Opioid-Induced Constipation (OIC): A Distinct Cause1,2

Constipation may be defined as having one or more symptoms: hard stools, infrequent stools, need for excessive straining, sense of incomplete bowel evacuation, and excessive time spent on the toilet or in unsuccessful defecation.3

Constipation can also be classified by etiology:

  • Primary constipation1
    • Results from intrinsic defects of colonic or anorectal function
    • Considered typically after secondary causes have been ruled out
  • Secondary constipation1
    • Caused by pathologic changes such as disease or intestinal obstruction
    • Caused by medications (iatrogenic) such as opioids
RELISTOR inhibits opioids from binding to mu-receptors in the gastrointestinal (GI) tract, decreasing their constipating effects.

Constipation is a frequent side effect of opioids2,4-6

  • Opioids are a major class of analgesics often used to relieve pain4
  • One of the most common side effects of opioids is constipation, with incidence ranging from 40% to 80%2,5,6

In a patient survey*

81% of patients taking oral opioids experienced constipation5

Up to 81% of patients taking oral opioids can experience constipation

In a meta-analysis of 18 clinical trials

41% of patients receiving oral opioids for chronic non-cancer pain reported constipation6

41% of patients receiving oral opioids for chronic non-cancer pain reported constipation

In a patient survey*

81% of patients taking oral opioids experienced constipation5

Up to 81% of patients taking oral opioids can experience constipation

In a meta-analysis of 18 clinical trials

41% of patients receiving oral opioids for chronic non-cancer pain reported constipation6

41% of patients receiving oral opioids for chronic non-cancer pain reported constipation

Indications

  • RELISTOR is an opioid antagonist. RELISTOR tablets and RELISTOR injection are indicated for the treatment of opioid-induced constipation (OIC) in adults with chronic non-cancer pain.
  • RELISTOR injection is also indicated for the treatment of OIC in adults with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient. Limitations of Use: Use beyond four months has not been studied in the advanced illness population.

IMPORTANT SAFETY INFORMATION - RELISTOR tablets and RELISTOR injection

  • RELISTOR tablets and injection are contraindicated in patients with known or suspected gastrointestinal obstruction and patients at increased risk of recurrent obstruction, due to the potential for gastrointestinal perforation.
  • Cases of gastrointestinal perforation have been reported in adult patients with opioid-induced constipation and advanced illness with conditions that may be associated with localized or diffuse reduction of structural integrity in the wall of the gastrointestinal tract (e.g., peptic ulcer disease, Ogilvie’s syndrome, diverticular disease, infiltrative gastrointestinal tract malignancies or peritoneal metastases). Take into account the overall risk-benefit profile when using RELISTOR in patients with these conditions or other conditions which might result in impaired integrity of the gastrointestinal tract wall (e.g., Crohn’s disease). Monitor for the development of severe, persistent, or worsening abdominal pain; discontinue RELISTOR in patients who develop this symptom.
  • If severe or persistent diarrhea occurs during treatment, advise patients to discontinue therapy with RELISTOR and consult their healthcare provider.
  • Symptoms consistent with opioid withdrawal, including hyperhidrosis, chills, diarrhea, abdominal pain, anxiety, and yawning have occurred in patients treated with RELISTOR. Patients having disruptions to the blood-brain barrier may be at increased risk for opioid withdrawal and/or reduced analgesia and should be monitored for adequacy of analgesia and symptoms of opioid withdrawal.
  • Avoid concomitant use of RELISTOR with other opioid antagonists because of the potential for additive effects of opioid receptor antagonism and increased risk of opioid withdrawal.
  • The use of RELISTOR during pregnancy may precipitate opioid withdrawal in a fetus due to the immature fetal blood brain barrier and should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because of the potential for serious adverse reactions, including opioid withdrawal, in breastfed infants, advise women that breastfeeding is not recommended during treatment with RELISTOR. In nursing mothers, a decision should be made to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.
  • A dosage reduction of RELISTOR tablets and RELISTOR injection is recommended in patients with moderate and severe renal impairment (creatinine clearance less than 60 mL/minute as estimated by Cockcroft-Gault). No dosage adjustment of RELISTOR tablets or RELISTOR injection is needed in patients with mild renal impairment.
  • A dosage reduction of RELISTOR tablets is recommended in patients with moderate (Child-Pugh Class B) or severe (Child-Pugh Class C) hepatic impairment. No dosage adjustment of RELISTOR tablets is needed in patients with mild hepatic impairment (Child-Pugh Class A). No dosage adjustment of RELISTOR injection is needed for patients with mild or moderate hepatic impairment. In patients with severe hepatic impairment, monitor for methylnaltrexone-related adverse reactions.
  • In the clinical studies, the most common adverse reactions were:
    • OIC in adult patients with chronic non-cancer pain
      • RELISTOR tablets (≥2% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (14%), diarrhea (5%), headache (4%), abdominal distention (4%), vomiting (3%), hyperhidrosis (3%), anxiety (2%), muscle spasms (2%), rhinorrhea (2%), and chills (2%).
      • RELISTOR injection (≥1% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (21%), nausea (9%), diarrhea (6%), hyperhidrosis (6%), hot flush (3%), tremor (1%), and chills (1%).
    • OIC in adult patients with advanced illness
      • RELISTOR injection (≥5% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (29%), flatulence (13%), nausea (12%), dizziness (7%), and diarrhea (6%).

To report SUSPECTED ADVERSE REACTIONS, contact Salix at 1-800-508-0024 or FDA at 1-800-FDA-1088 or www.fda.gov/Safety/MedWatch/

Please click here for full Prescribing Information for RELISTOR tablets and RELISTOR injection.

REFERENCES:

  1. Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25(suppl B):16B-21B.
  2. Sharma A, Jamal MM. Opioid induced bowel disease: a twenty-first century physicians' dilemma.Curr Gastroenterol Rep. 2013;15(7):334.
  3. Lembo A, Camilleri M. Chronic constipation. N Engl J Med. 2003;349(14):1360-1368.
  4. Vanegas G, Ripamonti C, Sbanotto A, De Conno F. Side effects of morphine administration in cancer patients. Cancer Nurs. 1998;21(4):289-297.
  5. Bell TJ, Panchal SJ, Miaskowski C, Bolge SC, Milanova T, Williamson R. The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European patient survey (PROBE 1). Pain Med. 2009;10(1):35-42.
  6. Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain. 2004;112(3):372-380.