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Guy D, Wootten JC, Wong M, Turski D, Lukewich M, Alboog A, Kandasamy AR, Gregory J, Poolacherla R. Pharmacodynamic effects following co-administration of cannabinoids and opioids: a scoping review of human experimental studies. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:423-434. [PMID: 38561178 DOI: 10.1093/pm/pnae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/29/2023] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Cannabinoids are increasingly used in the management of chronic pain. Although analgesic potential has been demonstrated, cannabinoids interact with a range of bodily functions that are also influenced by chronic pain medications, including opioids. OBJECTIVE We performed a scoping review of literature on the pharmacodynamic effects following the co-administration of cannabinoids and opioids. METHODS We systematically searched EMBASE, PubMed, and PsycINFO for studies that experimentally investigated the co-effects of cannabinoids and opioids in human subjects. Available evidence was summarized by clinical population and organ system. A risk of bias assessment was performed. RESULTS A total of 16 studies met the inclusion criteria. Study populations included patients with chronic non-cancer and cancer pain on long-term opioid regimens and healthy young adults without prior exposure to opioids who were subject to experimental nociceptive stimuli. Commonly administered cannabinoid agents included Δ9-tetrahydrocannabinol and/or cannabidiol. Co-administration of cannabinoids and opioids did not consistently improve pain outcomes; however, sleep and mood benefits were observed in chronic pain patients. Increased somnolence, memory and attention impairment, dizziness, gait disturbance, and nauseousness and vomiting were noted with co-administration of cannabinoids and opioids. Cardiorespiratory effects following co-administration appeared to vary according to duration of exposure, population type, and prior exposure to cannabinoids and opioids. CONCLUSIONS The available evidence directly investigating the pharmacodynamic effects following co-administration of cannabinoids and opioids for non-analgesic outcomes is scarce and suffers from a lack of methodological reporting. As such, further research in this area with comprehensive methodologic reporting is warranted.
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Affiliation(s)
- David Guy
- Department of Anesthesiology, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Jared C Wootten
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael Wong
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel Turski
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mark Lukewich
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Abdulrahman Alboog
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Anesthesia and ICU, University of Jeddah, College of Medicine Jeddah, Saudi Arabia
| | - Abirami R Kandasamy
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Hospital-London's Health Science Center, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Jonathan Gregory
- First Episode Mood & Anxiety Program, Emergency Diversion Clinic for Children's Hospital, and Ambulatory Child & Adolescent Mental Health Care Program, London, ON, Canada
| | - Raju Poolacherla
- Pediatric Chronic Pain Program, London Health Sciences Centre, London, ON, Canada
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Squeo F, Celiberto F, Ierardi E, Russo F, Riezzo G, D’Attoma B, Leo AD, Losurdo G. Opioid-induced Constipation: Old and New Concepts in Diagnosis and Treatment. J Neurogastroenterol Motil 2024; 30:131-142. [PMID: 38576366 PMCID: PMC10999847 DOI: 10.5056/jnm23144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 04/06/2024] Open
Abstract
Daily use of opioid analgesics has significantly increased in recent years due to an increasing prevalence of conditions associated with chronic pain. Opioid-induced constipation (OIC) is one of the most common, under-recognized, and under-treated side effects of opioid analgesics. OIC significantly reduces the quality of life by causing psychological distress, lowering work productivity, and increasing access to healthcare facilities. The economic and social burden of OIC led to the development of precise strategies for daily clinical practice. Key aspects are the prevention of constipation through adequate water intake and fiber support, avoidance of sedentariness, and early recognition and treatment of cofactors that could worsen constipation. Recommended first-line therapy includes osmotic (preferably polyethylene glycol) and stimulant laxatives. Peripherally acting μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, or naldemedine, should be used in patients that have not responded to the first-line treatments. The bowel functional index is the main tool for assessing the severity of OIC and for monitoring the response. The paper discusses the recent literature on the pathophysiology, clinical evaluation, and management of OIC and provides a pragmatic approach for its assessment and treatment.
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Affiliation(s)
- Francesco Squeo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesca Celiberto
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
- PhD Course in Organs and Tissues Transplantation and Cellular Therapies, Department of Precision Medicine Jonic Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Russo
- Functional Gastrointestinal Disorders Research Group, National Institute of Gastroenterology IRCCS “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Giuseppe Riezzo
- Functional Gastrointestinal Disorders Research Group, National Institute of Gastroenterology IRCCS “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Benedetta D’Attoma
- Functional Gastrointestinal Disorders Research Group, National Institute of Gastroenterology IRCCS “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
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Kistemaker KRJ, de Graeff A, Crul M, de Klerk G, van de Ven PM, van der Meulen MP, van Zuylen L, Steegers MAH. Magnesium hydroxide versus macrogol/electrolytes in the prevention of opioid-induced constipation in incurable cancer patients: study protocol for an open-label, randomized controlled trial (the OMAMA study). BMC Palliat Care 2023; 22:22. [PMID: 36915062 PMCID: PMC10012532 DOI: 10.1186/s12904-023-01143-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a common symptom in cancer patients treated with opioids with a prevalence of up to 59%. International guidelines recommend standard laxatives such as macrogol/electrolytes and magnesium hydroxide to prevent OIC, although evidence from randomized controlled trials is largely lacking. The aim of our study is to compare magnesium hydroxide with macrogol /electrolytes in the prevention of OIC in patients with incurable cancer and to compare side-effects, tolerability and cost-effectiveness. METHODS Our study is an open-label, randomized, multicenter study to examine if magnesium hydroxide is non-inferior to macrogol/electrolytes in the prevention of OIC. In total, 330 patients with incurable cancer, starting with opioids for pain management, will be randomized to treatment with either macrogol/electrolytes or magnesium hydroxide. The primary outcome measure is the proportion of patients with a score of < 30 on the Bowel Function Index (BFI), measured on day 14. The Rome IV criteria for constipation, side effects of and satisfaction with laxatives, pain scores, quality of life (using the EQ-5D-5L), daily use of laxatives and escape medication, and cost-effectiveness will also be assessed. DISCUSSION In this study we aim to examine if magnesium hydroxide is non-inferior to macrogol/electrolytes in the prevention of OIC. The outcome of our study will contribute to prevention of OIC and scientific evidence of guidelines on (opioid-induced) constipation. TRIAL REGISTRATION This trial is registered at clinicaltrials.gov: NCT05216328 and in the Dutch trial register: NTR80508. EudraCT number 2022-000408-36.
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Affiliation(s)
- K R J Kistemaker
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands. .,Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands. .,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, De Bilt, The Netherlands
| | - M Crul
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Clinical Pharmacology and Pharmacy, De Boelelaan 1117, Amsterdam, The Netherlands
| | - G de Klerk
- Spaarne Gasthuis Location Hoofddorp, Medical Oncology, Spaarnepoort 1, Hoofddorp, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M P van der Meulen
- Department of Epidemiology and Health Economics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L van Zuylen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - M A H Steegers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
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Abstract
Opioid-induced constipation (OIC) is a common condition in older adults who may not be responsive to traditional laxative therapy. OIC is defined as new or worsening constipation symptoms that occur with initiation of or altering the dose of opioid analgesia. For adult patients with OIC and noncancer pain, we recommend considering nonpharmacologic interventions (eg, dietary measures, increased physical activity, and biofeedback training) and over-the-counter laxatives, followed by prescription opioid receptor antagonists (methylnaltrexone, naloxegol, and naldemedine) if traditional over-the-counter laxatives fail. Other options may include lubiprostone, linaclotide, plecanatide, and prucalopride; however, these are not indicated for OIC specifically or studied in older adults. Because of the complex nature of absorption, distribution, metabolism, and excretion in the aging population, all agents used to treat OIC must be evaluated individually and reevaluated as patients continue to age. This review will serve as a guide to managing OIC in older adults.
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Candy B, Jones L, Vickerstaff V, Larkin PJ, Stone P. Mu-opioid antagonists for opioid-induced bowel dysfunction in people with cancer and people receiving palliative care. Cochrane Database Syst Rev 2022; 9:CD006332. [PMID: 36106667 PMCID: PMC9476137 DOI: 10.1002/14651858.cd006332.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Opioid-induced bowel dysfunction (OIBD) is characterised by constipation, incomplete evacuation, bloating, and gastric reflux. It is one of the major adverse events (AEs) of treatment for pain in cancer and palliative care, resulting in increased morbidity and reduced quality of life. This review is a partial update of a 2008 review, and critiques as previous update (2018) trials only for people with cancer and people receiving palliative care. OBJECTIVES To assess for OIBD in people with cancer and people receiving palliative care the effectiveness and safety of mu-opioid antagonists (MOAs) versus different doses of MOAs, alternative pharmacological/non-pharmacological interventions, placebo, or no treatment. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science (December 2021), clinical trial registries and regulatory websites. We sought contact with MOA manufacturers for further data. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the effectiveness and safety of MOAs for OIBD in people with cancer and people at a palliative stage irrespective of the type of terminal disease. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias and extracted data. The appropriateness of combining data from the trials depended upon sufficient homogeneity across trials. Our primary outcomes were laxation response, effect on analgesia, and AEs. We assessed the certainty of evidence using GRADE and created summary of findings tables. MAIN RESULTS We included 10 studies (two new trials) randomising in-total 1343 adults with cancer irrespective of stage, or at palliative care stage of any disease. The MOAs were oral naldemedine and naloxone (alone or in combination with oxycodone), and subcutaneous methylnaltrexone. The trials compared MOAs with placebo, MOAs at different doses, or in combination with other drugs. Two trials of naldemedine and three of naloxone with oxycodone were in people with cancer irrespective of disease stage. The trial on naloxone alone was in people with advanced cancer. Four trials on methylnaltrexone were in palliative care where most participants had advanced cancer. All trials were vulnerable to biases; most commonly, blinding of the outcome assessor was not reported. Oral naldemedine versus placebo Risk (i.e. chance) of spontaneous laxations in the medium term (over two weeks) for naldemedine was over threefold greater risk ratio (RR) 2.00, 95% confidence interval (CI) 1.59 to 2.52, 2 trials, 418 participants, I² = 0%. Number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 3 to 4; moderate-certainty evidence). Earlier risk of spontaneous laxations and patient assessment of bowel change was not reported. Very low-certainty evidence showed naldemedine had little to no effect on opioid withdrawal symptoms. There was little to no difference in the risk of serious (non-fatal) AEs (RR 3.34, 95% CI 0.85 to 13.15: low-certainty evidence). Over double the risk of AEs (non-serious) reported with naldemedine (moderate-certainty evidence). Low-dose oral naldemedine versus higher dose Risk of spontaneous laxations was lower for the lower dose (medium term, 0.1 mg versus 0.4 mg: RR 0.69, 95% CI 0.53 to 0.89, 1 trial, 111 participants (low-certainty evidence)). Earlier risk of spontaneous laxations and patient assessment of bowel change not reported. Low-certainty evidence showed little to no difference on opioid withdrawal symptoms (0.1 mg versus 0.4 mg mean difference (MD) -0.30, 95% CI -0.85 to 0.25), and occurrences of serious AEs (0.1 mg versus 0.4 mg RR 0.25, 95% CI 0.03 to 2.17). Low-certainty evidence showed little to no difference on non-serious AEs. Oral naloxone versus placebo Risk of spontaneous laxations and AEs not reported. Little to no difference in pain intensity (very low-certainty evidence). Full data not given. The trial reported that no serious AEs occurred. Oral naloxone + oxycodone versus oxycodone Risk of spontaneous laxations within 24 hours and in the medium term not reported. Low-certainty evidence showed naloxone with oxycodone reduced the risk of opioid withdrawal symptoms. There was little to no difference in the risk of serious (non-fatal) AEs (RR 0.68, 95% CI 0.44 to 1.06), 3 trials, 362 participants, I² = 55%: very low-certainty evidence). There was little to no difference in risk of AEs (low-certainty evidence). Subcutaneous methylnaltrexone versus placebo Risk of spontaneous laxations within 24 hours with methylnaltrexone was fourfold greater than placebo (RR 2.97, 95% CI 2.13 to 4.13. 