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Ghosh DK, Sarkar DK, Nath M, Ullah P, Khondaker MFA, Chowdhury SAM, Mahmuduzzaman M. Symptoms and Prevalence of Constipation among Adult Population of Bangladesh. Euroasian J Hepatogastroenterol 2023; 13:45-49. [PMID: 38222951 PMCID: PMC10785132 DOI: 10.5005/jp-journals-10018-1393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/09/2023] [Indexed: 01/16/2024] Open
Abstract
Background Constipation is one of the most common gastrointestinal disorders. The prevalence of constipation is rapidly increasing globally. It has adverse effects on the patient's quality of life including productivity and results in a high financial hardship on the healthcare system. The aim of the study was to estimate the symptoms and prevalence of constipation among the adult population of Bangladesh. Materials and methods It was a cross-sectional observational study based on a structured questionnaire and a checklist. In this study, three criteria were used for the diagnosis of chronic constipation (self-reported perception, Rome III criteria, and Bristol's criteria). The study was conducted among 1,550 population between July 2019 and December 2019. Result The study population consisted of 1,550 respondents, among them 41.61% male and 58.39% female, and the mean age was 32.71 ± 9.72 years. In the study, 12.2% of the population was categorized to have constipation according to self-reported perception, 11.2% according to Rome III, and 10.3% reported to have been suffering from constipation according to Bristol chart.Female gender tends to have a greater prevalence than male. In multivariate analysis for constipation, betel nut chewer, alcohol consumer, diabetes mellitus, hypertension, GI surgery, and bronchial asthma were significantly (p < 0.001) associated with constipation. According to Bristol's criteria, the most common stool form was Type III (sausage-shaped with cracked surface) among the Bangladeshi population in this study. Conclusion Chronic constipation is a common problem worldwide. The findings of this study suggest that there is a high prevalence of constipation among the general population of Bangladesh. Decreasing modifiable risk factors of constipation can reduce its prevalence and burden of the disease. Bangladesh is markedly deficient in literature citing constipation prevalence and determinants. These findings may commence a call for setting priority as one of the major public health problems and demanding attention for both at the clinical and community levels. How to cite this article Ghosh DK, Sarkar DK, Nath M, et al. Symptoms and Prevalence of Constipation among Adult Population of Bangladesh. Euroasian J Hepato-Gastroenterol 2023;13(2):45-49.
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Affiliation(s)
- Dilip Kumar Ghosh
- Department of Gastroenterology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh
| | - Debashis Kumar Sarkar
- Department of Gastroenterology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh
| | - Mukta Nath
- Department of Anatomy, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Parash Ullah
- Department of Gastroenterology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh
| | | | | | - Mohammad Mahmuduzzaman
- Department of Gastroenterology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh
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Mark EB, Nedergaard RB, Hansen TM, Nissen TD, Frøkjaer JB, Scott SM, Krogh K, Drewes AM. Tapentadol results in less deterioration of gastrointestinal function and symptoms than standard opioid therapy in healthy male volunteers. Neurogastroenterol Motil 2021; 33:e14131. [PMID: 34051122 DOI: 10.1111/nmo.14131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/17/2021] [Accepted: 03/09/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tapentadol is a combined opioid agonist and norepinephrine reuptake inhibitor with fewer gastrointestinal side effects at equianalgesic doses compared with classical strong opioids. Previous studies on tapentadol have included multi-morbid patients in whom confounders exclude detailed assessment of the mechanistic effects and strict comparison with other opioids or placebo. This study aimed at investigating the effects of tapentadol and oxycodone on gastrointestinal motility and gastrointestinal side effects. METHODS 21 healthy males participated in a randomized, double-blind, placebo-controlled, crossover study. Tapentadol (50 mg twice daily), oxycodone (10 mg twice daily), or placebo tablets were administered for 14 days. Segmental gastrointestinal transit times and colonic motility parameters were measured with electromagnetic capsules. Gastrointestinal side effects were assessed using questionnaires. KEY RESULTS During dosing with tapentadol, gastrointestinal side effects and motility parameters were on placebo level. Compared with tapentadol, oxycodone increased whole gut transit time by 17.9 hours (p = .015) and rectosigmoid transit time by 6.5 hours (p = .005). Compared with tapentadol, oxycodone also reduced long, fast antegrade colonic movements (p = .001). In comparison with placebo, oxycodone prolonged whole gut transit time by 31.6 hours, (p < .001). Moreover, less long, fast antegrade colonic movements (p = .002) were observed during oxycodone. For oxycodone only, slow colonic movements were associated with gastrointestinal side effects. CONCLUSIONS & INFERENCES In this mechanistic study, tapentadol caused significantly less colonic dysmotility and gastrointestinal side effects as compared with oxycodone in equianalgesic doses.
