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Faulkner W, DiScala S, Vartan C, Dakroub B, Silverman M, Bharadwaj M. Medication Use Evaluation of Docusate Sodium in Constipation Prophylaxis and Opioid Induced Constipation at the WPB VA HCS Community Living Center. Am J Hosp Palliat Care 2024; 41:1166-1172. [PMID: 37999649 DOI: 10.1177/10499091231218390] [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: 11/25/2023] Open
Abstract
INTRODUCTION Docusate sodium's efficacy is widely debated. Several studies on opioid induced constipation (OIC) concluded that docusate sodium vs either placebo or in combination with sennosides provided no benefit. OBJECTIVE This medication use evaluation aimed to investigate constipation treatment trends within the West Palm Beach VA Healthcare System Community Living Center, and to assess the therapeutic effectiveness of docusate sodium. METHODS This was a retrospective review of data extracted from April 1, 2022, to September 30, 2022. Patients were included if they had oral orders for docusate sodium, sennosides, lactulose, and/or polyethylene glycol. Patients without active bowel regimen medications were excluded. Requirements for rescue constipation medication was evaluated. RESULTS A total of 98 patients were reviewed. Docusate sodium was used in 43% (n = 42/98) of patients. Rescue medications were needed in 58% (n = 22/38) of patients receiving oral docusate sodium. 52% (n = 29/56) of patients without docusate sodium required rescue medications. For OIC treatment, when docusate sodium was added to other bowel regimens, 59% (n = 17/29) of patients needed a rescue medication, while 66% (n = 19/29) of patients without docusate sodium required a rescue medication. Patients on morphine were given the greatest quantity of rescue constipation medications (73%, n = 16/22). CONCLUSION Oral docusate sodium did not reduce the requirement for rescue constipation medications in the WPB VAHCS CLC population. When evaluating constipation treatment, docusate sodium may supply minimal benefit and could be identified as nonessential for deprescribing efforts. Morphine was the most constipating opioid used in this patient population, requiring more aggressive bowel regimens.
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Affiliation(s)
- Wesley Faulkner
- Departement of Pharmacy Service, VA North Texas Health Care System, Dallas, TX, USA
| | - Sandra DiScala
- West Palm Beach VA Health Care Services, West Palm Beach, FL, USA
| | - Christine Vartan
- West Palm Beach VA Health Care Services, West Palm Beach, FL, USA
| | - Belal Dakroub
- West Palm Beach VA Health Care Services, West Palm Beach, FL, USA
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Larsen IM, Okdahl T, Mark EB, Frøkjær JB, Drewes AM. The influence of tramadol on bowel function: A randomised, placebo-controlled trial. Basic Clin Pharmacol Toxicol 2024. [PMID: 39168825 DOI: 10.1111/bcpt.14067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/02/2024] [Accepted: 07/18/2024] [Indexed: 08/23/2024]
Abstract
Tramadol is a weak opioid used to treat moderate pain. Stronger opioids inhibit gastrointestinal function, but little is known about the gastrointestinal effects of tramadol. Our aim was to investigate if tramadol causes opioid-induced bowel dysfunction (OIBD). Twenty healthy male participants (mean age 24 [range 20-31] years) were included. Tramadol (extended-release formulation, 200 mg/day) or placebo was administered for 10 days in two study periods separated by 3 weeks. Gastrointestinal transit times and segmental volume, motility and water content were investigated with the 3D-transit system and magnetic resonance imaging. Bowel movements and gastrointestinal symptoms were recorded daily. Tramadol prolonged colonic transit time (34 h vs. 25 h, p < 0.001) and increased small bowel motility (p < 0.01) and water content (p = 0.002) compared to placebo. Across all days of treatment, tramadol reduced the number of mean daily bowel movements (p = 0.001) and increased mean stool consistency (p = 0.006). Gastrointestinal symptom scores increased with tramadol (indigestion: +358%, p = 0.01; constipation: +475%, p = 0.01). Additionally, more participants fulfilled the diagnostic criteria for constipation after tramadol treatment compared to placebo (40% vs. 0%, p < 0.001). This study showed that tramadol treatment is associated with OIBD, and management of constipation and other bowel symptoms should, therefore, be prioritised when treating pain patients with tramadol.
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Affiliation(s)
- Isabelle M Larsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Tina Okdahl
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Clinical Institute, Aalborg University, Aalborg, Denmark
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
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Ortega G, Lisenby A, Getz T, Zhang W, Mueller K, Schenker ML, Axson SA, Giordano NA. Opioid-Induced Constipation and Associated Symptoms After Orthopedic Trauma. Pain Manag Nurs 2024:S1524-9042(24)00198-X. [PMID: 39097419 DOI: 10.1016/j.pmn.2024.06.012] [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: 12/22/2023] [Revised: 03/19/2024] [Accepted: 06/14/2024] [Indexed: 08/05/2024]
Abstract
PURPOSE Opioid-induced constipation is an adverse effect often experienced among patients taking prescription opioid medication. Despite frequent opioid prescribing after orthopedic injury, there is a dearth of research examining opioid-induced constipation presentations in this population. This analysis examines the frequency of opioid-induced constipation manifestations and association with patient-reported outcomes among participants prescribed opioid medication following orthopedic injury. DESIGN Secondary analysis of 86 clinical trial participants following orthopedic trauma. METHODS Participants were assessed 2-weeks postoperatively with the following measures: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference, PROMIS Physical Function, past 24-hour average pain intensity captured on the numeric pain rating scale, and the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire. Linear regressions examined the association between PAC-SYM scores and both pain intensity and PROMIS T-scores while accounting for injury severity and opioid medication dosage. RESULTS Most participants (69%) reported experiencing opioid-induced constipation symptoms and 7% reported moderate to severe symptoms. Compared to those without symptoms, participants reporting opioid-induced constipation symptoms were found to have a 3-point increase in PROMIS Pain Interference (95% Confidence Interval [CI]: 0.28-5.90; p = .032), a 3-point decline in PROMIS Physical Function (95% CI: -6.57 to -0.02; p = .049), and a 1.7-point increase in average pain scores (95% CI: 0.50-3.01; p = .007) at 2-weeks following surgery. CONCLUSIONS Opioid-induced constipation symptoms are common after orthopedic trauma and linked to increased pain interference and pain intensity as well as reduced physical function. CLINICAL IMPLICATIONS Nurse-led assessments of opioid-induced constipation can support the timely delivery of interventions to alleviate symptoms and potentially improve patient-reported outcomes after injury.
