Laxatives for the management of constipation in palliative care patients

Comparing the effectiveness of magnesium oxide and naldemedine in preventing opioid-induced constipation: a proof of concept, single institutional, two arm, open-label, phase II, randomized controlled trial: the MAGNET study

Background

Patients taking opioids are known to develop opioid-induced constipation (OIC), which reduces their quality of life. The aim of this study is to compare magnesium oxide with naldemedine and determine which is more effective in preventing OIC.

Methods

This proof-of-concept, prospective, randomized controlled trial commenced in Japan in March 2018. Initially, a questionnaire-based survey will be conducted targeting adult patients with cancer who concomitantly commenced opioid treatment and OIC prevention treatment. Patients will then be randomly allocated to a magnesium oxide group (500 mg thrice daily) or a naldemedine group (0.2 mg once daily). Each drug will be orally administered for 12 weeks. The primary endpoint is defined as any improvement in scores on the Japanese version of Patient Assessment of Constipation Quality of Life questionnaire (JPAC-QOL) from baseline to 2 weeks of treatment.

Discussion

The primary endpoint is change in JPAC-QOL score from baseline to 2 weeks of intervention. The key secondary endpoint will be change in spontaneous bowel movements at 2 and 12 weeks of intervention. This study will determine whether magnesium oxide or naldemedine is more effective for the prevention of OIC.

Trial registration

University Hospital Medical Information Network (UMIN) Clinical Trials Registry, UMIN000031891. Registered March 25, 2018.

Efficacy and tolerability balance of oxycodone/naloxone and tapentadol in chronic low back pain with a neuropathic component: a blinded end point analysis of randomly selected routine data from 12-week prospective open-label observations

Objective

To evaluate the benefit–risk profile (BRP) of oxycodone/naloxone (OXN) and tapentadol (TAP) in patients with chronic low back pain (cLBP) with a neuropathic component (NC) in routine clinical practice.

Methods

This was a blinded end point analysis of randomly selected 12-week routine/open-label data of the German Pain Registry on adult patients with cLBP-NC who initiated an index treatment in compliance with the current German prescribing information between 1st January and 31st October 2015 (OXN/TAP, n=128/133). Primary end point was defined as a composite of three efficacy components (≥30% improvement of pain, pain-related disability, and quality of life each at the end of observation vs baseline) and three tolerability components (normal bowel function, absence of either central nervous system side effects, and treatment-emergent adverse event [TEAE]-related treatment discontinuation during the observation period) adopted to reflect BRP assessments under real-life conditions.

Results

Demographic as well as baseline and pretreatment characteristics were comparable for the randomly selected data sets of both index groups without any indicators for critical selection biases. Treatment with OXN resulted formally in a BRP noninferior to that of TAP and showed a significantly higher primary end point response vs TAP (39.8% vs 25.6%, odds ratio: 1.93; P=0.014), due to superior analgesic effects. Between-group differences increased with stricter response definitions for all three efficacy components in favor of OXN: ≥30%/≥50%/≥70% response rates for OXN vs TAP were seen for pain intensity in 85.2%/67.2%/39.1% vs 83.5%/54.1%/15.8% (P= ns/0.031/<0.001), for pain-related disability in 78.1%/64.8%/43.8% vs 66.9%/50.4%/24.8% (P=0.043/0.018/0.001), and for quality of life in 76.6%/68.0%/50.0% vs 63.9%/54.1%/34.6% (P=0.026/0.022/0.017). Overall, OXN vs TAP treatments were well tolerated, and proportions of patients who either maintained a normal bowel function (68.0% vs 72.2%), reported no central nervous system side effects (91.4% vs 89.5%), or completed the 12-week evaluation period without any TEAE-related treatment discontinuations (93.0% vs 92.5%) were similar for both index medications (P= ns for each comparison).

Conclusion

In daily practice, the BRP of OXN proved to be noninferior to that of TAP in patients with cLBP-NC, but showed a superior efficacy if stricter analgesic response definitions were evaluated.

Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach

Opioids affect motor and sensory function throughout the gastrointestinal tract, and are frequently associated with a number of gastrointestinal symptoms including constipation, which impairs the quality of life and may limit the dose of opioid or result in discontinuation altogether. Patients with opioid-induced constipation should be assessed by careful history and physical examination, and in some cases where the diagnosis is unclear with select diagnostic tests. Few clinical studies have been conducted to assess the efficacy of various treatments. However, it is generally recommended that first-line therapy begin with opioid rotation, as well as with low-cost and low-risk approaches such as lifestyle changes, consumption of fiber-rich food, stool softeners, and laxatives.

