Written by: Brady Quinn, PharmD and Britny Rogala, PharmD, BCOP – University of Rhode Island College of Pharmacy
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Discuss prevention and management strategies for treatment-related constipation
Background:
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
Many chemotherapeutic medications, antiemetics, and pain regimens can commonly cause constipation (see Supplemental Information for examples). 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
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 (see Supplemental Information: Drug Therapy below)
- 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.)
- See NCODA PQI on Opioid-induced Constipation here: https://www.ncoda.org/wp-content/uploads/2019/06/PQI-Opioid-Induced-Constipation-3.pdf
- 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:
- 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.
- Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25:16B-21B.
- 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.
Supplemental Information:
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