2 trials, 287 participants, I² = 31%. NNTB 3, 95% CI 2 to 3; low-certainty evidence). Risk of spontaneous laxations in the medium term was over tenfold greater with methylnaltrexone (RR 8.15, 95% CI 4.76 to 13.95, 2 trials, 305 participants, I² = 47%. NNTB 2, 95% CI 2 to 2; moderate-certainty evidence). Low-certainty evidence showed methylnaltrexone reduced the risk of opioid withdrawal symptoms, and did not increase risk of a serious AE (RR 0.59, 95% CI 0.38 to 0.93. I² = 0%; 2 trials, 364 participants). The risk of AEs was higher for methylnaltrexone (low-certainty evidence). Lower-dose subcutaneous methylnaltrexone versus higher dose There was little to no difference in risk of spontaneous laxations in the medium-term (1 mg versus 5 mg or greater: RR 2.91, 95% CI 0.82 to 10.39; 1 trial, 26 participants very low-certainty evidence), or in patient assessment of improvement in bowel status (RR 0.98, 95% CI 0.71 to 1.35, 1 trial, 102 participants; low-certainty evidence). Medium-term assessment of spontaneous laxations and serious AEs not reported. There was little to no difference in symptoms of opioid withdrawal (MD -0.25, 95% CI -0.84 to 0.34, 1 trial, 102 participants) or occurrence of AEs (low-certainty evidence). AUTHORS' CONCLUSIONS This update's findings for naldemedine and naloxone with oxycodone have been strengthened with two new trials, but conclusions have not changed. Moderate-certainty evidence for oral naldemedine on risk of spontaneous laxations and non-serious AEs suggests in people with cancer that naldemedine may improve bowel function over two weeks and increase the risk of AEs. There was low-certainty evidence on serious AEs. Moderate-certainty evidence for methylnaltrexone on spontaneous laxations over two weeks suggests subcutaneous methylnaltrexone may improve bowel function in people receiving palliative care, but certainty of evidence for AEs was low. More trials are needed, more evaluation of AEs, outcomes patients rate as important, and in children.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Philip J Larkin
- UCD School of Nursing, Midwifery and Health Systems and Our Lady's Hospice and Care Services, UCD College of Health Sciences, Dublin, Ireland
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Kern KU, Vogelmann T, Tölle TR. [Tapentadol versus classical WHO-III opioids for chronic back pain. Health services research study based on representative data from health insurance funds]. MMW Fortschr Med 2022; 164:19-27. [PMID: 35449488 DOI: 10.1007/s15006-022-0876-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND/OBJECTIVE In clinical trials, tapentadol prolonged release (PR) showed a more favourable gastrointestinal tolerability profile compared to other strong opioids in the treatment of pain. The present analysis compared tapentadol PR and classical WHO-III PR opioids in routine clinical practice. METHOD Retrospective cohort study (matched pair approach) using anonymised health insurance data of patients with chronic low back pain who were prescribed strong opioids following pretreatment with WHO-I/II analgesics. Data were analysed from the date of first prescription in 2015 over a maximum period of two years. The primary analysis parameter was the prescription of laxatives. RESULTS Data of 227 patients per cohort could be included in the analysis. Significantly fewer tapentadol PR than WHO-III PR patients were prescribed laxatives (20.3% vs. 37%; p < 0.0001). In addition, laxative dosages were significantly lower in the tapentadol PR cohort (26.4 vs. 82.5 defined daily doses; p < 0.0001). A significant difference in laxative prescription was also observed under long-term treatment (tapentadol PR patients 27.7% vs. WHO-III PR patients 50%; p = 0.0029). CONCLUSION Routine clinical practice indirectly confirmed the more favourable gastrointestinal tolerability of tapentadol PR in the treatment of chronic pain which had previously been demonstrated in clinical trials and non-interventional studies.
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Affiliation(s)
- Kai-Uwe Kern
- Schmerzpraxis Wiesbaden, Institut für Schmerzmedizin, Sonnenberger Str. 68, 65193, Wiesbaden, Germany.
| | | | - Thomas R Tölle
- Neurologische Klinik u. Poliklinik, Klinikum rechts d. Isar d. TU München, München, Germany
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Franco J, de Souza RN, Lima TDM, Moriel P, Visacri MB. Role of clinical pharmacist in the palliative care of adults and elderly patients with cancer: A scoping review. J Oncol Pharm Pract 2022; 28:664-685. [PMID: 35019805 DOI: 10.1177/10781552211073470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We conducted this scoping review to map and summarize scientific evidence on the role of clinical pharmacists in the palliative care of adults and elderly patients with cancer. DATA SOURCES A literature search was performed in MEDLINE, PubMed Central, Embase, Web of Science, Scopus, and BVS/BIREME for studies published until November 22nd, 2020. Studies that reported work experiences adopted by clinical pharmacists in the palliative care of adults and elderly patients with cancer were included. Two independent authors performed study selection and data extraction. Any disagreements were resolved by discussion with the third and fourth authors. The pharmacist interventions identified in the included studies were described based on key domains in the DEPICT v.2. DATA SUMMARY A total of 586 records were identified, of which 14 studies fully met the eligibility criteria. Most of them were conducted in the United States of America (n = 5) and Canada (n = 5) and described the workplace of the pharmacist in clinic/ambulatory (n = 10). Clinical pharmacists performed several activities and provided services, highlighting medication review (n = 12), patient and caregivers education (n = 12), medication histories and-or medication reconciliation (n = 6). The pharmacist interventions were mostly conducted for patients/caregivers (n = 13), by one-on-one contact (n = 14), and by face-to-face (n = 13). Pharmacists were responsible mainly for change or suggestion for change in therapy (n = 12) and patient counselling (n = 12). Pharmacist interventions were well accepted by the clinical team. Overall, studies showed that pharmacists, within an interdisciplinary team, had significant impacts on measured outcomes. CONCLUSIONS In recent years, there have been advances in the role of the pharmacist in palliative care of patients with cancer and there are great opportunities in this field. They play an important role in managing cancer pain and other symptoms, as well as resolving drug related problems. We encourage more research to be carried out to strengthen this field and to benefit patients with advanced cancer with higher quality of life.
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Affiliation(s)
- Julia Franco
- School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Rafael N de Souza
- School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Tácio de M Lima
- Department of Pharmaceutical Sciences, 67825Federal Rural University of Rio de Janeiro, Seropédica, RJ, Brazil
| | - Patricia Moriel
- Faculty of Pharmaceutical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Marília B Visacri
- School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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Kang HY, Kim Y, You AH, Kim YJ, Kim MK. A randomized controlled trial of the effect of ramosetron on postoperative restoration of bowel motility after gynecologic laparoscopic surgery. Int J Gynaecol Obstet 2021; 158:172-178. [PMID: 34614204 DOI: 10.1002/ijgo.13969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To investigate the effect of ramosetron after gynecological laparoscopic surgery on the recovery of bowel function. METHODS A prospective randomized controlled trial conducted at Kyung Hee University hospital, South Korea, from August 2016 to September 2017. Patients were randomized to receive either 10 mg dexamethasone before induction of anesthesia (control group C), followed by intravenous administration of patient-controlled analgesia (IV-PCA) or 2 ml normal saline before induction of anesthesia and 0.6 mg ramosetron (study group R) administered with IV-PCA. RESULTS A total of 88 patients were enrolled. Times to first flatus (group C 23.98 ± 6.31 vs. group R 27.14 ± 9.56 h; P = 0.148) and first defecation (group C 36.16 ± 16.04 vs. group R 43.41 ± 20.01 h; P = 0.138) showed no statistically significant differences. No significant differences were observed in the frequency of postoperative nausea and vomiting (PONV) and demand for additional analgesics. Multiple linear regression for analysis of factors affecting time to first flatus revealed no significant results. CONCLUSION Ramosetron did not delay bowel movement recovery after gynecologic laparoscopic surgery and was as effective as dexamethasone in regulating PONV. Ramosetron can be used with IV-PCA without concerns about delay in recovery of bowel function. ClinicalTrials.gov registration number: NCT02849483.
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Affiliation(s)
- Hee Yong Kang
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Youngsoon Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Ann Hee You
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Yeon Jin Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Mi Kyeong Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, South Korea
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Olson EA, Metzger AK, Mallory MJ, Mackey RM. Opioid-Induced Constipation and Acupuncture: A Case Discussion. J Pain Symptom Manage 2021; 62:876-880. [PMID: 33556492 DOI: 10.1016/j.jpainsymman.2021.01.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/23/2021] [Accepted: 01/29/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Use of acupuncture for treatment of functional constipation is well studied; however, studies examining use of acupuncture for opioid-induced constipation are limited. CASE DESCRIPTION A 70-year-old woman with newly diagnosed multiple myeloma discovered after presentation to the emergency room with severe back pain. Pain management required use of opioids, escalating to effect. Hospital course was complicated by opioid-induced constipation causing abdominal pain, nausea, and ileus despite aggressive titration of stimulant and osmotic laxatives as well as administration of suppositories and enemas on multiple occasions. Prior to nasogastric tube placement for the ileus, the patient requested acupuncture treatment in attempt to relieve constipation. Shortly after acupuncture session, patient passed multiple stools with improvement in abdominal pain and nausea and avoidance of nasogastric tube. CONCLUSION Acupuncture for opioid-induced constipation may provide symptom relief through use of nonpharmacologic interventions; however, further studies are needed to determine the optimal therapeutic approach.
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Affiliation(s)
- Emily A Olson
- General Internal Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Abbey K Metzger
- General Internal Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Molly J Mallory
- General Internal Medicine, Integrative Medicine and Health, Mayo Clinic, Rochester, Minnesota
| | - Regina M Mackey
- General Internal Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
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De Giorgio R, Zucco FM, Chiarioni G, Mercadante S, Corazziari ES, Caraceni A, Odetti P, Giusti R, Marinangeli F, Pinto C. Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel. Adv Ther 2021; 38:3589-3621. [PMID: 34086265 PMCID: PMC8279968 DOI: 10.1007/s12325-021-01766-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/28/2021] [Indexed: 12/14/2022]
Abstract
The prescribing and use of opioid analgesics is increasing in Italy owing to a profusion in the number and types of opioid analgesic products available, and the increasing prevalence of conditions associated with severe pain, the latter being related to population aging. Herein we provide the expert opinion of an Italian multidisciplinary panel on the management of opioid-induced constipation (OIC) and bowel dysfunction. OIC and opioid-induced bowel dysfunction are well-recognised unwanted effects of treatment with opioid analgesics that can profoundly affect quality of life. OIC can be due to additional factors such as reduced mobility, a low-fibre diet, comorbidities, and concomitant medications. Fixed-dose combinations of opioids with mu (μ) opioid receptor antagonists, such as oxycodone/naloxone, have become available, but have limited utility in clinical practice because the individual components cannot be independently titrated, creating a risk of breakthrough pain as the dose is increased. A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control. Recommended first-line pharmacological treatment of OIC is with an osmotic laxative (preferably polyethylene glycol [macrogol]), or a stimulant laxative such as an anthraquinone. A second laxative with a complementary mechanism of action should be added in the event of an inadequate response. Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as methylnaltrexone, naloxegol or naldemedine, should be considered in patients with OIC that has not responded to combination laxative treatment. Prokinetics or intestinal secretagogues, such as lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in Italy, and should therefore be restricted to settings such as specialist centres and clinical trials.
