Constipation--modern laxative therapy

Effect of prebiotic oligosaccharides on bowel habit and the gut microbiota in children with functional constipation (Inside study): study protocol for a randomised, placebo-controlled, multi-centre trial

BACKGROUND

Functional constipation (FC) in children is a common gastrointestinal disorder with a worldwide-pooled prevalence of 9.5%. Complaints include infrequent bowel movements, painful defecation due to hard and/or large stools, faecal incontinence, and abdominal pain. Prebiotic oligosaccharides have been shown to relieve constipation symptoms in young adults and elderly. However, sufficient evidence is lacking linking additional prebiotic intake to improve symptoms in children with FC. We hypothesise that prebiotic oligosaccharides are able to relieve symptoms of constipation in young children as well.

METHODS

In the present randomised, double-blind, placebo-controlled, multi-centre study, we will study the effects of two prebiotic oligosaccharides in comparison to placebo on constipation symptoms in children of 1-5 years (12 to 72 months) of age diagnosed with FC according to the Rome IV criteria for functional gastrointestinal disorders. The primary outcome measure will be change in stool consistency. Secondary outcomes include stool frequency and stool consistency in a number of cases (%). Tertiary outcomes include among others painful defecation, use of rescue medication, and quality of life. In addition, the impact on gut microbiome outcomes such as faecal microbiota composition and metabolites will be investigated. Participants start with a run-in period, after which they will receive supplements delivered in tins with scoops for 8 weeks, containing one of the two prebiotic oligosaccharides or placebo, followed by a 4-week wash-out period.

DISCUSSION

This randomised double-blind, placebo-controlled multi-centre study will investigate the effectiveness of prebiotic oligosaccharides in children aged 1-5 years with FC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04282551. Registered on 24 February 2020.

Comprehensive microbiomes and fecal metabolomics combined with network pharmacology reveal the effects of Jichuanjian on aged functional constipation

BACKGROUND

Functional constipation is a common gastrointestinal disorder especially severely affecting the life quality of the aged. Jichuanjian (JCJ) has been widely used for aged functional constipation (AFC) in clinic. Yet, the mechanisms of JCJ merely scratch the surface with being studied at a single level, rather than from a systematic perspective of the whole.

AIM

The purpose of this study was to explore the underlying mechanisms of JCJ in treating AFC from the perspectives of fecal metabolites and related pathways, gut microbiota, key gene targets and functional pathways, as well as "behaviors-microbiota-metabolites" relationships.

METHODS

16S rRNA analysis and fecal metabolomics combined with network pharmacology were applied to investigate the abnormal performances of AFC rats, as well as the regulatory effects of JCJ.

RESULTS

JCJ significantly regulated the abnormalities of rats' behaviors, the microbial richness, and the metabolite profiles that were interrupted by AFC. 19 metabolites were found to be significantly associated with AFC involving in 15 metabolic pathways. Delightfully, JCJ significantly regulated 9 metabolites and 6 metabolic pathways. AFC significantly interrupted the levels of 4 differential bacteria while JCJ significantly regulated the level of SMB53. HSP90AA1 and TP53 were the key genes, and pathways in cancer was the most relevant signaling pathways involving in the mechanisms of JCJ.

CONCLUSION

The current findings not only reveal that the occurrence of AFC is closely related to gut microbiota mediating amino acid and energy metabolism, but also demonstrate the effects and the underlying mechanisms of JCJ on AFC.

Pharmaceutical strategies for preventing toxicity and promoting antioxidant and anti-inflammatory actions of bilirubin

Bilirubin (BR) is the final product of haem catabolism. Disruptions along BR metabolic/transport pathways resulting from inherited disorders can increase plasma BR concentration (hyperbilirubinaemia). Unconjugated hyperbilirubinemia may induce BR accumulation in brain, potentially causing irreversible neurological damage, a condition known as BR encephalopathy or kernicterus, to which newborns are especially vulnerable. Numerous pharmaceutical strategies, mostly based on hemoperfusion, have been proposed over the last decades to identify new valid, low-risk alternatives for BR removal from plasma. On the other hand, accumulating evidence indicates that BR produces health benefits due to its potent antioxidant, anti-inflammatory and immunomodulatory action with a significant potential for the treatment of a multitude of diseases. The present manuscript reviews both such aspects of BR pharmacology, gathering literature data on applied pharmaceutical strategies adopted to: (i) reduce the plasma BR concentration for preventing neurotoxicity; (ii) produce a therapeutic effect based on BR efficacy in the treatment of many disorders.

Gastrointestinal Dysfunction in Parkinson’s Disease: Current and Potential Therapeutics

Abnormalities in the gastrointestinal (GI) tract of Parkinson’s disease (PD) sufferers were first reported over 200 years ago; however, the extent and role of GI dysfunction in PD disease progression is still unknown. GI dysfunctions, including dysphagia, gastroparesis, and constipation, are amongst the most prevalent non-motor symptoms in PD. These symptoms not only impact patient quality of life, but also complicate disease management. Conventional treatment pathways for GI dysfunctions (i.e., constipation), such as increasing fibre and fluid intake, and the use of over-the-counter laxatives, are generally ineffective in PD patients, and approved compounds such as guanylate cyclase C agonists and selective 5-hyroxytryptamine 4 receptor agonists have demonstrated limited efficacy. Thus, identification of potential targets for novel therapies to alleviate PD-induced GI dysfunctions are essential to improve clinical outcomes and quality of life in people with PD. Unlike the central nervous system (CNS), where PD pathology and the mechanisms involved in CNS damage are relatively well characterised, the effect of PD at the cellular and tissue level in the enteric nervous system (ENS) remains unclear, making it difficult to alleviate or reverse GI symptoms. However, the resurgence of interest in understanding how the GI tract is involved in various disease states, such as PD, has resulted in the identification of novel therapeutic avenues. This review focuses on common PD-related GI symptoms, and summarizes the current treatments available and their limitations. We propose that by targeting the intestinal barrier, ENS, and/or the gut microbiome, may prove successful in alleviating PD-related GI symptoms, and discuss emerging therapies and potential drugs that could be repurposed to target these areas.

