From the Guidelines
For a patient with opioid-induced constipation and cancer who is already taking polyethylene glycol and sennosides daily, adding a peripherally acting mu-opioid receptor antagonist (PAMORA) would be the most appropriate next step. According to the American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation 1, medications such as naloxegol (Movantik) at 25mg once daily, methylnaltrexone (Relistor) at 12mg subcutaneously once daily, or naldemedine (Symproic) at 0.2mg once daily are good options. These medications specifically target the underlying mechanism of opioid-induced constipation by blocking opioid receptors in the gastrointestinal tract without affecting pain control, as they don't cross the blood-brain barrier.
Some key points to consider when managing opioid-induced constipation include:
- Ensuring adequate fluid intake to help prevent dehydration and constipation
- Encouraging physical activity when possible to stimulate bowel movements
- Considering fiber intake, unless contraindicated, to support bowel function
- Monitoring for adverse effects such as abdominal pain or diarrhea and adjusting dosing accordingly
- Regularly reassessing the patient's bowel movement frequency and consistency to determine the effectiveness of the regimen
It's also important to note that the NCCN Guidelines for Adult Cancer Pain recommend a stimulant laxative or a heaping tablespoon (17 g) of polyethylene glycol with 8 oz of water 2 times daily along with maintaining adequate fluid intake for prophylaxis 1. However, in this case, the patient is already taking polyethylene glycol and sennosides, so adding a PAMORA would be the next step. If PAMORAs aren't available, adding a stimulant laxative like bisacodyl (5-10mg daily) or increasing the current sennosides dose could be considered, as suggested by the NCCN Guidelines for Adult Cancer Pain 1.
From the FDA Drug Label
Lubiprostone is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain The recommended oral dosage of Lubiprostone by indication and adjustments for patients with moderate (Child Pugh Class B) and severe (Child Pugh Class C) hepatic impairment are shown in Table 1. Table 1 Recommended Dosage Regimen CIC and OIC Recommended Adult Dosage Regimen 24 mcg twice daily
For a patient with opioid-induced constipation and cancer, already taking polyethylene glycol (PEG) and sennosides daily, lubiprostone can be considered as an additional treatment option. The recommended dosage is 24 mcg twice daily. However, it is essential to note that the effectiveness of lubiprostone in patients with cancer has not been established, and its use in this population may require careful consideration and monitoring 2.
methylnaltrexone bromide caused decreases in blood pressure, heart rate, cardiac output, left ventricular pressure, left ventricular end diastolic pressure, and +dP/dt at 1 mg/kg or more. The efficacy of RELISTOR tablets in the treatment of OIC in patients with chronic non-cancer pain was evaluated in a randomized, double-blind, placebo-controlled study (Study 1).
Another option to consider is methylnaltrexone, which has been shown to be effective in treating opioid-induced constipation in adult patients with chronic non-cancer pain 3. However, its use in patients with cancer may require careful evaluation of the potential risks and benefits.
It is crucial to consult the FDA drug label and clinical guidelines for the most up-to-date information and to make informed decisions about the treatment of opioid-induced constipation in patients with cancer.
From the Research
Additional Treatment Options for Opioid-Induced Constipation
For a patient with opioid-induced constipation and cancer, already taking polyethylene glycol (PEG) and sennosides daily, several additional treatment options can be considered:
- μ-opioid receptor antagonists, such as lubiprostone, linaclotide, or prucalopride, which can be used to escalate treatment 4
- Peripherally acting µ-opioid receptor antagonists (PAMORAs), such as naldemedine, naloxegol, and methylnaltrexone, which have been shown to be effective in treating opioid-induced constipation 5, 6
- Naloxone in a fixed combination with oxycodone, which has been found to improve bowel function and reduce adverse events compared to oxycodone with laxatives 5
- Magnesium oxide, which may be effective for prevention of opioid-induced constipation in cancer patients 5
Considerations for Treatment
When considering additional treatment options, it is essential to:
- Assess the patient's current bowel function and adjust treatment accordingly 7
- Monitor for adverse events, such as abdominal pain, diarrhea, and nausea, which may be associated with certain treatments 5
- Consider the patient's individual needs and preferences when selecting a treatment option 7
- Be aware that more studies are needed to compare standard laxatives with opioid antagonists and to establish recommendations for clinical practice 5