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Healy R. Effectiveness of two opioid antagonists in treating opioid-induced constipation. ACTA ACUST UNITED AC 2009; 18:998-1002. [PMID: 19773693 DOI: 10.12968/bjon.2009.18.16.43969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM This literature review reports the effectiveness of two peripheral opioid antagonists to relieve constipation caused by prolonged use of opioids, primarily in patients with advanced cancer. BACKGROUND Opioid-induced constipation can cause great discomfort to patients who use opioids for prolonged periods and on occasion decline pain-relief in an effort to help aid laxation. The use of peripheral opioid antagonists can help reverse the slowing of the gut caused by the opioids, but the correct one must be used in order not to reverse the important analgesic effects the opioids provide. DATA SOURCES Information was obtained by searching the databases British Nursing Index, CINAHL and Medline. REVIEW METHODS Selection criteria were as follows: original research in the form of randomized controlled trials; articles had to be written in English; articles had to focus on the effectiveness of naloxone and methylnaltrexone in the treatment of opioid-induced constipation; the search was limited to the period 1990-2008. RESULTS Nineteen articles were included in the study. The results from the studies indicate that due to fewer withdrawal effects and less reversal of analgesia experienced, methylnaltrexone is more effective at relieving opioid-induced constipation. CONCLUSION The recent development of methylnaltrexone into a commercially-viable drug indicates its effectiveness. It may help patients suffering from the intense discomfort that constipation can cause.
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Affiliation(s)
- Richard Healy
- University College, London Hospitals NHS Foundation Trust, London
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103
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Diego L, Atayee R, Helmons P, von Gunten CF. Methylnaltrexone: a novel approach for the management of opioid-induced constipation in patients with advanced illness. Expert Rev Gastroenterol Hepatol 2009; 3:473-85. [PMID: 19817669 DOI: 10.1586/egh.09.42] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In April 2008, the US FDA granted approval to methylnaltrexone (Relistor), the first peripheral micro-opioid-receptor antagonist for the treatment of opioid-induced constipation in advanced-illness patients receiving palliative care and for whom other laxative therapies failed to achieve adequate results. Methylnaltrexone, a quaternary derivative of naltrexone, introduces a novel mechanism of action that selectively antagonizes the peripheral micro-receptors in the GI tract without effects on the CNS. In clinical trials, subcutaneous methylnaltrexone reversed opioid-induced constipation after the first dose in approximately 50-60% of the patients. In most of the cases, effective laxation occurred within 1 h. The therapeutic benefit was sustained in multiple-dose studies. Owing to the nature of the population studied, safety data are available for approximately 4 months of use. Although it is not the focus of this article, methylnaltrexone's mechanism of action suggests it could be beneficial for other peripheral, opioid-induced adverse effects, such as opioid-related nausea, vomiting, urinary retention, pruritus or postoperative ileus.
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Affiliation(s)
- Laura Diego
- Universitat Pompeu Fabra, Department of Experimental and Health Sciences, Edifici Parc de Recerca Biomèdica de Barcelona, Carrer Dr. Aiguader, 88. 08003 Barcelona, Spain.
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Abstract
Opioids are the mainstay of treatment for moderate to severe cancer pain. In recent years there have been many advances in the use of opioids for cancer pain. Availability and consumption of opioids have increased and opioids other than morphine (including methadone, fentanyl, oxycodone) have become more widely used. Inter-individual variation in response to opioids has been identified as a significant challenge in the management of cancer pain. Many studies have been published demonstrating the benefits of opioid switching as a clinical maneuver to improve tolerability. Constipation has been recognized as a significant burden in cancer patients on opioids. Peripherally restricted opioid antagonists have been developed for the prevention and management of opioid induced constipation. The phenomenon of breakthrough pain has been characterized and novel modes of opioid administration (transmucosal, intranasal, sublingual) have been explored to facilitate improved management of breakthrough cancer pain. Advances have also been made in the realm of molecular biology. Pharmacogenetic studies have explored associations between clinical response to opioids and genetic variation at a DNA level. To date these studies have been small but future research may facilitate prospective prediction of response to individual drugs.
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Affiliation(s)
- Joanne Droney
- Palliative Medicine Department, Royal Marsden Hospital, London, UK
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6β-naltrexol preferentially antagonizes opioid effects on gastrointestinal transit compared to antinociception in mice. Life Sci 2009; 85:413-20. [DOI: 10.1016/j.lfs.2009.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 06/24/2009] [Accepted: 06/26/2009] [Indexed: 11/21/2022]
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[Opioid-induced bowel dysfunction: a literature analysis on pathophysiology and treatment]. Wien Med Wochenschr 2009; 158:621-6. [PMID: 19052708 DOI: 10.1007/s10354-008-0589-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 06/17/2008] [Indexed: 12/26/2022]
Abstract
Bowel dysfunction is a frequent and serious side effect of opioid analgetics. In spite of its common occurrence, in the course of clinical routine, it is frequently ignored or underestimated. Authors of the analysed literature widely agree that a prophylactic and routine pharmacotherapy is necessary. For this purpose, laxatives, enemas and suppositories, prokinetic agents and opioid antagonists can be considered. Bulk-forming laxatives did not prove to be effective, since the quantity of fluid intake required for the action usually cannot be provided. Furthermore, the benefit of emollient agents is doubted. As a monotherapy they are not sufficient. By contrast, stimulant and osmotic laxatives proved to be active. Prokinetic drugs are not recommended because of their serious side effects. Effective abatement of opioid-induced obstipation by opioid antagonists has been proven in numerous studies. However, the loss of analgesia and opioid withdrawal symptoms were described as adverse effects. Development of quaternary opioid antagonists such as methylnaltrexone was allowed for mitigating these adverse effects.
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Löwenstein O, Leyendecker P, Hopp M, Schutter U, Rogers PD, Uhl R, Bond S, Kremers W, Nichols T, Krain B, Reimer K. Combined prolonged-release oxycodone and naloxone improves bowel function in patients receiving opioids for moderate-to-severe non-malignant chronic pain: a randomised controlled trial. Expert Opin Pharmacother 2009; 10:531-43. [PMID: 19243306 DOI: 10.1517/14656560902796798] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND This randomised, double-blind, double-dummy, parallel-group multicentre study assessed the impact of a total daily dose of 60-80 mg oral oxycodone prolonged-release (PR)/naloxone PR (OXN PR) as fixed-ratio combination for patients with opioid-induced constipation (OIC) having moderate-to-severe, non-malignant pain. METHODS During pre-randomisation patients receiving opioids for moderate-to-severe non-malignant pain were converted to oxycodone PR (OXY PR) and titrated to an effective analgesic dose. During randomisation 265 patients on a stable OXY PR dose (60-80 mg/day) and with OIC were included in the full analysis population to receive OXN PR or OXY PR alone. Primary outcome was improvement in symptoms of constipation as measured by the Bowel Function Index (BFI). Secondary/exploratory outcomes examined analgesic efficacy and other bowel function parameters. RESULTS After 4 weeks of treatment, patients receiving OXN PR showed a significant improvement in bowel function compared with those in the OXY PR group (-14.9; 95% CI: -17.9, -11.9; p<0.0001) as measured by BFI which was seen after only 1 week of treatment continuing to the end of the study. After 4 weeks of treatment, patients receiving OXN PR had a median number of 3.0 complete spontaneous bowel movements (CSBM) per week compared with only 1.0 for OXY PR alone. Laxative intake was lower in the OXN PR than the OXY PR group. Furthermore, improvements in bowel function were achieved without loss of analgesic efficacy; pain intensity scores were comparable between the groups and consistent for duration of the study. Most frequently reported adverse events were consistent with those reported for opioid analgesics; no new or unexpected adverse reactions attributable to OXN PR used in higher doses were observed. CONCLUSION This study shows that the fixed-ratio combination of OXN PR is superior to OXY PR alone in terms of bowel function, while providing effective equivalent analgesia.
