A healthy 18-year-old patient was treated with psyllium husk (Metamucil) for constipation. When his constipation worsened, polyethylene glycol (MiraLAX) and a stool softener were added to the regimen. The constipation continued to worsen. A gastroenterologist found no abnormalities and suggested a significant increase in dietary fiber. This also proved unsuccessful. I do not want to start the patient on lubiprostone (Amitiza) at such a young age. What alternatives are available?—AVIVA PARNES, PA-C, Brooklyn, N.Y.

Even though this patient is noted to be healthy, it is still imperative to rule out secondary causes of constipation, such as medication, hypothyroidism, diabetes, and neurologic disease or dysfunction. If his constipation is believed to be truly functional and he has been compliant with diet, exercise, and medication, consider biofeedback, lubiprostone, and even subtotal colectomy. For more information, see Wald A. Treatment of constipation in adults. In: UpToDate, Rose, BD, ed. UpToDate. Wellesley, Mass.: UpToDate; 2010.—Reuben W. Zimmerman, PA-C (141-7)

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