Written by: Neal Dave, PharmD and Julianne Orr, PharmD NCODA Spring Forum PQI Workshop
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Opioids are commonly utilized in the management of moderate to severe cancer pain. Constipation is a major side effect of opioid administration and should be assessed and managed by the healthcare team.

Background: In cancer patients receiving chronic opioid therapy, the prevalence of constipation can be as high as 60 to 90 %. Constipation is the most common manifestation of opioid induced bowel dysfunction (OBD) and typically occurs through activation of both peripheral and central opioid receptors. Opioid induced constipation has the potential to effect patients’ quality of life or lead to complications such as bowel obstruction or anorexia.

PQI process:

  1. Prescription for an opioid is obtained
  2. Assess the medications patients are currently on
    1. Look for causative medications in addition to opioids
    2. If patient is already on an agent that is notorious for causing diarrhea, there may be no need for prevention of OIC.
  3. Educate patient on opioid induced constipation
    1. Symptoms of constipation
      1. Straining
      2. Lumpy or hard stools
  • Sensation of incomplete evacuation
  1. Consider adding preventative agents:
    1. Docusate/Senna: Two tablets (17.2 mg sennosides plus 100mg docusate) once daily
      1. Max dose of Senokot: 4 tablets twice daily
    2. Miralax: 17g in 4-8 oz of water daily
    3. Lactulose: 30mL daily (avoid in patients who are lactose intolerant)
  1. Pharmacologic options once preventative measures are ineffective, consider use with discretion as clinical efficacy varies:
    1. Magnesium citrate: 195 – 300mL given once or in divided doses

Consider milk of magnesia if citrate is unavailable

  1. Subcutaneous methylnaltrexone (Relistor): Dosing is according to body weight; Administer one dose every other day as needed (Max: 1 dose/24 hours)
    1. <38kg: 0.15mg/kg rounded to the nearest 0.1mL
    2. 38 to <62kg: 8mg
  • 62 to 114kg: 12 mg
  1. >114kg: 0.15mg/kg rounded to the nearest 0.1mL
  1. Naloxegol (Movantik): 25mg PO once daily
    1. Can decrease to 12.5mg if 25mg not tolerated
  2. Lubiprostone (Amitiza): 24mcg twice daily

Patient Centered Activities:

  • Non-pharmacologic counseling
    • Increase fluids
      • Common recommendation for water consumption is eight 8-ounce glasses, which is about 2 liters (or a half gallon)
      • Caffeine can contribute to dehydration
    • Increase fiber
      • USDA’s fiber intake recommendation is between 25 to 38g per day
    • Modifying diet
      • Eat several small meals throughout the day, rather than a few large ones
      • Avoid fatty, processed meats and fast foods
      • Eating natural laxatives:
        • Prunes, apple cider, bran cereals, watermelon, rhubarb, etc.
      • Increase activity
        • Exercise can increase circulation, which can naturally accelerate movement of stool
      • Consider offering diet counseling books (i.e. “Eating Well Through Cancer”)
      • Taking preventative agents daily
    • Patient Medication Education
      • Review maximum daily doses of any agent the patient starts.
      • Relistor – make sure the patient is aware that an instant bowel movement is possible after they receive their injection

References:

  1. Poulsen et al. Therap Adv Gastroenterol. 2015 Nov;8(6):360-72
  2. Dhingra et al. Palliative Medicine. 2012 June;27(5):447-457
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.
Victoria

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