151
|
Grønlund D, Vase L, Knudsen SA, Christensen M, Drewes AM, Olesen AE. Comparison of subjective and objective measures of constipation – Employing a new method for categorizing gastrointestinal symptoms. J Pharmacol Toxicol Methods 2018; 94:23-28. [DOI: 10.1016/j.vascn.2018.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/10/2018] [Accepted: 08/15/2018] [Indexed: 02/07/2023]
|
152
|
Webster LR, Israel RJ. Oral methylnaltrexone is efficacious and well tolerated for the treatment of opioid-induced constipation in patients with chronic noncancer pain receiving concomitant methadone. J Pain Res 2018; 11:2509-2516. [PMID: 30425563 PMCID: PMC6205130 DOI: 10.2147/jpr.s160625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose To evaluate the safety and efficacy of oral methylnaltrexone for opioid-induced constipation (OIC). Patients and methods This was a post hoc analysis of patients receiving methadone in a randomized, double-blind, placebo-controlled, Phase 3 trial. The trial included adults with chronic noncancer pain for ≥2 months receiving opioid doses ≥50 mg/day of oral morphine equivalents for ≥14 days and with a history of OIC. Patients were assigned to oral methylnaltrexone (150, 300, or 450 mg) or placebo once daily (QD) for 4 weeks followed by 8 weeks as needed. Percentage of dosing days that resulted in a rescue-free bowel movement (RFBM) within 4 hours of dosing was assessed during QD dosing (primary efficacy endpoint). Other endpoints included percentage of responders (ie, ≥3 RFBMs/week, with an increase of ≥1 RFBM/week from baseline for ≥3 of the 4 weeks) during QD dosing and change in weekly number of RFBMs. Adverse events were assessed. Results Concomitant methadone was reported in 120 patients (oral methylnaltrexone: 150 mg [n=33], 300 mg [n=30], and 450 mg [n=31]; placebo [n=26]). Oral methylnaltrexone-treated patients had significant increases in mean percentage of dosing days with RFBMs within 4 hours of dosing during weeks 1–4 with 300 mg (33.6%; P<0.01) and 450 mg (38.2%; P<0.001) vs placebo; improvements with 150 mg (20.0%) vs placebo (15.1%) did not reach statistical significance. The percentage of responders was greater vs placebo, but not significant, for the higher doses during the QD period (150 mg [39.4%], 300 mg [60.0%], 450 mg [67.7%], and placebo [38.5%]). Change from baseline in the mean number of weekly RFBMs (weeks 1–4) was significantly greater with oral methylnaltrexone 450 mg vs placebo (least-squares mean difference vs placebo, 1.2; P=0.04); no significant differences were found for 300 or 150 mg. Oral methylnaltrexone was well tolerated at all doses; few patients discontinued treatment. Conclusion Oral methylnaltrexone, particularly 450 mg, was efficacious and safe for treating OIC in these patients.
Collapse
Affiliation(s)
- Lynn R Webster
- Scientific Affairs, PRA Health Sciences, Salt Lake City, UT, USA
| | - Robert J Israel
- Clinical and Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA,
| |
Collapse
|
153
|
Nee J, Zakari M, Sugarman MA, Whelan J, Hirsch W, Sultan S, Ballou S, Iturrino J, Lembo A. Efficacy of Treatments for Opioid-Induced Constipation: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2018; 16:1569-1584.e2. [PMID: 29374616 DOI: 10.1016/j.cgh.2018.01.021] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Opioid-induced constipation (OIC) is a common problem in patients on chronic opioid therapy for cancer-related and non-cancer-related pain. Approved treatments for OIC are methylnaltrexone, naloxone, naloxegol, alvimopan, naldemedine, and lubiprostone. Since a meta-analysis performed in 2014, 2 new agents have been approved by the Food and Drug Administration for treatment of OIC (naloxegol and naldemedine). METHODS We conducted a search of the medical literature following the protocol outlined in the Cochrane Handbook for systematic review. We searched MEDLINE, EMBASE, EMBASE Classic, Web of Science, and the Cochrane Central Register of Controlled Trials until March 2017 to identify randomized controlled trials of peripheral μ-opioid-receptor antagonists (methylnaltrexone, naloxone, naloxegol, alvimopan, axelopran, or naldemedine), lubiprostone, or prucalopride. Response to therapy was extracted in a dichotomous assessment as an overall response to therapy. The effect of pharmacologic therapies was pooled and reported as a relative risk (RR) of failure to respond to the treatment drug, with 95% CIs. RESULTS We included 27 placebo-controlled trials in our meta-analysis (23 trials evaluated μ-opioid-receptor antagonists, 3 trials evaluated lubiprostone, and 1 trial evaluated prucalopride). In these trials, 5390 patients received a drug and 3491 received a placebo. Overall, μ-opioid-receptor antagonists, lubiprostone, and prucalopride were superior to placebo for the treatment of OIC, with a RR of failure to respond to therapy of 0.70 (95% CI, 0.64-0.75) and an overall number needed to treat of 5 (95% CI, 4-7). When restricted to only Food and Drug Administration-approved medications for OIC, the RR of failure to respond to therapy was 0.69 (95% CI, 0.62-0.77), with a number needed to treat of 5 (95% CI, 4-7). Sensitivity analyses and meta-regression performed to account for heterogeneity showed that treatment was more likely to be effective in study populations taking higher doses of opiates at baseline or refractory to laxatives. Study duration and prespecified primary outcome did not affect the RR of failure. Participants who received μ-opioid-receptor antagonists were significantly more likely to have diarrhea, abdominal pain, nausea, or vomiting than patients who received placebo. CONCLUSIONS In a systematic review and meta-analysis, we found μ-opioid-receptor antagonists to be safe and effective for the treatment of OIC. Prescription-strength laxatives (prucalopride, lubiprostone) are slightly better than placebo in reducing OIC.
Collapse
Affiliation(s)
- Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Mohammed Zakari
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael A Sugarman
- Department of Neuropsychology, Bedford Veterans Administration Medical Center, Bedford, Massachusetts
| | - Julia Whelan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - William Hirsch
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota and the Minneapolis Veterans Affairs Healthcare System, Minnesota, Minnesota
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Johanna Iturrino
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
154
|
Bruin FD, Hek K, Lieshout JV, Verduijn M, Langendijk P, Bouvy M, Teichert M. Laxative co-medication and changes in defecation patterns during opioid use. J Oncol Pharm Pract 2018; 25:1613-1621. [PMID: 30260269 PMCID: PMC6716205 DOI: 10.1177/1078155218801066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Opioid-induced constipation is a clinically relevant side effect and a cause
of potentially avoidable drug-related hospital admissions. Objectives To describe the presence of laxative co-medication, the reasons for not
starting laxatives and to evaluate changes in stool patterns of opioid
initiators. Methods In this observational study community pharmacists evaluated the availability
of laxative co-medication in starting opioid users and registered reasons
for non-use. Two opioid initiators per pharmacy were invited to complete
questionnaires (‘Bristol stool form scale’ and ‘Rome III Diagnostic
Questionnaire for the Adult Functional Gastrointestinal Disorders’) on their
defecation prior to and during opioid use. Descriptive statistics and Chi
square tests were used to analyse reasons for non-use of laxatives and
changes in defecation patterns. Results Eighty-one pharmacists collected data from 460 opioid initiators. Of those,
344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives
was that either prescribers or patients did not consider them necessary.
Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires
completed were not constipated at opioid start. Eleven of them (16%)
developed constipation during opioid use (Chi square p=0.003). At follow-up
within laxative users 10.6% were constipated compared to 20.7% in subjects
without laxatives. Conclusion One in four opioid starters did not dispose of laxative co-medication, mainly
because they were not considered necessary by either the prescriber or the
patient. The prevalence of constipation doubled during opioid use. A
watchful waiting strategy for the use of laxative co-medication might
include a monitoring of defecation patterns with validated
questionnaires.
Collapse
Affiliation(s)
- Frans de Bruin
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Karin Hek
- 2 Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Jan van Lieshout
- 3 Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Monique Verduijn
- 4 Department of Guideline Development and Research, Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Pim Langendijk
- 5 Department of Hospital Pharmacy, Reinier de Graaf Group Hospitals, Delft, The Netherlands
| | - Marcel Bouvy
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Martina Teichert
- 3 Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,6 Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
155
|
Webster LR, Israel RJ. Oral methylnaltrexone does not negatively impact analgesia in patients with opioid-induced constipation and chronic noncancer pain. J Pain Res 2018; 11:1503-1510. [PMID: 30147355 PMCID: PMC6095122 DOI: 10.2147/jpr.s160488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Purpose An oral formulation of methylnaltrexone has been developed for treating opioid-induced constipation (OIC). This manuscript examines the impact of oral methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, on opioid analgesia. Methods This Phase III, randomized, double-blind, placebo-controlled trial, evaluated changes in pain intensity scores (0= no pain to 10= worst possible pain) and opioid use in adults with chronic noncancer pain. Patients taking ≥50 mg/day oral morphine equivalent dose (MED) for ≥14 days before screening with less than three rescue-free bowel movements/week received oral methylnaltrexone 150 mg/day (n=201), 300 mg/day (n=201), 450 mg/day (n=200), or placebo (n=201) once daily for 4 weeks followed by 8 weeks of oral methylnaltrexone as needed. Results The primary condition requiring opioid use was back pain (68.2% of 803 patients). Baseline pain intensity scores were similar among treatment groups (mean range, 6.2–6.4) and remained stable throughout the 4-week double-blind (mean range, 6.1–6.5) and 8-week as needed (mean range, 6.3–6.5) periods. Baseline mean MED was comparable between oral methylnaltrexone 150 mg (200.0 mg/day), methylnaltrexone 450 mg (218.0 mg/day), and placebo (209.7 mg/day), but was slightly higher in the oral methylnaltrexone 300-mg group (252.6 mg/day). Nonsignificant, minimal changes in mean MED were observed after 4 weeks of treatment (214.5–235.6 mg/day) and at the end of the as needed phase (202.3–234.9 mg/day). The percentage of patients who initiated new opioid medications during the 4-week, once-daily dosing period was generally similar among the oral methylnaltrexone 150-mg, 300-mg, and 450-mg groups (44.8%, 43.3%, and 35.0%, respectively), the oral methylnaltrexone combined group (41.0%), and the placebo group (39.8%). The most common newly initiated opioid medications during this once-daily period were oxycodone (oral methylnaltrexone groups combined, 14.6%; placebo, 12.4%) and morphine (oral methylnaltrexone combined, 10.1%; placebo, 7.0%). Conclusion Oral methylnaltrexone does not elicit opioid withdrawal or interfere with opioid analgesia.
Collapse
Affiliation(s)
| | - Robert J Israel
- Clinical and Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA,
| |
Collapse
|
156
|
Gálvez R, Maire C, Tovar I, Vargas P. Naloxegol to Treat Constipation in a Patient Taking Opioids for Cancer Pain: A Case Report. A A Pract 2018; 11:22-24. [PMID: 29634552 DOI: 10.1213/xaa.0000000000000726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Opioid-induced constipation (OIC) is a common gastrointestinal adverse effect of opioids, which can severely affect compliance and adherence to pain medication regimens and quality of life. Naloxegol has demonstrated efficacy against OIC in several studies involving patients with nonmalignant chronic pain. Here we report efficacy and tolerability of naloxegol in a 68-year-old patient with metastatic lung cancer and severe pain, treated with opioids, who presented with OIC resistant to traditional measures. Addition of naloxegol produced rapid improvement in his OIC symptoms and no apparent adverse effects while taking extended-release morphine 130 mg orally every 12 hours.
