What is the medication to treat opiate-induced constipation?

From the Guidelines

The most effective pill to stop constipation from opiates is a peripherally acting mu-opioid receptor antagonist (PAMORA) such as naloxegol (12.5-25 mg once daily) or methylnaltrexone (450 mg orally once daily), as they work by blocking opioid receptors in the gut without affecting pain relief. Several medications are available to treat opioid-induced constipation, including stimulant laxatives like senna (8.6-17.2 mg daily) or bisacodyl (5-10 mg daily), often combined with stool softeners such as docusate sodium (100 mg twice daily) 1. For more severe cases, prescription medications specifically designed for opioid-induced constipation include PAMORAs such as methylnaltrexone, naloxegol, and naldemedine (0.2 mg once daily) 1. These medications work by blocking opioid receptors in the gut without affecting pain relief, as they don't cross the blood-brain barrier. Lubiprostone (24 mcg twice daily) is another option that increases intestinal fluid secretion. It's essential to maintain adequate hydration, increase dietary fiber, and engage in physical activity when possible. Patients should start with over-the-counter options and progress to prescription medications if needed. Unlike general constipation, opioid-induced constipation often doesn't respond to traditional treatments alone because it results from opioids binding to receptors in the gastrointestinal tract, slowing motility and reducing secretions 1. Some key points to consider when treating opioid-induced constipation include:

• The American Gastroenterological Association (AGA) recommends the use of laxatives as first-line agents (strong recommendation, moderate quality evidence) 1
• PAMORAs are effective in treating opioid-induced constipation, with naloxegol being a suitable option for patients with non-cancer pain 1
• Methylnaltrexone is another PAMORA that can be used to treat opioid-induced constipation, with a unique quaternary amine structure that restricts its ability to cross the blood-brain barrier 1

From the FDA Drug Label

MOVANTIK ®is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation. Lubiprostone is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.

The medications to treat opiate-induced constipation are:

• Lubiprostone (2)
• Naloxegol (3)

From the Research

Medications for Opiate-Induced Constipation

• Naloxegol is a peripherally acting μ-opioid receptor antagonist that has been shown to be effective in treating opioid-induced constipation 4.
• It works by inhibiting opioid binding in μ-opioid receptors in the gastrointestinal tract, resulting in significant improvements in spontaneous bowel movements 4.
• Other medications such as methylnaltrexone and naloxone have also been used to manage opioid-induced constipation 5, 6.
• A study comparing naloxone and methylnaltrexone found that both were effective in managing opioid-induced constipation without causing reversal of analgesia, but naloxone had a shorter time to first bowel movement 6.

Treatment Approaches

• Lifestyle modification and alteration of aggravating factors can be used to treat opioid-induced constipation 5.
• Simple laxatives can be used as a first-line treatment, and newer laxatives or opioid antagonists can be added if necessary 5.
• A comprehensive clinical assessment is beneficial in diagnosing and managing opioid-induced constipation, including evaluation of the patient's understanding of their constipation and underlying condition for which opioids are used 7.
• Preventive strategies, such as lifestyle changes, should be considered when patients start treatment with opioids 7.

Management of Opioid-Induced Constipation

• Health professionals should inquire about bowel function in patients receiving opioids, as opioid-induced constipation can limit the adequate dosing of opioids for pain relief and reduce quality of life 5.
• The management of opioid-induced constipation includes carefully re-evaluating the necessity, type, and dose of opioids at each visit 5.
• A bowel function index can be useful to objectively identify patients who are refractory to initial measures, and alternative treatments such as secretogogues or peripherally acting μ-opioid receptor antagonists can be considered 7.