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Expert Perspectives in the Management of Opioid Induced Constipation - Episode 10

Optimizing Treatment Selection Between Oral and Subcutaneous PAMORAs

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William F. Peacock, MD; Conar Fitton, MD; and Neel Mehta, MD, consider potential patient preferences when choosing oral vs subcutaneous peripheral μ-opioid receptor antagonists.

William F. Peacock, MD: What patient criteria would you consider when selecting patients for oral vs subcutaneous?

Neel Mehta, MD: For me, it’s often patient preference and how severe the problem is. If I tell them that there are 2 options and that 1 is a subcutaneous injection that works fast, some patients don’t even like the sight or the sound of it. When others hear that there’s a chance to get relief in under 30 minutes, which the subcutaneous can do pretty well, that resonates with them. Oral is generally the long-term preference, and that’s generally how we transition them from subcutaneous. But like Conar was saying, we have patients who swear by the subcutaneous and don’t want to deviate from that.

Conar Fitton, MD: For some patients, it’s an easy choice because they have head and neck cancer and swallowing pills is an issue. I tend to use it a lot for patients with cancer or advanced illness whom we help take care of. When they’re on palliative care, the last thing you want is for someone who may have a shorter life expectancy to be miserable the entire time. I find the reliability of subcutaneous in that setting to be very efficacious. Like Neel said, there are some patient things, including patient preference. About 84% of our patients prefer oral. I was surprised that 16% prefer subcutaneous, but about 1 of every 6 of my patients prefer that for the variety of reasons that Neel said. It works fantastic and fast.

William F. Peacock, MD: Yes, I’ve found that there are 2 populations that I can convince that subcutaneous is the better option. One is diabetics, because like you said, they made their peace with that a long time ago, at least the ones on insulin. The other is nurses. Because the nurses are familiar with needles, they aren’t upset by them. They know that it’s a tiny one. They’re more than happy to do that because it avoids other complications. But the average Joe looks at me like I’m out of my mind, and goes: “What? I’m going to go do that at home?” That’s a much more difficult conversation.

Neel Mehta, MD: The subcutaneous concept has to be explained. They’re thinking that they’re giving themselves flu shots. They get very nervous and say: “I don’t have anybody to help me do this injection. How am I going to reach all the way up here?” And I say, “No, you don’t need to go all the way up there.”

Transcript Edited for Clarity