National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf

The guidelines recommend the following for management of opioid-induced constipation.

Preventive Measures:

• Take polyethylene glycol or a combination of stool softener and stimulant laxative daily.
• Maintain adequate fluid intake.
• Maintain adequate fiber intake. Compounds such as psyllium are not recommended because they are unlikely to control opioid-induced constipation.

If Constipation Occurs:

• Rule out other causes and begin treating.
• Titrate stool softeners and laxatives as needed.
• Consider coanalgesics to enable opioid dose reduction.

Persistent Constipation:

• Consider the addition of agents such as magnesium hydroxide, bisacodyl, rectal suppository, lactulose, and sorbitol.
• Use enemas.
• Consider methylnaltrexone 0.15 mg/kg subcutaneously daily.

Recommendations were identified as having low-level evidence and uniform consensus.