January 09, 2019
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New AGA OIC Guidelines Promote ‘High-quality, High-value’ Care

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Seth Crockett, MD
Seth D. Crockett

The American Gastroenterological Association released a clinical guideline on the management of opioid-induced constipation, informed by the most recent medical research and expert opinion.

“This guideline primarily makes recommendations regarding medical therapies for patients with confirmed [opioid-induced constipation], after other causes have been excluded,” Seth D. Crockett, MD, MPH, associate professor of gastroenterology at University of North Carolina, and guideline co-author, told Healio Gastroenterology and Liver Disease.

Opioid-induced constipation (OIC) is estimated to affect approximately 40% to 80% of patients taking opioids for chronic pain, according to the guidelines.

As a result, the authors of the guideline suggest that one of the most important first steps in managing patients with OIC is ensuring that the indication for opioid therapy is appropriate, that patients are participating in a pain management program, and that they are taking the minimum necessary opioid dose.

The authors also suggested that physicians take a careful history of patients to evaluate if they have OIC. For instance, the guideline authors suggest physicians evaluate a patient’s defecation and dietary pattern, as well as stool consistency, symptoms of dyssynergic defecation or alarming symptoms.

Additionally, the authors recommend that physicians explore and exclude other possible causes of constipation such as pelvic outlet dysfunction, mechanical obstruction and metabolic abnormalities.

Lifestyle modifications such as increasing fluid intake, regular to moderate exercise and using the bathroom as soon as possible when experiencing an urge to defecate, were listed as appropriate first steps for patients experiencing constipation.

Recommendations

If non-pharmacologic approaches fail to relieve OIC symptoms in patients, the guidelines recommend a scheduled dosing of at least two laxatives from a variety of classes including stimulants, stool softeners, lubricants and osmotics.

The guidelines then recommend the initiation of peripherally acting mu-opioid receptor antagonists (PAMORAs) if symptoms persist despite the use of laxatives.

“Laxatives are recommended as first-line therapy,” Crockett said. “For patients with OIC that is not controlled with laxatives alone, various prescription medications were evaluated. There is good evidence that the PAMORA class of medications are effective in OIC. However, evidence is limited for other classes of medications such as secretagogues or 5HT agonists.”

Naldemedine (Symproic, Shionogi) and naloxegol (Movantik, AstraZeneca) both received “strong recommendations” in the guidelines based on a review of their clinical trial data. The data supporting naldemedine was considered “high-quality evidence,” while the data recommending naloxegol was considered “moderate-quality evidence.”

Methylnaltrexone (Relistor, Salix) received a “conditional recommendation,” and lubiprostone (Amitiza, Takeda) and prucalopride (Motegrity, Shire) received “no recommendation” for use to treat OIC in the guidelines.

Additionally, the authors of the guideline recommended using the Bowel Function Index – a three-question tool – to determine which patients have inadequately responded to first-line laxative therapy and would potentially benefit from escalation therapy.

A score of 30 or more, as the authors noted, is consistent with a clinically significant diagnosis of constipation.

Laxatives best option

Although several studies, including one from Charles E. Argoff, MD, and colleagues published in Pain Medicine, have indicated that less than half of patients diagnosed with OIC reported achieving their desired treatment outcomes while receiving laxatives, Crockett said he believes they are still the best initial treatment choice.

“Not all patients with constipation will have an adequate response to laxatives, but there is good rationale to use these agents first-line given relative safety, efficacy and low cost,” he said. “Osmotic laxatives in particular, like polyethylene glycol, are very safe and quite effective as long as patients are adequately dosed and have sufficient fluid intake.” – by Ryan McDonald

Reference:

Argoff CE, et al. Pain Med. 2015;doi:10.1111/pme.12937.

Disclosure: Crockett reports no relevant financial disclosures.