Prokinetic effects of diatrizoate meglumine (Gastrografin®) in a zebrafish for opioid-induced constipation model

Constipation is a common disease that reduces life quality. Drugs of various mechanisms are being developed to resolve this affliction. Intestinal motility can be easily monitored in zebrafish, and so we selected this organism to develop a constipation model to measure drug-induced prokinetic effects. In this study, intestinal motility was monitored in zebrafish by tracking intestinal transit using fluorescence, after which an opioid-induced constipation model was established using loperamide. We then evaluated the prokinetic effect of diatrizoate meglumine (Gastrografin®), which has been empirically used to treat post-operative ileus or adhesive small bowel obstructions. Diatrizoate meglumine was effective in promoting bowel movements in an opioid-induced zebrafish constipation model and its prokinetic effect was associated with an increased expression of interstitial cells of Cajal (ICC) markers. Therefore, the loperamide-induced zebrafish constipation model developed herein is a promising tool to evaluate novel constipation therapies.

Laxative Use in the Community: A Literature Review

Laxatives are widely available without prescription and, as a consequence, they are commonly used for self-management of constipation by community-dwelling adults. However, it is not clear to what extent laxatives are used. Nor is it clear how laxatives are chosen, how they are used and whether consumers are satisfied with their performance. This review of published literature in the last 30 years shows the prevalence of laxative use in community-dwelling adults varied widely from 1% to 18%. The prevalence of laxative use in adults with any constipation (including both chronic and sporadic constipation) also varied widely from 3% to 59%. Apart from any geographical differences and differences in research methodologies, this wide range of estimated prevalence may be largely attributed to different definitions used for laxatives. This review also shows that laxative choice varies, and healthcare professionals are infrequently involved in selection. Consequently, satisfaction levels with laxatives are reported to be low and this may be because the laxatives chosen may not always be appropriate for the intended use. To improve constipation management in community and primary healthcare settings, further research is required to determine the true prevalence of laxative use and to fully understand laxative utilisation.

How adding the abdominal massage to polyethylene glycol can improve symptom and quality of life in patients with functional constipation in comparison with each one of the treatment modalities alone: A randomized clinical trial

BACKGROUND

A variety of medical and non-medical treatments have been introduced for functional constipation relief. Here, we aimed to compare the efficacy of a combination of polyethylene glycol (PEG) and abdominal massage with each one of the treatments alone.

MATERIALS AND METHODS

Patients with functional constipation based on Rome IV criteria were randomly assigned into the three treatment groups: group A (abdominal massage for 15 min daily), group B (PEG 20 g daily), and group C (PEG 20 g plus abdominal massage for 15 min daily) for 14 days. PAC-QOL questionnaire, Bristol stool scale were evaluated at baseline and two weeks after treatment. Constipation-associated symptom scores were recorded at baseline, two weeks and four weeks after treatment beginning. Descriptive statistics were provided as the mean ± standard deviation or number and percentage. P-value<0.05 was considered statistically significant.

RESULTS

Forty eight, 47 and 48 patients in group A, B, and C completed the study, respectively. PAC-QOL, Bristol and Constipation-associated symptom scores showed a significant improvement in all study groups two weeks after the treatment compared to the baseline. At the end of treatment, the rate of straining, incomplete evacuation sensation, finger evacuation and the number of defecation was significantly lower in the group C (P < 0.04). Bristol score were significantly improved in group B (P = 0.029) in compare to other groups. The total quality of life score was also significantly improved in the group C (P = 0.028).

CONCLUSION

A combination of abdominal massage and PEG is safe, tolerable and more effective than each one of the treatments alone.

Characteristics of fecal metabolic profiles in patients with irritable bowel syndrome with predominant diarrhea investigated using 1 H-NMR coupled with multivariate statistical analysis

BACKGROUND

Gut microbiota are known to be closely related to irritable bowel syndrome (IBS). However, not much is known about characteristic fecal metabolic profiles of IBS. We aimed to characterize fecal metabolites in patients with IBS with predominant diarrhea (IBS-D) using ¹ H-nuclear magnetic resonance (¹ H-NMR) spectroscopy.

METHODS

In this study, we enrolled 29 patients diagnosed with IBS-D according to the Rome IV criteria, 22 healthy controls (HC) and 11 HC administered laxatives (HC-L) in the age group of 20-69 year. The usual diet of the patients and HC was maintained, their fecal samples were collected and investigated by NMR-based global metabolic profiling coupled with multivariate statistical analysis.

RESULTS

We detected 55 metabolites in ¹ H-NMR spectra of fecal samples: four amines, 16 amino acids, six fatty acids, eight organic acids, three sugars, and 18 other compounds. Orthogonal partial least square-discriminant analysis derived score plots showed clear separation between the IBS-D group and the HC and HC-L groups. Among the 55 metabolites identified, we found five disease-relevant potential biomarkers distinguishing the IBS-D from the HC, namely, cadaverine, putrescine, threonine, tryptophan, and phenylalanine.

CONCLUSIONS

The patients with IBS-D were clearly differentiated from the HC and HC-L by fecal metabolite analysis using ¹ H-NMR spectroscopy, and five fecal metabolites characteristic of IBS-D were found. The findings of this study could be used to develop alternative and complementary diagnostic methods and as a source of fundamental information for developing novel therapies for IBS-D.

Anatomy, physiology, and updates on the clinical management of constipation

Clinical management of constipation has evolved from the prescription of dietary supplements, to potent stimulant laxatives, to corrective surgeries for organic blockage. Yet constipation does not respond to a one-size-fits-all treatment. In recent decades, the Bristol Stool Form Scale and Rome III diagnostic criteria have allowed for algorithmic diagnosis, yet these criteria could benefit from further extension and meaningful discussion. This review incorporates pertinent clinical updates and uses the anatomy and physiology of constipation as helpful signposts for the practicing clinician.