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Affiliation(s)
- Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thomas Dahl Nissen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - S Mark Scott
- Neurogastroenterology Group (GI Physiology Unit), Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Mark EB, Frøkjær JB, Hansen TM, Nedergaard RB, Drewes AM. Although tapentadol and oxycodone both increase colonic volume, tapentadol treatment resulted in softer stools and less constipation: a mechanistic study in healthy volunteers. Scand J Pain 2021; 21:406-414. [PMID: 33606931 DOI: 10.1515/sjpain-2020-0151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/01/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Opioids are often used in treatment of severe pain, although many patients experience gastrointestinal side-effects like constipation. The aim of the current study was to investigate changes in colonic volume, as the result of both colonic motility and fluid transport, in healthy volunteers during opioid treatment with tapentadol as compared with oxycodone and placebo. METHODS In a randomized, double-blind, cross-over study, 21 healthy male volunteers were administered equianalgesic dosages of oral tapentadol (50 mg bid), oxycodone (10 mg bid) or corresponding placebo for 14 days. Segmental colonic volumes were quantified using T2-weighted magnetic resonance images, and gastrointestinal side-effects were assessed with questionnaires. RESULTS Total colonic volume increase during treatment was higher during tapentadol and oxycodone treatment (median 48 and 58 mL) compared to placebo (median -14 mL, both p≤0.003). Tapentadol (and placebo) treatment resulted in more bowel movements (both p<0.05) and softer stool consistency as compared with oxycodone (both p<0.01). Only oxycodone treatment was associated with increased constipation, straining during defecation, and tiredness (all p≤0.01). The colonic volume increase during treatment was directly associated with softer stools during tapentadol treatment (p=0.019). CONCLUSIONS Tapentadol treatment increased colonic volume without leading to harder stools, likely as the opioid sparing effects result in less water absorption from the gut lumen. Oxycodone treatment also increased colonic volume, but with a simultaneous increase in stool dryness and gastrointestinal and central nervous system side-effects. The results confirm that tapentadol treatment may be advantageous to oxycodone regarding tolerability to pain treatment.
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Affiliation(s)
- Esben Bolvig Mark
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Radiology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Department of Radiology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tine Maria Hansen
- Department of Radiology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Lugoboni F, Vignoni F, Tamburin S. Pharmacological treatment of opioid-induced constipation: moving ahead to new targets. Gut 2020; 69:2264-2265. [PMID: 32209607 DOI: 10.1136/gutjnl-2020-320602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/04/2020] [Accepted: 03/12/2020] [Indexed: 12/08/2022]
Affiliation(s)
- Fabio Lugoboni
- Department of Medicine, Addiction Medicine Unit, Integrated University Hospital of Verona, Verona, Veneto, Italy
| | - Federico Vignoni
- Department of Medicine, Addiction Medicine Unit, Integrated University Hospital of Verona, Verona, Veneto, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine & Movement Sciences, University of Verona, Verona, Italy
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Effect of an electronic medical record design modification on laxative co-prescribing among hospitalised patients taking opioids: A before-and-after study. Int J Med Inform 2020; 140:104172. [PMID: 32473568 DOI: 10.1016/j.ijmedinf.2020.104172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/03/2020] [Accepted: 05/07/2020] [Indexed: 11/21/2022]
Abstract
CONTEXT Constipation occurs in up to 71.7% (33/46) of hospital inpatients taking opioid analgesics. Co-prescribing laxatives with opioid analgesics is recommended to prevent opioid-induced constipation. OBJECTIVES This study aimed to examine the effect of an electronic medical record (EMR) design modification to increase laxative co-prescribing among hospitalised inpatients taking opioid analgesics. METHODS In this retrospective 3-month before-and-after study, an EMR modification to improve docusate with sennosides order sentence visibility was implemented on 21 February 2018, at a teaching hospital in Sydney, Australia. The primary outcome was the co-prescription rate of docusate with sennosides within 24-h of the first opioid analgesic administered. International Classification of Diseases 10th Revision Australian Modification diagnosis codes were collected from the EMR. Multivariable logistic regression was performed to determine the impact of the EMR modification on co-prescribing of laxatives with opioid analgesics. RESULTS Of the 1832 adult inpatients included in the study (51.0% male), 50.5% were admitted before the EMR modification implementation and 49.5% were admitted afterwards. Docusate with sennosides was co-prescribed in 12.5% of patients before and 14.9% of patients after the EMR modification. Although the EMR modification did not change laxative co-prescribing among surgical patients (odds ratio [OR] = 1.1, 95% confidence interval [CI] 0.8-1.6, p = 0.54), a significant increase in co-prescription of docusate with sennosides among aged care patients (OR = 1.8, 95% CI 1.0-3.0, p = 0.03) was observed. CONCLUSIONS An EMR design modification did not change laxative co-prescribing in hospital inpatients overall. However, the EMR modification was associated with a significant increase in laxative co-prescribing among aged care patients prescribed opioid analgesics.
