Laxatives: Types, Mechanisms, and Caution

Laxatives are medications that facilitate bowel movements in various ways: by increasing the bulk of intestinal contents, retaining water in the intestinal lumen, enhancing peristalsis, increasing fluid secretion, or accelerating colonic transit. They do not form a single group with identical effects, so the question of "which laxative is best" always depends on the clinical situation. [1]

Constipation itself isn't limited to infrequent bowel movements. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) states that symptoms of constipation include fewer than three bowel movements per week, hard, dry, or lumpy stools, difficult or painful bowel movements, and a feeling of incomplete evacuation. Therefore, laxatives are selected not only based on bowel frequency but also on the primary complaint: hard stools, straining, incomplete evacuation, bloating, or lack of urgency. [2]

A modern approach almost always begins not with medication, but with an assessment of lifestyle and warning signs. The National Institute of Diabetes and Digestive and Kidney Diseases in the United States recommends initially increasing dietary fiber and fluid intake, adding regular physical activity, establishing a regular bowel schedule, and, if possible, eliminating medications that may worsen constipation. Only then is a decision made on whether and which medication is needed. [3]

For adults with chronic idiopathic constipation, the American Gastroenterological Association and the American College of Gastroenterology issued a joint drug therapy guideline in 2023. Among over-the-counter medications, polyethylene glycol received a strong recommendation, while among prescription medications, linaclotide, plecanatide, and prucalopride received strong recommendations. However, fiber, lactulose, magnesium oxide, senna, and lubiprostone received conditional recommendations. [4]

It's crucial to distinguish between episodic constipation and chronic idiopathic constipation. In the episodic form, a short course of over-the-counter medication and regimen adjustments are often sufficient. In the chronic form, a step-by-step regimen must be developed, sometimes combining medications with different mechanisms, and in some cases, identifying an evacuation disorder that responds poorly to conventional laxatives. [5]

Table 1. When a laxative is usually appropriate and when another route is needed

Situation	What is most often appropriate
A short episode of constipation without alarming signs	Self-help, water, fiber, short course over-the-counter remedy
Chronic idiopathic constipation	A step-by-step scheme with the choice of a remedy based on its mechanism and tolerability
Constipation due to opioids	First, laxatives; if refractory, special drugs against opioid constipation
Suspected evacuation violation	Not only laxatives, but also functional diagnostics
Blood in the stool, weight loss, constant pain, vomiting	Not a new package of laxative, but a diagnosis

Sources for the table. [6]

When laxatives are really needed, and when they just mask the problem

A laxative shouldn't be an automatic response to any abdominal discomfort. If a person hasn't urinated for 1-2 days after traveling, changing their diet, becoming dehydrated, or becoming inactive, this doesn't necessarily make the situation a medical condition. However, if hard stools, straining, incomplete evacuation, and infrequent bowel movements occur regularly, laxatives may become part of a sound treatment plan. [7]

Laxatives are especially often needed when lifestyle changes are compounded by medication. The National Institute of Diabetes and Digestive and Kidney Diseases lists aluminum- and calcium-containing antacids, anticholinergics, some anticonvulsants, calcium channel blockers, diuretics, iron supplements, antiparkinsonian drugs, opioid analgesics, and some antidepressants as medications that can worsen constipation. In such situations, a laxative may provide symptomatic relief, but sometimes the underlying medication itself needs to be reconsidered. [8]

There's a downside, too. If constipation is caused not simply by slow transit, but by a lack of coordination between the pelvic floor and anorectal muscles, the response to laxatives may be incomplete. In an interview regarding the joint guideline, Lin Chang specifically emphasizes that some patients with an unsatisfactory response to medications actually have a bowel movement disorder, and in such cases, anorectal manometry, biofeedback, or pelvic floor physiotherapy should be considered, not just the next medication. [9]

Against this backdrop, "red flags" are especially important. The US National Institute of Diabetes and Digestive and Kidney Diseases recommends urgently seeking medical attention for rectal bleeding, blood in the stool, persistent abdominal pain, inability to pass gas, vomiting, fever, lower back pain, and unexplained weight loss. With such symptoms, laxatives may not only be ineffective but may also delay the diagnosis of an intestinal obstruction, tumor, inflammatory disease, or other serious condition. [10]