Management of the lower gastrointestinal system in burn: A comprehensive review

BACKGROUND

Burn produces complex gastrointestinal (GI) responses. Treatment, including large volume fluid resuscitation and opioid analgesia, may exacerbate GI dysfunction. Complications include constipation and opioid-induced bowel dysfunction (OBD), acute colonic pseudo-obstruction (ACPO), bacterial translocation and sepsis, and abdominal compartment syndrome (ACS). Contamination of perineal burns contributes to delayed healing, skin graft failure and sepsis and may impact upon morbidity and mortality. The authors carried out a literature review on management of the lower GI system in burn. This study aimed to explain: current prevention and treatment modalities; drawbacks and complications associated with available treatments, and to provide direction for development of best practice guidelines. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis, to minimise and remove oedema.

METHODS

A comprehensive search of English language literature was performed on PubMed, Medline and Embase. Both MeSH and keywords searches were used.

RESULTS

Evidence available on the management of lower gastrointestinal system in burn is summarised. Levels of evidence available are generally low (level III-IV).

CONCLUSION

Structured, graded interventions are required for prevention and treatment of constipation and OBD. Correction of electrolyte imbalance, adequate enteral intake and mobilisation are pre-requisites. Laxatives should be used according to World Gastroenterology Organisation recommendations. Resistant constipation may respond to changes in medication, but ACPO should be suspected and treated when present. Other complications, such as bacterial translocation and ACS are common in major burns. There is evidence that selective digestive tract decontamination reduces mortality and infectious episodes in major burns. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis. Surgery is reserved for non-responsive and severe cases. Perineal burns present challenges in wound and bowel management. Faecal management systems and negative pressure wound therapy (NPWT) may improve wound control and hygiene, but diversion colostomy will still be beneficial in some cases. There is a clear need for rigorous studies to guide practice more effectively in these challenging conditions.

Genetic and Non-genetic Factors Associated With Constipation in Cancer Patients Receiving Opioids

Objectives:

To examine whether the inter-individual variation in constipation among patients receiving opioids for cancer pain is associated with genetic or non-genetic factors.

Methods:

Cancer patients receiving opioids were included from 17 centers in 11 European countries. Intensity of constipation was reported by 1,568 patients on a four-point categorical scale. Non-genetic factors were included as covariates in stratified regression analyses on the association between constipation and 75 single-nucleotide polymorphisms (SNPs) within 15 candidate genes related to opioid- or constipation-signaling pathways (HTR3E, HTR4, HTR2A, TPH1, ADRA2A, CHRM3, TACR1, CCKAR, KIT, ARRB2, GHRL, ABCB1, COMT, OPRM1, and OPRD1).

Results:

The non-genetic factors significantly associated with constipation were type of laxative, mobility and place of care among patients receiving laxatives (N=806), in addition to Karnofsky performance status and presence of metastases among patients not receiving laxatives (N=762) (P<0.01). Age, gender, body mass index, cancer diagnosis, time on opioids, opioid dose, and type of opioid did not contribute to the inter-individual differences in constipation. Five SNPs, rs1800532 in TPH1, rs1799971 in OPRM1, rs4437575 in ABCB1, rs10802789 in CHRM3, and rs2020917 in COMT were associated with constipation (P<0.01). Only rs2020917 in COMT passed the Benjamini–Hochberg criterion for a 10% false discovery rate.

Conclusions:

Type of laxative, mobility, hospitalization, Karnofsky performance status, presence of metastases, and five SNPs within TPH1, OPRM1, ABCB1, CHRM3, and COMT may contribute to the variability in constipation among cancer patients treated with opioids. Knowledge of these factors may help to develop new therapies and to identify patients needing a more individualized approach to treatment.

Laxatives for the management of constipation in people receiving palliative care

BACKGROUND

This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations.

OBJECTIVES

To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI-S) for trials to September 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity.

MAIN RESULTS

We identified five studies involving the laxatives lactulose, senna, co-danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta-analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects.

AUTHORS' CONCLUSIONS

This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative.

Complementary and integrative medicine for older adults in palliative care

Complementary and Integrative Medicine (CIM) encompasses many diverse therapies, including natural products and mind and body practices. Use of CIM is common and can benefit patients in palliative care. However, because patients in palliative care are often frail and elderly, the clinician should consider a patient's comorbidities before recommending certain therapies, such as natural products. In this article, specific examples of CIM are provided for symptoms commonly seen in palliative care.