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11
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Rekatsina M, Paladini A, Drewes AM, Ayob F, Viswanath O, Urits I, Corli O, Pergolizzi J, Varrassi G. Efficacy and Safety of Peripherally Acting μ-Opioid Receptor Antagonist (PAMORAs) for the Management of Patients With Opioid-Induced Constipation: A Systematic Review. Cureus 2021; 13:e16201. [PMID: 34367804 PMCID: PMC8339109 DOI: 10.7759/cureus.16201] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/05/2021] [Indexed: 12/13/2022] Open
Abstract
In treating chronic and acute pain, opioids are widely used. Although they do provide analgesia, their usage does come with adverse events (AEs). One of the most burdensome is opioid-induced bowel dysfunction, and more specifically opioid-induced constipation (OIC). The pathogenesis of these AEs is well known as the consequence of the action of opioids on m-receptors in the enteric nervous system. In recent years, medicines counteracting this specific action at the receptors have been registered for clinical use: the peripherally acting μ-opioid receptor antagonists (PAMORAs). The knowledge of their comparative efficacy and tolerability is very important for physicians and patients in opioid therapy. This systematic review of the existing literature on PAMORAs aimed to study the relative clinical advantages and disadvantages. The most important data banks, including "PubMed," "Embase," "CT.gov," "ICTRP" and "CINAHL" were used to find the published material on PAMORAs. The selected publications were examined to systematically analyze the efficacy and safety of the four existing PAMORAs. All of the medications are superior to placebo in reducing OIC. There are few published data on alvimopan used to treat OIC, and it is only indicated for the treatment of post-abdominal surgery ileus. Methylnaltrexone is studied mainly in its subcutaneous (SC) formulation. When used in its oral formulation, it seems more rapid than naloxegol and placebo in the reduction of OIC. Naldemedine is able to produce more spontaneous bowel movements (SBMs) when compared to alvimopan and naloxegol. Tolerability was found to be similar for all of them. In particular, they affect the gastrointestinal tract (GI), with flatulence and diarrhea, especially at high dosages. For some of them, nasopharyngitis and abdominal pain were observed as treatment adverse effects (TEAs). Several cardiovascular TEAs were reported after methylnaltrexone use, but it is not clear whether they were consequences of the drug or related to the general conditions of the patients. Considering the existing data, naloxegol and naldemedine seem to be the best choices, with a higher number of spontaneous bowel movements following naldemedine administration.
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Affiliation(s)
- Martina Rekatsina
- Pain Management, Whipps Cross Hospital Barts Health NHS, London, GBR
| | - Antonella Paladini
- Department of Clinical Medicine, Public Health and Life Science (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, DNK
| | | | - Omar Viswanath
- Pain Management, Valley Pain Consultants - Envision Physician Services, Phoenix, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Oscar Corli
- Pain and Palliative Care Research Unit, Mario Negri Institute IRCCS, Milano, ITA
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12
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Townsel C, Stone J, Debolt C, Hussain N, Campbell WA. Fetal gastric area ratio to predict severe neonatal opioid withdrawal syndrome. J Matern Fetal Neonatal Med 2021; 35:7957-7961. [PMID: 34151686 DOI: 10.1080/14767058.2021.1939302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Neonatal opioid withdrawal syndrome (NOWS) can occur in newborns exposed to opioids in pregnancy. Opioids delay gastric emptying and inhibit gastric motility in adults, but little is known about their effect in the fetus. We sought to assess gastric area ratio (GAR) in opioid-exposed fetuses. STUDY DESIGN Retrospective cohort study including opioid-exposed maternal-neonatal dyads between 2007-2017. Primary outcome: severe NOWS (three consecutive Finnegan scores ≥8 or three scores totaling ≥24 within 96 h of life). GAR: (gastric area)/(transverse abdominal area) × 100. Data analysis was by descriptive, parametric, and non-parametric tests. RESULTS Forty-nine maternal-neonatal dyads were included, 67% (n = 33) with severe NOWS. GAR <95th percentile for gestational age was seen in 80% of neonates (n = 39). However, GAR was not different between groups (p = .90) and did not predict severe NOWS. CONCLUSION Fetal GAR was <95th percentile in 80% of opioid-exposed neonates. However, fetal GAR may not predict NOWS treatment.
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Affiliation(s)
- Courtney Townsel
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Julie Stone
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA, USA
| | - Chelsea Debolt
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Naveed Hussain
- Department of Pediatrics, Division of Neonatology, Connecticut Children's Hospital, Farmington, CT, USA
| | - Winston A Campbell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Connecticut, Farmington, CT, USA
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13
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Mishra S, Singh R, Satapathy S, Bhatnagar S. Validity and Reliability of the Hindi Version of the Patient Assessment of Constipation Quality of Life Questionnaire in Cancer Patients on Opioids for Pain Management at Tertiary Care Center, India. Indian J Palliat Care 2021; 27:95-98. [PMID: 34035624 PMCID: PMC8121236 DOI: 10.4103/ijpc.ijpc_187_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/02/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Opioid-induced constipation (OIC) causes a significant worsening of quality of life (QOL). The patient assessment of constipation QOL questionnaire (PAC-QOL) is a validated scale in English language to assess the QOL in patients with chronic constipation and guide the management by measuring response to a targeted therapy. Objective: The objective of the study was to evaluate the validity and reliability of PAC-QOL questionnaire after translation in Hindi language for Indian cancer patients with OIC. Materials and Methods: This was a prospective observational cross-sectional study. Three hundred and thirteen adult cancer patients receiving opioid treatment for pain and experiencing self-reported symptoms of constipation were evaluated. The severity of constipation was assessed at baseline and at an interval of at least 2 weeks by the physician using constipation scoring system (CSS) and self-reported Hindi version of PAC-QOL questionnaire. Results: The data obtained from 313 patients were taken for analysis. The internal consistency of the tool was established with the favorable value of Cronbach's alfa coefficient (i.e., >0.70) obtained for all four subgroups and overall score. The intraclass correlation coefficient value of >0.70 also established good correlation between overall and subgroups scores of Hindi version of PAC-QOL, obtained at 1st and 2nd visit. It was observed from the result that a significant correlation existed between the overall and subgroups scores of Hindi version of PAC-QOL and CSS, thus establishing concurrent validity. Conclusion: It was concluded from the study results that Hindi version of PAC-QOL is both reliable and valid to assess the QOL in patients with OIC.
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Affiliation(s)
- Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Ram Singh
- Department of Onco-Anaesthesia and Palliative Medicine, National Cancer Institute, Jhajjar, Haryana, India
| | - Sujata Satapathy
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
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14
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Eitan S, Madison CA, Kuempel J. The self-serving benefits of being a good host: A role for our micro-inhabitants in shaping opioids' function. Neurosci Biobehav Rev 2021; 127:284-295. [PMID: 33894242 DOI: 10.1016/j.neubiorev.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 04/07/2021] [Accepted: 04/18/2021] [Indexed: 02/07/2023]
Abstract
Opioids are highly efficacious in their ability to relieve pain, but they are liable for abuse, dependence, and addiction. Risk factors to develop opioid use disorders (OUD) include chronic stress, socio-environment, and preexisting major depressive disorders (MDD) and posttraumatic stress disorders (PTSD). Additionally, opioids reduce gut motility, induce loss of gut barrier function, and alter the composition of the trillions of microbes hosted in the gastrointestinal tract, known as the gut microbiota. The microbiota are significant contributors to the reciprocal communication between the central nervous system (CNS) and the gut, termed the gut-brain axis. They have strong influences on their host behaviors, including the ability to cope with stress, sociability, affect, mood, and anxiety. Thus, they are implicated in the etiology of MDD and PTSD. Here we review the latest studies demonstrating that intestinal flora can, directly and indirectly, by affecting sociability levels, responses to stress, and mental state, alter the responses to opioids. It suggests that microbiota can potentially be used to increase the resilience to develop analgesic tolerance and OUD.
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Affiliation(s)
- Shoshana Eitan
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX, 77843, USA.
| | - Caitlin A Madison
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX, 77843, USA
| | - Jacob Kuempel
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX, 77843, USA
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15
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Abstract
Gastric motility disorders present both diagnostic and therapeutic challenges and likely are under-recognized in small animal practice. This review includes a comparative overview of etiopathogenesis and clinical presentation of gastric motility disorders, suggests a practical approach to the diagnosis of these conditions, and provides an update on methods to evaluate gastric motor function. Furthermore, management of gastric dysmotility is discussed, including a review of the documented effect of gastric prokinetics.
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Affiliation(s)
- Roman Husnik
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, 625 Harrison Street, West Lafayette, IN 47907, USA.
| | - Frédéric Gaschen
- Department of Veterinary Clinical Sciences, Louisiana State University School of Veterinary Medicine, Skip Bertman Drive, Baton Rouge, LA 70803, USA
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16
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Hegde S, Lin YM, Fu Y, Savidge T, Shi XZ. Precision Lactobacillus reuteri therapy attenuates luminal distension-associated visceral hypersensitivity by inducing peripheral opioid receptors in the colon. Pain 2020; 161:2737-2749. [PMID: 32569084 PMCID: PMC7669621 DOI: 10.1097/j.pain.0000000000001967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Luminal distension and abdominal pain are major clinical hallmarks of obstructive bowel disorders and functional bowel disorders linked to gut dysbiosis. Our recent studies found that chronic lumen distension increased visceral sensitivity and decreased abundance of gut commensal Lactobacillus reuteri in a rodent model of partial colon obstruction (OB). To establish causation, we performed precision microbial therapy to assess whether recolonization of L. reuteri prevents visceral hypersensitivity in lumen distension, and if so, to identify the gut-microbiota mechanism. Lumen distension was induced in Sprague-Dawley rats by implanting an OB band in the distal colon for up to 7 days. L. reuteri strains or vehicle were gavage ingested 1 × 10 colony-forming units/g daily starting 2 days before OB. L. reuteri rat strains that were able to recolonize obstructed colon significantly improved food intake and body weight in OB rats, and attenuated referred visceral hyperalgesia measured by the withdrawal response to von Frey filament applications to the abdomen. Mechanistically, L. reuteri treatment attenuated hyperexcitability of the dorsal root ganglia neurons projecting to the distended colon by promoting opioid receptor function in affected tissues. The expression of µ, δ, and κ opioid receptors was significantly downregulated in colonic muscularis externae and sensory neurons in OB rats. However, L. reuteri treatment prevented the loss of opioid receptors. Furthermore, administration of peripheral opioid receptor antagonist naloxone methiodide abolished the analgesic effect of L. reuteri in OB. In conclusion, precision L. reuteri therapy prevents lumen distension-associated visceral hypersensitivity by local bacterial induction of opioid receptors.
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Affiliation(s)
- Shrilakshmi Hegde
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - You-Min Lin
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yu Fu
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Tor Savidge
- Dept. of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Xuan-Zheng Shi
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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17
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Hussain N, Naeem M, Pinato DJ. Concomitant medications and immune checkpoint inhibitor therapy for cancer: causation or association? Hum Vaccin Immunother 2020; 17:55-61. [PMID: 32574106 DOI: 10.1080/21645515.2020.1769398] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The majority of cancer patients assume concomitant medications for the treatment of cancer-related symptoms or co-morbidities. As immune checkpoint inhibitors expand in the treatment of a widening range of malignancies, drug-drug interactions have become an area of increasing interest due to the potential for some concomitant medications to exert immune-modulatory effects and influence outcomes from immunotherapy. Here, we review the evidence supporting this association across selected drug classes including antibiotics, proton pump inhibitors, metformin, and opioids.