Transient Osmotic Perturbation Causes Long-Term Alteration to the Gut Microbiota

Osmotic diarrhea is a prevalent condition in humans caused by food intolerance, malabsorption, and widespread laxative use. Here, we assess the resilience of the gut ecosystem to osmotic perturbation at multiple length and timescales using mice as model hosts. Osmotic stress caused reproducible extinction of highly abundant taxa and expansion of less prevalent members in human and mouse microbiotas. Quantitative imaging revealed decimation of the mucus barrier during osmotic perturbation, followed by recovery. The immune system exhibited temporary changes in cytokine levels and a lasting IgG response against commensal bacteria. Increased osmolality prevented growth of commensal strains in vitro, revealing one mechanism contributing to extinction. Environmental availability of microbiota members mitigated extinction events, demonstrating how species reintroduction can affect community resilience. Our findings (1) demonstrate that even mild osmotic diarrhea can cause lasting changes to the microbiota and host and (2) lay the foundation for interventions that increase system-wide resilience.

Expert consensus on the assessment and treatment of chronic constipation in the elderly

It is of significant importance to scientifically assess and efficiently address chronic constipation in the elderly population. Therefore, organizing some domestic experts of geriatrics and gastroenterology, we have formulated this consensus to reference for clinical staff.

The Mexican consensus on chronic constipation

INTRODUCTION

Significant advances have been made in the knowledge and understanding of the epidemiology, pathophysiology, diagnosis, and treatment of chronic constipation, since the publication of the 2011 guidelines on chronic constipation diagnosis and treatment in Mexico from the Asociación Mexicana de Gastroenterología.

AIMS

To present a consensus review of the current state of knowledge about chronic constipation, providing updated information and integrating the new scientific evidence.

METHODS

Three general coordinators reviewed the literature published within the time frame of January 2011 and January 2017. From that information, 62 initial statements were formulated and then sent to 12 national experts for their revision. The statements were voted upon, using the Delphi system in 3 voting rounds (2 electronic and one face-to-face). The statements were classified through the GRADE system and those that reached agreement >75% were included in the consensus.

RESULTS AND CONCLUSIONS

The present consensus is made up of 42 final statements that provide updated knowledge, supplementing the information that had not been included in the previous guidelines. The strength of recommendation and quality (level) of evidence were established for each statement. The current definitions of chronic constipation, functional constipation, and opioid-induced constipation are given, and diagnostic strategies based on the available diagnostic methods are described. The consensus treatment recommendations were established from evidence on the roles of diet and exercise, fiber, laxatives, new drugs (such as prucalopride, lubiprostone, linaclotide, plecanatide), biofeedback therapy, and surgery.

Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments

Gastrointestinal (GI) side-effects of chemotherapy are a debilitating and often overlooked clinical hurdle in cancer management. Chemotherapy-induced constipation (CIC) and Diarrhea (CID) present a constant challenge in the efficient and tolerable treatment of cancer and are amongst the primary contributors to dose reductions, delays and cessation of treatment. Although prevalence of CIC is hard to estimate, it is believed to affect approximately 16% of cancer patients, whilst incidence of CID has been estimated to be as high as 80%. Despite this, the underlying mechanisms of both CID and CIC remain unclear, but are believed to result from a combination of intersecting mechanisms including inflammation, secretory dysfunctions, GI dysmotility and alterations in GI innervation. Current treatments for CIC and CID aim to reduce the severity of symptoms rather than combating the pathophysiological mechanisms of dysfunction, and often result in worsening of already chronic GI symptoms or trigger the onset of a plethora of other side-effects including respiratory depression, uneven heartbeat, seizures, and neurotoxicity. Emerging treatments including those targeting the enteric nervous system present promising avenues to alleviate CID and CIC. Identification of potential targets for novel therapies to alleviate chemotherapy-induced toxicity is essential to improve clinical outcomes and quality of life amongst cancer sufferers.

Comparable Efficacy of a 1-L PEG and Ascorbic Acid Solution Administered with Bisacodyl versus a 2-L PEG and Ascorbic Acid Solution for Colonoscopy Preparation: A Prospective, Randomized and Investigator-Blinded Trial

BACKGROUND

Two liters of polyethylene glycol (PEG) solution administered with ascorbic acid (Asc) can provide efficacy similar to that of a 4-L PEG solution for colonoscopy preparation. In addition, oral bisacodyl (Bis) has been shown to reduce the volume of PEG needed for a bowel preparation with comparable efficacy. This study aimed to compare the efficacy, tolerability and safety of a 2-L PEG solution mixed with Asc versus the combination of Bis, Asc and a 1-L PEG solution.

METHODS

This was a prospective, randomized, multi-centre, single-blind, non-inferiority trial. Participants who were scheduled for colonoscopy were included and randomized to receive either 2-L PEG and Asc (2L PEG/Asc group) or 1-L PEG, Asc and 20 mg Bis (1L PEG/Asc + Bis group). The quality of bowel preparation was assessed using the Boston Bowel Preparation Scale. Data regarding tolerance, compliance and adverse events were also gathered.

RESULTS

A total of 187 participants were analyzed; 96 were allocated to the 2L PEG/Asc group and 91 to the 1L PEG/Asc + Bis group. Bowel preparation was adequate in 87.5% (84/96) of patients in the 2L PEG/Asc group and 94.5% of the 1L PEG/Asc + Bis group (86/91, p = 0.10). There was no significant difference between the two groups with respect to compliance, tolerability or safety. The patients allocated to the 1L PEG/Asc + Bis group expressed more willingness to repeat the procedure than patients in the 2L PEG/Asc group (p = 0.01).

CONCLUSIONS

Bowel preparation with Bis and a 1-L PEG/Asc solution is as effective, well-tolerated, and safe as a 2-L PEG/Asc solution.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 01745835; Clinical Research Information Service (CRiS) KCT0000708.

Comparison of the effectiveness of polyethylene glycol with and without electrolytes in constipation: a systematic review and network meta-analysis

Background

Polyethylene glycol is commonly used to manage constipation and is available with or without electrolytes. The addition of electrolytes dates back to its initial development as lavage solutions in preparation for gastrointestinal interventions. The clinical utility of the addition of electrolytes to polyethylene glycol for the management of constipation is not established.

The objective of this systematic review and network meta-analysis (NMA) was to assess the relative effectiveness of polyethylene glycol with (PEG + E) or without electrolytes (PEG) in the management of functional constipation in adults.

