Manage Cancer Treatment-Related Constipation With ONS Guidelines™
As many as 43%–58% of patients with cancer experience constipation related to their treatment, and the side effect is both distressing and potentially life threatening if severe enough. Constipation-related emergency department visits increased by 41.5% from 2006–2011, with older adults (aged 85 years or older) making up most of the visits. Estimates suggest that the cost of managing severe cancer-related constipation may range from $500 to more than $2,300 per person per month. Supporting patients who experience the side effect is critical for their well-being.
The ONS GuidelinesTM for Opioid-Induced and Non-Opioid–Related Cancer Constipation provide evidence-based recommendations for practitioners to manage the types of constipation that patients with cancer typically experience. The full guideline by Rogers et al. was published in the November 2020 issue (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691) of the Oncology Nursing Forum.
Cancer Treatment-Related Constipation
Constipation from cancer can be related to a variety of factors that range from patients’ lifestyle behaviors to use of medications for pain, other cancer-
related side effects, or comorbidities, so the first step in managing it is identifying the source. It’s one of the most common side effects of opioid medications, with incidence rates ranging from 40%–80%, Rogers et al. said (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691). The drugs affect the mobility and water content of the gastrointestinal tract, slowing transit time and changing the composition of stool.
Managing constipation from opioids is notoriously difficult, and patients and providers appear to have different priorities. Providers tend to focus on pain control over constipation effects, but patients have reported not receiving enough education about the side effect and its treatment, Rogers et al. reported (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691). Treatment approaches have ranged from lifestyle changes (particularly dietary) to over-the-counter medications.
Constipation is also associated with other cancer-related medications, such as vinca alkaloids and certain antiemetics. If a patient’s tumor or disease directly affects the gastrointestinal tract, it can also contribute to constipation. Patients may have preexisting or chronic constipation, or their treatments for comorbidities may cause constipation. Other considerations include lifestyle factors such as dehydration, inactivity, or poor fiber intake.
Constipation Prevention and Treatment Recommendations
The ONS Guideline provides evidence-based recommendations for prevention and treatment strategies for both opioid-induced and non-opioid–related cancer constipation.
Opioid-induced constipation: To prevent the development of constipation in patients receiving opioids for cancer-related pain, the ONS Guidelines panel developed a good practice statement (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691): before beginning an opioid regimen, ensure patients have a clear understanding of constipation prophylaxis lifestyle behaviors, including increased fiber intake, hydration, and exercise.
If constipation occurs despite following the good practice statement, use osmotic or stimulant laxatives and lifestyle education in adult patients with cancer rather than lifestyle education alone, which the ONS Guidelines panel classified as a strong recommendation with a moderate level of evidence. Or, use osmotic polyethylene glycol and lifestyle education rather than lifestyle education alone in adult patients with cancer, which the panel classified as a conditional recommendation with a low level of evidence.
Alternatively, for adult patients with cancer, use either a prophylactic bowel regimen with laxatives and lifestyle education or lifestyle education alone, which the ONS Guidelines panel classified as a conditional recommendation with a very low level of evidence. “Patients who place a higher value on avoidance of constipation may prefer to start on a prophylactic regimen; however, patients who place a higher value on avoiding undue costs, taking pills, or undue harms (diarrhea) may prefer to not start on a bowel regimen prophylactically,” the panel commented (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691).
Opioid-induced constipation that has not responded to a bowel regimen: Sometimes, conservative patient education and lifestyle changes aren’t enough and treatment approaches must be more aggressive. In adult patients with cancer who have not responded to a bowel regimen, use naldemedine and a bowel regimen rather than the bowel regimen alone, which the ONS Guidelines panel classified as a strong recommendation with a moderate level of evidence.
Alternatively, use naldemedine or methylnaltrexone and a bowel regimen rather than a bowel regimen alone in adult patients with cancer, both of which the panel classified as conditional recommendations with a very low level of evidence. The panel noted that methylnaltrexone may be better tolerated by patients who are unable to take other forms of peripherally acting mu-opioid receptor antagonists; however, any agent in this class of drugs should be used only if a patient has not responded (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691) to a bowel regimen.
The ONS Guidelines panel investigated three additional treatment options, but the evidence was insufficient to draw any conclusions on their use in adult patients with opioid-related constipation. It recommended only using the treatments in the context of clinical trials that would build the evidence base and reduce the knowledge gap:
Non-opioid–related constipation: Among adult patients with cancer, use osmotic or stimulant laxatives and lifestyle education over lifestyle education alone for constipation. The ONS Guidelines panel classified the recommendation as conditional with a moderate level of evidence. However, the panel also advised (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691) that patients who find their constipation less bothersome or who want to avoid laxatives may choose to decline laxative interventions in favor of lifestyle education alone.
The panel also found (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691) insufficient evidence on acupuncture and electroacupuncture interventions for adult patients with non-opioid–related cancer constipation and therefore only recommended using them in the context of clinical trials intended to reduce the knowledge gap.
The ONS Guidelines panel concluded that because of the prevalence of cancer-related constipation, improved management strategies are needed. It called for continuing education and practice improvement focused on management for patients at risk for and experiencing constipation.
For more information about the ONS Guidelines for Opioid-Induced and Non-Opioid–Related Cancer Constipation, including an overview of the methods used to develop the guidelines, refer to the full article (https://doi.org/10.1188/20.ONF.10.1188/20.ONF.671-691) by Rogers et al. Or listen to an interview with Deborah M. Thorpe, PhD, APRN, on the Oncology Nursing Podcast (http://ons.org/podcasts/episode-130-manage-cancer-related-constipation-ons-guidelinestm), then subscribe to the podcast on your favorite listening platform to get other episodes—all with free NCPD—delivered directly to your phone.