Oxycodone/Naloxone: role in chronic pain management, opioid-induced constipation, and abuse deterrence

The use of opioids in the treatment of chronic pain is widespread; the prevalence of specific opioids varies from country to country and depends on product availability, national formulary systems, and provider preferences. Patients often receive opioids for legitimate treatment of pain conditions, but on the opposite side of the spectrum, nonmedical use of opioids is a significant public health concern. Opioids are associated with several side effects, and constipation is the most commonly reported and persistent symptom. Unlike some adverse effects associated with opioid use, tolerance does not develop to constipation. Opioid-induced constipation (OIC) is the most prevalent patient complaint associated with opioid use and has been associated with declines in various quality of life measures. OIC can be extremely difficult for patients to tolerate and may prompt patients to decrease or discontinue opioid treatment. Current management strategies for OIC are often insufficient. A prolonged-release formulation of oxycodone/naloxone (OXN) has been investigated for the treatment of nonmalignant and cancer pain and mitigation of OIC, and evidence is largely favorable. Studies have demonstrated the capability of OXN to alleviate OIC while maintaining pain control comparable to oxycodone-only regimens. There is insufficient evidence for OXN efficacy for patients with mild OIC or patients maintained on high doses of opioids, and use in these populations is controversial. The reduction of costs associated with OIC may provide overall cost effectiveness with OXN. Additionally, the presence of naloxone may deter abuse/misuse by those seeking to misuse the formulation by modes of administration other than oral ingestion. Most studies to date have occurred in European countries, and phase 3 trials continue in the United States. This review will include current therapeutic options for pain and constipation, unique characteristics of OXN, evidence related to use of OXN and its place in therapy, discussion of opioid abuse/misuse, and various abuse-deterrent mechanisms, and areas of continuing research.

The Quintessence of Traditional Chinese Medicine: Syndrome and Its Distribution among Advanced Cancer Patients with Constipation

Constipation is a common problem in advanced cancer patients; however, specific clinical guidelines on traditional Chinese medicine (TCM) syndrome (Zhang) are not yet available. In this cross-sectional study, the TCM syndromes distribution and their common symptoms and signs among 225 constipated advanced cancer patients were determined. Results showed that 127 patients (56.4%) and 7 patients (3.1%) were in deficient and excessive patterns, respectively, while 91 patients (40.4%) were in deficiency-excess complex. The distributions of the five syndromes were: Qi deficiency (93.3%), Qi stagnation (40.0%), blood (Yin) deficiency (28.9%), Yang deficiency (22.2%), and excess heat (5.8%). Furthermore, age, functional status, and level of blood haemoglobin were factors related to the type of TCM syndrome. A TCM prescription with the functions on replenishing the Deficiency, redirecting the flow of Qi stagnation and moistening the dryness caused by the blood (Yin) deficiency can be made for the treatment of advance cancer patients with constipation. Robust trials are urgently needed for further justifying its efficacy and safety in evidence-based approaches.

Laxative prescriptions to cancer outpatients receiving opioids: a study from the Norwegian prescription database

BACKGROUND

During opioid treatment of cancer pain, constipation is one of the most prevalent and bothersome side effects. Guidelines suggest that treatment with laxatives should be initiated when opioid therapy is started.

AIM

This study aims: (1) to determine to what extent patients, starting on opioids due to cancer pain, receive laxatives; (2) to examine the temporal relationship between initiation of opioid therapy and initiation of treatment with laxatives; and (3) to study to which extent the treatment follows current guidelines.

METHODS

Data from the Norwegian prescription database (NorPD) were used to investigate dispensed prescriptions of laxatives to outpatients in Norway, who are receiving opioids for cancer pain. Data from NorPD cover all dispensed prescriptions of drugs to outpatients, making it possible to follow patients over time. The study cohort was followed from 2005 to the end of 2008.

RESULTS

Of 2,982 patients who started opioid therapy directly with WHO step III opioids, 1,325 patients (44.4 %) did not receive laxatives during the study period. Only 738 patients (24.7 %) received laxatives at the same time as opioid therapy was initiated. Another 657 patients (22.0 %) received laxatives after their initiation of opioids at some time during the study period.

CONCLUSION

Of those who started directly on a strong opioid, only one fourth received laxatives concomitantly with the first opioid, and nearly half did not receive laxatives at all. These findings indicate that the current guidelines are not followed.