Methods

A systematic review was conducted to identify randomised controlled clinical trials that assessed the use of polyethylene glycol in functional constipation. The primary outcome was the mean number of bowel movements per week.

Results

Nineteen studies were included in the NMA (PEG N = 9, PEG + E N = 8, PEG versus PEG + E N = 2; involving 2247 patients). PEG and PEG + E are both effective, increasing the number of bowel movements per week by 1.8 (95 % Crl 1.0, 2.8) and 1.9 (95 % Crl 0.9, 3.0) respectively versus placebo and by 1.8 (95 % Crl 0.0, 3.5) and 1.9 (95 % Crl 0.2, 3.6) respectively versus lactulose. There was no efficacy difference between PEG + E and PEG (0.1, 95 % Crl −1.1, 1.2) and there were no differences in safety or tolerability.

Conclusions

Polyethylene glycol with and without electrolytes are effective and safe treatments for constipation in adults. The addition of electrolytes to polyethylene glycol does not appear to offer any clinical benefits over polyethylene glycol alone in the management of constipation.

Approaches to managing chronic constipation in older people within the community setting

Constipation is a common presenting problem within the community setting, but its treatment is often unsatisfactory. It is important for nurses to remember that constipation is a symptom and not a disease. For older adults, constipation can have a gradual onset over a number of years, with many people 'self-medicating' with over-the-counter laxatives and herbal products, which then result in the need for daily laxatives. This article will consider best practice for the assessment, treatment, and prevention of constipation in adults within the community.

Interventions for treating constipation in pregnancy

BACKGROUND

Constipation is a common symptom experienced during pregnancy. It has a range of consequences from reduced quality of life and perception of physical health to haemorrhoids. An understanding of the effectiveness and safety of treatments for constipation in pregnancy is important for the clinician managing pregnant women.

OBJECTIVES

To assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered all published, unpublished and ongoing randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs, evaluating interventions (pharmacological and non-pharmacological) for constipation in pregnancy. Cross-over studies were not eligible for inclusion in this review. Trials published in abstract form only (without full text publication) were not eligible for inclusion.We compared one intervention (pharmacological or non-pharmacological) against another intervention, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Four studies were included, but only two studies with a total of 180 women contributed data to this review. It was not clear whether they were RCTs or quasi-RCTs because the sequence generation was unclear. We classified the overall risk of bias of three studies as moderate and one study as high risk of bias. No meta-analyses were carried out due to insufficient data.There were no cluster-RCTs identified for inclusion. Comparisons were available for stimulant laxatives versus bulk-forming laxatives, and fibre supplementation versus no intervention. There were no data available for any other comparisons.During the review process we found that studies reported changes in symptoms in different ways. To capture all data available, we added a new primary outcome (improvement in constipation) - this new outcome was not prespecified in our published protocol. Stimulant laxatives versus bulk-forming laxativesNo data were identified for any of this review's prespecified primary outcomes: pain on defecation, frequency of stools and consistency of stools.Compared to bulk-forming laxatives, pregnant women who received stimulant laxatives had significantly more improvement in constipation (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.21 to 2.09; 140 women, one study, moderate quality of evidence), but also significantly more abdominal discomfort (RR 2.33, 95% CI 1.15 to 4.73; 140 women, one study, low quality of evidence), and borderline difference in diarrhoea (RR 4.50, 95% CI 1.01 to 20.09; 140 women, one study, moderate quality of evidence). In addition, there was no significant difference in women's satisfaction (RR 1.06, 95% CI 0.77 to 1.46; 140 women, one study, moderate quality of evidence).No usable data were identified for any of this review's secondary outcomes: quality of life; dehydration; electrolyte imbalance; acute allergic reaction; or asthma. Fibre supplementation versus no interventionPregnant women who received fibre supplementation had significantly higher frequency of stools compared to no intervention (mean difference (MD) 2.24 times per week, 95% CI 0.96 to 3.52; 40 women, one study, moderate quality of evidence). Fibre supplementation was associated with improved stool consistency as defined by trialists (hard stool decreased by 11% to 14%, normal stool increased by 5% to 10%, and loose stool increased by 0% to 6%).No usable data were reported for either the primary outcomes of pain on defecation and improvement in constipation or any of this review's secondary outcomes as listed above. Quality Five outcomes were assessed with the GRADE software: improvement in constipation, frequency of stools, abdominal discomfort, diarrhoea and women's satisfaction. These were assessed to be of moderate quality except for abdominal discomfort which was assessed to be of low quality. The results should therefore be interpreted with caution. There were no data available for evaluation of pain on defecation or consistency of stools.

AUTHORS' CONCLUSIONS

There is insufficient evidence to comprehensively assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy, due to limited data (few studies with small sample size and no meta-analyses). Compared with bulk-forming laxatives, stimulant laxatives appear to be more effective in improvement of constipation (moderate quality evidence), but are accompanied by an increase in diarrhoea (moderate quality evidence) and abdominal discomfort (low quality evidence) and no difference in women's satisfaction (moderate quality evidence). Additionally, fibre supplementation may increase frequency of stools compared with no intervention (moderate quality evidence), although these results were of moderate risk of bias.There were no data for a comparison of other types of interventions, such as osmotic laxatives, stool softeners, lubricant laxatives and enemas and suppositories.More RCTs evaluating interventions for treating constipation in pregnancy are needed. These should cover different settings and evaluate the effectiveness of various interventions (including fibre, osmotic, and stimulant laxatives) on improvement in constipation, pain on defecation, frequency of stools and consistency of stools.

Evaluation of the structured bowel management program in inpatient rehabilitation: a prospective study

PURPOSE

The purpose of this study is to evaluate the impact of the structured bowel management program (SBMP) in an inpatient rehabilitation service.

METHOD

Prospective recruitment of consecutive patients admitted to the rehabilitation unit (n = 100). Each patient was assessed for bowel dysfunction on admission and an individualised SBMP was instituted based on the clinical needs. The assessments were at baseline (T1), and discharge from ward (T2) using validated questionnaires. Program evaluation was at 3-month (T3) post-discharge.

