1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC  – Oncology Education in Palliative and End-of-life Care – Oncology Module 3f: Symptoms - Constipation Module 3f: Symptoms - Constipation

3. Constipation... l Straining l Hard stool l Sensation of  Incomplete evacuation  Anorectal obstruction l Fewer than 3 bowel movements per week l 12 weeks duration with 2 or more symptoms l Straining l Hard stool l Sensation of  Incomplete evacuation  Anorectal obstruction l Fewer than 3 bowel movements per week l 12 weeks duration with 2 or more symptoms

4. ... Constipation Epidemiology l Impact: abdominal discomfort / pain, nausea and vomiting l Prevalence: up to 90% among cancer patients treated with opioids l Prognosis: can limit prognosis if untreated l Management always possible Epidemiology l Impact: abdominal discomfort / pain, nausea and vomiting l Prevalence: up to 90% among cancer patients treated with opioids l Prognosis: can limit prognosis if untreated l Management always possible

5. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

6. Pathophysiology l Medications o Opioids o Calcium- channel blockers o Anticholinergic l Decreased motility l Ileus l Mechanical obstruction l Medications o Opioids o Calcium- channel blockers o Anticholinergic l Decreased motility l Ileus l Mechanical obstruction l Metabolic abnormalities l Spinal cord compression l Dehydration l Autonomic dysfunction l Malignancy

7. Assessment l Specifically ask about bowel function l Establish what is normal for patient l Specifically ask about bowel function l Establish what is normal for patient

8. Management l General measures o Regular toileting o Gastrocolic reflex o Activity l General measures o Regular toileting o Gastrocolic reflex o Activity l Specific measures o Softeners o Osmotics o Stimulants o Lubricants o Large-volume enemas

9. Stool softeners ( detergent laxatives) l Sodium docusate l Calcium docusate l Phospho-soda enema PRN l Sodium docusate l Calcium docusate l Phospho-soda enema PRN

10. Stimulant laxatives l Prune juice l Senna l Casanthranol l Bisacodyl l Prune juice l Senna l Casanthranol l Bisacodyl

11. Osmotic laxatives l Lactulose or sorbitol l Milk of magnesia (other Mg salts) l Magnesium citrate l Polyethylene glycol Lederle FA, et al. Am J Med. 1990. Attar A, et al. Gut. 1999. l Lactulose or sorbitol l Milk of magnesia (other Mg salts) l Magnesium citrate l Polyethylene glycol Lederle FA, et al. Am J Med. 1990. Attar A, et al. Gut. 1999.

12. Lubricants / enemas l Glycerin suppositories l Phosphate enema l Oil retention enema l Tap water, 500 – 1,000 ml l Glycerin suppositories l Phosphate enema l Oil retention enema l Tap water, 500 – 1,000 ml

13. Constipation from opioids... l Occurs with all opioids l Pharmacologic tolerance develops slowly, or not at all l Dietary interventions alone usually not sufficient l Avoid bulk-forming agents in debilitated patients Bagnol D, et al. Neuroscience. 1997. l Occurs with all opioids l Pharmacologic tolerance develops slowly, or not at all l Dietary interventions alone usually not sufficient l Avoid bulk-forming agents in debilitated patients Bagnol D, et al. Neuroscience. 1997.

14. ... Constipation from opioids l Combination stimulant / softeners are useful first-line medications Casanthranol + docusate sodium Senna + docusate sodium l Prokinetic agents l Opioid antagonists Sykes NP. Palliat Med. 2000. l Combination stimulant / softeners are useful first-line medications Casanthranol + docusate sodium Senna + docusate sodium l Prokinetic agents l Opioid antagonists Sykes NP. Palliat Med. 2000.

15. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.