Download Management and Prevention of Opioid Related Constipation

GUIDELINE
MANAGEMENT AND PREVENTION OF OPIOID RELATED
CONSTIPATION
Applicable to: MidCentral Health, Medical
Wards & AT&R Wards
1.
Issued by: Medical Services
Contact: Medical Staff
PURPOSE
Guidance on the management and prevention of opioid related constipation in medical patients.
This guideline has been developed in association with MDHB Opioid Collaborative with the
objective of reducing opioid related harm to patients. This guideline may also be used in other
circumstances even with patients that are not on opioid medications.
2. SCOPE
Applies to relevant medical & nursing practitioners and nursing staff managing medical patients
with opioid related constipation or other causes of constipation where appropriate.
3. ROLES & RESPONSIBILITIES
Every attempt should be made to prevent and anticipate potential constipation related to use of
opioid medications. For instance, co-prescribing as needed (PRN) or regular laxatives or
aperients may be appropriate whenever prescribing opioids. Furthermore, non-pharmacological
methods to prevent and manage constipation should also be considered where appropriate.
A medical or nurse practitioner should assess patients before considering prescribing treatments
outlined in flowchart below. Nursing staff may also administer pre-approved standing order
laxatives or aperients within their scope of practice. Pre-existing medical conditions, comorbidities and drug interactions must also be considered in managing these patients.
There is an expectation for ongoing monitoring of effect of prescribed medications. There is also
an expectation that accurate documentation of bowel habit with appropriate language is
practised. For instance, terminology that includes BNO for X days and use of Bristol stool chart
type.
4. GUIDELINE
Staff Health and Safety

Appropriate equipment (gloves/aprons etc) should be worn when in contact with faecal
material or when administering rectal preparations of aperients

In event of uncertainty, consultation should be had with MDHB Infection Control services
Document No: MDHB-7120
Prepared by: Medical Registrar & Pharmacist
Authorised by: MAPC
Page 1 of 6
Version: 1
Issue Date: 21/Apr/2016
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 MidCentral District Health Board 2016. CONTROLLED DOCUMENT. The electronic version is the most up-to-date version.
MDHB will NOT take any responsibility in case of any outdated paper copy being used and leading to any undesirable consequence.
Printed 28/04/2017 8:54:00 p.m.
Guideline for Management and Prevention of Opioid Related Constipation
Initial management
ALL patients that are prescribed regular opioids,
co-prescribe regular Laxsol 1-2 tablets PO BD AND Docusate 120mg PO BD
Non-pharmacological measures:

Encourage adequate fluid intake, where
appropriate

Encourage mobility

Consider Kiwi Crush – regular or PRN

High fibre diet – fruit and vegetables
Bowels open?
YES
Continue current management and
monitoring.
NB: see appendix 1
YES
Continue current management and
monitoring. Consider weaning Laxsachet as appropriate.
BNO 24-48 hrs
Add Bisacodyl
5mg 1-2 tablets
PO nocte
Other considerations:


Review therapy – stopping/weaning opioids and
laxatives when appropriate, and other medication
that may contribute to constipation e.g. CCB,
ondansetron, TCA, antipsychotics
Check calcium levels, thyroid function
BNO 48-72 hrs
Add Lax-sachets
1-2 sachets, PO,
BD to TDS
Other differentials:

