Burden of Constipation: Looking Beyond Bowel Movements : Official journal of the American College of Gastroenterology | ACG

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Official journal of the American College of Gastroenterology | ACG

Burden of Constipation: Looking Beyond Bowel Movements

Harris, Lucinda A. MD1; Chang, Christopher H. MD, PhD2

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The American Journal of Gastroenterology 117(4S):p S2-S5, April 2022. | DOI: 10.14309/ajg.0000000000001708
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Abstract

INTRODUCTION

Chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) are associated with significant social, medical, and economic burdens. As of 2021, CIC affects 11.7% of the global population and IBS-C affects 1.3% (1). The prevalence of irritable bowel syndrome in adults based on Rome IV criteria is 4.1%, with approximately a third of them meeting the IBS-C subtype criteria (1).

Although separate diagnoses, CIC and IBS-C present with overlapping symptoms, including abdominal pain, difficulty with defecation, bloating, and distension, and are considered by some to exist along a spectrum, with abdominal pain, frequency, intensity, and discomfort of symptoms determining severity (2–7). Along this continuum, patients can fluctuate between the diagnosis of either CIC or IBS-C (3,5,8), making differentiating between the 2 conditions difficult (8). Patients with IBS-C commonly experience visceral hyperalgesia and allodynia (collectively, visceral hypersensitivity) (9). While the Rome IV criteria classify pain as the predominant symptom of IBS-C, Rome concedes that individuals with CIC can also experience this symptom. However, individuals with CIC should not identify pain as their predominant symptom (6). Patients are generally diagnosed with CIC when they do not meet the full criteria for IBS-C (6,10). Ultimately, differentiating between CIC and IBS-C may not be crucial because multiple treatment options are indicated and approved for both conditions.

The aim of this review is to summarize the burdens experienced by individuals with CIC and IBS-C, highlighting differences in the patient experience with constipation symptoms, symptom impact on health-related quality of life, and challenges in receiving effective care.

COMORBIDITIES

Generally, patients with CIC or IBS-C present with a variety of comorbidities. The most common comorbidities associated with CIC include diabetes and obesity, whereas patients with IBS-C experience overlapping psychological comorbidities (anxiety/depression), functional dyspepsia, and conditions outside of the gastrointestinal tract, such as fibromyalgia and interstitial cystitis (11). Because comorbidities are so common in patients with CIC or IBS-C, management of symptoms can be challenging, further emphasizing the need for individualized treatments (11–13).

QUALITY OF LIFE AND THE BURDEN-CIC AND BURDEN IBS-C STUDIES

Symptoms of both CIC and IBS-C have a significant burden on the health-related quality of life (4,14,15). Patients often report difficult bowel movement, bloating, abdominal discomfort, and abdominal pain as the most bothersome symptoms (4,5,16). In addition, the most common comorbid emotional symptom reported for both CIC and IBS-C is frustration, followed by acceptance (4,15). Interestingly, patients and healthcare providers (HCPs) have disparate perceptions of the emotional toll induced by CIC and IBS-C (Table 1) (4,15). Significantly more patients report greater acceptance, less frustration and obsession, and better control of their CIC or IBS-C symptoms compared with HCPs' perceptions of their patients' challenges (4,15). Consequently, this disparity between patients' and HCPs' perceptions can have a significant effect on the ability of HCPs to optimize treatment for individual patients.

T1
Table 1.:
Patient attitudes to CIC and IBS-C compared with HCPs' perceptions of patient attitudes from the BURDEN studies (4,15)

The disconnect between patients' and HCPs' perceptions was investigated in the BURDEN-CIC and BURDEN IBS-C studies, which reported that both CIC and IBS-C affect physical, mental, and social aspects of patients' lives (4,15). The 2 studies noted that only a minority of patients were satisfied with the care they were receiving for their condition (4,15). Only 40% and 36% of patients with CIC and IBS-C, respectively, reported satisfaction with over-the-counter (OTC) medications, whereas 56% and 37% of patients were satisfied with prescription therapies (4,15). In total, 60% of patients with CIC indicated that their condition on average interfered with personal activities 4 days per month, and 25% of respondents missed an average of 60 days of work or school per year (4). Patients with IBS-C experienced a similar personal and work-related or school-related impact (4 and 5 days each month, respectively) (15). Only one-fifth of all patients believed their CIC or IBS-C symptoms were under control (4,15), emphasizing the need to better understand constipation disorders from the patient perspective to improve the current standard of care.

PATIENT PERSPECTIVE OF CIC AND IBS-C

Patients with CIC and IBS-C commonly report feelings of frustration, shame, and embarrassment because their symptoms result in helplessness, poor self-image, and social withdrawal (4,17,18). However, only a small proportion of patients with chronic constipation seek medical care because embarrassment breeds a reluctance to discuss bowel habits with their HCP (17). For example, among patients with undiagnosed IBS-C (i.e., patients who met Rome IV criteria for IBS-C based on questionnaire responses but had not been formally diagnosed by an HCP), almost two-thirds had not discussed their symptoms with an HCP (15).

