AGA issues guideline on opioid-induced constipation

Opioid-induced constipation differs mechanistically from other forms of the disorder, and its medical management deserves dedicated attention, the American Gastroenterological Association (AGA) said.

The American Gastroenterological Association (AGA) has issued recommendations on the medical management of opioid-induced constipation (OIC).

“Because OIC results from the specific effects of opioids, it differs mechanistically from other forms of constipation, and therefore, medical management of this disorder deserves dedicated attention,” the guideline stated. The guideline, which is intended to reduce practice variation and promote high-quality and high-value care in OIC, was published Oct. 16 by Gastroenterology.

The guideline's recommendations include the following:

  • Traditional laxatives are recommended as first-line agents (strong recommendation, moderate-quality evidence).
  • For peripherally acting mu-opioid receptor antagonists, in patients with laxative-refractory OIC, naldemedine is recommended over no treatment (strong recommendation, high-quality evidence). Naloxegol is also recommended over no treatment, but while this is also a strong recommendation, the evidence to support it is of moderate quality.
  • In patients with laxative-refractory OIC, methylnaltrexone is suggested over no treatment (conditional recommendation, low-quality evidence).

The guideline made no recommendations regarding use of lubiprostone or prucalopride due to lack of evidence.

The guideline also stated that a suggested general approach to patients with suspected OIC involves taking a careful history to evaluate defecation patterns, dietary patterns, stool consistency, symptoms of dyssynergic defecation (such as a sensation of incomplete evacuation), or alarm symptoms such as blood in stool or accompanying weight loss. The medical history should assess comorbid illnesses and regular medication use, the guideline said.

Other potential causes or contributors to constipation should be excluded, such as pelvic outlet dysfunction, mechanical obstruction, metabolic abnormalities, and other diseases or medications. Lifestyle modifications, such as increased fluid intake and regular moderate exercise as tolerated, are an appropriate first step for all types of constipation, the guideline noted. Switching opioids or changing to an alternative with less constipating effects may also be of benefit, the guideline said.

The guideline focuses on medical management and does not address psychological therapy, alternative medicine, surgery, or devices. In addition, it does not directly address questions about diagnostic evaluation of OIC or combination opioid agonists and antagonists.