Guideline for the management of Opioid Induced Constipation in Adults With thanks to Dr Qamar Abbas, Palliative Care Consultant On initiation of an opioid analgesic provide dietary, fluid & exercise advice and co-prescribe a stimulant and softener laxative. Consider bisacodyl or senna (stimulant) and (sodium docusate) laxatives. Review the need for opioids on a regular basis and titrate laxative dose to effective / maximum tolerated dose.

The definition of constipation includes the following: For guidelines on the use of opioid medicines for . Infrequent bowel movements (typically three times or fewer per week) pain see Faculty of Pain Medicines . Difficulty during defecation (straining during more than 25% of bowel movements or a http://www.fpm.ac.uk/faculty-of-pain- medicine/opioids-aware subjective sensation of hard stools), or the sensation of incomplete bowel evacuation

Any Red Flags present? New onset in elderly, unexplained anaemia, rectal bleeding, positive faecal Refer to 2 week occult blood test, family history of bowel cancer or inflammatory bowel disease, tenesmus, weight loss, Yes wait pathway new/worsening back pain, altered sensation legs, gait disturbance, bladder dysfunction. No Optimise stimulant (bisacodyl or senna) and softener (docusate) laxatives to maximum effective tolerated dose, review once a week. If there is impaction consider an enema.

At 2 to 3 weeks if inadequate response, prescribe macrogols, preferred brand Laxido® (1 to 3 sachet day) and consider rectal intervention Discuss with Palliative care team or Bowel & Bladder CNS in community or secondary care if no If partial response with no response / patient discomfort, and consider naldemedine 200microgram daily (preferred choice) significant discomfort to patient, or naloxegol 12.5mg to25 mg daily, see SPC for full prescribing advice. increase the macrogol dose When initiating naldemedine other laxatives can be continued, when initiating naloxegol stop all other laxative treatment until clinical effect is determined. ASSESS AFTER TWO WEEKS

 Improved in 2 weeks (3 or more spontaneous bowel movements (SBMs) per week and patient feeling comfortable). Continue.  Partial response: consider continuing till 4 weeks.  No response: stop and assess other options  Improved in 4 weeks: (3 or more SBMs per week and patient (discuss with Palliative care team or Bowel and Bladder feeling comfortable). Continue  CNS in community or secondary care) Partial response at 4 weeks, stop or add additional medication.  No response stop and assess other options (discuss with Palliative care team or Bowel & Bladder CNS in community / secondary care)

For palliative care patients naldemedine Patients on naldemedine or naloxegol should be counselled and advised at if they or naloxegol can be initiated by the GP following discussion with and advice develop any sudden severe abdominal pain they should stop taking immediately and let the doctor know. They should also be warned of the potential of opioid withdrawal from a Palliative Care Consultant. Ensure patient is counselled and aware of symptoms which should also be reported to their doctor immediately (can occur hours review process. or days after taking).

Opioid induced constipation (OIC) Naldemedine (Rizmoic®) and Naloxegol (Moventig®) are recommended by NICE * within their marketing authorisations, as an option for treating( can OIC occur in adults minutes whose or days constipation after taking has naldemedinenot adequately or responded naloxegol )to laxatives. An inadequate response is defined as opioid-induced constipationAdvise patients symptoms of the of atsymptoms least moderate of opioid severity withdrawal in at least symptoms. 1 of the 4 stool symptom domains (that is, incomplete bowel movement, hard stools, straining or false alarms) while taking at least 1 laxative class for at least 4 days during the prior 2 weeks.

From SPCs: Moventig® and Rizmoic® 1.Concomittant use with strong and moderate CYP3A Inducers and inhibitors : see separate SPC for contra -indication guidance and dose adjustment. 2.Contra-indicated in patients with underlying cancer who are at heightened risk of GI perforation, such as: underlying malignancies of GI tract or peritoneum, recurrent or advanced ovarian cancer, vascular endothelial growth factor (VEGF) inhibitor treatment 3. See Moventig SPC for specific cautions with cancer pain NICE TA 345 concluded that taking into account the special warnings highlighted in the SPC its recommendations regarding the use of naloxegol in clinical practice also applies to people with cancer pain who have OIC

Oxycodone/naloxone combination (Targinact®)which is not should also be reportedMethylnaltrexone to their doctor is notimmediately to be prescribed. and will NICEnecessitate cannot recommended for prescribing as clinical benefit and economic immediaterecommend discontinuation its use of in naldemedine/naloxegol. OIC as no evidence was submitted and

case is not proven – see RED list TA 468 has been withdrawn

BNF online https://bnf.nice.org.uk/treatment-summary/constipation.html , NICE CKS http://cks.nice.org.uk/constipation#!scenario *NICE TA 345 Naloxegol for treating opioid-induced constipation https://www.nice.org.uk/guidance/ta345 *NICE TA 651 Naldemedine for treating opioid-induced constipation https://www.nice.org.uk/guidance/ta651 Approved MOPB Jan 2021 review Jan 2024 Produced MOPB December 2017, Review Dec 20 Next review date Dec 25