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Palliative cancer care - constipation - Management
What should I do if the response to laxatives is insufficient?

  • Check that the dose of stimulant and softening laxative has been adequately titrated.
    • Adjust the dose of stimulant to produce defecation without colic.
    • Adjust the dose of softener to produce a comfortable stool.
    • Higher and more frequent doses than specified by the product licence may be needed.
    • The laxative dose also needs to increase with increases in opioid dose.
  • Consider whether additional short-term treatment for faecal loading/impaction is needed.
  • Consider adding in a macrogol, or a prokinetic drug such as metoclopramide, domperidone, or erythromycin 250–500 mg four times a day (off-licence use) — exclude obstruction before use.
  • If passing a stool is painful, exclude (or manage) anal fissure, painful haemorrhoids, or local tumour.
  • If neurological gut dysmotility is present, consider a weekly dose of sodium picosulfate.
    • Neurological gut dysmotility is more likely in people with other neurological symptoms or signs, diabetes, small cell lung cancer, a history of chemotherapy with vinca alkaloids or platinum, a history of long term laxative abuse, or resistance to usual laxatives.
  • Seek specialist advice if constipation still persists — a switch to another possibly less constipating opioid may be considered (e.g. fentanyl, methadone) but dose conversion may be difficult so specialist advice is advised.
Basis for recommendation
  • These recommendations are pragmatically based on a synthesis of published expert opinion [Regnard et al, 2004; Sykes, 2004].
  • Constipation due to opioid analgesics is an ongoing problem as tolerance does not develop. There is no linear relationship between morphine dose and the level of constipation [Fallon and Hanks, 1999].
  • There is limited evidence that suggests that switching from morphine to fentanyl or methadone may be helpful for some individuals, but this is not routine clinical practice. In addition dose conversion can be difficult and requires specialist advice.
  • There is very limited evidence that suggests that adding in a peripheral opioid-antagonist such as oral naloxone (off-licence use) may also be helpful for some individuals, but this is not routine clinical practice. Naloxone is only available in the UK as a 400 microgram/mL ampoule for injection; this has a bitter taste when taken orally.

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