RESULTS

Participants were predominantly female (52%), mean age 68 ± 13 years. Almost one-half (43%) had neurological conditions and 41% musculoskeletal problems. At admission, 62% self-reported bowel dysfunction, mainly constipation (82%) and faecal incontinence (FI) (11%). At T2, participants showed significant improvement in bowel habit and stool consistency (Bristol stool chart, p < 0.001); severity of bowel symptoms such as FI (Wexner FI score, p < 0.05); and impact on quality of life (FI Quality of Life (QoL) subscales: "life style" and "coping/behavior", p < 0.05 for both). All functional independent measure "motor" and "cognition" subscales improved significantly (p < 0.01 for all), with moderate to large effect sizes (r = 0.5-0.7). No adverse effects were reported.

CONCLUSIONS

Bowel management should be a priority within rehabilitative services. Evidence-based SBMP can improve bowel symptoms and enhance overall QoL in patients admitted to rehabilitation settings.

IMPLICATIONS FOR REHABILITATION

Bowel dysfunction is common in inpatient rehabilitation settings. A structured bowel management program can improve bowel symptoms and enhance overall QoL in patient. Bowel management should be a priority for patients admitted to rehabilitation settings.

Efficacy of Adaptive Biofeedback Training in Treating Constipation-Related Symptoms

Biofeedback therapy is a well-known and effective therapeutic treatment for constipation. A previous study suggested that adaptive biofeedback (ABF) training was more effective than traditional (fixed training parameters) biofeedback training. The aim of this study was to verify the effectiveness of ABF in relieving constipation-related symptoms. We noticed that in traditional biofeedback training, a patient usually receives the training twice per week. The long training sessions usually led to poor compliance. This study proposes an intensive biofeedback therapy and compares intensive therapy with nonintensive therapy in patients with constipation-related symptoms. Methods. 63 patients with constipation-related symptoms were treated with ABF between 2012 and 2013. These patients were further divided into the intensive therapy and nonintensive therapy groups. Results. A total of 63 patients were enrolled in the study, including 24 in the nonintensive therapy group and 39 in the intensive therapy group. 100% (N = 21) of constipation patients achieved the primary efficacy endpoint (≥3 bowel movements/week). There was significant improvement in constipation-related symptoms after adaptive biofeedback. The intensive biofeedback therapy did not show better performance compared to nonintensive biofeedback therapy. Conclusions. This investigation provides support for the efficacy of biofeedback for constipation-related symptoms. The efficacy of intensive therapy is similar to nonintensive therapy.

Incidence and predictors of new-onset constipation during acute hospitalisation after stroke

OBJECTIVES

We investigated new-onset constipation in patients with stroke compared with orthopaedic conditions and explored the predictors associated with constipation during acute hospitalisation.

METHODS

This was a prospective matched cohort study of 110 patients comparing stroke patients (n = 55) with orthopaedic patients (n = 55) admitted to a large tertiary acute hospital. Both cohorts were matched by age and sex. The incidence of new-onset constipation which occurred during a patient's acute hospitalisation was determined. Demographics, comorbidity, clinical factors, laboratory parameters and medications were evaluated as possible predictors of constipation.

RESULTS

The incidence of new-onset constipation was high for both stroke (33%) and orthopaedic patients (27%; p = 0.66). Seven stroke patients (39%) and four orthopaedic patients (27%) developed their first onset of constipation on day 2 of admission. Mobility gains (RR 0.741, p < 0.001) and the use of prophylactic laxatives (RR 0.331, p < 0.01) had a protective effect against constipation. Bedpan use (RR 2.058, p < 0.05) and longer length of stay (RR 1.032, p < 0.05) increased the risk of developing new-onset constipation.

CONCLUSIONS

New-onset constipation is common among patients admitted for stroke and orthopaedic conditions during acute hospitalisation. The early occurrence, on day 2 of admission, calls for prompt preventive intervention for constipation.

Current and emerging pharmacotherapeutic options for irritable bowel syndrome

Treatment of irritable bowel syndrome (IBS) is challenging for both primary care physicians and gastroenterologists because of the heterogeneity of the patient population and the multifactorial pathophysiologies responsible for the symptoms in IBS. This review focuses on the current and emerging pharmacological treatments for IBS. Many of the current medications used to treat this disorder have distinct properties such as efficacy for different symptoms, safety profiles, contraindications, costs, dosing regimens, treatment duration and long-term data. All of these factors, in addition to patient preference and cognitive, food and environmental triggers, must be considered prior to any medication selection. This review will focus on randomized controlled trials with a general uniformity in study design, a rigorous patient selection and appropriate treatment durations. We will also discuss other exciting emerging treatments for IBS such as the µ-opioid receptor (agonists and antagonists), selective κ-opioid receptor agonists, anti-inflammatory drugs, serotonergic agents, bile acid modulators and intestinal bile acid transporters, which may prove promising in treating our patients.

Comparative effectiveness of senna to prevent problematic constipation in pediatric oncology patients receiving opioids: a multicenter study of clinically detailed administrative data

CONTEXT

Pediatric oncology patients often receive prolonged courses of opioids, which can result in constipation.

OBJECTIVES

Comparing patients who received senna matched with similar patients who received other oral bowel medications, determine the subsequent risk of "problematic constipation," assessed as the occurrence of the surrogate markers of receiving an enema, escalation of oral bowel medications, and abdominal radiographic imaging.

METHODS

This was a retrospective cohort study of hospitalized pediatric oncology patients less than 21 years of age in 78 children's and adult hospitals between 2006 and 2011 who were started on seven consecutive days or more of opioid therapy and were started on an oral bowel medication within the first two days of opioid therapy. Clinically detailed administrative data were used from the Pediatric Health Information System and the Premier Perspective Database. After performing propensity score matching of similar patients who started senna and who started a different oral bowel medication, Cox regression modeling was used to compare the subsequent hazard of the surrogate markers.