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Affiliation(s)
- O Löwenstein
- Mundipharma Research GmbH & Co KG, Limburg (Lahn), Germany
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Porreca F, Ossipov MH. Nausea and Vomiting Side Effects with Opioid Analgesics during Treatment of Chronic Pain: Mechanisms, Implications, and Management Options. PAIN MEDICINE 2009; 10:654-62. [PMID: 19302436 DOI: 10.1111/j.1526-4637.2009.00583.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Frank Porreca
- Department of Pharmacology, University of Arizona, Tuscon, Arizona 85724, USA.
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McNicol E, Boyce DB, Schumann R, Carr D. Efficacy and safety of mu-opioid antagonists in the treatment of opioid-induced bowel dysfunction: systematic review and meta-analysis of randomized controlled trials. PAIN MEDICINE 2009; 9:634-59. [PMID: 18828197 DOI: 10.1111/j.1526-4637.2007.00335.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
CONTEXT Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life. OBJECTIVE To compare the efficacy and safety of traditional and peripherally active opioid antagonists vs conventional interventions for OBD. DESIGN We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE. Additional reports were identified from the reference lists of retrieved articles. STUDY SELECTION Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD. DATA EXTRACTION Data were extracted by two independent investigators and included demographic variables, diagnoses, interventions, efficacy, and adverse events. RESULTS OF DATA SYNTHESIS Twenty-two articles met inclusion criteria and provided data on 2,352 opioid antagonist-treated patients. The opioid antagonist investigated was alvimopan (eight studies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan are efficacious in reversing opioid-induced increased gastrointestinal transit time and constipation, and that alvimopan is safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate. CONCLUSIONS Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.
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Affiliation(s)
- Ewan McNicol
- Department of Pharmacy, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
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Holzer P. Opioid receptors in the gastrointestinal tract. ACTA ACUST UNITED AC 2009; 155:11-7. [PMID: 19345246 DOI: 10.1016/j.regpep.2009.03.012] [Citation(s) in RCA: 263] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 03/25/2009] [Indexed: 12/14/2022]
Abstract
Opium is arguably one of the oldest herbal medicines, being used as analgesic, sedative and antidiarrheal drug for thousands of years. These effects mirror the actions of the endogenous opioid system and are mediated by the principal mu-, kappa- and delta-opioid receptors. In the gut, met-enkephalin, leu-enkephalin, beta-endorphin and dynorphin occur in both neurons and endocrine cells. When released, opioid peptides activate opioid receptors on the enteric circuitry controlling motility and secretion. As a result, inhibition of gastric emptying, increase in sphincter tone, induction of stationary motor patterns and blockade of peristalsis ensue. Together with inhibition of ion and fluid secretion, these effects cause constipation, one of the most frequent and troublesome adverse reactions of opioid analgesic therapy. Although laxatives are most frequently used to ameliorate opioid-induced bowel dysfunction, their efficacy is unsatisfactory. Specific antagonism of peripheral opioid receptors is a more rational approach. This goal is addressed by the use of opioid receptor antagonists with limited absorption such as oral prolonged-release naloxone and opioid receptor antagonists that do not penetrate the blood-brain barrier such as methylnaltrexone and alvimopan. Preliminary evidence indicates that peripherally restricted opioid receptor antagonists may act as prokinetic drugs in their own right.
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Affiliation(s)
- Peter Holzer
- Research Unit of Translational Neurogastroenterology, Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Universitätsplatz 4, A-8010 Graz, Austria.
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Arpino PA, Thompson BT. Safety of enteral naloxone for the reversal of opiate-induced constipation in the intensive care unit. J Clin Pharm Ther 2009; 34:171-5. [DOI: 10.1111/j.1365-2710.2008.00982.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Akkawi R, Eksborg S, Andersson A, Lundeberg S, Bartocci M. Effect of oral naloxone hydrochloride on gastrointestinal transit in premature infants treated with morphine. Acta Paediatr 2009; 98:442-7. [PMID: 19046344 DOI: 10.1111/j.1651-2227.2008.01128.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Opioids are common drugs for pain treatment in preterm newborn infants, in spite of several adverse effects. Constipation is a frequent problem when opioids are used in both adults and neonates. Although several studies indicate that the oral administration of naloxone hydrochloride (NH) improves intestinal motility during opioid therapy, there is still a lack of evidence in newborns. AIM The aim of this study was to assess the efficacy of NH against reduced intestinal motility during opioid treatment. METHODS A retrospective cohort study was performed. We analysed the medical records of fifteen infants (Group 1) treated with continuous morphine (MO) infusion and fourteen infants (Group 2) treated with both oral NH (3 microg/kg 4 times daily) and MO. RESULTS There was no statistically significant difference in the total MO dose. Infants treated both with NH and MO had a tendency to improve their mean stool frequency/day. A statistically significant improvement was observed in the mean total food intake (mL/kg/day) of the infants treated with NH (p = 0.014). No difference in the mean food retention between the two groups was observed. CONCLUSION Orally administrated NH seems to improve intestinal motility resulting in increased food intake/day and improved stool frequency/day in premature newborn infants treated with MO. Further studies are needed to corroborate these findings.
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Affiliation(s)
- Ranaa Akkawi
- Karolinska Pharmacy, Karolinska University Hospital, Stockholm, Sweden
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Single- and multiple-dose pharmacokinetic evaluation of oxycodone and naloxone in an opioid agonist/antagonist prolonged-release combination in healthy adult volunteers. Clin Ther 2009; 30:2051-68. [PMID: 19108793 DOI: 10.1016/j.clinthera.2008.11.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2008] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is an increasing body of evidence supporting the need for prophylactic management of the adverse events (AEs) associated with long-term opioid use in patients with chronic pain. Symptoms of bowel dysfunction, such as constipation, may have a significant impact on a patient's quality of life and willingness to continue opioid therapy, and therefore should be managed proactively to ensure that the patient can continue effective pain management. The fixed-dose combination (FDC) prolonged-release (PR) oxycodone/naloxone (OXN) may be an effective therapeutic approach to delivering analgesia, with a reduced risk for opioid-induced constipation. OBJECTIVE The aim of this paper was to report the pharmacokinetic results from a single-dose study and a multiple-dose bioequivalence study of OXN versus separate formulations of oxycodone PR and naloxone PR administered concurrently in healthy subjects. METHODS Both studies were open-label, randomized crossover studies in healthy adult male and female subjects. In the single-dose study, subjects were randomly assigned to 1 of 4 treatment groups: OXN FDC (44 x 10/55-mg, 2 x 20/110-mg, or 1 x 40/20-mg dose strength [each given at a total combined dose of 40/220 mg]) or oxycodone PR 40 mg + naloxone PR 20 mg given in separate formulations. In the multiple-dose study, 34 subjects were randomly assigned to 1 of 3 treatment groups: OXN FDC 40/20 mg, oxycodone PR 40 mg, or naloxone PR 20 mg. Treatments were considered bioequivalent if the 90% CIs for relative bioavailability calculations fell within a predetermined range of 80% to 125%. AEs were assessed by the investigator at each study visit. RESULTS The single-dose study included 28 subjects (22 men, 6 women; mean [SD] age, 32.3 [5.44] years; weight, 75.5 [9.3] kg; and body mass index [BMI], 24.2 [2.5] kg/mm(2)). The mean plasma oxycodone concentration-time curves for OXN and oxycodone PR + naloxone PR were similar. With oxycodone, the mean (SD) AUC(t) values with OXN 10/5, 20/10, and 40/20 mg and oxycodone PR + naloxone PR were 473.49 (72.16), 491.22 (82.18), 488.89 (91.04), and 502.28 (84.13) ng . h/mL, respectively; mean C(max) values were 34.91 (4.36), 35.73 (4.93), 34.46 (5.03), and 40.45 (4.71) ng/mL. For naloxone-3-glucuronide (the primary analyte of naloxone), the mean (SD) AUC(t) values with OXN 10/5, 20/10, and 40/20 mg and oxycodone PR + naloxone PR were 539.93 (142.24), 522.45 (128.57), 520.10 (133.18), and 523.37 (119.75) ng . h/mL, respectively; mean C(max) values were 62.01 (15.96), 63.62 (19.51), 61.95 (18.37), and 63.55 (16.75) ng/mL. There were no statistically significant differences between the treatments, and each of the treatment comparisons resulted in 90% CIs within the range for bioequivalence. The multiple-dose steady-state bioequivalence study included 34 subjects (28 men, 6 women; mean [SD] age, 36 [9.4] years; weight,78.9 [11.7] kg; and BMI, 24.6 [1.9] kg/m(2)). No significant differences were observed between the treatments, with the exception of naloxone-3-glucuronide C(min,ss) values. Mean C(min,ss) values of 22.6 and 24.0 ng/mL were obtained for the OXN combination and naloxone PR tablet, respectively. In the multiple-dose study, the most frequently reported AEs with OXN,oxycodone PR, and naloxone PR were headache (7%, 26%, and 17%, respectively), anorexia (10%, 16%, and 13%), and nausea (10%, 13%, and 7%). CONCLUSIONS The results from the single-dose study were consistent with the regulatory definition of bioequivalence of the FDCs and single components across the range of doses administered. The pharmacokinetic properties of the OXN FDC were similar to those of oxycodone PR + naloxone PR given as separate formulations, based on the regulatory definition. These findings were consistent with the results of the multiple-dose steady-state bioequivalence study. In this population of healthy volunteers, the pharmacokinetic properties of oxycodone apparently were not significantly influenced by administering oxycodone in a combination product, and the availability of naloxone-3-glucuronide from OXN was similar to that from the naloxone PR tablet. These findings suggest that the coadministration of oxycodone PR and naloxone PR in an FDC would not significantly affect the bioavailability of either of its constituents in these subjects.
