Visual summary MODIFY PAIN RELIEF Managing opioid-induced constipation Is the current dose of opioid needed to control pain? Constipation affects many patients using opioids Could pain be relieved in other ways? to relieve pain associated with advanced cancer Non-opioid analgesics Interventional pain management or terminal disease.

Constipation is often multifactorial in such patients, Could an opioid with less constipating effect be used? and opioids may be one of several causes. As well Buprenorphine Transdermal fentanyl as direct treatment of the constipation, adjusting medication regimens and treating exacerbating factors may help to provide relief from bowel transit Is a referral to other specialists needed? symptoms. Palliative care Neuro-gastroenterology Pain clinic

ADDRESS EXACERBATING FACTORS DIRECTLY TREAT CONSTIPATION Drugs Non-pharmacological options

5HT3 antagonists Anticholinergics Opioids Increase fluid consumption Increase dietary fibres

Antipsychotics Diuretics Iron Increase physical activity (within patients’ capabilities)

Calcium supplements Calcium channel blockers Privacy and comfort during defecation

Chemotherapies Complementary therapy

Thalidomide Vinca alkaloids Positioning on toilet (to relax the puborectalis muscle) knees higher than hips, leaning forward Busulfan Carboplatin with elbows on knees, straightened spine

Manual removal Nutritional and if the constipation is severe and refractory to other therapies metabolic issues Pharmacological management Dehydration Reduced food and fluids intake Oral laxatives Poor diet Hypothyroidism Stool softeners such as docusate Hypercalcaemia especially in patients with bone metastasis Stimulant laxatives such as bisacodyl, senna

Osmotic laxatives Pain on defecation such as macrogol (polyethylene glycol), lactulose Anal fissure Rectal laxatives Structural problems Lubricants such as glycerin suppositories Radiation fibrosis Bowel obstruction Stimulant laxatives such as bisacodyl suppositories Adhesions Enemas such as phosphate enema Neurological problems Neuromuscular problems Spinal cord compression Peripherally acting μ-opioid receptor antagonists Autonomic neuropathy such as due to diabetes or chemotherapy Methylnaltrexone bromide

Social issues Prolonged release oxycodone in fixed dose combination with Naloxone Reduced mobility Lack of privacy Naloxegol oxalate Use of a communal toilet, commode, or bed pan

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