Collapse
Affiliation(s)
| | | | - Isabel Tovar
- Radiotherapy Service, Hospital Virgen de las Nieves, Granada, Spain
| | - Pilar Vargas
- Radiotherapy Service, Hospital Virgen de las Nieves, Granada, Spain
| |
Collapse
|
157
|
Emmanuel A, Johnson M, McSkimming P, Dickerson S. Laxatives Do Not Improve Symptoms of Opioid-Induced Constipation: Results of a Patient Survey. PAIN MEDICINE 2018; 18:1932-1940. [PMID: 28339544 PMCID: PMC5914325 DOI: 10.1093/pm/pnw240] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction Laxatives are commonly used to treat opioid-induced constipation, the commonest and most bothersome complication of opioids. However, laxatives have a nonspecific action and do not target underlying mechanisms of opioid-induced constipation; their use is associated with abdominal symptoms that negatively impact quality of life. Objective To assess the effects of laxatives in patients taking opioids for chronic pain. Methods One hundred ninety-eight UK patients who had taken opioid analgesics for at least one month completed a cross-sectional online or telephone survey. Questions addressed their pain condition, medication, and laxative use (including efficacy and side effects). The survey also assessed bowel function using the Bowel Function Index. Results Since starting their current opioid, 134 of 184 patients (73%) had used laxatives at some point and 122 (91%) of these were currently taking them. The most common laxatives were osmotics and stimulants. Laxative side effects were reported in 75%, most commonly gas, bloating/fullness, and a sudden urge to defecate. Side effects were more common in patients less than 40 years of age. Approximately half of patients said laxatives interfered with work and social activities, and one-fifth needed an overnight hospital stay because of their pain condition and/or constipation. Laxatives did not improve the symptoms of constipation, as assessed by the Bowel Function Index. Constipation was not related to opioid strength, dose of opioid, or number of laxatives taken. Conclusions Use of laxatives to treat opioid-induced constipation is often ineffective and associated with side effects. Instead of relieving the burden of opioid-induced constipation, laxative use is associated with a negative impact.
Collapse
Affiliation(s)
- Anton Emmanuel
- Department of Gastroenterology, University College Hospital, London, UK
| | - Martin Johnson
- Chronic Pain Policy Coalition (CPPC) Policy Connect, CAN Mezzanine, 32-36 Loman Street, London
| | - Paula McSkimming
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, UK
| | | |
Collapse
|
158
|
Katakami N, Harada T, Murata T, Shinozaki K, Tsutsumi M, Yokota T, Arai M, Tada Y, Narabayashi M, Boku N. Randomized phase III and extension studies: efficacy and impacts on quality of life of naldemedine in subjects with opioid-induced constipation and cancer. Ann Oncol 2018; 29:1461-1467. [PMID: 32151367 PMCID: PMC6005145 DOI: 10.1093/annonc/mdy118] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The efficacy and safety of naldemedine (a peripherally acting µ-opioid receptor antagonist) for opioid-induced constipation (OIC) in subjects with cancer was demonstrated in the primary report of a phase III, double-blind study (COMPOSE-4) and its open-label extension (COMPOSE-5). The primary end point, the proportion of spontaneous bowel movement (SBM) responders, was met. Here, we report results from secondary end points, including quality of life (QOL) assessments from these studies. PATIENTS AND METHODS In COMPOSE-4, eligible adults with OIC and cancer were randomly assigned 1:1 to receive once-daily oral naldemedine 0.2 mg (n = 97) or placebo (n = 96) for 2 weeks, and those who continued on to COMPOSE-5 received naldemedine for 12 weeks (n = 131). Secondary assessments in COMPOSE-4 included the proportion of complete SBM (CSBM) responders, SBM or CSBM responders by week, and subjects with ≥1 SBM or CSBM within 24 h postinitial dose. Changes from baseline in the frequency of SBMs or CSBMs per week were assessed at weeks 1 and 2. Time to the first SBM or CSBM postinitial dose was also evaluated. In both studies, QOL impact was evaluated by Patient Assessment of Constipation-Symptoms (PAC-SYM) and PAC-QOL questionnaires. RESULTS Naldemedine improved bowel function for all secondary efficacy assessments versus placebo (all P ≤ 0.0002). The timely onset of naldemedine activity versus placebo was evidenced by median time to the first SBM (4.7 h versus 26.6 h) and CSBM (24.0 h versus 218.5 h) postinitial dose (all P < 0.0001). In COMPOSE-4, significant differences between groups were observed with the PAC-SYM stool domain (P = 0.045) and PAC-QOL dissatisfaction domain (P = 0.015). In COMPOSE-5, significant improvements from baseline were observed for overall and individual domain scores of PAC-SYM and PAC-QOL. CONCLUSIONS Naldemedine provided effective and timely symptomatic relief from OIC and improved the QOL of subjects with OIC and cancer. TRIAL REGISTRATION ID: www.ClinicalTrials.jp: JAPIC-CTI-132340 (COMPOSE-4) and JAPIC-CTI-132342 (COMPOSE-5).
Collapse
Affiliation(s)
- N Katakami
- Kobe City Medical Center General Hospital, Kobe, Japan.
| | - T Harada
- Center for Respiratory Diseases, JCHO Hokkaido Hospital, Sapporo, Japan
| | - T Murata
- Department of Breast Oncology, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - K Shinozaki
- Department of Clinical Oncology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - M Tsutsumi
- Department of Urology, Hitachi General Hospital, Hitachi, Japan
| | - T Yokota
- Global Development, Shionogi & Co., Ltd, Osaka, Japan
| | - M Arai
- Global Development, Shionogi & Co., Ltd, Osaka, Japan
| | - Y Tada
- Global Development, Shionogi & Co., Ltd, Osaka, Japan
| | - M Narabayashi
- Department of Palliative Therapy, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - N Boku
- Division of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
159
|
Wittbrodt ET, Gan TJ, Datto C, McLeskey C, Sinha M. Resource use and costs associated with opioid-induced constipation following total hip or total knee replacement surgery. J Pain Res 2018; 11:1017-1025. [PMID: 29881304 PMCID: PMC5978464 DOI: 10.2147/jpr.s160045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose Constipation is a well-known complication of surgery that can be exacerbated by opioid analgesics. This study evaluated resource utilization and costs associated with opioid-induced constipation (OIC). Patients and methods This retrospective, observational, and propensity-matched cohort study utilized the Premier Healthcare Database. The study included adults ≥18 years of age undergoing total hip or total knee replacement as inpatients who received an opioid analgesic and were discharged between January 1, 2012, and June 30, 2015. Diagnosis codes identified patients with OIC who were then matched 1:1 to patients without OIC. Generalized linear and logistic regression models were used to compare inpatient resource utilization, total hospital costs, inpatient mortality, and 30-day all-cause readmissions and emergency department visits. Results Of 788,448 eligible patients, 40,891 (5.2%) had OIC. Covariates were well balanced between matched patients with and without OIC (n=40,890 each). In adjusted analyses, patients with OIC had longer hospital lengths of stay (3.6 versus 3.3 days; p<0.001), higher total hospital costs (US$17,479 versus US$16,265; p<0.001), greater risk of intensive care unit admission (odds ratio [OR]=1.12, 95% CI: 1.01-1.24), and increased likelihood of 30-day hospital read-missions (OR=1.16, 95% CI: 1.11-1.22) and emergency department visits (OR=1.38, 95% CI: 1.07-1.79) than patients without OIC. No statistically significant difference was found with inpatient mortality (OR=0.89, 95% CI: 0.59-1.35). Conclusion OIC was associated with greater resource utilization and hospital costs for patients undergoing primarily elective total hip or total knee replacement surgery. These results support OIC screening and management strategies as part of perioperative care management.
Collapse
Affiliation(s)
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY, USA
| | | | | | - Meenal Sinha
- Premier Applied Sciences, Premier, Inc., Charlotte, NC, USA
| |
Collapse
|
160
|
Webster LR, Michna E, Khan A, Israel RJ, Harper JR. Long-Term Safety and Efficacy of Subcutaneous Methylnaltrexone in Patients with Opioid-Induced Constipation and Chronic Noncancer Pain: A Phase 3, Open-Label Trial. PAIN MEDICINE 2018; 18:1496-1504. [PMID: 28810695 PMCID: PMC5914419 DOI: 10.1093/pm/pnx148] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, alleviates opioid-induced constipation. Understanding its long-term safety and efficacy profile in patients with chronic noncancer pain is warranted given the persistence of opioid-induced constipation. Methods. In this phase 3, multicenter, open-label trial, adults with chronic noncancer pain (N = 1034) received subcutaneous methylnaltrexone 12 mg once daily for 48 weeks. Results. The most common adverse events were gastrointestinal related (e.g., abdominal pain, diarrhea, nausea) and were mild to moderate in intensity. Only 15.2% of patients discontinued because of an adverse event. Serious cardiac-related adverse events occurred in nine patients. Of the seven instances of major adverse coronary events reported, three were adjudicated after external review; all instances occurred in patients with cardiovascular risk factors. Methylnaltrexone elicited a bowel movement within four hours in 34.1% of the injections throughout the 48-week treatment period. Conclusions. Change from baseline in mean weekly bowel movement rate, Bowel Movement Straining Scale score, Bristol Stool Scale score, and mean percentage of patients with complete evacuation from baseline to week 48 were significantly improved (P < 0.001 for all). Long-term subcutaneous methylnaltrexone was well tolerated, with no new safety concerns, and provided consistent opioid-induced constipation relief in patients with chronic noncancer pain.
Collapse
Affiliation(s)
| | - Edward Michna
- Pain Trials Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arif Khan
- Northwest Clinical Research Center, Bellevue, Washington.,Duke University Medical Center, Durham, North Carolina
| | | | | |
Collapse
|
161
|
The perceptions and experiences of osteopathic treatment among cancer patients in palliative care: a qualitative study. Support Care Cancer 2018; 26:3627-3633. [PMID: 29728845 DOI: 10.1007/s00520-018-4233-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 04/26/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE This research aimed to explore the perceptions and experiences of cancer patients receiving osteopathic treatment as a complementary therapy when it is used in addition to conventional treatment for cancer pain. METHODS This qualitative study employed semi structured interviews of cancer patients in a palliative care unit in Lyon, France, who received treatment from an osteopath alongside their conventional cancer treatment. We analysed data using grounded theory and qualitative methods. RESULTS We interviewed 16 patients. The themes identified through the analysis included a low awareness of osteopathy among the population and an accompanying high level of misconceptions. The benefits of osteopathy were described as more than just the manual treatments with participants valuing osteopathy as a holistic, meditative, and non-pharmaceutical approach. Participants also described the osteopathic treatments as assisting with a range of cancer-related health complaints such as pain, fatigue, and sleep problems. Offering osteopathic treatment at an accessible location at low or no cost were identified by participants as enablers to the continued use of osteopathy. CONCLUSIONS The findings of this study provides preliminary data which suggests, when delivered alongside existing medical care, osteopathy may have health benefits for patients with complex conditions such as cancer.
Collapse
|
162
|
Ortiz V, García-Campos M, Sáez-González E, delPozo P, Garrigues V. A concise review of opioid-induced esophageal dysfunction: is this a new clinical entity? Dis Esophagus 2018. [PMID: 29529126 DOI: 10.1093/dote/doy003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Opioids have become the most widely prescribed analgesics in Western countries. Opioid-induced bowel dysfunction is a widely known adverse effect, with constipation the most common manifestation. Most of the opioid-related effects occur in the stomach, small intestine, and colon and have been widely studied. However, the effects related to esophageal motility are less known. Recently published retrospective studies have suggested that long-term use of opioids can cause esophageal motility dysfunction, reflecting symptoms similar to motility disorders, such as achalasia and functional esophagogastric junction outflow obstruction. The most common manometric findings, as reported in the literature, for patients with opioid-induced dysphagia undergoing long-term therapy with these drugs are impaired lower esophageal sphincter relaxation, high amplitude/velocity, and simultaneous esophageal waves, higher integrated relaxation pressure, lower distal latency, and the esophageal contractility can be normal, hypercontractile, or premature. Based on these studies, a new clinical entity known as opioid-induced esophageal dysfunction has been postulated. For these patients, the diagnostic method of choice is high-resolution manometry, although other causes should be ruled out through endoscopy or Computed Tomography (CT). The best therapeutic option for these patients is withdrawal of the opioid; however, this is not always possible, and other options need to be investigated, such as pneumatic dilation and botulinum toxin injection, considering the risks versus the benefits.
