Why this cheap drug is still the best constipation treatment

Why this cheap drug is still the best constipation treatment

See Consumer Reports' surprising top pick to remedy a common condition (that you probably hate to discuss)

Published: August 2015


Like headaches and colds, almost everyone will experience a bout of constipation at some point. For most, the episode is brief and won’t require medical treatment. But if you have problems for three months or longer, doctors start to get concerned. Having fewer than three bowel movements per week, excessive straining, a sense of not being finished, or having hard, lumpy stools are signals you may have constipation. At any one time, some 43 million adults in the U.S. suffer from the condition. Women are twice as likely as men to experience constipation, while seniors who take multiple medications are also at high risk.

If you are constipated, it’s worth eating more fiber-rich foods such as vegetables, fruits, whole grains, and nuts. You can also drink more fluids and make sure you exercise regularly. Fiber supplements are another option to consider. Our analysis found that those containing psyllium are best.

If those strategies don’t help and your constipation persists for two weeks or longer, you may need a medication to relieve your symptoms. A variety are available in both nonprescription and prescription options. Most people will get the help they need from inexpensive, nonprescription drugs, such as stool softeners and laxatives.

Been constipated before? Don't be shy—if it's been a problem for you (and it probably has!) share below how you treated it.

Our 'Best Buy' pick


Taking cost and the evidence for effectiveness and safety into account, we chose the nonprescription generic drug polyethylene glycol as our Best Buy for both temporary and chronic bouts of constipation. This medication improves constipation symptoms and is just as effective as a prescription drug called lactulose. In addition, it has a track record of being safe and well tolerated by most people.


Stimulant laxatives such as senna (Ex-lax, Senokot, and generic) and bisacodyl (Correctal, Dulcolax and generic) may also be effective though they tend to cause more abdominal cramps and diarrhea. Their potency may also decrease over time.


If you’re unable to tolerate polyethylene glycol or it doesn’t improve your symptoms, talk to your doctor about other options, such as generic lactulose, linaclotide (Linzess), or lubiprostone (Amitiza). But Linzess is relatively new, so its safety profile is not fully established and both it and Amitiza are expensive prescription drugs. Our review of the evidence shows that they that may be no more effective than MiraLax or lactulose.

What causes constipation?

To understand how constipation develops, it helps to know how your large intestine, or colon, works. Muscles in the walls of your bowels propel the “waste” through your intestines after food is digested and the nutrients are absorbed in the small intestine.​ As this happens, water is reabsorbed, forming a solid stool. To function optimally, the intestine needs a steady supply of bulk material—sometimes called “roughage”—to process. This gives the powerful intestinal muscles something substantial to propel through the system and also keeps the stool soft by holding onto intestinal water like a sponge.

But if too much water is reabsorbed, if your diet doesn’t contain enough fiber, or the nerves or muscles in the intestinal walls are not functioning properly, the stool can become hard, dry, and difficult to pass, resulting in constipation symptoms. That usually means discomfort—excessive straining, difficulty completing a bowel movement, or having hard stools that hurt to pass. If symptoms like those go on for three months or longer, and there is no obvious cause, doctors call it “chronic constipation.” That can lead to hemorrhoids, painful tears in the lining around the anus (anal fissures), or stools that become so hard that they will not pass on their own (fecal impaction).


Table 1: Factors that increase the chance of constipation

Diet low in fiber. Fiber makes stools softer, bulkier and easier to pass. Foods high in fiber include fruits, vegetables, beans, legumes, and whole grains.
Pregnancy. Constipation is a common problem for women during and after pregnancy. About half of pregnancy women experience it. Natural increases in the hormones estrogen and progesterone, as well as increased pressure on the bowels from carrying the baby can both affect regularity in passing stools.
Age. Constipation is more common in older people. Slowing of the bowel functions is a natural part of aging, and because the older people are often on medications that slow the gastrointestinal tract.
Changes in routine.  Many people become constipated while traveling, especially when it involves time zone differences. Changes in your regular daily eating and sleeping habits, physical activity, and toilet routines while traveling can affect your metabolism and result in constipation.
Medicines. Constipation is a common side effect of many prescription and over-the-counter drugs. Some prescription drugs commonly known to cause constipation include pain killers, antidepressants, high blood pressure pills, and drugs to treat Parkinson’s Disease. See Table 2.


Another common cause of constipation—especially for busy people on the go—is ignoring the urge to have a bowel movement. This is a bad habit that can, over time, lead to irregularity and chronic constipation.