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Affiliation(s)
- Nadiya Hussain
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital , London, UK
| | - Muntaha Naeem
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital , London, UK
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital , London, UK
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18
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Simpson S, Kimbrough A, Boomhower B, McLellan R, Hughes M, Shankar K, de Guglielmo G, George O. Depletion of the Microbiome Alters the Recruitment of Neuronal Ensembles of Oxycodone Intoxication and Withdrawal. eNeuro 2020; 7:ENEURO.0312-19.2020. [PMID: 32341122 PMCID: PMC7242819 DOI: 10.1523/eneuro.0312-19.2020] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/26/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
Substance use disorders have a complex etiology. Genetics, the environment, and behavior all play a role in the initiation, escalation, and relapse of drug use. Recently, opioid use disorder has become a national health crisis. One aspect of opioid addiction that has yet to be fully examined is the effects of alterations of the microbiome and gut-brain axis signaling on central nervous system activity during opioid intoxication and withdrawal. The effect of microbiome depletion on the activation of neuronal ensembles was measured by detecting Fos-positive (Fos+) neuron activation during intoxication and withdrawal using a rat model of oxycodone dependence. Daily oxycodone administration (2 mg/kg) increased pain thresholds and increased Fos+ neurons in the basolateral amygdala (BLA) during intoxication, with a decrease in pain thresholds and increase in Fos+ neurons in the periaqueductal gray (PAG), central nucleus of the amygdala (CeA), locus coeruleus (LC), paraventricular nucleus of the thalamus (PVT), agranular insular cortex (AI), bed nucleus of the stria terminalis (BNST), and lateral habenula medial parvocellular region during withdrawal. Microbiome depletion produced widespread but region- and state-specific changes in neuronal ensemble activation. Oxycodone intoxication and withdrawal also increased functional connectivity among brain regions. Microbiome depletion resulted in a decorrelation of this functional network. These data indicate that microbiome depletion by antibiotics produces widespread changes in the recruitment of neuronal ensembles that are activated by oxycodone intoxication and withdrawal, suggesting that the gut microbiome may play a role in opioid use and dependence. Future studies are needed to better understand the molecular, neurobiological, and behavioral effects of microbiome depletion on addiction-like behaviors.
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Affiliation(s)
- Sierra Simpson
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093
- Department of Neuroscience, The Scripps Research Institute, La Jolla, CA 92037
| | - Adam Kimbrough
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093
| | - Brent Boomhower
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093
| | - Rio McLellan
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093
| | - Marcella Hughes
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093
| | - Kokila Shankar
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093
- Department of Neuroscience, The Scripps Research Institute, La Jolla, CA 92037
| | | | - Olivier George
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093,
- Department of Neuroscience, The Scripps Research Institute, La Jolla, CA 92037
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19
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DiCello JJ, Carbone SE, Saito A, Rajasekhar P, Ceredig RA, Pham V, Valant C, Christopoulos A, Veldhuis NA, Canals M, Massotte D, Poole DP. Mu and Delta Opioid Receptors Are Coexpressed and Functionally Interact in the Enteric Nervous System of the Mouse Colon. Cell Mol Gastroenterol Hepatol 2019; 9:465-483. [PMID: 31759144 PMCID: PMC7036548 DOI: 10.1016/j.jcmgh.2019.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Functional interactions between the mu opioid receptor (MOR) and delta opioid receptor (DOR) represent a potential target for novel analgesics and may drive the effects of the clinically approved drug eluxadoline for the treatment of diarrhea-predominant irritable bowel syndrome. Although the enteric nervous system (ENS) is a likely site of action, the coexpression and potential interaction between MOR and DOR in the ENS are largely undefined. In the present study, we have characterized the distribution of MOR in the mouse ENS and examined MOR-DOR interactions by using pharmacologic and cell biology techniques. METHODS MOR and DOR expression was defined by using MORmCherry and MORmCherry-DOR-eGFP knockin mice. MOR-DOR interactions were assessed by using DOR-eGFP internalization assays and by pharmacologic analysis of neurogenic contractions of the colon. RESULTS Although MOR was expressed by approximately half of all myenteric neurons, MOR-positive submucosal neurons were rarely observed. There was extensive overlap between MOR and DOR in both excitatory and inhibitory pathways involved in the coordination of intestinal motility. MOR and DOR can functionally interact, as shown through heterologous desensitization of MOR-dependent responses by DOR agonists. Functional evidence suggests that MOR and DOR may not exist as heteromers in the ENS. Pharmacologic studies show no evidence of cooperativity between MOR and DOR. DOR internalizes independently of MOR in myenteric neurons, and MOR-evoked contractions are unaffected by the sequestration of DOR. CONCLUSIONS Collectively, these findings demonstrate that although MOR and DOR are coexpressed in the ENS and functionally interact, they are unlikely to exist as heteromers under physiological conditions.
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MESH Headings
- Analgesics, Opioid/pharmacology
- Animals
- Benzamides/pharmacology
- CHO Cells
- Colon/metabolism
- Cricetulus
- Enteric Nervous System/drug effects
- Enteric Nervous System/metabolism
- Gastrointestinal Motility/drug effects
- Gastrointestinal Motility/physiology
- Gene Knock-In Techniques
- Genes, Reporter/genetics
- Green Fluorescent Proteins/genetics
- Humans
- Luminescent Proteins/genetics
- Mice
- Morphine/pharmacology
- Piperazines/pharmacology
- Piperidines/pharmacology
- Protein Multimerization/physiology
- Receptors, Opioid, delta/agonists
- Receptors, Opioid, delta/genetics
- Receptors, Opioid, delta/metabolism
- Receptors, Opioid, mu/agonists
- Receptors, Opioid, mu/genetics
- Receptors, Opioid, mu/metabolism
- Recombinant Proteins/genetics
- Recombinant Proteins/metabolism
- Red Fluorescent Protein
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Affiliation(s)
- Jesse J DiCello
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville Campus, Melbourne, VIC, Australia
| | - Simona E Carbone
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville Campus, Melbourne, VIC, Australia
| | - Ayame Saito
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville Campus, Melbourne, VIC, Australia
| | - Pradeep Rajasekhar
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville Campus, Melbourne, VIC, Australia
| | - Rhian A Ceredig
- Centre de la Recherche Nationale Scientifique, Université de Strasbourg, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | - Vi Pham
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Celine Valant
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Arthur Christopoulos
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Nicholas A Veldhuis
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville Campus, Melbourne, VIC, Australia
| | - Meritxell Canals
- Division of Physiology, Pharmacology and Neuroscience, Queen's Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom; Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, The Midlands, United Kingdom
| | - Dominique Massotte
- Centre de la Recherche Nationale Scientifique, Université de Strasbourg, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | - Daniel P Poole
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville Campus, Melbourne, VIC, Australia; Department of Anatomy and Neuroscience, University of Melbourne, Parkville, VIC, Australia.
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20
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DiCello JJ, Saito A, Rajasekhar P, Sebastian BW, McQuade RM, Gondin AB, Veldhuis NA, Canals M, Carbone SE, Poole DP. Agonist-dependent development of delta opioid receptor tolerance in the colon. Cell Mol Life Sci 2019; 76:3033-3050. [PMID: 30904952 PMCID: PMC11105391 DOI: 10.1007/s00018-019-03077-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/26/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
The use of opioid analgesics is severely limited due to the development of intractable constipation, mediated through activation of mu opioid receptors (MOR) expressed by enteric neurons. The related delta opioid receptor (DOR) is an emerging therapeutic target for chronic pain, depression and anxiety. Whether DOR agonists also promote sustained inhibition of colonic transit is unknown. This study examined acute and chronic tolerance to SNC80 and ARM390, which were full and partial DOR agonists in neural pathways controlling colonic motility, respectively. Excitatory pathways developed acute and chronic tolerance to SNC80, whereas only chronic tolerance developed in inhibitory pathways. Both pathways remained functional after acute or chronic ARM390 exposure. Propagating colonic motor patterns were significantly reduced after acute or chronic SNC80 treatment, but not by ARM390 pre-treatment. These findings demonstrate that SNC80 has a prolonged inhibitory effect on propagating colonic motility. ARM390 had no effect on motor patterns and thus may have fewer gastrointestinal side-effects.
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MESH Headings
- Analgesics, Opioid/pharmacology
- Animals
- Benzamides/pharmacology
- Colon/drug effects
- Colon/physiology
- Drug Tolerance
- Electric Stimulation
- Mice
- Mice, Inbred C57BL
- Microscopy, Confocal
- Muscle Contraction/drug effects
- Neurons/metabolism
- Piperazines/pharmacology
- Receptors, Opioid, delta/agonists
- Receptors, Opioid, delta/metabolism
- Receptors, Opioid, mu/agonists
- Receptors, Opioid, mu/metabolism
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Affiliation(s)
- Jesse J DiCello
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia.
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia.
| | - Ayame Saito
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia
| | - Pradeep Rajasekhar
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia
| | - Benjamin W Sebastian
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
| | - Rachel M McQuade
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Arisbel B Gondin
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
| | - Nicholas A Veldhuis
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia
| | - Meritxell Canals
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia
| | - Simona E Carbone
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia
| | - Daniel P Poole
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia.
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, VIC, Australia.
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, VIC, Australia.
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21
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Blackney KA, Kamdar NV, Liu CA, Edwards DA. Methylnaltrexone-Associated Bowel Perforation in Postoperative Opioid-Induced Constipation and Ogilvie Syndrome: A Case Report. A A Pract 2019; 12:44-46. [PMID: 30020107 DOI: 10.1213/xaa.0000000000000840] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pain management with opioids is often limited by medication side effects. One of the most common and distressing side effects is opioid-induced constipation (OIC), a syndrome that is now getting significant national attention. We report the case of an opioid-dependent 56-year-old man who underwent lumbar decompression for spinal stenosis. Postoperatively, he developed OIC and Ogilvie syndrome, then following treatment with methylnaltrexone experienced an acute bowel perforation. We briefly review the recommended management of OIC as well as indications and contraindications of methylnaltrexone and similar new medications.
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Affiliation(s)
- Kevin A Blackney
- From the Kaiser Permanente of Northern California, Oakland, California
| | - Nirav V Kamdar
- David Geffen School of Medicine at UCLA/UCLA Health, Los Angeles, California
| | - Chang Amber Liu
- Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts
| | - David A Edwards
- Vanderbilt University School of Medicine/Vanderbilt University Medical Center, Nashville, Tennessee
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22
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Nishie K, Yamamoto S, Yamaga T, Horigome N, Hanaoka M. Peripherally acting μ-opioid antagonist for the treatment of opioid-induced constipation: Systematic review and meta-analysis. J Gastroenterol Hepatol 2019; 34:818-829. [PMID: 30597600 DOI: 10.1111/jgh.14586] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 12/08/2018] [Accepted: 12/22/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Opioid-induced constipation (OIC) is a frequent adverse event (AE) that impairs patients' quality of life (QOL). Peripherally acting μ-opioid receptor antagonists (PAMORAs) have been recognized as a treatment option for OIC, but the effect consistent across the studies has not been evaluated. METHODS We conducted a quantitative meta-analysis to explore the efficacy of PAMORA for OIC (registered with PROSPERO: CRD42018085298). We systematically searched randomized controlled trials (RCTs) in Medline, Embase, and Central databases. Change from baseline in spontaneous bowel movements, pooled proportion of responders, QOL, and AEs were calculated and compared with results in placebo cases. RESULTS We included 31 RCTs with 7849 patients. A meta-analysis revealed that patients under PAMORA therapy had considerably improved spontaneous bowel movement from baseline compared with those given placebo (20 RCTs; mean difference, 1.43; 95% confidence interval [CI], 1.18-1.68; n = 5622) and more responded (21 RCTs; risk ratio [RR], 1.81; 95% CI, 1.55-2.12; n = 4821). Moreover, QOL of patients receiving PAMORA was significantly better (8 RCTs; mean difference, -0.22; 95% CI, -0.28 to -0.17; n = 2884). AEs were increased significantly in the PAMORA group (26 RCTs; RR, 1.10; 95% CI, 1.06-1.15; n = 7715), especially in gastrointestinal disorders, whereas serious AEs were not significant (17 RCTs; RR, 1.04; 95% CI, 0.85-1.28; n = 5890). CONCLUSION Peripherally acting μ-opioid receptor antagonist has been shown to be effective and durable for patients with OIC and is the only drug with confirmed evidence in meta-analysis. The possibility of publication bias was the limitation of this study.
