For Your Consideration
Constipation Management:
An Update
This article reviews the most current information available about the prevention and treatment of three types of constipation: chronic idiopathic (CIC), opioid induced (OIC) and irritable bowel syndrome (IBS-C).
The common thread through all the research is that prevention is key. Where possible diet and lifestyle can have significant positive impact in the management of constipation. However, hospice patients are often at a point in their life/disease trajectory where changing diet and lifestyle are not possible. Regardless of situation the use of appropriate medications to prevent/treat constipation is essential in good quality of life. What follows will be specific to hospice patients.
In general hospice patients have multiple factors that affect bowel function including; serious illness(es), advanced age, metabolic disturbances, multiple medications, compromised physical function, reduced fluid and food intake, etc. Standard, first line treatment for constipation is the use of stimulant laxatives and stool softeners. Movement to the newer products should not be made unless the first line drugs have failed.
| Medication | Avg Monthly Cost |
|---|---|
| First Line | |
| Bulk* | |
| Psyllium (10g daily) | $8 |
| Non absorbed Substances | |
| Polyethylene glycol (17g daily) | $9 |
| Lactulose (29g daily) | $31 |
| Stimulants | |
| Senna (17g daily) | $7 |
| Bisacodyl (10mg daily) | $5 |
| Secretory | |
| Lubiprostone/Amitiza (8-24μg twice daily) | $445 |
| Linaclotide/Linzess (72-290μg daily) | $509 |
| Plecanatide/Trulance (3-6mg daily) | $494 |
| Serotonin Agonist | |
| Prucalopride/Motegrity (1-2mg daily) | $508 |
| PAMORAs (OIC only) | |
| Naldemedine/Symproic (0.2mg daily) | $377 |
| Naloxegol/Movantik (12.5-25mg daily) | $427 |
| Methylnaltrexone/Relistor | |
| Subq (12mg every other day) | $2080 |
| Oral (450mg daily) | $2079 |
*Bulk laxatives should be used with caution, if at all, in end of life constipation management.
As with many symptoms there are evaluation tools. One you might consider using (see link below) is the Rome IV Diagnostic Criteria for Constipation.
JAMA. Published online November 4, 2019:
https://doi.org/10.1001/jama.2019.16029
https://www.mdcalc.com/rome-iv-diagnostic-criteria-constipation
Regulatory Center
Hospice Care Improvement
Act of 2019
On November 7, 2019 this bipartisan bill was introduced in the Senate specifically written to address the concerns identified by the HHS Office of Inspector General about hospice survey deficiencies and patient harm. The following is a very basic outline of the proposed legislation:
- IMPROVING QUALITY REPORTING AND TRANSPARENCY FOR HOSPICE CARE
- Increasing Reported Hospice Data
- Improving the Hospice Survey Process
- Annual Report of Deficiencies
- INCREASING COMPLIANCE OF QUALITY STANDARDS FOR HOSPICE CARE
- Increasing Payment Reductions for Failure to Report Quality Measures
- Authority to Impose Alternative Sanctions
According to NHPCO they will continue to work with their legislative champions in the Senate to shepherd this bill through the legislative process and will continue to engage with their House champions on a companion bill.
If you are an NHPCO member please check Policy Alert dated November 8, 2019 for their information regarding this bill. You can get the full text of the bill (S.2807) by clicking on the link below.
https://www.portman.senate.gov/sites/default/files/2019-11/GOE19A43.pdf
Wise Services
Education for 2020
Beginning January 2020, we will be focusing on providing education live, online via our Ring Central platform. We know just how busy you are and how difficult it can be to come to a central location for meetings and education. Our system will allow you to login from wherever you have internet access and join our education session.
We will be scheduling quarterly sessions on current clinical topics such as; Comprehensive Pain Management, Appropriate Deprescribing and Documentation. In our January newsletter we will post our education schedule and topics. Login information for each session will be sent to your hospice’s education coordinator along with handout and reference material.
There will also be the option for your hospice to request online sessions outside of those quarterly sessions. Once again, that will be processed through your education coordinator.
Please stay tuned for updates and more details in January. Address any questions to David Bougher at dbougher@wiseop.com.
Follow-Up
Updates to Management of C. Diff
(November Newsletter)
An alternative recommendation to the non-formulary vancomycin capsules (2-week supply ~$1050):
The IDSA/SHEA indicates the use of metronidazole (Flagyl) as an alternative for non-severe, initial episodes of C-Diff: metronidazole 500mg TID x 10 days, ~$40.
Literature also supports that oral metronidazole is as effective as oral vancomycin for the treatment of C-difficile and over utilization of vancomycin can lead to enterococcal and other staphylococcal resistance. Vancomycin should be reserved for those with severe-life threatening cases of C-Diff, is unable to tolerate, or otherwise contraindicated.
A more cost-efficient alternative to vancomycin capsules is the oral solution (Firvanq ~$130/2-week supply).
Updated
Drug Shortages
These shortages are due either from manufacturing delays or shortage of raw ingredients. This is not an inclusive list, but the listed drugs may be used for hospice patients, especially in the inpatient setting. For a complete list of drugs on shortage follow this link:
https://www.ashp.org/drug-shortages/current-shortages/drug-shortages-list?page=CurrentShortages
NOTE: Items marked with a syringe are new from the previous month’s newsletter
To close click the X in the top right hand corner.
About the Author
David Bougher
Senior VP of Regulatory Affairs
David is a seasoned veteran of the hospice world and an essential member of the Wise Hospice Options clinical team.
Education:
RN, BSN
Experience:
- Former hospice COO
- 20 Years of education & training experience
- 10 Years of experience at Wise Hospice Options
Connect
- (800) 856-9757 Ext: 203
- dbougher@wiseop.com
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Wise Clinical Team
Deanna Rice
Vice President
Clinical Services
drice@wiseop.com
(800) 856-9757:
EXT. 216
Tino Vilches
Senior Vice President
Clinical Services
tvilches@wiseop.com
(800) 856-9757:
EXT. 208
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