Collapse
Affiliation(s)
- V Ortiz
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe.,Medical Research Institute La Fe (IIS La Fe), Valencia, Spain
| | - M García-Campos
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe
| | - E Sáez-González
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe.,Medical Research Institute La Fe (IIS La Fe), Valencia, Spain
| | - P delPozo
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe
| | - V Garrigues
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe.,Department of Medicine, Universitat de Valencia.,Medical Research Institute La Fe (IIS La Fe), Valencia, Spain
| |
Collapse
|
163
|
Webster LR, Nalamachu S, Morlion B, Reddy J, Baba Y, Yamada T, Arjona Ferreira JC. Long-term use of naldemedine in the treatment of opioid-induced constipation in patients with chronic noncancer pain: a randomized, double-blind, placebo-controlled phase 3 study. Pain 2018; 159:987-994. [PMID: 29419653 PMCID: PMC5916485 DOI: 10.1097/j.pain.0000000000001174] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/09/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
The long-term safety of naldemedine, a peripherally acting µ-opioid receptor antagonist, was evaluated in patients with opioid-induced constipation and chronic noncancer pain in a 52-week, randomized, double-blind, phase 3 study. Eligible adults who could be on a routine laxative regimen were randomized 1:1 to receive once-daily oral naldemedine 0.2 mg (n = 623) or placebo (n = 623). The primary endpoint was summary measures of treatment-emergent adverse events (AEs). Additional endpoints included opioid withdrawal on the Clinical Opiate Withdrawal Scale and the Subjective Opiate Withdrawal Scale, pain intensity on Numeric Rating Scale, frequency of bowel movements, and constipation-related symptoms and quality of life on the Patient Assessment of Constipation Symptoms and Patient Assessment of Constipation Quality of Life scales, respectively. Treatment-emergent AEs (naldemedine, 68.4% vs placebo, 72.1%; difference: -3.6% [95% confidence interval: -8.7 to 1.5]) and treatment-emergent AEs leading to study discontinuation (6.3% vs 5.8%; difference: 0.5% [-2.2 to 3.1)] were reported for similar proportions of patients. Diarrhea was reported more frequently with naldemedine (11.0%) vs placebo (5.3%; difference: 5.6% [2.6-8.6]). There were no meaningful differences between groups in opioid withdrawal or pain intensity. Sustained significant improvements in bowel movement frequency and overall constipation-related symptoms and quality of life were observed with naldemedine (P ≤ 0.0001 vs placebo at all time points). Naldemedine was generally well tolerated for 52 weeks and did not interfere with opioid-mediated analgesia or precipitate opioid withdrawal. Naldemedine significantly increased bowel movement frequency, improved symptomatic burden of opioid-induced constipation, and increased patients' quality of life vs placebo.
Collapse
Affiliation(s)
- Lynn R. Webster
- Scientific Affairs -- Neuroschences PRA Health Sciences, PRA Health Sciences, Salt Lake City, UT, USA
| | | | - Bart Morlion
- Department of Cardiovascular Sciences, Unit Anesthesiology and Algology, University of Leuven, Leuven Center for Algology and Pain Management, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium
| | | | | | | | | |
Collapse
|
164
|
Abstract
BACKGROUND Gastroparesis is characterized by abnormal gastric motility and delayed emptying with symptoms of early satiety, postprandial fullness, bloating, nausea, vomiting and abdominal pain. Pharmacological discovery has been lagging because potential drugs often are associated with abnormalities of electrical conduction of the myocardium due to interaction with cardiac ion channels leading to limited pharmaceutical options for development of new drugs. OBJECTIVE Addresses the safety of drugs for gastroparesis in terms of cardiotoxicity related to the clinical use of prokinetics and antiemetics. METHODS Survey of QT drugs List and review of current literature. RESULTS Many prokinetic drugs are associated with cardiac adverse events and manifest as prolongation of ventricular repolarization, i.e., QT-interval prolongation of the electrocardiogram. This disturbance may develop into a potentially fatal polymorphic ventricular tachyarrhythmia; Torsade de Pointes. Co-administration of prokinetics with other drugs affecting the repolarization process, pharmacokinetic interactions leading to increased blood levels, or the presence of clinical risk factors could further increase the risk for cardiac arrhythmias. CONCLUSIONS It is important that clinicians managing gastroparesis are aware of the arrhythmogenic potential of drugs used clinically and risk factors that contribute to QT prolongation to safeguard patients at risk for drug-induced cardiac arrhythmia.
Collapse
Affiliation(s)
- Per M Hellström
- a Department of Medical Sciences, Faculty of Medicine , Uppsala University , Uppsala , Sweden
| | - Ahmad Al-Saffar
- a Department of Medical Sciences, Faculty of Medicine , Uppsala University , Uppsala , Sweden
| |
Collapse
|
165
|
Farmer AD, Holt CB, Downes TJ, Ruggeri E, Del Vecchio S, De Giorgio R. Pathophysiology, diagnosis, and management of opioid-induced constipation. Lancet Gastroenterol Hepatol 2018; 3:203-212. [DOI: 10.1016/s2468-1253(18)30008-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/11/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022]
|
166
|
Bui K, Zhou D, Xu H, Floettmann E, Al-Huniti N. Clinical Pharmacokinetics and Pharmacodynamics of Naloxegol, a Peripherally Acting µ-Opioid Receptor Antagonist. Clin Pharmacokinet 2018; 56:573-582. [PMID: 28035588 DOI: 10.1007/s40262-016-0479-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Naloxegol is a peripherally acting µ-opioid receptor antagonist approved for use as an orally administered tablet (therapeutic doses of 12.5 and 25 mg) for the treatment of opioid-induced constipation. Over a wide dose range (i.e. single supratherapeutic doses up to 1000 mg in healthy volunteers), the pharmacokinetic properties of naloxegol appear to be time- and dose-independent. Naloxegol is rapidly absorbed, with mean time to maximum plasma concentration of <2 h. Following once-daily administration, steady state is achieved within 2-3 days and minimal accumulation is observed. The primary route of naloxegol elimination is via hepatic metabolism, with renal excretion playing a minimal role. In clinical studies, six metabolites were found in feces, urine or plasma, none of which have been identified as unique or disproportionate human metabolites. The major plasma circulating species is naloxegol. There are small effects of mild and moderate renal impairment, age, race, and body mass index on the systemic exposure of naloxegol; however, gender has no effect on the pharmacokinetics of this agent. Naloxegol is a sensitive substrate of cytochrome P450 (CYP) 3A4 and its exposure can be significantly altered by strong or moderate CYP3A modulators. Food increases the bioavailability of naloxegol, and the relative bioavailability of the tablet formulation was not limited by dissolution. Naloxegol in the dose range of 8-125 mg can antagonize morphine-induced peripheral effects without impacting the effect of morphine on the central nervous system, consistent with a peripheral mode of action.
Collapse
Affiliation(s)
- Khanh Bui
- AstraZeneca Pharmaceuticals LP, 35 Gatehouse Drive, Waltham, MA, 02451, USA.
| | - Diansong Zhou
- AstraZeneca Pharmaceuticals LP, 35 Gatehouse Drive, Waltham, MA, 02451, USA
| | - Hongmei Xu
- AstraZeneca Pharmaceuticals LP, 35 Gatehouse Drive, Waltham, MA, 02451, USA
| | | | - Nidal Al-Huniti
- AstraZeneca Pharmaceuticals LP, 35 Gatehouse Drive, Waltham, MA, 02451, USA
| |
Collapse
|
167
|
Bantel C, Tripathi SS, Molony D, Heffernan T, Oomman S, Mehta V, Dickerson S. Prolonged-release oxycodone/naloxone reduces opioid-induced constipation and improves quality of life in laxative-refractory patients: results of an observational study. Clin Exp Gastroenterol 2018; 11:57-67. [PMID: 29416370 PMCID: PMC5788929 DOI: 10.2147/ceg.s143913] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background Opioids are an effective treatment for moderate-to-severe pain. However, they are associated with a number of gastrointestinal side effects, most commonly constipation. Laxatives do not target the underlying mechanism of opioid-induced constipation (OIC), so many patients do not have their symptoms resolved. Fixed-dose prolonged-release (PR) oxycodone/naloxone (OXN) tablets contain the opioid agonist oxycodone and the opioid antagonist naloxone. Nal-oxone blocks the action of oxycodone in the gut without compromising its analgesic effects. Aim To evaluate the effectiveness of PR OXN in patients with severe pain who had laxative-refractory OIC with their previous opioid. Methods The study was carried out in 13 centers across the UK and Ireland, using a bespoke online tool to capture patients’ data. Patients were reviewed according to normal clinical practice of each center and rated any changes in their constipation and quality of life (QoL) since starting PR OXN. Any change in patients’ laxative use was also recorded. Results One hundred and seven patients were entered into the database, and 81 went on to attend at least one review. Of these, 54 (66.7%) reported an improvement in constipation and 50 (61.7%) reported an improvement in QoL since starting PR OXN. Fifty-seven patients (70.4%) said they had reduced laxative intake; 48 (59.3%) only needed laxatives as required. Conclusion PR OXN reduced symptoms of constipation, improved QoL and reduced laxative intake in patients with OIC. It has a potential place early in any treatment strategy for severe pain in patients using opioids, particularly in patients who may be predisposed to constipation.
Collapse
Affiliation(s)
- Carsten Bantel
- Chelsea and Westminster Hospital NHS Foundation Trust, London
| | | | - David Molony
- Mallow Primary Healthcare Centre, Mallow, Ireland
| | | | | | - Vivek Mehta
- Pain & Anaesthesia Research Centre, Barts Health NHS Trust, London
| | | |
Collapse
|
168
|
Stern EK, Brenner DM. Spotlight on naldemedine in the treatment of opioid-induced constipation in adult patients with chronic noncancer pain: design, development, and place in therapy. J Pain Res 2018; 11:195-199. [PMID: 29391826 PMCID: PMC5774487 DOI: 10.2147/jpr.s141322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Opioid-induced constipation (OIC) is an increasingly prevalent problem in the USA due to the growing use of opioids. A novel class of therapeutics, the peripherally acting μ-opioid receptor antagonists (PAMORAs), has been developed to mitigate the deleterious effects of opioids in the gastrointestinal tract while maintaining central analgesia and minimizing opioid withdrawal. This review aimed to summarize the literature on naldemedine, the third PAMORA to gain US Food and Drug Administration (FDA) approval for the treatment of OIC in adults with chronic noncancer pain-related syndromes. Naldemedine has a chemical structure similar to naltrexone, an opioid receptor antagonist, with chemical modifications that limit its ability to cross the blood-brain barrier. Naldemedine was evaluated in two Phase II and three Phase III clinical trials prior to gaining FDA approval. In two pivotal identical Phase III trials, COMPOSE-I (NCT 01965158) and COMPOSE-II (NCT 01993940), patients receiving naldemedine were significantly more likely to respond when compared with placebo (COMPOSE-I: 47.6 vs 34.6%, P=0.002 and COMPOSE-II: 52.5 vs 33.6%, P<0.0001). The most frequent adverse events were abdominal pain (8%) and diarrhea (7%) - rates similar to the other PAMORAs. Based on the available data, naldemedine appears to be an effective and safe drug for the treatment of OIC in adults with chronic noncancer pain.
Collapse
Affiliation(s)
- Emily K Stern
- Division of Gastroenterology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Darren M Brenner
- Division of Gastroenterology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
169
|
O'Brien T, Christrup LL, Drewes AM, Fallon MT, Kress HG, McQuay HJ, Mikus G, Morlion BJ, Perez-Cajaraville J, Pogatzki-Zahn E, Varrassi G, Wells JCD. European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain 2018; 21:3-19. [PMID: 27991730 PMCID: PMC6680203 DOI: 10.1002/ejp.970] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 02/06/2023]
Abstract
Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non‐specialist opioid prescribers. There is much confusing and conflicting information available to non‐specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi‐faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non‐specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. Significance This position paper provides expert recommendations for primary care physicians and other non‐ specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi‐faceted approach to pain management, in properly selected and supervised patients.
