PAMORAs in Opioid-Induced Constipation: Are We Following the Guidelines?

Peripherally acting u-opioid receptor antagonists (PAMORAs) are a safe and efficacious medication for treating opioid-induced constipation (OIC). This study evaluates the utilization of PAMORAs in patients with laxative-refractory OIC.

Patients diagnosed with OIC from 2018 to 2023 were retrospectively identified at a tertiary care center. As recommended by the guidelines, patients were considered eligible for PAMORAs if they had failed at least 2 laxatives. Data on PAMORA prescription, demographics, clinical characteristics, and specialty of the managing provider were collected and analyzed using logistic regression and χ 2 analysis.

Of 281 patients diagnosed with OIC, 204 (73%) were eligible for a PAMORA, of which only 58 (28%) were prescribed one. There were no differences in demographic or clinical characteristics between those who were offered PAMORAs vs not. There was a significant difference in prescribing patterns based on provider specialty ( P < 0.001). Although gastrointestinal (GI) specialists saw less than half of the eligible patients, they offered PAMORAs at the highest proportion of 59% compared with non-GI specialists (13-16%) or primary care providers (18%). Multivariable logistic regression analysis showed 12.7-fold increased odds of being offered a PAMORA if the provider was from the GI department compared with all non-GI providers ( P < 0.001).

PAMORAs are underutilized in patients with OIC. GI prescribers offer PAMORAs at a higher proportion than other departments, and being seen in GI independently increases the likelihood of a patient receiving a PAMORA. This suggests that underutilization may be due to a lack of awareness and further education about PAMORAs is warranted.