Gastrointestinal Complications (PDQ®): Supportive care - Health Professional Information [NCI] - Constipation
Another approach, shown below in two parts, is adapted from the MD Anderson Cancer Center practice consensus algorithm for the prevention and management of opioid-induced constipation. Copyright 2008 The University of Texas MD Anderson Cancer Center
MD Anderson Cancer Center Algorithm for the Prevention of Opioid-induced Constipation
|Unless there are existing alterations in bowel patterns (e.g., bowel obstruction or diarrhea), patients receiving opioids are started on a laxative bowel regimen and receive education for bowel management.
- Stimulant laxative plus stool softener (e.g., Senokot-S [senna 8.6 mg plus docusate 50 mg]), two tablets per day and titrate up (maximum nine tablets per day).
- Ensure adequate fluids, dietary fiber, and exercise, if feasible.
- Prune juice followed by warm beverage may be considered.
MD Anderson Cancer Center Algorithm for the Management of Opioid-induced Constipation
- Assess potential cause of constipation (e.g., recent opioid dose increase, use of other constipating medications, or new bowel obstruction).
- Increase Senokot-S (or senna and docusate tablets, if using separately), and add one or both of the following:
- Milk of magnesia oral concentrate (1170/5 mL), 10 mL by mouth 2 to 4 times per day.
- Polyethylene glycol (MiraLAX), 17 g in 8-oz beverage daily.
- If no response to above, perform digital rectal examination to rule out low impaction. Continue above steps AND:
- If impacted, disimpact manually if stool is soft. If not, soften with mineral oil fleets enema before disimpaction. Follow up with milk of molasses enemas until clear with no formed stools.
- Consider use of rescue analgesics before disimpaction.
- If not impacted on rectal examination, patient may still have higher level impaction; if history is appropriate, consider abdominal imaging and/or administer milk of molasses enema with magnesium citrate 8 oz by mouth. Consider bowel management consult.
- If patient is neutropenic or thrombocytopenic, arrange for bowel management consult.
- Start one of the following regimens if the patient has not had a stool in 3 days or on the first day that any patient starts taking drugs associated with constipation:
- Stool softeners (e.g., docusate sodium, one to two capsules per day). For opioid-related constipation, stool softeners may be used in combination with a stimulant laxative. Bulk-producing agents are not recommended in a regimen used to counteract the bowel effects of opioids.
- Two tablets of a senna preparation twice daily.
- One bisacodyl tablet at bedtime.
- Milk of magnesia, 30 to 45 mL, if a bowel movement is not achieved in 24 hours after other methods are instituted.
- If the amount of stool is still inadequate, increase stool softeners up to six capsules per day or a senna preparation (e.g., Senokot) gradually to a maximum of eight tablets (four tablets twice a day); bisacodyl may be increased gradually to three tablets.
- If the amount of stool is still inadequate, a glycerin or bisacodyl suppository or enema (phosphate/biphosphate, oil retention, or tap water) is used with caution, especially in patients with neutropenia or thrombocytopenia.