What is the dosage and treatment plan for Movantik (naloxegol) for opioid-induced constipation?

Dosage and Treatment Plan for Movantik (Naloxegol) for Opioid-Induced Constipation

The recommended dosage of Movantik (naloxegol) for opioid-induced constipation is 25 mg once daily in the morning on an empty stomach, at least 1 hour before the first meal of the day or 2 hours after a meal. 1

Standard Dosing Protocol

• The standard starting dose is 25 mg once daily in the morning 1
• If patients cannot tolerate the 25 mg dose, reduce to 12.5 mg once daily 1
• Take on an empty stomach at least 1 hour before the first meal of the day or 2 hours after a meal 1
• Discontinue all maintenance laxative therapy prior to initiation of Movantik 1
• Laxatives can be used as needed if there is a suboptimal response to Movantik after three days 1

Special Population Considerations

• For patients with renal impairment (creatinine clearance <60 mL/min):

  • Start with 12.5 mg once daily 1
  • If well tolerated but OIC symptoms continue, may increase to 25 mg once daily 1
  • Monitor for increased risk of adverse reactions due to potentially higher drug exposure 1

• For patients taking moderate CYP3A4 inhibitors (e.g., diltiazem, erythromycin, verapamil):

  • Reduce Movantik dosage to 12.5 mg once daily 1
  • Monitor for adverse reactions 1

Administration Methods

• For patients who cannot swallow tablets whole:

  • Crush tablet to powder and mix with 4 ounces (120 mL) of water 1
  • Drink immediately 1
  • Refill glass with 4 ounces of water, stir and drink contents 1

• For nasogastric (NG) tube administration:

  • Flush NG tube with 1 ounce (30 mL) of water 1
  • Crush tablet to powder and mix with 2 ounces (60 mL) of water 1
  • Administer through NG tube 1
  • Add 2 ounces of water to container, draw up and use to flush NG tube 1

Important Clinical Considerations

• Avoid consumption of grapefruit or grapefruit juice during treatment 1
• Discontinue Movantik if opioid pain medication is discontinued 1
• Patients receiving opioids for less than 4 weeks may be less responsive to Movantik 1
• Movantik is contraindicated in patients with known or suspected gastrointestinal obstruction 1

Treatment Algorithm for Opioid-Induced Constipation

1. First-line treatment: Traditional laxatives (osmotic or stimulant) 2

   • Examples: polyethylene glycol (PEG), lactulose, bisacodyl, senna 2

2. If constipation persists despite laxative therapy (laxative-refractory OIC):

   • Consider Movantik (naloxegol) 25 mg once daily 2, 1
   • Alternative PAMORAs: naldemedine or methylnaltrexone 2

3. Monitor response:

   • Goal: ≥3 spontaneous bowel movements per week 2
   • If inadequate response after 3 days, consider adding rescue laxatives 1

Efficacy and Safety Profile

• Naloxegol has demonstrated clinical efficacy in treating OIC while maintaining opioid-related analgesia 3, 4
• As a peripherally acting μ-opioid receptor antagonist (PAMORA), naloxegol blocks opioid binding in gastrointestinal tract receptors without affecting central pain relief 4
• Common side effects are mainly gastrointestinal (abdominal pain, diarrhea, nausea) and usually transient and mild 3, 5
• No significant signs of opioid withdrawal have been observed in clinical studies 3

Clinical Pitfalls and Caveats

• Always rule out bowel obstruction before initiating Movantik therapy 1
• Consumption of naloxegol may result in detection of naloxone in urine drug testing, which could be misinterpreted in pain management settings 6
• Patients should be informed that traditional laxatives must be discontinued when starting Movantik but can be reintroduced if needed after 3 days 1
• Movantik is FDA approved specifically for 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 opioid dosage escalation 1