The American Gastroenterological Association (AGA) has issued new guidelines on the medical management of opioid-induced constipation (OIC). The guideline was developed by the AGA Institute’s Clinical Guidelines Committee using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and approved by the AGA Governing Board. The recommendations have been published in the AGA’s official journal, Gastroenterology.
Opioids are potent analgesics used for the treatment of acute and chronic pain. Side-effects are common and among the most bothersome are those associated with opioid-induced bowel dysfunction, which includes opioid-induced constipation.
In the new guidelines of management of Opioid-induced constipation, OIC, Key recommendations are:
- In patients with OIC, the use of laxatives as first-line agents is recommended.( Strong; moderate-quality evidence)
- In patients with laxative refractory OIC, naldemedine is recommended over no treatment (Strong; high-quality evidence)
- In patients with laxative refractory OIC, naloxegol is recommended over no treatment (Strong; moderate-quality evidence)
- In patients with laxative refractory OIC, methylnaltrexone is suggested over no treatment (Conditional; low-quality evidence)
- The AGA makes no recommendation for the use of lubiprostone in OIC (No recommendation; evidence gap)
- The AGA makes no recommendation for the use of prucalopride in OIC (No recommendation; evidence gap)
With respect to recommendations on newer agents like intestinal secretagogues, selective 5-HT agonists, the guideline panel writes that additional studies are needed to establish the benefits of these drugs due to lack of published data on long-term use.
“Physicians have struggled with treating this condition due to previous lack of clinical guidance,” said Seth D. Crockett, MD, MPH, lead author of the guideline, University of North Carolina School of Medicine, Chapel Hill. “The new AGA guideline clarifies existing data and provides clear direction for physicians on how to best treat opioid-induced constipation.”
“These guidelines presume that patients have been appropriately diagnosed and that they have either a prolonged requirement or dependence on opioids,” write the authors. “Therefore, one of the first steps to managing patients with OIC is to ensure that the indication for opioid therapy is appropriate, that patients are participating in a pain management program (ideally in conjunction with a pain specialist), and that they are taking the minimum necessary opioid dose.”
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Dr. Kamal Kant Kohli
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