Approximately half of patients with cancer will experience constipation, ranging in severity from slight discomfort to impaction. It is a common adverse effect of some treatments, such as opioid-based therapy. In these cases, it is referred to as opioid-induced constipation (OIC). However, it may also occur as a chronic condition in patients who are not receiving opioid-based therapy. “OIC can be a challenge for clinicians to treat and can result in serious medical complications and negatively affect quality of life and pain management,” stated the authors of the ONS Guidelines article describing the new guidelines and published in Oncology Nursing Forum.1
Developed by an ONS Guidelines panel that included oncology nurses at all levels of practice, a gastroenterologist, a registered dietitian, and a patient representative, these guidelines were based on updates of 2 systematic reviews, each dealing with either OIC or chronic idiopathic constipation.2,3
Regarding the necessity for these guidelines, the Panel stated, “Despite the prevalence of non-opioid–related constipation and OIC and the available clinical practice guidelines, there remains a need for management strategies for patients with constipation. Continuing education and practice improvement focused on management for patients at risk for and experiencing constipation is needed.”1
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Each recommendation was rated as strong, conditional, or representing a research/knowledge gap, reflecting the consensus of the ONS Guidelines panel regarding the benefits and harms, as well as the values and preferences, associated with the proposed intervention. In addition, the level of the evidence associated with each recommendation was rated on a scale of very low to high.
Fundamental to these guidelines is an overarching recommendation specifying that, in general, constipation in patients with cancer should be managed with a stepwise approach involving use of pharmacologic interventions only in situations where lifestyle practice education and laxatives are not effective.
Regarding prevention and treatment of OIC, the ONS Guidelines panel stated in a “good practice statement” that patients should be educated about lifestyle practices — such as increased dietary fiber, water intake, and exercise — that can help prevent OIC prior to initiation of opioid therapy.
In addition, the Guidelines offer the following recommendations:
- For those patients who place a greater emphasis on preventing OIC, a prophylactic, laxative-based, bowel regimen plus lifestyle practice education is suggested over lifestyle practice education alone (strength: conditional; level of evidence: low)
- For patients with OIC, use of osmotic or stimulant laxatives in combination with lifestyle practice education was recommended over lifestyle practice education alone (strength: strong; level of evidence: moderate)
- For patients with OIC, use of osmotic polyethylene glycol (PEG) laxatives in combination with lifestyle practice education was suggested over lifestyle practice education alone (strength: conditional; level of evidence: low)
In the case of OIC not responsive to a bowel regimen, the Guidelines suggest using a peripherally acting µ-opioid receptor antagonist (PAMORA), such as naldemedine, methylnaltrexone, or naloxegol, in combination with a bowel regimen. Strength of the recommendation for naldemedine is strong and level of evidence is moderate, but are conditional and very low, respectively, for the other 2 PAMORAs.
Regarding the management of non-opioid–related constipation, the Guidelines suggested use of osmotic or stimulant laxatives in combination with lifestyle practice education over lifestyle practice education alone (strength: conditional; level of evidence: moderate).
Identified research/knowledge gaps for which evaluation within the context of a clinical trial was recommended include prucalopride, a selective 5-HT₄ receptor agonist; lubiprostone, a chloride channel activator; and linaclotide, a selective guanylate cyclase C receptor agonist, for OIC not responsive to a bowel regimen; and the use of acupuncture and electroacupuncture for non-opioid–related cancer constipation.
In summarizing the clinical implications of these guidelines, the ONS Guidelines panel emphasized that “now is the time to move this evidence into practice.”1
References
1. Rogers B, Ginex PK, Anbari A, et al. ONS guidelines™ for opioid-induced and non-opioid-related cancer constipation. Oncol Nurs Forum. 2020;47(6):671-691. doi:10.1188/20.ONF.671-691
2. Hanson B, Siddique SM, Scarlett Y, Sultan S; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute technical review on the medical management of opioid-induced constipation. Gastroenterology. 2019;156(1):229-253. doi:10.1053/j.gastro.2018.08.018
3. Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut. 2011;60(2):209-218. doi:10.1136/gut.2010.227132