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Rentz AM, Yu R, Müller-Lissner S, Leyendecker P. Validation of the Bowel Function Index to detect clinically meaningful changes in opioid-induced constipation. J Med Econ 2009; 12:371-83. [PMID: 19912069 DOI: 10.3111/13696990903430481] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The Bowel Function Index (BFI) is a clinician-administered, patient-reported, 3-item questionnaire to evaluate opioid-induced constipation in cancer and non-cancer chronic pain patients. The objective of the present analysis was to evaluate the psychometric characteristics of the BFI using data from clinical studies of oral prolonged release (PR) oxycodone/naloxone. METHODS OXN2401 was a multicenter, controlled, randomized, double-blind, parallel-group study including oral PR oxycodone combined with oral PR naloxone as well as oral PR oxycodone combined with corresponding naloxone placebo. OXN3401 and OXN3001 were 12-week multicenter, controlled, randomized, double-blind, parallel-group studies of a fixed combination of oral PR oxycodone/naloxone versus PR oxycodone. In addition, a placebo group was included in study OXN3401. BFI psychometric characteristics (reliability, reproducibility, convergent/known groups validity, and responsiveness) were evaluated. RESULTS Demographic data (n=985) were comparable and analyses indicated a high degree of internal consistency (Cronbach's alpha >0.7). Change of less than 5 points in BFI was indicative of high reproducibility. Correlations between BFI item and total scores to stool frequency were statistically significant and in the low-to-moderate range (OXN2401 -0.23 to -0.29, p < 0.001; OXN3401 range -0.26 to -0.40, p < 0.001; OXN3001 -0.14 to -0.15, p < 0.05). Data indicate that a BFI score change of ≥12 points represents a clinically meaningful change in constipation. LIMITATIONS This publication for validation of BFI only includes data from three clinical trials. However, another publication of an additional specifically designed cross-sectional validation study is in preparation. CONCLUSION The BFI is a valid and reliable instrument for the assessment of opioid-induced constipation in chronic pain patients. Psychometric analyses from clinical trials support the BFI's psychometric properties.
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Affiliation(s)
- A M Rentz
- Center for Health Outcomes Research, United Biosource Corporation, Bethesda, MD, USA
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115
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Thomas JR, Cooney GA, Slatkin NE. Palliative care and pain: new strategies for managing opioid bowel dysfunction. J Palliat Med 2008; 11 Suppl 1:S1-19; quiz S21-2. [PMID: 18800914 DOI: 10.1089/jpm.2008.9839.supp] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Opioid analgesics are a cornerstone of pain therapy in the hospice and palliative care population. However, opioid-induced bowel dysfunction (OBD) is a commonly associated condition that frequently compromises the usefulness of these agents. Although its most common and debilitating symptom is constipation, the impact of OBD extends beyond constipation to encompass a myriad of gastrointestinal (GI) signs and symptoms, ranging from decreased gastric emptying and reflux to abdominal pain, cramping, bloating, nausea, and vomiting. Even after aggressive therapies to improve bowel function have been implemented, many patients continue to experience symptoms of OBD. To avoid these unwanted effects, some even choose to decrease or discontinue therapy with opioid analgesics, and experience inadequate pain control. The net result of OBD is a seriously negative impact on quality of life (QOL). For these reasons, it is important that palliative care practitioners have an adequate understanding of normal GI function and the underlying mechanisms responsible for OBD, the burden of OBD in the context of appropriate and effective pain management, and the benefits provided by effective pharmacotherapy. Several real-world cases are discussed to illustrate the application of optimal symptom management and the use of strategies that minimize the effects of OBD and improve patient QOL.
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Simpson K, Leyendecker P, Hopp M, Müller-Lissner S, Löwenstein O, De Andrés J, Troy Ferrarons J, Bosse B, Krain B, Nichols T, Kremers W, Reimer K. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. Curr Med Res Opin 2008; 24:3503-12. [PMID: 19032132 DOI: 10.1185/03007990802584454] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Opioid therapy is frequently associated with treatment-limiting constipation. Naloxone is an opioid antagonist with low oral systemic bioavailability. This Phase III clinical trial assessed the safety and efficacy of an oral fixed-ratio combination of oxycodone prolonged-release (PR) and naloxone PR compared with oxycodone PR in relieving opioid-induced constipation. STUDY DESIGN This double-blind, multicenter trial was conducted in specialist and primary care centers in four European countries in an out-patients setting. The study included 322 adult patients with moderate-to-severe, noncancer pain requiring opioid therapy in a range of >or=20 mg/day and <or=50 mg/day oxycodone. Following a run-in phase patients were randomized to receive oxycodone PR/naloxone PR or oxycodone PR for 12 weeks. The primary outcome was improvement in constipation as measured using the Bowel Function Index (BFI). Secondary/exploratory assessments focused on pain intensity and additional bowel parameters. TRIAL REGISTRATION NCT00412152. RESULTS A significant improvement in BFI scores occurred with oxycodone PR/naloxone PR compared with oxycodone PR after 4 weeks of double-blind treatment (-26.9 vs. -9.4, respectively; p < 0.0001), observed after only 1 week of treatment and continued until study end. A significant increase in the number of complete spontaneous bowel movements and decrease in laxative use were also reported. This improvement in bowel function was achieved without compromising the analgesic efficacy of the oxycodone component; pain intensity remained constant throughout the study. The incidence of adverse events was comparable in both groups and consistent with those expected of opioid analgesics. As the study was limited to a dose range of up to 50 mg oxycodone equivalent per day, further research on higher doses would be recommended. CONCLUSION The fixed-ratio combination of oxycodone PR/naloxone PR is superior to oxycodone PR alone, offering patients effective analgesia while significantly improving opioid-induced constipation.
