Constipation in Advanced Cancer Clinical Practice Guidelines (2018)

European Society for Medical Oncology

Reviewed and summarized by Medscape editors

August 09, 2018

The clinical practice guidelines on constipation in advanced cancer patients were released on July 17, 2018, by the ESMO.[1]

Assessment should include questions to determine possible causes for constipation.

The use of PROMs is recommended.

If constipation is identified, physical examination should include abdominal examination, perineal inspection, and DRE.

If suspected clinically, corrected calcium levels and thyroid function should be checked. More extensive investigation is warranted for those with severe symptoms, sudden changes in number and consistency of BMs or blood in the stool, and for older adults relative to their health and stage of disease.

Plain abdominal x-ray, although limited as a tool in itself, may be useful to image the extent of fecal loading and to exclude bowel obstruction.

Best practice is based on a balance between strategies for prevention and self-care and prescribed oral and rectal laxative therapy.

Key factors for prevention and self-care in the management of constipation include ensuring privacy and comfort to allow a patient to defecate normally; positioning (to assist gravity, a small footstool may help patient exert pressure more easily); increased fluid intake; increased activity and increased mobility within patient limits (even bed to chair); anticipatory management of constipation when opioids are prescribed.

There is some evidence that abdominal massage can be efficacious in reducing gastrointestinal symptoms and improving bowel efficiency, particularly in those patients with concomitant neurogenic problems.

When laxatives are needed, preferred options include the osmotic laxatives [polyethylene glycol (PEG), lactulose, or magnesium and sulfate salts] or stimulant laxatives (senna, cascara, bisacodyl and sodium picosulfate).

Magnesium and sulfate salts can lead to hypermagnesemia and should be used cautiously in renal impairment.

Suppositories and enemas are a preferred first-line therapy when DRE identifies a full rectum or fecal impaction.

Enemas are contraindicated for patients with neutropenia or thrombocytopenia, paralytic ileus or intestinal obstruction, recent colorectal or gynecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain, or recent radiotherapy to the pelvic area.

Recommendations for the management of opioid-induced constipation (OIC):

Unless contraindicated by pre-existing diarrhea, all patients receiving opioid analgesics should be prescribed a concomitant laxative.

Osmotic or stimulant laxatives are generally preferred.

Bulk laxatives such as psyllium are not recommended for OIC.

In unresolved OIC, peripheral opioid antagonists such as methylnaltrexone or naloxegol may be of value.

Combined opiate/naloxone medications have been shown to reduce the risk of OIC through both open-label, phase II and III studies.


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