The impact of opioid analgesics on the gastrointestinal tract function and the current management possibilities

Opioid-induced bowel dysfunction (OIBD) comprises gastrointestinal symptoms such as constipation, anorexia, nausea, vomiting, gastro-oesophageal reflux, delayed digestion, abdominal pain, bloating, hard stool and incomplete evacuation that significantly deteriorate patients' quality of life and compliance. Approximately one third of patients treated with opioids do not adhere to the opioid regimen or simply quit the treatment due to OIBD. Several strategies are undertaken to prevent or treat OIBD. Traditional oral laxatives are used but their effectiveness is limited and they display adverse effects. Other possibilities comprise opioid switch or changing the administration route. New therapies target opioid receptors in the gut that seem to be the main source of OIBD. One is a combination of an opioid and opioid antagonist (oxycodone/naloxone) in prolonged-release tablets, and another is a purely peripherally acting opioid receptor antagonist (methylnaltrexone) available in subcutaneous injections. The aim of this article is to review the pathomechanism and possible treatment strategies of OIBD.

Implementation of the victoria bowel performance scale

CONTEXT

There is a lack of evidence to guide constipation management in patients receiving palliative care. Data collection requires the systematic use of validated assessment tools.

OBJECTIVES

The objective of this study was to assess the usefulness of the Victoria Bowel Performance Scale (BPS) as an audit tool.

METHODS

Charts were reviewed before and after the implementation of a program to monitor constipation through repeated use of the Victoria Bowel Scale. The program was initiated at three oncology pain and symptom management clinics, four palliative care units, and four residential hospices. An additional "control" palliative care unit introduced new nursing assessment tools without the new scale.

RESULTS

The Victoria BPS was recorded at 86% of 192 postimplementation outpatient clinic visits and was easy to use in this setting. Documentation of bowel performance at comparable visits improved from 44% to 66% (P<0.001), and the frequency of changes to laxatives increased from 14% to 39% of visits (P<0.001). The scale was completed on 21%-55% of inpatient days, and variations in the proportion of recordings being rated as satisfactory between -1 and +1 (possible range from -4 to +4) revealed important deficiencies in bowel care, which led to change in management.

CONCLUSION

The Victoria BPS was found to be an acceptable and a useful bowel function assessment tool, uniquely incorporating the patient's usual bowel function. Modifications to the scale have been made to improve clarity and allow for the expected drop in bowel activity seen in end-of-life care. Considerable educational effort and appropriate organization of the charts are required for optimal implementation. The proportion of revised BPS scores ranging from -1 to +1 is proposed as an indicator of satisfactory bowel management for clinical, audit, and research purposes.

Assessment and management of gastrointestinal symptoms in advanced illness

Primary care clinicians increasingly encounter patients with advanced illness, many suffering from symptoms other than pain. Key principles that guide palliative care must be incorporated into a plan of care for each patient and family. Although medical management continues to be the mainstay of treatment, the generalist in palliative care needs to be familiar with the patient's preferences and goals of care. This article provides an overview of gastrointestinal symptoms including anorexia, cachexia, nausea, vomiting, and constipation. Advanced progressive illnesses are defined here as incurable conditions that have significant morbidity in the later stages of illness.

Laxative management in ambulatory cancer patients on opioid therapy: a prospective, open-label investigation of polyethylene glycol, sodium picosulphate and lactulose

Constipation and the laxatives polyethylene glycol (PEG), sodium picosulphate (SPS) and lactulose (L) were investigated in outpatients with cancer and on opioid therapy. Randomly selected patients were enrolled in a prospective, controlled, open-label trial. Endpoints were number of patients taking laxatives >28 days, number of patients with a stool-free interval >72 h (sfi72), dosage, numerical rating scale (NRS) for constipation, and European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QoL) questionnaire scores. The 348 patients had comparable demographic and medical data. In this ambulatory population, mobility scores remained unaffected. Constipation incidence was 5.7%, with sfi72 42, mean NRS 2.3557 and mean QoL 2.1. A total of 53.2% discontinued their laxative medication. Laxative use correlated with higher opioid usage (morphine-equivalent mg/day: no laxative 98.2, SPS 128.2, PEG 139.9, L 154.5). PEG was the most frequently prescribed laxative (PEG 27.3%, SPS 10.3%, L 9.2%). PEG (sfi72 12.6%, NRS 2.2, QoL 2.1) and SPS (sfi72 11.1%, NRS 2.7, QoL 2.2) proved more effective than L (sfi72 15.5%, NRS 3.8, QoL 2.5). In spite of opioid therapy, the incidence of constipation was low in these ambulatory cancer pain patients at an early disease stage. For prevention of constipation, PEG or SPS is recommended instead of L.

