Gastrointestinal (GI) Motility, Chronic Therapeutic Class Review (TCR) March 7, 2019 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. March 2019 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All Rights Reserved. FDA-APPROVED INDICATIONS Drug Manufacturer Indication(s) alosetron (Lotronex®)1 generic, . Treatment of severe, diarrhea-predominant irritable bowel syndrome Prometheus (IBS-D) in women who have chronic IBS symptoms and have failed conventional therapy eluxadoline* (Viberzi®)2 Actavis . Treatment of irritable bowel syndrome with diarrhea (IBS-D) in adult patients linaclotide (Linzess®)3 Allergan . Treatment of chronic idiopathic constipation (CIC) . Treatment of irritable bowel syndrome with constipation (IBS-C) lubiprostone (Amitiza®)4 Takeda . Treatment of chronic idiopathic constipation (CIC) . Treatment of irritable bowel syndrome with constipation (IBS-C) in females ≥ 18 years old . Treatment of opioid-induced constipation (OIC) in adults with chronic, non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation† methylnaltrexone‡ Salix . Treatment of opiate-induced constipation (OIC) in adult patients with (Relistor®)5 advanced illness or pain caused by active cancer who require opioid dosage escalation for palliative care (injection only)§ . Treatment of OIC in patients taking opioids for chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation (tablet and injection formulations) naldemedine (Symproic®)6 Shionogi . Treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation naloxegol (Movantik®)7 AstraZeneca . Treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation plecanatide (Trulance®)8 Synergy . Treatment of chronic idiopathic constipation (CIC) in adult patients . Treatment of irritable bowel syndrome with constipation (IBS-C) prucalopride (Motegrity™)9 Shire . Treatment of chronic idiopathic constipation (CIC) in adults * Eluxadoline (Viberzi) is considered a Schedule IV controlled substance, while naldemedine (Symproic) has been descheduled and is no longer classified as a controlled substance. Other agents in this review are non-controlled prescription products. † Effectiveness of lubiprostone for the treatment of opioid-induced constipation (OIC) in patients taking diphenylheptane opioids (e.g., methadone) has not been established. ‡ Use of methylnaltrexone beyond 4 months has not been studied in patients with advanced illness. OVERVIEW The American Gastroenterological Association (AGA) classifies constipation as a syndrome that is defined by bowel symptoms specific to the difficult passage of stool, infrequent passage of stool, abnormal hardness of stool, or a feeling of incomplete evacuation after a bowel movement. Though constipation can occur secondary to another disease (e.g., Parkinson’s disease, spinal cord injury), Gastrointestinal (GI) Motility Review – March 2019 Page 2 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All Rights Reserved. idiopathic constipation occurs independent of any other underlying disorder.10 Chronic idiopathic constipation (CIC) is diagnosed if there are < 3 spontaneous bowel movements (SBMs) per week with symptoms occurring for ≥ 6 months and at least 2 of the previously mentioned bowel symptoms. Irritable bowel syndrome (IBS) is a functional bowel disorder which can be chronic, relapsing, and often life long.11,12,13 IBS occurs in up to 15% of the population and is up to 2.5 times more common in women than men. IBS is characterized by symptoms of abdominal pain or discomfort associated with abnormal stool frequency, abnormal stool consistency, abnormal stool passage, and/or bloating or abdominal distension, which may or may not be relieved by defecation, ≥ 3 days per month in the past 3 months. Patients present with a combination of symptoms that are typically constipation predominant (IBS-C), diarrhea predominant (IBS-D), and/or alternating between both, or mixed (IBS- M). Patients with IBS experience significant negative impact on their quality of life due to adverse symptoms. Causes of IBS have not been fully identified, but could potentially include gut hypersensitivity, disturbed colonic motility, post-infective bowel dysfunction, or a defective anti- nociceptive system. There may also be contributing factors (e.g., stress, food intolerance, abnormal intestinal flora) which can hinder the effectiveness of treatment if left unresolved. Symptoms of IBS are common to other gastrointestinal (GI) disorders and it is important to assess the presence of warning signs (e.g., fever, unintended weight loss, blood in stool, anemia, abnormal physical finding or blood studies, family history of inflammatory bowel disease or cancer), which might be indicative of a more serious condition.14,15,16 Diagnosis of IBS usually occurs in the presence of symptoms while excluding organ disease or other GI disorders. IBS can also present with non-colonic features (e.g., functional urinary and gynecologic problems, gallbladder and stomach symptoms, back pain, migraine, and depression) which can lead to inappropriate patient referrals. IBS is a chronic condition without a cure. Therefore, treatment of IBS is based on management of the patient’s symptoms and may require a combination of modalities to achieve relief. In 2018, the American College of Gastroenterology (ACG) provided a monograph on the management of IBS as an update to their 2014 monograph on IBS and CIC.17 Based on available data, strong recommendations for symptom improvement are provided for the use of soluble fiber, psyllium, and tricyclic antidepressants (TCAs). Loperamide is an effective antidiarrheal; however, there is no evidence to support the use of loperamide for relief of symptoms in IBS. The osmotic laxative polyethylene glycol (PEG) has shown to be effective in chronic constipation, but its efficacy in IBS-C is less certain. No recommendations of other laxatives are provided. They suggest the non-absorbable antibiotic rifaximin (Xifaxan®) for reduction in global IBS symptoms as well as bloating in non-constipated IBS patients (weak recommendation). Linaclotide (Linzess), lubiprostone (Amitiza), and plecanatide (Trulance) are all effective in IBS-C (Strong recommendations for all; linaclotide, high level of evidence [LOE]; others, moderate LOE). Alosetron (Lotronex, generic) and eluxadoline (Viberzi) are indicated for IBS-D; the ACG suggests use of these agents for overall symptom improvement based on low and moderate LOE, respectively. This monograph does not address CIC. The 2014 AGA guidelines recommend laxatives as well as linaclotide and lubiprostone in patients with IBS-C over no drug treatment; however, they note that patients may prefer alternatives due to cost. They also recommend rifaximin (Xifaxan®), an antibacterial indicated for IBS-D, and alosetron (Lotronex, generic) over no drug treatment in patients with IBS-D.18 The guidelines do not address eluxadoline, as it was not available at the time of publication. Patients with mild symptoms often respond to dietary changes, such as increasing fiber intake and reducing exposure to intolerant foods, while Gastrointestinal (GI) Motility Review – March 2019 Page 3 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All Rights Reserved. pharmacologic intervention is typically reserved for patients with moderate to severe symptoms.19,20,21