What are the considerations for using Movantik (naldemedine) for opioid-induced constipation in patients with a history of diverticulitis and colon resection?

Movantik (Naloxegol) Use in Patients with History of Diverticulitis and Colon Resection

Direct Recommendation

Movantik is contraindicated in patients with a history of diverticulitis and should be avoided in patients with prior colon resection due to elevated risk of gastrointestinal perforation. 1

Critical Safety Concerns

Gastrointestinal Perforation Risk

• The FDA label explicitly warns that postmarketing cases of GI perforation, including fatal cases, occurred when naloxegol was used in patients with diverticular disease including diverticulitis 1
• Patients with recent gastrointestinal tract surgery are specifically identified as at-risk populations for perforation with peripherally acting opioid antagonists 1
• The mechanism involves antagonism of μ-opioid receptors in the GI tract, which can unmask underlying structural weaknesses in patients with compromised intestinal wall integrity 1

Absolute and Relative Contraindications

• Naloxegol is absolutely contraindicated in patients with known or suspected gastrointestinal obstruction and patients at risk of recurrent obstruction 1
• The FDA label specifically states to "take into account the overall risk-benefit profile when using MOVANTIK in patients with diverticular disease including diverticulitis" and to monitor for severe, persistent or worsening abdominal pain, discontinuing the drug if this symptom develops 1
• Patients with prior colon resection have altered bowel anatomy that may increase perforation risk, particularly at anastomotic sites 1

Alternative Management Strategy

First-Line Approach

• Traditional laxatives are recommended as first-line agents for opioid-induced constipation, with strong recommendation from the AGA 2
• Osmotic laxatives (polyethylene glycol, magnesium hydroxide, lactulose) and stimulant laxatives (bisacodyl, senna) should be titrated with the goal of achieving one non-forced bowel movement every 1-2 days 2

Second-Line Options for This Population

• If laxatives fail, naldemedine (Symproic) is the preferred PAMORA with strong AGA recommendation based on high-quality evidence 2, 3
• Naldemedine has similar efficacy to naloxegol but may have a more favorable safety profile in vulnerable populations 3
• Methylnaltrexone is suggested as an alternative PAMORA, though with conditional recommendation based on lower quality evidence 2

Additional Considerations

• Lubiprostone (intestinal secretagogue) may be considered, though the AGA makes no formal recommendation due to evidence gaps 2
• Opioid rotation to fentanyl or methadone may reduce constipation burden while maintaining analgesia 2
• Non-pharmacological interventions including increased fluid intake and physical activity should be emphasized 2

Clinical Monitoring Requirements

• If naloxegol is considered despite contraindications (which should be exceptional), patients must be monitored for severe, persistent, or worsening abdominal pain and the drug discontinued immediately if this occurs 1
• Patients should be educated about symptoms of perforation (severe abdominal pain that worsens or doesn't resolve) and instructed to seek emergency care 1
• The risk of severe abdominal pain and/or diarrhea requiring hospitalization is highest within the first few days of naloxegol initiation 1

Key Pitfall to Avoid

Do not assume that a "healed" episode of diverticulitis or remote colon resection eliminates perforation risk. The FDA label specifically identifies diverticular disease (not just acute diverticulitis) as a risk factor, and altered bowel anatomy from prior surgery creates permanent structural vulnerability 1. The safer approach is to exhaust all other OIC management options before considering any PAMORA in this population, and if a PAMORA is necessary, choose naldemedine over naloxegol given the explicit FDA warnings about the latter 2, 1, 3.