What is the bowel regimen for opioid (narcotic) induced constipation?

From the Guidelines

A bowel regimen for opioid-induced constipation should include a stimulant laxative like senna (8.6-17.2 mg daily) or bisacodyl (5-10 mg daily) combined with a stool softener such as docusate sodium (100 mg twice daily), as recommended by the American Gastroenterological Association 1.

Key Components of the Regimen

• Start the regimen when opioid therapy begins, rather than waiting for constipation to develop
• For patients who don't respond adequately, add an osmotic agent like polyethylene glycol (17 g in 8 oz water daily) or lactulose (15-30 ml daily)
• Ensure adequate fluid intake (at least 8 glasses of water daily) and encourage physical activity as tolerated
• If constipation persists despite these measures, consider adding prescription medications specifically for opioid-induced constipation such as methylnaltrexone, naloxegol, or lubiprostone

Rationale

Opioids cause constipation by binding to mu-receptors in the gastrointestinal tract, which decreases peristalsis and intestinal secretions while increasing fluid absorption and anal sphincter tone, as explained in the American Gastroenterological Association technical review 1. Unlike other opioid side effects, tolerance to constipation rarely develops, making preventive treatment essential for patients on chronic opioid therapy. The American Gastroenterological Association recommends the use of laxatives as first-line agents for the treatment of opioid-induced constipation, with a strong recommendation and moderate quality evidence 1.

From the FDA Drug Label

Prior to screening, patients had been receiving opioid therapy for pain for 1 month or longer (median daily baseline oral morphine equivalent dose of 161 mg) and had OIC (less than 3 spontaneous bowel movements per week during the screening period) Constipation due to opioid use had to be associated with 1 or more of the following: A Bristol Stool Form Scale score of 1 or 2 for at least 25% of the bowel movements (BM), straining during at least 25% of the BMs or a sensation of incomplete evacuation after at least 25% of the BMs Eligible patients were required to discontinue all previous laxative therapy and use only the study-permitted rescue laxative (bisacodyl tablets). If patients did not have a bowel movement for 3 consecutive days during the study, they were permitted to use rescue medication (up to 4 bisacodyl tablets taken orally once during a 24-hour period)

The bowel regimen for opioid-induced constipation includes:

• Discontinuing all previous laxative therapy
• Using only the study-permitted rescue laxative (bisacodyl tablets)
• Taking up to 4 bisacodyl tablets orally once during a 24-hour period if no bowel movement occurs for 3 consecutive days 2 Key points:
• Opioid-induced constipation (OIC) is associated with less than 3 spontaneous bowel movements per week
• Patients with OIC may experience straining, sensation of incomplete evacuation, or hard stools
• Bisacodyl tablets are used as rescue medication if no bowel movement occurs for 3 consecutive days 2

From the Research

Bowel Regimen for Opioid-Induced Constipation

• A comprehensive prevention and management strategy for opioid-induced constipation (OIC) should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control 3.
• Recommended first-line pharmacological treatment of OIC is with an osmotic laxative (preferably polyethylene glycol [macrogol]), or a stimulant laxative such as an anthraquinone 3.
• A second laxative with a complementary mechanism of action should be added in the event of an inadequate response 3.
• Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as methylnaltrexone, naloxegol or naldemedine, should be considered in patients with OIC that has not responded to combination laxative treatment 3.

Treatment Options

• The most commonly used preparations for the treatment of OIC for patients during their length of stay in hospice were senna plus docusate, senna alone, docusate alone, bisacodyl, polyethylene glycol 3350, and lactulose 4.
• Polyethylene glycol (PEG) was found to be superior to sennosides with respect to overall effectiveness in cancer patients with opioid-induced constipation 5.
• Patient preference for treating opioid-induced constipation using naloxegol or polyethylene glycol (PEG) 3350 was similar, with almost equal proportions of patients reporting preference for daily naloxegol or PEG 3350 treatment 6.

Management Approach

• Health professionals must therefore inquire about bowel function in patients receiving opioids 7.
• The management of OIC includes carefully re-evaluating the necessity, type and dose of opioids at each visit 7.
• Lifestyle modification and alteration of aggravating factors, the use of simple laxatives and, when essential, the addition of newer laxatives or opioid antagonists (naloxone, naloxegol or methylnaltrexone) can be used to treat OIC 7.