Prophylactic laxatives are the provision of laxatives prior to any symptoms of constipation to prevent or avoid constipation. This approach has been suggested for patients with cancer on opioids for pain management.
Ishihara, M., Iihara, H., Okayasu, S., Yasuda, K., Matsuura, K., Suzui, M., & Itoh, Y. (2010). Pharmaceutical interventions facilitate premedication and prevent opioid-induced constipation and emesis in cancer patients. Supportive Care in Cancer, 18, 1531–1538.
In part 1, patients who were admitted and receiving opioids were surveyed for use of prophylactic laxatives to prevent constipation.
In part 2, prescribers were given drug information, orders were reviewed, and patients were educated about laxatives to manage constipation.
Patients were undergoing the active treatment phase of care.
This was a retrospective survey followed by an interventional study.
Laxative use prophylactically reduced the incidence of constipation in patients taking opioid therapy but did not completely prevent it.
Laxative prophylaxis is beneficial to reduce the risk of opioid-induced constipation. Proactive interventions to increase laxative use may be beneficial to patients.
Ishihara, M., Ikesue, H., Matsunaga, H., Suemaru, K., Kitaichi, K., Suetsugu, K., . . . Japanese Study Group for the Relief of Opioid-Induced Gastrointestinal Dysfunction. (2012). A multi-institutional study analyzing effect of prophylactic medication for prevention of opioid-induced gastrointestinal dysfunction. Clinical Journal of Pain, 28, 373–381.
To evaluate the effectiveness of prophylactic laxatives and antiemetics on constipation, nausea, and vomiting in patients with cancer receiving opioids for the first time.
Medical records were reviewed from 2009 to 2010 for patients experiencing constipation, nausea, or vomiting during the first week of opioid analgesic administration. Number of stools recorded was used in the analysis. Constipation was defined as a stool-free interval of at least 72 hours during the first week. One episode of vomiting was counted as evidence of vomiting. Nausea grading was recorded for seven days.
This was a descriptive, retrospective study.
National Cancer Institute Common Toxicity Criteria for Adverse Events (NCI CTCAE), version 4.0, for nausea grading
Use of prophylactic laxatives in patients receiving opioids for the first time was effective in reducing the risk and prevalence of constipation.
Findings suggested use of prophylactic laxatives can reduce opioid-induced constipation during the first week in which patients receive opioids. Findings also suggested older patients may be at greater risk for opioid-induced constipation. Nurses can ensure that prophylactic regimens to prevent constipation are suggested for patients beginning opioid use and older adult patients.
Larkin, P.J., Sykes, N.P., Centeno, C., Ellershaw, J.E., Elsner, F., Eugene, B., . . . European Consensus Group on Constipation in Palliative Care. (2008). The management of constipation in palliative care: Clinical practice recommendations. Palliative Medicine, 22, 796–807.
To raise awareness of constipation in palliative care; to provide guidance on the assessment, diagnosis, and management of constipation; and to encourage research in this area.
Databases searched were PubMed and the Cochrane Library (2001-2006).
Search keywords were constipation, laxatives, palliative care, terminal care, terminally ill, hospice, guidelines, recommendations, and systematic reviews.
Four publications were found for consideration. They were graded according to the UK National Service Framework for Long Term Conditions and the Oxford Quality Scale. A pan-European work group of healthcare professionals with experience in management of constipation in palliative care was assembled to debate and reach consensus on best practice.
Key approaches to the prevention of constipation include
Principles of treatment include
This guideline provides a practical algorithm for constipation management based on consensus, rather than actual evidence. Specific choices of oral laxatives are not recommended; however, substantial evidence-based information for comparison of available oral laxatives agents is given.
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.
If Constipation Occurs:
Recommendations were identified as having low-level evidence and uniform consensus.
National Comprehensive Cancer Network. (2012). NCCN Clinical Practice Guidelines in Oncology: Palliative Care [v.2.2012]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
The objective of the guidelines is to provide palliative care practice guidelines for patients with cancer, facilitating the appropriate integration of palliative care into oncology practice.
These are consensus-based guidelines.
Included in the guidelines are multiple phases of care with palliative care applications.
The NCCN made recommendations on the following symptoms.
Nutritional support, including enteral and parenteral feeding, should be considered. Appetite stimulants such as megestrol acetate and corticosteroids can be used when appetite is an important aspect of quality of life.
Chemotherapy-Induced Nausea and Vomiting (CINV)
Recommendations include prochlorperazine, haloperidol, metoclopramide, or benzodiazepines. Adding 5-HT3 receptor agonists, anticholinergics, antihistamines, corticosteroids, antipsychotics, and cannabinoids also can be considered. Palliative sedation can be considered as a last resort.
Increase fluid intake, dietary fiber, and physical activity. Opioid-induced constipation should be anticipated and treated prophylactically with laxatives.
Pharmacologic interventions include opioids or benzodiazapines. Scopolamine, atropine hyoscyamine, and glycopyrrolate are options to reduce excessive secretions.
Do not reduce opioid dose for symptoms such as decreased blood pressure or respiratory rate. Palliative sedation can be considered for refractory pain.
For refractory insomnia with no underlying physiologic cause, pharmacologic management includes diazepam, zolpidem, and sedating antidepressants. Cognitive behavioral therapy may be effective. If present, restless leg syndrome can be treated with ropinirole.
Recommendations provide expert opinion/consensus-level suggestions for management of various symptoms. Many recommendations, such as those for CINV, do not agree with current evidence in these areas.