Collapse
Affiliation(s)
- T O'Brien
- Marymount University Hospital & Hospice, Curraheen, Cork, Ireland.,Cork University Hospital, Wilton, Cork and College of Medicine and Health, University College, Cork, Ireland
| | - L L Christrup
- Department of Drug Design and Pharmacology, University of Copenhagen, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark
| | - M T Fallon
- Edinburgh Cancer Research Centre, University of Edinburgh, UK
| | - H G Kress
- Department of Special Anaesthesia and Pain Therapy, Medical University of Vienna/AKH, Austria
| | | | - G Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital, Heidelberg, Germany
| | - B J Morlion
- Leuven Centre for Algology & Pain Management, University Hospital Leuven, Belgium
| | | | - E Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Müenster, Germany
| | | | | |
Collapse
|
170
|
Bowers BL, Crannage AJ. The Evolving Role of Long-Term Pharmacotherapy for Opioid-Induced Constipation in Patients Being Treated for Noncancer Pain. J Pharm Pract 2017; 32:558-567. [PMID: 29207909 DOI: 10.1177/0897190017745395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Nationally, the prescription of opioids for acute and chronic pain is increasing. As opioid use continues to expand and become of increased concern for health-care practitioners, so do the adverse effects and long-term management of those effects. Opioid-induced constipation (OIC) presents a unique challenge because tolerance does not develop to this particular adverse effect, making chronic pain management a delicate balance between relieving pain and preventing long-term adverse effects such as constipation and dependence. Several agents have been developed for the treatment of OIC in patients with chronic noncancer pain on the basis of short-term studies of 12 weeks or less. However, chronic pain management often extends beyond this 12-week boundary, resulting in health-care professionals questioning the safety and efficacy of continued treatment with OIC agents. This review evaluates available literature on long-term treatment of OIC in patients with chronic noncancer pain with lubiprostone, naloxegol, and methylnaltrexone as well as preliminary results of the recently completed naldemedine long-term trial, COMPOSE-3.
Collapse
Affiliation(s)
| | - Andrew J Crannage
- Department of Pharmacy Practice, St Louis College of Pharmacy, St Louis, MO, USA
| |
Collapse
|
171
|
Koopmans-Klein G, Van Op den Bosch J, van Megen Y, Prenen H, Huygen F, Mancini I. Prolonged release oxycodone and naloxone treatment counteracts opioid-induced constipation in patients with severe pain compared to previous analgesic treatment. Curr Med Res Opin 2017; 33:2217-2227. [PMID: 28805471 DOI: 10.1080/03007995.2017.1367276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Treatment with prolonged-release oxycodone/naloxone (PR OXN) has been shown to improve opioid induced constipation (OIC) in constipated patients. This publication reports on a real-life observational study investigating the efficacy of PR OXN with regard to bowel function in patients switching to PR OXN from WHO step 1, step 2 and step 3 opioids. METHODS Patients with chronic pain experiencing insufficient pain relief and/or unacceptable side effects were switched to PR OXN and monitored in this observational study with respect to efficacy regarding bowel function and efficacy regarding pain relief in comparison with previous analgesic therapy. A patient was considered a responder with respect to efficacy if this assessment was "slightly better", "better" or "much better" compared with previous therapy. Bowel function index, pain intensity, quality of life, laxative medication use, and safety analgesic were also evaluated. RESULTS A total of 1338 patients (mean [SD] age 64.3 [14.9], 63% female) were observed for 43 [3-166] days (median [range]) during treatment with PR OXN. Overall response rate regarding bowel function efficacy was 82.5%. Patients with symptoms of constipation at study entry obtained a clinically relevant improvement of the bowel function index (BFI) within the first 2 weeks of PR OXN treatment. Non-constipated patients at study entry maintained normal bowel function despite switching to treatment with the opioid PR OXN. CONCLUSION In conclusion, treatment with PR OXN results in a significant and clinically relevant improvement of bowel function. During the observation of the treatment with PR OXN patients reported an improvement of quality of life (QoL). More interestingly, non-constipated patients maintained a normal bowel function, showing prevention of constipation despite the use of an opioid.
Collapse
Affiliation(s)
- Gineke Koopmans-Klein
- a Mundipharma Pharmaceuticals BV , Medical Department , Leusden , The Netherlands
- b Center for Pain Medicine, Erasmus MC , Rotterdam , The Netherlands
| | | | - Yvonne van Megen
- a Mundipharma Pharmaceuticals BV , Medical Department , Leusden , The Netherlands
| | - Hans Prenen
- d Digestive Oncology Unit , University Hospital Leuven , Leuven , Belgium
| | - Frank Huygen
- b Center for Pain Medicine, Erasmus MC , Rotterdam , The Netherlands
| | | |
Collapse
|
172
|
Morlion BJ, Mueller-Lissner SA, Vellucci R, Leppert W, Coffin BC, Dickerson SL, O'Brien T. Oral Prolonged-Release Oxycodone/Naloxone for Managing Pain and Opioid-Induced Constipation: A Review of the Evidence. Pain Pract 2017; 18:647-665. [DOI: 10.1111/papr.12646] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Bart J. Morlion
- Leuven Centre for Algology and Pain Management; Anaesthesiology and Algology; Department of Cardiovascular Sciences; University Hospitals Leuven; University of Leuven; Leuven Belgium
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit; University Hospital; Careggi Florence Italy
| | - Wojciech Leppert
- Department of Palliative Medicine; Poznan University of Medical Sciences; Poznan Poland
- Department of Quality of Life Research; Medical University of Gdansk; Gdansk Poland
| | - Benoît C. Coffin
- Department of Gastroenterology; Louis Mourier Hospital; Assistance Publique - Hôpitaux de Paris; Colombes France
- University Denis Diderot-Paris VII; Paris France
| | - Sara L. Dickerson
- Mundipharma International Ltd; Cambridge Science Park; Cambridge U.K
| | - Tony O'Brien
- Marymount University Hospital and Hospice; Cork Ireland
- Cork University Hospital and College of Medicine and Health; University College Cork; Cork Ireland
| |
Collapse
|
173
|
Webster L, Diva U, Tummala R, Sostek M. Treatment with Naloxegol Versus Placebo: Pain Assessment in Patients with Noncancer Pain and Opioid-Induced Constipation. Pain Pract 2017; 18:505-514. [PMID: 28898536 DOI: 10.1111/papr.12640] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/18/2017] [Accepted: 09/06/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To summarize results from pain and opioid use assessments with naloxegol in adults with opioid-induced constipation (OIC) and chronic noncancer pain. METHODS Two phase 3 randomized, double-blind, 12-week studies evaluated the efficacy and safety of oral naloxegol (12.5 or 25 mg daily) in adults (18 to < 85 years) with confirmed OIC and chronic noncancer pain: KODIAC-04 (NCT01309841) and KODIAC-05 (NCT01323790). Pain level was assessed daily (11-point numeric rating scale [NRS]; 0 = no pain, 10 = worst imaginable pain). Changes from baseline in mean weekly pain scores and opioid dose (weeks 1 through 12) were analyzed using mixed-model repeated measures. RESULTS At baseline, mean daily NRS average pain scores ranged from 4.5 to 4.8 for all groups in KODIAC-04 (N = 652) and were 4.6 for each group in KODIAC-05 (N = 700). Respective mean ± SD changes from baseline average pain for placebo, naloxegol 12.5 mg, and naloxegol 25 mg were -0.2 ± 1.07, -0.3 ± 1.05 (P = 0.773 vs. placebo), and 0.2 ± 0.95 (P = 0.837 vs. placebo; KODIAC-04) and -0.1 ± 0.94, -0.1 ± 0.87 (P = 0.744), and 0.0 ± 1.18 (P = 0.572; KODIAC-05). At baseline, mean daily opioid doses ranged from 135.6 to 143.2 morphine equivalent units (MEUs)/day in KODIAC-04, and from 119.9 to 151.7 MEUs/day in KODIAC-05. Respective mean ± SD changes from baseline dose were -1.8 ± 30.19, -2.3 ± 20.52 (P = 0.724 vs. placebo), and 0.4 ± 13.01 (P = 0.188 vs. placebo; KODIAC-04) and -0.3 ± 17.14, -1.3 ± 17.11 (P = 0.669 vs. placebo), and 0.1 ± 8.54 (P = 0.863 vs. placebo; KODIAC-05). Changes in maintenance opioid dose were few; reasons for such changes were similar across treatment groups. CONCLUSION Centrally mediated opioid analgesia was maintained during treatment with naloxegol in patients with noncancer pain and OIC.
Collapse
Affiliation(s)
- Lynn Webster
- PRA Health Sciences, Salt Lake City, Utah, U.S.A
| | - Ulysses Diva
- Bioinformatics and Information Sciences, AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland, U.S.A
| | - Raj Tummala
- Global Medicines Development, AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland, U.S.A
| | - Mark Sostek
- Global Medicines Development, AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland, U.S.A
| |
Collapse
|
174
|
Murphy JA, Sheridan EA. Evidence Based Review of Pharmacotherapy for Opioid-Induced Constipation in Noncancer Pain. Ann Pharmacother 2017; 52:370-379. [PMID: 29092627 DOI: 10.1177/1060028017739637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To summarize and evaluate the existing literature regarding medications to treat opioid-induced constipation (OIC) in patients with chronic noncancer pain (CNCP). DATA SOURCES PubMed, EMBASE, and Web of Science were searched using the following terms: constipation, opioid, chronic, pain, noncancer, nonmalignant, methylnaltrexone, alvimopan, lubiprostone, naloxegol, and naldemedine. STUDY SELECTION AND DATA EXTRACTION The search was limited to randomized controlled trials reporting human outcomes. Data extracted included the following: study design, population, intervention, control, outcomes related to OIC and safety, and potential biases assessed using Cochrane Collaboration's Risk of Bias Assessment Tool. DATA SYNTHESIS After assessment, 16 of the 190 studies were included: methylnaltrexone (n = 4), naloxegol (n = 3), naldemedine (n = 2), lubiprostone (n = 3), and alvimopan (n = 4). Lubiprostone was the only nonperipherally acting µ-opioid receptor antagonist included. Only 1 study (naloxegol) used "usual care" (nonstudy laxative) rather than placebo as a comparator. Placebo-controlled trials demonstrated benefit for methylnaltrexone, naloxegol, naldemedine, and lubiprostone, with conflicting evidence for alvimopan. No data suggest that one agent is better than another. Overall risk of bias across all studies was low to moderate. CONCLUSIONS With risk of bias determined to be low to moderate, published data to date suggest that methylnaltrexone, naloxegol, and naldemedine may be appropriate to treat OIC in patients with CNCP.
Collapse
Affiliation(s)
- Julie A Murphy
- 1 University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Erica A Sheridan
- 1 University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| |
Collapse
|
175
|
Huang L, Zhou JG, Zhang Y, Wang F, Wang Y, Liu DH, Li XJ, Lv SP, Jin SH, Bai YJ, Ma H. Opioid-Induced Constipation Relief From Fixed-Ratio Combination Prolonged-Release Oxycodone/Naloxone Compared With Oxycodone and Morphine for Chronic Nonmalignant Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Pain Symptom Manage 2017; 54:737-748.e3. [PMID: 28736104 DOI: 10.1016/j.jpainsymman.2017.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/16/2017] [Accepted: 07/06/2017] [Indexed: 01/08/2023]
Abstract
CONTEXT Opioid-induced constipation (OIC) is one of the most frequent and severe adverse events (AEs) after treatment with opioids. Recent studies have indicated that fixed-ratio combination prolonged-release oxycodone/naloxone (OXN PR) could decrease OIC with similar pain relief compared with other opioids. OBJECTIVES We systematically reviewed (PROSPERO registration numbers: CRD42016036244) the constipation relief of OXN PR compared with other opioids regardless of formulation, prolonged release, or extended release used for the relief of chronic pain. METHODS Relevant studies were identified by searching PubMed, EMBASE, Web of Science, and the Cochrane library from inception to May 2016, with an update to December 2016. We quantitatively analyzed OIC (assessed by bowel function index [BFI]), pain intensity, and AEs. RESULTS A total of 167 articles were identified from the databases. Finally seven studies with 3217 patients were included in our meta-analysis, including 1322 patients in OXN PR treatment groups and 1885 patients in prolonged-release oxycodone (OXY PR) or prolonged-release morphine (MOR PR) control group. The relative risk (RR) of OIC was decreased in OXN PR (RR 0.52, 95% CI 0.44; 0.62). Whether BFI was better or worse at baseline, the mean difference (MD) of BFI -17.48 95% CI -21.60; -13.36) was better after treatment with OXN PR with clinical importance at the end of intervention; moreover, the BFI of the OXN PR-treated group was closer to normal BFI scores. However, clinical BFI change from baseline to the end measurement only existed in patients when the baseline BFI was high (mean [SDs] 61.0 [23.39]-67.40 [19.51]), and the MD of the BFI was -15.96 (95% CI -25.56; -15.48). The RR of AEs was also smaller (RR 0.80; 95% CI 0.69-0.93), but the severity or duration of AEs was not reported. Pain intensity was also significantly decreased in the OXN PR treatment groups (MD -3.84, 95% CI -7.14; -0.55), although there was no clinically meaningful difference. CONCLUSION For people with chronic pain, treatment with OXN PR decreases the incidence of OIC and provides intermediate-term bowel function improvement with clinical importance; in addition, pain relief is not weakened. The OIC after treatment with OXN PR for cancer-related pain and over the long term remains unknown.