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Affiliation(s)
- Gabriela Ortega
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Alexa Lisenby
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Tatiana Getz
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Wenhui Zhang
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Kenneth Mueller
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Mara L Schenker
- School of Medicine, Emory University, Atlanta, Georgia; Grady Memorial Hospital, Atlanta, Georgia
| | - Sydney A Axson
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, State College, Pennsylvania
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
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Shimizu M, Maeda I, Kessoku T, Ishiki H, Matsuura T, Hiratsuka Y, Matsuda Y, Hasegawa T, Imai K, Oyamada S, Satomi E. The safety and effectiveness of naldemedine for opioid-induced constipation in patients with advanced cancer in real-world palliative care settings: a multicenter prospective observational study. Support Care Cancer 2024; 32:504. [PMID: 38985364 DOI: 10.1007/s00520-024-08716-8] [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] [Received: 01/21/2024] [Accepted: 07/04/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE In this study, we aimed to evaluate the safety and effectiveness of naldemedine for treating opioid-induced constipation (OIC) in patients with advanced cancer, who are receiving palliative care, and particularly explored its early effects. METHODS Palliative care teams and inpatient palliative care units across 14 institutions in Japan were included in this multicenter, prospective, observational study. Patients who were newly prescribed a daily oral dose of 0.2 mg naldemedine were enrolled. The spontaneous bowel movement (SBM) within 24 h after the first dose of naldemedine was considered the primary outcome, whereas, the secondary outcomes included weekly changes in SBM frequency and adverse events. RESULTS A total of 204 patients were enrolled and 184 completed the 7-day study. The average age of the participants (103 males, 101 females) was 63 ± 14 years. The primary cancer was detected in the lungs (23.5%), gastrointestinal tract (13.7%), and urological organs (9.3%). A considerable proportion of patients (34.8%) had ECOG performance status of 3-4. Most patients were undergoing active cancer treatment, however, 40.7% of the patients were receiving the best supportive care. Within 24 h of the first naldemedine dose, 146 patients (71.6%, 95% CI: 65.4-77.8%) experienced SBMs. The weekly SBM counts increased in 62.7% of the participants. The major adverse events included diarrhea and abdominal pain, detected in 17.6% and 5.4% of the patients, respectively. However, no serious adverse events were observed. CONCLUSION Conclusively, naldemedine is effective and safe for OIC treatments in real-world palliative care settings. TRIAL REGISTRATION NUMBER UMIN000031381, registered 20/02/2018.
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Affiliation(s)
- Masaki Shimizu
- Department of Palliative Care, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Toyonaka, Osaka, Japan.
| | - Takaomi Kessoku
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Japan
- Department of Palliative Medicine, International University Health and Welfare Narita Hospital, Narita, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Tetsuya Matsuura
- Palliative Care Center, Fujisawa Shounandai Hospital, Kanagawa, Japan
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Takeda General Hospital, Aizu Wakamatsu, Japan
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, NHO Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Takaaki Hasegawa
- Center for Psycho-Oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | | | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
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Mathe A, Sudre E, Averous V. [Appropriate use of strong opioids in medical units: Recommendations and action to be taken in daily practice]. Rev Med Interne 2024; 45:400-408. [PMID: 38839485 DOI: 10.1016/j.revmed.2024.05.010] [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] [Received: 12/07/2023] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024]
Abstract
The use of strong opioids in medical units is recurrent, mainly for analgesic purposes. The risk of occurrence of an overdose or an opioid use disorders causes very legitimate concerns for the physician, which may limit the use of opioid treatment or the adaptation of the doses necessary to relieve the patient. We provide a summary of the literature aimed at defining the indications, the adverse effects and the risks involved, the prescribing methods in order to reassure professionals and promote the safe use of these molecules.
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Affiliation(s)
- A Mathe
- Service de médecine palliative et accompagnement, CHU de Bordeaux, Bordeaux, France.
| | - E Sudre
- Service de médecine palliative et accompagnement, CHU de Bordeaux, Bordeaux, France
| | - V Averous
- Service de médecine palliative et accompagnement, université de Bordeaux, CHU, Bordeaux, France
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Abe H, Sumitani M, Matsui H, Inoue R, Fushimi K, Uchida K, Yasunaga H. Association between hospital palliative care team intervention volume and patient outcomes. Int J Clin Oncol 2024:10.1007/s10147-024-02574-4. [PMID: 38913218 DOI: 10.1007/s10147-024-02574-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/19/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND The benefits of palliative care in patients with advanced cancer are well established. However, the effect of the skills of the palliative care team (PCT) on patient outcomes remains unclear. Our aim was to evaluate the association between hospital PCT intervention volume and patient outcomes in patients with cancer. METHODS A retrospective cohort study was conducted using a nationwide inpatient database in Japan. Patients with cancer receiving chemotherapy and PCT intervention from 2015 to 2020 were included. The outcomes were incidence of hyperactive delirium within 30 days of admission, mortality within 30 days of admission, and decline in activities of daily living (ADL) at discharge. The exposure of interest was hospital PCT intervention volume (annual number of new PCT interventions in a hospital), which was categorized into low-, intermediate-, and high-volume groups according to tertiles. Multivariate logistic regression and restricted cubic-spline regression were conducted. RESULTS Of 29,076 patients, 1495 (5.1%), 562 (1.9%), and 3026 (10.4%) developed delirium, mortality, and decline in ADL, respectively. Compared with the low hospital PCT intervention volume group (1-103 cases/year, n = 9712), the intermediate (104-195, n = 9664) and high (196-679, n = 9700) volume groups showed significant association with lower odds ratios of 30-day delirium (odds ratio, 0.79 [95% confidence interval, 0.69-0.91] and 0.80 [0.69-0.93], respectively), 30-day mortality (0.73 [0.60-0.90] and 0.59 [0.46-0.75], respectively), and decline in ADL (0.77 [0.70-0.84] and 0.52 [0.47-0.58], respectively). CONCLUSION Hospital PCT intervention volume is inversely associated with the odds ratios of delirium, mortality, and decline in ADL among hospitalized patients with cancer.
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Affiliation(s)
- Hiroaki Abe
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Zimmerman A, Laitman A. Safe Management of Adverse Effects Associated with Prescription Opioids in the Palliative Care Population: A Narrative Review. J Clin Med 2024; 13:2746. [PMID: 38792289 PMCID: PMC11121850 DOI: 10.3390/jcm13102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/26/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
In the palliative care population, prescription opioids are often considered viable pain relief options. However, in this complex patient population, the adverse effects of opioid medications should be identified and managed without delay. Common adverse effects can include constipation, nausea, somnolence, dizziness, vomiting, and pruritus. Less common adverse effects can include potentially lethal respiratory depression and cardiovascular effects. Critical aspects of safe opioid prescribing are recognition of side effects and knowledge of effective management strategies; prompt management is necessary for uninterrupted pain relief. Most complications are managed with general approaches such as dose reduction, opioid rotation, alternate routes of administration, and symptomatic management. The only opioid-induced complication for which US Food and Drug Administration-approved treatments currently exist is constipation. Treating laxative-refractory opioid-induced constipation (OIC) with peripherally acting mu-opioid receptor antagonists (PAMORAs), which block gastrointestinal opioid receptors, can restore gastrointestinal motility and fluid secretion. This narrative review discusses key complications of prescription opioid treatment and their management in the palliative care setting.
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Affiliation(s)
| | - Adam Laitman
- Salix Pharmaceuticals, Bridgewater, NJ 08807, USA;
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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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Chelly JE, Goel SK, Kearns J, Kopac O, Sadhasivam S. Nanotechnology for Pain Management. J Clin Med 2024; 13:2611. [PMID: 38731140 PMCID: PMC11084313 DOI: 10.3390/jcm13092611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.
