How should opiate pain medications be managed in patients with or at risk of ileus?

From the Guidelines

Opiate pain medications should be used with caution in patients with or at risk of ileus, and alternative pain management strategies should be considered to minimize the risk of worsening intestinal motility problems. When pain management is necessary, use the lowest effective dose of opioids for the shortest duration possible, preferring short-acting agents like immediate-release morphine or hydromorphone over long-acting formulations. Consider alternative pain management strategies such as:

• Acetaminophen (1000 mg every 6 hours, not exceeding 4000 mg daily)
• NSAIDs like ketorolac (15-30 mg IV every 6 hours for short-term use)
• Regional anesthesia techniques when appropriate For patients requiring opioids, implement a proactive bowel regimen including:
• Stool softeners (docusate sodium 100 mg twice daily)
• Stimulant laxatives (bisacodyl 5-10 mg daily)
• Osmotic agents (polyethylene glycol 17 g daily) Peripherally acting mu-opioid receptor antagonists like methylnaltrexone (8-12 mg subcutaneously every other day) or naloxegol (12.5-25 mg orally daily) can treat opioid-induced constipation without reversing analgesia, as recommended by 1 and 1. Monitor bowel function closely with daily assessment of bowel movements, abdominal distention, and bowel sounds. Opioids delay gastric emptying, decrease intestinal propulsion, and increase sphincter tone through mu-receptor activation in the enteric nervous system and central nervous system, making them particularly problematic in patients with compromised gut motility. The use of thoracic epidural analgesia (TEA) has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use, as suggested by 1 and 1.

From the FDA Drug Label

Morphine sulfate tablets are contraindicated in patients with gastrointestinal obstruction, including paralytic ileus. The morphine in morphine sulfate tablets may cause spasm of the sphincter of Oddi. Opioids may cause increases in serum amylase Monitor patients with biliary tract disease, including acute pancreatitis for worsening symptoms.

Paralytic ilieus (4)

Management of Opiate Pain Medications in Patients with or at Risk of Ileus:

• Contraindication: Morphine is contraindicated in patients with paralytic ileus.
• Alternative Treatment: Consider the use of non-opioid analgesics in patients with or at risk of ileus.
• Monitoring: Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms.
• Key Consideration: Avoid the use of morphine in patients with gastrointestinal obstruction, including paralytic ileus 2, 3.

From the Research

Management of Opiate Pain Medications in Patients with or at Risk of Ileus

• Opioids are widely used in clinical anesthesia, but their use is strongly associated with impaired gastrointestinal motility, which can lead to postoperative ileus 4.
• To prevent postoperative ileus, the use of opioids should be minimized and replaced with other drugs when possible 4.
• Peripheral opioid antagonists, such as methylnaltrexone and alvimopan, can reverse opioid-induced side effects on the gastrointestinal system without compromising pain relief 5, 6.
• These agents may be effective in treating opioid-induced bowel dysfunction and postoperative ileus, but further research is needed to assess their effectiveness and safety in clinical practice 5, 6.

Treatment and Prevention of Ileus

• Ileus can be treated conservatively, and supportive measures usually suffice, depending on the etiology 7.
• Proper treatment depends on the timely determination of the pathogenesis (mechanical versus functional) and close interdisciplinary collaboration 7.
• Bowel management protocols using osmotic laxatives may be safe, but their effectiveness in preventing ileus is unclear 8.
• Cholinesterase inhibitors may be safe and effective in treating constipation, but their use is not well established 8.
• Enteral opioid antagonists may be a promising strategy for patients treated with high doses of opioids during sedation 8.

Opioid-Induced Constipation and Postoperative Ileus

• Opioid-induced constipation has a negative impact on quality of life for patients with chronic pain and can affect more than a third of patients 6.
• Postoperative ileus is an abnormal pattern of gastrointestinal motility after surgery, and peripherally acting μ-opioid receptor antagonists may be effective in treating it 6.
• Nonselective μ-opioid receptor antagonists can reverse constipation and opioid-induced ileus, but may also reverse analgesia 6.
• Peripherally acting μ-opioid receptor antagonists, such as alvimopan, methylnaltrexone, and naloxegol, target the μ-opioid receptor without reversing analgesia 6.