The age of symptom onset and family history are also important to consider. The diagnostic guidelines from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) recommend that the physician determine the presence of anemia, a family history of colorectal cancer, bowel surgery, weight loss, and other factors that alter the scope of the examination. Therefore, a laxative is a symptomatic treatment tool, but not a substitute for diagnostic testing if suspicious signs are present. [11]

Table 2. Signs that indicate that self-medication with laxatives is not recommended

Sign	Why is this important?
Blood in the stool or bleeding from the rectum	Serious intestinal pathology must be excluded.
Constant abdominal pain	The cause may not only be functional
Inability to pass gases	We need to think about obstruction
Vomit	Intestinal obstruction or other acute pathology is possible
Temperature	An inflammatory or infectious process is possible
Unmotivated weight loss	A search for the causative disease is required
New persistent symptoms in an adult without previous episodes	A medical examination and tests are often needed.

Sources for the table. [12]

The main classes of laxatives and how they work

Bulk-forming laxatives work by increasing the mass of intestinal contents. The UK National Health Service explains that these laxatives increase the bulk and mass of stool, which stimulates the intestines to move the contents. This group includes preparations based on psyllium, methylcellulose, and polycarbophil. They are often used as a gentle starting option, especially if the diet is low in fiber. [13]

Osmotic laxatives retain water in the intestinal lumen, thereby softening stool. The UK National Health Service classifies lactulose, macrogol, and polyethylene glycol as such, while MedlinePlus specifically notes that polyethylene glycol retains water in the stool, increases the number of bowel movements, and facilitates stool passage. Among all over-the-counter laxatives, polyethylene glycol has one of the strongest evidence positions in the current joint guideline. [14]

Magnesium-containing osmotic agents occupy a middle ground between mild and faster-acting. Magnesium hydroxide typically induces bowel movements within 30 minutes to 6 hours and is therefore more often perceived as a faster-acting agent. However, magnesium preparations have an important limitation: they should be used with caution in patients with impaired renal function, as magnesium accumulation cannot be considered safe. [15]

Stimulant laxatives increase colonic motility and fluid secretion. The UK National Health Service (NHS) states that bisacodyl, senna, and sodium picosulfate stimulate the intestinal wall muscles and typically begin to work within 6-12 hours. A joint guideline recommends bisacodyl and sodium picosulfate as short-term or rescue therapy, while senna has received a conditional recommendation as a possible option. [16]

Stool softeners and emollients have traditionally been widely used, but their evidence base is weaker than that of polyethylene glycol or stimulants. Docusate remains a common medication in everyday practice and in some clinical scenarios, but it was not included in the current joint guideline among the 10 recommended pharmacological options with a separate recommendation, whereas polyethylene glycol, magnesium oxide, lactulose, bisacodyl, sodium picosulfate, senna, lubiprostone, linaclotide, plecanatide, and prucalopride received formal recommendations or suggestions. [17]

Rectal forms, such as suppositories or microenemas, are not intended for basic, long-term treatment, but for a more rapid, localized effect. MedlinePlus indicates that rectal bisacodyl suppositories typically take effect within 15-60 minutes, while enemas take effect within 5-20 minutes. This is convenient when a quick, one-time result is needed, but is not suitable as a sole, permanent strategy for chronic constipation. [18]

Prescription medications act differently. Linaclotide, plecanatide, and lubiprostone increase fluid secretion into the intestinal lumen, while prucalopride, a 5-hydroxytryptamine receptor 4 agonist, accelerates colonic transit. A joint guideline recommended linaclotide, plecanatide, and prucalopride as strong recommendations after failure of over-the-counter therapy, while lubiprostone received a conditional recommendation. [19]

Table 3. Classes of laxatives and their main role

Class	Mechanism	Typical examples	Where are they most commonly used?
Volume-forming	Increases stool bulk	Psyllium, methylcellulose	Soft starter therapy
Osmotic	They retain water in the intestinal lumen	Polyethylene glycol, macrogol, lactulose	Basic over-the-counter therapy
Magnesium-containing	Osmotic effect, faster response	Magnesium hydroxide, magnesium oxide	Occasional constipation or isolated regimens
Stimulating	Enhance peristalsis and secretion	Bisacodyl, senna, sodium picosulfate	Briefly, on demand, as a rescue measure
Softeners	Increases the water content in feces	Dokuzat	Limited space, weaker evidence base
Secretagogues	Increase fluid secretion	Linaclotide, plecanatide, lubiprostone	After over-the-counter remedies failed
Prokinetics	Accelerates transit through the colon	Prucalopride	After over-the-counter remedies failed

Sources for the table. [20]

Table 4. How quickly different options typically start working

Tool or class	Normal onset of action
Volume-forming	About 2-3 days
Osmotic	About 2-3 days
Polyethylene glycol	About 2-4 days
Bisacodyl orally	Approximately 6-12 hours
Bisacodyl rectally	Approximately 15-60 minutes
Senna	Approximately 6-12 hours
Magnesium hydroxide	Approximately 30 minutes to 6 hours

Sources for the table. [21]

How is a laxative typically chosen for an adult today?