Constipation can also be due a condition called pelvic floor dysfunction. That’s when muscles in the pelvis and around the anus that help you pass stools are not working the way they should; they clinch up when they should be relaxing. Generally, this condition does not respond very well to medication and is helped most by a technique called biofeedback that retrains the muscles to work properly.

Occasionally going a day or two without a bowel movement is not that unusual and normally doesn’t require a visit to a doctor. There’s no established frequency of bowel movements that separates “healthy” from “unhealthy”— people vary in how often they go. If your frequency drops below three bowel movements a week, especially if that represents a change from your previous pattern, it’s time to see your doctor.

You should see a doctor if you are older than 50 or any of the following occur:

  • Bowel movements are less than three per week for two weeks or longer;
  • A feeling of abdominal bloating, cramping and discomfort;
  • Blood in your stools or it’s black or tarry-looking;
  • Pain when you have a bowel movement;
  • Persistent or recurring abdominal pain;
  • Sudden or sharp change in how often you move your bowels;
  • Straining during bowel movements, or it takes a long time to have one;
  • Stools are hard, rocky or pellet-like;
  • Over-the-counter treatments have failed to relieve your symptoms.

Medication side effect

Constipation is also a common side effect of many medicines. Morphine and other “opioid-based” painkillers (for example, oxycodone, codeine, Vicodin, Percocet, and Dilaudid) are the biggest offenders. They can cause constipation by slowing down bowel function, leading to increased water absorption in the colon and ultimately drier, harder stools that are difficult to pass.

Many other medicines are guilty, too. These include antacids that contain calcium, antihistamines, certain antidepressants, cholesterol-lowering drugs, and calcium and iron supplements.


Table 2: Drugs that can cause constipation




codeine, hydromorphone (Dilaudid), morphine, oxycodone/acetaminophen (Percocet), hydrocodone/acetaminophen (Vicodin)


diphenhydramine (Benadryl Allergy, Nytol, Sominex)

Anticholinergics, antispasmodics, and Antidiarrheal medications

loperamide (Imodium), diphenoxylate, alosetron (Lotronex), dicyclomine (Bentyl), oxybutynin (Oxytrol), propantheline, tolterodine (Detrol)


amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor), fluoxetine (Prozac), bupropion (Wellbutrin)

Blood pressure medications: beta blockers, calcium channel blockers

diltiazem (Cardizem), amlodipine (Norvasc), verapamil (Verelan)

Parkinson’s disease medications

benztropine (Cogentin), carbidopa (Parcopa), levodopa, trihexyphenidyl


pseudoephedrine (Sudafed)


haloperidol (Haldol), risperidone (Risperdal), olanzapine (Zyprexa)

Cholesterol-lowering drugs

cholestyramine (Questran), colestipol (Colestid)


furosemide (Lasix), hydrochlorthiazide


phenytoin (Dilantin), valproic acid (Depakene)

Calcium supplements

calcium citrate, calcium carbonate (OsCal)

Iron supplements (including multivitamins with iron)

ferrous fumarate, ferrous gluconate, ferrous sulfate


Carafate, Maalox, Mylanta, Rolaids, Tums

* Not intended to be a comprehensive list.

Treatment choices

There are several types of medications available to treat constipation. Some are available over-the-counter without a prescription, while some are prescription only. The right choice for you will depend on the type of constipation you have.

Doctors usually follow a step-by-step approach to the treatment of constipation. And you should, too. First, if you have occasional, infrequent bouts, you probably don’t need to take any medicines or see a doctor. Instead, first try adjusting your eating habits to include more fiber-rich foods. Also, stick to a regular bathroom schedule, and don’t ignore or put off the urge to go. Let nature take its course even if the timing is not particularly convenient.

Table 3: The treatments we evaluate in this report

Generic name

Selected brand name(s)

Type of drug

Available as a generic?

Available as an over-the-counter drug?

Over-the-counter medications








Colace, D.O.S.


Stool softener



Polyethylene glycol





Psyllium, Calcium Polycarbophil,


Metamucil, Fiber,

Genfiber, Benefiber,


Citrucel, FiberCon

Fiber supplement



Senna (Sennosides)

Senokot, Ex-Lax




Prescription medications


















Fiber supplements

It’s best to start trying to get more fiber in your diet by gradually increasing your intake of foods high in fiber. Fiber can also be obtained from supplements. So if diet changes alone don’t do the trick, taking a fiber supplement can be effective, and is usually the next step. We recommend fiber supplements that contain psyllium since it’s the active ingredient that’s been studied the most in treating chronic constipation.

