The prescribing and use of
opioid analgesics is increasing in Italy owing to a profusion in the number and types of
opioid analgesic products available, and the increasing prevalence of conditions associated with severe
pain, the latter being related to population aging. Herein we provide the expert opinion of an Italian multidisciplinary panel on the management of
opioid-induced constipation (OIC) and bowel dysfunction. OIC and
opioid-induced bowel dysfunction are well-recognised unwanted effects of treatment with
opioid analgesics that can profoundly affect quality of life. OIC can be due to additional factors such as reduced mobility, a low-fibre diet, comorbidities, and concomitant medications. Fixed-dose combinations of
opioids with mu (μ)
opioid receptor antagonists, such as
oxycodone/
naloxone, have become available, but have limited utility in clinical practice because the individual components cannot be independently titrated, creating a risk of
breakthrough pain as the dose is increased. A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising
pain control. Recommended first-line pharmacological treatment of OIC is with an osmotic
laxative (preferably
polyethylene glycol [
macrogol]), or a stimulant
laxative such as an
anthraquinone. A second
laxative with a complementary mechanism of action should be added in the event of an inadequate response. Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as
methylnaltrexone,
naloxegol or
naldemedine, should be considered in patients with OIC that has not responded to combination
laxative treatment. Prokinetics or intestinal
secretagogues, such as
lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in Italy, and should therefore be restricted to settings such as specialist centres and clinical trials.