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Daniali M, Nikfar S, Abdollahi M. Evaluating naloxegol for the treatment of opioid-induced constipation. Expert Opin Pharmacother 2020; 21:883-891. [DOI: 10.1080/14656566.2020.1735354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Marzieh Daniali
- Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Toxicology and Pharmacology, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Evidence-Based Evaluation of Cost-Effectiveness and Clinical Outcomes Group, Pharmaceutical Sciences Research Center (PSRC), and the Pharmaceutical Management and Economics Research Center (PMERC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Toxicology and Pharmacology, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Raffa RB, Taylor R, Pergolizzi JV. Treating opioid‐induced constipation in patients taking other medications: Avoiding CYP450 drug interactions. J Clin Pharm Ther 2019; 44:361-371. [DOI: 10.1111/jcpt.12812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Robert B. Raffa
- University of Arizona College of Pharmacy Tucson Arizona
- Temple University School of Pharmacy Philadelphia Pennsylvania
- Neumentum Inc Palo Alto California
- The NEMA Research Group Naples Florida
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Grønlund D, Vase L, Knudsen SA, Christensen M, Drewes AM, Olesen AE. Comparison of subjective and objective measures of constipation – Employing a new method for categorizing gastrointestinal symptoms. J Pharmacol Toxicol Methods 2018; 94:23-28. [DOI: 10.1016/j.vascn.2018.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/10/2018] [Accepted: 08/15/2018] [Indexed: 02/07/2023]
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Poulsen JL, Mark EB, Brock C, Frøkjær JB, Krogh K, Drewes AM. Colorectal Transit and Volume During Treatment With Prolonged-release Oxycodone/Naloxone Versus Oxycodone Plus Macrogol 3350. J Neurogastroenterol Motil 2018; 24:119-127. [PMID: 29291613 PMCID: PMC5753910 DOI: 10.5056/jnm17058] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/21/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Opioid-induced constipation (OIC) is the most common gastrointestinal (GI) side effect to opioid treatment. Opioid receptor antagonists against OIC have been introduced, but their efficacy has not been directly compared to conventional laxatives. Our aim was to compare symptoms and objective parameters of gut function in an experimental model of OIC during treatment with the opioid antagonist naloxone and oxycodone in prolonged-release (PR) formulation versus oxycodone plus macrogol 3350. METHODS In this randomized, double-blind, crossover trial 20 healthy men received a 5-day treatment of combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350. Regional GI transit times and segmental colorectal transit were assessed with the Motilis 3D-Transit electromagnetic capsule system. Colorectal volumes were determined by MRI. OIC symptoms were assessed with validated questionnaires, along with stool frequency and consistency. RESULTS Total colorectal volume did not change after 5 days' treatment with PR oxycodone/naloxone (941 vs 1036 mL; P = 0.091), but increased significantly after PR oxycodone plus macrogol treatment (912 vs 1123 mL; P < 0.001). Neither regional GI transit times nor segmental colorectal transit differed between the treatments (all P > 0.05). The Patient Assessment of Constipation Symptom Questionnaire abdominal symptoms score was lower during PR oxycodone/naloxone compared to PR oxycodone plus macrogol (0.2 vs 3.2; P = 0.002). Stool frequency was lower during PR oxycodone/naloxone compared to PR oxycodone plus macrogol (4.2 vs 5.4; P = 0.035). CONCLUSIONS PR oxycodone plus macrogol increases colorectal volume, but does not improve GI transit compared to PR oxycodone/naloxone. However, PR oxycodone/naloxone results in a lower abdominal symptom burden, despite higher stool frequency during macrogol treatment.
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Affiliation(s)
- Jakob L Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg,
Denmark
| | - Esben B Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg,
Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg,
Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg,
Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen,
Denmark
| | - Jens B Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg,
Denmark
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aarhus,
Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus,
Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg,
Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg,
Denmark
- Correspondence: Asbjørn M Drewes, MD, PhD, DMSc, Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, DK-9000 Aalborg, Denmark, Tel: +45-9766-3562, Fax: +45-9766-3577, E-mail:
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Poulsen JL, Brock C, Grønlund D, Liao D, Gregersen H, Krogh K, Drewes AM. Prolonged-Release Oxycodone/Naloxone Improves Anal Sphincter Relaxation Compared to Oxycodone Plus Macrogol 3350. Dig Dis Sci 2017; 62:3156-3166. [PMID: 28986667 DOI: 10.1007/s10620-017-4784-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 09/27/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Opioid analgesics inhibit anal sphincter function and contribute to opioid-induced bowel dysfunction (OIBD). However, it is unknown whether the inhibition can be reduced by opioid antagonism with prolonged-release (PR) naloxone and how this compares to laxative treatment. AIMS To compare the effects of combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350 on anal sphincter function and gastrointestinal symptoms. METHODS A randomized, double-blind, crossover trial was conducted in 20 healthy men. Participants were treated for 5 days with combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350. Resting anal pressure, anal canal distensibility, and relaxation of the internal sphincter to rectal distension were evaluated before treatment (baseline) and on day 5. The Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire, stool frequency, and stool consistency were assessed daily. RESULTS Both PR oxycodone/naloxone and PR oxycodone plus macrogol treatment decreased sphincter relaxation compared to baseline (- 27.5%; P < 0.001 and - 14.7%; P = 0.01). However, sphincter relaxation was increased after PR naloxone/oxycodone treatment compared to macrogol (difference = + 17.6%; P < 0.001). Resting anal pressure and anal canal distensibility did not differ between treatments. PAC-SYM abdominal symptoms score was lower during PR naloxone compared to macrogol (0.2 vs. 3.2; P = 0.002). The number of bowel movements was lower during PR naloxone versus macrogol (4.2 vs. 5.4; P = 0.035). CONCLUSION Relaxation of the internal anal sphincter was significantly better after PR oxycodone/naloxone treatment compared to PR oxycodone plus macrogol 3350. These findings highlight that OIBD may require specific therapy against the complex, pan-intestinal effects of opioids.
