Would another glycerin suppository be beneficial for a palliative patient with opioid-induced constipation, currently on polyethylene glycol (PEG), senna (Senakot), and lactulose, who has not had a bowel movement in over 1 week despite a previous glycerin suppository?

From the Guidelines

Another glycerin suppository may not be the most beneficial option for this palliative cancer patient, and instead, a bisacodyl suppository (10mg) could be considered as it provides stronger stimulation. Since the first suppository was ineffective after 24 hours, and the patient is already on a regimen of PEG, senokot, and lactulose, adding a bisacodyl suppository could help stimulate bowel evacuation 1. The patient's lack of bowel movement for over a week despite multiple laxatives indicates significant opioid-induced constipation, which occurs because opioids slow intestinal motility by binding to mu-receptors in the gut 1.

Some key points to consider in the management of this patient's constipation include:

• Ensuring adequate fluid intake (1.5-2L daily) to help soften stools and make them easier to pass
• Considering the addition of oral naloxegol (12.5-25mg daily) or methylnaltrexone (subcutaneous, weight-based dosing) as opioid antagonists that don't affect pain control 1
• Maintaining the current laxative regimen with possible dose adjustments to achieve the goal of one non-forced bowel movement every 1-2 days
• Ruling out other causes of constipation, such as impaction, obstruction, hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 1

It's also important to note that the use of enemas, such as sodium phosphate enema, may be necessary to provide more immediate relief if the patient's constipation persists despite the above measures 1. However, enemas are contraindicated in certain situations, such as neutropenia or thrombocytopenia, paralytic ileus or intestinal obstruction, recent colorectal or gynecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain, or recent radiotherapy to the pelvic area 1.

Overall, the management of this patient's constipation requires a multifaceted approach that takes into account the underlying cause of the constipation, the patient's current medication regimen, and their overall health status.

From the Research

Patient's Current Situation

• The patient is a palliative patient on opioids for cancer, eating well, but has not had a bowel movement in over 1 week.
• The patient is currently on peg, senakot, lactulose, and was given a glycerin suppository with no bowel movement 24 hours later.
• The patient does not have any symptoms.

Use of Suppositories

• According to 2, suppositories are unique dosage forms that provide pharmacists with an opportunity for a detailed discussion when counseling a patient.
• The study 3 compared the use of polyethylene glycol versus vegetable oil-based bisacodyl suppositories and found that the polyethylene glycol base reduced the time required for bowel care.
• The administration of a suppository requires skill and competence on behalf of the practitioner, as well as compliance with guidelines on the administration of medicines and local drug administration policy 4.

Efficacy of Another Suppository

• There is limited evidence to suggest that another suppository would be beneficial in this case, as the patient has already been given a glycerin suppository with no bowel movement 24 hours later.
• However, the study 5 suggests that stimulant laxatives, like Senna and Bisacodyl, can be effective in treating constipation, and suppositories can be used as an adjunct therapy in specific clinical scenarios.
• The use of hollow-type suppositories, as discussed in 6, may provide additional options for patients in the future, but more research is needed to determine their efficacy in this specific situation.