Validated tools for evaluating opioid-induced bowel dysfunction

Adverse effects on the gastrointestinal system are problematic for pain patients receiving opioid treatment. Opioid-induced bowel dysfunction (OIBD) is often misinterpreted as constipation as this is the most frequently reported symptom of OIBD; however, it actually comprises the whole gut with symptoms such as nausea, reflux, bloating, and anorexia being very prevalent as well. Validated methods to evaluate these symptoms are essential before the action of a drug on bowel dysfunction can be evaluated, but only the effect on the most frequently reported symptom, constipation, has been evaluated systematically. Constipation is a personal symptom and there is little correlation between subjective methods for assessment of constipation and objective evaluations, such as transit time and fecal loading. Few questionnaires specific to constipation exist, since most that are regularly used form part of general gastrointestinal investigations, which furthermore are often complicated and time consuming to complete. This article gives an overview of the different evaluation regimes for OIBD with a particular focus on the most frequently reported symptom; constipation.

Nausea and other nonpain symptoms in long-term care

There is a need to improve the quality of end-of-life care in nursing homes by improving the timely assessment and management of various sources of suffering. Much of the research/discussion in this area has focused on the assessment and treatment of pain. This article reviews the frequency and management of nonpain symptoms in the long-term care setting, particularly focusing on patients at the end of life. Although the long-term care setting presents challenges to effective management, an approach for addressing these challenges is discussed and applied to 3 commonly encountered nonpain symptoms.

Effectiveness and tolerability of amidotrizoate for the treatment of constipation resistant to laxatives in advanced cancer patients

CONTEXT

Constipation is a common problem for advanced cancer patients, and is generally inadequately treated.

OBJECTIVES

The aim of this study was to prospectively evaluate the effectiveness and tolerability of amidotrizoate (AM) in patients unresponsive to current laxatives.

METHODS

A consecutive sample of advanced cancer patients was surveyed. Inclusion criteria were no bowel movements for three days despite receiving regular doses of senna or lactulose. AM 50 mL was administered orally; the dose could be repeated the day after, based on clinical judgment and/or patients' preference. Age, sex, primary tumor, previous abdominal surgery, chemotherapy and radiotherapy performed in the previous month, and the use of opioids were recorded. Nausea, the presence of early satiety, and fluid and food intake also were measured. Time to first bowel movement was recorded, and adverse effects attributable to AM.

RESULTS

Ninety-nine patients were surveyed (36 women/63 men). The mean age was 65.7 years (SD±12.2) and the mean Karnofsky score was 46.8 (SD±9.4). Patients had no bowel movement for a mean of four days (SD±1.8, range 3-15 days). A total of 80.8% of patients were receiving opioids in doses of mean daily oral morphine equivalents of 164 mg (SD±235). After AM administration (mean 9.9±6.5 hours), 44.4% of patients had a bowel movement within 24 hours. This effect was associated with significant improvement of other symptoms and was independent of age (P=0.513), gender (P=0.090), Karnofsky status (P=0.979), days of constipation (P=0.198), concomitant chemotherapy (P=0.098) or radiotherapy (P=0.414), the use of opioids (P=0.361), opioid doses (P=0.420), and primary tumor (P=0.231). The treatment was more effective in patients who had previous abdominal surgery (HR=3.33).

CONCLUSION

AM was found to be an easy and inexpensive breakthrough medication to induce a bowel movement in about 45% of advanced cancer patients not responsive to common laxatives, with limited and acceptable adverse effects.

Laxatives or methylnaltrexone for the management of constipation in palliative care patients

BACKGROUND

Constipation is common in palliative care; it can generate considerable suffering due to the unpleasant physical symptoms. In the first Cochrane Review on effectiveness of laxatives for the management of constipation in palliative care patients, published in 2006, no conclusions could be drawn because of the limited number of evaluations. This article describes the first update of this review.

OBJECTIVES

To determine the effectiveness of laxatives or methylnaltrexone for the management of constipation in palliative care patients.

SEARCH STRATEGY

We searched databases including MEDLINE and CENTRAL (The Cochrane Library) in 2005 and in the update to August 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating laxatives for constipation in palliative care patients. In the update we also included RCTs on subcutaneous methylnaltrexone; an opioid-receptor antagonist that is now licensed for the treatment of opioid-induced constipation in palliative care when response to usual laxative therapy is insufficient.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity.