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Affiliation(s)
- Jakob Lykke Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100, Copenhagen, Denmark
| | - Debbie Grønlund
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Donghua Liao
- GIOME Academia, Department of Clinical Medicine, Aarhus University, Nordre Ringgade 1, 8000, Aarhus, Denmark
| | - Hans Gregersen
- GIOME, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark.
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Müller-Lissner S, Bassotti G, Coffin B, Drewes AM, Breivik H, Eisenberg E, Emmanuel A, Laroche F, Meissner W, Morlion B. Opioid-Induced Constipation and Bowel Dysfunction: A Clinical Guideline. PAIN MEDICINE (MALDEN, MASS.) 2017; 18:1837-1863. [PMID: 28034973 PMCID: PMC5914368 DOI: 10.1093/pm/pnw255] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction. SETTING Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction." METHODS A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system. RESULTS From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction. CONCLUSIONS In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.
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Affiliation(s)
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia School of Medicine, Piazza Università, 1, Perugia, Italy
| | - Benoit Coffin
- AP-HP Hôpital Louis Mourier, University Denis Diderot-Paris 7, INSERM U987, Paris, France
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Harald Breivik
- Department of Pain Management and Research, University of Oslo, Rikshospitalet, Oslo, Norway
| | - Elon Eisenberg
- Institute of Pain Medicine, Rambam Health Care Campus, The Technion, Israel Institute of Technology, Haifa, Israel
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, Queen Square, London, UK
| | | | | | - Bart Morlion
- The Leuven Center for Algology and Pain Management, University of Leuven, KU Leuven, Leuven, Belgium
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Yoon SC, Bruner HC. Naloxegol in opioid-induced constipation: a new paradigm in the treatment of a common problem. Patient Prefer Adherence 2017; 11:1265-1271. [PMID: 28769555 PMCID: PMC5533475 DOI: 10.2147/ppa.s99412] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Opioid-induced constipation (OIC) imposes a significant burden for patients taking pain medications, often resulting in decreased quality of life. Treatment of OIC with traditional medications for functional constipation can be incompletely effective, leading to nonadherence with opioid treatment and undertreated pain. An emerging class of medications that counteract the adverse effects of opioids in the gastrointestinal tract while preserving central nervous system-based pain relief may represent a paradigm shift in the prevention and treatment of OIC. One of these medications, naloxegol, is a once-daily, oral opioid antagonist that is effective, well-tolerated, and approved for treatment of OIC in patients with noncancer pain. More studies are needed to demonstrate this same utility in patients with cancer-related pain.
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Affiliation(s)
- Stephanie C Yoon
- Scripps Health and University of California San Diego, Joint Hospice and Palliative Medicine Fellowship, San Diego
| | - Heather C Bruner
- Department of Medicine, University of California San Diego, Doris A. Howell Palliative Care Service, La Jolla, CA, USA
- Correspondence: Heather C Bruner, Department of Medicine, University of California San Diego, 3855 Health Sciences Drive, #0987, La Jolla, CA 92093-0987, USA, Tel +1 858 534 7079, Email
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Lugoboni F, Mirijello A, Zamboni L, Faccini M, Casari R, Cossari A, Gasbarrini A, Addolorato G, On Behalf Of Gics. High prevalence of constipation and reduced quality of life in opioid-dependent patients treated with opioid substitution treatments. Expert Opin Pharmacother 2016; 17:2135-2141. [PMID: 27603712 DOI: 10.1080/14656566.2016.1232391] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives To evaluate prevalence and severity of constipation and quality of life (QoL) in a cohort of opioid-addicted patients treated with opioid substitution treatments (OST). METHODS A total of 1057 heroin-dependent patients treated with methadone or buprenorphine were enrolled in a multicenter observational study. Constipation was assessed by Wexner Constipation Scoring System (Wexner CSS), QoL by General Health Questionnaire (GHQ-12). RESULTS 38.5% patients reported mild constipation, 33.3% reported moderate constipation, 14.8% severe constipation and 5.1% very severe constipation. Mean Wexner CSS score was 6.6 ± 4.8. 44.9% patients showed a GHQ-12 score ≥14; of these 18.3% patients showed a GHQ-12 score ≥20. Mean GHQ score was 13.8 ± 6.5. Mean Wexner CSS score was significantly higher in methadone patients (p = 0.004), in those taking psychoactive drugs (p = 0.0001) and in female (p < 0.0001) with respect to counterparts. Similarly, GHQ-12 mean scores were higher methadone group (p = 0.003), in those taking psychoactive drugs (p < 0.0001), and in female (p = 0.039) with respect to counterparts. ANOVA and ANCOVA showed a significant influence of methadone and female gender on Wexner CSS score while psychoactive drugs significantly influenced both tests. CONCLUSIONS The present study shows that patients affected by opioid-dependence in OST with methadone and buprenorphine have a high prevalence of constipation and reduced QoL.