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Netzer P, Sendensky A, Wissmeyer MP, Baumeler S, Batista C, Scheurer U, Krause T, Reber P, Brenneisen R. The effect of naloxone-3-glucuronide on colonic transit time in healthy men after acute morphine administration: a placebo-controlled double-blinded crossover preclinical volunteer study. Aliment Pharmacol Ther 2008; 28:1334-41. [PMID: 18808445 DOI: 10.1111/j.1365-2036.2008.03855.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Constipation is a significant side effect of opioid therapy. We have previously demonstrated that naloxone-3-glucuronide (NX3G) antagonizes the motility-lowering-effect of morphine in the rat colon. AIM To find out whether oral NX3G is able to reduce the morphine-induced delay in colonic transit time (CTT) without being absorbed and influencing the analgesic effect. METHODS Fifteen male volunteers were included. Pharmacokinetics: after oral administration of 0.16 mg/kg NX3G, blood samples were collected over a 6-h period. Pharmacodynamics: NX3G or placebo was then given at the start time and every 4 h thereafter. Morphine (0.05 mg/kg) or placebo was injected s.c. 2 h after starting and thereafter every 6 h for 24 h. CTT was measured over a 48-h period by scintigraphy. Pressure pain threshold tests were performed. RESULTS Neither NX3G nor naloxone was detected in the venous blood. The slowest transit time was observed during the morphine phase, which was significantly different from morphine with NX3G and placebo. The pain perception was not significantly influenced by NX3G. CONCLUSIONS Orally administered NX3G is able to reverse the morphine-induced delay of CTT in humans without being detected in peripheral blood samples. Therefore, NX3G may improve symptoms of constipation in-patients using opioid medication without affecting opioid-analgesic effects.
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Affiliation(s)
- P Netzer
- Department of Gastroenterology, Inselspital, University Hospital Bern, Bern, Switzerland.
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Vondrackova D, Leyendecker P, Meissner W, Hopp M, Szombati I, Hermanns K, Ruckes C, Weber S, Grothe B, Fleischer W, Reimer K. Analgesic Efficacy and Safety of Oxycodone in Combination With Naloxone as Prolonged Release Tablets in Patients With Moderate to Severe Chronic Pain. THE JOURNAL OF PAIN 2008; 9:1144-54. [DOI: 10.1016/j.jpain.2008.06.014] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Revised: 06/12/2008] [Accepted: 06/18/2008] [Indexed: 10/21/2022]
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119
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Therapie der opioidinduzierten Obstipation. Anaesthesist 2008. [DOI: 10.1007/s00101-008-1420-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jage J, Laufenberg-Feldmann R, Heid F. [Drugs for postoperative analgesia: routine and new aspects: Part 2: opioids, ketamine and gabapentinoids]. Anaesthesist 2008; 57:491-8. [PMID: 18409073 DOI: 10.1007/s00101-008-1327-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In part 1 of this review, perioperative aspects of the use of non-opioids (acetaminophene, dipyrone, traditional NSAR, coxibs) were discussed. In part 2 the perioperative aspects of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids; ketamine) will now be presented. The main aim of the review is to describe the use, risks and cost of some substances to facilitate the differential indication. New aspects concerning the use of gabapentinoids and ketamine are discussed.
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Affiliation(s)
- J Jage
- Klinik für Anästhesiologie, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131 Mainz.
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121
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Meissner W, Leyendecker P, Mueller-Lissner S, Nadstawek J, Hopp M, Ruckes C, Wirz S, Fleischer W, Reimer K. A randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. Eur J Pain 2008; 13:56-64. [PMID: 18762438 DOI: 10.1016/j.ejpain.2008.06.012] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2007] [Revised: 06/05/2008] [Accepted: 06/30/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Opioid-induced constipation can have a major negative impact on patients' quality of life. This randomised, double-blinded study evaluated the analgesic efficacy of prolonged-release (PR) oral oxycodone when co-administered with PR oral naloxone, and its impact on opioid-induced constipation in patients with severe chronic pain. Another objective was to identify the optimal dose ratio of oxycodone and naloxone. METHODS A total of 202 patients with chronic pain (mainly non-cancer related, 2.5% of patients had cancer-related pain) under stable oral oxycodone therapy (40, 60 or 80 mg/day) were randomised to receive 10, 20, 40 mg/day naloxone or placebo. After a 4-week maintenance phase, patients received oxycodone only for 2 weeks. Pain intensity was evaluated using a numerical analogue scale and bowel function was assessed using the bowel function index. RESULTS No loss of analgesic efficacy with naloxone was observed. Mean pain intensity scores on randomisation were comparable for placebo, 10mg, 20mg and 40 mg naloxone dose, and remained unchanged during treatment. Bowel function improved with increasing naloxone dose. Naloxone 20mg and 40 mg significantly improved bowel function at the end of the maintenance phase compared with placebo (p<0.05). Overall, the combination was well tolerated, with no unexpected adverse events. There was a trend towards an increased incidence of diarrhoea with higher doses of naloxone. The 2:1 oxycodone/naloxone ratio was identified as the most suitable for further development. CONCLUSION Co-administration of PR oral naloxone and PR oral oxycodone is associated with a significant improvement in bowel function compared with PR oral oxycodone alone, with no reduction in the analgesic efficacy of oxycodone.
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Affiliation(s)
- Winfried Meissner
- Clinic of Anaesthesiology and Intensive Care, Friedrich-Schiller-University, 07740 Jena, Germany
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Nadstawek J, Leyendecker P, Hopp M, Ruckes C, Wirz S, Fleischer W, Reimer K. Patient assessment of a novel therapeutic approach for the treatment of severe, chronic pain. Int J Clin Pract 2008; 62:1159-67. [PMID: 18705820 PMCID: PMC2658020 DOI: 10.1111/j.1742-1241.2008.01820.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Opioid-induced constipation can have a major negative impact on patients' quality of life. This randomised clinical trial evaluated patient assessment of the efficacy and tolerability of oral prolonged-release (PR) oxycodone when co-administered with oral naloxone PR. METHODS Two hundred and two patients with chronic cancer- or non-cancer-related pain undergoing stable oxycodone PR therapy (40, 60 or 80 mg/day) were randomised to one of four intervention groups: 10, 20 or 40 mg/day naloxone PR or placebo. Following a 4-week maintenance phase, patients were followed-up for 2 weeks in which time they received oxycodone PR only. At the end of the maintenance phase, patients and investigators were asked to assess treatment efficacy and tolerability, as well as preference for the titration or maintenance phase. RESULTS Patient and investigator global assessment of efficacy and tolerability improved with increasing naloxone dose. Efficacy was ranked as 'good' or 'very good' by 50.0%, 67.4% and 72.5% of patients in the 10, 20 and 40 mg naloxone PR dose groups, respectively, compared with 43.5% of patients in the placebo group. Patient assessment of tolerability was similar between treatment groups and placebo, being ranked as 'good' or 'very good' by 83.3%, 79.1% and 82.5% of patients in the 10, 20 and 40 mg/day naloxone PR dose groups, respectively, compared with 71.7% of patients in the placebo group. The maintenance treatment phase was preferred by patients in the naloxone groups. A 2 : 1 dose ratio of oxycodone to naloxone was also assessed. Efficacy was ranked as 'good' or 'very good' by 70.4% of patients treated with the 2 : 1 dose ratio compared with 43.5% of patients receiving placebo. Tolerability of the 2 : 1 dose ratio was ranked as being 'good' or 'very good' by 81.5% of patients compared with 71.1% for the placebo group and patients preferred the maintenance phase. CONCLUSIONS The co-administration of oral naloxone PR with oxycodone PR improves patient assessment of analgesic opioid therapy for severe chronic pain, in terms of both efficacy and tolerability.
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Affiliation(s)
- J Nadstawek
- Clinic of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany
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123
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Chappell D, Rehm M, Conzen P. Opioid-induced constipation in intensive care patients: relief in sight? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:161. [PMID: 18598388 PMCID: PMC2575552 DOI: 10.1186/cc6930] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Constipation is the most common gastrointestinal complication associated with opioid therapy in chronic pain patients, and also frequently occurs in sedated intensive care unit patients. Conventional therapy may not provide sufficient relief from constipation, which can be severe enough to limit opioid use or the dose. In a recent study on terminally ill patients suffering from laxative-resistant opioid-induced constipation, Thomas and colleagues demonstrated subcutaneous methylnaltrexone to rapidly induce defecation. This appealing result might also have favourable prospects for intensive care patients, as their outcome is often codetermined by recovery of bowel functioning.
