What is the treatment for opioid-induced constipation?

From the Guidelines

For opioid-induced constipation, I recommend starting with preventive measures when initiating opioid therapy, including a stimulant laxative such as senna (8.6-17.2 mg daily) or bisacodyl (5-10 mg daily), as suggested by the most recent guidelines 1. Increase fluid intake to 2-3 liters daily, add dietary fiber, and encourage physical activity when possible. If constipation develops despite prevention, use a combination approach with a stimulant laxative plus an osmotic agent like polyethylene glycol (17 g in 8 oz water daily) 2, 3. For refractory cases, consider adding docusate sodium (100 mg twice daily) or switch to prescription medications such as methylnaltrexone (450 mg orally once daily), naloxegol (12.5-25 mg daily), or lubiprostone (24 mcg twice daily) 4, 1. These prescription options work by blocking peripheral opioid receptors in the gut without affecting pain control, as they don't cross the blood-brain barrier. Avoid bulk-forming laxatives like psyllium alone as they may worsen symptoms if fluid intake is inadequate, as noted in the guidelines 5. Regular reassessment of bowel function is essential, with a goal of maintaining regular bowel movements every 1-3 days without straining. Some key points to consider include:

• The American Gastroenterological Association recommends the use of laxatives as first-line agents for opioid-induced constipation 2.
• Peripherally acting mu opioid receptor antagonists, such as methylnaltrexone, naloxegol, and naldemedine, can be effective in treating opioid-induced constipation 3, 4.
• Lubiprostone and linaclotide are also options for treating constipation, particularly in patients with chronic noncancer pain 4, 1.
• It is essential to rule out other causes of constipation, such as bowel obstruction or impaction, before initiating treatment 3, 1.
• A prophylactic bowel regimen should be started when initiating opioid therapy to prevent constipation, as recommended by the guidelines 1, 5.

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.

2. 1 Recommended Dosage The recommended oral dosage of Lubiprostone by indication and adjustments for patients with moderate (Child Pugh Class B) and severe (Child Pugh Class C) hepatic impairment are shown in Table 1.

Table 1 Recommended Dosage Regimen CIC and OIC

• 24 mcg twice daily

Treatment of Opioid-Induced Constipation:

• Lubiprostone is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain.
• The recommended oral dosage for OIC is 24 mcg twice daily.
• Contraindications and warnings should be considered, including mechanical gastrointestinal obstruction, nausea, diarrhea, syncope, and hypotension 6.

From the Research

Opioid-Induced Constipation Treatment

• Opioid-induced constipation (OIC) is a common side effect of opioid use that can be undertreated despite the existence of effective and safe treatment options 7.
• The management of OIC can be improved with a simple setup of concise and behaviorally-oriented steps, and escalation of treatment may be necessary in some cases 7.
• Over-the-counter laxatives are recommended as first-line agents for OIC due to their efficacy, low cost, and high safety profiles 8.
• The Bowel Function Index can be used to assess symptoms of OIC and responses to therapy, and individuals with OIC refractory to laxatives may be responsive to peripherally acting μ-opioid receptor antagonists 8.

Treatment Options

• Laxatives, such as senna, docusate, and polyethylene glycol 3350, are commonly used to treat OIC 9.
• Newer agents, such as lubiprostone, linaclotide, and prucalopride, may be used in patients who do not respond to first-line treatments 7, 10.
• Peripherally acting μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, and naldemedine, may be considered in patients with OIC that has not responded to combination laxative treatment 10.
• Prokinetics or intestinal secretagogues, such as lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in some countries and should be restricted to specialist centers and clinical trials 10.

Prevention and Management Strategies

• A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fiber and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control 10.
• Educational strategies need to be developed to improve the knowledge base of healthcare providers on the identification and management of OIC 11.
• Preventive strategies, such as lifestyle changes, should be considered when patients start treatment with opioids 11.