The management of constipation in palliative care: clinical practice recommendations

Abstract

Constipation is one of the most common problems in patients receiving palliative care and can cause extreme suffering and discomfort. The aims of this study are to raise awareness of constipation in palliative care, provide clear, practical guidance on management and encourage further research in the area. A pan-European working group of physicians and nurses with significant experience in the management of constipation in palliative care met to evaluate the published evidence and produce these clinical practice recommendations. Four potentially relevant publications were identified, highlighting a lack of clear, practical guidance on the assessment, diagnosis and management of constipation in palliative care patients. Given the limited data available, our recommendations are based on expert clinical opinion, relevant research findings from other settings and best practice from the countries represented. Palliative care patients are at a high risk of constipation, and while general principles of prevention should be followed, pharmacological treatment is often necessary. The combination of a softener and stimulant laxative is generally recommended, and the choice of laxatives should be made on an individual basis. The current evidence base is poor and further research is required on many aspects of the assessment, diagnosis and management of constipation in palliative care.

Effectiveness and Tolerability of Amidotrizoate for the Treatment of Constipation Resistant to Laxatives in Advanced Cancer Patients

“…Current recommendations by a panEuropean working group suggest secondand third-line treatments, including rectal suppository or enema, and manual evacuation, respectively. 6 These maneuvers are universally considered as a last resort because they are uncomfortable for patients, particularly manual interventions.…”

“…After inadequate management with traditional laxatives, including a softener and a stimulant, recommendations suggest second-and third-line treatments, including rectal suppository or enema, and manual evacuation, respectively. 6 Enemas, besides being stressful, have some potential to cause intestinal perforations. These maneuvers, particularly manual interventions, are highly stressful and troublesome for both patients and personnel.…”

Are we able to Manage Effectively Opioid-Induced Bowel Dysfunction?

“…In majority of patients with OIBD laxatives need to be administered. The general recommendation is to combine oral administration of osmotic agents (usually lactulose or macrogol) which have an osmotic effect in the colon with stimulants activating neurons in the myenteric and submucosal plexus in colon and reducing absorption of water and electrolytes from the intraluminal contents: anthracenes (senna), polyphenolics (bisacodyl) or sodium picosulphate [8].…”

Palliative Care in General Practice

“…The rate of patients with terminal disease affected by constipation varies from 23% to 87% (Librach, 2010;Noguera, 2009;Larkin, 2008;Lagman, 2005), with the highest incidence observed in patients treated with opioids (prevalence 50-95% in several studies: Clark, 2010;Noguera, 2009;Woolery, 2008;Lagman, 2005). Among opioid-treated cancer patients constipation can cause extreme suffering and discomfort.…”

“…Recommendations (Larkin, 2008;VaDoD, 2010) for the farmacologic treatment of constipation in palliative care patients are listed below:…”