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Affiliation(s)
- Kenichi Nishie
- Department of Respiratory Medicine, Iida Municipal Hospital, Iida, Nagano, Japan.,The First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shuhei Yamamoto
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Takayoshi Yamaga
- Department of Occupational Therapy, Health Science University, Fujikawaguchikomachi, Yamanashi, Japan
| | - Naoto Horigome
- Department of Digestive Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| | - Masayuki Hanaoka
- The First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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23
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Lang-Illievich K, Bornemann-Cimenti H. Opioid-induced constipation: a narrative review of therapeutic options in clinical management. Korean J Pain 2019; 32:69-78. [PMID: 31091505 PMCID: PMC6549585 DOI: 10.3344/kjp.2019.32.2.69] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/02/2019] [Accepted: 01/14/2019] [Indexed: 12/12/2022] Open
Abstract
Pain therapy often entails gastrointestinal adverse events. While opioids are effective drugs for pain relief, the incidence of opioid-induced constipation (OIC) varies greatly from 15% to as high as 81%. This can lead to a significant impairment in quality of life, often resulting in discontinuation of opioid therapy. In this regard, a good doctor-patient relationship is especially pivotal when initiating opioid therapy. In addition to a detailed history of bowel habits, patient education regarding the possible gastrointestinal side effects of the drugs is crucial. In addition, the bowel function must be regularly evaluated for the entire duration of treatment with opioids. Furthermore, if the patient has preexisting constipation that is well under control, continuation of that treatment is important. In the absence of such history, general recommendations should include sufficient fluid intake, physical activity, and regular intake of dietary fiber. In patients of OIC with ongoing opioid therapy, the necessity of opioid use should be critically reevaluated in terms of an with acceptable quality of life, particularly in cases of non-cancer pain. If opioids must be continued, lowering the dose may help, as well as changing the type of opioid. If these measures do not suffice, the next step for persistent OIC is the administration of laxatives. If these are ineffective as well, treatment with peripherally active μ-opioid receptor antagonists should be considered. Enemas and irrigation are emergency measures, often used as a last resort.
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Affiliation(s)
- Kordula Lang-Illievich
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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24
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Farmer AD, Drewes AM, Chiarioni G, De Giorgio R, O'Brien T, Morlion B, Tack J. Pathophysiology and management of opioid-induced constipation: European expert consensus statement. United European Gastroenterol J 2019; 7:7-20. [PMID: 30788113 PMCID: PMC6374852 DOI: 10.1177/2050640618818305] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/18/2018] [Indexed: 12/31/2022] Open
Abstract
Background Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options. Objective The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice. Methods This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature. Results The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed. Conclusion Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.
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Affiliation(s)
- Adam D Farmer
- Institute of Applied Clinical Science, Keele University, Keele, UK
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
- Centre for Trauma and Neuroscience, Queen Mary University of London, London, UK
| | - Asbjørn M Drewes
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Giuseppe Chiarioni
- Division of Gastroenterology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | - Tony O'Brien
- Marymount University Hospital and Hospice, Curraheen, Ireland
- Cork University Hospital, Wilton, Ireland
| | - Bart Morlion
- Leuven Centre for Algology and Pain Management, University of Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
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25
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Streicher JM, Bilsky EJ. Peripherally Acting μ-Opioid Receptor Antagonists for the Treatment of Opioid-Related Side Effects: Mechanism of Action and Clinical Implications. J Pharm Pract 2018; 31:658-669. [PMID: 28946783 PMCID: PMC6291905 DOI: 10.1177/0897190017732263] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Opioid receptors are distributed throughout the central and peripheral nervous systems and on many nonneuronal cells. Therefore, opioid administration induces effects beyond analgesia. In the enteric nervous system (ENS), stimulation of µ-opioid receptors triggers several inhibitory responses that can culminate in opioid-induced bowel dysfunction (OBD) and its most common side effect, opioid-induced constipation (OIC). OIC negatively affects patients' quality of life (QOL), ability to work, and pain management. Although laxatives are a common first-line OIC therapy, most have limited efficacy and do not directly antagonize opioid effects on the ENS. Peripherally acting µ-opioid receptor antagonists (PAMORAs) with limited ability to cross the blood-brain barrier have been developed. The PAMORAs approved by the U S Food and Drug Administration for OIC are subcutaneous and oral methylnaltrexone, oral naloxegol, and oral naldemedine. Although questions of cost-effectiveness and relative efficacy versus laxatives remain, PAMORAs can mitigate OIC and improve patient QOL. PAMORAS may also have applications beyond OIC, including reducing the increased cardiac risk or potential tumorigenic effects of opioids. This review discusses the burden of OIC and OBD, reviews the mechanism of action of new OIC therapies, and highlights other potential opioid-related side effects mediated by peripheral opioid receptors in the context of new OIC therapies.
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Affiliation(s)
- John M Streicher
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Edward J Bilsky
- Pacific Northwest University of Health Sciences, Yakima, WA, USA
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26
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Fu Y, Lin YM, Winston JH, Radhakrishnan R, Huang LYM, Shi XZ. Role of brain-derived neurotrophic factor in the pathogenesis of distention-associated abdominal pain in bowel obstruction. Neurogastroenterol Motil 2018; 30:e13373. [PMID: 29781158 PMCID: PMC6160336 DOI: 10.1111/nmo.13373] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies found that visceral sensitivity is increased in bowel obstruction (BO). We hypothesized that mechanical stress-induced expression of BDNF in smooth muscle cells (SMC) of the distended bowel plays a critical role in visceral hypersensitivity in BO by altering voltage-gated K+ channel (Kv ) activity in sensory neurons. METHODS Partial colon obstruction was maintained in rats for 7 days. Colon-projecting neurons in the dorsal root ganglia (DRG, T13 to L2) were isolated for electrophysiological and gene expression studies. KEY RESULTS Compared to controls, membrane excitability of colon-projecting DRG neurons was markedly enhanced in BO. The densities of total Kv and transient A-type (IA ) K+ currents, but not sustained delayed IK current, were significantly reduced in the neurons in BO. The mRNA expression of IA subtype Kv 1.4 in colon neurons was down-regulated in BO. Expression of BDNF mRNA and protein was dramatically increased in colonic smooth muscle of the distended segment, but not in the non-distended aboral segment. Mechanical stretch of colon SMC in vitro increased BDNF expression. Treatment with anti-BDNF antibody restored total Kv and IA currents of neurons from BO rats. Administration of Trk B inhibitor ANA-12 blocked BO-associated changes of neuronal excitability, Kv activity and gene expression in obstruction. CONCLUSIONS AND INFERENCES Mechanical stress-induced expression of BDNF in colon SMC plays a critical role in visceral hypersensitivity in BO by suppressing A-type K+ currents and gene expression in sensory nerve. These findings help to identify therapeutic targets for distention-associated abdominal pain in the gut.
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Affiliation(s)
- Yu Fu
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - You-Min Lin
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - John H. Winston
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ravi Radhakrishnan
- Dept. of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Li-Yen M. Huang
- Dept. of Neuroscience & Cell Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Xuan-Zheng Shi
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA,Address for communication: Dr. Xuan-Zheng Shi, Department of Internal Medicine, Division of Gastroenterology, The University of Texas Medical Branch, 301 University Boulevard, 4.106 Basic Science Building, Galveston, TX 77555-0655, Phone: (409) 772-0940, FAX: (409) 747-3084,
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27
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Predictors of inadequate bowel preparation for colonoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:819-826. [PMID: 29847488 DOI: 10.1097/meg.0000000000001175] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate factors contributing to poor bowel preparation in patients undergoing colonoscopy procedures. We used a reproducible search strategy to identify studies, searching 10 medical databases, including PubMed, Ovid, Medline, and Cochrane Library Database for reports published between 2000 and 2016. Fully published studies, evaluating risk factors for inadequate bowel preparation, were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted with both fixed-effects and random-effects models; results were presented from the random effects model when heterogeneity was significant. Odds ratios (OR) estimates with 95% confidence interval were calculated. Heterogeneity was assessed by I statistics. Twenty-four studies with a total of 49 868 patients met the inclusion criteria. Age (OR: -1.20), male sex (OR: 0.85), inpatient status (OR: 0.57), diabetes mellitus (OR: 0.58), hypertension (OR: 0.58), cirrhosis (OR: 0.49), narcotic use (OR: 0.59), constipation (OR: 0.61), stroke (OR; 0.51), and tricyclic antidepressant (TCA) use (0.51), were associated with inadequate bowel preparation. In our sensitivity analysis comparing Western and Asian countries, we found that diabetes, cirrhosis, male sex, history of stroke and TCA use were stronger risk factors for inadequate bowel preparation in Western countries than in Asian countries. We also found that history of stroke, TCA use, and race were risk factors for inadequate bowel preparation in patients receiving conventional bowel preparation compared with those receiving split-dose bowel preparation. Multiple risk factors affect the quality of bowel preparation and specific risk factors can be intervened upon, in different populations, to optimize preparation.
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28
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Danford CJ, Lin SC, Smith MP, Wolf JL. Encapsulating peritoneal sclerosis. World J Gastroenterol 2018; 24:3101-3111. [PMID: 30065556 PMCID: PMC6064970 DOI: 10.3748/wjg.v24.i28.3101] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/07/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
Encapsulating peritoneal sclerosis (EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents (i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPS-specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is time-consuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.
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Affiliation(s)
- Christopher J Danford
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States
| | - Steven C Lin
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States
| | - Martin P Smith
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States
| | - Jacqueline L Wolf
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States
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29
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Shi XZ, Lin YM, Hegde S. Novel Insights Into the Mechanisms of Abdominal Pain in Obstructive Bowel Disorders. Front Integr Neurosci 2018; 12:23. [PMID: 29937720 PMCID: PMC6002527 DOI: 10.3389/fnint.2018.00023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022] Open
Abstract
Obstructive bowel disorders (OBD) are characterized by lumen distention due to mechanical or functional obstruction in the gut. Abdominal pain is one of the main symptoms in OBD. In this article, we aim to critically review the potential mechanisms for acute and chronic pain in bowel obstruction (BO). While clustered contractions and associated increase of intraluminal pressure may account for colicky pain in simple obstruction, ischemia may be involved in acute pain in severe conditions such as closed loop obstruction. Recent preclinical studies discovered that visceral sensitivity is increased in BO, and visceral hypersensitivity may underlie the mechanisms of chronic abdominal pain in BO. Mounting evidence suggests that lumen distension, as a circumferential mechanical stretch, alters gene expression (mechano-transcription) in the distended bowel, and mechano-transcription of nociceptive and inflammatory mediators plays a critical role in the development of visceral hypersensitivity in BO. Mechano-transcription of nerve growth factor (NGF) in gut smooth muscle cells is found to increase voltage-gated Na+ channel (Nav) activity of the primary sensory neurons by up-regulating expression of TTX-resistant Nav1.8, whereas mechanical stretch-induced brain-derived neurotrophic factor (BDNF) reduces Kv currents especially A-type (IA) currents by down-regulating expression of specific IA subtypes such as Kv1.4. The NGF and BDNF mediated changes in gene expression and channel functions in the primary sensory neurons may constitute the main mechanisms of visceral hypersensitivity in OBD. In addition, mechanical stretch-induced COX-2 and other inflammatory mediators in the gut may also contribute to abdominal pain by activating and sensitizing nociceptors.