Bowel obstruction

Pseudo-obstruction

Other bowel pathology

Overflow constipation
Bowels open?
NO
If faecal loading
suspected perform PR
examination
Perform
Abdominal X-ray
Consider
alternative
diagnosis
NO
Is the rectum
full?
Bisacodyl 10mg suppository
STAT (against rectum wall)
and STAT glycerol
suppository (into the faeces)
YES
NO
Bowels open?
YES
Faecal
loading?
NO
Give 2 x Microlax
Enema STAT
YES
Faecal disimpaction protocol
(unless otherwise contraindicated):
Bowels open?
Lax-sachet 8 sachets/24 hours
(maximum 3 days)
Continue
monitoring
NB: see
appendix 1
YES
YES
Continue monitoring
NB: see appendix 1
BNO > 6 hrs
Give Fleet enema
STAT
NB: see red box
Bowels open?
NO
Bowels open?
Consider patient factors, if
appropriate, give STAT PicoPrep
NB: see appendix
YES
NO
Seek further specialist opinion –
general surgery vs.
gastroenterology
Continue
monitoring
NB: see
appendix
YES
Bowels open?
NO
Please note
* Two types of Fleet enema available:
Fleet Mineral Oil Or Fleet Phosphate (see appendix)
Fleet phosphate enema is not recommended in elderly or those with renal impairment due to
potential electrolyte imbalances.
Seek further professional
opinion
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Guideline for Management and Prevention of Opioid Related Constipation
5.
DEFINITION
CCB
TCA
BD
TDS
PRN
PR
STAT
Calcium channel blocker
Tricyclic antidepressant
Twice a day (Latin: bis die)
Three times a day (Latin: ter die sumendum)
As and when necessary (Latin: pro re nata)
Rectal examination
Give at once or immediately (Latin: statim)
6. RELATED MDHB DOCUMENTS
MDHB-4184
7.
Pain, Acute: Pharmacological Management in Adults
FURTHER INFORMATION / ASSISTANCE
Clinical Pharmacist
Opioid Collaborative Group
8. APPENDICES
APPENDIX 1
Monitoring and laxative information
9. KEYWORDS
Constipation, opioid
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Guideline for Management and Prevention of Opioid Related Constipation
APPENDIX 1
Monitoring
All nursing staff should monitor, record and review patient’s bowel status during every shift and notify
the medical practitioner overseeing the patient’s care if loose stools are observed or if a new step in the
flow-diagram needs to be initiated.
If a patient declines any treatments indicated in the guideline, nursing staff should notify practitioners
overseeing the patient’s care. Medical practitioners should review the patient and consider
appropriate alternative treatment options. It is expected that nursing staff and medical practitioner
addresses patient concerns and provides information about the treatment as stipulated by the Code of
Rights.
All practitioners should monitor and review patient’s bowel status daily, and stop laxatives when
appropriate.
Oral Laxatives
Bulk-forming laxatives such as psyllium husk or sterculia are not recommended for patients with
opioid-induced constipation due to an increased risk of bowel obstruction, especially in patients that
are immobile or have poor fluid intake. However these agents are considered first-line for general
constipation alongside non-pharmacological measures. It may take 72 hours before laxative effect is
seen.
Laxative
class
Generic name
(Brand name)
Stool
softeners
Docusate
sodium
(Coloxyl®)
Mechanism and
expected onset of
action
Act as surfactants
resulting in an increased
penetration of fluid into
the stool.
24 – 72 hours onset
Stimulant
Senna
(Senokot®)
Bisacodyl
(Lax-tab®,
Dulcolax®)
Stool
softener +
Stimulant
Osmotic
Docusate +
senna
(Laxsol®)
Lactulose
syrup
(Laevolac®)
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Direct stimulation of
sensory nerve endings in
colonic mucosa resulting
in increased motility.
Administration & Safety
considerations
Adverse effects:
Infrequent
Abdominal discomfort, colic, cramps.
Often combined with a stimulant
laxative for opioids-induced
constipation. There is limited
evidence of effectiveness when used
alone.
Adverse effects:
Infrequent
Abdominal pain, nausea, vomiting,
dizziness.
6 – 12 hours onset
See above
See above
A non-absorbable
disaccharide that is
broken down by colonic
bacteria. The metabolites
exert an osmotic effect in
the colon, resulting in
distention and stimulates
Adverse effects:
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Common
Flatulence, bloating
Contraindicated in intestinal or bowel
obstruction.
Take each dose with a large glass of
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Guideline for Management and Prevention of Opioid Related Constipation
peristalsis.
24 – 72 hours onset.
Needs to be charted
regular for maximal
effect.
Macrogol 3350
(Lax-Sachet®,
Movicol®)
A large polymer that
exerts iso-osmotic activity
with respect to normal
intestinal contents, thus
retaining water in the gut.
0.5 – 3 hours onset
water. Requires adequate fluid to
exert its pharmacological action.
Avoid if poor fluid intake.
Less effective in opioid-induced
constipation, however this may be
considered for constipation of other
causes.
Adverse effects:
Common
Abdominal distension and pain,
nausea, flatulence
Fluid and electrolyte disturbances
may occur, monitor accordingly. Use
with caution in patients with
congestive heart failure and renal
impairment.
**Restricted medication on
PHARMAC Hospital Medicines
List**
Refer to prescribing criteria on
PHARMAC website. Requires Special
Authority number for full subsidy in
the community.
Rectal Laxatives
Laxative
class
Generic name
(Brand name)
Osmotic
Glycerol
suppository
Stool
Sodium citrate
+ sodium
lauryl
sulfoacetate +
sorbitol enema
(Microlax®
5mL)
Phosphate
enema
(Fleet
Phosphate®
133mL)
Paraffin liquid
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Mechanism and
expected onset of
action
A non-absorbable sugar,
draws water into the
stool. It has lubricating
effects as well as
stimulant effects due to its
local irritant effects.
5 – 30 minutes onset
Non-absorbable salts
exerts osmotic effects by
retaining fluid in the
colon and stimulates
peristalsis.
2 – 30 minutes onset
Softens and lubricates
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Administration & Safety
considerations
Adverse effects:
Infrequent
Rectal discomfort
Adverse effects:
Serious fluid and electrolyte
disturbance (hypocalcaemia,
hyperphosphataemia and
hyperkalaemia), nausea, bloating,
rectal irritation.
Fluid and electrolyte disturbances
may occur, monitor accordingly. Use
with caution in patients with
congestive heart failure, renal
impairment and in the elderly.
Adverse effects:
Infrequent
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Guideline for Management and Prevention of Opioid Related Constipation
softener
enema
(Fleet Mineral
Oil® 133mL)
Stimulant
Bisacodyl
suppository
(Laxsuppositories®,
Ducolax®)
stool to facilitate passing
of motion.
2 – 15 minutes onset
Direct stimulation of
sensory nerve endings in
colonic mucosa resulting
in increased motility.
Anal leakage, rectal irritation
Adverse effects:
Infrequent
Rectal irritation, abdominal pain,
nausea, vomiting, dizziness.
15 – 60 minutes onset
Bowel-cleansing Preparations
Generic name (Brand
name)
Mechanism and
expected onset of action
Administration & Safety
considerations
Macrogol-3350
(Klean-Prep®)
A large polymer that exerts
iso-osmotic activity with
respect to normal intestinal
contents, thus retaining
water in the gut.
Adverse effects:
NB: 1 Klean-Prep sachet ≈ 4
Lax-Sachets. Hence 2 KleanPrep ≈ 8 Lax-Sachets faecal
disimpaction dose.
Sodium picosulfate +
magnesium oxide + citric
acid
(Pico-Prep®)
1 to 2 hours onset
Broken down by colonic
bacteria and metabolites
exerts an osmotic effect and
results in watery stool.
0.5 – 3 hours onset
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Common
Abdominal distension and pain,
nausea, flatulence
Fluid and electrolyte disturbances
may occur, monitor accordingly. Use
with caution in patients with
congestive heart failure, renal
impairment and the elderly. Elderly
patients must receive adequate fluids
during administration.
Oral drugs should not be taken 1-hour
before or after administration may be
flushed from the gut thus absorption
may be impaired.
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