A modern stepwise approach to chronic idiopathic constipation begins with identifying warning signs and assessing diet. In an interview about the joint guideline, Lin Chang emphasizes that the first step is to rule out warning signs and determine whether the doctor is truly dealing with chronic idiopathic constipation, rather than a structural pathology or other secondary cause. After this, increasing fiber is usually the first line of treatment, especially if the diet is initially low in fiber. [22]

This isn't a blanket recommendation to "eat more fiber for everyone." Lin Chang specifically notes that a physician should consider a person's baseline fiber intake. If a person already eats a lot of fiber and primarily complains of bloating and straining, adding even more fiber may only increase discomfort. In practice, psyllium husk has the best supporting fiber base, while the data for bran and inulin are weaker. [23]

If the response to fiber is unsatisfactory, the next step is usually an osmotic agent. In the algorithm discussed by Lin Chang, the patient maintains the fiber and adds an osmotic agent. Of this group, polyethylene glycol has a strong recommendation, while magnesium oxide and lactulose are conditional. Clinically, polyethylene glycol is often considered before lactulose, as lactulose often causes more gas and bloating. [24]

If this is insufficient, the next step may be a stimulant as short-term or rescue therapy. The same algorithm considers bisacodyl a good on-demand option, especially during periods of increased constipation, such as when traveling or taking new medications. The joint guideline explicitly states the place of bisacodyl and sodium picosulfate as short-term or rescue therapy, rather than as a mandatory daily regimen for everyone. [25]

After over-the-counter therapy fails, prescription medications are often used. Here, linaclotide, plecanatide, and prucalopride receive strong recommendations, while lubiprostone receives a conditional recommendation. The choice between these medications depends not only on symptoms but also on cost, availability, insurance coverage, and side effects. In their commentary on the guideline, both Lin Chang and William Chey emphasize that shared decision-making with the patient and consideration of treatment costs are not secondary considerations, but rather part of the correct approach. [26]

Finally, if even consistent drug therapy is only weakly effective, the question should not be "what other laxative should I add?" but "is there a defecation disorder?" Lin Chang directly states that some such patients have dyssynergic defecation, and in these cases, conventional oral medications are less effective, with anorectal biofeedback or pelvic floor physiotherapy becoming the key treatment. This same idea has long been consistently developed by Satish S.C. Rao in his work on dyssynergic defecation. [27]

Table 5. Modern stepwise tactics for chronic idiopathic constipation

Stage	What do they usually do?
1	Look for warning signs and secondary causes
2	Adjust diet, water, activity, and bowel habits
3	Add fiber, often psyllium, if the diet is low in fiber.
4	If the response is insufficient, they switch to an osmotic agent, most often polyethylene glycol.
5	If necessary, a short-term stimulant is used as a rescue measure.
6	After failure of over-the-counter therapy, linaclotide, plecanatide, prucalopride, or lubiprostone are considered
7	If the response is weak, consider defecation disorder and functional diagnostics.

Sources for the table. [28]

Risks, side effects, and common myths

The most common practical mistake is to assume all laxatives are equally safe simply because many are sold over-the-counter. In reality, their side effect profiles vary greatly. Polyethylene glycol is more likely to cause bloating, cramping, and gas, stimulants are more likely to cause cramping abdominal pain and diarrhea, and magnesium-containing products require caution in patients with kidney failure and taking other medications. [29]

The myth that stimulants "necessarily damage the colon" with any long-term use has been reconsidered in recent years. A 2024 critical review found no convincing evidence that the recommended use of bisacodyl, sodium picosulfate, or senna causes clinically significant colon damage or increases the risk of colorectal cancer. At the same time, the same review emphasized that much of the older research on which these fears were based was poorly designed and did not adequately account for confounding factors. [30]