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Affiliation(s)
- Fabio Lugoboni
- a Addiction Unit, Department of Medicine , Verona University Hospital , Verona , Italy
| | - Antonio Mirijello
- b Alcohol Use Disorders Unit, Department of Internal Medicine, Gastroenterology and Hepatology , Catholic University of Rome , Rome , Italy.,c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
| | - Lorenzo Zamboni
- a Addiction Unit, Department of Medicine , Verona University Hospital , Verona , Italy
| | - Marco Faccini
- a Addiction Unit, Department of Medicine , Verona University Hospital , Verona , Italy
| | - Rebecca Casari
- a Addiction Unit, Department of Medicine , Verona University Hospital , Verona , Italy
| | - Anthony Cossari
- d Department of Economics, Statistics and Finance , University of Calabria , Rende , Italy
| | - Antonio Gasbarrini
- b Alcohol Use Disorders Unit, Department of Internal Medicine, Gastroenterology and Hepatology , Catholic University of Rome , Rome , Italy
| | - Giovanni Addolorato
- b Alcohol Use Disorders Unit, Department of Internal Medicine, Gastroenterology and Hepatology , Catholic University of Rome , Rome , Italy
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Leppert W, Woron J. The role of naloxegol in the management of opioid-induced bowel dysfunction. Therap Adv Gastroenterol 2016; 9:736-46. [PMID: 27582887 PMCID: PMC4984326 DOI: 10.1177/1756283x16648869] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Opioid-induced constipation (OIC) and other gastrointestinal (GI) symptoms of opioid-induced bowel dysfunction (OIBD) significantly deteriorate patients' quality of life and may lead to noncompliance with opioid schedule and undertreatment of pain. Although traditional oral laxatives are the first-line treatment of OIC, they do not address OIBD pathophysiology, and display numerous adverse effects. OIC treatment includes prokinetics (lubiprostone), opioid switch, and changing route of opioid administration. Targeted management of OIBD comprises the use of purely peripherally acting μ-opioid receptor antagonists (PAMORA): naloxegol and methylnaltrexone. Naloxegol (NKTR-118) is a polymer conjugate of the opioid antagonist naloxone. The polyethylene glycol limits naloxegol capacity to cross the blood-brain barrier (BBB). Naloxegol is substrate for the P-glycoprotein (P-gp) transporter. The central nervous system penetration of naloxegol is negligible due to reduced permeability and its increased efflux across the BBB, related to P-gp transporter. Naloxegol antagonizes μ- and κ-opioid receptors and displays low affinity to δ-opioid receptors in the GI tract, thereby decreasing OIBD symptoms without reversing central analgesic effects. Naloxegol is metabolised through CYP3A4 to six metabolites, with the majority of the dose (68%) excreted with faeces and less (16%) with urine. The dose of naloxegol equals 25 mg administered orally once daily on a fasting condition. Mild or moderate hepatic impairment has no impact on naloxegol dosing; naloxegol was not studied and is not recommended in patients with hepatic failure. Dose reduction (12.5 mg once daily) and caution is recommended in patients with moderate-to-severe renal impairment. Efficacy (bowel movement in 42-49% of patients not responsive to laxatives) and safety of naloxegol were confirmed in studies conducted in patients with OIC and nonmalignant pain. Naloxegol may be useful for cancer patients with OIC, although studies in this population are lacking.
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Affiliation(s)
| | - Jaroslaw Woron
- Department of Clinical Pharmacology, Jagiellonian University College of Medicine, Krakow, Poland,Department of Pain Treatment and Palliative Care, Jagiellonian University College of Medicine, Krakow, Poland
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15
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Opioid-induced bowel dysfunction in healthy volunteers assessed with questionnaires and MRI. Eur J Gastroenterol Hepatol 2016; 28:514-24. [PMID: 26795566 DOI: 10.1097/meg.0000000000000574] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Opioid treatment is associated with numerous gastrointestinal adverse effects collectively known as opioid-induced bowel dysfunction (OIBD). Most current knowledge of the pathophysiology derives from animal studies limited by species differences and clinical studies, which have substantial confounders that make evaluation difficult. An experimental model of OIBD in healthy volunteers in a controlled setting is therefore highly warranted. The aim of this study was to assess bowel function in healthy volunteers during opioid treatment using subjective and objective methods. METHODS Twenty-five healthy men were assigned randomly to oxycodone or placebo for 5 days in a cross-over design. The analgesic effect was assessed with muscle pressure algometry and adverse effects were measured using questionnaires including the bowel function index, gastrointestinal symptom rating scale, patient assessment of constipation symptoms and the Bristol stool form scale. Colorectal volumes were determined using a newly developed MRI method. RESULTS Compared with baseline, oxycodone increased pain detection thresholds by 8% (P=0.02). Subjective OIBD was observed as increased bowel function index (464% increase; P<0.001), gastrointestinal symptom rating scale (37% increase; P<0.001) and patient assessment of constipation symptoms (198% increase; P<0.001). Objectively, stools were harder and drier during oxycodone treatment (P<0.001) and segmental colorectal volumes increased in the caecum/ascending colon by 41% (P=0.005) and in the transverse colon by 20% (P=0.005). No associations were detected between questionnaire scores and colorectal volumes. CONCLUSION Experimental OIBD in healthy volunteers was induced during oxycodone treatment. This model has potential for future interventional studies to discriminate the efficacies of different laxatives, peripheral morphine antagonists and opioid treatments.