Collapse
Affiliation(s)
- Lang Huang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jian-Guo Zhou
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yu Zhang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fei Wang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yi Wang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Da-Hai Liu
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xin-Juan Li
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shui-Ping Lv
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Su-Han Jin
- Affiliated Stomatological Hospital of Zunyi Medical University, Zunyi, China
| | - Yu-Ju Bai
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Hu Ma
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
| |
Collapse
|
176
|
Schüning J, Maier C, Schwarzer A. [Pain treatment with opioids for non-cancer pain by the family physician]. MMW Fortschr Med 2017; 159:52-61. [PMID: 29086255 DOI: 10.1007/s15006-017-9599-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Julia Schüning
- Abteilung für Geriatrie/Neurologie, Elisabeth Krankenhaus GmbH, Recklinghausen, Deutschland
| | - Christoph Maier
- Abteilung für Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Andreas Schwarzer
- Abteilung für Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH, Ruhr-Universität Bochum, Bochum, Deutschland.
- Abt. für Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, D-44789, Bochum, Deutschland.
| |
Collapse
|
177
|
Poulsen JL, Brock C, Grønlund D, Liao D, Gregersen H, Krogh K, Drewes AM. Prolonged-Release Oxycodone/Naloxone Improves Anal Sphincter Relaxation Compared to Oxycodone Plus Macrogol 3350. Dig Dis Sci 2017; 62:3156-3166. [PMID: 28986667 DOI: 10.1007/s10620-017-4784-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 09/27/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Opioid analgesics inhibit anal sphincter function and contribute to opioid-induced bowel dysfunction (OIBD). However, it is unknown whether the inhibition can be reduced by opioid antagonism with prolonged-release (PR) naloxone and how this compares to laxative treatment. AIMS To compare the effects of combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350 on anal sphincter function and gastrointestinal symptoms. METHODS A randomized, double-blind, crossover trial was conducted in 20 healthy men. Participants were treated for 5 days with combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350. Resting anal pressure, anal canal distensibility, and relaxation of the internal sphincter to rectal distension were evaluated before treatment (baseline) and on day 5. The Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire, stool frequency, and stool consistency were assessed daily. RESULTS Both PR oxycodone/naloxone and PR oxycodone plus macrogol treatment decreased sphincter relaxation compared to baseline (- 27.5%; P < 0.001 and - 14.7%; P = 0.01). However, sphincter relaxation was increased after PR naloxone/oxycodone treatment compared to macrogol (difference = + 17.6%; P < 0.001). Resting anal pressure and anal canal distensibility did not differ between treatments. PAC-SYM abdominal symptoms score was lower during PR naloxone compared to macrogol (0.2 vs. 3.2; P = 0.002). The number of bowel movements was lower during PR naloxone versus macrogol (4.2 vs. 5.4; P = 0.035). CONCLUSION Relaxation of the internal anal sphincter was significantly better after PR oxycodone/naloxone treatment compared to PR oxycodone plus macrogol 3350. These findings highlight that OIBD may require specific therapy against the complex, pan-intestinal effects of opioids.
Collapse
Affiliation(s)
- Jakob Lykke Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100, Copenhagen, Denmark
| | - Debbie Grønlund
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Donghua Liao
- GIOME Academia, Department of Clinical Medicine, Aarhus University, Nordre Ringgade 1, 8000, Aarhus, Denmark
| | - Hans Gregersen
- GIOME, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark.
| |
Collapse
|
178
|
Jehangir A, Parkman HP. Chronic opioids in gastroparesis: Relationship with gastrointestinal symptoms, healthcare utilization and employment. World J Gastroenterol 2017; 23:7310-7320. [PMID: 29142478 PMCID: PMC5677192 DOI: 10.3748/wjg.v23.i40.7310] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/08/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the relationship of chronic scheduled opioid use on symptoms, healthcare utilization and employment in gastroparesis (Gp) patients. METHODS Patients referred to our tertiary care academic center from May 2016 to July 2017, with established diagnosis or symptoms suggestive of Gp filled out the Patient Assessment of Upper GI Symptoms, abdominal pain and demographics questionnaires, and underwent gastric emptying and blood tests. They were asked about taking pain medicines and the types, doses, and duration. We used Mann Whitney U test, Analysis of Variance, Student's t test and χ2 tests where appropriate for data analyses. RESULTS Of 223 patients with delayed gastric emptying, 158 (70.9%) patients were not taking opioids (GpNO), 22 (9.9%) were taking opioids only as needed, while 43 (19.3%) were on chronic (> 1 mo) scheduled opioids (GpCO), of which 18 were taking opioids for reasons that included gastroparesis and/or stomach pain. Median morphine equivalent use was 60 mg per day. GpCO reported higher severities of many gastrointestinal symptoms compared to GpNO including nausea (mean ± SE of mean of 4.09 ± 0.12 vs 3.41 ± 0.12, P = 0.011), retching (2.86 ± 0.25 vs 1.98 ± 0.14, P = 0.003), vomiting (2.93 ± 0.24 vs 2.07 ± 0.15, P = 0.011), early satiety (4.17 ± 0.19 vs 3.57 ± 0.12, P = 0.004), post-prandial fullness (4.14 ± 0.18 vs 3.63 ± 0.11, P = 0.022), loss of appetite (3.64 ± 0.21 vs 3.04 ± 0.13, P = 0.039), upper abdominal pain (3.86 ± 0.20 vs 2.93 ± 0.13, P = 0.001), upper abdominal discomfort (3.74 ± 0.19 vs 3.09 ± 0.13, P = 0.031), heartburn during day (2.55 ± 0.27 vs 1.89 ± 0.13, P = 0.032), heartburn on lying down (2.76 ± 0.28 vs 1.94 ± 0.14, P = 0.008), chest discomfort during day (2.42 ± 0.20 vs 1.83 ± 0.12, P = 0.018), chest discomfort at night (2.40 ± 0.23 vs 1.61 ± 0.13, P = 0.003), regurgitation/reflux during day (2.77 ± 0.25 vs 2.18 ± 0.13, P = 0.040) and bitter/acid/sour taste in the mouth (2.79 ± 0.27 vs 2.11 ± 0.14, P = 0.028). GpCO had a longer duration of nausea per day (median of 7 h vs 4 h for GpNO, P = 0.037), and a higher number of vomiting episodes per day (median of 3 vs 2 for GpNO, P = 0.002). Their abdominal pain more frequently woke them up at night (78.1% vs 57.3%, P = 0.031). They had a lower employment rate (33.3% vs 54.2%, P = 0.016) and amongst those who were employed less number of working hours per week (median of 23 vs 40, P = 0.005). They reported higher number of hospitalizations in the last 1 year (mean ± SE of mean of 2.90 ± 0.77 vs 1.26 ± 0.23, P = 0.047). CONCLUSION GpCO had a higher severity of many gastrointestinal symptoms, compared to GpNO. Hospitalization rates were more than 2-fold higher in GpCO than GpNO. GpCO also had lower employment rate and working hours, when compared to GpNO.
Collapse
Affiliation(s)
- Asad Jehangir
- Department of Internal Medicine, Reading Health System, Spruce St/6th Ave, West Reading, PA 19611, United States
- Department of Gastroenterology, Temple University Hospital, Philadelphia, PA 19140, United States
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Hospital, Philadelphia, PA 19140, United States
| |
Collapse
|
179
|
Katakami N, Harada T, Murata T, Shinozaki K, Tsutsumi M, Yokota T, Arai M, Tada Y, Narabayashi M, Boku N. Randomized Phase III and Extension Studies of Naldemedine in Patients With Opioid-Induced Constipation and Cancer. J Clin Oncol 2017; 35:3859-3866. [PMID: 28968171 DOI: 10.1200/jco.2017.73.0853] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose Opioid-induced constipation (OIC) is a frequent and debilitating adverse effect (AE) of opioids-common analgesics for cancer pain. We investigated the efficacy and safety of a peripherally acting μ-opioid receptor antagonist, naldemedine (S-297995), for OIC, specifically in patients with cancer. Patients and Methods This phase III trial consisted of a 2-week, randomized, double-blind, placebo-controlled study (COMPOSE-4) and an open-label, 12-week extension study (COMPOSE-5). In COMPOSE-4, eligible adults with OIC and cancer were randomly assigned on a 1:1 basis to receive once-daily oral naldemedine 0.2 mg or placebo. The primary end point was the proportion of spontaneous bowel movement (SBM) responders (≥ 3 SBMs/week and an increase of ≥ 1 SBM/week from baseline). The primary end point of COMPOSE-5 was safety. Results In COMPOSE-4, 193 eligible patients were randomly assigned to naldemedine (n = 97) or placebo (n = 96). The proportion of SBM responders in COMPOSE-4 was significantly greater with naldemedine than with placebo (71.1% [69 of 97 patients] v 34.4% [33 of 96 patients]; P < .0001). A greater change from baseline was observed with naldemedine than with placebo in the frequency of SBMs/week (5.16 v 1.54; P < .0001), SBMs with complete bowel evacuation/week (2.76 v 0.71; P < .0001), and SBMs without straining/week (3.85 v 1.17; P = .0005). In COMPOSE-4, more patients treated with naldemedine than with placebo reported treatment-emergent AEs (TEAEs) (44.3% [43 of 97 patients] v 26.0% [25 of 96 patients]; P = .01); in COMPOSE-5, 105 (80.2%) of 131 of patients reported TEAEs. Diarrhea was the most frequently reported TEAE in COMPOSE-4 (19.6% [19 of 97 patients] v 7.3% [seven of 96 patients] with naldemedine v placebo) and COMPOSE-5 (18.3% [24 of 131 patients] with naldemedine). Naldemedine was not associated with signs or symptoms of opioid withdrawal and had no notable impact on opioid-mediated analgesia. Conclusion Once-daily oral naldemedine 0.2 mg effectively treated OIC and was generally well tolerated in patients with OIC and cancer.
Collapse
Affiliation(s)
- Nobuyuki Katakami
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Toshiyuki Harada
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Toru Murata
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Katsunori Shinozaki
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Masakazu Tsutsumi
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Takaaki Yokota
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Masatsugu Arai
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Yukio Tada
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Masaru Narabayashi
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Narikazu Boku
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Toshiyuki Harada, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo; Toru Murata, Aichi Hospital, Okazaki; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masakazu Tsutsumi, Hitachi General Hospital, Hitachi; Takaaki Yokota, Masatsugu Arai, and Yukio Tada, Shionogi & Co Ltd, Osaka; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
180
|
Müller-Lissner S, Bassotti G, Coffin B, Drewes AM, Breivik H, Eisenberg E, Emmanuel A, Laroche F, Meissner W, Morlion B. Opioid-Induced Constipation and Bowel Dysfunction: A Clinical Guideline. PAIN MEDICINE (MALDEN, MASS.) 2017; 18:1837-1863. [PMID: 28034973 PMCID: PMC5914368 DOI: 10.1093/pm/pnw255] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction. SETTING Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction." METHODS A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system. RESULTS From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction. CONCLUSIONS In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.