MAIN RESULTS

We included seven studies involving 616 participants; all under-reported methodological features. In four studies the laxatives lactulose, senna, co-danthramer, misrakasneham, and magnesium hydroxide with liquid paraffin were evaluated. In three methylnaltrexone.In studies comparing the different laxatives evidence was inconclusive. Evidence on subcutaneous methylnaltrexone was clearer; in combined analysis (287 participants) methylnaltrexone, in comparison with a placebo, significantly induced laxation at 4 hours (odds ratio 6.95; 95% confidence interval 3.83 to 12.61). In combined analyses there was no difference in the proportion experiencing side effects, although participants on methylnaltrexone suffered more flatulence and dizziness. No evidence of opioid withdrawal was found. In one study severe adverse events, commonly abdominal pain, were reported that were possibly related to methylnaltrexone. A serious adverse event considered to be related to the methylnaltrexone also occurred; this involved a participant having severe diarrhoea, subsequent dehydration and cardiovascular collapse.

AUTHORS' CONCLUSIONS

The 2010 update found evidence on laxatives for management of constipation remains limited due to insufficient RCTs. However, the conclusions of this update have changed since the original review publication in that it now includes evidence on methylnaltrexone. Here it found that subcutaneous methylnaltrexone is effective in inducing laxation in palliative care patients with opioid-induced constipation and where conventional laxatives have failed. However, the safety of this product is not fully evaluated. Large, rigorous, independent trials are needed.

Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study

OBJECTIVE

Adverse drug events (ADEs) can cause serious harm to patients and can lead to hospitalization or even death. ADEs are a burden not only to patients and their relatives, but also to society and have the potential to involve high costs. To provide more information on the economic burden of preventable adverse drug events of outpatients, we performed a cost study on the data collected in the Hospital Admissions Related to Medication (HARM) study. In this study we examined the frequency, preventability, and risk factors for hospital admissions related to medication.

METHODS

The average costs for a preventable medication-related hospital admission were calculated by summing the direct medical costs and the production losses of all the preventable admissions, taking into account the different types of hospitals (academic and general) and the age of the admitted patients.

RESULTS

The average medical costs for one preventable medication-related hospital admission were €5461. The average production loss costs for one admission were €1712 for a person younger than 65 years of age. Combining the medical costs and the costs of production losses resulted in average costs of €6009 for one, potentially preventable, medication-related hospital admission for all ages.

CONCLUSIONS

The costs of potentially preventable hospital admissions related to medication are considerable. Therefore, patient safety interventions to prevent ADEs and hospital admissions may be cost-effective or even cost saving.

Consensus recommendations for the management of constipation in patients with advanced, progressive illness

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Symptom management in palliative care and end of life care

There is a need for generalist- and specialist-level palliative care clinicians proficient in symptom management and care coordination. Major factors contributing to this need include changed disease processes and trajectories, improved medical techniques and diagnostic testing, successful screening for chronic conditions, and drugs that often prolong life. The rapid progressive illnesses and deaths that plagued the first half of the twentieth century have been replaced in the twenty-first century by increased survival rates. Conditions that require ongoing medical care beyond a year define the current chronic illness population. Long years of survival are often accompanied by a reduced quality of life that requires more medical and nursing care and longer home care. This article reviews the management of selected symptoms in palliative and end of life care.

The use of opioids at the end of life: knowledge level of pharmacists and cooperation with physicians

Purpose

What is the level of knowledge of pharmacists concerning pain management and the use of opioids at the end of life, and how do they cooperate with physicians?

Methods

A written questionnaire was sent to a sample of community and hospital pharmacists in the Netherlands. The questionnaire was completed by 182 pharmacists (response rate 45%).

Results

Pharmacists were aware of the most basic knowledge about opioids. Among the respondents, 29% erroneously thought that life-threatening respiratory depression was a danger with pain control, and 38% erroneously believed that opioids were the preferred drug for palliative sedation. One in three responding pharmacists did not think his/her theoretical knowledge was sufficient to provide advice on pain control. Most pharmacists had working agreements with physicians on euthanasia (81%), but fewer had working agreements on palliative sedation (46%) or opioid therapy (25%). Based on the experience of most of responding pharmacists (93%), physicians were open to unsolicited advice on opioid prescriptions. The majority of community pharmacists (94%) checked opioid prescriptions most often only after dispensing, while it was not a common practice among the majority of hospital pharmacists (68%) to check prescriptions at all.

Conclusions

Although the basic knowledge of most pharmacists was adequate, based on the responses to the questionnaire, there seems to be a lack of knowledge in several areas, which may hamper pharmacists in improving the quality of care when giving advice to physicians and preventing or correcting mistakes if necessary. If education is improved, a more active role of the pharmacist may improve the quality of end-of-life pharmacotherapy.