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Affiliation(s)
- Jacques E. Chelly
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA
| | - Shiv K. Goel
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Jeremy Kearns
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Orkun Kopac
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
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10
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Kistemaker KRJ, Sijani F, Brinkman DJ, de Graeff A, Burchell GL, Steegers MAH, van Zuylen L. Pharmacological prevention and treatment of opioid-induced constipation in cancer patients: A systematic review and meta-analysis. Cancer Treat Rev 2024; 125:102704. [PMID: 38452708 DOI: 10.1016/j.ctrv.2024.102704] [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] [Received: 10/31/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Cancer-related pain often requires opioid treatment with opioid-induced constipation (OIC) as its most frequent gastrointestinal side-effect. Both for prevention and treatment of OIC osmotic (e.g. polyethylene glycol) and stimulant (e.g. bisacodyl) laxatives are widely used. Newer drugs such as the peripherally acting µ-opioid receptor antagonists (PAMORAs) and naloxone in a fixed combination with oxycodone have become available for the management of OIC. This systematic review and meta-analysis aims to give an overview of the scientific evidence on pharmacological strategies for the prevention and treatment of OIC in cancer patients. METHODS A systematic search in PubMed, Embase, Web of Science and the Cochrane Library was completed from inception up to 22 October 2022. Randomized and non-randomized studies were systematically selected. Bowel function and adverse drug events were assessed. RESULTS Twenty trials (prevention: five RCTs and three cohort studies; treatment: ten RCTs and two comparative cohort studies) were included in the review. Regarding the prevention of OIC, three RCTs compared laxatives with other laxatives, finding no clear differences in effectivity of the laxatives used. One cohort study showed a significant benefit of magnesium oxide compared with no laxative. One RCT found a significant benefit for the PAMORA naldemedine compared with magnesium oxide. Preventive use of oxycodone/naloxone did not show a significant difference in two out of three other studies compared to oxycodone or fentanyl. A meta-analysis was not possible. Regarding the treatment of OIC, two RCTs compared laxatives, of which one RCT found that polyethylene glycol was significantly more effective than sennosides. Seven studies compared an opioid antagonist (naloxone, methylnaltrexone or naldemedine) with placebo and three studies compared different dosages of opioid antagonists. These studies with opioid antagonists were used for the meta-analysis. Oxycodone/naloxone showed a significant improvement in Bowel Function Index compared to oxycodone with laxatives (MD -13.68; 95 % CI -18.38 to -8.98; I2 = 58 %). Adverse drug event rates were similar amongst both groups, except for nausea in favour of oxycodone/naloxone (RR 0.51; 95 % CI 0.31-0.83; I2 = 0 %). Naldemedine (NAL) and methylnaltrexone (MNTX) demonstrated significantly higher response rates compared to placebo (NAL: RR 2.07, 95 % CI 1.64-2.61, I2 = 0 %; MNTX: RR 3.83, 95 % CI 2.81-5.22, I2 = 0 %). With regard to adverse events, abdominal pain was more present in treatment with methylnaltrexone and diarrhea was significantly more present in treatment with naldemedine. Different dosages of methylnaltrexone were not significantly different with regard to both efficacy and adverse drug event rates. CONCLUSIONS Magnesium oxide and naldemedine are most likely effective for prevention of OIC in cancer patients. Naloxone in a fixed combination with oxycodone, naldemedine and methylnaltrexone effectively treat OIC in cancer patients with acceptable adverse events. However, their effect has not been compared to standard (osmotic and stimulant) laxatives. More studies comparing standard laxatives with each other and with opioid antagonists are necessary before recommendations for clinical practice can be made.
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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.
| | - F Sijani
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - D J Brinkman
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC location Vrije Universiteit Amsterdam, Internal Medicine, Section Pharmacotherapy, De Boelelaan 1117, Amsterdam, the Netherlands
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, de Bilt, the Netherlands
| | - G L Burchell
- Medical Library, Vrije Universiteit Amsterdam, 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
| | - 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
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11
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Roller MD, Panchal A, Duesing L, Mikhailov TA. Incidence of opioid-induced constipation in the pediatric intensive care unit: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:354-359. [PMID: 38142301 DOI: 10.1002/jpen.2592] [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] [Received: 06/26/2023] [Revised: 11/23/2023] [Accepted: 12/13/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a well-known phenomenon, although there is limited literature evaluating the incidence of OIC in children admitted to the pediatric intensive care unit (PICU). The primary aim of this study was to determine the incidence of OIC in the PICU and to determine if it is associated with a higher rate of morbidities or prolonged length of stay (LOS). METHODS We conducted a single-center retrospective chart review from July 1, 2014, to June 30, 2015, in our PICU. We included all patients aged ≤18 years with a PICU stay of ≥96 h who received opioids during their admission. Data were collected on the frequency of bowel movements and characteristics of opioid administration. Demographic and clinical data were obtained from Virtual Pediatric Systems, LLC. RESULTS Of the 94 patients who met the study criteria, 39.4% developed constipation. These patients tended to be older (P = 0.06) and were noted to weigh more (P = 0.03). There was no significant difference in the total or median daily doses, duration of opioid treatment, or mode of administration. Constipation rates did not differ by the severity of illness. There was a higher incidence of constipation in the patients who were admitted for neurological issues or after trauma or abdominal surgery (P = 0.002). Patients with constipation had a longer LOS than patients without constipation, but the difference was not statistically significant. CONCLUSION These results indicate that opioid use is not the sole risk factor for constipation in the PICU setting.
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Affiliation(s)
- Meghan D Roller
- Department of Pediatrics, Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Apurva Panchal
- Critical Care, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Lori Duesing
- Children's Wisconsin, Milwaukee, Wisconsin, USA
- Department of General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Theresa A Mikhailov
- Department of Pediatrics, Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Milwaukee, Wisconsin, USA
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12
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Braun UK, Jackson LK, Garcia MA, Imam SN. A Systematic Review of Naldemedine and Naloxegol for the Treatment of Opioid-Induced Constipation in Cancer Patients. PHARMACY 2024; 12:48. [PMID: 38525728 PMCID: PMC10961755 DOI: 10.3390/pharmacy12020048] [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: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a pervasive and distressing side effect of chronic opioid therapy in patients with cancer pain, significantly impacting their quality of life. Peripherally acting μ-opioid receptor antagonists (PAMORAS) were developed for treatment-resistant OIC but most studies were conducted with non-cancer patients. OBJECTIVE to discuss two oral formulations of PAMORAs, naldemedine and naloxegol, and to review available evidence of the effectiveness of these drugs for OIC in cancer patients. METHODS a comprehensive search to identify primary literature for either naldemedine or naloxegol for OIC in cancer patients. RESULTS Only three prospective randomized, double-blind, placebo-controlled clinical trials for naldemedine enrolling cancer patients were identified; the results of a subgroup analysis of two of those studies and two non-interventional post marketing surveillance studies of these trials are also reported here. For naloxegol, only two randomized controlled trials were identified; both were unsuccessful in enrolling sufficient patients. An additional four prospective non-interventional observational studies with naloxegol were found that enrolled cancer patients. There were significantly higher rates of responders in the PAMORA groups than in the placebo groups. The most common side effect for both PAMORAs was diarrhea. LIMITATIONS All studies were industry-funded, and given that only three trials were randomized controlled studies, the overall quality of the studies was lacking. CONCLUSION Naldemedine or naloxegol appeared safe and useful in the treatment of OIC in cancer patients and may improve their quality of life. Larger-scale randomized placebo-controlled studies of PAMORAs in cancer patients would strengthen existing evidence.
