Opioid-Induced Constipation Pocket Guide

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American Society of Pain Educators

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The Opioid-Induced Constipation Pocket Guide is endorsed by the American Society of Pain Educators and is based on current practice recommendations. This practical quick-reference tool contains key points, a treatment algorithm, a table of commonly used drugs, and a table of newer agents. The Opioid-Induced Constipation Pocket Guide provides all that is needed to make accurate clinical decisions at the point of care.

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Key Points
Treatment Algorithm
Tables of Commonly Used and Newer Agents
Current Medication Tables With Brand and Generic Names
Detailed Drug Information: Strengths, Formulations, Comments

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Opioid-Induced Constipation Pocket Guide

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American Society of Pain Educators

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Key Points

Opioid bowel dysfunction (OBD) is the term used to define the constellation of gastrointestinal (GI) adverse events related to opioid therapy.
OBD and opioid-induced constipation (OIC) are interchangeable terms.
Opioid medications more than double the need for laxative therapy.
OIC can occur with the first opioid dose given.
Severity of OIC is not related linearly to the dosage.
Tolerance to the constipating effects of opioids does not develop.
Nearly half of patients with OIC find laxatives ineffective.
Reversal of opioid effects in the GI system is possible without loss of analgesia.

Selecting a Treatment Regimen

Strategies for Treating Opioid-Induced Constipation

Table 1. Some Commonly Used Laxative Preparations

Product (Brand)	Starting Dosage*	Onset Time	Side Effects	Comments
Bulk-Forming Laxatives
Metamucil®, FiberChoice®, Phillips’ FiberCaps®	Varying doses per product labeling	12 h- 4 days	Flatulence Bloating Intestinal blockage Swallowing difficulty and choking if not taken with adequate fluid, or with dehydration†	Must be taken with 8 oz of fluid Requires total fluid intake of ≥ 64 oz/day Not appropriate for patients with impaired peristalsis (eg, OBD)
Lubricant Laxatives
Fleet Mineral Oil®	15-45 mL rectally at bedtime	6-8 h	Anal incontinence Anal irritation Oil leakage from anus	Prolonged use decreases absorption of vitamins A, D, E, and K Avoid in patients with aspiration risk (lipid pneumonitis) Separate from other medications by 2 h Contraindicated in pregnancy Bleeding risk in newborns
Osmotic Laxatives
Saline — Magnesium hydroxide	15-40 mL PO	30 min-3 h	Anal incontinence Anal irritation Oil leakage from anus	Rectal irritation Abdominal cramping Excessive diuresis Nausea and vomiting Dehydration	Systemic absorption Electrolyte imbalance Avoid in dehydration, renal insufficiency, congestive heart failure, or cirrhosis
Sodium phosphate Fleet Enema®	118 mL rectally	15-30 min
Sugars, alcohols — Lactulose, sorbitol	15-60 mL	24-48 h	Bloating Cramping Flatulence Diarrhea Nausea and vomiting Epigastric pain	Electrolyte imbalance Excessive gas More nausea and vomiting with lactulose May be given as a retention enema
Macrogols — Polyethylene glycol MiraLAX®	17 g dailydissolved in 4-8 oz liquid, for a maximum of 7 days	1-3 days	Loose, watery, more frequent stools	Discontinue use and contact physician if rectal bleeding, diarrhea or worsened nausea, bloating, cramping, or abdominal pain occurs
Stimulant Laxatives
Senna Senokot–S®	2 tabs (17.2 mg)	6-12 h	Abdominal cramping Flatulence Diarrhea Electrolyte disturbance	Use standardized senna glycosides Melanosis coli—reversible (senna) Cathartic colon (unproven)
Bisacodyl Dulcolax® Fleet®	5-10 mg PO 10 mg suppository 10 mg enema	6-12 h 15-60 min 5-20 min		Enteric-coated tablets—do not crush (oral bisacodyl) Rectal burning with daily use (rectal bisacodyl)
Stool Softeners
Colace® Dialose® Docusate® DOS® Doxinate® Fleet Sof-Lax® Hemaspan® Modane Soft® Surfak®	According to package directions	1-3 days	Stomach or intestinal cramps Nausea Throat irritation (from oral liquid)	Discontinue use and contact physician if skin rash (hives), difficulty breathing or swallowing, fever, vomiting or stomach pain occurs

*Adjust dose as needed to produce formed bowel movement.

† Rare side effect.

Fakata KL, et al. In: Handbook of Opioid Bowel Syndrome. Binghamton, NY: Haworth Medical Press; 2005:101-118.

Swegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician. 2006;74(8):1347-1354.

Herndon CM, Jackson KC 2nd, Hallin PA. Management of opioid-induced gastrointestinal effects in patients receiving palliative care. Pharmacotherapy. 2002;22(2):240-250.
MiraLAX (polyethylene glycol) [product information]. Schering-Plough HealthCare Products;
www.miralax.com. Accessed May 9, 2007.

Table 2. Newer Agents

Product (Brand)	Starting Dose	Onset	Side Effects	Comments
Peripheral μ-Antagonists
Alvimopan Entereg ®	12 mg PO	< 8h	Constipation Dyspepsia Flatulence Hypokalemia Back pain Urinary retention	Activity localized to the GI system Indicated to accelerate the time to upper and lower gastrointestinal recovery following partial large or small bowel resection surgery with primary anastomosis, not OIC
Methylnaltrexone Relistor ®	q2d subcut < 84 lbs – 0.15 mg/kg 84-136 lbs – 8 mg 136-251 lbs – 12 mg > 251 lbs – 0.15 mg/kg	< 4h	Abdominal pain Flatulence Nausea Dizziness Diarrhea Hyperhidrosis Warning: Intestinal perforation	Indicated for the treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient
Type II Chloride Channel Activator
Lubiprostone Amitiza ®	8 or 24 mcg bid PO	< 48h	Abdominal pain Nausea Diarrhea Headache	Approved to treat Chronic Idiopathic Constipation in adults and IBS with Constipation in women ≥ 18 yo, not OIC

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Opioid-Induced Constipation Pocket Guide

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Opioid-Induced Constipation Pocket Guide

Key Points

Selecting a Treatment Regimen

Strategies for Treating Opioid-Induced Constipation

Table 1. Some Commonly Used Laxative Preparations

Table 2. Newer Agents

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