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Constipation is a frequent complaint in the general community, and more common in palliative care patients. [1-2] Chronic constipation is one of the most frequent side effects of opioids, and occurs in 40 – 70% of patients treated for cancer pain with oral morphine. [3] However other causes of constipation should also be sought and addressed.

An assessment of constipation in the palliative context needs to address opioid induced bowel dysfunction. Other possible contributing factors include:

• Medications – 5-HT3 antagonists, anticholinergics, iron, some antihypertensives
• Decreased oral intake, alterations in diet
• Metabolic abnormalities  (eg. hypercalcaemia, uraemia, hypothyroidism, hypokalaemia, diabetes)
• Decreased mobility, weakness
• Obstruction
• Neurological disorder or damage, eg, due to spinal cord lesion
• Autonomic neuropathy
• Depression.

Despite the prevalence of constipation in the palliative care population, it is frequently under treated. [2]

The evidence base supporting the choice of a specific laxative is not strong, either for use in the general population [4], or specifically in a palliative care population. [5]

Related CareSearch pages

• Laxatives

Key messages 

• A recent systematic review did not show that any particular laxative, or combination of laxatives, is more effective than any other. [5] 
• Prescribing of laxatives is therefore based on expert opinion, [3] cost effectiveness assessments of the available medications, and individual response.
• Assessment for constipation, and prevention of constipation by co-prescribing regular laxatives along with regular opioids, is identified as best practice in all clinical guidelines for pain management in palliative care patients. [6-8]

Active research areas / controversies

• One of the difficulties in researching constipation is the lack of a consensus definition. As a result, research on the prevalence of constipation and on the outcomes of treatment is difficult to interpret. The challenge in developing such a definition relates to the considerable differences which exist between individuals, which make it difficult to propose a general description of normal and abnormal bowel habits. [1]
• The relationship of opioids to constipation may be complex, [1-2] with very little correlation between opioid doses and laxative requirements, and differences in individuals’ responses to both opioids and laxatives. An independent link between deteriorating performance status and constipation has been suggested. [9]
• There is some evidence to suggest that fentanyl may cause less constipation than other opioids. [10]
• Clinical studies of new drugs for the management of opioid induced bowel dysfunction are ongoing. Several novel opioid antagonists which have only local effects on the gastrointestinal tract, including alvimopan and methylnaltrexone, seem to show promise in clinical trials. [11-12]
• Other newer potential pharmacological approaches to managing chronic constipation include selective calcium channel agonists (lubipristone) or 5HT3 serotonin receptor agonists (tegaserod).  These agents are not generally available in Australia and have not yet been studied in the palliative care population. [13] 

References

1. Davis M P.  Cancer constipation: are opioids really the culprit? Supportive Care in Cancer. 2008 May;16(5):427-9.  
2. Droney J, Ross J, Gretton S, Welsh K, Sato H, Riley J. Constipation in cancer patients on morphine. Supportive Care in Cancer. 2008 May;16(5):453-9. 
3. Cherny N, Ripamonti C, Pereira J, Davis C, Fallon M, McQuay H, et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report.  Journal of Clinical Oncology. 2001 May 1;19(9): 2542-2554. 
4. Jones M P, Talley NJ, Nuyts G, Dubois D.  Lack of objective evidence of efficacy of laxatives in chronic constipation. Digestive Diseases & Sciences. 2002 Oct;47(10): 2222-30. 
5. Miles C L, Fellowes D, Goodman ML, Wilkinson S.  Laxatives for the management of constipation in palliative care patients. Cochrane Database of Systematic Reviews. 2006 Oct 18;(4):CD003448.  
6. NHS Quality Improvement Scotland (NHS QIS).  Best Practice Statement - The management of pain in patients with cancer.  Edinburgh; NHS QIS: 2009 Nov.
7. Berger A M, Parker KP, Young-McCaughan S, Mallory GA, Barsevick AM, Beck SL, et al.  Sleep/wake disturbances in people with cancer and their caregivers: state of the science.  Oncology Nursing Forum. 2005 Nov 3;32(6):E98-126.  
8. Palliative Care Expert Group. Therapeutic Guidelines: Palliative Care. Melbourne; Therapeutic Guidelines Limited: 2005 
9. Fallon MT, Hanks GW. Morphine, constipation and performance status in advanced cancer patients. Palliative Medicine. 1999 Mar;13(2):159-160.   [no abstract available]
10. Radbruch L, Sabatowski R, Loick G, Kulbe C, Kasper M Grond S, et al. Constipation and the use of laxatives: a comparison between transdermal fentanyl and oral morphine. Palliative Medicine. 2000 Mar;14(2):111-9. 
11. Becker G, Galandi D, Blum HE.  Peripherally acting opioid antagonists in the treatment of opiate-related constipation: a systematic review.  Journal of Pain and Symptom Management. 2007 Nov;34(5):547-65. 
12. Thomas J. Opioid-Induced Bowel Dysfunction.  Journal of Pain and Symptom Management. 2008 Jan;35(1):103-13.  
13. Thomas J. Cancer-related constipation. Current Oncology Reports. 2007 Jul;9(4): 278-284. 

This page was created on 20 May 2008 and is due for review in May 2010
Last updated 15 December 2009