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16
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Poulsen JL, Nilsson M, Brock C, Sandberg TH, Krogh K, Drewes AM. The Impact of Opioid Treatment on Regional Gastrointestinal Transit. J Neurogastroenterol Motil 2016; 22:282-91. [PMID: 26811503 PMCID: PMC4819867 DOI: 10.5056/jnm15175] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/22/2015] [Accepted: 12/31/2015] [Indexed: 12/28/2022] Open
Abstract
Background/Aims To employ an experimental model of opioid-induced bowel dysfunction in healthy human volunteers, and evaluate the impact of opioid treatment compared to placebo on gastrointestinal (GI) symptoms and motility assessed by questionnaires and regional GI transit times using the 3-dimensional (3D)-Transit system. Methods Twenty-five healthy males were randomly assigned to oxycodone or placebo for 5 days in a double blind, crossover design. Adverse GI effects were measured with the bowel function index, gastrointestinal symptom rating scale, patient assessment of constipation symptom questionnaire, and Bristol stool form scale. Regional GI transit times were determined using the 3D-Transit system, and segmental transit times in the colon were determined using a custom Matlab® graphical user interface. Results GI symptom scores increased significantly across all applied GI questionnaires during opioid treatment. Oxycodone increased median total GI transit time from 22.2 to 43.9 hours (P < 0.001), segmental transit times in the cecum and ascending colon from 5.7 to 9.9 hours (P = 0.012), rectosigmoid colon transit from 2.7 to 9.0 hours (P = 0.044), and colorectal transit time from 18.6 to 38.6 hours (P = 0.001). No associations between questionnaire scores and segmental transit times were detected. Conclusions Self-assessed GI adverse effects and increased GI transit times in different segments were induced during oxycodone treatment. This detailed information about segmental changes in motility has great potential for future interventional head-to-head trials of different laxative regimes for prevention and treatment of constipation.
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Affiliation(s)
- Jakob L Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Matias Nilsson
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Thomas H Sandberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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17
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Nilsson M, Sandberg TH, Poulsen JL, Gram M, Frøkjaer JB, Østergaard LR, Krogh K, Brock C, Drewes AM. Quantification and variability in colonic volume with a novel magnetic resonance imaging method. Neurogastroenterol Motil 2015; 27:1755-63. [PMID: 26598050 DOI: 10.1111/nmo.12673] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/13/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Segmental distribution of colorectal volume is relevant in a number of diseases, but clinical and experimental use demands robust reliability and validity. Using a novel semi-automatic magnetic resonance imaging-based technique, the aims of this study were to describe: (i) inter-individual and intra-individual variability of segmental colorectal volumes between two observations in healthy subjects and (ii) the change in segmental colorectal volume distribution before and after defecation. METHODS The inter-individual and intra-individual variability of four colorectal volumes (cecum/ascending colon, transverse, descending, and rectosigmoid colon) between two observations (separated by 52 ± 10) days was assessed in 25 healthy males and the effect of defecation on segmental colorectal volumes was studied in another seven healthy males. KEY RESULTS No significant differences between the two observations were detected for any segments (All p > 0.05). Inter-individual variability varied across segments from low correlation in cecum/ascending colon (intra-class correlation coefficient [ICC] = 0.44) to moderate correlation in the descending colon (ICC = 0.61) and high correlation in the transverse (ICC = 0.78), rectosigmoid (ICC = 0.82), and total volume (ICC = 0.85). Overall intra-individual variability was low (coefficient of variance = 9%). After defecation the volume of the rectosigmoid decreased by 44% (p = 0.003). The change in rectosigmoid volume was associated with the true fecal volume (p = 0.02). CONCLUSIONS & INFERENCES Imaging of segmental colorectal volume, morphology, and fecal accumulation is advantageous to conventional methods in its low variability, high spatial resolution, and its absence of contrast-enhancing agents and irradiation. Hence, the method is suitable for future clinical and interventional studies and for characterization of defecation physiology.
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Affiliation(s)
- M Nilsson
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - T H Sandberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - J L Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - J B Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - L R Østergaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Poulsen JL, Brock C, Olesen AE, Nilsson M, Drewes AM. Evolving paradigms in the treatment of opioid-induced bowel dysfunction. Therap Adv Gastroenterol 2015; 8:360-72. [PMID: 26557892 PMCID: PMC4622283 DOI: 10.1177/1756283x15589526] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years prescription of opioids has increased significantly. Although effective in pain management, bothersome gastrointestinal adverse effects are experienced by a substantial proportion of opioid-treated patients. This can lead to difficulties with therapy and subsequently inadequate pain relief. Collectively referred to as opioid-induced bowel dysfunction, these adverse effects are the result of binding of exogenous opioids to opioid receptors in the gastrointestinal tract. This leads to disturbance of three important gastrointestinal functions: motility, coordination of sphincter function and secretion. In the clinic this manifests in a wide range of symptoms such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation, although the most known adverse effect is opioid-induced constipation. Traditional treatment with laxatives is often insufficient, but in recent years a number of novel pharmacological approaches have been introduced. In this review the pathophysiology, symptomatology and prevalence of opioid-induced bowel dysfunction is presented along with the benefits and caveats of a suggested consensus definition for opioid-induced constipation. Finally, traditional treatment is appraised and compared with the latest pharmacological developments. In conclusion, opioid antagonists restricted to the periphery show promising results, but use of different definitions and outcome measures complicate comparison. However, an international working group has recently suggested a consensus definition for opioid-induced constipation and relevant outcome measures have also been proposed. If investigators within this field adapt the suggested consensus and include symptoms related to dysfunction of the upper gut, it will ease comparison and be a step forward in future research.