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Affiliation(s)
- Xuan-Zheng Shi
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - You-Min Lin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Shrilakshmi Hegde
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
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30
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Candy B, Jones L, Vickerstaff V, Larkin PJ, Stone P. Mu-opioid antagonists for opioid-induced bowel dysfunction in people with cancer and people receiving palliative care. Cochrane Database Syst Rev 2018; 6:CD006332. [PMID: 29869799 PMCID: PMC6513061 DOI: 10.1002/14651858.cd006332.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid-induced bowel dysfunction (OIBD) is characterised by constipation, incomplete evacuation, bloating, and gastric reflux. It is one of the major adverse events of treatment for pain in cancer and in palliative care, resulting in increased morbidity and reduced quality of life.This is an update of two Cochrane reviews. One was published in 2011, Issue 1 on laxatives and methylnaltrexone for the management of constipation in people receiving palliative care; this was updated in 2015 and excluded methylnaltrexone. The other was published in 2008, Issue 4 on mu-opioid antagonists (MOA) for OIBD. In this updated review, we only included trials on MOA (including methylnaltrexone) for OIBD in people with cancer and people receiving palliative care. OBJECTIVES To assess the effectiveness and safety of MOA for OIBD in people with cancer and people receiving palliative care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, and Web of Science to August 2017. We also searched clinical trial registries and regulatory websites. We contacted manufacturers of MOA to identify further data. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed the effectiveness and safety of MOA for OIBD in people with cancer and people at a palliative stage irrespective of the type of terminal disease they experienced. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias and extracted data. The appropriateness of combining data from the trials depended upon sufficient homogeneity across the trials. Our primary outcomes were laxation, impact on pain relief, and adverse events. Impact on pain relief was a primary outcome because a possible adverse effect of MOAs is a reduction in pain relief from opioids. We assessed the evidence on these outcomes using GRADE. MAIN RESULTS We identified four new trials for this update, bringing the total number included in this review to eight. In total, 1022 men and women with cancer irrespective of stage or at a palliative care stage of any disease were randomised across the trials. The MOAs evaluated were oral naldemedine and naloxone (alone or in combination with oxycodone), and subcutaneous methylnaltrexone. The trials compared with MOA with a placebo or with the active intervention administered at different doses or in combination with other drugs. The trial of naldemedine and the two of naloxone in combination with oxycodone were in people with cancer irrespective of disease stage. The trial on naloxone alone was in people with advanced cancer. The four trials on methylnaltrexone were undertaken in palliative care where most participants had cancer. All trials were vulnerable to biases; four were at a high risk as they involved a sample of fewer than 50 participants per arm.In the trial of naldemedine compared to placebo in 225 participants, there were more spontaneous laxations over the two-week treatment for the intervention group (risk ratio (RR) 1.93, 95% confidence intervals (CI) 1.36 to 2.74; moderate-quality evidence). In comparison with higher doses, lower doses resulted in fewer spontaneous laxations (0.1 mg versus 0.2 mg: RR 0.73, 95% CI 0.55 to 0.95; 0.1 mg versus 0.4 mg: RR 0.69, 95% CI 0.53 to 0.89; moderate-quality evidence). There was moderate-quality evidence that naldemedine had no effect on opiate withdrawal. There were five serious adverse events. All were in people taking naldemedine (low-quality evidence). There was an increase in the occurrence of other (non-serious) adverse events in the naldemedine groups (RR 1.36, 95% CI 1.04 to 1.79, moderate-quality evidence). The most common adverse event was diarrhoea.The trials on naloxone taken either on its own, or in combination with oxycodone (an opioid) compared to oxycodone only did not evaluate laxation response over the first two weeks of administration. There was very low-quality evidence that naloxone alone, and moderate-quality evidence that oxycodone/naloxone, had no effect on analgesia. There was low-quality evidence that oxycodone/naloxone did not increase the risk of serious adverse events and moderate-quality evidence that it did not increase risk of adverse events.In combined analysis of two trials of 287 participants, we found methylnaltrexone compared to placebo induced more laxations within 24 hours (RR 2.77, 95% CI 1.91 to 4.04. I² = 0%; moderate-quality evidence). In combined analysis, we found methylnaltrexone induced more laxation responses over two weeks (RR 9.98, 95% CI 4.96 to 20.09. I² = 0%; moderate-quality evidence). The proportion of participants who had a rescue-free laxation response within 24 hours of the first dose was 59.1% in the methylnaltrexone arms and 19.1% in the placebo arm. There was moderate-quality evidence that the rate of opioid withdrawal was not affected. Methylnaltrexone did not increase the likelihood of a serious adverse event; there were fewer in the intervention arm (RR 0.59, 95% CI 0.38 to 0.93; I² = 0%; moderate-quality evidence). There was no difference in the proportion of participants experiencing an adverse event (RR 1.17, 95% CI 0.94 to 1.45; I² = 74%; low-quality evidence). Methylnaltrexone increased the likelihood of abdominal pain and flatulence.Two trials compared differing methylnaltrexone schedules of higher doses with lower doses. For early laxation, there was low-quality evidence of no clear difference between doses on analgesia and adverse events. Both trials measured laxation response within 24 hours of first dose (trial one: RR 0.82, 95% CI 0.41 to 1.66; trial two: RR 1.07, 95% CI 0.81 to 1.42). AUTHORS' CONCLUSIONS In this update, the conclusions for naldemedine are new. There is moderate-quality evidence to suggest that, taken orally, naldemedine improves bowel function over two weeks in people with cancer and OIBD but increases the risk of adverse events. The conclusions on naloxone and methylnaltrexone have not changed. The trials on naloxone did not assess laxation at 24 hours or over two weeks. There is moderate-quality evidence that methylnaltrexone improves bowel function in people receiving palliative care in the short term and over two weeks, and low-quality evidence that it does not increase adverse events. There is a need for more trials including more evaluation of adverse events. None of the current trials evaluated effects in children.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry6th Floor, Maple House149 Tottenham Court RoadLondonUKW1T 7NF
| | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry6th Floor, Maple House149 Tottenham Court RoadLondonUKW1T 7NF
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry6th Floor, Maple House149 Tottenham Court RoadLondonUKW1T 7NF
| | - Philip J Larkin
- UCD College of Health SciencesUCD School of Nursing, Midwifery and Health Systems and Our Lady's Hospice and Care ServicesDublinIreland
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, UCL Division of PsychiatryDivision of PsychiatryRoom 119, First Floor, Charles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
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Halawi H, Vijayvargiya P, Busciglio I, Oduyebo I, Khemani D, Ryks M, Rhoten D, Burton D, Szarka LA, Acosta A, Camilleri M. Effects of naloxegol on whole gut transit in opioid-naïve healthy subjects receiving codeine: A randomized, controlled trial. Neurogastroenterol Motil 2018; 30:e13298. [PMID: 29405492 PMCID: PMC5924457 DOI: 10.1111/nmo.13298] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/04/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nausea, vomiting, and constipation (OIC) are common adverse effects of acute or chronic opioid use. Naloxegol (25 mg) is an approved peripherally active mu-opiate opioid receptor antagonist. AIM To compare the effects on pan-gut transit of treatment with codeine, naloxegol, or combination in healthy volunteers. METHODS We conducted a randomized, double-blind, placebo-controlled, single-center, parallel-group study in 72 healthy opioid-naïve adults, randomized to: codeine (30 mg q.i.d.), naloxegol (25 mg daily), codeine and naloxegol, or matching placebo. During 3 days of treatment, we measured gastric emptying (GE) T1/2 , colonic filling at 6 hours (CF6), colonic geometric center at 24 and 48 hours, and ascending colon emptying (ACE) T1/2 . KEY RESULTS Participants were 59.7% women, median BMI 25.0 kg/m2 , and median age 33.8 years. Codeine significantly retarded GE T1/2, CF6, overall colonic transit, and ACE T1/2 . There was significant difference (P = .026) in GE T1/2 between codeine (144.0 min [IQR 110.5-238.6]) and naloxegol (95.5 min [89.1-135.4]). There was a significant overall group difference in CF6 (P = .023), with significant difference (P = .019) between codeine (11.0% [0.0-45.0]) and naloxegol (51% [18.8-76.2]). However, no significant differences were found between codeine-treated participants concomitantly receiving placebo or naloxegol. CONCLUSIONS AND INFERENCES Short-term administration of naloxegol (25 mg) in healthy, opioid-naïve volunteers does not reverse the retardation of gastric, small bowel, or colonic transit induced by acute administration of codeine. Further studies with naloxegol at higher dose are warranted to assess the ability to reverse the retardation of transit caused by acute administration of codeine in opioid-naïve subjects.
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Affiliation(s)
- H Halawi
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - P Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - I Busciglio
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - I Oduyebo
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - D Khemani
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - M Ryks
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - D Rhoten
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - D Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - L A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - A Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - M Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Shi XZ. Mechanical Regulation of Gene Expression in Gut Smooth Muscle Cells. Front Physiol 2017; 8:1000. [PMID: 29259559 PMCID: PMC5723328 DOI: 10.3389/fphys.2017.01000] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/20/2017] [Indexed: 12/15/2022] Open
Abstract
Intraluminal contents and their movement along the gastrointestinal tract create shear stress and mechanical stretch on the gut wall. While the shear stress is important in the initiation of immediate physiological responses, the circumferential mechanical stretch, such as that in obstructive bowel disorders, exerts long-lasting impacts on bowel functions by mainly affecting the deeper muscularis externae. Recent studies demonstrate that mechanical stretch alters gene transcription in gut smooth muscle cells (SMC), and the stretch-altered gene expression (mechano-transcription) may play a critical role in pathogenesis of motility dysfunction and abdominal pain in obstruction. Specifically, stretch-induced cyclo-oxygenase-2 and other pro-inflammatory mediators in gut SMC account for impairments of muscle contractility. Mechano-transcription of pain mediators such as nerve growth factor may contribute to visceral hypersensitivity, by sensitizing primary sensory neurons. This review aims to highlight the novel findings of mechano-transcription in the gut, and to discuss the signaling mechanisms and pathophysiological significance of mechano-transcription.
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Affiliation(s)
- Xuan-Zheng Shi
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
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Juel J, Brock C, Olesen SS, Madzak A, Farmer AD, Aziz Q, Frøkjær JB, Drewes AM. Acute physiological and electrical accentuation of vagal tone has no effect on pain or gastrointestinal motility in chronic pancreatitis. J Pain Res 2017; 10:1347-1355. [PMID: 28615966 PMCID: PMC5459955 DOI: 10.2147/jpr.s133438] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background The effective management of pain in chronic pancreatitis (CP) remains a therapeutic challenge. Analgesic drugs, such as opioids, and the underlying pathology can impair gut function. The autonomic nervous system influences hormone secretion and gut motility. In healthy volunteers, electrical (using noninvasive transcutaneous vagal nerve stimulation [t-VNS]) and physiological (using deep slow breathing [DSB]) modulation of parasympathetic tone results in pain attenuation and enhanced gut motility. Thus, the aims were to investigate whether t-VNS and DSB could enhance the parasympathetic tone, decrease pain sensitivity and improve gut motility in CP. Patients and methods A total of 20 patients (12 males, mean age=61 years, range: 50–78 years) with CP were randomized to short-term (60 minutes) t-VNS and DSB, or their placebo equivalent, in a crossover design. Cardiometrically derived parameters of autonomic tone, quantitative sensory testing of bone and muscle pain pressure, conditioned pain modulation (CPM) and assessments of gastroduodenal motility with ultrasound were performed. Results In comparison to sham, t-VNS and DSB increased cardiac vagal tone (CVT) (P<0.001). However, no changes in pain pressure thresholds for bone (P=0.95) or muscle (P=0.45) were seen. There was diminished CPM (P=0.04), and no changes in gastroduodenal motility were observed (P=0.3). Conclusion This explorative study demonstrated that t-VNS and DSB increased CVT in patients with CP. However, this short-lasting increase did not affect pain sensitivity to musculoskeletal pain or gastroduodenal motility. The chronic pain in CP patients is complex, and future trials optimizing neuromodulation for pain relief and improved motility are needed.