Methylnaltrexone: the evidence for its use in the management of opioid-induced constipation

Introduction:

Constipation is a distressing side effect of opioid treatment, being so irksome in some cases that patients would rather suffer the pain than the side effect of opioid analgesics. Stool softeners or stimulating laxatives are often ineffective or even aggravate the situation. A new efficacious and safe drug is needed to limit the frequently observed side effects induced by effective opioid-based analgesic therapy and to improve the quality of life for patients, most of whom are impaired by a severe disease.

Aims:

The purpose of this article is to assess current evidence supporting the use of the peripherally acting μ-opioid receptor antagonist, methylnaltrexone, to restrict passage across the blood–brain barrier in patients with opioid-induced bowel dysfunction.

Evidence review:

There are now convincing data from phase II and multicenter phase III randomized, double-blind, placebo-controlled trials that methylnaltrexone induces laxation in patients with long-term opioid use without affecting central analgesia or precipitation of opioid withdrawal. Onset of the effect is rapid and improvement is maintained for at least 3 months during the drug treatment. The action of methylnaltrexone is dose dependent. Weight-related dosing appeared to be effective. There were no severe side effects or signs of opioid withdrawal. Adverse events, most frequently abdominal cramping or nausea, were usually mild to moderate. Methylnaltrexone is contraindicated in patients with known or suspected mechanical intestinal stenosis. Patients receiving methylnaltrexone must be monitored.

Place in therapy:

Methylnaltrexone applied subcutaneously every other day may be given to patients suffering from chronic constipation due to opioid therapy for whom laxatives do not provide adequate relief of their symptoms.

Randomized clinical trial of a phytotherapic compound containing Pimpinella anisum, Foeniculum vulgare, Sambucus nigra, and Cassia augustifolia for chronic constipation

Background

A phytotherapic compound containing Pimpinella anisum L., Foeniculum vulgare Miller, Sambucus nigra L., and Cassia augustifolia is largely used in Brazil for the treatment of constipation. However, the laxative efficacy of the compound has never been tested in a randomized clinical trial. The aim of this study was to evaluate the efficacy and safety of the product.

Methods

This randomized, crossover, placebo-controlled, single-blinded trial included 20 patients presenting with chronic constipation according to the criteria of the American Association of Gastroenterology. The order of treatments was counterbalanced across subjects: half of the subjects received the phytotherapic compound for a 5-day period, whereas the other half received placebo for the same period. Both treatment periods were separated by a 9-day washout period followed by the reverse treatment for another 5-day period. The primary endpoint was colonic transit time (CTT), measured radiologically. Secondary endpoints included number of evacuations per day, perception of bowel function, adverse effects, and quality of life.

Results

Mean CTT assessed by X ray was 15.7 hours (95%CI 11.1-20.2) in the active treatment period and 42.3 hours (95%CI 33.5-51.1) during the placebo treatment (p < 0.001). Number of evacuations per day increased during the use of active tea; significant differences were observed as of the second day of treatment (p < 0.001). Patient perception of bowel function was improved (p < 0.01), but quality of life did not show significant differences among the study periods. Except for a small reduction in serum potassium levels during the active treatment, no significant differences were observed in terms of adverse effects throughout the study period.

Conclusions

The findings of this randomized controlled trial allow to conclude that the phytotherapic compound assessed has laxative efficacy and is a safe alternative option for the treatment of constipation.

Trial registration

ClinicalTrial.gov NCT00872430

Recent advances in the use of opioids for cancer pain

Opioids are the mainstay of treatment for moderate to severe cancer pain. In recent years there have been many advances in the use of opioids for cancer pain. Availability and consumption of opioids have increased and opioids other than morphine (including methadone, fentanyl, oxycodone) have become more widely used. Inter-individual variation in response to opioids has been identified as a significant challenge in the management of cancer pain. Many studies have been published demonstrating the benefits of opioid switching as a clinical maneuver to improve tolerability. Constipation has been recognized as a significant burden in cancer patients on opioids. Peripherally restricted opioid antagonists have been developed for the prevention and management of opioid induced constipation. The phenomenon of breakthrough pain has been characterized and novel modes of opioid administration (transmucosal, intranasal, sublingual) have been explored to facilitate improved management of breakthrough cancer pain. Advances have also been made in the realm of molecular biology. Pharmacogenetic studies have explored associations between clinical response to opioids and genetic variation at a DNA level. To date these studies have been small but future research may facilitate prospective prediction of response to individual drugs.

