29

April

Chemotherapy-, Antiemetic-, and Opioid-Induced Constipation

Written by: Brady Quinn and Britny Rogala, PharmD – University of Rhode Island College of Pharmacy
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The utilization of proper diet, over-the-counter medications, and alternative prescriptions can be helpful for patients suffering from multisource drug-induced constipation. Preventing this type of constipation requires less interventions than treating the symptoms once they occur.1

Background:

Many chemotherapeutic medications, antiemetics, and pain regimens can commonly cause constipation. Drug-induced constipation, often characterized by infrequent, hard, or difficult to pass bowel movements, can significantly impair quality of life or cause severe pain, rectal fissures, or bowel obstruction.1-3

Oral chemotherapy agents that commonly cause constipation(>30%): alectinib, crizotinib, ponatinib, ixazomib, lenalidomide, niraparib, pomalidomide, rucaparib, temozolomide, and thalidomide

Anti-emetics that commonly cause constipation: 5-HT3 antagonists (e.g. ondansetron)

Diet/Exercise:

  • Increase fiber intake; patients prone to small bowel obstruction (i.e. abdominal surgery) should avoid additional fiber intake
    • Whole grains, brown rice, raw fruits and vegetables, etc.
  • Drink plenty of fluids
    • 8-10 glasses of water, fruit/vegetable juices, decaffeinated teas
  • Try some sort of physical activity

Drug Therapy

Osmotic Laxative

  • Polyethylene Glycol (OTC/RX)
    • Take 1 capful/packet/heaping tablespoon (17g) of powder dissolved in 4-8 ounces of any beverage daily.
    • Onset of action: 12-72 hours

Stool softener

  • Docusate Sodium (OTC)
    • Take 1 softgel (100mg) up to 3 times per day in divided doses
    • Onset of action: 12-72 hours
    • Can take in combination with a stimulant laxative for best results

Stimulant laxatives

  • Senna (OTC)
    • Take 2 tablets (17.2mg) as one dose once daily to start. If needed can take up to 4 tablets (34.4mg) twice daily
    • Onset of action: 6-12 hours
  • Bisacodyl (OTC)
    • Take 1 tablet (5mg) once daily to start. If needed can take up to 3 tablets (15mg) once daily.
    • Onset of action: 6-12 hours

Prescription Options

  • Methylnaltrexone (RX only)
    • Used to treat opioid-induced constipation
    • Rule out GI obstruction – contraindicated
    • Inject 1 prefilled syringe (dose may vary) subcutaneously up to every other day as needed
    • Rotate injection site between abdomen, thighs, and upper arms
    • Discontinue methylnaltrexone immediately if severe or persistent diarrhea or abdominal pain occurs
  • Naloxegol (RX only)
    • Used to treat opioid-induced constipation
    • Rule out GI obstruction – contraindicated
    • Usual dose: take 1 tablet (25mg) daily at least 1 hour before the first meal of the day (dose may differ due to tolerability)
    • Concomitant use with strong CYP3A4 inhibitors is not recommended
    • Providers may request samples directly from the manufacturer

PQI Process:

Upon receipt of an oral chemotherapy agent with known constipation side effect

  • Counsel patient on constipation management
  • Provide information on foods to eat to prevent the onset of constipation
  • Provide stool softener and stimulant laxative to patient if patient reports signs of constipation
  • Keep stool softener and stimulant laxative well stocked if patient experiences intermittent constipation
  • Consider scheduling a follow up phone call with patient within one week after initiation of therapy to assess if patient is experiencing constipation
    • Assess the cause of constipation (chemotherapy/antiemetic/opioid)
    • If opioid therapy is the cause of the constipation and significant effort to alleviate constipation has been made with no relief, consider prescription therapy (methylnaltrexone, naloxegol, etc.)
    • If antiemetic therapy is the cause of constipation provide a prescription for a different type of antiemetic for chemotherapy-induced nausea/vomiting (Refer to CINV PQI)

Patient Centered Activities:

Educate patients on different forms of laxatives (bulk forming, polyethylene glycol), if bowel movements do not become regular continue on to OTC agents.

Advise patient to:

  • Try to find a diet and regimen that helps to keep bowel movements regular
  • Attempt to treat to what their regular bowel movement schedule would normally be
  • Keep track of how many bowel movements they make in a week
  • Be sure to drink plenty of fluids while taking laxative and stool softening medications
  • Contact clinic if they have not had a bowel movement in 2 or more days
  • Notify your provider if you have been taking OTC medications continuously for 7 days.

References:

  1. McQuade RM, Stojnovska V, Abalo R, Bomstein JC, Nurgali K. Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments. Front Pharmacol. 2016;7:414.
  2. Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25:16B-21B.
  3. Kumar L, Barker C, Emmanuel A. Opioid-Induced Constipation: Pathophysiology, Clinical Consequences, and Management. Gastroenterology Research and Practice. 2014; https://doi.org/10.1155/2014/141737.
Important notice: National Community Oncology Dispensing Association, Inc. (NCODA), has developed this Positive Quality Intervention platform. This platform represents a brief summary of medication uses and therapy options derived from information provided by the drug manufacturer and other resources. This platform is intended as an educational aid and does not provide individual medical advice and does not substitute for the advice of a qualified healthcare professional. This platform does not cover all existing information related to the possible uses, directions, doses, precautions, warning, interactions, adverse effects, or risks associated with the medication discussed in the platform and is not intended as a substitute for the advice of a qualified healthcare professional. The materials contained in this platform are for informational purposes only and do not constitute or imply endorsement, recommendation, or favoring of this medication by NCODA, which assumes no liability for and does not ensure the accuracy of the information presented. NCODA does not make any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual consuming the medication. All decisions related to taking this medication should be made with the guidance and under the direction of a qualified healthcare professional.
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