Management of opioid-induced constipation in adults
Farmer, 2019Farmer, 2018Ginex, 2020Muller-Lissner, 2017
It is important to assess diet and lifestyle factors (eg fluid intake, exercise) and concurrent medications (see Examples of drugs that commonly cause constipation) as these can increase the risk of developing opioid-induced constipation. Encourage patients to modify diet and lifestyle factors that can contribute to constipation. Although there is insufficient evidence to recommend routine prophylactic laxative therapy to prevent opioid-induced constipation, it may be considered in patients with a high risk of opioid-induced constipation.
If a patient develops opioid-induced constipation, always reassess the indication for the opioid therapy—changing therapy or reducing the dose may restore bowel function (see Desprescribing analgesics for chronic noncancer pain). If appropriate, consider switching to the oral combination formulation of modified-release oxycodone+naloxone—this may be less constipating compared with modified-release oxycodone alone, but evidence is weakHuang, 2017.
To treat opioid-induced constipation, standard laxatives are generally appropriate. However, many patients with opioid-induced constipation report bloating and excess gas, so fermentable osmotic laxatives (eg lactulose) and bulk-forming laxatives should be avoided.
Prucalopride has evidence of short-term improvement in bowel function and quality of life in patients with opioid-induced constipation associated with noncancer painNee, 2018; consider:
prucalopride 2 mg orally, daily. For patients older than 65 years, use 1 mg orally, daily1. prucalopride prucalopride prucalopride
If standard laxative therapy or prucalopride is ineffective, consider referral to a gastroenterologist.
In Australia, methylnaltrexone, a peripherally acting opioid antagonist, is only approved for opioid-induced constipation in patients receiving palliative care who do not respond to other laxative therapy. However, it may be used by a gastroenterologist for patients who are not receiving palliative care.Mehta, 2016Nishie, 2019Sridharan, 2018Vijayvargiya, 2020Candy, 2018
LubiprostonePassos, 2020Nee, 2018 and linaclotide are effective for opioid-induced constipation but are not available in Australia at the time of writing.