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. 2024 Nov 7;13(22):6689.
doi: 10.3390/jcm13226689.

Improving Diagnosis and Management of Opioid-Induced Constipation (OIC) in Clinical Practice: An Italian Expert Opinion

Giustino Varrassi  1 , Giuseppe Casale  2 , Maria Grazia De Marinis  3 , Francesco Dentali  4 , Paolo Evangelista  5 , Gino Gobber  6 , Gaetano Lanzetta  7 , Pierangelo Lora Aprile  8 , Maria Caterina Pace  9 , Piero Portincasa  10 , Franco Radaelli  11 , Andrea Ungar  12
Affiliations

Improving Diagnosis and Management of Opioid-Induced Constipation (OIC) in Clinical Practice: An Italian Expert Opinion

Giustino Varrassi et al. J Clin Med. .

Abstract

Opioid-induced constipation (OIC) is a very common and troublesome gastrointestinal side effect following the use of opioids. Despite existing international guidelines, OIC is largely underdiagnosed and undertreated. ECHO OIC is a European project designed to improve the diagnosis and management of OIC at the primary care level. The next phase of the ECHO OIC project is to review and adapt the proposed European pathway at national level, considering the local patient journey and clinical practice. A multidisciplinary group of 12 Italian experts reviewed and discussed the European path and formulated a seven-step guide for the practical management of OIC that is also easily applicable in primary care: 1. When prescribing long-term opioids, the physician should inform the patient of the possibility of the onset of OIC; 2. At opioid prescription, doctors should also prescribe a treatment for constipation, preferably macrogol or stimulant laxatives; 3. The patient should be evaluated for OIC within the second week of initiating opioid treatment, by clinical history and Rome IV criteria; 4. In the presence of constipation despite laxatives, prescription of a PAMORA (Peripherally Acting Mu Opioid Receptor Antagonist) should be considered; 5. When prescribing a PAMORA, prescribing information should be carefully reviewed, and patients should be accurately instructed for appropriate use; 6. Efficacy and tolerability of the PAMORA should be monitored regularly by Bowel Function Index, considering a cut-off of 30 for the possible step-up of OIC treatment; 7. After 4 weeks of treatment, if the efficacy of PAMORA is deemed inadequate, discontinuation of the PAMORA, addition of an anti-constipation drugs, change of opioid type, or referral to a specialist should be considered. Spreading knowledge about the OIC problem as much as possible to the health community is crucial to obtain not only an early treatment of the condition but also to promote its prevention.

Keywords: PAMORAs; clinical practice; diagnosis; management; opioid; opioid-induced constipation; primary care.

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Conflict of interest statement

G.V. is consultant of several pharmaceutical companies, including (but not limited to) Abbott, Berlin-Chemie, Menarini, Shionogi; F.D. has had direct financing relationships with the following parties with commercial interests in healthcare: Bayer, Il, Sanofi, Boehringer, Daiichi Sankyo, Menarini, Alfa Wassermann, Alfasigma, Novartis; G.L. has received a speaker honorarium from Company Molteni; P.L.A. has received a speaker honorarium from Company Angelini Pharma Spa; P.P. has received research grants/speaker honorariums from Aboca, Allergosan, Daichi-Sankio, Omega Pharma; F.R. has received research grants from Fujifilm and speaker honorarium from Norgine, Astra Zeneca, B.M.S., Pfizer. G.C., M.G.D.M., P.E., G.G., M.C.P., A.U. declare no conflicts of interest. Shionogi SRL had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, or on the decision to publish the results.

Figures

Figure 1
Figure 1
Molecular formulas of PAMORAs approved for opioid-induced constipation.
See this image and copyright information in PMC

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