However, this does not mean that any dose or regimen can be used without supervision. MedlinePlus for bisacodyl and senna warns that frequent or prolonged use may lead to laxative dependence and decreased bowel function. It is important to understand the implications of this recommendation: it is not a prohibition on rational short-term use or a mandatory risk of harm with each course, but rather the risk of improper daily self-medication without assessing the cause of constipation. [31]

A separate risk is confusion between the treatment of constipation and the abuse of laxatives. With abuse, the risk of dehydration, diarrhea, electrolyte disturbances, and arrhythmia increases dramatically, especially if large doses of stimulants or salt osmotic agents are used concurrently. A 2024 review emphasized that hypokalemia and other electrolyte disturbances are primarily associated not with routine recommended use, but with improper use, abuse, or bowel preparation. [32]

It's also important to be aware of drug interactions and administration nuances. MedlinePlus recommends separating magnesium hydroxide from other medications by at least 2 hours, and bisacodyl specifically states that tablets should not be taken within 1 hour of dairy products. These seemingly minor details, but they are precisely why patients often experience less effect or more irritation than expected. [33]

Finally, it's important to distinguish between two distinct issues: "adverse effects" and "inappropriate mechanism." If constipation is caused by pelvic floor dysfunction, a person may spend months trying different laxatives without achieving the desired results, believing they have "the heaviest bowel ever." In reality, the problem isn't that all laxatives are bad, but that the wrong mechanism is being treated. This is why a long history of ineffective medications isn't a reason for a fifth experiment in a row, but rather for a reassessment of the diagnosis. [34]

Table 6. Common side effects and main precautions

Class or means	What happens most often	The main precaution
Fibers	Bloating, gas formation	Adequate fluid is needed
Polyethylene glycol	Bloating, cramping, gas, and sometimes diarrhea	Do not go beyond the recommended regime without a doctor
Lactulose	Gas and bloating	Not the best choice for severe flatulence
Bisacodyl and senna	Cramps, diarrhea	Do not use uncontrolled for weeks
Magnesium hydroxide	Fast stool, sometimes diarrhea	Caution in case of renal failure and taking other medications
Any laxative if abused	Dehydration and electrolyte imbalances	It is especially dangerous with unauthorized constant increase of doses.

Sources for the table. [35]

Special situations: pregnancy, breastfeeding, opioids and refractory constipation

During pregnancy, non-drug measures remain the first step. The UK National Health Service advises that, whether using macrogol or lactulose, a doctor or midwife should first try to correct constipation without medication—by increasing fiber intake, fluids, and gentle physical activity. This is especially important because constipation during pregnancy is often associated with hormonal changes, decreased mobility, and iron supplements. [36]

If diet and exercise are ineffective, macrogol and lactulose are considered acceptable options. The UK National Health Service advises that macrogol is safe to take during pregnancy, and lactulose is not considered harmful to the fetus. Docusate is sometimes used during pregnancy, but not usually as a first-choice medication, as more safety data has accumulated for other options. [37]

Differences between medications are also important during breastfeeding. The UK National Health Service advises that macrogol does not pass into breast milk and is unlikely to cause adverse effects in the baby, and lactulose also does not pass into milk in clinically significant amounts. Docusate is approved, but again with the caveat that it is generally used for the shortest possible time. [38]

Constipation associated with opioids is a different story. The American Gastroenterological Association recommends starting with regular laxatives as first-line treatment for opioid-induced constipation. If the response remains unsatisfactory, the next step is peripheral mu-opioid receptor antagonists: naldemedine and naloxegol are recommended, and methylnaltrexone is suggested as a possible option. In other words, with opioid-induced constipation, the problem may not be the "strength of the laxative," but rather the need for a drug that specifically reverses the opioid effect in the intestines. [39]

Refractory constipation is a separate issue. Satish S. C. Rao's joint manual and work emphasize that some patients with chronic constipation have dyssynergic defecation. In this situation, new laxatives don't address the underlying problem, and anorectal biofeedback and treatment of evacuation disorders provide the best results. Therefore, the term "refractory" should not automatically mean "an increasingly stronger laxative is needed." Sometimes it means "a different diagnosis is needed." [40]

Table 7. Special clinical situations

Situation	What is generally considered a reasonable first choice?
Pregnancy	First, food, water and activity; then, if indicated, macrogol or lactulose
Breast-feeding	Macrogol and lactulose are usually compatible; docusate is acceptable briefly
Constipation due to opioids	First, regular laxatives
Opioid-refractory constipation	Naldemedine or naloxegol, sometimes methylnaltrexone
Suspected dyssynergic defecation	Functional diagnostics and biofeedback
Severe bloating with lactulose	More often, a switch to another osmotic drug is considered.