While studies of psyllium are not conclusive, they suggest it increases the frequency of bowel movements by at least one or two per week, on average, when compared with placebo. So, don’t expect miracles. Metamucil is the best-known brand containing psyllium but there are generic versions that may be less expensive at your local pharmacy or food store. Read the ingredients list to make sure you are buying a psyllium supplement.

Be careful though, because taking too much of a fiber supplement when you first start is a common mistake, and can lead to cramping, bloating, and gas. Always start with the recommended, low dose and increase it gradually over time as needed. Some fiber supplements contain sugar, which may not be suitable for people with diabetes.

Drinking more fluids

While there’s little research supporting that increased fluid intake helps relieve constipation, it’s also worth a try and can’t hurt. Many people routinely don’t drink enough liquids. If you take fiber supplements, drinking plenty of water is even more advisable.


Exercise also is often recommended as a potential remedy, but the available research suggests it provides little, if any, benefit.

Over-the-counter medications

If lifestyle changes and fiber supplements don’t resolve your constipation problem, it may be time to try a drug. But which one? As you saw from the list in Table 3, a variety of drugs are available.

After fiber supplements, stool softeners are one possible next step in treatment. Examples are Colace and Regulan, both of which contain an active ingredient called docusate (with either sodium or calcium). This drug helps retain water with the stool and soften it.

While there aren’t any rigorous studies showing how effective stool softeners are in relieving chronic constipation, they are considered to be safe when taken as directed, and they can be useful in preventing constipation from developing when short-term use of medications, such as narcotic pain relievers after surgery, is unavoidable.

Which drugs should I skip for treating constipation?


Laxatives are another option and there are several different types. Saline laxatives are magnesium-based drugs and are best known as “milk of magnesia.” Others contain sodium phosphate or “phospho-soda”. They draw water into the colon and soften the stool. But extended use of saline laxatives can lead to electrolyte imbalance, especially in children, and they should not be used at all by people with kidney problems.

So-called stimulant laxatives include such drugs as senna (sometimes called the sennosides; Ex-Lax, Senokot, other brands and generics) and bisacodyl (Correctol, Dulcolax, other brands and generics). These drugs stimulate the muscles of the intestines to move the stool along. That rapid movement, which can cause cramping, lessens water absorption and softens the stool. These drugs can help alleviate single episodes of constipation, but they don’t help improve chronic constipation and are not recommended for long-term use (more than 7 days).

One final group of laxatives is called the osmotic laxatives. The most common ones are based on either the active ingredient lactulose (various brands and generics) or polyethylene glycol (MiraLax, Glycolax, and generics). Polyethylene glycol is commonly available at pharmacies, grocery stores and other outlets without a prescription.

Polyethylene glycol

Between lactulose and polyethylene glycol, the evidence points fairly strongly to polyethylene glycol as the first best bet for adults. In the few studies that have compared the two head-to-head in adults, people taking polyethylene glycol consistently had greater improvements in their constipation symptoms. In addition, several studies that compared constipation drugs in children found polyethylene glycol effective for up to a year with fewer side effects than milk of magnesia or lactulose.

Although not conclusive, some studies have suggested kids had fewer side effects when taking polyethylene glycol as well. One study, for example, found children taking lactulose had more abdominal pain, more pain when passing a stool, and more straining than those taking polyethylene glycol. However, in 2014, the FDA announced it was funding a study to determine if polyethylene glycol can trigger neurological problems in children. The FDA has received reports of children who developed obsessive compulsive disorder, seizures, tics, and other problems after taking polyethylene glycol. In some cases, the children had taken an adult dose for two years. The agency said the available data does not indicate the polyethylene glycol caused the neurological problems. Two previous reviews of adverse event reports related to polyethylene glycol and a review of studies from 2009 to 2013 did not find an increased risk of those issues in children.

Note that in this report we do not discuss or evaluate two other over-the-counter laxatives: mineral oil and castor oil. These are no longer widely used because the unpleasantness of taking them outweighs any benefit, and because other, better medicines are available.

Prescription medications

The three prescription-only medicines used to treat constipation are lactulose (Enulose, Kristalose and generic), linaclotide (Linzess) and lubiprostone (Amitiza).