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Affiliation(s)
- Jakob Lykke Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anne Estrup Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Matias Nilsson
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, DK-9000 Aalborg, Denmark
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19
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Bruner HC, Atayee RS, Edmonds KP, Buckholz GT. Clinical utility of naloxegol in the treatment of opioid-induced constipation. J Pain Res 2015; 8:289-94. [PMID: 26109876 PMCID: PMC4472065 DOI: 10.2147/jpr.s61326] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Opioids are a class of medications frequently used for the treatment of acute and chronic pain, exerting their desired effects at central opioid receptors. Agonism at peripherally located opioid receptors, however, leads to opioid-induced constipation (OIC), one of the most frequent and debilitating side effects of prolonged opioid use. Insufficient relief of OIC with lifestyle modification and traditional laxative treatments may lead to decreased compliance with opioid regimens and undertreated pain. Peripherally acting mu-opioid receptor antagonists (PAMORAs) offer the reversal of OIC without loss of central pain relief. Until recently, PAMORAs were restricted to subcutaneous route or to narrow patient populations. Naloxegol is the first orally dosed PAMORA indicated for the treatment of OIC in noncancer patients. Studies have suggested its efficacy in patients failing traditional constipation treatments; however, insufficient evidence exists to establish its role in primary prevention of OIC at this time.
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Affiliation(s)
- Heather C Bruner
- Scripps Health and University of California San Diego, Joint Hospice and Palliative Medicine Fellowship, San Diego, CA, USA
| | - Rabia S Atayee
- University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Kyle P Edmonds
- Department of Medicine, University of California San Diego, Doris A Howell Palliative Care Service, La Jolla, CA, USA
| | - Gary T Buckholz
- Department of Medicine, University of California San Diego, Doris A Howell Palliative Care Service, La Jolla, CA, USA
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20
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Leppert W. Emerging therapies for patients with symptoms of opioid-induced bowel dysfunction. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:2215-31. [PMID: 25931815 PMCID: PMC4404965 DOI: 10.2147/dddt.s32684] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Opioid-induced bowel dysfunction (OIBD) comprises gastrointestinal (GI) symptoms, including dry mouth, nausea, vomiting, gastric stasis, bloating, abdominal pain, and opioid-induced constipation, which significantly impair patients’ quality of life and may lead to undertreatment of pain. Traditional laxatives are often prescribed for OIBD symptoms, although they display limited efficacy and exert adverse effects. Other strategies include prokinetics and change of opioids or their administration route. However, these approaches do not address underlying causes of OIBD associated with opioid effects on mostly peripheral opioid receptors located in the GI tract. Targeted management of OIBD comprises purely peripherally acting opioid receptor antagonists and a combination of opioid receptor agonist and antagonist. Methylnaltrexone induces laxation in 50%–60% of patients with advanced diseases and OIBD who do not respond to traditional oral laxatives without inducing opioid withdrawal symptoms with similar response (45%–50%) after an oral administration of naloxegol. A combination of prolonged-release oxycodone with prolonged-release naloxone (OXN) in one tablet (a ratio of 2:1) provides analgesia with limited negative effect on the bowel function, as oxycodone displays high oral bioavailability and naloxone demonstrates local antagonist effect on opioid receptors in the GI tract and is totally inactivated in the liver. OXN in daily doses of up to 80 mg/40 mg provides equally effective analgesia with improved bowel function compared to oxycodone administered alone in patients with chronic non-malignant and cancer-related pain. OIBD is a common complication of long-term opioid therapy and may lead to quality of life deterioration and undertreatment of pain. Thus, a complex assessment and management that addresses underlying causes and patomechanisms of OIBD is recommended. Newer strategies comprise methylnaltrexone or OXN administration in the management of OIBD, and OXN may be also considered as a preventive measure of OIBD development in patients who require opioid administration.