Sources for the table. [41]

When you need to diagnose the cause, not change your laxative

If a laxative only helps while it's being taken, but the problem quickly returns after discontinuing it, this isn't necessarily a worrying scenario. Chronic idiopathic constipation can indeed require long-term treatment, and some medications don't have a strictly defined shelf life, even if the initial clinical trials were short. However, such a situation still requires an understanding of the underlying cause of the chronic complaints. [42]

The National Institute of Diabetes and Digestive and Kidney Diseases explains that a doctor looks for the cause through a medical history, physical examination, medication evaluation, and, if necessary, laboratory tests. Possible secondary causes include anemia, hypothyroidism, celiac disease, diabetes, inflammation, blood loss, and a family history of bowel disease. Therefore, long-term constipation is not just an inconvenience, but a symptom that sometimes requires a systematic search for the cause. [43]

A particularly alarming situation is when a person is forced to continually increase dosages or try new medications, yet still fails to achieve satisfactory bowel movements. In an interview regarding the joint guidelines, Lin Chang emphasizes that in such patients, it's important to evaluate not only stool frequency but also the specific symptom that remains the primary one: infrequent stools, hard consistency, bloating, incomplete stool, or pain. Sometimes this helps us understand that the problem isn't the strength of the medication, but rather the incorrect targeting. [44]

If constipation has been going on for a long time and is accompanied by blood in the stool, weight loss, anemia, persistent abdominal pain, gas incontinence, or vomiting, self-medication with laxatives is no longer considered safe. The National Institute of Diabetes and Digestive and Kidney Diseases (NID) classifies such symptoms as situations requiring immediate medical attention. This is precisely the case when a laxative may relieve one symptom but miss the underlying problem. [45]

Finally, quality of life must not be forgotten. A joint guideline from the American Gastroenterological Association and the American College of Gastroenterology emphasizes that chronic idiopathic constipation significantly reduces quality of life, and that cost and drug availability play a significant role in treatment selection. Therefore, appropriate constipation care involves more than just pharmacology; it also requires a clear, realistic, and long-term strategy that patients can implement. [46]

Table 8. When it's time to look deeper for the cause

Situation	What does this mean in practice?
No response to consistent over-the-counter therapy	A review of the diagnosis and tactics is needed.
A marked feeling of incomplete evacuation and straining	We need to think about disrupting the evacuation
Constipation began due to new medications	The drug list needs to be revised.
There is anemia, weight loss, or blood in the stool	Diagnosis of the cause is required
There is constant abdominal pain, vomiting, no gas	Urgent assessment is needed, not self-medication.
Constipation greatly impairs daily life.	We need to move from self-help to systemic management

Sources for the table. [47]

FAQ

What laxative is currently considered the most evidence-based first choice for chronic idiopathic constipation in adults?
Among over-the-counter medications, polyethylene glycol has the best evidence base. In a joint guideline of the American Gastroenterological Association and the American College of Gastroenterology, it received a strong recommendation, while fiber, lactulose, magnesium oxide, and senna received conditional recommendations. [48]

Is it possible to start with stimulants, such as senna or bisacodyl, right away?
Sometimes it's possible, but usually it's not necessary. Bisacodyl and sodium picosulfate are considered short-term or rescue therapy in the current guidelines, while senna is considered a possible option with a conditional recommendation. For a permanent baseline regimen, fiber and osmotic agents are often used first. [49]

Is it true that laxatives cause "sluggish bowels" in everyone who takes them for more than a few days?
No, that's a gross oversimplification. A recent review from 2024 found no convincing evidence that the recommended use of stimulants damages the colon or increases the risk of cancer. However, MedlinePlus still warns that frequent and uncontrolled use of bisacodyl or senna can lead to laxative dependence and a decrease in normal bowel function. The risk is primarily associated with improper use and abuse, not with any reasonable course of action. [50]

If you need a quick result, which remedy is usually most effective?
For a quick effect, magnesium hydroxide or rectal bisacodyl are most often used. Magnesium hydroxide typically produces a bowel movement within 30 minutes to 6 hours, while bisacodyl suppositories typically produce a bowel movement within 15-60 minutes. However, this does not make them the best choice for long-term, ongoing control of chronic constipation. [51]

