Constipation: the unglamorous guide

Why we wrote this one first

Of all the things members say they wish they had handled sooner, this is top of the list and it is not close. Nausea gets talked about. Fatigue gets talked about. Constipation gets endured in silence for six weeks and then turns into an out-of-hours appointment, a great deal of misery and, for a handful of members, a hospital visit.

So we are going to be direct about it, and if you find the subject mortifying, that is exactly why the guide exists. Tomás reckons he has had this conversation four hundred times and reports that the embarrassment evaporates in about ninety seconds once somebody else goes first.

In STEP 1 (Wilding, NEJM, 2021) constipation was among the commonly reported adverse events on semaglutide, clearly more frequent than on placebo, and the same is true across the tirzepatide programme (SURMOUNT-1, Jastreboff, NEJM, 2022). It is not an unusual reaction or a sign you are doing something wrong. It is one of the two or three things this drug class does to a digestive system.

What is actually happening

Three things at once, which is why single fixes often disappoint.

Transit has slowed. These medicines slow gastric emptying and reduce gut motility more generally. Material moves through more slowly, and the longer it sits in the colon the more water is drawn out of it.

You are eating less. Less volume in means less bulk moving through, and for many people it also means considerably less fibre than they used to get without thinking about it.

You are probably drinking less than you think. Appetite suppression tends to blunt thirst signalling as well, and the drink you used to have with a large meal has gone with the large meal. Dry stool plus slow transit is the whole mechanism in six words.

All three are worth attacking, and the order matters: fluid first, then movement, then fibre, then a pharmacist. Adding fibre while dehydrated is the classic mistake and reliably makes people feel worse — we go into it in fibre, gently.

What members have found helps

Collected from our constipation-and-gut circle. Not a protocol, not trial evidence, and people contradict each other in places, which we have left in.

• Fluid, unromantically and constantly. The single most repeated fix. Not one heroic pint but a mug on the go all day. Warm drinks first thing help a lot of people.
• Walking. Twenty minutes after a meal comes up again and again, including from people who resent being told it.
• Fibre added slowly, from food where possible. Oats, ground linseed, kiwi fruit, prunes, beans if you tolerate them. Added over a fortnight, not in one determined afternoon.
• A magnesium preparation, discussed with a pharmacist. Very widely used in this community. Also not neutral if you have kidney problems or take certain medicines, which is exactly why we say pharmacist rather than internet.
• Osmotic laxatives. The type designed to pull water into the bowel is the one most members were eventually recommended, and most report wishing they had asked in week two.
• Not straining, and not sitting there for forty minutes. A footstool and a shorter attempt beats determination; haemorrhoids and fissures are a real complication of a determined approach.
• A routine time of day. Boring, effective, and mildly humiliating to discover works.

Things members regret: taking a stimulant laxative daily for weeks without advice, ignoring it entirely, and assuming that because they were eating less there was nothing to pass.

Talking to a pharmacist, which is the underused move

Pharmacists deal with this professionally, daily, without a flicker, and in most countries you can talk to one without an appointment. Members consistently report better and faster help from a pharmacy counter than from a rushed GP appointment for this particular problem.

Useful things to tell them: how long it has been going on, what a normal week used to look like, what you have already tried and for how long, what else you take, and whether you have any kidney or heart condition. That last bit matters because it changes which preparations are suitable.

Bring the actual boxes of anything you are taking. Iron supplements, some antidepressants, certain painkillers — particularly codeine-containing ones — and several blood pressure medicines all slow the bowel too, and the interaction with a GLP-1 is additive. Members have discovered that their constipation was ninety per cent the codeine they take for their back.

When it is not routine

Constipation is usually a nuisance. Occasionally it is the beginning of something that needs seeing, and the difference is worth knowing.

Seek urgent care today if you have severe abdominal pain with a bloated, hard abdomen and you are vomiting and passing nothing at all, including no wind. That combination can mean an obstruction and it is not something to manage at home.

Contact your clinician promptly, rather than urgently, for: blood in the stool or bleeding that is not obviously a small tear, constipation lasting more than a week or two despite sensible measures, alternating constipation and diarrhoea that is new, unexplained weight change you cannot account for, or a persistent change in the shape or calibre of what you pass. Those are the things clinicians actively want to hear about, and the fact that you are on a medicine that causes constipation does not mean everything is explained by it.

If you have a history of bowel surgery, inflammatory bowel disease, or previous obstruction, that history changes the calculation and is worth flagging to your prescriber before you start rather than after. The gastro-history circle exists for people carrying exactly that.

The complete red-flag list is at when a symptom needs a clinician.

The bit nobody writes down

Two things members say in circle that never make it into a leaflet.

The first is that this symptom has a social cost out of all proportion to its seriousness. People cancel plans. They avoid travelling. Noor’s travel circle has a running conversation about which countries’ pharmacies stock what, because a fortnight away with an unfamiliar bathroom and no plan is genuinely miserable. Rowan, four hours from the nearest pharmacy in the Highlands, keeps a supply in the house for that reason.

The second is that it interacts with everything else. Constipation makes nausea worse. It makes reflux worse. It makes you feel bloated so you eat less so the problem compounds. Members who finally sorted it out frequently report that two other symptoms improved at the same time, which is why we put this guide near the front rather than at the back.

Gavin in Dundee, who joined for his knees and stayed for the company, said it best in circle: nobody warns you that the least dignified part of this is the part that decides whether your week is bearable.