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Affiliation(s)
- Wojciech Leppert
- Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland
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21
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Poulsen JL, Brock C, Olesen AE, Nilsson M, Drewes AM. Clinical potential of naloxegol in the management of opioid-induced bowel dysfunction. Clin Exp Gastroenterol 2014; 7:345-58. [PMID: 25278772 PMCID: PMC4179399 DOI: 10.2147/ceg.s52097] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Opioid-induced bowel dysfunction (OIBD) is a burdensome condition which limits the therapeutic benefit of analgesia. It affects the entire gastrointestinal tract, predominantly by activating opioid receptors in the enteric nervous system, resulting in a wide range of symptoms, such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation. The majority of studies evaluating OIBD focus on constipation experienced in approximately 60% of patients. Nevertheless, other presentations of OIBD seem to be equally frequent. Furthermore, laxative treatment is often insufficient, which in many patients results in decreased quality of life and discontinuation of opioid treatment. Novel mechanism-based pharmacological approaches targeting the gastrointestinal opioid receptors have been marketed recently and even more are in the pipeline. One strategy is prolonged release formulation of the opioid antagonist naloxone (which has limited systemic absorption) and oxycodone in a combined tablet. Another approach is peripherally acting, μ-opioid receptor antagonists (PAMORAs) that selectively target μ-opioid receptors in the gastrointestinal tract. However, in Europe the only PAMORA approved for OIBD is the subcutaneously administered methylnaltrexone. Alvimopan is an oral PAMORA, but only approved in the US for postoperative ileus in hospitalized patients. Finally, naloxegol is a novel, oral PAMORA expected to be approved soon. In this review, the prevalence and pathophysiology of OIBD is presented. As PAMORAs seem to be a promising approach, their potential effect is reviewed with special focus on naloxegol's pharmacological properties, data on safety, efficacy, and patient-focused perspectives. In conclusion, as naloxegol is administered orally once daily, has proven efficacious compared to placebo, has an acceptable safety profile, and can be used as add-on to existing pain treatment, it is a welcoming addition to the targeted treatment possibilities for OIBD.
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Affiliation(s)
- Jakob Lykke Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark ; Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anne Estrup Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark ; Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Matias Nilsson
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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22
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Brock C, Olesen SS, Olesen AE, Frøkjaer JB, Andresen T, Drewes AM. Opioid-induced bowel dysfunction: pathophysiology and management. Drugs 2012; 72:1847-65. [PMID: 22950533 DOI: 10.2165/11634970-000000000-00000] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Opioids are the most commonly prescribed medications to treat severe pain in the Western world. It has been estimated that up to 90% of American patients presenting to specialized pain centres are treated with opioids. Along with their analgesic properties, opioids have the potential to produce substantial side effects, such as nausea, cognitive impairment, addiction and urinary retention. In the gut, opioids exert their action on the enteric nervous system, where they bind to the myenteric and submucosal plexuses, causing dysmotility, decreased fluid secretion and sphincter dysfunction, which all leads to opioid-induced bowel dysfunction (OIBD). In the clinic, this is reported as nausea, vomiting, gastro-oesophageal reflux-related symptoms, constipation, etc. One of the most severe symptoms is constipation, which can be assessed using different scales for subjective assessment. Objective methods such as radiography and colonic transit time can also be used, together with manometry and evaluation of anorectal function to explore the pathophysiology. Dose-limiting adverse symptoms of OIBD can lead to insufficient pain treatment. Even though several treatment strategies are available, the side effects are still a major challenge. Traditional laxatives are normally prescribed but they are often insufficient to alleviate symptoms, especially those from the upper gastrointestinal tract. Newer prokinetics, such as prucalopride and lubiprostone, may be more effective in alleviating OIBD. Another treatment approach is co-administration of opioid antagonists, which either cannot cross the blood-brain barrier or selectively target opioid receptors in the gastrointestinal tract. However, although these new agents have proved to be more efficacious than placebo, clinical trials still need to prove their superiority to standard co-prescribed laxative regimes.
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Affiliation(s)
- Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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Olesen AE, Olofsen E, Olesen SS, Staahl C, Andresen T, Dahan A, Drewes AM. The absorption profile of pregabalin in chronic pancreatitis. Basic Clin Pharmacol Toxicol 2012; 111:385-90. [PMID: 22716224 DOI: 10.1111/j.1742-7843.2012.00914.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 06/13/2012] [Indexed: 12/29/2022]
Abstract
It was recently shown that pregabalin decreased pain associated with chronic pancreatitis. It is well known that pancreatitis patients suffer from fat malabsorption with accompanying diarrhoea because of loss of exocrine pancreatic enzyme production. This may lead to changes in the mucosal surface in the small intestine and possibly affect the absorption of pregabalin. The pharmacokinetics of pregabalin has never been investigated in patients suffering from chronic pancreatitis. The aim of this study was to develop a population pharmacokinetic model of pregabalin administered to patients with chronic pancreatitis. The pregabalin population pharmacokinetic analysis was conducted on data from fifteen patients with chronic pancreatitis. Each patient received 75 mg of pregabalin (oral capsule). Pregabalin concentrations were measured using a validated liquid chromatographic method. Data analysis was performed using non-linear mixed effects modelling methodology as implemented by NONMEM. A one-compartment model with first-order absorption and elimination adequately described pregabalin pharmacokinetics. Time to maximum observed plasma concentration (T(max) ) was 1.53 (95% CI 1.09-2.05). The maximum plasma concentration (C(max) ) was 1.98 μg/ml (95% CI 1.69-2.34), and area under the plasma concentration-time profile (area under the curve) was 18.2 μg*hr/ml (95% CI 14.7-26.3). Pregabalin is well absorbed in patients with chronic pancreatitis, and the pharmacokinetic profile of pregabalin is not extensively affected by chronic pancreatitis.
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Affiliation(s)
- Anne E Olesen
- Mech-Sense, Department of Gastroenterology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:109-25. [DOI: 10.1097/spc.0b013e328350f70c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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