Collapse
Affiliation(s)
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia School of Medicine, Piazza Università, 1, Perugia, Italy
| | - Benoit Coffin
- AP-HP Hôpital Louis Mourier, University Denis Diderot-Paris 7, INSERM U987, Paris, France
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Harald Breivik
- Department of Pain Management and Research, University of Oslo, Rikshospitalet, Oslo, Norway
| | - Elon Eisenberg
- Institute of Pain Medicine, Rambam Health Care Campus, The Technion, Israel Institute of Technology, Haifa, Israel
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, Queen Square, London, UK
| | | | | | - Bart Morlion
- The Leuven Center for Algology and Pain Management, University of Leuven, KU Leuven, Leuven, Belgium
| |
Collapse
|
181
|
Fukumura K, Yokota T, Baba Y, Arjona Ferreira JC. Phase 1, Randomized, Double-Blind, Placebo-Controlled Studies on the Safety, Tolerability, and Pharmacokinetics of Naldemedine in Healthy Volunteers. Clin Pharmacol Drug Dev 2017; 7:474-483. [PMID: 28960888 DOI: 10.1002/cpdd.387] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/24/2017] [Indexed: 01/22/2023]
Abstract
Naldemedine (S-297995) is a peripherally acting μ-opioid receptor antagonist for the treatment of opioid-induced constipation, a common side effect of opioid therapy. We determined the safety, tolerability, and pharmacokinetic profiles of oral naldemedine in healthy volunteers in 2 randomized, double-blind, placebo-controlled, phase 1 studies. In the single ascending dose study, subjects received a single dose of naldemedine (0.1-100 mg; n = 42) or placebo (n = 14). In the multiple ascending dose study, subjects received once-daily naldemedine (3-30 mg; n = 27) or placebo (n = 9) for 10 days. On day 1 of the single ascending dose studies and day 10 of the multiple ascending dose studies, respectively, the maximum plasma concentration levels of naldemedine were 1.98 to 2510 ng/mL and 73.8 to 700 ng/mL, peaked at 0.5 hours and 0.5 to 0.75 hours, and the fraction excreted in urine was 15.9% to 20.5% and 19.7% to 19.1%. There were no major safety or tolerability concerns even at naldemedine doses 150 to 500 times the therapeutic dose of 0.2 mg. The incidence of adverse events was not dose dependent. Gastrointestinal adverse events occurred more frequently with naldemedine vs placebo, and all of these were considered treatment related. Overall, naldemedine was rapidly absorbed, and no safety or tolerability issues were noted at the doses evaluated.
Collapse
|
182
|
Al-Huniti N, Xu H, Zhou D, Aksenov S, Fox R, Bui KH. Population Exposure-Response Modeling Supported Selection of Naloxegol Doses in Phase III Studies in Patients With Opioid-Induced Constipation. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:705-711. [PMID: 28782266 PMCID: PMC5658281 DOI: 10.1002/psp4.12229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 06/30/2017] [Accepted: 07/26/2017] [Indexed: 12/23/2022]
Abstract
Naloxegol is approved for the treatment of opioid‐induced constipation (OIC) in adults with chronic noncancer pain. Population exposure‐response models were developed using data from a phase II study comprising 185 adults with OIC. The weekly probability of response defined as having ≥3/week spontaneous bowel movements (SBMs) and ≥1 SBM/week increase over baseline was characterized by a longitudinal mixed‐effects logistic regression dose‐response model, and the probability of time to discontinuation was modeled with a Weibull distribution function. The predicted probability of SBM in a given week increased with increasing naloxegol dose. The model predicted that 12.5, 25, and 37.5 mg doses would produce median response rates of 40%, 50%, and 60%, and dropout rates of 13.3%, 16.7%, and 23.3%, respectively. The large overlap of predicted difference of the response rate between placebo and the 25 or 37.5 mg doses suggested little utility of using a 37.5 mg dose in phase III studies.
Collapse
Affiliation(s)
| | - Hongmei Xu
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| | - Diansong Zhou
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| | - Sergey Aksenov
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| | - Robert Fox
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| | - Khanh H Bui
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| |
Collapse
|
183
|
Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res 2017; 10:2287-2298. [PMID: 29026331 PMCID: PMC5626380 DOI: 10.2147/jpr.s144066] [Citation(s) in RCA: 625] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.
Collapse
Affiliation(s)
- Tong J Gan
- Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
184
|
Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol 2017; 15:1338-1349. [PMID: 28529168 PMCID: PMC5565678 DOI: 10.1016/j.cgh.2017.05.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023]
Abstract
The use of opioid medications on both an acute and chronic basis is ubiquitous in the United States. As opioid receptors densely populate the gastrointestinal tract, symptoms and side effects can be expected in these patients. In the esophagus, dysmotility may result, manifesting with dysphagia and a syndrome indistinguishable from primary achalasia. In the stomach, a marked delay in gastric emptying may occur with postprandial nausea and early satiety. Postoperatively, particularly with abdominal surgery, opioid-induced ileus may ensue. In the colon, opioid-induced constipation is common. A unique syndrome termed narcotic bowel syndrome is characterized by chronic abdominal pain often accompanied by nausea and vomiting in the absence of other identifiable causes. With the recognition of the important role of opioids on gastrointestinal function, novel drugs have been developed that use this physiology. These medications include peripheral acting opioid agonists to treat opioid-induced constipation and combination agonist and antagonists used for diarrhea-predominant irritable bowel syndrome. This review summarizes the most recent data in these areas.
Collapse
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Anthony Lembo
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David A Katzka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
185
|
Becker G, Siemens W. Opioid-induced constipation: reflections on efficacy assessment. Lancet Gastroenterol Hepatol 2017; 2:540-541. [PMID: 28576450 DOI: 10.1016/s2468-1253(17)30144-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany.
| | - Waldemar Siemens
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| |
Collapse
|
186
|
Pergolizzi JV, LeQuang JA, Berger GK, Raffa RB. The Basic Pharmacology of Opioids Informs the Opioid Discourse about Misuse and Abuse: A Review. Pain Ther 2017; 6:1-16. [PMID: 28341939 PMCID: PMC5447545 DOI: 10.1007/s40122-017-0068-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Indexed: 02/01/2023] Open
Abstract
Morphine and other opioids are widely used to manage moderate to severe acute pain syndromes, such as pain associated with trauma or postoperative pain, and they have been used to manage chronic pain, even chronic nonmalignant pain. However, recent years have seen a renewed recognition of the potential for overuse, misuse, and abuse of opioids. Therefore, prescribing opioids is challenging for healthcare providers in that clinical effectiveness must be balanced against negative outcomes-with the possibility that neither are achieved perfectly. The current discourse about the dual 'epidemics' of under-treatment of legitimate pain and the over-prescription of opioids is clouded by inadequate or inaccurate understanding of opioid drugs and the endogenous pain pathways with which they interact. An understanding of the basic pharmacology of opioids helps inform the clinician and other stakeholders about these simultaneously under- and over-used agents.
Collapse
Affiliation(s)
| | | | | | - Robert B Raffa
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| |
Collapse
|
187
|
Hale M, Wild J, Reddy J, Yamada T, Arjona Ferreira JC. Naldemedine versus placebo for opioid-induced constipation (COMPOSE-1 and COMPOSE-2): two multicentre, phase 3, double-blind, randomised, parallel-group trials. Lancet Gastroenterol Hepatol 2017; 2:555-564. [PMID: 28576452 DOI: 10.1016/s2468-1253(17)30105-x] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/28/2017] [Accepted: 03/31/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Opioid-induced constipation is a frequent side-effect of opioid treatment, and standard interventions have limited or inconsistent efficacy. This study assessed the efficacy and safety of naldemedine, a peripherally acting μ-opioid receptor antagonist, for the treatment of opioid-induced constipation in patients with chronic non-cancer pain. METHODS We report two double-blind, randomised, placebo-controlled trials in adults with chronic non-cancer pain and opioid-induced constipation. The first (COMPOSE-1) was done in 68 outpatient sites in seven countries and the second (COMPOSE-2) at 69 outpatient sites in six countries; both studies were done in Europe and the USA. Eligible patients were aged 18-80 years, did not use laxatives, and had a stable opioid regimen for treatment of chronic non-cancer pain with a total daily dose averaging at least 30 mg (morphine equivalent) for at least 1 month before screening. Patients were randomly assigned (1:1) to receive either oral naldemedine 0·2 mg or matching placebo once a day for 12 weeks. Randomisation was stratified by average total daily opioid dose (30-100 mg and >100 mg equivalents of oral morphine sulphate). The primary endpoint was proportion of responders. A responder had at least three spontaneous bowel movements (SBMs) per week with an increase from baseline of at least one SBM per week for at least 9 weeks of the 12-week treatment period including at least three of the last 4 weeks. Efficacy endpoints were analysed by intention to treat and the safety population included all patients who received at least one dose of study drug. These trials have both been completed and are registered with ClinicalTrials.gov, numbers NCT01965158 and NCT01993940. FINDINGS In COMPOSE-1, 547 patients were recruited between Aug 29, 2013, and Jan 22, 2015, and were randomly assigned to receive naldemedine (n=274) or placebo (n=273). Patients for COMPOSE-2 were recruited between Nov 4, 2013, and June 9, 2015; 553 patients were randomly assigned to receive naldemedine (n=277) or placebo (n=276). Five patients were enrolled at more than one site, so were excluded from the intention-to-treat population (COMPOSE-1: one per group; COMPOSE-2: one in the naldemedine group, two from the placebo group), with intention-to-treat group sizes of 273 in the naldemedine group and 272 in the placebo group in COMPOSE-1, and 276 in the naldemedine group and 274 in the placebo group in COMPOSE-2. The proportion of responders in both trials was significantly higher with naldemedine than with placebo in COMPOSE-1 (130 responders [47·6%] of 273 in the naldemedine group vs 94 responders [34·6%] of 272 in the placebo group, difference 13·0% [95% CI 4·8-21·3]; p=0·002) and in COMPOSE-2 (145 [52·5%] of 276 vs 92 [33·6%] of 274, difference 18·9% [10·8-27·0]; p<0·0001). Incidence of adverse events with naldemedine was similar to placebo (COMPOSE-1: 132 [49%] of 271 in the naldemedine group vs 123 [45%] of 272 in the placebo group; COMPOSE-2: 136 [50%] of 271 vs 132 [48%] of 274). Treatment-related adverse events were noted in 59 (22%) of 271 patients in the naldemedine group and 45 (17%) of 272 in the placebo group in COMOPOSE-1, and in 54 (20%) of 271 patients in the naldemedine group and 31 (11%) of 274 in the placebo group of COMPOSE-2; the between-group differences were largely due to gastrointestinal disorders, which were more common with naldemedine than placebo (COMPOSE-1: 40 [15%] patients in the naldemedine group vs 18 [7%] in the placebo group; COMPOSE-2: 42 [16%] vs 20 [7%]). INTERPRETATION Naldemedine treatment led to a significantly higher responder rate than did placebo and was generally well tolerated. These results support that naldemedine could be a new option for the treatment of opioid-induced constipation in patients with chronic non-cancer pain. FUNDING Shionogi & Co, Ltd.
Collapse
Affiliation(s)
- Martin Hale
- Gold Coast Research LLC, Plantation, FL, USA
| | - James Wild
- Upstate Clinical Research Associates, Williamsville, NY, USA
| | | | | | | |
Collapse
|
188
|
Da-Cheng-Qi Decoction Combined with Conventional Treatment for Treating Postsurgical Gastrointestinal Dysfunction. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:1987396. [PMID: 28928788 PMCID: PMC5592004 DOI: 10.1155/2017/1987396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/28/2017] [Indexed: 02/05/2023]
Abstract
Aim To assess the current clinical evidence of the effectiveness of Da-Cheng-Qi Decoction (DCQD) for the treatment of Postoperative gastrointestinal dysfunction (PGD). Methods Randomized controlled trails (RCTs) of Da-Cheng-Qi Decoction (DCQD) to PGD were searched from available major electronic databases to September 2016. The intervention must be a modified DCQD or DCQD integrated to Western Medicine (WM) compared with WM or placebo or blank. The main outcome index was clinical effectiveness and improvement of major symptoms. Data extraction, data analysis, and methodological quality assessment are conducted according to the Cochrane Handbook for Systematic Review of Interventions, version 5.0.2. RevMan 5.3 software was applied to our data analyses. Results Seven RCTs involving 494 participants were recruited and identified. The methodological quality of all trials were assessed and generally of low-level. Those studies were published between 2004 and 2013. All 7 studies which used herbals (modified DCQD) integrate WM in test group compared with WM as the intervention and only one study (Sunyouxu 2013) integrates placebo to Western Medicine as the control group intervention. The treatment course was 1 week to 2 weeks. Evaluation of intervention effectiveness consists of the clinical effective rate indicator and the PGD symptoms indicator including time of borborygmus, time of gastrointestinal exhaust, and time of defecate. The clinical effectiveness results are beneficial to the test group. Conclusion DCQD could improve PGD symptoms and promotion clinical effectiveness.
