What are the treatment options for opioid-induced constipation (OIC)?

From the Guidelines

Opioid-induced constipation should be treated with a combination of lifestyle modifications and medications, starting with prophylactic laxative therapy when initiating opioid treatment, as recommended by the most recent guidelines 1.

First-Line Treatment

First-line treatment includes increasing fluid intake to 2-3 liters daily, adding dietary fiber, and encouraging physical activity when possible. For medications, start with stimulant laxatives like senna or bisacodyl, which can be combined with stool softeners such as docusate sodium.

• Increase dose of laxative when increasing dose of opioids
• Maintain adequate fluid intake
• Maintain adequate dietary fiber intake

Second-Line Treatment

If these are ineffective, add an osmotic laxative like polyethylene glycol or lactulose.

• Consider adding another agent, such as magnesium hydroxide, bisacodyl, or lactulose
• Fleet, saline or tap water enema
• Consider use of a prokinetic agent (e.g., metoclopramide)

Refractory Cases

For refractory cases, consider peripherally acting mu-opioid receptor antagonists (PAMORAs) such as methylnaltrexone, as it has been shown to be effective in treating opioid-induced constipation in advanced cancer patients 1.

• Methylnaltrexone 0.15 mg/kg subcutaneously, maximum dose per day
• Naloxegol (12.5-25 mg daily) or naldemedine (0.2 mg daily) can also be considered

Key Points

• Prophylactic laxative therapy should be initiated when starting opioid treatment rather than waiting for constipation to develop, as prevention is easier than treatment.
• Regular bowel movement assessment and laxative dose adjustments are essential for effective management of this common and distressing side effect of opioid therapy.
• The goal of treatment is to achieve soft, formed bowel movements every 1-2 days without straining or pain.
• Consider coanalgesic to allow reduction of the opioid dose.

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.

Treatment for Opioid-Induced Constipation:

• Lubiprostone (2) and naloxegol (3) are indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain.
• The recommended oral dosage of Lubiprostone for OIC is 24 mcg twice daily (2).
• Naloxegol is also an option for the treatment of OIC in adult patients with chronic non-cancer pain (3).

From the Research

Treatment Options for Opioid-Induced Constipation

• First-line management includes simple over-the-counter laxatives, as well as lifestyle changes such as increased fluid intake and physical activity 4
• If initial measures are ineffective, alternative over-the-counter laxatives, secretogogues, or peripherally acting μ-opioid receptor antagonists may be considered 4
• Medications such as methylnaltrexone, lubiprostone, linaclotide, and prucalopride have been shown to be effective in treating opioid-induced constipation 5, 6, 7
• Methylnaltrexone, in particular, has been found to induce laxation in patients with opioid-induced constipation without affecting central analgesia or precipitating opioid withdrawal 6, 8

Management Algorithms

• 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 4
• The bowel function index can be useful in objectively identifying patients who are refractory to initial measures 4
• A proposed clinical management algorithm for treating opioid-induced constipation in patients with noncancer pain has been suggested, taking into account the patient's individual needs and response to treatment 7

Efficacy of Methylnaltrexone

• Methylnaltrexone has been found to be effective in treating opioid-induced constipation, with a statistically significant difference in rescue-free bowel movement between treatment and placebo groups 8
• The medication has been shown to be effective at various doses, including 0.15 mg/kg, 0.30 mg/kg every other day, and 12 mg/day 8
• Methylnaltrexone may also decrease the use of healthcare resources, increase work productivity, and improve cost utilization 8