Even so, for those patients who do consult an HCP, a diagnosis of CIC or IBS-C is not guaranteed. The variety of symptoms (4), the fluctuating nature of those symptoms, and the lack of specific disease biomarkers make diagnosing CIC or IBS-C challenging (17,19). Consequently, many patients with chronic constipation may not receive a definitive diagnosis, which may contribute to the performance of unnecessary invasive tests, an increase in patient anxiety regarding symptom etiology, and an increase in healthcare-seeking behavior (17,20). In addition, patients in these studies were not queried about their knowledge of current therapies. Patients may be unaware of available treatment options or potentially more efficacious options compared with their current treatment, which may contribute to acceptance of their symptoms.

Insurance providers can also contribute to roadblocks to optimized treatment, with prescription prices and costs used in lieu of clinical efficacy to tier treatment preferences. This process stands in contrast to patient-centered cost-effectiveness modeling data, which have identified time, financial commitment, and impact on absenteeism as important factors to be incorporated into treatment decision algorithms (21). Newer prescription medications usually require previous authorizations and documentation of failed responses to older, less evidence-based therapies. Such obstacles further impede treatment optimization and increase patient and HCP frustration (21,22).

These issues are further compounded by the fact that symptom-based diagnoses such as CIC and IBS-C may not be accepted (23). For example, only 1 in 13 patients diagnosed with a disorder of gut–brain interaction agrees with their diagnosis (23). This affects patient adherence to treatments and may predicate recurrent HCP consultations (18,23). It is crucial that patients receive clear explanations of their diagnoses and that HCPs actively seek to understand patients' concerns and goals of treatment (24) because involvement in treatment decisions improves patient adherence and overall satisfaction (24).

SEX AND CULTURAL INFLUENCES ON DISEASE BURDEN AND SYMPTOM REPORTING

Significant differences exist between men and women in the experience of constipation. Women with IBS report significantly lower health-related quality of life than men (25,26), and this difference is attributed to multiple influences. Because women are socialized to consider the discussion of bowel function private, women with IBS are more likely to report shame and embarrassment related to their bowel movements than men (27), a potential barrier to women seeking treatment. Women also report greater bloating and abdominal distention than do men (18,28), which may be influenced by the sociocultural view that a slim profile equates to attractiveness; thus, women may be hypervigilant to any signs of bloating and abdominal distention compared to men (18). It should be noted, however, that visible distention occurs only in approximately half of patients with bloating (18). The menstrual cycle has also been shown to influence IBS symptoms (18,29). Higher levels of progesterone and estradiol, which occur during the luteal phase of the menstrual cycle, delay gastrointestinal transit, causing firmer stools (29). In addition, estrogen is believed to contribute to visceral hypersensitivity in women (14,25).

Overall, patients with IBS-C are more likely than patients with CIC to seek healthcare consultation (5). However, constipation subtype is associated with sex and cultural differences regarding patients seeking medical advice. Women with IBS are more likely to seek medical care in the United States than men, whereas in Asian countries, men are more likely to seek medical care than women (14,25). By contrast, men with CIC in the United States are more likely to seek medical care compared with those in several other countries, where it is more common for women to seek health care for CIC (30–32).

The decision to access health care for constipation and its symptoms can differ by ethnicity (31). A recent US study revealed that non-Hispanic Black individuals were 46% more likely to seek healthcare than non-Hispanic White individuals (31). Although the reason for this difference is unknown, it could reflect cultural differences in seeking health care and how specific symptoms were conveyed to HCPs (31).

ECONOMIC BURDEN

Direct costs attributed to constipation-related health care in the United States are estimated to be greater than US$230 million per annum (22,33). Both CIC and IBS-C patients are associated with similar and significantly higher use of outpatient services, imaging, and diagnostic tests compared with the general population (34). In the United States, nearly half of patients seeking health care for CIC or IBS-C receive a colonoscopy (31). Although patient insistence often drives demand for colonoscopy (35), its efficacy in identifying underlying causes of CIC or IBS-C is limited. As such, current IBS guidelines recommend against the use of colonoscopy as part of a standard diagnostic assessment for IBS-C (36). Colonoscopy is just one example of unnecessary diagnostic testing that is overused and further contributes to the economic burden of constipation disorders on healthcare systems (31,35). In addition, it has been reported that IBS patients in the United States receive high amounts of medical radiation through radiological examinations such as computed tomography scans, which in addition to raising their healthcare costs increase their risk for malignancy (37).