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124
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Holzer P. Methylnaltrexone for the management of unwanted peripheral opioid effects. ACTA ACUST UNITED AC 2008. [DOI: 10.2217/14750708.5.4.531] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Thomas J, Karver S, Cooney GA, Chamberlain BH, Watt CK, Slatkin NE, Stambler N, Kremer AB, Israel RJ. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med 2008; 358:2332-43. [PMID: 18509120 DOI: 10.1056/nejmoa0707377] [Citation(s) in RCA: 366] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Constipation is a distressing side effect of opioid treatment. As a quaternary amine, methylnaltrexone, a mu-opioid-receptor antagonist, has restricted ability to cross the blood-brain barrier. We investigated the safety and efficacy of subcutaneous methylnaltrexone for treating opioid-induced constipation in patients with advanced illness. METHODS A total of 133 patients who had received opioids for 2 or more weeks and who had received stable doses of opioids and laxatives for 3 or more days without relief of opioid-induced constipation were randomly assigned to receive subcutaneous methylnaltrexone (at a dose of 0.15 mg per kilogram of body weight) or placebo every other day for 2 weeks. Coprimary outcomes were laxation (defecation) within 4 hours after the first dose of the study drug and laxation within 4 hours after two or more of the first four doses. Patients who completed this phase were eligible to enter a 3-month, open-label extension trial. RESULTS In the methylnaltrexone group, 48% of patients had laxation within 4 hours after the first study dose, as compared with 15% in the placebo group, and 52% had laxation without the use of a rescue laxative within 4 hours after two or more of the first four doses, as compared with 8% in the placebo group (P<0.001 for both comparisons). The response rate remained consistent throughout the extension trial. The median time to laxation was significantly shorter in the methylnaltrexone group than in the placebo group. Evidence of withdrawal mediated by central nervous system opioid receptors or changes in pain scores was not observed. Abdominal pain and flatulence were the most common adverse events. CONCLUSIONS Subcutaneous methylnaltrexone rapidly induced laxation in patients with advanced illness and opioid-induced constipation. Treatment did not appear to affect central analgesia or precipitate opioid withdrawal. (Clinical Trials.gov number, NCT00402038 [ClinicalTrials.gov].).
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Affiliation(s)
- Jay Thomas
- San Diego Hospice and the Institute for Palliative Medicine, San Diego, CA 92103, USA.
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126
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Leri F. Co-administration of opioid agonists and antagonists in addiction and pain medicine. Expert Opin Pharmacother 2008; 9:1387-96. [DOI: 10.1517/14656566.9.8.1387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
BACKGROUND Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life. OBJECTIVES To compare the efficacy and safety of traditional and peripherally active opioid antagonists versus conventional interventions for OBD. SEARCH STRATEGY We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE in January 2007. Additional reports were identified from the reference lists of retrieved papers. SELECTION CRITERIA Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD. DATA COLLECTION AND ANALYSIS Data were extracted by two independent review authors and included demographic variables, diagnoses, interventions, efficacy, and adverse events. MAIN RESULTS Twenty-three studies met inclusion criteria and provided data on 2871 opioid antagonist-treated patients. The opioid antagonists investigated were alvimopan (nine studies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan were better than placebo in reversing opioid-induced increased gastrointestinal transit time and constipation, and that alvimopan appears to be safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate. AUTHORS' CONCLUSIONS Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.
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Affiliation(s)
- E D McNicol
- New England Medical Center, Pharmacy and Anesthesia, Box #420, 750 Washington Street, Boston, MA 02111, USA.
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128
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The involvement of the μ-opioid receptor in gastrointestinal pathophysiology: Therapeutic opportunities for antagonism at this receptor. Pharmacol Ther 2008; 117:162-87. [DOI: 10.1016/j.pharmthera.2007.09.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 09/25/2007] [Indexed: 12/26/2022]
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Abstract
Opioid-induced bowel dysfunction is a distressing condition that may persist indefinitely in the clinical setting. As we understand more about normal gastrointestinal (GI) physiology, we are also beginning to understand more fully how opioids cause bowel dysfunction. Current therapeutic interventions for opioid-induced bowel dysfunction can be burdensome and sometimes lack efficacy. Systemic opioid antagonists administered orally can induce laxation, but can unpredictably induce systemic or local GI tract withdrawal symptoms. Two new investigational agents, alvimopan and methylnaltrexone, are peripherally acting opioid antagonists that do not cross the blood-brain barrier. Studies to date show promise that these agents may relieve opioid-induced bowel dysfunction in a well-tolerated manner without reversing central analgesia.
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Affiliation(s)
- Jay Thomas
- San Diego Hospice & Palliative Care, San Diego, California 92103, USA.
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Webster L, Jansen JP, Peppin J, Lasko B, Irving G, Morlion B, Snidow J, Pierce A, Mortensen E, Kleoudis C, Carter E. Alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist for the treatment of opioid-induced bowel dysfunction: results from a randomized, double-blind, placebo-controlled, dose-finding study in subjects taking opioids for chronic non-cancer pain. Pain 2007; 137:428-440. [PMID: 18164818 DOI: 10.1016/j.pain.2007.11.008] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 11/13/2007] [Accepted: 11/14/2007] [Indexed: 12/21/2022]
Abstract
Our objective was to investigate the efficacy and safety of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, in subjects with non-cancer pain and opioid-induced bowel dysfunction (OBD), and to identify at least one treatment regimen that improves OBD. Following a 2-week baseline period, 522 subjects reporting <3 spontaneous bowel movements (SBMs)/week (with >or=25% accompanied by a sensation of incomplete evacuation, straining, or lumpy hard stools), requiring analgesia equivalent to >or=30 mg oral morphine/day were randomized to alvimopan 0.5mg twice daily (BID), 1mg once daily (QD), 1mg BID, or placebo for 6 weeks. Compared with placebo, there was a statistically and clinically significant increase in mean weekly SBM frequency over the initial 3 weeks of treatment (primary endpoint) with alvimopan 0.5mg BID (+1.71 mean SBMs/week), alvimopan 1mg QD (+1.64) and alvimopan 1mg BID (+2.52); P<0.001 for all comparisons. Increased SBM frequency and additional treatment effects, including improvements in symptoms such as straining, stool consistency, incomplete evacuation, abdominal bloating/discomfort, and decreased appetite, were sustained over 6 weeks. The most frequently reported adverse events were abdominal pain, nausea, and diarrhea, occurring more frequently in the higher dosage groups. The alvimopan 0.5mg BID regimen demonstrated the best benefit-to-risk profile for managing OBD with alvimopan in this study population, with a side effect profile similar to that of placebo. There was no evidence of opioid analgesia antagonism. Competitive peripheral antagonism of opioids with alvimopan can restore GI function and relieve OBD without compromising analgesia.
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Affiliation(s)
- Lynn Webster
- Lifetree Clinical Research and Pain Clinic, 3838 South 700 East, Ste. 200, Salt Lake City, UT 84106, USA Schwerpunktpraxis für Schmerztherapie und Ambulante Anästhesie, Berlin, Germany The Pain Treatment Center of the Bluegrass, Lexington, KY, USA Manna Research, Toronto, Ont., Canada Swedish Medical Center, Seattle, WA, USA The Leuven Centre for Algology & Pain Management, University Hospital, Leuven, Belgium GlaxoSmithKline, Research Triangle Park, NC, USA
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131
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Abstract
PURPOSE Characteristics of the ideal drug therapy for postoperative ileus (POI); the pharmacology, efficacy, and safety of currently available nonselective opioid antagonists and the new peripherally selective opioid antagonists methylnaltrexone and alvimopan for the treatment of POI; and formulary considerations associated with the introduction of these new POI drug therapies are discussed. SUMMARY The ideal drug therapy for treating POI would selectively antagonize the inhibitory effects on the gastrointestinal (GI) tract of all of the potential factors implicated in the pathophysiology of POI (neurogenic, inflammatory, hormonal, and pharmacologic mediators). The most promising target to date is inhibition of the adverse GI effects of endogenous and exogenous opioids. Selective inhibition of the mu-opioid receptors in the GI tract, without reversing centrally mediated opioid-induced analgesia, may be beneficial in reducing POI. The nonselective opioid antagonists naloxone and nalmefene have not been studied for POI, and they cross the blood-brain barrier. Therefore, they are not appropriate for preventing or treating POI. The peripherally selective opioid antagonist methylnaltrexone shortens the duration of POI and the hospital length of stay (LOS). Alvimopan, a more extensively studied peripherally selective opioid antagonist, has been shown to reduce the duration of POI, frequency of postoperative nausea and vomiting, and hospital LOS. Both methylnaltrexone and alvimopan also appear effective for treating opioid-induced constipation. Preliminary results of a long-term study of alvimopan safety have revealed some potential concerns, and the significance of the adverse effects must be understood before the most appropriate role of alvimopan in patient care can be determined. Restricting the prescribing of new POI drug therapies to certain types of patients, surgeries, and prescribers; incorporating these therapies into preoperative and postoperative policies, procedures, and protocols; and the potential cost savings from reducing hospital LOS are among the considerations in adding these agents to health-system formularies. CONCLUSION Peripherally selective opioid receptor antagonists are promising new drug therapies that can reduce the clinical and economic burden of POI.