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Affiliation(s)
- Jacob Juel
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University, Aalborg.,Department of Rheumatology, Aarhus University Hospital, Aarhus.,Drug Design and Pharmacology, University of Copenhagen, Copenhagen
| | - Søren S Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University, Aalborg
| | - Adnan Madzak
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Adam D Farmer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent.,Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Qasim Aziz
- Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Jens B Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University, Aalborg
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Lin YM, Fu Y, Winston J, Radhakrishnan R, Sarna SK, Huang LYM, Shi XZ. Pathogenesis of abdominal pain in bowel obstruction: role of mechanical stress-induced upregulation of nerve growth factor in gut smooth muscle cells. Pain 2017; 158:583-592. [PMID: 28079757 PMCID: PMC5354958 DOI: 10.1097/j.pain.0000000000000797] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abdominal pain is one of the major symptoms in bowel obstruction (BO); its cellular mechanisms remain incompletely understood. We tested the hypothesis that mechanical stress in obstruction upregulates expression of nociception mediator nerve growth factor (NGF) in gut smooth muscle cells (SMCs), and NGF sensitizes primary sensory nerve to contribute to pain in BO. Partial colon obstruction was induced with a silicon band implanted in the distal bowel of Sprague-Dawley rats. Colon-projecting sensory neurons in the dorsal root ganglia (T13 to L2) were identified for patch-clamp and gene expression studies. Referred visceral sensitivity was assessed by measuring withdrawal response to stimulation by von Frey filaments in the lower abdomen. Membrane excitability of colon-projecting dorsal root ganglia neurons was significantly enhanced, and the withdrawal response to von Frey filament stimulation markedly increased in BO rats. The expression of NGF mRNA and protein was increased in a time-dependent manner (day 1-day 7) in colonic SMC but not in mucosa/submucosa of the obstructed colon. Mechanical stretch in vitro caused robust NGF mRNA and protein expression in colonic SMC. Treatment with anti-NGF antibody attenuated colon neuron hyperexcitability and referred hypersensitivity in BO rats. Obstruction led to significant increases of tetrodotoxin-resistant Na currents and mRNA expression of Nav1.8 but not Nav1.6 and Nav1.7 in colon neurons; these changes were abolished by anti-NGF treatment. In conclusion, mechanical stress-induced upregulation of NGF in colon SMC underlies the visceral hypersensitivity in BO through increased gene expression and activity of tetrodotoxin-resistant Na channels in sensory neurons.
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Affiliation(s)
- You-Min Lin
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yu Fu
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - John Winston
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ravi Radhakrishnan
- Dept. of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Sushil K. Sarna
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Li-Yen M. Huang
- Dept. of Neuroscience & Cell Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Xuan-Zheng Shi
- Dept. of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Diabetics on Narcotics Are Less Likely to Achieve Excellent Bowel Preparation Than Are Patients with Either Condition. Dig Dis Sci 2017; 62:723-729. [PMID: 28035547 DOI: 10.1007/s10620-016-4417-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 12/07/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Diabetes and chronic narcotic use negatively affect the quality of bowel preparation before colonoscopy. AIM To investigate whether narcotic use and diabetes have an additive negative impact on bowel preparation. PATIENTS AND METHODS We performed a retrospective study of 2841 patients (mean age 61 ± 10.2; 94% male) who received outpatient colonoscopies at our Veterans Affairs Medical Center between June 2012 and December 2014. We collected information related to demographics, body mass index, indications, and medical/surgical history (diabetes mellitus, stroke, cirrhosis, dementia, constipation, hypothyroidism, and use of narcotics or antidepressants/anxiolytics for more than three months). Patients were classified into four groups: (1) diabetics on narcotics, (2) diabetics only, (3) on narcotics only, and (4) neither diabetic nor using narcotics. Quality of the bowel preparation was scored using the Boston Bowel Preparation Scale (BBPS) and categorized as either excellent (BBPS ≥7, with no individual segment scoring <2) or not excellent (BBPS <7). Multivariate logistic regression analysis was performed to identify the combined impact of narcotic use and diabetes on bowel preparation. RESULTS Bowel preparation quality was excellent in 49%. Thirty-eight percent of patients with diabetes who were using narcotics (adjusted OR 0.6, CI [0.4, 0.8]) achieved excellent bowel preparation compared with 44% (adjusted OR 0.7, CI [0.6, 0.9]) of patients on narcotics only, 48% (adjusted OR 0.8, CI [0.7, 0.9]) of diabetics only, and 54% of patients with neither condition. CONCLUSION Concomitant narcotic use and diabetes have a compounding effect on the quality of bowel preparation prior to colonoscopy.
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Chokhavatia S, John ES, Bridgeman MB, Dixit D. Constipation in Elderly Patients with Noncancer Pain: Focus on Opioid-Induced Constipation. Drugs Aging 2016; 33:557-74. [PMID: 27417446 PMCID: PMC5012150 DOI: 10.1007/s40266-016-0381-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Constipation is a common and often debilitating condition in the elderly, which may be caused by underlying disease conditions, structural abnormalities in the bowel, and a variety of medications such as anticholinergics, antidepressants, and opiates. In this review, we focus on opioid-induced constipation (OIC), which is often underrecognized and undertreated in the elderly. When opioid therapy is initiated, healthcare providers are encouraged to evaluate risk factors for the development of constipation as part of a thorough patient history. To this end, the patient assessment should include the use of validated instruments, such as the Bristol Stool Scale and Bowel Function Index, to confirm the diagnosis and provide a basis for evaluating treatment outcomes. Healthcare providers should use a stepwise approach to the treatment of OIC in the elderly. Conventional laxatives are a first-line option and considered well tolerated with short-term use as needed; however, evidence is lacking to support their effectiveness in OIC. Moreover, because of the risk of adverse events and other considerations, such as chewing difficulties and swallowing disorders, conventional oral laxatives may be inappropriate for the treatment of OIC in the elderly. Thus, the availability of new pharmacologic agents such as the peripherally acting µ-opioid receptor antagonists methylnaltrexone and naloxegol, which target the underlying causes of OIC, and the secretagogue lubiprostone may provide more effective treatment options for elderly patients with OIC.
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Affiliation(s)
- Sita Chokhavatia
- Division of Gastroenterology and Hepatology, Rutgers, Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB Room 478C, New Brunswick, NJ, 08901, USA.
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
| | - Elizabeth S John
- Division of Gastroenterology and Hepatology, Rutgers, Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB Room 478C, New Brunswick, NJ, 08901, USA
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Mary Barna Bridgeman
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- Critical Care, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Dorn S, Lembo A, Cremonini F. Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach. ACTA ACUST UNITED AC 2016; 2:31-7. [PMID: 25207610 DOI: 10.1038/ajgsup.2014.7] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Spencer Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony Lembo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Sanders KJC, Kneppers AEM, van de Bool C, Langen RCJ, Schols AMWJ. Cachexia in chronic obstructive pulmonary disease: new insights and therapeutic perspective. J Cachexia Sarcopenia Muscle 2016; 7:5-22. [PMID: 27066314 PMCID: PMC4799856 DOI: 10.1002/jcsm.12062] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 07/05/2015] [Accepted: 07/12/2015] [Indexed: 12/19/2022] Open
Abstract
Cachexia and muscle wasting are well recognized as common and partly reversible features of chronic obstructive pulmonary disease (COPD), adversely affecting disease progression and prognosis. This argues for integration of weight and muscle maintenance in patient care. In this review, recent insights are presented in the diagnosis of muscle wasting in COPD, the pathophysiology of muscle wasting, and putative mechanisms involved in a disturbed energy balance as cachexia driver. We discuss the therapeutic implications of these new insights for optimizing and personalizing management of COPD-induced cachexia.
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Affiliation(s)
- Karin J C Sanders
- Department of Respiratory Medicine NUTRIM School of Nutrition and Translational Research in Metabolism Maastricht The Netherlands
| | - Anita E M Kneppers
- Department of Respiratory Medicine NUTRIM School of Nutrition and Translational Research in Metabolism Maastricht The Netherlands
| | - Coby van de Bool
- Department of Respiratory Medicine NUTRIM School of Nutrition and Translational Research in Metabolism Maastricht The Netherlands
| | - Ramon C J Langen
- Department of Respiratory Medicine NUTRIM School of Nutrition and Translational Research in Metabolism Maastricht The Netherlands
| | - Annemie M W J Schols
- Department of Respiratory Medicine NUTRIM School of Nutrition and Translational Research in Metabolism Maastricht The Netherlands
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Mosińska P, Zielińska M, Fichna J. Expression and physiology of opioid receptors in the gastrointestinal tract. Curr Opin Endocrinol Diabetes Obes 2016; 23:3-10. [PMID: 26702845 DOI: 10.1097/med.0000000000000219] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Stimulation of opioid receptors elicits analgesic effect not only in the central nervous system, but also in the gastrointestinal tract, where a high concentration of opioid receptors can be found within the enteric nervous system as well as muscular and immune cells. Along with antinociception, opioid receptors in the stomach and intestine relay signals crucial for secretory and motor gastrointestinal function. RECENT FINDINGS The review focuses on the utility of opioid receptor antagonists, which is generally contributing to the management of postoperative ileus and opioid bowel dysfunction in chronic pain patients nonetheless, opioid receptor antagonists can also be useful in the treatment of irritable bowel syndrome and chronic idiopathic constipation. The study also discusses several antidiarrheal opioid agonists, as well as opioids and opioid mimetics encompassing the concept of ligand-biased agonism and truncated opioid receptor splice variants. SUMMARY Good understanding of the localization and the role of opioid receptors is vital for regulation of various pathophysiological processes in the gastrointestinal tract and may simultaneously provide a tempting approach in eliminating adverse effects related to centrally acting opioids.
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Affiliation(s)
- Paula Mosińska
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
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Abstract
PURPOSE OF REVIEW Opioid-based management of noncancer pain has become much more prevalent over the last 2 decades and is responsible for a wide range of side-effects, particularly affecting the intestinal tract causing opioid-induced constipation (OIC). This review will consider results of recent clinical trials that have provided evidence of new pharmacological management options for the treatment of OIC. RECENT FINDINGS Supportive use of conventional agents, such as stool softeners, osmotic laxatives, and stimulating laxatives in OIC has limited efficacy. The peripheral μ-opioid receptor antagonist (PAMORA) methylnaltrexone (MNTX) was first FDA approved for OIC in patients with advanced illness and later also for OIC in noncancer pain patients; clinical trial results indicated MNTX did not reverse opioid analgesia and did not trigger central opioid withdrawal. Another PAMORA, the orally available naloxegol, has also gained recent FDA approval for the treatment of OIC in adults with chronic, noncancer pain. Lubiprostone, a bicyclical fatty acid acting via activation of intestinal chloride channel-2 (ClC-2), was also approved for OIC treatment in patients with noncancer pain. SUMMARY PAMORA MNTX and naloxegol and the intestinal chloride channel-2 (ClC-2) activator lubiprostone represent additional possible therapeutic options for the management of OIC in patients with chronic noncancer pain.