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Affiliation(s)
- Ursula K. Braun
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; (L.K.J.); (M.A.G.)
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Leanne K. Jackson
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; (L.K.J.); (M.A.G.)
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Mary A. Garcia
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; (L.K.J.); (M.A.G.)
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Syed N. Imam
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
- Office of Connected Care, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
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13
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Mills KP, McPherson CC, Said AS, Lahart MA. Successful Use of Intravenous Methylnaltrexone for Opioid-Induced Constipation in Critically Ill Pediatric Patients. J Pediatr Intensive Care 2024; 13:25-31. [PMID: 38571990 PMCID: PMC10987215 DOI: 10.1055/s-0041-1736335] [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: 06/15/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022] Open
Abstract
Objectives Methylnaltrexone is U.S. Food and Drug Administration (FDA) approved as a subcutaneous injection for adults with opioid-induced constipation (OIC). Case series have described the use of methylnaltrexone for OIC in the pediatric oncology population. There are limited data describing its intravenous use in critically ill pediatric patients. Methods We conducted a retrospective observational study at St. Louis Children's Hospital. Patients less than 18 years old who received at least one dose of intravenous methylnaltrexone while admitted to an intensive care unit between January 2016 and August 2019 were included. The primary outcome was documented laxation within 24 hours of methylnaltrexone administration. Results Sixteen patients received a total of 34 doses of intravenous methylnaltrexone. Patients received a median of 1.69 (interquartile range [IQR], 0.9-4.86) morphine milligram equivalents per kilogram per 24 hours, over a median of 14 days (IQR, 11-30), before methylnaltrexone administration. The median dose of methylnaltrexone was 0.15 mg/kg (IQR, 0.15-0.16). Ten patients (63%) responded to the first dose of methylnaltrexone, and 14 patients (88%) responded to at least one dose. Overall, 26 doses (76%) led to patient response. Four patients (25%) experienced adverse events (emesis, abdominal pain) after methylnaltrexone administration. No signs or symptoms of opioid withdrawal were documented. Conclusions Intravenous methylnaltrexone appears to be safe and effective in treating OIC in critically ill pediatric patients. No serious adverse events or signs of opioid withdrawal were observed after single and repeat dosing. Patients responded to methylnaltrexone with varying opioid dosing and durations prior to administration.
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Affiliation(s)
- Kimberly P. Mills
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
| | - Christopher C. McPherson
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Ahmed S. Said
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States
- Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Michael A. Lahart
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
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14
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Kessoku T, Higashibata T, Morioka Y, Naya N, Koretaka Y, Ichikawa Y, Hisanaga T, Nakajima A. Naldemedine and Magnesium Oxide as First-Line Medications for Opioid-Induced Constipation: A Comparative Database Study in Japanese Patients With Cancer Pain. Cureus 2024; 16:e55925. [PMID: 38601408 PMCID: PMC11004843 DOI: 10.7759/cureus.55925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/12/2024] Open
Abstract
Introduction Naldemedine and magnesium oxide are common first-line early laxative medications used in the real-world scenario in Japan, for patients with cancer pain who receive opioid prescriptions, as per a nationwide hospital claims database study. However, the real-world prescription patterns and associated outcomes are unknown. Methods In this retrospective, cohort study using the Medical Data Vision (MDV) database (January 2018 to December 2020), data were collected from eligible patients (who had a long-term prescription of strong opioids, for >30 days) in Japan with naldemedine or magnesium oxide as the first-line laxative prescription, for a long-term opioid prescription for cancer pain with ≥6 months post-opioid observation period. A laxative prescription within three days after the opioid prescription date was termed an "early" prescription. The composite incidence of dose increase or addition/change of laxatives at three months after the start of the opioid prescription was the primary endpoint after adjusting baseline characteristics between the treatment arms by propensity score matching. Results After propensity score matching, 1717 and 544 patients who were prescribed naldemedine and magnesium oxide each were included in the early prescription and non-early prescription groups, respectively. Even after matching, the incidence of death was not adjusted enough and was significantly higher in the naldemedine arm than in the magnesium oxide arm in the non-early group but comparable in the early group. The incidence of addition, change, or dose increase was significantly higher in the naldemedine arm than in the magnesium oxide arm of the early prescription group (hazard ratio (95% confidence interval), 1.08 (1.00, 1.17); p=0.0402); the incidence was comparable between the arms of the non-early group. Conclusion These findings may provide valuable insights into real-world clinical treatment patterns and preliminary evidence for the selection of first-line medications to mitigate opioid-induced constipation in Japanese patients with cancer pain.
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Affiliation(s)
- Takaomi Kessoku
- Department of Palliative Medicine, International University of Health and Welfare Narita Hospital, Narita, JPN
- Department of Gastroenterology, International University of Health and Welfare School of Medicine, Narita, JPN
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, JPN
| | - Takahiro Higashibata
- Department of Palliative and Supportive Care, University of Tsukuba Hospital, Tsukuba, JPN
| | | | - Noriyuki Naya
- Department of Medical Affairs, Shionogi & Co. Ltd., Osaka, JPN
| | | | - Yasushi Ichikawa
- Department of Oncology, Yokohama City University School of Medicine, Yokohama, JPN
| | - Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, JPN
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, JPN
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15
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Serra J, Alcedo J, Barber C, Ciriza de Los Ríos C. Review document of the Spanish Association of Neurogastroenterology and Motility on the management of opioid-induced constipation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38305669 DOI: 10.17235/reed.2024.10242/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Opioid induced constipation is a rising problem due to the progressive increment in the prescription of opioids. By contrast to functional constipation, opioid-induced constipation is not a functional gut disorder, but a side effect of the use of opioids. Opioids produce constipation due to a decrease in gastrointestinal motility and a reduction in the gastrointestinal secretions. The treatment of OIC focuses on three basic pillars: optimizing opioid drug indication, preventing constipation onset, and treating it if it occurs. As with any other cause of constipation, lifestyle adjustments and laxatives should be the first-line treatment in the pharmacological management of OIC. Osmotic laxatives such as polyethylene glycol (PEG) are the agents of choice. PEG is inert and is neither fermented nor absorbed in the gastrointestinal tract. Furthermore, it has broad clinical applicability due to its favourable safety profile. If first-line treatments fail, peripheral mu receptor antagonists (PAMORA) are the drugs of choice. They reduce the peripheral effects of OIC with minimal potential to diminish analgesia or induce centrally mediated withdrawal syndrome. Different PAMORA are available in the market, both for oral and subcutaneous administration, with demonstrated efficacy for management of OIC in different clinical trials.