RESULTS

The final matched sample of 586 patients averaged 11.5 years of age (range 0-20 years); 41.8% (n = 245) had blood cancer, 50.3% (n = 295) had solid tumor cancer, and 7.9% (n = 46) had brain cancer. Initiating senna therapy within two days of starting the prolonged opioid course, compared with initiating another oral bowel medication, was significantly associated with a lower hazard during the ensuing five days for receipt of an enema (hazard ratio [HR], 0.31; 95% CI, 0.11-0.91) or undergoing abdominal radiographic imaging (HR, 0.74; 95% CI, 0.55-0.98), was marginally associated with a lower hazard of oral bowel medicine escalation (HR, 0.78; 95% CI, 0.59-1.03), and overall was significantly associated with a lower hazard of the composite end point of problematic constipation (HR, 0.70; 95% CI, 0.56-0.88).

CONCLUSION

Initiating senna therapy, compared with other oral bowel medications, diminishes the subsequent risk of surrogate markers of problematic constipation in this population.

Remedies for Children Constipation in Medieval Persia

Constipation in children with bowel movement less than 3 times a week and lasting for more than 3 months is defined as pediatric chronic constipation. According to traditional Persian medicine resources, dryness of food, low nutrition, hotness or dryness of the gastrointestinal tract, intestine sensory loss, excessive urination, increase of evaporation, and sweating because of heavy exercise will together constitute the condition for constipation occurrence. Lifestyle changes considered as premier of medical intervention for constipation. Treatment of constipation in children vastly benefitted from traditional Persian medicine, including simple dietary measures, oil massages, and herbal medicines. This investigation was performed to somewhat help the anxious academics to achieve proper findings in the field of gastroenterology, in pursuit of the traditional Persian medicine advices.

Health-related quality of life in dialysis patients with constipation: a cross-sectional study

OBJECTIVES

To evaluate differences in the health-related quality of life (HRQoL) between patients with constipation receiving hemodialysis (HD) and those receiving peritoneal dialysis (PD).

METHODS

In this cross-sectional study, 605 dialysis patients (478 HD cases and 127 PD cases; all patients were older than 18 years) from our hospital were included. A questionnaire was used to evaluate their constipation statuses. The effect of constipation on HRQoL was assessed, using the Chinese version of the 12-item short-form (SF-12) general health survey. Karnofsky score, sociodemographic, and clinical data were also collected. We performed multiple logistic regression analysis to define independent risk factors for constipation and impaired HRQoL.

RESULTS

A total of 605 participants (326 men [53.9%] and 279 women [46.1%]) were surveyed. The incidence of constipation was 71.7% in HD patients and 14.2% in PD patients. Dialysis patients with constipation had significantly lower mean SF-12 Physical Component Summary scale and Mental Component Summary scale scores than the nonconstipation group (P < 0.05), whereas HD patients had better SF-12 Physical Component Summary and Mental Component Summary scores than PD patients (P < 0.05). When we performed multivariate logistic regression analysis, dialysis modality, diabetes, and the number of constipation-related medications were three independent risk factors associated with constipation. As for impaired HRQoL in the constipated dialysis population, dialysis modality was found to be another independent risk factor in addition to age and diabetes.

CONCLUSION

PD patients with constipation had worse HRQoL than HD control participants. We should pay more attention to the patients with constipation receiving PD, as peritonitis caused by constipation was associated with a higher mortality.

An in vitro investigation of the cardiovascular effects of the 5-HT(4) receptor selective agonists, velusetrag and TD-8954

The 5-HT(4) receptor agonists, and gastrointestinal (GI) prokinetic agents, cisapride and tegaserod, lack selectivity for the 5-HT(4) receptor. Cisapride is a potent human ether-à-go-go-related gene (hERG) potassium channel inhibitor while cisapride and tegaserod have significant affinity for 5-HT(1) and 5-HT(2) receptor subtypes. Marketing of both compounds was discontinued due to cardiovascular concerns (cardiac arrhythmias with cisapride and ischemic events with tegaserod). The reported association of tegaserod with ischemia has been postulated to involve coronary artery constriction or augmentation of platelet aggregation. This in vitro study investigated the effects of two of the new generation of highly selective 5-HT(4) receptor agonists, velusetrag and TD-8954, on canine, porcine and human coronary artery tone, human platelet aggregation and hERG potassium channel conductance. No significant off-target actions of velusetrag or TD-8954 were identified in these, and prior, studies. While cisapride inhibited potently the hERG channel currents, tegaserod failed to affect platelet aggregation, and had only a small contractile effect on the canine coronary artery at high concentrations. Tegaserod inhibited the 5-HT-induced contractile response in the porcine coronary artery. New generation 5-HT(4) receptor agonists hold promise for the treatment of patients suffering from GI motility disorders with a reduced cardiovascular risk.

Clinical trial: marine lipid suppositories as laxatives

Cod-liver oil and other marine products containing polyunsaturated fatty acids have anti-inflammatory, anti-bacterial and anti-viral effects and may be useful in the treatment of various inflammatory and infectious diseases. We developed suppositories and ointment with 30% free fatty acid (FFA) extract from omega-3 fish oil. Our purpose was to evaluate the safety of marine lipid suppositories and ointment in healthy volunteers and to explore the laxative effect of the suppositories. Thirty healthy volunteers were randomized either to a study group administrating 30% FFA suppositories and applying 30% FFA ointment to the perianal region twice per day for two weeks, or to a control group using placebo suppositories and ointment in a double blinded manner. Results: No serious toxic effects or irritation were observed. In the study group 93% felt the urge to defecate after administration of the suppositories as compared to 37% in the control group (P = 0.001). Subsequently 90% in the study group defecated, compared to 33% in the control group (P = 0.001). Conclusion: The marine lipid suppositories and ointment were well tolerated with no significant toxic side effects observed during the study period. The suppositories have a distinct laxative effect and we aim to explore this effect in further clinical trials.