TREATMENT BURDEN

Nearly two-thirds of individuals with constipation do not seek care from an HCP (5,31), and fewer than half take medications (31). The reason for the latter may be multifactorial. Undiagnosed patients generally report infrequent stools as their first symptom of constipation (4) and report less bothersome abdominal symptoms compared with those diagnosed with CIC or IBS-C (4,15). Consequently, they may determine that their symptoms fall below a threshold necessitating the use of medicine. Alternatively, patients' perceptions or attitudes regarding the etiology of their constipation could influence management. If they believe that their constipation is caused by diet or decreased water intake, they may be more likely to attempt to make lifestyle changes instead of using medication to resolve their symptoms (31).

Among patients who report using medication to manage their constipation, most (94%) were taking only OTC medications, whereas 1% used only prescription therapies. The remaining 5% were taking a combination of OTC and prescription medications (31). This significant difference between the use of OTC and prescription medications may reflect the observation that only approximately one-third of patients had discussed their constipation symptoms with their HCP (31). Hence, many patients may not be aware of prescription options, especially if their HCP is not a gastroenterologist (31). For example, the BURDEN-CIC study indicated that 40% of patients used an average of 3 OTC products before consulting their HCP (4). Only 22% of patients reported being offered prescription medication, and 38% received recommendations to continue using their current OTC therapy (23% with a dosage change) (4). Of the patients offered prescription medication, only 16% adopted the recommendation (4). Comparatively, despite increased symptom severity with IBS-C vs CIC, a similar number of patients (22%) reported prescription medication being recommended, and only 12% reported currently using prescription medication for their IBS-C symptoms (15).

BURDEN OF TREATMENT-RELATED ADVERSE EVENTS

The main challenges HCPs face with managing patients' CIC or IBS-C symptoms with prescription medication include patient adherence and inadequate treatment responses, followed by the need to manage treatment-emergent diarrhea (4,15). Treatment-emergent diarrhea is a common adverse event experienced with both OTC and prescription medications (4,15), and most HCPs and patients with CIC or IBS-C do not consider diarrhea as an acceptable outcome (4,15). Notably, in the BURDEN-CIC study, 53% of patients who discontinued prescription medication did so because of the adverse event of diarrhea (4). For patients with IBS-C, the lack of treatment options remains a key issue, whereas there are more treatment classes and options available for patients with CIC (4).

CONCLUSIONS

There are several factors and barriers to care, which contribute to the high social and economic burdens of patients with CIC and IBS-C. CIC and IBS-C are 2 disorders considered by some to exist along a spectrum, with bowel and pain severity determining where a patient resides along this continuum. The overlapping nature of constipation symptoms and comorbidities in CIC and IBS-C pose challenges to treatment strategies underscoring the need for an individualized treatment. Constipation disorders are associated with relatively high levels of economic and social burdens amplified by patients' general low satisfaction levels with current management options. To improve the current standard-of-care alignment between patients and HCPs on the perceived challenges of constipation, management is necessary. Of importance, differences are observed between women and men and among different ethnicities in symptom reporting, quality-of-life impairments, and pursuit of treatment; these differences should be considered in the management of each patient. Patients with CIC and IBS-C face significant social and economic burdens. Social burdens are presented as feelings of frustration, shame, and embarrassment, which lead to poor self-image and social withdrawal. Economic burdens include the need for insurance authorization and documentation of failed response to previous therapy, overuse of unnecessary diagnostic tests, underuse of available treatment options, and management of adverse events. To minimize the burden of CIC and IBS-C symptoms on their patients, HCPs should establish a patient-centric management approach that accounts for comorbidities, quality-of-life impacts, demographic and cultural differences, previous medical experiences, and discussion of available therapies. By establishing a clear understanding of their patients' experience with CIC or IBS-C and discussing strategies to manage their most bothersome symptoms, HCPs can develop individualized treatment strategies to improve standard of care and alleviate social and economic burdens.

CONFLICTS OF INTEREST

Guarantor of the article: Lucinda A. Harris, MD.

Specific author contributions: All authors participated in the advisory board discussion. All authors contributed to the drafting of the manuscript, provided critical revision of all manuscript drafts for important intellectual content, and approved the final version for publication.

Financial support: This supplement was funded by Salix Pharmaceuticals, Inc.

Potential competing interests: L.A.H. is a consultant for Allergan Pharmaceuticals, Alnylam, Gemelli Biotech, Ironwood Pharmaceuticals, the Rome Foundation, Salix Pharmaceuticals, and Takeda (Shire). C.H.C. has received honorarium from Salix Pharmaceuticals for the advisory board.

ACKNOWLEDGEMENT

Medical writing and editorial assistance was provided by Julie O'Grady, BA, and Kate Katsaval, BSc, of The Medicine Group, LLC (New Hope, PA). Funding for the advisory board meeting and medical writing support was provided by Salix Pharmaceuticals, Inc., in accordance with Good Publication Practice. The authors especially thank Wm. Lesley Castro for his significant contributions at the onset of this work before his passing.

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