Comment: update on the management of constipation in the elderly: new treatment options.

To the editor,

I read with great interest the recent article by Rao and Go regarding new treatment options for the management of constipation in the elderly.1 In this article, alvimopan was described as having been “recently…introduced for the treatment of opioid-induced constipation”. Furthermore, alvimopan was included in a treatment algorithm for management of opioid-induced chronic constipation in the elderly (see Figure 1 in Rao and Go).1 Additionally, other “potential uses” for peripherally acting mu-opioid receptor antagonists (including alvimopan) were identified by the authors and included treatment of “opioid-related nausea and vomiting, urinary retention, pruritus or post-operative ileus”. This characterization of alvimopan requires further clarification.

Alvimopan was approved by the US Food and Drug Administration (FDA) in 2008 for the acceleration of gastrointestinal recovery following partial small or large bowel resection with primary anastomosis.2 Alvimopan has not been approved for any other indication, such as treatment of opioid-induced constipation. Importantly, the Warnings and Precautions section of the label describes the potential adverse effects that may be associated with administration of alvimopan 12 mg to patients recently exposed to opioids. Furthermore, alvimopan is approved only for short-term, in-hospital use, and hospitals dispensing alvimopan must register in and meet all of the requirements of the Entereg® Access Support and Education (E.A.S.E.™) Program.3

It is important that your readers understand these facts about alvimopan use in light of the information provided by Rao and Go.1