From the Guidelines
The treatment of opiate-induced constipation should start with lifestyle modifications and over-the-counter laxatives, with peripherally acting mu-opioid receptor antagonists (PAMORAs) such as naloxegol, methylnaltrexone, or naldemedine considered for patients with persistent constipation, as recommended by the most recent guidelines 1. The treatment approach involves a stepwise progression, beginning with non-pharmacological measures including increased fluid intake (at least 8 glasses of water daily), dietary fiber (25-30g daily), and physical activity as tolerated. For medication management, stool softeners like docusate sodium (100mg twice daily) can be used alongside stimulant laxatives such as senna (8.6-17.2mg daily) or bisacodyl (5-10mg daily). Osmotic laxatives like polyethylene glycol (17g in 8oz water daily) are also effective. Key considerations include assessing the cause and severity of constipation, ruling out obstruction, and titrating laxatives as needed to achieve one non-forced bowel movement every 1 to 2 days, as outlined in recent clinical practice guidelines 1. Peripherally acting mu-opioid receptor antagonists (PAMORAs) are recommended for patients with persistent constipation despite initial measures, with options including naloxegol (12.5-25mg daily), methylnaltrexone (8-12mg subcutaneously every other day), or naldemedine (0.2mg daily), which work by blocking opioid receptors in the gut without affecting pain control, as they don't cross the blood-brain barrier 1. Regular reassessment is crucial, as constipation management may need adjustment with changes in opioid dosing or other factors affecting bowel function. Other second-line agents include lubiprostone and linaclotide, which can be considered for patients with opioid-induced constipation, particularly those with noncancer pain, including those with chronic pain related to prior cancer or treatment 1. It is essential to note that these agents should not be used in patients with known or suspected mechanical bowel obstruction. Neuraxial analgesics, neuroablative techniques, or other interventions to decrease pain and/or reduce systemic opioid dose may also be considered to reduce opioid-related adverse effects, as suggested by recent guidelines 1.
From the FDA Drug Label
- 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.
Treatment Options for Opiate Induced Constipation:
- Lubiprostone (PO): 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 opioid dosage escalation 2.
- Naloxegol (PO): 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 opioid dosage escalation 3.
From the Research
Treatment Options for Opiate-Induced Constipation
- Opioid-induced constipation (OIC) is a common side effect of opioid therapy, and it can be challenging to manage 4.
- Standard treatment with laxatives and fluid intake may not be sufficient, and escalation of treatment may be needed 5.
- μ-opioid receptor antagonists, such as methylnaltrexone, have been shown to be effective in treating OIC without affecting central analgesia or precipitating opioid withdrawal 6, 7, 8.
- Methylnaltrexone has been found to induce laxation in patients with OIC, with a rapid onset of action and sustained improvement over time 6, 7, 8.
- Other treatment options, such as lubiprostone, linaclotide, and prucalopride, may also be effective in managing OIC 5.
Management of Opiate-Induced Constipation
- Simplified recommendations for managing OIC have been proposed, which include a concise and behaviorally-oriented approach to treatment 5.
- These recommendations have been validated in primary care and may lead to better management of OIC 5.
- It is essential to consider the underlying mechanism of OIC, which is the blockade of peripheral mu-receptors, when selecting a treatment option 4.
- Doctor-patient communication is crucial in managing OIC, and patients should be informed about the available treatment options and their potential benefits and risks 4.
Efficacy of Methylnaltrexone
- Methylnaltrexone has been shown to be effective in inducing laxation in patients with OIC, with a statistically significant difference in rescue-free bowel movement (RFBM) compared to placebo 7.
- The efficacy of methylnaltrexone has been demonstrated in several studies, including randomized controlled trials and meta-analyses 6, 7, 8.
- Methylnaltrexone has been found to be safe and well-tolerated, with minimal risk of adverse events or opioid withdrawal 6, 7, 8.