German Expert Consensus on Opioid-Induced Constipation (OIC): Recommendations and a Treatment Algorithm for Clinical Practice

Journal of Clinical Medicine, vol. 15, pp. 2369

Abstract

Background/Objectives: Opioid-induced constipation (OIC) is a frequent adverse effect of opioid therapy. In contrast to other opioid-related side effects, OIC usually does not improve over time and significantly impairs the quality of life of affected patients. Despite its high prevalence, OIC remains underdiagnosed and undertreated in clinical practice, which has been demonstrated in several European countries. Healthcare data indicates that approximately 2.3 million people in Germany received potentially OIC-inducing opioids in 2023, the majority being patients with chronic non-cancer pain. Methods: An interdisciplinary board of experts in gastroenterology, pain medicine, neurology, oncology, and palliative care developed consensus-based recommendations to improve the diagnosis and management of OIC. Fifteen statements were drafted according to current national German and international guidelines and literature and subsequently discussed. Out of the fifteen statements, twelve statements remained, which achieved consensus with at least 90% agreement. Results: The consensus statements address key aspects of OIC management, including pathophysiology, patient education, diagnosis, prevention, treatment and structured follow-up. Following the statements, a practical treatment algorithm was developed to facilitate clinical implementation. Use of validated tools such as the Bowel Function Index (BFI) for diagnosis and monitoring, early initiation of laxative therapy and timely escalation to mechanism-oriented therapy with peripherally acting μ-opioid receptor antagonists (PAMORAs) in cases of inadequate response have been recommended by the panel. Accordingly, treatment should follow an approach with the following steps: (1) Laxative, (2) switch to PAMORA, (3) rotation of PAMORA, and (4) combination of PAMORA with laxative. In Europe, the PAMORAs methylnaltrexone, naloxegol and naldemedine are approved for the treatment of OIC. Conclusions: This consensus paper provides both evidence-based and practice-oriented recommendations for the systematic management of OIC. By promoting patient education, early recognition, structured evaluation and stepwise treatment escalation, the presented statements and algorithm aim to improve patient outcomes and quality of life under opioid therapy including better adherence to opioid therapy.

Authors 13

1. Bastian Wobbe corresponding

   Klinikum Oldenburg

   Affiliation as printed

   Department of Internal Medicine—Oncology and Hematology, Klinikum Oldenburg AoR, 26133 Oldenburg, Germany

2. Viola Andresen
   Affiliation as printed

   Medizinicum Stephansplatz, 20354 Hamburg, Germany

3. Ralf Baron

   University Hospital Schleswig-Holstein

   Affiliation as printed

   Division of Neurological Pain Research and Therapy, University Hospital Schleswig-Holstein, Campus Kiel, 24149 Kiel, Germany

4. Jürgen Eiche
   Affiliation as printed

   DGS Regional Center, 36433 Bad Salzungen, Germany

   Median Heinrich Mann Klinik, 36448 Bad Liebenstein, Germany

5. Frank Elsner Aachen Medical Faculty Department of Palliative Medicine

   RWTH Aachen University

   Affiliation as printed

   Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany

6. Sven Gottschling

   Universitätsklinikum des Saarlandes · Saarland University

   Affiliation as printed

   Centre of Palliative Care and Pediatric Pain, Saarland University Medical Center, 66421 Homburg, Germany

7. Jens Keßler

   Heidelberg University

   Affiliation as printed

   Pain Medicine Section, Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany

8. Hartmut Link

   Westpfalz Klinikum

   Affiliation as printed

   Hematology and Medical Oncology, Westpfalz-Klinikum, 677655 Kaiserslautern, Germany

9. Philipp C. G. Müller-Schwefe
   Affiliation as printed

   Pain and Palliative Care Center, 73033 Göppingen, Germany

10. Ulf Schutter
    Affiliation as printed

    DGS Regional Center, Specialist Medical Center, Multimodal Pain Therapy at Marienhospital Marl, 45768 Marl, Germany

11. Martin Storr

    Starnberg Hospital

    Affiliation as printed

    Center for Endoscopy, Internal Medicine Center Starnberg-Gauting, 82319 Starnberg, Germany

12. Michael A. Überall
    Affiliation as printed

    Institute of Neurological Sciences, 90411 Nuremberg, Germany

13. Stefan Wirz

    St. Marien-Hospital Bonn

    Affiliation as printed

    Department for Anesthesiology, Intensive Medicine, Pain and Palliative Medicine, Center for Pain Medicine, Weaning Center, Cura Hospital/GFO-Clinics Bonn, 53604 Bad Honnef, Germany