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Affiliation(s)
- Jordi Serra
- Digestive System Research Unit, Hospital Universitari Vall d'Hebron, España
| | - Javier Alcedo
- Gastroenterology, Hospital Universitario Miguel Servet, España
| | - Claudia Barber
- Digestive System Research Unit, Hospital Universitari Vall d'Hebron, España
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16
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Wobbe B, Gerner M, Köhne CH. Naldemedine versus placebo in opioid-induced constipation: a meta-analysis. BMJ Support Palliat Care 2024; 13:e578-e584. [PMID: 36517204 DOI: 10.1136/spcare-2022-003896] [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] [Received: 07/31/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Opioid-induced constipation (OIC) is a frequent adverse event among patients receiving chronic pain therapy that is requiring opioids. Naldemedine was approved by the Food and Drug Administration to treat OIC and appears to be more efficient than any other peripherally acting µ-opioid receptor antagonist. This meta-analysis aimed at assessing the available data on naldemedine in terms of efficacy. METHODS We searched the Cochrane Library, PubMed and ClinicalTrials on 24 May 2022 to identify randomised controlled trials (RCTs) comparing naldemedine to placebo among patients reporting OIC. RESULTS Evaluation of 6 RCTs enrolling 2769 participants showed significantly greater respondence to treatment (OR=2.48; 95% CI: 2.02 to 3.06; p<0.00001), change in weekly spontaneous bowel movements (SBMs) (mean difference=1.45; 95% CI: 1.14 to 1.76; p<0.00001), complete SBMs (mean difference=0.89; 95% CI: 0.62 to 1.17; p<0.00001) and SBMs without straining (mean difference=0.89; 95% CI: 0.61 to 1.17; p<0.00001) for patients treated with naldemedine. We found no difference in numeric pain rating scales after one (mean difference=0.05; 95% CI: -0.22 to 0.31; p=0.73) and two weeks of treatment (mean difference= -0.04; 95% CI: -0.31 to 0.22; p=0.75). Funding and clinical diversity were possible risks of bias. CONCLUSIONS Naldemedine improves a variety of bowel function parameters while preserving analgesia, confirming its efficacy for patients with OIC. However, head-to-head trials are needed to establish naldemedine as treatment of first choice for laxative-refractory OIC. PROSPERO REGISTRATION NUMBER CRD42022281353.
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Affiliation(s)
- Bastian Wobbe
- Department of Oncology and Hematology, Klinikum Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Maximilian Gerner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Claus-Henning Köhne
- Department of Oncology and Hematology, Klinikum Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Kvarstein G, Kindlundh-Högberg AM, Ould Setti M, Namane R, Muzwidzwa R, Richter H, Hakkarainen KM. An observational post-authorization safety study (PASS) of naloxegol drug utilization in four European countries. Pharmacoepidemiol Drug Saf 2024; 33:e5710. [PMID: 37969030 DOI: 10.1002/pds.5710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/01/2023] [Accepted: 09/22/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE Naloxegol has been shown to be an efficient alternative to treat opioid-induced constipation (OIC). This study aimed at describing the characteristics of naloxegol users and assessing patterns of naloxegol use and associated factors. METHODS This drug utilization cohort study used observational registry data on patients newly prescribed naloxegol in four European countries. Patient characteristics and patterns of naloxegol use and associated factors were described. RESULTS A total of 17 254 naloxegol users were identified across the countries. Their median age was 56-71 years, and each country had a majority of women (ranging 57.5%-62.9%). Multiple comorbidities, including cancer, were common. Natural opium alkaloids and osmotically acting laxatives (excluding saline) were the most frequently used opioids and laxatives. Overall prior use of opioids ranged from 91.9% to 99.6% and overall prior use of laxatives ranged from 69.9% to 92.4%. Up to 77.7% had prior use of medications with interaction potential, and up to 44.5% used them concurrently with naloxegol. Naloxegol was discontinued by 55.1%-90.9% of users, typically during the first 30 days. Approximately 10%-30% switched to or augmented the treatment with another constipation medication or restarted naloxegol after discontinuation. Augmentation with another constipation medication was relatively common, suggesting that naloxegol was used for multifactorial constipation. CONCLUSION The present study reflects real-world clinical use of naloxegol, including in vulnerable patient groups. Some naloxegol users lacked laxative or regular opioid use within six months before index date or used naloxegol concomitantly with medications presenting an interaction potential.
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Affiliation(s)
- Gunnvald Kvarstein
- Institute for Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | - Mounir Ould Setti
- Global Database Studies, Real World Solutions, IQVIA, Espoo, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Rafik Namane
- Kyowa Kirin International plc, Galabank Business Park, Galashiels, UK
| | | | - Hartmut Richter
- Epidemiology, Real World Solutions, IQVIA, Frankfurt/Main, Germany
| | - Katja M Hakkarainen
- Global Database Studies, Real World Solutions, IQVIA, Mölndal, Sweden
- Epidemiology & Real-World Science, RWE Scientific Affairs, Parexel International, Gothenburg, Sweden
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18
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Cobo Dols M, Beato Zambrano C, Cabezón-Gutiérrez L, Chicas-Sett R, Blancas López-Barajas MI, García Navalón FJ, Fírvida Pérez JL, Serrano Bermúdez G, Togores Torres P, Delgado Mingorance I, Giraldo Marín A, Librán Oriol A, Paredes Lario A, Sánchez Mauriño P, Higuera Gómez O, Moreno Muñoz D, Huerta González I, Sanz-Yagüe A, Soler López B. One-year efficacy and safety of naloxegol on symptoms and quality of life related to opioid-induced constipation in patients with cancer: KYONAL study. BMJ Support Palliat Care 2023; 13:e318-e326. [PMID: 33707299 PMCID: PMC10715504 DOI: 10.1136/bmjspcare-2020-002816] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Naloxegol is a peripherally acting µ-opioid receptor antagonist (PAMORA) for treatment of opioid-induced constipation (OIC). The main objective was to analyse the long-term efficacy, quality of life (QOL) and safety of naloxegol in patients with cancer in a real-world study. METHODS This one-year prospective study included patients older than 18 years, with active oncological disease who were under treatment with opioids for pain control and Karnofsky≥50 and OIC with inadequate response to treatment with laxative (s). All the patients received treatment with naloxegol according to clinical criteria. The main efficacy objectives were measured by the patient assessment of constipation QOL questionnaire (PAC-QOL), the PAC symptoms (PAC-SYM), the response rate at day 15, and months 1-3-6-12, and global QOL (EuroQoL-5D-5L). RESULTS A total of 126 patients (58.7% males) with a mean age of 61.5 years (95% CI 59.4 to 63.7) were included. PAC-SYM and PAC-QOL total score and all their dimensions improved from baseline (p<0.0001). At 12 months, 77.8% of the patients were responders to naloxegol treatment. Global QOL was conserved from baseline. A total of 28 adverse reactions, mainly gastrointestinal were observed in 15.1% of the patients (19/126), being 75% (21) mild, 17.9% (5) moderate and 7.1% (2) severe. Most adverse reactions (67.9%) appeared the first 15 days of treatment. CONCLUSION The results of this first long-term and real-world-data study in patients with cancer, showed the sustained efficacy and safety of naloxegol for the treatment of OIC in this group of patients.
