From the Guidelines
The best treatment for opioid-induced constipation is a stepwise approach starting with lifestyle modifications and over-the-counter laxatives, followed by prescription medications if needed, with the AGA recommending use of laxatives as first-line agents (strong recommendation, moderate quality evidence) 1.
Treatment Approach
The treatment approach should include:
- Increasing fluid intake, dietary fiber, and physical activity
- Using stimulant laxatives like bisacodyl (5-10mg daily) or senna (8.6-17.2mg daily) combined with stool softeners such as docusate sodium (100mg twice daily)
- Considering prescription peripherally acting mu-opioid receptor antagonists (PAMORAs) like naloxegol (12.5-25mg daily), methylnaltrexone (8-12mg subcutaneously every other day), or naldemedine (0.2mg daily) if initial measures are insufficient
Mechanism of Action
PAMORAs work by blocking opioid receptors in the gut without affecting pain control since they don't cross the blood-brain barrier 1.
Combination Approach
For severe cases, a combination approach may be necessary, potentially adding osmotic laxatives like polyethylene glycol (17g daily) 1.
Maintenance of Treatment
It's essential to maintain these treatments for as long as opioid therapy continues, as constipation typically persists throughout opioid use and doesn't improve with tolerance to other opioid side effects 1.
Key Considerations
- Assessing the cause and severity of constipation to rule out obstruction
- Titration of laxatives as needed to achieve one non-forced bowel movement every 1 to 2 days
- Considering adjuvant analgesic to allow reduction of the opioid dose
- Avoiding rectal suppositories or enemas in patients with neutropenia or thrombocytopenia 1
From the FDA Drug Label
1.2 Opioid-Induced Constipation in Adult Patients with Chronic Non-Cancer Pain 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.
1 INDICATIONS AND USAGE
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.
The best treatment for opioid-induced constipation is Lubiprostone or Naloxegol, as both are indicated for the treatment of OIC in adult patients with chronic non-cancer pain 2 3.
- Key points:
- Lubiprostone is available as an oral capsule containing 8 mcg or 24 mcg of lubiprostone.
- Naloxegol is also available for the treatment of OIC.
- The choice of treatment should be based on individual patient needs and medical history.
From the Research
Treatment Options for Opioid-Induced Constipation
- The treatment of opioid-induced constipation often involves a combination of lifestyle changes, laxatives, and medications such as μ-opioid receptor antagonists or newer medications like lubiprostone, linaclotide, or prucalopride 4.
- Studies have shown that peripherally acting μ-opioid receptor antagonists (PAMORAs) such as methylnaltrexone, naloxegol, and naldemedine are effective in treating opioid-induced constipation with a low risk of serious adverse events 5.
- Subcutaneous methyl naltrexone has been found to perform better than other interventions for managing opioid-induced constipation, including lubiprostone, naloxegol, oral methyl naltrexone, and prucalopride 6.
Management Strategies
- A comprehensive clinical assessment is beneficial in managing opioid-induced constipation, including evaluation of the patient's understanding of their constipation and underlying condition for which opioids are used 7.
- First-line management includes simple over-the-counter laxatives, and the bowel function index can be useful to objectively identify patients who are refractory to these initial measures 7.
- Alternative over-the-counter laxatives, secretogogues, or PAMORAs might also be considered for patients who do not respond to initial measures 7.
Medication Efficacy
- Naloxegol, a PAMORA, has demonstrated clinical efficacy and was well tolerated in placebo-controlled trials in patients with non-cancer pain and opioid-induced constipation 8.
- Lubiprostone and linaclotide have been found to be less effective than PAMORAs in treating opioid-induced constipation, with a higher risk of adverse effects 5.
- The efficacy of treatments for opioid-induced constipation can be evaluated based on diverse endpoints, including continuous variables and responder analysis 5.