Opioid-Induced Constipation and Bowel Dysfunction: A Clinical Guideline

Abstract

ObjectiveTo formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction.SettingConstipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term “opioid-induced bowel dysfunction.”MethodsA literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system.ResultsFrom a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction.ConclusionsIn recent years, more insight has been gained in the pathophysiology of this “entity”; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.

Efficacy of pharmacological therapies for the treatment of opioid-induced constipation: systematic review and network meta-analysis

“…However, a group of experts in the field have made recent recommendations based on the current available evidence 59. The authors noted that there was no evidence for any benefit of lifestyle modifications or dietary changes in patients with OIC.…”

Insights on efficacious doses of PAMORAs for patients on chronic opioid therapy or opioid‐naïve patients

“…Unfortunately, opioid use, especially for non‐cancer pain, has led to addiction or abuse, an epidemic of opioid use, and deaths due to overdose . Important clinical guidelines have been published to enhance management of OIC …”

“…In fact, laxatives are prescribed first or simultaneously with step III opioids (morphine, buprenorphine, fentanyl, hydromorphone, methadone, oxycodone) in about 45% of cases, with an equal percentage of cases not receiving laxatives at all . Multinational initiatives and algorithms by individual hospitals or units prescribing opioids for pain (eg, burns units) propose combining opioids with laxatives, or an opioid antagonist, or switching to another opioid. If there is insufficient response, a combination of two laxatives or opioid antagonists should be considered.…”

Peripherally acting μ‐opioid antagonist for the treatment of opioid‐induced constipation: Systematic review and meta‐analysis

“…Three PAMORAs, methylnaltrexone bromide (Relistor), naloxegol (Movantik), and naldemedine (Symproic), have been approved by the Food and Drug Administration (FDA) for the treatment of patients with OIC . In the latest guidelines of OIC, PAMORA is a treatment option alongside laxatives …”

“…11 In the latest guidelines of OIC, PAMORA is a treatment option alongside laxatives. 12 However, to date, to our knowledge, the consistent effect of PAMORA across studies has not been systemically evaluated. In trials of PAMORA in patients with OIC, patient backgrounds were well balanced between randomized groups, but the groups showed differences in the prevalence of ethnicities, malignant or nonmalignant diseases, and opioid doses.…”