Treatment of chronic constipation: current pharmacologic approaches and future directions

Chronic constipation is a common condition that affects up to 27% of the population. Dietary and lifestyle measures are usually the first-line therapy, but if these fail to have an effect then a variety of prescription and consumer laxatives are available. Traditional laxatives include bulking agents, osmotic agents, stool softeners, and stimulants of the gastrointestinal tract. All have been found to be more effective than placebo at relieving symptoms of constipation, but these results have been obtained primarily in short (4-week) trials and no class of laxative has been shown to be superior to another. Traditional laxatives work in many, but not all, patients and some patients cannot cope with the side effects, unpleasant taste, the requirements of the dosing regimen, or the notion of dose increase. New enterokinetic agents that affect peristalsis through selective interaction with 5-hydroxytryptamine-4 receptors and novel agents acting on intestinal secretion could offer an alternative option for patients with chronic constipation who cannot get adequate relief from current laxatives.

How useful are systematic reviews for informing palliative care practice? Survey of 25 Cochrane systematic reviews

BACKGROUND

In contemporary medical research, randomised controlled trials are seen as the gold standard for establishing treatment effects where it is ethical and practical to conduct them. In palliative care such trials are often impractical, unethical, or extremely difficult, with multiple methodological problems. We review the utility of Cochrane reviews in informing palliative care practice.

METHODS

Published reviews in palliative care registered with the Cochrane Pain, Palliative and Supportive Care Group as of December 2007 were obtained from the Cochrane Database of Systematic Reviews, issue 1, 2008. We reviewed the quality and quantity of primary studies available for each review, assessed the quality of the review process, and judged the strength of the evidence presented. There was no prior intention to perform any statistical analyses.

RESULTS

25 published systematic reviews were identified. Numbers of included trials ranged from none to 54. Within each review, included trials were heterogeneous with respect to patients, interventions, and outcomes, and the number of patients contributing to any single analysis was generally much lower than the total included in the review. A variety of tools were used to assess trial quality; seven reviews did not use this information to exclude low quality studies, weight analyses, or perform sensitivity analysis for effect of low quality. Authors indicated that there were frequently major problems with the primary studies, individually or in aggregate. Our judgment was that the reviewing process was generally good in these reviews, and that conclusions were limited by the number, size, quality and validity of the primary studies.We judged the evidence about 23 of the 25 interventions to be weak. Two reviews had stronger evidence, but with limitations due to methodological heterogeneity or definition of outcomes. No review provided strong evidence of no effect.

CONCLUSION

Cochrane reviews in palliative care are well performed, but fail to provide good evidence for clinical practice because the primary studies are few in number, small, clinically heterogeneous, and of poor quality and external validity. They are useful in highlighting the weakness of the evidence base and problems in performing trials in palliative care.

Constipation in cancer patients on morphine

GOALS OF WORK

Constipation is a significant problem in patients taking morphine for cancer pain. The aims of this study were (1) to assess the magnitude of constipation in this study cohort, (2) to analyse the constipation treatment strategies and (3) to look for evidence of inter-individual variation in both susceptibility to constipation and response to treatment with laxatives in this patient group.

MATERIALS AND METHODS

This was an observational study carried out in a tertiary referral cancer hospital. Two hundred seventy four patients were recruited to the study. All had a diagnosis of cancer and were on oral morphine for cancer pain. The main outcomes measured were subjective patient assessment of constipation severity in the preceding week and laxative use. Patients were asked to grade constipation in the preceding week on a four-point categorical scale: "not at all" (grade 0), "a little" (grade 1), "quite a bit" (grade 2) and "very much" (grade 3). Laxative dose groups (LDGs) were developed to assess laxative dosing.

RESULTS

Constipation affects 72% of this cohort of patients. Constipation in this population is poorly managed. Eighty nine percent of constipated patients were on inadequate laxative therapy. Inter-individual variation in constipation on morphine exists: some patients do not experience constipation and do not need to take any laxatives, some patients do not experience constipation because they are taking laxatives and some patients experience constipation despite being on high dose laxatives. These three groups were compared in terms of cancer diagnosis, time on morphine, dose of morphine and other concomitant factors. No factor was identified to account for this inter-individual variation. Improvement in the clinical management of constipation is needed, with titration of laxatives according to individual patient need.

CONCLUSION

Constipation affects a large proportion of cancer patients taking oral morphine. Constipation in these patients is generally inadequately treated.