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Affiliation(s)
- Manuel Cobo Dols
- Medical Oncology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
- IBIMA, Málaga, Spain
| | - Carmen Beato Zambrano
- Medical Oncology Department, Complejo Hospitalario Virgen de la Macarena, Sevilla, Spain
| | - Luis Cabezón-Gutiérrez
- Medical Oncology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - Rodolfo Chicas-Sett
- Radiation Oncology Department, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | | | | | | | - Gala Serrano Bermúdez
- Palliative Care Service, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | | | - Anna Librán Oriol
- Palliative Care Department, Consorci Sanitari Terrassa, Terrassa, Barcelona, Spain
| | - Alfredo Paredes Lario
- Medical Oncology Department, Hospital Universitario de Donostia, San Sebastian, Guipúzcoa, Spain
| | | | - Oliver Higuera Gómez
- Medical Oncology Department, Hospital General Universitario La Paz, Madrid, Spain
| | - Diana Moreno Muñoz
- Medical Oncology Department, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
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Davies AN, Leach C, Butler C, Patel SD, Shorthose K, Batsari K. Opioid-induced constipation: a stepwise treatment algorithm feasibility study. BMJ Support Palliat Care 2023; 13:e446-e453. [PMID: 34348942 DOI: 10.1136/bmjspcare-2020-002754] [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] [Received: 10/20/2020] [Accepted: 07/08/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Opioid-induced constipation (OIC) is frequently undertreated in patients with advanced cancer. Our hypothesis is that the use of a stepwise treatment algorithm, supported by regular patient-reported outcome measures, should improve the management of OIC. The aim of this feasibility study was to determine whether a definitive study could be successfully completed. METHODS Patients with OIC (Rome Foundation diagnostic criteria positive), and a Bowel Function Index (BFI) score of ≥30, were recruited to the study. The study involved weekly assessments, and decisions about management were based on the current BFI score (and the tolerability of the current treatment). Management was based on a four-step treatment algorithm, developed from recent international guidelines. RESULTS One hundred patients entered the study, and 79 patients completed the study. Fifty-seven (72%) participants responded to treatment, with 34 (43%) participants having a 'complete' response (ie, final BFI<30) and 23 (29%) participants having a 'partial' response (ie, change in BFI≥12). In participants with a complete response, 73.5% were prescribed conventional laxatives, 12% were prescribed a peripherally acting mu-opioid receptor antagonist (PAMORA) and 14.5% were prescribed a PAMORA and conventional laxative. DISCUSSION The feasibility study suggests that a definitive study can be successfully completed. However, we will amend the methodology to try to improve participant recruitment, participant retention and adherence to the treatment algorithm. The feasibility study also suggests that the use of the BFI to monitor OIC, and the use of a treatment algorithm to manage OIC, can result in clinically important improvements in OIC.Trial registration number NCT04404933.
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Affiliation(s)
- Andrew Neil Davies
- Academic Department of Palliative Medicine, Trinity College Dublin, Dublin, Ireland
- Academic Department of Palliative Medicine, University College Dublin, Dublin, Ireland
| | - Charlotte Leach
- Supportive & Palliative Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Claire Butler
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | | | | | - Kabir Batsari
- Clinical Trials Unit, Royal Marsden Hospital Sutton, Sutton, London, UK
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Umbrello M, Venco R, Palandri C, Racagni M, Muttini S. Peripherally-active mu-opioid receptor antagonists for constipation in critically ill patients receiving opioids: A case-series and a systematic review and meta-analysis of the literature. Neurogastroenterol Motil 2023; 35:e14694. [PMID: 37869768 DOI: 10.1111/nmo.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Constipation is frequent in critically ill patients, and potentially related to adverse outcomes. Peripherally-active mu-opioid receptor antagonists (PAMORAs) are approved for opioid-induced constipation, but information on their efficacy and safety in critically ill patients is limited. We present a single-center, retrospective, case-series of the use of naldemedine for opioid-associated constipation, and we systematically reviewed the use of PAMORAs in critically ill patients. METHODS Case-series included consecutive mechanically-ventilated patients; constipation was defined as absence of bowel movements for >3 days. Naldemedine was administered after failure of the local laxation protocol. Systematic review: PubMed was searched for studies of PAMORAs to treat opioid-induced constipation in adult critically ill patients. PRIMARY OUTCOMES time to laxation, and number of patients laxating at the shortest follow-up. SECONDARY OUTCOMES gastric residual volumes and adverse events. KEY RESULTS A total of 13 patients were included in the case-series; the most common diagnosis was COVID-19 ARDS. Patients had their first bowel movement 1 [0;2] day after naldemedine. Daily gastric residual volume was 725 [405;1805] before vs. 250 [45;1090] mL after naldemedine, p = 0.0078. Systematic review identified nine studies (two RCTs, one prospective case-series, three retrospective case-series and three case-reports). Outcomes were similar between groups, with a trend toward a lower gastric residual volume in PAMORAs group. CONCLUSIONS & INFERENCES In a highly-selected case-series of patients with refractory, opioid-associated constipation, naldemedine was safe and associated to reduced gastric residuals and promoting laxation. In the systematic review and meta-analysis, the use of PAMORAs (mainly methylnaltrexone) was safe and associated with a reduced intolerance to enteral feeding but no difference in the time to laxation.
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Affiliation(s)
- Michele Umbrello
- SC Rianimazione e Anestesia, Ospedale Nuovo di Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Roberto Venco
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Chiara Palandri
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Milena Racagni
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Stefano Muttini
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
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21
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Liang J, Almario CV, Chey WD, Higgins CS, Spiegel BMR. Prevalence and Burden of Illness of Rome IV Chronic Idiopathic Constipation, Opioid-Induced Constipation, and Opioid-Exacerbated Constipation in the United States. Am J Gastroenterol 2023; 118:2033-2040. [PMID: 37335135 DOI: 10.14309/ajg.0000000000002376] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) and opioid-induced constipation (OIC) are disorders that negatively affect quality of life. We sought to assess the prevalence, symptom severity, and medication use among people with Rome IV CIC, OIC, and opioid-exacerbated constipation (OEC) using a nationally representative data set with nearly 89,000 people in the United States. METHODS From May 3, 2020, to June 24, 2020, we recruited a representative sample of people in the United States ≥ 18 years to complete an online national health survey. The survey guided participants through the Rome IV CIC and OIC questionnaires, Patient-Reported Outcome Measurement Information System gastrointestinal scales (percentile 0-100; higher = more severe), and medication questions. Individuals with OEC were identified by asking those with OIC whether they experienced constipation before starting an opioid and whether their symptoms worsened afterward. RESULTS Among the 88,607 participants, 5,334 (6.0%) had Rome IV CIC, and 1,548 (1.7%) and 335 (0.4%) had Rome IV OIC and OEC, respectively. When compared with people with CIC (Patient-Reported Outcome Measurement Information System score, 53.9 ± 26.5; reference), those with OIC (62.7 ± 28.0; adjusted P < 0.001) and OEC (61.1 ± 25.8, adjusted P = 0.048) had more severe constipation symptoms. People with OIC (odds ratio 2.72, 95% confidence interval 2.04-3.62) and OEC (odds ratio 3.52, 95% confidence interval 2.22-5.59) were also more likely to be taking a prescription medication for their constipation vs those with CIC. DISCUSSION In this nationwide US survey, we found that Rome IV CIC is common (6.0%) while Rome IV OIC (1.7%) and OEC (0.4%) are less prevalent. Individuals with OIC and OEC have a higher burden of illness with respect to symptom severity and prescription constipation medication use.
