|OPIOID-INDUCED CONSTIPATION TREATMENTS|
|The management of opioid-induced constipation is based on recommendations from the American Gastroenterological Association (AGA). The guideline only focuses on medical management (both prescription and over-the-counter products) and does not address the role of psychological therapy, alternative medicine approaches, surgery, or devices.|
|lactulose||—||10g/15mL||oral soln||15–30mL once daily; max 60mL/day.|
|Kristalose||10g, 20g||crystals for reconstitution||Dissolve 10–20g in 4oz water once daily; max 40g/day.|
|magnesium citrate||—||1.745g/30mL||oral soln||Take with a full 8oz glass of liquid. 6.5–10oz (192–296mL) once daily or in divided doses. Max 10oz/24hrs.|
|magnesium hydroxide||—||400mg/5mL, 1200mg/15mL||liquid, oral susp||Take with a full 8oz glass of liquid. 30–60mL once daily or in divided doses.|
|polyethylene glycol (PEG) 3350||Miralax||17g||pwd for oral soln||Dissolve 17g in 4–8oz liquid and drink once daily for max 7 days.|
|bisacodyl||Dulcolax||5mg||e-c tabs||1–3 tabs daily. Results usually within 6–12hrs; reevaluate if ineffective.|
|10mg||supp||1 supp rectally once daily. Retain for 15–20mins. Results usually within 15–60mins; reevaluate if ineffective.|
|Fleet||5mg||tabs||1–3 tabs daily. Results usually within 6–12hrs; reevaluate if ineffective.|
|10mg||supp||1 supp rectally daily. Retain for 15–20mins. Results usually within 15–60mins; reevaluate if ineffective.|
|10mg/30mL||enema||1 enema rectally daily. Results usually within 5–20mins; reevaluate if ineffective.|
|senna||Senokot||8.6mg||tabs||2 tabs once daily; max 4 tabs twice daily.|
|Senokot Extra Strength||17.2mg||tabs||1 tab once daily; max 2 tabs twice daily.|
|Detergent/surfactant stool softeners|
|docusate sodium||—||10mg/mL||liquid||Mix in 6–8oz of milk or juice. 50–150mg once or twice daily.|
|Colace||50mg, 100mg||caps||50–300mg daily in single or divided doses.|
|mineral oil||Fleet Mineral Oil Enema||100%||enema||1 enema rectally daily. Results usually within 2–15mins; reevaluate if ineffective.|
|senna / docusate||Senokot-S||8.6mg/50mg||tabs||2 tabs once daily; max 4 tabs twice daily.|
|PERIPHERALLY ACTING μ-OPIOID RECEPTOR ANTAGONISTS (PAMORAs)2|
|methylnaltrexone||Relistor3,4||150mg||tabs||Take on an empty stomach with water ≥30mins before first meal of day. 450mg once daily in the AM. CrCl<60mL/min or hepatic impairment (Child-Pugh B or C): 150mg once daily.|
|8mg/0.4mL, 12mg/0.6mL||soln for SC inj||12mg SC once daily. Advanced illness: give once every other day as needed (max 1 dose/24hrs). <38kg or >114kg: 0.15mg/kg. 38–<62kg: 8mg. 62–114kg: 12mg. Renal (CrCl<60mL/min) or severe hepatic impairment: reduce dose by ½ (see full labeling).|
|naldemedine||Symproic4||0.2mg||tabs||0.2mg once daily.|
|naloxegol||Movantik3,4||12.5mg, 25mg||tabs||Take on an empty stomach. 25mg once daily in the AM; may reduce to 12.5mg once daily if not tolerated. Renal impairment (CrCl<60mL/min): 12.5mg once daily; may increase to 25mg once daily if tolerated. Concomitant moderate CYP3A4 inhibitors: if unavoidable, reduce to 12.5mg once daily; monitor.|
|Key:e-c = enteric coated; pwd = powder; soln = solution; supp = suppository.
1 Once OIC is confirmed and other causes of constipation excluded, the AGA recommends the use of laxatives as first-line agents. For laxative-refractory OIC, it is recommended to use PAMORAs such as naldemedine or naloxegol, and suggested to use methylnaltrexone, over no treatment. The AGA recommends using a combination of ≥2 types of laxatives before escalating therapy, and that scheduled use of laxatives (vs “as needed” basis) is required before considering alternative treatment.
2 Avoid in conditions that compromise the blood-brain barrier due to potential for serious withdrawal or reversal of anesthesia.
3 Discontinue all laxative therapy prior to initiation; may use as needed if suboptimal response after 3 days.
4 Discontinue if opioid pain therapy is also discontinued.
Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.
Adapted from Crockett SD, Greer KB, Heidelbaugh JJ, et al. American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation. Gastroenterology. 2018 Oct 16. pii: S0016-5085(18)34782-6. doi: 10.1053/j.gastro.2018.07.016.
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