Common strategies for managing opioid-induced constipation

Nonpharmacologic approaches for all patients, unless contraindicated by medical status

Increase fluid intake

Increase dietary soluble fiber (avoid if severely debilitated or bowel obstruction is suspected)

Encourage mobility

Ensure comfort and privacy for defecation

Select a pharmacologic strategy^*

Intermittent use of a rectal therapy, either a suppository such as bisacodyl or glycerin, or mineral oil and/or sodium phosphate enema

Intermittent use (every 2 to 3 days) of an osmotic laxative, such as polyethylene glycol, magnesium hydroxide, or magnesium citrate

Trial of a daily softening agent (docusate) for patients who describe hard, dry stools

Intermittent use (every 2 to 3 days) of a contact cathartic, such as senna or bisacodyl

Daily use of polyethylene glycol

Daily use of lactulose (unless lactose-intolerant) or sorbitol

Daily use of a contact cathartic

Adjust dose and dosing schedule of selected therapy to optimize effects

Switch or combine conventional approaches if initial therapy is inadequate

Consider adding a peripheral opioid antagonist (eg, methylnaltrexone, naloxegol, or an opioid-naloxone fixed combination) or lubiprostone; if constipation continues to be refractory, consider alternative drugs (eg, metoclopramide or linaclotide).

* Fiber supplements and/or bulk-forming laxatives (eg, psyllium) are an option for treating non-debilitated patients who maintain good oral hydration; however, efficacy is generally modest in patients with slow transit constipation, who are also more likely to experience bloating and distention. If used, patients should start with small amounts of fiber or bulking laxatives and increase gradually as tolerated.

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Common strategies for managing opioid-induced constipation