Amitiza and Linzess are relatively new drugs that cause the cells that line the intestines to secrete chloride, sodium and water to help soften stools. The FDA approved both to treat chronic constipation and irritable bowel syndrome (IBS) where the main symptom is constipation.


In studies, about 45 percent of people with chronic constipation did not see any improvement after taking Amitiza, compared with about 67 percent of those who took a placebo. In one study in adults with constipation, after four weeks, Amitiza boosted the number of weekly bowel movements from one to more than five—those who took a placebo went from one to 3.5 weekly bowel movements. About 57 percent of the Amitiza group had a bowel movement within 24 hours of the first dose compared with just 37 percent of those on placebo.

Most people who take Amitiza experience side effects. In one of the main studies, for example, 70 percent of people taking Amitiza experienced at least one side effect versus 50 percent taking the placebo. The most common problem was nausea and headache. About 9 percent of patients had to stop taking Amitiza because of side effects. The drug has also been linked to a feeling of chest tightness and difficulty breathing.

Is a prescription or OTC drug best for me?


The case is even weaker for Linzess. In three randomized trials, nearly 80 percent of people with chronic constipation did not get any benefit from Linzess, versus 95 percent for placebo.

In addition, Linzess has only been available since 2012, so its safety profile is not fully established. It should not be used in children under the age of 18 because of concerns that it caused severe dehydration that led to death in young mice.

The most common side effect of Linzess is diarrhea, especially if taken with a high fat meal. It also should not be taken by pregnant or nursing women because high doses were toxic to both the mother and fetus in animal studies.


Lactulose has been available for nearly 40 years. It helps relieve constipation by pulling water into your bowels, which softens stools. Its side effects include cramps, diarrhea, excessive or frequent bowel movements, gas, and nausea. It can also leave a bad taste in your mouth.

It hasn’t been shown to cause any harm to developing fetuses in animal studies, but since no studies have been conducted in pregnant or nursing women, our medical advisers recommend that you don’t use it if you are pregnant or breastfeeding.

There are several different generic versions, so it is an inexpensive medication compared with newer prescription medications, such as Amitiza and Linzess. A month’s supply will run about $40-$80, depending on dose.

Other medications

Two other drugs to treat severe constipation caused by opioid painkillers. They are methylnaltrexone (Relistor) and naloxegol (Movantik). Naloxegol is available as oral tablets while methylnaltrexone is only available as an injection.

Which is the best medicine for you?

You and your doctor’s choice of treatment will depend on the type of constipation you have, its duration and severity, other medical conditions you may have and other medicines you take.

People with chronic constipation and those with IBS who have severe persistent symptoms are more likely to get a prescription medicine than people who have mild occasional constipation. Also, there are treatment preferences by age and population group. For example, parents should not give their children a laxative unless it is recommended by a doctor. And only the laxatives polyethylene glycol or lactulose should be tried, at smaller doses than those given adults. Senna and bisacodyl are not recommended for children under 6.

Pregnant and nursing women should also consult their doctor before using any laxative drug. Some laxatives can have adverse effects during pregnancy. And most are not recommended for women who are breast-feeding because they can be excreted in the milk. Better options for pregnant women are adding more fiber to their diet, taking fiber supplements, increasing their fluid intake, and exercising.

What other medicine should I avoid if I'm pregnant?

Table 4: Description of constipation treatments

Drug type/ How it works

Brands (examples)

Active ingredient(s)

Common minor side effects/ Cautions

Fiber supplements:

They absorb water into the stool to make it softer and easier to pass.


Fiber, Genfiber,





calcium polycarbophil,




• Bloating, diarrhea, rumbling sounds, nausea, stomach cramps.


• Can leave bad taste or grittiness in mouth

Stool softeners: These cause water and fats to mix with the stool, making it easier to move along the bowels.

Surfak, Colace


• Stomach ache, cramping,dehydration, or irritated throat (liquid and syrup forms)  

Osmotic laxatives: They attract more water into your bowels from other parts of the body to soften the stools.





• Cramps, diarrhea, excessive or frequent bowel movements, gas, nausea.


• Can leave bad taste in mouth.


• Pregnant and nursing women should not use.


• New concerns about chronic use in children.




Stimulant laxatives: They stimulate your bowels to secrete more water and electrolytes.



• Dizziness, diarrhea, nausea.

• Pregnant and nursing women should not use.


Senokot, Ex-Lax


Pro-secretory agents: Stimulates your bowels to secrete more water.