Collapse
|
189
|
Khemani D, Camilleri M, Roldan A, Nelson AD, Park SY, Acosta A, Zinsmeister AR. Opioid analgesic use among patients presenting with acute abdominal pain and factors associated with surgical diagnoses. Neurogastroenterol Motil 2017; 29:10.1111/nmo.13000. [PMID: 28019066 PMCID: PMC5393942 DOI: 10.1111/nmo.13000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/26/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prevalence of chronic opioid use among non-cancer patients presenting with acute abdominal pain (AAP) is unknown. The aim was to characterize opioid use, constipation, diagnoses, and risk factors for surgical diagnoses among non-cancer patients presenting with AAP to an emergency department (ED). METHODS We performed a retrospective, observational cohort study of all (n=16,121) adult patients (88% from MN, IA and WI) presenting during 2014 with AAP. We used electronic medical records, and focused on 2352 adults with AAP who underwent abdominal CT scan within 24 hours of presentation. We determined odds ratios of association with constipation and features predicting conditions that may require surgery (surgical diagnosis). KEY RESULTS There were 2352 eligible patients; 18.8% were opioid users. Constipation was more frequent in opioid (35.1%) compared to non-opioid users [OR 2.88 (95% CI 2.28, 3.62)]. Prevalence of surgical diagnosis in the opioid and non-opioid users was 35.3% and 41.7% respectively (P=.019). By univariate analysis, age and neutrophil count independently predicted increased risk, and chronic opioid use decreased risk of surgical diagnosis. Internal validation of logistic models using a randomly selected validation subset (25% of entire cohort, 587/2352) showed receiver operating characteristic (ROC) curves for the validation and full cohorts were similar. CONCLUSIONS AND INFERENCES Approximately 19% of adults presenting with AAP were opioid users; constipation is almost three times as likely in opioid users compared to non-opioid users presenting with AAP. Factors significantly associated with altered risk of surgical diagnoses were age, opioid use, and neutrophil count.
Collapse
Affiliation(s)
- D Khemani
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - M Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - A Roldan
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - A D Nelson
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - S-Y Park
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - A Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - A R Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
190
|
Katakami N, Oda K, Tauchi K, Nakata K, Shinozaki K, Yokota T, Suzuki Y, Narabayashi M, Boku N. Phase IIb, Randomized, Double-Blind, Placebo-Controlled Study of Naldemedine for the Treatment of Opioid-Induced Constipation in Patients With Cancer. J Clin Oncol 2017; 35:1921-1928. [PMID: 28445097 DOI: 10.1200/jco.2016.70.8453] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose This randomized, double-blind, multicenter study aimed to determine the dose of naldemedine, a peripherally-acting μ-opioid receptor antagonist, for future trials by comparing the efficacy and safety of three doses of naldemedine versus placebo in patients with cancer and opioid-induced constipation. Methods Patients ≥ 18 years old with cancer, an Eastern Cooperative Oncology Group performance status ≤ 2, who had been receiving a stable regimen of opioid analgesics for ≥ 2 weeks, had at least one constipation symptom despite laxative use, and no more than five spontaneous bowel movements (SBMs) during the past 14 days, were randomly assigned (1:1:1:1) to oral, once-daily naldemedine 0.1, 0.2, or 0.4 mg, or placebo, for 14 days. The primary end point was change in SBM frequency per week from baseline during the treatment period. Secondary end points included SBM responder rates, change from baseline in the frequency of SBM without straining, and complete SBM. Safety was also assessed. Results Of 227 patients who were randomly assigned, 225 were assessed for efficacy (naldemedine 0.1 mg, n = 55; 0.2 mg, n = 58; 0.4 mg, n = 56; placebo, n = 56) and 226 for safety. Change in SBM frequency (primary end point) was higher with all naldemedine doses versus placebo ( P < .05 for all comparisons), as were SBM responder rates and change in complete SBM frequency. Change in SBM frequency without straining was significantly improved with naldemedine 0.2 and 0.4 (but not 0.1) mg versus placebo (at least P < .05). Treatment-emergent adverse events were more common with naldemedine (0.1 mg: 66.1%; 0.2 mg: 67.2%; 0.4 mg: 78.6%) than placebo (51.8%); the most common treatment-emergent adverse event was diarrhea. Conclusion Fourteen-day treatment with naldemedine significantly improved opioid-induced constipation in patients with cancer and was generally well tolerated. Naldemedine 0.2 mg was selected for phase III studies.
Collapse
Affiliation(s)
- Nobuyuki Katakami
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Oda
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Katsunori Tauchi
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Ken Nakata
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Katsunori Shinozaki
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Takaaki Yokota
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Yura Suzuki
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Masaru Narabayashi
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| | - Narikazu Boku
- Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe; Koji Oda, Aichi Cancer Center, Aichi; Katsunori Tauchi, Aizawa Hospital, Nagano; Ken Nakata, Sakai City Medical Center; Takaaki Yokota and Yura Suzuki, Shionogi & Co, Ltd, Osaka; Katsunori Shinozaki, Hiroshima Prefectural Hospital, Hiroshima; Masaru Narabayashi, Cancer Institute Hospital of Japanese Foundation for Cancer Research; and Narikazu Boku, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
191
|
Simren M, Palsson OS, Whitehead WE. Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Curr Gastroenterol Rep 2017; 19:15. [PMID: 28374308 PMCID: PMC5378729 DOI: 10.1007/s11894-017-0554-0] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The purpose of the review was to provide an update of the Rome IV criteria for colorectal disorders with implications for clinical practice. RECENT FINDINGS The Rome diagnostic criteria are expert consensus criteria for diagnosing functional gastrointestinal disorders (FGIDs). The current version, Rome IV, was released in May of 2016 after Rome III had been in effect for a decade. It is the collective product of committees that included more than 100 leading functional GI experts. For functional bowel and anorectal disorders, the majority of changes relative to Rome III are relatively minor and will have little impact on clinical practice. However, notable changes with potential impact on clinical practice and research include the changes in the diagnostic criteria for IBS, the modified approach for subtyping of IBS, the view on functional bowel disorders as a spectrum of disorders, and the new definition of fecal incontinence. New features in the Rome IV diagnostic criteria for functional bowel and anorectal disorders will likely have modest influence on clinical practice, with a few exceptions.
Collapse
Affiliation(s)
- Magnus Simren
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 40530, Gothenburg, Sweden.
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Olafur S Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
192
|
Abstract
Aim: Naloxegol is an oral peripherally acting μ-opioid receptor antagonist approved for the treatment of opioid-induced constipation. Sensitive, robust, bioanalytical methods were required to quantitate naloxegol in human biological matrices as part of the clinical development program. Methodology/results: Analytical plasma samples were prepared using Solid Phase Extraction (SPE) coupled with concentration. The method’s linearity was established at 0.1–50 ng/ml with up to 100-fold dilution. Urine samples were analyzed directly postdilution; dialysate samples were extracted by supported liquid extraction. Sensitive liquid chromatography/mass spectrometry (LC–MS/MS) assays were developed and validated, and demonstrated acceptable precision, accuracy and selectivity for naloxegol in the appropriate matrices. Conclusion: Methods for quantifying naloxegol in human biological matrices have been successfully validated.
Collapse
|
193
|
Drewes AM. Opioids and the gut; not only constipation and laxatives. Scand J Pain 2017; 15:81-82. [DOI: 10.1016/j.sjpain.2017.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Asbjørn Mohr Drewes
- Department of Gastroenterology & Hepatology, Clinical Institute, Aalborg University Hospital , Mølleparkvej, DK-9000 , Aalborg Denmark
| |
Collapse
|
194
|
Floettmann E, Bui K, Sostek M, Payza K, Eldon M. Pharmacologic Profile of Naloxegol, a Peripherally Acting µ-Opioid Receptor Antagonist, for the Treatment of Opioid-Induced Constipation. J Pharmacol Exp Ther 2017; 361:280-291. [PMID: 28336575 PMCID: PMC5399635 DOI: 10.1124/jpet.116.239061] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/08/2017] [Indexed: 12/20/2022] Open
Abstract
Opioid-induced constipation (OIC) is a common side effect of opioid pharmacotherapy for the management of pain because opioid agonists bind to µ-opioid receptors in the enteric nervous system (ENS). Naloxegol, a polyethylene glycol derivative of naloxol, which is a derivative of naloxone and a peripherally acting µ-opioid receptor antagonist, targets the physiologic mechanisms that cause OIC. Pharmacologic measures of opioid activity and pharmacokinetic measures of central nervous system (CNS) penetration were employed to characterize the mechanism of action of naloxegol. At the human µ-opioid receptor in vitro, naloxegol was a potent inhibitor of binding (Ki = 7.42 nM) and a neutral competitive antagonist (pA2 - 7.95); agonist effects were <10% up to 30 μM and identical to those of naloxone. The oral doses achieving 50% of the maximal effect in the rat for antagonism of morphine-induced inhibition of gastrointestinal transit and morphine-induced antinociception in the hot plate assay were 23.1 and 55.4 mg/kg for naloxegol and 0.69 and 1.14 mg/kg by for naloxone, respectively. In the human colon adenocarcinoma cell transport assay, naloxegol was a substrate for the P-glycoprotein transporter, with low apparent permeability in the apical to basolateral direction, and penetrated the CNS 15-fold slower than naloxone in a rat brain perfusion model. Naloxegol-derived radioactivity was poorly distributed throughout the rat CNS and was eliminated from most tissues within 24 hours. These findings corroborate phase 3 clinical studies demonstrating that naloxegol relieves OIC-associated symptoms in patients with chronic noncancer pain by antagonizing the µ-opioid receptor in the ENS while preserving CNS-mediated analgesia.
Collapse
Affiliation(s)
- Eike Floettmann
- AstraZeneca UK Ltd., Cambridge, United Kingdom (E.F.); AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (K.B.); AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland (M.S.); AstraZeneca Canada, Montreal, Quebec, Canada (K.P.); and Nektar Therapeutics, San Francisco, California, Primary laboratory of origin: AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (M.E.)
| | - Khanh Bui
- AstraZeneca UK Ltd., Cambridge, United Kingdom (E.F.); AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (K.B.); AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland (M.S.); AstraZeneca Canada, Montreal, Quebec, Canada (K.P.); and Nektar Therapeutics, San Francisco, California, Primary laboratory of origin: AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (M.E.)
| | - Mark Sostek
- AstraZeneca UK Ltd., Cambridge, United Kingdom (E.F.); AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (K.B.); AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland (M.S.); AstraZeneca Canada, Montreal, Quebec, Canada (K.P.); and Nektar Therapeutics, San Francisco, California, Primary laboratory of origin: AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (M.E.)
| | - Kemal Payza
- AstraZeneca UK Ltd., Cambridge, United Kingdom (E.F.); AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (K.B.); AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland (M.S.); AstraZeneca Canada, Montreal, Quebec, Canada (K.P.); and Nektar Therapeutics, San Francisco, California, Primary laboratory of origin: AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (M.E.)
| | - Michael Eldon
- AstraZeneca UK Ltd., Cambridge, United Kingdom (E.F.); AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (K.B.); AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland (M.S.); AstraZeneca Canada, Montreal, Quebec, Canada (K.P.); and Nektar Therapeutics, San Francisco, California, Primary laboratory of origin: AstraZeneca Pharmaceuticals LP, Wilmington, Delaware (M.E.)
| |
Collapse
|
195
|
Tafelski S, Beutlhauser T, Bellin F, Reuter E, Fritzsche T, West C, Schäfer M. [Incidence of constipation in patients with outpatient opioid therapy]. Schmerz 2017; 30:158-65. [PMID: 26115741 DOI: 10.1007/s00482-015-0018-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Constipation is a common complication in patients with opioid therapy. Additionally, patient-related risk factors also contribute to the development of constipation and these factors have to be integrated into an individualized treatment plan. OBJECTIVE The aim of this study was to assess the incidence of constipation in patients with opioid therapy in an outpatient setting and to analyze the risk factors that contribute to the development of constipation. MATERIAL AND METHODS This retrospective cohort study was conducted in two university affiliated outpatient departments at the Charité hospital in Berlin. The trial included all consecutively treated patients with opioid therapy of at least 4 weeks duration. The study was conducted from January 2013 to August 2013. Constipation was defined according to the Rome III criteria. RESULTS Out of 1166 screened patients, altogether 171 patients were included with a median duration of opioid therapy of 5 years. The most common diagnoses were back pain, musculoskeletal pain and neuropathic pain. In 14% of the treated patients symptoms of constipation were detected and another 35% needed laxatives for symptom control resulting in an overall incidence of constipation of 49%. The remaining 51% of the patients did not use any laxatives and did not experience symptoms of constipation. Age and dosing of opioid therapy significantly increased the risk of consipation but duration of opioid therapy was not related to the incidence of constipation. DISCUSSION The incidence of constipation in this population remains high although a relevant number of patients were intermittently free of symptoms without using laxatives. An individualized therapy plan and patient education seem to be important elements to control opioid-associated constipation.
