Laxative logic: when lifestyle is not enough.

PURPOSE OF REVIEW: Chronic constipation remains challenging to manage, particularly when lifestyle measures prove insufficient. With an expanding range of pharmacologic options available, clinicians face the task of choosing the right agent for the right patient. This review explores recent developments in prescription laxatives and their evolving role in practice.

RECENT FINDINGS: Randomized controlled trials have confirmed the safety and efficacy of newer prescription laxative agents including secretagogues (linaclotide, lubiprostone, plecanatide), sodium/hydrogen exchanger isoform 3 (NHE3) inhibitors (tenapanor), serotonin 5-hydroxytryptamine receptor agonists (prucalopride), and bile acid reabsorption inhibitors (elobixibat). Each drug offers its own unique advantages, with new evidence suggesting these therapies may provide symptom relief beyond managing stool consistency alone.

SUMMARY: Patients with constipation now have access to a wide range of medications, from over-the-counter osmotic and stimulant agents to prescription laxative combination strategies. This breadth allows clinicians to tailor therapy to diverse pathophysiology and symptom profiles. Yet despite this choice, real-world adherence remains poor and many patients are dissatisfied, reflecting the complexity of treating constipation and frequent mismatches between therapy and patients' most bothersome symptoms. Management should emphasize careful symptom assessment, shared decision-making, and clear expectation setting, while leveraging the available armamentarium.