Dr William F. Peacock shares clinical pearls for the management of opioid-induced constipation.
William F. Peacock, MD: If you see a patient with OIC [opioid-induced constipation], this is a reasonable option to try. If it works, then it’s reasonable getting the patient on board. If they want to go home, let that happen. If it doesn’t work, then you go back to the same plan B we’ve always had, which is enemas, manual disimpaction, hospitalization, and observation. The majority of patients from the data we’ve presented will have relief and be discharged home.
In the hospital, with medicine, emergency doctors can use only the drugs that are on formulary. I can’t use anything else, not in the ER [emergency department]. I can write a prescription and discharge the patient. In this setting, if it’s not on formulary, I’m not going to have much of an effect. If a patient comes in with abdominal pain and I think it’s opioid-induced constipation, I don’t want to send them home until they feel better. If I can’t use methylnaltrexone to make them feel better, I’m not going to send them home on a pill that I haven’t even tried. The limiting factor in the house of medicine is the formulary. It controls what I can and cannot use.
What I’ve found is that it seems to be used in the majority of institutions and in those with large cancer populations in patients who are on a high amount of opioids. In places that don’t have large cancer populations, it doesn’t seem so well adapted.
What our studies have shown is that in patients receiving methylnaltrexone, about 60% will have a defecation within an hour or 2. At that point it’s a clinical decision of hospitalization or discharge, most of which will be able to be discharged. This results in a significant cost savings, about $730 for every dose used in the emergency department.
The biggest challenge for using methylnaltrexone for OIC treatment is the formulary. If it’s on formulary, then that becomes a selection choice that I can make with the patient. If it’s not on formulary, it’s an outpatient drug that’s not going to work for me in the emergency department. That’s the biggest challenge.
Transcript Edited for Clarity