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Affiliation(s)
- Jeff Liang
- Department of Medicine, Cedars-Sinai, Los Angeles, California, USA
| | - Christopher V Almario
- Department of Medicine, Cedars-Sinai, Los Angeles, California, USA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai, Los Angeles, California, USA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | - Brennan M R Spiegel
- Department of Medicine, Cedars-Sinai, Los Angeles, California, USA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai, Los Angeles, California, USA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA
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22
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Mehta N, Slatkin NE, Israel RJ, Stambler N, Shah ED. Impact of Patient Subgroups on the Efficacy and Safety of Methylnaltrexone for Opioid-Induced Constipation in Patients with Advanced Illness. J Pain Res 2023; 16:3529-3543. [PMID: 37881233 PMCID: PMC10595216 DOI: 10.2147/jpr.s416307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Purpose We evaluated the impact of baseline patient characteristics on safety and efficacy of methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, in patients with advanced illness with opioid-induced constipation (OIC). Patients and Methods This analysis pooled data from 2 randomized, double-blind, placebo-controlled studies (study 302: NCT00402038; study 4000: NCT00672477) in patients with advanced illness, including cancer, and OIC. Patients were randomized to receive subcutaneous methylnaltrexone (study 302: 0.15 mg/kg; study 4000: 8 or 12 mg based on weight) or placebo every other day for 2 weeks. The proportions of patients achieving rescue-free laxation within 4 or 24 hours after the first dose of study drug were assessed in patient subgroups stratified by baseline age, Eastern Cooperative Oncology Group (ECOG) performance status, cancer status, laxative type, and opioid requirement. Treatment-emergent adverse events (TEAEs) were evaluated. Results Overall, 363 patients were included in this analysis (methylnaltrexone, 178; placebo, 185). Mean (SD) age was 66.3 (13.7) years and 48.5% were men overall. A significantly greater proportion of patients receiving methylnaltrexone versus placebo achieved rescue-free laxation within 4 hours (111/178 [62.4%] vs 31/185 [16.8%]; P<0.0001) and 24 hours (135/178 [75.8%] vs 81/185 [43.8%]; P<0.0001) of the first dose. These trends were consistent across all subgroups. Most patients experienced ≥1 TEAE in the overall population (methylnaltrexone, 82.1%; placebo, 76.2%), which remained consistent when stratified by baseline characteristics. More than half of TEAEs were gastrointestinal in nature. Abdominal pain was more common in patients receiving methylnaltrexone than placebo across baseline characteristic subgroups. Conclusion Methylnaltrexone treatment was superior to placebo in achieving rescue-free laxation within 4 and 24 hours after the first dose, irrespective of patients' cancer status, baseline ECOG performance status, or baseline opioid or laxative use. The methylnaltrexone safety profile remained consistent across baseline characteristic subgroups.
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Affiliation(s)
- Neel Mehta
- Department of Anesthesiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Neal E Slatkin
- School of Medicine, University of California Riverside, Riverside, CA, USA
- Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA
| | - Robert J Israel
- Clinical and Medical Affairs, Bausch Health US LLC, Bridgewater, NJ, USA
| | - Nancy Stambler
- Clinical Research, Progenics Pharmaceuticals, a Subsidiary of Lantheus Holdings Inc, North Billerica, MA, USA
| | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
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Harris D, Kalir D, Chevalier C, Dobbie K, Fielding F, Lagman R, Makhoul A, McInnes S, Najafi S, Neale K, Rybicki L, Robbins-Ong M, Neuendorf K. Response Rates to Methylnaltrexone in Hospitalized Cancer Patients. Am J Hosp Palliat Care 2023; 40:1093-1097. [PMID: 36565253 DOI: 10.1177/10499091221147903] [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: 12/25/2022] Open
Abstract
Context: Methylnaltrexone is a peripherally-acting mu-opioid receptor antagonist studied in both cancer and non-cancer patients with opioid-induced constipation (OIC), but mostly in the outpatient setting. For adult hospitalized cancer patients with OIC, its effectiveness is unknown. Objectives: Describe the efficacy of methylnaltrexone for OIC in the inpatient setting, defined as bowel movement (BM) within 24 hours of methylnaltrexone administration. Methods: We performed a single-center, retrospective chart review of all hospitalized, adult patients with a cancer diagnosis who received methylnaltrexone from the palliative care team between January 1st, 2012 and July 1st, 2019. Results: We identified 194 patients. The mean age was 59, 50.5% were male and 88% were white. 192 patients (98%) received the 8 mg dose subcutaneously. The median oral morphine equivalent (OME) was 135 mg (IQR 70-354 mg). 45% (95% confidence interval, 38-53%) had a BM within 24 hours. Higher OME was correlated with successful BM, with a response in 93% (86/92) of patients receiving ≥150 OME and 2% (2/102) of patients receiving <150 OME (P < .0001). Prior laxative use did not predict response at 24 hours whether these were osmotic laxatives (40.7% vs 47.1%, P = .52), stimulant laxatives (45.7% vs 45.2%, P > .99), or stool softeners (44.7% vs 46.1%, P = .89). Conclusion: Methylnaltrexone has a high response rate when used as treatment for OIC in hospitalized adult cancer patients, especially for patients taking ≥150 OME.
