From the Guidelines
For a 72-year-old male with opioid-induced constipation not responding to standard treatments, I strongly recommend adding naloxegol (Movantik) 25mg daily, which specifically targets opioid receptors in the gut without affecting pain control, as the most recent and highest quality evidence supports its efficacy in treating opioid-induced constipation 1. This approach is based on the latest guidelines from the American Gastroenterological Association, which suggest the use of peripherally acting mu opioid receptor antagonists such as naloxegol for the treatment of opioid-induced constipation 1. Alternatively, lubiprostone (Amitiza) 24mcg twice daily may help increase intestinal fluid secretion, as supported by studies demonstrating its effectiveness in treating constipation associated with irritable bowel syndrome and chronic idiopathic constipation 1. For immediate relief, a glycerin suppository followed by a mineral oil enema might stimulate evacuation, as suggested by the NCCN Palliative Care Panel for patients experiencing constipation that has not responded to standard laxative therapy 1. From an integrative perspective, incorporating ground flaxseed (2 tablespoons daily mixed with fluids), increasing hydration to at least 2 liters of water daily, and encouraging gentle physical activity like walking for 15-20 minutes after meals may also help stimulate bowel movements. Abdominal massage in a clockwise direction for 10 minutes twice daily may also stimulate peristalsis, and probiotic supplementation with Lactobacillus and Bifidobacterium strains could help restore gut flora balance. If these interventions fail within 3-4 days, consider a manual disimpaction under appropriate sedation to rule out fecal impaction, followed by a colonoscopy to exclude other pathologies, as recommended by the NCCN Clinical Practice Guidelines in Oncology for adult cancer pain 1. Key considerations include:
- Assessing the cause and severity of constipation to rule out obstruction or other treatable causes
- Using laxatives judiciously, with awareness of possible electrolyte abnormalities
- Avoiding the use of rectal suppositories or enemas in patients with neutropenia or thrombocytopenia
- Limiting the use of oral laxatives or enemas that contain sodium phosphate to a maximum dose of once daily in patients at risk for renal dysfunction.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Conventional Medicine Recommendations
- The patient has already been treated with methylnaltrexone bromide, a selective mu-opioid receptor antagonist, which has been shown to be effective in reversing opioid-induced constipation without affecting central effects such as pain relief 2, 3.
- Other options for treating opioid-induced constipation include lubiprostone, linaclotide, plecanatide, and prucalopride, although these are not specifically indicated for opioid-induced constipation or have not been studied in older adults 4, 5.
- Peripherally acting mu-opioid receptor antagonists (PAMORAs) such as methylnaltrexone, naloxegol, and naldemedine have been shown to be effective in relieving constipation in patients with opioid-induced constipation, with a low risk of serious adverse events 6.
Functional and Integrative Medicine Recommendations
- Nonpharmacologic interventions such as dietary measures, increased physical activity, and biofeedback training may be considered as an adjunct to pharmacologic treatment 4.
- Over-the-counter laxatives may also be used, although the patient is already on a bowel regimen that includes osmotic and stimulant laxatives, as well as milk of magnesium and lactulose.
Considerations for Older Adults
- The management of opioid-induced constipation in older adults requires careful consideration of the complex nature of absorption, distribution, metabolism, and excretion in this population, and all agents used to treat opioid-induced constipation must be evaluated individually and reevaluated as patients continue to age 4.