Toxicology and safety of the tincture of Operculina alata in patients with functional constipation

The tincture of Operculina alata, popularly known as "tincture of jalapa", is used in Northeast Brazil to treat constipation and encephalic vascular accident, but it has not yet been adequately tested for safety and efficacy. The aim of this study was to evaluate the toxicology and safety of the tincture of O. alata in patients with functional constipation. This was a double-blind, randomized, placebo-controlled clinical trial. The study consisted of three phases: pre-treatment, treatment and post-treatment, each phase with duration of seven days. Arterial pressure, heart rate, body weight, adverse events, hematological, metabolic, liver and kidney functions were monitored. Forty patients were randomized to receive tincture of O. alata and 43 patients to receive placebo. There were statistical differences in the clinical aspects between groups, but these changes were not considered clinically significant. Adverse events were considered not serious and of mild intensity, especially dizziness, headache, abdominal pain and nausea. This clinical trial confirmed the safety of the tincture of O. alata in the pharmaceutical form and dosage tested, allowing the product to be safely used in a larger population for the assessment of its clinical efficacy.

Randomized controlled trial of laxative use in postcolostomy surgery patients

PURPOSE

We compared a standardized postoperative laxative protocol to laxatives provided on an ad hoc basis by the surgical team.

SUBJECTS AND SETTING

Forty-five patients who underwent colostomy surgery participated in the study. The research setting was 2 acute care facilities in south-eastern Sydney, New South Wales, Australia.

METHODS

A randomized controlled trial was conducted. The intervention group (n 5 19) received a standardized laxative protocol postsurgery. Two types of laxatives were selected for first-line treatment: sterculia and frangula bark (Normacol Plus), a bulking agent and stimulant; and liquid paraffin (Agarol), a stool softener. An iso-osmotic polyethylene glycol macrogel (Movicol) was chosen as second-line treatment. The comparison group (n = 26) received laxative intervention(s) as preferred by the surgical team. Constipation, measured as fecal loading on plain abdominal film, stomal therapy nurse activity, patient comfort, and length of hospital stay were compared between intervention and control groups.

RESULTS

The presence of fecal loading favored the intervention group (1 episode in the treatment group vs 7 episodes in the comparison group; χ5 = 3.8; P = .05). This finding suggests that the laxative protocol given to the treatment group was more likely to prevent fecal loading/constipation when compared to the ad hoc laxative group. Stomal therapy nurse activity in terms of the number of empty bag changes was significantly higher in the comparison group (F 5 4.8; P 5 .03).

CONCLUSION

The findings of this study support the benefits of a standardized laxative protocol for prevention of constipation. Data collection was discontinued after 3 years due to a contamination effect developing, because our surgeons observed the utility of the laxative protocol and incorporated it into their routine practice. Further experimental research is needed to explore the best constipation prevention approaches for postcolostomy surgery patients.

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.

Deconstructing 14-phenylpropyloxymetopon: minimal requirements for binding to mu opioid receptors

A series of phenylpropyloxyethylamines and cinnamyloxyethylamines were synthesized as deconstructed analogs of 14-phenylpropyloxymetopon and analyzed for opioid receptor binding affinity. Using the Conformationally Sampled Pharmacophore modeling approach, we discovered a series of compounds lacking a tyrosine mimetic, historically considered essential for μ opioid binding. Based on the binding studies, we have identified the optimal analogs to be N-methyl-N-phenylpropyl-2-(3-phenylpropoxy)ethanamine, with 1520 nM, and 2-(cinnamyloxy)-N-methyl-N-phenethylethanamine with 1680 nM affinity for the μ opioid receptor. These partial opioid structure analogs will serve as the novel lead compounds for future optimization studies.

Managing constipation: a focus on care and treatment in the palliative setting

Constipation can cause unnecessary discomfort and suffering for patients, and there appears to be a lack of awareness among nurses and doctors about its cause, impact and management. A large proportion of the evidence for the assessment and management of constipation in the context of palliative care is derived from the perspective of advanced cancer and from guidelines developed at a European level. Although constipation remains a problem for palliative care patients, early intervention combined with continuous and impeccable assessment can assist in its management and improve patient comfort at the end of life.

Most recent developments and modifications of 14-alkylamino and 14-alkoxy-4,5-epoxymorphinan derivatives

The 14-position of natural opiates (e.g. morphine) are unsubstituted, however synthetic approaches have uncovered that functionalizing position 14 gives rise to a wide range of diverse activities. This review focuses on SAR of the position, with the aim of aiding in the search for opioid analgesics with improved clinical profiles.

Alternatives to prokinetics to move the pylorus and colon

PURPOSE OF REVIEW

Gastrointestinal motility disorders (GMDs) are common in the ICU. When encountering these problems, one typically thinks of prokinetics. This review summarizes current evidence of treatments.

RECENT FINDINGS

Prokinetics are not the first-line therapy for GMDs. In fact, the clinical implications of using prokinetic agents are rather controversial. Current evidence on alternative treatment modalities such as fluid and electrolyte management, laxatives, opioid antagonists, purgative enemas, acupuncture, physical therapies and probiotics is growing.

SUMMARY

Current state of the art to treat GMDs is primarily focused at the elimination of underlying trigger factors. Fluid and electrolyte management as well as laxatives and peripherally acting μ-opioid receptor antagonists are the recommended first-line therapies that can be complemented with prokinetics. Acupuncture as well as physical modalities, such as massage or warming of the abdomen, is promising with few side-effects and should be considered as well.

Medical management of constipation

Constipation is a common clinical problem. Initial management of chronic constipation should include lifestyle maneuvers, and increased fiber and fluids. Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide were all more effective than placebo for treating chronic idiopathic constipation. Many commonly used agents lack quality evidence supporting their use.

Chronic constipation in the elderly

Constipation is one of the most frequent gastrointestinal disorders encountered in clinical practice in Western societies. Its prevalence increases with age and is more frequently reported in female patients. Chronic constipation has been associated with considerable impairment in quality of life, can result in large individual healthcare costs, and represents a burden to healthcare delivery systems. This review will focus on the definition, epidemiology, diagnostic approach, and non-pharmacologic as well as pharmacologic management of chronic constipation in the elderly, including an overview of new medications currently under clinical investigation.

The LUCK study: Laxative Usage in patients with GP-diagnosed Constipation in the UK, within the general population and in pregnancy. An epidemiological study using the General Practice Research Database (GPRD)

BACKGROUND

Despite the high prevalence of constipation and its related public health implications, there is relatively little research available on the condition from large epidemiological studies. The aim of this study was to investigate the epidemiology of general practitioner (GP)-diagnosed constipation and the prescribing trends for laxatives in the UK, within the general population and during pregnancy.