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Gannon RH. Current strategies for preventing or ameliorating postoperative ileus: A multimodal approach. Am J Health Syst Pharm 2007; 64:S8-12. [PMID: 17909275 DOI: 10.2146/ajhp070429] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Internal and external factors that contribute to postoperative ileus (POI), the efficacy and safety of various nonpharmacologic and pharmacologic interventions that have been evaluated for the prevention or amelioration of POI, and the current multimodal approach used in patients undergoing major abdominal surgery are described. SUMMARY Catecholamine and cytokine release associated with the stress response to surgery and the use of certain antiemetic medications, opioid analgesics, and inhaled anesthetics are among the factors that contribute to POI. Early ambulation does not affect the duration of POI, although it has other benefits for patients undergoing abdominal surgery. Clinical experience supports the use of laparoscopy instead of laparotomy if possible, removal of nasogastric tubes shortly after surgery, restriction of intravenous fluids, and initiation of clear oral liquids and ambulation on the first postoperative day. The recommended therapeutic approach for patients undergoing major abdominal surgery involves thoracic epidural analgesia using a local anesthetic with or without an epidural opioid analgesic, and systemic nonsteroidal anti-inflammatory drugs for their opioid-sparing effect if systemic opioid analgesics are used. Buprenorphine may be preferred if a systemic opioid analgesic is used, because it has little effect on gastrointestinal smooth muscle. Metoclopramide, erythromycin, beta blockers, laxatives, neostigmine, naloxone, and gum chewing are not useful for treating POI. CONCLUSION Most pharmacologic interventions that have been tried in an effort to prevent or ameliorate POI are ineffective or cause intolerable adverse effects. Research is needed to identify and develop new drug therapies for POI.
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133
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Santucci G, Mack JW. Common gastrointestinal symptoms in pediatric palliative care: nausea, vomiting, constipation, anorexia, cachexia. Pediatr Clin North Am 2007; 54:673-89, x. [PMID: 17933617 DOI: 10.1016/j.pcl.2007.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Gastrointestinal symptoms are suffered commonly by children at the end of life. Diagnosis and management of these common symptoms include careful history and physical examination to assess for possible causes; treatment - pharmacologic and nonpharmacologic; and a discussion with patients and families of care goals. Aggressive management of these symptoms is essential to improving the quality of life for these children.
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Affiliation(s)
- Gina Santucci
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, 4th floor Wood Building, Philadelphia, PA 19104, USA
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Shaiova L, Rim F, Friedman D, Jahdi M. A review of methylnaltrexone, a peripheral opioid receptor antagonist, and its role in opioid-induced constipation. Palliat Support Care 2007; 5:161-6. [PMID: 17578067 DOI: 10.1017/s147895150707023x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Opioid medications are frequently used in pain and palliative care patients with malignancy to manage symptoms such as pain and dyspnea. However, opiates are associated with various side effects. Constipation is a particularly problematic and common side effect of opioid pharmacology. Opioid antagonists have been studied in the management of opioid-induced constipation. Methylnaltrexone (MNTX) is a peripheral opioid antagonist currently under clinical investigation. It offers the potential to reverse undesirable side effects without reversing analgesia. METHODS This article attempts to review existing clinical data, focusing on antagonism of opioid-induced adverse effects on the gastrointestinal system. RESULTS MNTX seems to be well tolerated with limited or transient side effects. MNTX has been shown to improve oral-cecal transit times in opioid treated patients, induce laxation in chronic opioid users, and neither reverses the analgesic effects of morphine nor cause withdrawal symptoms. SIGNIFICANCE OF RESULTS Larger clinical trials of MNTX are still necessary to support its use as a standard for treatment of opioid-induced constipation.
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Affiliation(s)
- Lauren Shaiova
- Department of Neurology, Pain and Palliative Care, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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135
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Abstract
BACKGROUND Pain, not responsive to opioid analgesics, remains a problem for patients with chronic and cancer pain as well as their families, and clinicians. Opioid antagonists have various uses in pain and palliative care. Their use in the reversal of tolerance and hyperalgesia remains at the basic science level and has limited clinical exposure. OBJECTIVE To improve symptom control and quality of life in patients with pain not responsive to opioid analgesics. DESIGN Present three cases in which patients have undergone administration of opioid antagonists for the purpose of analgesia. METHODS Patients on opioids analgesics received parenteral opioid antagonist, naloxone. Complete withdrawal under a sedative or conscious sedation was allowed and then the opioid at smaller doses was restarted and analgesia was observed. RESULTS All patients had improved analgesia on a significantly lower dose of opioid analgesics. CONCLUSIONS Only three patients who have received this procedure were presented yet all have responded positively to this procedure. Further research is needed to elucidate the mechanism and clinical relevance in the acute use of opioid antagonists.
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Affiliation(s)
- Jane E Loitman
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri 63110, USA.
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136
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Miles CL, Fellowes D, Goodman ML, Wilkinson S. Laxatives for the management of constipation in palliative care patients. Cochrane Database Syst Rev 2006:CD003448. [PMID: 17054172 DOI: 10.1002/14651858.cd003448.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Constipation is a common problem for palliative care patients which can generate considerable suffering for patients due to both the unpleasant physical symptoms and psychological preoccupations that can arise. There is uncertainty about the 'best' management of constipation in palliative care patients and variation in practice between palliative care settings. OBJECTIVES To determine the effectiveness of laxative administration for the management of constipation in palliative care patients, and the differential efficacy of the laxatives used to manage constipation. SEARCH STRATEGY We searched The Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue four, 2005), MEDLINE (1966 to January 2005), EMBASE (1980 to January 2005), CANCERLIT, PUBMED, Science Citation Index, CINAHL, The Cochrane Library, SIGLE, NTIS, DHSS-DATA, Dissertation Abstracts, Index to Scientific and Technical Proceedings and NHS-NRR and reference lists of articles. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing laxatives for constipation in palliative care patients. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted patient-reported data measuring changes in stool frequency and ease of passing stools, using objective and validated scales. Tolerance or adverse effects of laxatives used were also sought. The appropriateness of synthesizing data from the controlled trials depended upon the clinical and statistical homogeneity of studies identified. If the controlled trials were homogeneous, a meta-analysis would be attempted. MAIN RESULTS Four trials involving 280 people were included. Between these trials, the laxatives lactulose; senna; danthron combined with poloxamer (Co-danthramer); Misrakasneham; magnesium hydroxide combined with liquid paraffin (Milpar) were evaluated. All four trials included number and frequency of bowel movements and relative ease of defecation as part of the assessment of laxative efficacy. All of the laxatives demonstrated a limited level of efficacy, although a significant number of participants required rescue laxatives in each of the studies. The only significantly different treatments were in the trial where lactulose plus senna were more effective than danthron combined with poloxamer. Patient preference did not favour either treatment option. Other related systematic reviews have similarly identified that there is a lack of evidence to support the use of one laxative, or combination of laxatives, over another. AUTHORS' CONCLUSIONS The treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient RCT data. Recommendations for laxative use can be related to costs as much as to efficacy. There have been few comparative studies, equally there have been few direct comparisons between different classes of laxative and between different combinations of laxatives. There persists an uncertainty about the 'best' management of constipation in this group of patients.
