium phosphate laxatives used for bowel cleansing before colonoscopy and said they should be used only by prescription. Because of those concerns, Fleet took its oral non-prescription version off the market, the company announced in 2008. But it said the enemas were safe.
In its update for consumers this week, the FDA said oral and rectal sodium phosphate products can be used safely for constipation by many older children and healthy adults. It said anyone over age 55 should check with a doctor. It said sodium phosphate enemas should never be given to children under age 2, and caregivers should check with doctors before giving the oral products to children under age 5.
In a statement Friday, Fleet said it "fully supports the efforts of the FDA to encourage the safe use of sodium phosphate products." It encouraged consumers "to follow the recommended dosing instructions as recommended by the FDA."