How does polyethylene glycol differ from lactulose?
Both are osmotic laxatives, but polyethylene glycol has a stronger recommendation in the joint guideline, while lactulose has a conditional recommendation. The clinical commentary to the guideline specifically notes that lactulose is more likely to cause gas and bloating, so it is often chosen later than polyethylene glycol. [52]

Is it safe to take laxatives during pregnancy?
Yes, but with some caveats. Initially, diet, water, and gentle activity are recommended. If this isn't enough, the UK National Health Service advises that macrogol is safe to take during pregnancy, and lactulose is not considered harmful to the fetus. Docusate is sometimes used, but not usually as a first choice. [53]

What should you do if constipation develops while taking opioid painkillers?
For opioid-induced constipation, the American Gastroenterological Association recommends using regular laxatives first. If this doesn't help, consider medications that block the opioid effect in the intestines, primarily naldemedine or naloxegol. [54]

When laxatives are barely effective, what should you consider?
One important cause is dyssynergic defecation, which is a lack of coordination of the pelvic floor muscles during bowel movements. With this mechanism, conventional laxatives are often weak, and the best treatment is biofeedback or pelvic floor physiotherapy. [55]

Is it bad if your bowel movements become more regular only with medication?
Not necessarily. Chronic idiopathic constipation can require long-term treatment. It's not so important that the medication is used for more than a few days, but rather that the correct cause is being identified, there are no warning signs, and the dosage is not being overdone. [56]

When is it time to see a doctor and not experiment at home?
When blood in the stool, persistent abdominal pain, vomiting, fever, inability to pass gas, weight loss, or persistent constipation unresponsive to self-care appear. The National Institute of Diabetes and Digestive and Kidney Diseases (USA) considers these symptoms to be reasons for an urgent medical evaluation. [57]

Key points from experts

1. Lin Chang, MD, FAGA, FACG, vice chairman of the Division of Digestive Diseases at the David Geffen School of Medicine at the University of California, Los Angeles, and co-author of the 2023 joint guideline on chronic idiopathic constipation.
Her main thesis is that the treatment of chronic idiopathic constipation should be a framework, not a rigid scheme. She explicitly emphasizes the need for shared decision-making with the patient and consideration of cost, availability, and previous options. In practical terms, this means that there is no single “ideal” laxative for everyone. [58]

2. William D. Chey, MD, FAGA, FACG, professor of medicine and nutrition at the University of Michigan, director of the Gut-Brain Disorders Section, and co-chair of the 2023 joint guideline.
His practical thesis is that treatment choice cannot be separated from cost and insurance coverage. In his commentary on the guideline, he specifically notes that some modern drugs are available only under the brand name and require pre-approval of payment. For clinical practice, this means that the “best evidence” drug may not always be the first realistic choice if the patient cannot afford it. [59]

3. Darren M. Brenner, MD, a gastroenterologist, pelvic floor and motility specialist, professor of medicine at Northwestern University, author of papers on chronic constipation, and contributor to the Rome Foundation expert papers.
His key message is that prescription laxatives should not be automatically used for every occasional constipation. The Rome Foundation consensus document emphasizes that polyethylene glycol and stimulants are reasonable first interventions, and prescription medications should be reserved primarily for chronic constipation. This helps avoid overtreating brief episodes and confusing occasional constipation with a chronic disorder. [60]

4. Satish S. C. Rao, MD, PhD, professor of medicine, chief of the division of gastroenterology and director of the Center for Digestive Health at Augusta University, is one of the world's leading experts on dyssynergic defecation and biofeedback.
His main thesis is that not all refractory constipation can be treated by increasing laxatives. His work emphasizes that dyssynergic defecation is common and is the leading problem in a significant proportion of patients with chronic constipation, and biofeedback is superior to many other methods. The practical conclusion is simple: if medications are not helping well, sometimes what is needed is not a new remedy, but functional diagnostics and pelvic floor therapy. [61]

5. Seth D. Crockett, MD, MPH, a gastroenterologist and clinical epidemiologist, is an instructor at the University of North Carolina School of Medicine and the lead author of the American Gastroenterological Association's opioid-induced constipation guidelines.
His key thesis concerns a specific patient population: opioid-induced constipation is treated initially with conventional laxatives, followed by refractory treatment with peripheral mu-opioid receptor antagonists, primarily naldemedine and naloxegol. This is important because opioid-induced constipation has a different mechanism than regular chronic constipation and often requires a different treatment approach. [62]