• Headache, nausea

• Pregnant and nursing women should not use.



• Should not be used in children.

• May cause diarrhea, especially if taken with a high fat meal.


Special note about drug-induced constipation

If your constipation is linked to a drug you are taking, your doctor will most likely recommend changing to a different medication that will not have the same constipating effect or increasing your intake of fiber-rich foods first. Fiber supplements are another option but they have not been shown to help with drug-induced constipation.

If dietary changes don’t help, a laxative is usually the next step. For constipation triggered by an opioid drug, some research suggests polyethylene glycol is better than lactulose, but neither drug is approved by the FDA for opioid-induced constipation and they have not been rigorously studied for treating it.

As mentioned already, people who take high doses of opioid medications to control pain may be prescribed the drug Relistor or Movantik to relieve severe constipation. The drugs are quite potent, however, and can trigger the opposite problem: diarrhea. So people who take these drugs must be closely monitored.

Our 'Best Buy' pick

Unfortunately, very few studies have directly compared the various constipation drugs with each other.

If you decide to try a fiber supplement, a psyllium-based one is the best bet; avoid the others.

If you have chronic constipation, we’d recommend that you rule out both stool softeners and stimulant laxatives. Stool softeners probably won’t help you much. Stimulant laxatives, such as bisacodyl, and senna are OK for short-term use for an occasional episode of constipation, and can help with chronic constipation, but they aren’t recommended for long-term use, or for children under the age of 6.

We also recommend using prescription medications Amitiza, lactulose, and Linzess, only after you’ve tried other options. They have not been shown to be better than over-the-counter polyethylene glycol. And some of them are new, so their side effects have not been fully established. Plus, in clinical trials, at least one caused more side effects than a placebo, while polyethylene glycol did not.

The prices of Amitiza and Linzess are another downside. They are both expensive brand-name drugs costing more than $300 a month (see Table 5), and there have been no studies comparing them to more established constipation medicines.

For those reasons, and because it is an inexpensive drug, we have chosen nonprescription polyethylene glycol (MiraLax and generic) as our Best Buy for treating constipation if your doctor and you have decided that you need to take a medicine. Generic and store-brand versions are available. It comes in powder form that is mixed with water.

Note that polyethylene glycol is also available as a more expensive prescription drug. You’ll probably save money with the nonprescription version, but check with your insurance to be sure.

Table 5., below, gives you a run down of the costs of the constipation drugs. The good news is that most medicines used to treat the condition—including MiraLax—are inexpensive. Of course, the cost of these medicines depends on how often you take them. Use of all the constipation drugs varies widely. Many people only need to take one or two or a few doses a month, on an as-needed basis. Others need to take a constipation medicine on a longer-term basis. Table 5 presents pricing of drugs that are more likely to be prescribed longer-term and those that are often recommended for short-term use.

Table 5: Constipation Drugs Comparison

How we select the 'Best Buy'

This report compares the effectiveness, safety, and cost of medicines used to treat chronic constipation. Our evaluation of medicines used to treat constipation is primarily based on a systematic review conducted by the Oregon Health & Science University’s Drug Effectiveness Review Project (DERP) and a comprehensive review of treatments for constipation conducted by the American College of Gastroenterology. We also conducted a recent literature review (2015) to update the findings of a previous report.

Consumer Reports is solely responsible for selecting the Best Buy Drugs

Prices for a drug can vary quite widely, even within a single city or town. The prices for prescription drugs in this report are national averages based on sales of the drugs in retail outlets. They reflect the retail cash price that would be paid for a month’s supply of each drug in June 2015. The prescription drug costs cited were obtained from a health-care information company, Symphony Health Solutions, which tracks sales of prescription drugs in the U.S. Symphony Health Solutions is not involved in Consumer Reports Best Buy Drugs analysis or recommendations.

Prices for nonprescription drugs were obtained from a nationwide sampling in February 2015 by Consumer Reports secret shoppers from four major chain pharmacies—CVS, Target, Walgreens, and Walmart.

Consumer Reports selected the Best Buy Drugs using the following criteria. The drug (and dose) had to:

■ Be approved by the FDA for treating constipation.

■ Be as effective as any other constipation-relieving drug.

■ Have a safety record equal to or better than other medications to treat constipation.

■ Substantially lower cost for an average, 30-day supply compared to the most costly medications also meeting the other three criteria.


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Editor's Note:

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

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