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Affiliation(s)
- C L Miles
- Royal Free & University College Medical School, Marie Curie Palliative Care R&D unit, Department of Mental Health Services, Hampstead Campus, Rowland Hill Street, London, UK.
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Tofil NM, Benner KW, Faro SJ, Winkler MK. The use of enteral naloxone to treat opioid-induced constipation in a pediatric intensive care unit. Pediatr Crit Care Med 2006; 7:252-4. [PMID: 16575353 DOI: 10.1097/01.pcc.0000216421.72002.09] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the effects of enteral naloxone used to treat opioid-induced constipation in pediatric intensive care patients. DESIGN Retrospective chart review. SETTING Pediatric intensive care unit. PATIENTS Twenty-three patients who received opioid therapy and enteral naloxone in our institution from January 2003 to February 2004 were compared with a randomly sampled control group matched for age, weight, sex, and length of stay who received opioids but had not received enteral naloxone. INTERVENTIONS None. MEASUREMENTS Daily stool output, daily opiate usage, nutrition, adjuvant laxative use, and side effects were assessed. RESULTS Patients stayed an average of 5 days (range, 0-13 days) in the pediatric intensive care unit before enteral administration of naloxone was instituted and received it for an average of 9 consecutive days (range, 3-30 days). Mean stool output for study patients before administration of enteral naloxone was 0.14 +/- 0.38 stools per day, whereas after its initiation it was 1.60 +/- 1.14 stools per day (p < .001). However, two patients developed significant opiate withdrawal symptoms after receiving enteral naloxone. The average stool output for control patients was 0.53 +/- 1.21 stools per day. CONCLUSIONS Enteral naloxone may be effective in increasing stool output in opioid-induced constipation but carries the risk of introducing withdrawal symptoms. Further studies are needed to evaluate this agent for opioid-induced constipation in the intensive care unit.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
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138
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139
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Sinatra RS. Peripherally Acting Mu-Opioid-Receptor Antagonists and the Connection Between Postoperative Ileus and Pain Management: The Anesthesiologist’s View and Beyond. J Perianesth Nurs 2006; 21:S16-23. [PMID: 16597531 DOI: 10.1016/j.jopan.2006.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The adverse effects of opioids are well documented. Because opioid receptors have a wide-ranging anatomic distribution, the effects subsequent to opioid binding, both good and bad, occur centrally and in the periphery. Postoperative strategies to reduce opioid burden, therefore, are in the patient's best interest. Multimodal analgesia is the key towards balancing the need for opioids while simultaneously reducing their burden. Alternative anesthesia and analgesia options such as regional anesthesia, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 enzyme inhibitors should be considered part of multimodal protocols. Familiarity of where these drugs are active in the body and how they can be employed is imperative for all surgical team members. Optimal implementation of multimodal approaches can reduce hospital stay and improve clinical outcomes, including patient satisfaction. Finally, strategies that may help reduce rates of hospital readmission also contribute to overall improved outcome. New peripherally acting mu-opioid-receptor antagonists represent significant progress in the ability of perianesthesia nurses to play an even greater role in achieving these goals. In contrast to older opioid-receptor antagonists, these agents specifically target an important aspect of the multifactorial etiology of postoperative ileus (POI), mu-opioid-receptor-mediated activity in the GI tract. In addition, they do not pass the blood-brain barrier or diminish opioid-mediated analgesia. Advanced clinical trials have already demonstrated the ability of one of these agents, alvimopan, to reduce POI and improve other postoperative outcomes while maintaining adequate analgesia. Combined with other options aimed at reducing opioid burden, alvimopan and similar drugs in development hold promise as part of multimodal protocols to optimize pain management while minimizing postoperative morbidities.
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Affiliation(s)
- Raymond S Sinatra
- Acute Pain and Analgesic Research Center, Department of Anesthsiology, Yale University School of Medicine, New Haven, CT, USA.
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140
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Abell TL, Bernstein RK, Cutts T, Farrugia G, Forster J, Hasler WL, McCallum RW, Olden KW, Parkman HP, Parrish CR, Pasricha PJ, Prather CM, Soffer EE, Twillman R, Vinik AI. Treatment of gastroparesis: a multidisciplinary clinical review. Neurogastroenterol Motil 2006; 18:263-83. [PMID: 16553582 DOI: 10.1111/j.1365-2982.2006.00760.x] [Citation(s) in RCA: 261] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This clinical review on the treatment of patients with gastroparesis is a consensus document developed by the American Motility Society Task Force on Gastroparesis. It is a multidisciplinary effort with input from gastroenterologists and other specialists who are involved in the care of patients with gastroparesis. To provide practical guidelines for treatment, this document covers results of published research studies in the literature and areas developed by consensus agreement where clinical research trials remain lacking in the field of gastroparesis.
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Affiliation(s)
- T L Abell
- University of Mississippi Medical Center, Jackson, USA
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141
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Saclarides TJ. Current Choices—Good or Bad—for the Proactive Management of Postoperative Ileus: A Surgeon’s View. J Perianesth Nurs 2006; 21:S7-15. [PMID: 16597534 DOI: 10.1016/j.jopan.2006.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Postoperative ileus (POI) is frequently experienced by many patients undergoing abdominal operations and other surgical procedures. Postoperative ileus causes physical discomfort and may increase risk for prolonged hospital length of stay. Despite its prevalence, there is currently no accepted standard definition of POI and, consequently, no standardized mode of prevention or treatment; it is no wonder that a variety of management approaches for POI have been developed. Some of these include alternative surgical techniques such as laparoscopic or endoscopic procedures to minimize trauma and help lessen the release of endogenous mediators of POI. Others have evaluated alternate analgesic regimens such as thoracic epidural anesthetics to avoid stimulating opioid receptors in the gut. These approaches have had varying results. Other pharmacologic attempts to reduce POI have focused on the blockade of opioid receptors to prevent opioid-induced GI-related adverse effects. A new class of agents, peripherally acting mu-opioid-receptor antagonists such as methylnaltrexone and alvimopan, may improve the pharmacologic management of POI and reshape the current paradigm of multimodal management of POI. Protocols that incorporate these agents may offer yet another avenue to mitigate the adverse effects of POI, and thus help improve surgical outcomes. To date, alvimopan has been shown in phase 3 clinical trials to significantly reduce the duration of POI while maintaining satisfactory analgesia and reducing length of hospital stay. Combinations of strategies with demonstrated effectiveness such as early feeding, epidural analgesia, laparoscopic surgery, and peripherally acting mu-opioid-receptor antagonists may help transform the management of POI into an effective multimodal paradigm that targets the diverse etiologic factors leading to this common clinical problem. Clearly, all surgical team members are crucial in the optimal implementation of such multimodal approaches.
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Affiliation(s)
- Theodore J Saclarides
- Rush Medical College, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, IL 60612, USA.
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142
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Dahlin C, Lynch M, Szmuilowicz E, Jackson V. Management of Symptoms Other than Pain. ACTA ACUST UNITED AC 2006; 24:39-60, viii. [PMID: 16487895 DOI: 10.1016/j.atc.2005.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Symptom management requires an understanding of the likely cause of the symptom in the individual patient, comprehensive assessment, and evidence-based interventions. This article explores the management strategies for common symptoms encountered in palliative care practice. Stomatitis, xerostomia, dysphagia, nausea and vomiting, anorexia, constipation, dyspnea, and fatigue are among the symptoms reviewed.
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Affiliation(s)
- Constance Dahlin
- Palliative Care Service, Founders 604, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114-2696, USA.