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Affiliation(s)
- H Christian Weber
- Section of Gastroenterology, Boston University School of Medicine, Boston, Massachusetts, USA
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Rumman A, Gallinger ZR, Liu LWC. Opioid induced constipation in cancer patients: pathophysiology, diagnosis and treatment. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/23809000.2016.1131595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abdominal wall reconstruction: Enhancing outcomes for patients with ventral incisional hernias. Nursing 2016; 46:30-8; quiz 38-9. [PMID: 26735854 DOI: 10.1097/01.nurse.0000476227.49890.ec] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Argoff CE, Brennan MJ, Camilleri M, Davies A, Fudin J, Galluzzi KE, Gudin J, Lembo A, Stanos SP, Webster LR. Consensus Recommendations on Initiating Prescription Therapies for Opioid-Induced Constipation. PAIN MEDICINE 2015; 16:2324-37. [PMID: 26582720 PMCID: PMC4738423 DOI: 10.1111/pme.12937] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective Aims of this consensus panel were to determine (1) an optimal symptom‐based method for assessing opioid‐induced constipation in clinical practice and (2) a threshold of symptom severity to prompt consideration of prescription therapy. Methods A multidisciplinary panel of 10 experts with extensive knowledge/experience with opioid‐associated adverse events convened to discuss the literature on assessment methods used for opioid‐induced constipation and reach consensus on each objective using the nominal group technique. Results Five validated assessment tools were evaluated: the Patient Assessment of Constipation–Symptoms (PAC‐SYM), Patient Assessment of Constipation–Quality of Life (PAC‐QOL), Stool Symptom Screener (SSS), Bowel Function Index (BFI), and Bowel Function Diary (BF‐Diary). The 3‐item BFI and 4‐item SSS, both clinician administered, are the shortest tools. In published trials, the BFI and 12‐item PAC‐SYM are most commonly used. The 11‐item BF‐Diary is highly relevant in opioid‐induced constipation and was developed and validated in accordance with US Food and Drug Administration guidelines. However, the panel believes that the complex scoring for this tool and the SSS, PAC‐SYM, and 28‐item PAC‐QOL may be unfeasible for clinical practice. The BFI is psychometrically validated and responsive to changes in symptom severity; scores range from 0 to 100, with higher scores indicating greater severity and scores >28.8 points indicating constipation. Conclusions The BFI is a simple assessment tool with a validated threshold of clinically significant constipation. Prescription treatments for opioid‐induced constipation should be considered for patients who have a BFI score of ≥30 points and an inadequate response to first‐line interventions.
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Affiliation(s)
- Charles E Argoff
- The American Academy of Pain Medicine Foundation and Comprehensive Pain Center, Albany Medical Center, Albany, New York, USA
| | | | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Andrew Davies
- Supportive and Palliative Care, Royal Surrey County Hospital and St. Luke's Cancer Centre, Surrey, UK
| | - Jeffrey Fudin
- Remitigate, LLC, and Department of Pharmacy, Stratton Veterans Affairs Medical Center, Albany, New York, USA
| | - Katherine E Galluzzi
- Department of Geriatrics, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey Gudin
- Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, New Jersey, USA
| | - Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Steven P Stanos
- Pain and Headache Center, Swedish Medical Center, Seattle, Washington, USA
| | - Lynn R Webster
- Scientific Affairs, PRA Health Sciences, Salt Lake City, Utah, USA
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Quality of life and healthcare resource in patients receiving opioids for chronic pain: a review of the place of oxycodone/naloxone. Clin Drug Investig 2015; 35:1-11. [PMID: 25479959 PMCID: PMC4281369 DOI: 10.1007/s40261-014-0254-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In patients managed with opioids for chronic pain, opioid-induced bowel dysfunction—specifically, opioid-induced constipation (OIC)—is a common side effect, which has a significant impact on quality of life (QoL). The most recent developments for management of OIC are opioid antagonists, including naloxone, a competitive antagonist of peripheral opioid receptors that reverses opioid-induced peripheral gastrointestinal (GI) effects. A prolonged-release formulation of naloxone is available in combination with oxycodone (OXN PR). To review the specific role of OXN PR in the management of chronic pain and OIC and its impact on QoL and healthcare costs, a review of available relevant literature was conducted. Healthcare costs can be up to ten times higher for patients with GI events than for those without. Assessment of QoL in patients with OIC is essential, and multiple tools for its evaluation are available. The Bowel Function Index (BFI), a tool that was specifically developed and validated to measure bowel function in patients with OIC, can be an indication of QoL. In patients with moderate-to-severe chronic pain, randomized trials have demonstrated that OXN PR has equal analgesic efficacy and safety, but results in improved bowel function, compared with prolonged-release oxycodone (Oxy PR) alone. In conclusion, randomized studies using the BFI, as well as real-world clinical practice observations, have demonstrated improved QoL for patients taking OXN PR. This combination should allow more patients to benefit from the analgesic efficacy of opioid therapy and should minimize the side effects of constipation that correspond to improvements in QoL and healthcare offsets.
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Hernández Mateo MM, Martínez-López I, Hernando-Rydings M, Revuelta-Suero S, Marqués de Marino P, Serrano Hernando FJ. Systematic nasogastric tube in aortic surgery: is it necessary? Ann Vasc Surg 2015; 29:786-91. [PMID: 25749609 DOI: 10.1016/j.avsg.2015.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 11/05/2014] [Accepted: 01/01/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Routine nasogastric tube (NGT) decompression has been traditionally used to prevent nausea and vomiting after abdominal surgery. Besides, many studies having demonstrated no benefits derived from this practice after an elective laparotomy, little evidence has been published regarding its use in aortic surgery. In this study, we analyze the effects of the selective use of the NGT in patients undergoing infrarenal aortic surgery in our center. METHODS Prospective cohort study including patients who underwent elective infrarenal aortic surgery between January 2011 and December 2012. Patients were prospectively included in group A (systematic NGT placement) and group B (nonsystematic NGT). The main end point was the occurrence of postoperative nausea and vomiting (PONV). Secondary end points were postoperative complications, time to first oral intake, and hospital stay. RESULTS One hundred patients were finally included in the study, 50 patients per group. Preoperative and intraoperative data were similar between both groups. Higher incidence of PONV (48% vs. 10%; relative risk, 2.4; 95% confidence interval [CI], 1.3-4.5; P = 0.003) was observed in group A. Selective NGT behaved as a protective factor regarding earlier first oral intake in first postoperative 48 hours (hazard ratio, 0.67; 95% CI, 0.45-0.99; P = 0.05). There were no differences in other adverse events although a trend toward fewer respiratory complications was observed in patients with nonsystematic NGT. CONCLUSIONS This study demonstrates higher incidence of PONV and longer time to first oral intake in patients with systematic NGT with no benefits derived from this practice. Based on these results, selective NGT decompression should be encouraged in patients undergoing infrarenal aortic surgery.
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Affiliation(s)
| | - Isaac Martínez-López
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Sergio Revuelta-Suero
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
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Szigethy E, Schwartz M, Drossman D. Narcotic bowel syndrome and opioid-induced constipation. Curr Gastroenterol Rep 2014; 16:410. [PMID: 25183577 DOI: 10.1007/s11894-014-0410-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Prescription opioid use for chronic non-cancer pain has reached epidemic levels in the USA. With this increased use is the recognition of serious opioid-related gastrointestinal complications such as narcotic bowel syndrome (NBS) and opioid-induced constipation (OIC). NBS consists of a paradoxical worsening of abdominal pain with escalating doses of opioids and is likely mediated by the central nervous system. Therapy requires an intensive multidisciplinary approach to detoxification. OIC is the most common gastrointestinal side effect of opioids. Several novel therapeutics are available to treat OIC that fails to respond to laxative therapy. This review will summarize recent findings on the pathophysiology and treatment approaches to NBS and OIC with a focus on controversies about diagnosis and intervention.
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Affiliation(s)
- Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Medical Arts Building, 3708 Fifth Ave, Pittsburgh, PA, 15213, USA,
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Boules M, Shimizu H, Zelisko A, El-Hayek K, Rizk MK, Kroh M. Pre-operative opioid analgesia reduces clinical success of laparoscopic gastric electrical stimulation placement in patients with gastroparesis. Surg Endosc 2014; 29:805-9. [PMID: 25115865 DOI: 10.1007/s00464-014-3754-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/10/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Gastroparesis is a common chronic and costly disorder for which medical therapy is often unsuccessful. Gastric electrical stimulation (GES) has been used to treat refractory cases, however, response is variable and difficult to predict. This study aims to assess whether pre-operative opioid analgesics (OA) use affects clinical success of GES. METHODS Records of 128 patients who underwent laparoscopic GES placement from March 2001 to September 2012 were analyzed retrospectively. Data collected included demographics, surgical outcomes, and clinical parameters. Pre- and post-operative opioid analgesic dosing (No = 0 morphine equivalents (ME)/day, Low = 0-40 ME/day, Mid = 41-80 ME/day, High >80 ME/day), as well as clinical symptom assessment was collected for up to 3 years post-operatively. Clinical success was defined as (1) OA reduction of >50 %, (2) maintenance of weight, or (3) symptom improvement. Descriptive statistics were computed for all factors. A p < 0.05 was considered statistically significant. RESULTS Fifty-three patients were on OA pre-operatively compared to 69 patients who were not. Patients not on OA pre-operatively were less likely than those on OA pre-op group to be on OA post-operatively (p = 0.005); however, there were no differences in weight or symptom improvement. Sub-group analysis of the 53 patients on OA demonstrated significant improvement in clinical symptoms in the low-morphine cohort compared to the mid-morphine cohort (p = 0.02), and OA dosing post-operatively in the low-morphine cohort diminished significantly compared to mid- and high-morphine cohort (p = 0.032). There was no significant difference in weight. CONCLUSION OA dosing pre-operatively significantly affects clinical success of GES placement. Criteria for offering GES implantation may need to take OA dosing into consideration.
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Affiliation(s)
- Mena Boules
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA,
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A review of the clinical manifestations, pathophysiology and management of opioid bowel dysfunction and narcotic bowel syndrome. Middle East J Dig Dis 2014; 6:5-12. [PMID: 24829698 PMCID: PMC4005483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/22/2013] [Indexed: 11/24/2022] Open
Abstract
Opioids are widely used for the treatment of malignant and non-malignant pains. These medications are accompanied by adverse effects, in particular gastrointestinal symptoms known as opioid bowel dysfunction (OBD). The most common symptom of OBD is refractory constipation that is usually stable regardless of the use of laxatives. Narcotic bowel syndrome (NBS) is a subset of OBD described as ambiguous chronic pain aggravated by continual or increased opioid use for pain relief. Pathophysiology of these disorders are not definitely disentangled. Some challenging hypothesis have been posed leading to specific management in order to mitigate the adverse effects. This article is a review of the literature on the prevalence, pathophysiology and management of OBD and NBS.
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Nash B, Meucci O. Functions of the chemokine receptor CXCR4 in the central nervous system and its regulation by μ-opioid receptors. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2014; 118:105-28. [PMID: 25175863 PMCID: PMC4369781 DOI: 10.1016/b978-0-12-801284-0.00005-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Activation of the G protein-coupled receptor CXCR4 by its chemokine ligand CXCL12 regulates a number of physiopathological functions in the central nervous system, during development as well as later in life. In addition to the more classical roles of the CXCL12/CXCR4 axis in the recruitment of immune cells or migration and proliferation of neural precursor cells, recent studies suggest that CXCR4 signaling also modulates synaptic function and neuronal survival in the mature brain, through direct and indirect effects on neurons and glia. These effects, which include regulation of glutamate receptors and uptake, and of dendritic spine density, can significantly alter the ability of neurons to face excitotoxic insults. Therefore, they are particularly relevant to neurodegenerative diseases featuring alterations of glutamate neurotransmission, such as HIV-associated neurocognitive disorders. Importantly, CXCR4 signaling can be dysregulated by HIV viral proteins, host HIV-induced factors, and opioids. Potential mechanisms of opioid regulation of CXCR4 include heterologous desensitization, transcriptional regulation and changes in receptor expression levels, opioid-chemokine receptor dimer or heteromer formation, and the newly described modulation by the protein ferritin heavy chain-all leading to inhibition of CXCR4 signaling. After reviewing major effects of chemokines and opioids in the CNS, this chapter discusses chemokine-opioid interactions in neuronal and immune cells, focusing on their potential contribution to HIV-associated neurocognitive disorders.
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Affiliation(s)
- Bradley Nash
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Olimpia Meucci
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
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