Opioid-Induced Constipation Treatments- MPR

Opioid-Induced Constipation Treatments

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.

Generic	Brand	Strength	Form	Adult Dose
TRADITIONAL LAXATIVES¹
Osmotic
lactulose	—	10g/15mL	oral soln	15–30mL once daily; max 60mL/day.
lactulose	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.
Stimulant
bisacodyl	Dulcolax	5mg	e-c tabs	1–3 tabs daily. Results usually within 6–12hrs; reevaluate if ineffective.
	Dulcolax	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.
senna	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.
docusate sodium	Colace	50mg, 100mg	caps	50–300mg daily in single or divided doses.
Lubricant
mineral oil	Fleet Mineral Oil Enema	100%	enema	1 enema rectally daily. Results usually within 2–15mins; reevaluate if ineffective.
Combination Products
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	Relistor^3,4	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.
methylnaltrexone	Relistor^3,4	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	Movantik^3,4	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.
NOTES
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.
REFERENCE
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. (Rev. 2/2023)

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