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143
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Use of Naloxone for Relief of Constipation. J Hosp Palliat Nurs 2005. [DOI: 10.1097/00129191-200507000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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144
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Gallantine EL, Meert TF. A Comparison of the Antinociceptive and Adverse Effects of the mu-Opioid Agonist Morphine and the delta-Opioid Agonist SNC80. Basic Clin Pharmacol Toxicol 2005; 97:39-51. [PMID: 15943758 DOI: 10.1111/j.1742-7843.2005.pto_97107.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
delta-Opioid receptor agonists have been postulated to induce analgesia without the adverse effects commonly associated with mu-opioids e.g. morphine. In the present study, we evaluated the occurrence of antinociceptive and opioid-like side effects in rats (n=5-7) treated with a single dose of subcutaneous morphine (0.01 to 40 mg/kg) or SNC80 (0.63 to 80 mg/kg). The antinociceptive effects of morphine and SNC80 were compared using a range of nociceptive tests including the tail withdrawal test, the acetic acid-induced abdominal constriction (writhing) assay, the automated formalin test and a model of inflammation-induced thermal hyperalgesia. The adverse effects of both drugs were examined in animal models for gastrointestinal (GI) inhibition (charcoal test; ricinus oil test), respiratory depression (blood-gas analysis), motor disturbances (automated rotarod model) and abuse liability (drug discrimination learning). Morphine displayed significant antinociceptive and adverse effects in all the animal models employed. SNC80 exhibited a significant effect in the writhing test and limited efficacy in a model of inflammation-induced thermal hypersensitivity. A delay in the occurrence of diarrhoea and some limited increases in PCO(2) were observed with the higher doses of SNC80 (> or =40 mg/kg). In conclusion, the delta-opioid agonist SNC80 lacks both the analgesic efficacy and adverse effects of mu-opioids. However, the activity of SNC80 in the inflammatory model suggests delta-opioid agonists may be useful analgesics in the treatment of some forms of inflammatory pain.
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Affiliation(s)
- Elizabeth L Gallantine
- CNS Discovery Research, Johnson and Johnson Pharmaceutical Research and Development, Turnhoutseweg 30, B-2340 Beerse, Belgium.
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145
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Abstract
In cancer pain therapy treatment with strong opioids is essential. However, it may be accompanied by the occurrence of various adverse effects. The most frequent and persistent side effect in the course of opioid treatment is constipation. It is mainly caused by linkage of the opioid to the peripheral mu-receptors in the bowel and may increase as a result of certain concomitant circumstances, such as poor intake of fluids or electrolyte disorder. Present research indicates that there is a relation between type of opioid and degree of constipation, i.e. treatment with transdermal fentanyl or methadone tends to cause less constipation compared to morphine or hydromorphone. The route of administration of morphine--oral vs. subcutaneous--does not seem to affect the incidence of opioid-induced constipation. Furthermore, prophylaxis and efficient control of opioid-induced constipation still fail to be part of the routine in pain treatment.
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Affiliation(s)
- A Schwarzer
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn.
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146
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Abstract
Alvimopan is a synthetic peripherally restricted mu-receptor opioid antagonist. Alvimopan has a greater affinity for the mu-receptor than the kappa- or sigma-opioid receptors (Ki = 0.77 nM). The polarity of the molecule limits gastrointestinal absorption and central nervous system penetration. It has limited systemic bioavailability and higher affinity for the mu-opioid receptor than naloxone (Ki = 3.7 nM). Completed Phase III trials suggest efficacy in accelerating the recovery of gastrointestinal function after abdominal surgery. Adverse events with all doses have been similar to placebo groups. Further efficacy in alleviating opioid-induced bowel dysfunction in patients with chronic opioid usage has also been demonstrated. This evidence-based review assesses this new drug and discusses its potential role in clinical practice.
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Affiliation(s)
- Paul Neary
- Department of Colorectal Surgery/A-30, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
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147
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Liu BH, Mo P, Zhang SB. Effects of mu and kappa opioid receptor agonists and antagonists on contraction of isolated colon strips of rats with cathartic colon. World J Gastroenterol 2004; 10:1672-4. [PMID: 15162549 PMCID: PMC4572778 DOI: 10.3748/wjg.v10.i11.1672] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To study the effects of mu and kappa opioid receptor agonists and antagonists on the isolated colon strips of rats with cathartic colon.
METHODS: Cathartic colon model was established by feeding rats with contact laxatives, and effects of mu and kappa opioid receptor agonists and antagonists on electricity-stimulated contraction of isolated colon strips of rats with cathartic colon were observed.
RESULTS: Compared with control group, exogenous mu and kappa agonists inhibited significantly electricity-stimulated contraction of strips of cathartic colon (8.50 ± 0.89 mm, 6.24 ± 0.91 mm, 3.35 ± 0.6 mm vs 11.40 ± 0.21 mm P < 0.01; 8.98 ± 0.69 mm, 6.89 ± 0.71 mm, 4.43 ± 0.99 mm vs 11.40 ± 0.21 mm, P < 0.01). In contrast, the exogenous mu antagonist significantly enhanced electricity-stimulated contraction of isolated colon strips (13.18 ± 0.93 mm, 15.87 ± 0.98 mm, 19.46 ± 1.79 mm vs 11.40 ± 0.21 mm, P < 0.01), but kappa antagonist had no effect on the isolated colon strips of rats with cathartic colon.
CONCLUSION: Mu and kappa opioid receptors are involved in the regulation of colon motility of rats with cathartic colon.
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MESH Headings
- Analgesics, Opioid/pharmacology
- Animals
- Cathartics/pharmacology
- Colon/drug effects
- Colon/physiology
- Colonic Diseases, Functional/chemically induced
- Colonic Diseases, Functional/drug therapy
- Colonic Diseases, Functional/physiopathology
- Constipation/drug therapy
- Electric Stimulation
- Enkephalin, Ala(2)-MePhe(4)-Gly(5)-/pharmacology
- Female
- Gastrointestinal Motility/drug effects
- In Vitro Techniques
- Male
- Muscle Contraction/drug effects
- Naloxone/pharmacology
- Narcotic Antagonists/pharmacology
- Rats
- Rats, Wistar
- Receptors, Opioid, kappa/agonists
- Receptors, Opioid, kappa/antagonists & inhibitors
- Receptors, Opioid, kappa/metabolism
- Receptors, Opioid, mu/agonists
- Receptors, Opioid, mu/antagonists & inhibitors
- Receptors, Opioid, mu/metabolism
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Affiliation(s)
- Bao-Hua Liu
- Department of General Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China.
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148
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Ali SZ, Kurz A. Methylnaltrexone and alvimopan: economic management of opioid-induced bowel dysfunction. Expert Rev Pharmacoecon Outcomes Res 2004; 4:153-7. [DOI: 10.1586/14737167.4.2.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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149
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Mixides G, Liebl MG, Bloom K. Enteral Administration of Naloxone for Treatment of Opioid-Associated Intragastric Feeding Intolerance. Pharmacotherapy 2004; 24:291-4. [PMID: 14998227 DOI: 10.1592/phco.24.2.291.33149] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Intragastric enteral feeding intolerance, common in the intensive care setting, is attributed to many causes. Opioid antagonists such as naloxone may have a role in reversing the intolerance when it is associated with intravenous opioid infusions. A 38-year-old woman hospitalized for acute respiratory distress syndrome was supported with low tidal volume mechanical ventilation. She required lorazepam and morphine administered by continuous intravenous infusion to achieve ventilator synchrony and pain control. While receiving these therapies, the patient developed persistent intolerance to intragastric feeding. Intravenous metoclopramide and laxatives did not decrease gastric volume residuals, and insertion of a jejunal tube was deemed unsafe due to worsening of her respiratory status. Total parenteral nutrition was begun to meet her caloric needs, but she experienced repeated catheter-related bloodstream infections. Naloxone 2 mg by gastric tube every 8 hours for 8 days was started; the dosage then was increased to 4 mg every 8 hours. Tube feeding was restarted, which provided the patient with more than 90% of her daily caloric needs and allowed for discontinuation of parenteral nutrition. With this dosage of naloxone, tolerance to intragastric feeding was maintained until the patient's death due to refractory respiratory failure. Enterally administered naloxone is an effective, noninvasive means of reversing intolerance to intragastric feeding associated with opioids.
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Affiliation(s)
- George Mixides
- Intensive Care Unit, Brandon General Hospital. Brandon, Manitoba, Canada
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150
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Abstract
This review covers beta-phenylethylamines and isoquinoline alkaloids derived from them, including further products of oxidation. condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2002 to June 2003 is reviewed, with 568 references cited.
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