American Gastroenterological Association technical review on constipation.

Peripherally acting mu-opioid antagonists are expensive, and should be used only when other options are ineffective.īharucha AE, Pemberton JH, Locke GR.

Naloxegol is administered orally and is approved for opioid-induced constipation in patients who do not have cancer. Alvimopan, approved for short-term treatment of postoperative ileus, is available only through a restricted prescribing program because of increased risk of myocardial infarction. 34 Methylnaltrexone should not be used in patients with intestinal obstruction and should be used with caution in patients with intestinal malignancy. 23 Methylnaltrexone is administered subcutaneously and is effective for opioid-induced constipation in palliative care patients with symptoms resistant to other laxatives. 33 A systematic review of studies with patients up to 78 years of age who had malignant or nonmalignant pain found that methylnaltrexone, naloxone, and alvimopan were more effective than placebo for chronic opioid-induced constipation. Up to 40% of patients taking opioids are constipated of these, only 46% have an acceptable response to laxatives more than 50% of the time. These agents include methylnaltrexone (Relistor), alvimopan (Entereg), and naloxegol (Movantik), which decrease the gastrointestinal effects of opioids without reducing centrally mediated analgesia, and naloxone, which is also effective for constipation but can decrease analgesia. Peripherally Acting mu-Opioid Antagonists.

Weight-based subcutaneous injection, once or twice per dayĭiarrhea in 16%, which led to treatment cessation in 4% 24 Peripherally acting mu-opioid antagonists Minimal adverse effects of cramping and gas 18Ģ to 3 tbsp, single dose or short-term daily doseĭiarrhea and abdominal pain in 56% in week 1 and 5% in week 4 21 Increase in magnesium, causing lethargy, hypotension, respiratory depression 20 Peripherally acting mu-opioid antagonists are effective for opioid-induced constipation but are expensive.ġ tsp or 1 packet one to three times per dayīloating, abdominal distension in 4% to 18% 16, 17īloating and cramping nausea in up to 20% 19ġ50 to 300 mL, single dose or short-term daily dose If symptoms do not improve, a trial of linaclotide or lubiprostone may be appropriate, or the patient may be referred for further diagnostic evaluation. Long-term use of magnesium-based laxatives should be avoided because of potential toxicity. The next step in the treatment of constipation is the use of an osmotic laxative, such as polyethylene glycol, followed by a stool softener, such as docusate sodium, and then stimulant laxatives. Fiber intake should be slowly increased over several weeks to decrease adverse effects. Additional fiber intake in the form of polycarbophil, methylcellulose, or psyllium may improve symptoms. Most patients are initially treated with lifestyle modifications, such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake. Fecal impaction should be treated with mineral oil or warm water enemas. Secondary constipation is associated with chronic disease processes, medication use, and psychosocial issues. Primary constipation is also referred to as functional constipation. Chronic constipation is common in adults older than 60 years, and symptoms occur in up to 50% of nursing home residents.

Fecal impaction overflow diarrhea