PEG 3350
Place In Therapy
After reviewing the available literature pertaining to Polyethylene glycol 3350 (PEG), there is considerable evidence as to support its use in the management and treatment of chronic constipation in the self-care population.
The primary and secondary literature shows that osmotic agents, namely PEG and lactulose, are deemed effective and safe for use in chronic constipation (1)(2)(3)(4). Due to their overall favourable safety and efficacy, guidelines suggest the use of osmotic agents as second line therapy (1)(2), following an inadequate response to a gradual increase in fibre intake in the management of chronic constipation (1). Polyethylene glycol 3350 (PEG) has been consistently shown to increase stool frequency and improve stool consistency in trials (1)(2)(3)(5)(6). PEG has also been found to facilitate discontinuation of other laxatives (1). Evidence in primary and secondary literature suggests PEG has superior efficacy compared to lactulose in the management of CC. PEG has been found in trials to have a superior efficacy in terms of weekly stool frequency and form of stools compared to lactulose (6). It is important to be aware of the limitations of the systematic Cochrane review, which states PEG is a more effective than lactulose in the management of CC (e.g.: trial heterogeneity and lack of standardized CC criteria and symptom scoring in trials). Though found to have similar stool frequency, form and ease of passage to lactulose in some trials, PEG has been reported to be superior to lactulose in terms reducing total colonic transit time (4). PEG is also preferred over lactulose in global and subjective assessments, potentially due to its ease of administration compared to lactulose especially in pediatric populations (4).
Regarding the safety of PEG, literature indicates PEG is generally well tolerated with side effects comparable to placebo (5). Though flatulence, transient diarrhea, nausea, retching, abdominal bloating, cramping, and anal irritation have been reported with the use of PEG (3)(5)(7). PEG has been used safely for up to 6 months in clinical trials in the management of chronic constipation (1)(5). Furthermore, the use of PEG in the management of CC has been studied in children, adults and the elderly and is deemed effective and appropriate for use in these populations (1)(2)(3)(4)(5)(6). Caution should be undertaken in the elderly in terms of close monitoring for fluid and electrolyte loss due to dehydration secondary to diarrhea (7). PEG should not be used in patients with bowel obstruction or intestinal perforation due to structural or functional disorders or gut wall, Crohn’s disease, ulcerative colitis or toxic megacolon (7)(8). These patients have been excluded from trials. Caution should be used in pregnancy and lactation due to lack of trials on safety and efficacy in these populations (7).
References
1.
The primary and secondary literature shows that osmotic agents, namely PEG and lactulose, are deemed effective and safe for use in chronic constipation (1)(2)(3)(4). Due to their overall favourable safety and efficacy, guidelines suggest the use of osmotic agents as second line therapy (1)(2), following an inadequate response to a gradual increase in fibre intake in the management of chronic constipation (1). Polyethylene glycol 3350 (PEG) has been consistently shown to increase stool frequency and improve stool consistency in trials (1)(2)(3)(5)(6). PEG has also been found to facilitate discontinuation of other laxatives (1). Evidence in primary and secondary literature suggests PEG has superior efficacy compared to lactulose in the management of CC. PEG has been found in trials to have a superior efficacy in terms of weekly stool frequency and form of stools compared to lactulose (6). It is important to be aware of the limitations of the systematic Cochrane review, which states PEG is a more effective than lactulose in the management of CC (e.g.: trial heterogeneity and lack of standardized CC criteria and symptom scoring in trials). Though found to have similar stool frequency, form and ease of passage to lactulose in some trials, PEG has been reported to be superior to lactulose in terms reducing total colonic transit time (4). PEG is also preferred over lactulose in global and subjective assessments, potentially due to its ease of administration compared to lactulose especially in pediatric populations (4).
Regarding the safety of PEG, literature indicates PEG is generally well tolerated with side effects comparable to placebo (5). Though flatulence, transient diarrhea, nausea, retching, abdominal bloating, cramping, and anal irritation have been reported with the use of PEG (3)(5)(7). PEG has been used safely for up to 6 months in clinical trials in the management of chronic constipation (1)(5). Furthermore, the use of PEG in the management of CC has been studied in children, adults and the elderly and is deemed effective and appropriate for use in these populations (1)(2)(3)(4)(5)(6). Caution should be undertaken in the elderly in terms of close monitoring for fluid and electrolyte loss due to dehydration secondary to diarrhea (7). PEG should not be used in patients with bowel obstruction or intestinal perforation due to structural or functional disorders or gut wall, Crohn’s disease, ulcerative colitis or toxic megacolon (7)(8). These patients have been excluded from trials. Caution should be used in pregnancy and lactation due to lack of trials on safety and efficacy in these populations (7).
References
1.
- P Paré, R Bridges, MC Champion, et al. Recommendations on chronic
constipation (including constipation associated with irritable bowel syndrome)
treatment. Can J Gastroenterol 2007;21(Suppl B):3B-22B. - American College of Gastroenterology
Chronic Constipation Task Force.
An Evidence-Based Approach to the Management of Chronic
Constipation in North America.
American Journal of Gastroenterology. 2005; 100(S1)S1-S4.
- Brandt LJ, Prather CM, Quigley EMM,
Schiller LR, Schoenfeld P, Talley NJ.
Systematic Review on the Management of Chronic Constipation in
North America. American
Journal of Gastroenterology. 2005; 100(S1)S5-S22.
- Gremse D, Hixon J, Crutchfield A.
Comparison of Polyethylene Glycol 3350 and Lactulose for Treatment of
Chronic Constipation in Children. Clinical Pediatrics
2002;41:225. - DiPalma JA, Cleveland MV, McGowan J,
Herrera JL. A Randomized, Multicenter, Placebo-Controlled Trial of
Polyethylene Glycol Laxative for Chronic Treatment of Chronic
Constipation. The American Journal of Gastroenterology. 2007;102
(7):1436-1441. - Lee-Robichaud
H, Thomas K, Morgan J, Nelson RL. Lactulose
versus polyethylene glycol for chronic constipation. Cochrane
Database Syst Rev. 2010;(7):CD007570. - Polyethylene Glycol 3350. Lexi-drugs
online. 2010. Accessed March 2, 2012 at http://online.lexi.com/crlsql/servlet/crlonline. - Larkin PJ, Sykes NP, Centeno C, et al. The management of
constipation in palliative care: clinical practice recommendations.
Palliative Medicine 2008; 22(7): 796 –
807. - Bowles-Jordan J. Gastrointestinal
Conditions Chapter 31: Constipation. Patient Self-Care: helping your
patients make therapeutic choices. 2nd ed.
(2010).pp262-279. - Polyethylene Glycol.
Health Canada. Drug and Health Products: Drug Product Database
Online Query. Accessed March 2, 2012 at
http://webprod3.hc-sc.gc.ca/dpd-bdpp/dispatch-repartition.do?lang=eng