II. Indications

  1. Severe refractory Constipation due to Opioids

III. Mechanism

  1. Block Opioid binding in the intestinal tract
  2. Decreases mu-Opioid receptor mediated bowel paralysis

IV. Preparations

  1. Movantik (Naloxegol) once daily orally in morning ($10/day)
    1. Approved for non-cancer, Opioid-Induced Constipation
    2. Requires Renal Dosing adjustment
    3. Chey (2014) N Engl J Med 370:2387-96 [PubMed]
  2. Methylnaltrexone (Relistor) injection ($70/day)
    1. Methylnaltrexone 5 mg or 0.15 mg/kg SQ
    2. Weight-based SQ Injection once or twice daily
    3. Diarrhea occurs in 8% and Abdominal Pain in 13%
    4. Requires Renal Dosing adjustment
  3. Symproic (Nalmedemedine)
    1. Dose: Once daily
    2. No renal dose adjustment needed
  4. Alvimopan (Entereg)
    1. Approved only for short-term management of post-operative ileus
    2. Restricted prescribing due to risk of Myocardial Infarction

V. Advantages

  1. Does not cross blood-brain barrier

VI. Disadvantages

  1. All agents in this class are expensive as of 2017 (costs range between $10 to $70 per day)

VII. Efficacy

  1. In general, results in one more Bowel Movement per week
  2. Terminally ill patients
    1. Bowel Movement occurs within 4 hours of dose in 48% of patients (15% wiith Placebo)
    2. Median time to Bowel Movement is 45 minutes (>6 hours for Placebo)

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Cost: Medications

relistor (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
RELISTOR 12 MG/0.6 ML SYRINGE $159.82 per ml
RELISTOR 150 MG TABLET $15.90 each
movantik (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
MOVANTIK 12.5 MG TABLET $10.08 each
MOVANTIK 25 MG TABLET $10.04 each