METHODS

A cohort study for the period from 2005 to 2009 was performed using the UK primary care database (General Practice Research Database), which contains information on over 3 million individuals.

RESULTS

The prevalence of GP-diagnosed constipation ranged from 12 per 1000 persons in 2005 (0.012 per person year) to 12.8 per 1000 in 2009 (0.013 per person year). The prevalence was almost twice as high in women as in men, and was higher in older patients. In 2005 the most commonly prescribed laxatives were lactulose (37%), senna (26%), macrogol (19%), ispaghula (6%), docusate sodium (5%), bisacodyl (4%) and glycerol suppositories (2%). By 2009, this pattern had changed: macrogol (31%), lactulose (29%), senna (22%), ispaghula (5%), docusate sodium (6%), bisacodyl (3%) and glycerol suppositories (3%). In pregnancy, lactulose accounted for 81% of laxative use in 2005, falling to 64% by 2009. In contrast, macrogol use in pregnancy rose from 13% in 2005 to 32% in 2009.

CONCLUSIONS

GP-diagnosed constipation is common, accounting for a large number of consultations. Laxative prescribing trends have changed over the 5-year study period, prescriptions for macrogol becoming increasingly common and prescriptions for lactulose and senna less common. Macrogol also appears to have been replacing lactulose for treating constipation in pregnant women.

Effectiveness of palliative care services in symptom control of patients with advanced terminal cancer: a spanish, multicenter, prospective, quasi-experimental, pre-post study

CONTEXT

In implementing the National Strategy of Palliative Care in Spain, there needs to be an evaluation of services, especially of their effectiveness, efficiency, and satisfaction of patients and families.

OBJECTIVES

To assess the effectiveness of palliative care services (PCS) in improving symptom control in Spain.

METHODS

This multicenter, prospective, quasi-experimental, pre-post intervention study evaluated symptoms, such as pain, breakthrough pain, anorexia, nausea/vomiting, constipation, insomnia, dyspnea at rest and with movement, anxiety, and depression, using patient-reported numeric rating scales on Days 0, 7, and 14 after referral to a PCS.

RESULTS

Of the 318 PCSs included in the National Directory for 2004, 105 services in the 17 autonomous regions of Spain were able to report 265 eligible (treatment-naïve) patients. Nonparticipation by some centers was because of excessive workload or because their patients were not treatment-naïve. Median survival was 42 days. Pain severity and number of crises of breakthrough pain significantly improved, as did other indicators of patient satisfaction. Symptom improvement was independent of type of service (in acute bed hospitals, medium-term stay facilities, hospital support teams, home care support teams, and outpatient clinics).

CONCLUSION

Our national plan appears to be successful in reducing symptoms irrespective of the type of organization providing the PCS. An area for improvement could be to lessen the workload of individual teams.

The role of opioid receptor antagonists in the treatment of opioid-induced constipation: a review

Opioid-induced constipation (OIC) is associated with negative impact of opioid analgesics on opioid receptors located in the gut wall. Until recently, OIC was treated symptomatically only, with different laxatives which did not target the pathophysiology of OIC. Recently, several opioid receptor antagonists have been introduced in the treatment of OIC. Methylnaltrexone (MNTX) is a peripheral mu-opioid receptor antagonist for subcutaneous administration, which does not evoke symptoms of opioid abstinence. MNTX is indicated for patients with OIC who are not amenable to therapy with oral laxatives. In clinical trials, the effectiveness of MNTX assessed as its ability to induce spontaneous bowel movement, is 50%-60% of treated patients; MNTX demonstrates significant superiority over placebo. Another product is combination of oral formulation of prolonged release oxycodone and prolonged release naloxone (PR oxycodone/PR naloxone), indicated for patients who require opioid administration for chronic pain and have already developed OIC, and for those who need opioid therapy and take the drug to prevent OIC. Naloxone administered orally displays local, antagonist effects on opioid receptors in the gut wall, negligible systemic bioavailability, and significantly reduces the oxycodone constipating effect. PR oxycodone/PR naloxone has similar analgesic efficacy, but causes less constipation and less laxative consumption in comparison with patients treated with oxycodone alone. Both products are expensive, therefore their administration should be carefully considered. On the other hand, uncontrolled OIC and the necessity to perform rectal invasive procedures (enema, manual evacuation) lead not only to increased health care costs, but most importantly, cause severe patient suffering.

Methylnaltrexone: treatment for opioid-induced constipation

Opioids have become the gold standard for treatment of severe pain in advanced disease, but adverse effects can affect the quality of life. Opioid-induced bowel dysfunction can lead to refractory constipation. Methylnaltrexone bromide is a peripherally acting mu antagonist and is indicated for the treatment of opioid-induced constipation in patients with advanced illness, when response to standard laxative therapy has been inefficacious. This pharmacology update will review the etiology, pathophysiology, and treatment of opioid-induced constipation, focused on methylnaltrexone as a novel treatment for refractory cases.

[Methylnaltrexone. A new approach for therapy of opioid-induced obstipation]

Chronic pain patients using opioids frequently suffer from constipation which compromises well-being. Such an opioid-induced gastro-intestinal complication can occur regularly in patients in palliative care as well as in analgesic sedated intensive care patients or during prolonged perioperative pain therapy. Discomfort and distress in the affected patients can be so severely pronounced that they would rather suffer from the pain than from the side effect of constipation. Conventional therapy can be insufficient in providing satisfactory relief of constipation, mostly because this opioid-induced bowel hypomotility can be laxative-resistant. Moreover, constipation does not decrease during the course of therapy as do other side effects. It is well known that opioid-induced constipation is mediated via activation of micro-opioid receptors in the gastrointestinal tract. Selective peripheral micro-receptor antagonists (such as methylnaltrexone, Relistor) can effectively treat opioid-induced constipation. An interference with central analgesia does not occur as the molecules cannot pass the blood-brain barrier due to their charged states. A reduction of opioid therapy or the development of withdrawal symptoms can be avoided. Studies have shown that methylnaltrexone is not only safe and efficient for chronically constipated palliative care patients but offers promising therapeutic options for further patient collectives.