Collapse
Affiliation(s)
- S Tafelski
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - T Beutlhauser
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - F Bellin
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - E Reuter
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - T Fritzsche
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - C West
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - M Schäfer
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| |
Collapse
|
196
|
Conaghan PG, Serpell M, McSkimming P, Junor R, Dickerson S. Satisfaction, Adherence and Health-Related Quality of Life with Transdermal Buprenorphine Compared with Oral Opioid Medications in the Usual Care of Osteoarthritis Pain. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2017; 9:359-71. [PMID: 27314487 PMCID: PMC4925685 DOI: 10.1007/s40271-016-0181-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Osteoarthritis (OA) causes substantial pain and reduced health-related quality of life (HRQL). Although opioid analgesics are commonly used, the relative benefits of different opioids are poorly studied. Transdermal buprenorphine (TDB) offers an alternative to oral opioids for the treatment of moderate-to-severe chronic pain. This observational study of people with OA pain assessed satisfaction, HRQL and medication adherence. Methods Patients in the UK with self-reported knee and/or hip OA who had been receiving one or more of TDB, co-codamol (an oral paracetamol/codeine combination) and tramadol for at least 1 month completed an online or telephone questionnaire. Medication satisfaction scores, HRQL scores (Short-Form 36 [SF-36]), medication adherence (Morisky Medication Adherence Scale [MMAS™]), adverse events and treatment discontinuations were recorded. Linear and logistic regression models were used to compare the treatment effect of TDB with co-codamol or tramadol. Results Overall, 966 patients met the inclusion criteria; 701 were taking only one of the target medications (TDB: 85; co-codamol: 373; tramadol: 243). The largest age group was 50–59 years and 76.0 % of patients were female. The TDB group was younger, with more male patients, therefore the statistical models were adjusted for age and sex. Medication satisfaction scores were significantly higher in the TDB group than the other two groups (TDB vs. co-codamol: 3.56, 95 % confidence interval [CI] 1.90–6.68, p < 0.0001; TDB vs. tramadol: 3.22, 95 % CI 1.67–6.20, p = 0.0005). Physical Component Summary scores for HRQL and mean adherence were also higher in the TDB group, while Mental Component Summary HRQL scores were similar across the three groups. Conclusions Patients with knee and/or hip OA pain treated with TDB were more satisfied and more adherent with their medication, and reported higher Physical Component Summary HRQL scores than those treated with co-codamol or tramadol, although demographic differences were observed between groups. Electronic supplementary material The online version of this article (doi:10.1007/s40271-016-0181-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine and National Institute of Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, University of Leeds, Leeds, UK
| | - Michael Serpell
- University Department of Anaesthesia, Gartnavel General Hospital, Glasgow, UK
| | - Paula McSkimming
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Rod Junor
- Napp Pharmaceuticals Limited, Cambridge, UK
| | - Sara Dickerson
- Napp Pharmaceuticals Limited, Cambridge, UK. .,Mundipharma International Limited, Cambridge Science Park, Milton Road, Cambridge, CB4 0GW, UK.
| |
Collapse
|
197
|
Dueñas M, Mendonça L, Sampaio R, Gouvinhas C, Oliveira D, Castro-Lopes JM, Azevedo LF. Reliability and validity of the Bowel Function Index for evaluating opioid-induced constipation: translation, cultural adaptation and validation of the Portuguese version (BFI-P). Curr Med Res Opin 2017; 33:563-572. [PMID: 27981871 DOI: 10.1080/03007995.2016.1273204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The Bowel Function Index (BFI) is a simple and sound bowel function and opioid-induced constipation (OIC) screening tool. We aimed to develop the translation and cultural adaptation of this measure (BFI-P) and to assess its reliability and validity for the Portuguese language and a chronic pain population. METHODS The BFI-P was created after a process including translation, back translation and cultural adaptation. Participants (n = 226) were recruited in a chronic pain clinic and were assessed at baseline and after one week. Internal consistency, test-retest reliability, responsiveness, construct (convergent and known groups) and factorial validity were assessed. RESULTS Test-retest reliability had an intra-class correlation of 0.605 for BFI mean score. Internal consistency of BFI had Cronbach's alpha of 0.865. The construct validity of BFI-P was shown to be excellent and the exploratory factor analysis confirmed its unidimensional structure. The responsiveness of BFI-P was excellent, with a suggested 17-19 point and 8-12 point change in score constituting a clinically relevant change in constipation for patients with and without previous constipation, respectively. CONCLUSIONS This study had some limitations, namely, the criterion validity of BFI-P was not directly assessed; and the absence of a direct criterion for OIC precluded the assessment of the criterion based responsiveness of BFI-P. Nevertheless, BFI may importantly contribute to better OIC screening and its Portuguese version (BFI-P) has been shown to have excellent reliability, internal consistency, validity and responsiveness. Further suggestions regarding statistically and clinically important change cut-offs for this instrument are presented.
Collapse
Affiliation(s)
- María Dueñas
- a Salus Infirmorum Faculty of Nursing , University of Cádiz , Cádiz , Spain
- b The Observatory of Pain (External Chair of Pain) , University of Cádiz , Cádiz , Spain
| | - Liliane Mendonça
- c Centro Nacional de Observação em Dor - OBSERVDOR (National Observatory for Pain - NOPain) , Portugal
| | - Rute Sampaio
- d Department of Experimental Biology, Faculty of Medicine , University of Porto , Portugal
- e IBMC - Institute for Molecular and Cell Biology, University of Porto , Portugal
| | - Cláudia Gouvinhas
- d Department of Experimental Biology, Faculty of Medicine , University of Porto , Portugal
| | - Daniela Oliveira
- d Department of Experimental Biology, Faculty of Medicine , University of Porto , Portugal
| | - José Manuel Castro-Lopes
- c Centro Nacional de Observação em Dor - OBSERVDOR (National Observatory for Pain - NOPain) , Portugal
- d Department of Experimental Biology, Faculty of Medicine , University of Porto , Portugal
- e IBMC - Institute for Molecular and Cell Biology, University of Porto , Portugal
| | - Luís Filipe Azevedo
- c Centro Nacional de Observação em Dor - OBSERVDOR (National Observatory for Pain - NOPain) , Portugal
- f Department of Health Information and Decision Sciences (CIDES), Faculty of Medicine , University of Porto , Portugal
- g CINTESIS - Centre for Health Technology and Services Research, University of Porto , Portugal
| |
Collapse
|
198
|
Epstein RS, Teagarden JR, Cimen A, Sostek M, Salimi T. When People with Opioid-Induced Constipation Speak: A Patient Survey. Adv Ther 2017; 34:725-731. [PMID: 28181146 PMCID: PMC5350191 DOI: 10.1007/s12325-017-0480-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Indexed: 12/15/2022]
Abstract
Introduction Opioid-induced constipation (OIC) is a common consequence of opioid use for chronic pain. OIC creates problems for patients independent of their pain syndromes, in addition to threatening pain treatment effectiveness. Healthcare practitioners need to be alert to how patients talk about OIC so that it is not missed. Using a survey mechanism, we sought patient expressions of the personal impact OIC imposes on how they are able to live their lives and on meanings that symptom relief would produce. Methods We used an online survey asking adults with OIC about quality of life implications of OIC and focused on open-ended text responses to questions about personal impacts of straining and meanings attached to OIC symptom relief. Participants were from the US, Canada, UK, Germany, Sweden, and Norway. Results A survey of 513 people with OIC produced 280 text responses concerning the impacts of straining on quality of life and 469 text responses on the meaning OIC symptom relief would confer. Text responses about the quality of life impacts of straining often included explicit descriptions conveying physical, psychological, or practical problems. Text responses about the meaning conferred from OIC symptom relief primarily concentrated around freedom from the constraints that OIC can impose. Conclusions Patients are willing and able to comment on the problems OIC cause them, using a variety of terms and phrases. Their comments concerning impacts on their lives will often refer to physical consequences, psychological effects, or practical implications. These insights provide healthcare practitioners guidance on how to engage patients about OIC.
Collapse
|
199
|
Søndergaard J, Christensen HN, Ibsen R, Jarbøl DE, Kjellberg J. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark. Scand J Pain 2017; 15:83-90. [PMID: 28850356 DOI: 10.1016/j.sjpain.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Opioid analgesics are often effective for pain management, but may cause constipation. The aim of this study was to determine healthcare resource use and costs in non-cancer and cancer patients with opioid-induced constipation (OIC). METHODS This was a nationwide register-based cohort study including patients ≥18 years of age initiating ≥4 weeks opioid therapy (1998-2012) in Denmark. A measure of OIC was constructed based on data from Danish national health registries, and defined as ≥1 diagnosis of constipation, diverticulitis, mega colon, ileus/subileus, abdominal pain/acute abdomen or haemorrhoids and/or ≥2 subsequent prescription issues of laxatives. Total healthcare resource utilization and costs (including pharmacy dispense, inpatient-, outpatient-, emergency room- and primary care) were estimated according to OIC status, opioid treatment dosage and length, gender, age, marital status, and comorbidities using Generalised Linear Model. RESULTS We identified 97169 eligible opioid users (77568 non-cancer and 19601 patients with a cancer diagnosis). Among non-cancer patients, 15% were classified with OIC, 10% had previous constipation, and 75% were without OIC. Patients characteristics of non-cancer OIC patients showed a higher frequency of strong opioid treatment (69% versus 41%), long-term opioid treatment (1189 days versus 584 days), advanced age (73 years versus 61 years), and cardiovascular disease (31% versus 19%) compared to those without OIC (P<0.001 for all comparisons). Non-cancer patients with OIC had 34% higher total healthcare costs compared to those without OIC (P<0.001) after adjusting for age, gender, opioid usage, marital status and comorbidities. Among cancer patients, 35% were classified with OIC, 14% had previous constipation, and 51% were without OIC. A higher proportion of cancer patients with OIC were continuous opioid users (85% versus 83%) and strong opioid users (97% versus 85%), compared to those without OIC (P<0.001 for both comparisons). Further, the mean number of days on opioids were higher for cancer patients with versus without OIC (329 days versus 238 days, P<0.001). Total healthcare costs were 25% higher for cancer patients with versus without OIC (P<0.001) after adjusting for age, gender, opioid usage, marital status and comorbidities. CONCLUSIONS The results of this nationwide study based on real life data suggested that both non-cancer patients and cancer patients suffering from opioid-induced constipation (OIC) may have higher healthcare resource utilization and higher associated costs compared to those without OIC. IMPLICATIONS Reducing the number of OIC patients has potential cost savings for the health care system. Special attention should be on patients at potential high risk of OIC, such as strong and long-term opioid treatment, advanced age, and concomitant cardiovascular disease.
Collapse
Affiliation(s)
- Jens Søndergaard
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | | | | | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jakob Kjellberg
- KORA, Danish Institute for Local and Regional Government Research, Copenhagen, Denmark
| |
Collapse
|
200
|
Rauck R, Slatkin NE, Stambler N, Harper JR, Israel RJ. Randomized, Double-Blind Trial of Oral Methylnaltrexone for the Treatment of Opioid-Induced Constipation in Patients with Chronic Noncancer Pain. Pain Pract 2017; 17:820-828. [DOI: 10.1111/papr.12535] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/05/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Richard Rauck
- The Center for Clinical Research; Winston-Salem North Carolina U.S.A
| | - Neal E. Slatkin
- School of Medicine; University of California Riverside; Riverside California U.S.A
| | - Nancy Stambler
- Progenics Pharmaceuticals, Inc.; New York New York U.S.A
| | | | | |
Collapse
|