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Affiliation(s)
- David Harris
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Kalir
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cory Chevalier
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Krista Dobbie
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Flannery Fielding
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ruth Lagman
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahed Makhoul
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Susan McInnes
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sina Najafi
- Department of Supportive and Palliative Care, Baylor Scott and White Health, Dallas, TX, USA
| | - Kyle Neale
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa Rybicki
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Melanie Robbins-Ong
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kathleen Neuendorf
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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24
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G Rler H, Y Ld Z FT, Bekmez F. A Common Complication in Orthopedic Patients: Postoperative Constipation and Related Risk Factors. J Perianesth Nurs 2023; 38:e15-e20. [PMID: 37578408 DOI: 10.1016/j.jopan.2023.05.004] [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] [Received: 01/17/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE The purpose of this study was to determine the frequency of postoperative constipation and risk factors in orthopedic patients. DESIGN A descriptive model was used. METHODS A total of 140 patients who underwent surgical intervention in the Orthopedics and Traumatology Clinic were included in the present study. The Descriptive Characteristics Form, Constipation Risk Assessment Scale, and Visual Analog Scale were used to collect the study data. Frequencies, percentages, Mann Whitney U, Kruskal-Wallis, and Spearman Correlation tests were used to evaluate the data. FINDINGS In the present study, 72.1% of the individuals experienced constipation during the hospitalization period, and the constipation risk score was 12.77.á...á4.83. Those who were female, over 65 years old, unemployed, had lower extremity surgery, used opioid analgesics, were dependent on their activities, had prehospital constipation, had a chronic disease, and used drugs regularly had higher constipation risk scores at statistically significant levels. A significant correlation was detected between the constipation risk score and age, pain severity, hospital stay, time to first defecation after surgery, and the amount of fluid consumed daily. CONCLUSIONS The majority of the individuals experienced constipation during the hospitalization period, and the constipation risk score was moderate. Those who were female, had advanced age, were unemployed, had high pain severity, opioid use, previous constipation, chronic disease, regular medication, long hospital stay, those whose first defecation period was prolonged after the surgery and whose fluid intake was insufficient had a higher risk of constipation. In this regard, nurses must evaluate orthopedic patients in terms of constipation risk factors and apply nondrug methods that prevent and relieve constipation with laxatives.
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Affiliation(s)
- Hesna G Rler
- Operating Room Services Program, Vocational School of Health Services, Sivas Cumhuriyet University, Sivas, Turkey.
| | - Fatma Tok Y Ld Z
- Anesthesia Program, Medical Services and Techniques, Vocational School of Health Services, Sivas Cumhuriyet University, Sivas, Turkey
| | - Fatma Bekmez
- Health Services Application and Research Hospital, Sivas Cumhuriyet University, Sivas, Turkey
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25
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Sayuk GS, Yu QT, Shy C. Management of Constipation in Hospitalized Patients. J Clin Med 2023; 12:6148. [PMID: 37834791 PMCID: PMC10573544 DOI: 10.3390/jcm12196148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Constipation is frequently encountered in hospital settings and can have potentially serious consequences yet is often underrecognized and undertreated. Opioid-induced constipation is a common cause of constipation in hospitalized patients. Opioids induce constipation through agonistic effects on enteric µ-opioid receptors. This review aims to provide insight on the identification and management of constipation in inpatient settings, with a particular focus on opioid-induced constipation. Constipation assessment should be routinely initiated at hospital admission and can be facilitated by thorough symptom assessments; relevant patient history, including recent medication use; physical examination; and patient assessment tools developed to evaluate the impact of constipation. Management of opioid-induced constipation should begin with ensuring adequate hydration and electrolyte balance and encouraging patient mobilization. Other treatments may include laxatives, enemas, intestinal secretagogues, peripherally acting µ-opioid receptor antagonists, and manual disimpaction. Surgical intervention may be required for some patients as a salvage therapy in severe, refractory cases.
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Affiliation(s)
- Gregory S. Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Qi T. Yu
- Hospice and Palliative Medicine, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Corey Shy
- Division of Hospital Medicine, Department of Medicine, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA
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26
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Gonzalez K, Sanchez K, Mauch K, Burchill CN, Bena JF, Morrison SL, Distelhorst KS. Efficacy of One Dose of Laxative on Postoperative Constipation Following Total Knee Arthroplasty. Orthop Nurs 2023; 42:304-309. [PMID: 37708528 DOI: 10.1097/nor.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Postoperative constipation is a common problem among orthopaedic surgical patients leading to discomfort, increased length of stay, and other complications. The primary purpose of this study was to determine the effectiveness of polyethylene glycol compared with docusate sodium for the prevention of constipation, after total knee arthroplasty. The secondary purpose was to examine the effectiveness of polyethylene glycol on pain and strain with bowel movement. A two-group nonequivalent cohort design was used to evaluate the effect of one 17-g dose of polyethylene glycol by mouth on postoperative day 1 compared with usual care with docusate sodium 100 mg starting the day of surgery and continued twice daily at home. There was no significant difference in the rate of constipation between the two cohorts in the 3 days after surgery. There was no difference in reported pain and strain. Future research should focus on the use of pharmacologic and nursing interventions together for prevention of postoperative constipation in patients with arthroplasty surgery.
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Affiliation(s)
- Kathleen Gonzalez
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
| | - Karen Sanchez
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
| | - Katelyn Mauch
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
| | - Christian N Burchill
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
| | - James F Bena
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
| | - Shannon L Morrison
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
| | - Karen S Distelhorst
- Kathleen Gonzalez, DNP, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Karen Sanchez, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Katelyn Mauch, MBA, BSN, RN, Cleveland Clinic Lutheran Hospital, Cleveland, OH
- Christian N. Burchill, PhD, MSN, RN, CEN, Cleveland Clinic, Cleveland, OH; Penn Medicine Lancaster General Hospital, Lancaster, PA
- James F. Bena, MS, Cleveland Clinic, Cleveland, OH
- Shannon L. Morrison, MS, Cleveland Clinic, Cleveland, OH
- Karen S. Distelhorst, PhD, APRN, GCNS-BC, Cleveland Clinic, Cleveland, OH
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Naya N, Oka H, Hashimoto S, Morioka Y, Kizawa Y. Real-World Evidence for the Safety and Effectiveness of Naldemedine in the Management of Opioid-Induced Constipation in Patients With Cancer Pain: Post-hoc Subgroup Analysis of Post-marketing Surveillance in Japan. Cureus 2023; 15:e46090. [PMID: 37900431 PMCID: PMC10611588 DOI: 10.7759/cureus.46090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Opioid-induced constipation is common and greatly affects the quality of life but is often under-recognised and undertreated. This study aimed to investigate the safety and effectiveness of naldemedine for opioid-induced constipation with cancer pain according to specific subgroups of clinical interest. METHODS In this exploratory post-hoc subgroup analysis of post-marketing surveillance from Japan (UMIN: 000042851), data were investigated by the subgroups: age (≥75, <75 years), Eastern Cooperative Oncology Group performance status (PS 0-2, 3-4), constipation severity (mild, moderate, severe), brain metastasis (yes, no), anticancer drug treatment (yes, no), opioid at naldemedine initiation (fentanyl only, only strong opioids other than fentanyl, weak opioids only, other), and prior or concomitant use of laxative (only osmotic/saline laxatives, only stimulant laxatives, other, none). Enrolled patients (n = 1184) received naldemedine (0.2 mg once daily) orally for up to 12 weeks. Regarding safety endpoints, the incidence of adverse drug reactions, including diarrhoea, was determined within each subgroup. Regarding effectiveness endpoints, improvement rates in the frequency and condition of bowel movements were investigated by subgroups. RESULTS The incidence of adverse drug reactions, including diarrhoea, among subgroups ranged from 7.74% to 16.08% (diarrhoea: 5.95% to 13.19%), compared to 11.30% (diarrhoea: 9.09%) in the total population. Through week two to week 12, improvement rates in the frequency and condition of bowel movement among subgroups ranged from 63.6% to 89.7% and 67.6% to 94.9%, compared to 75.0% to 83.2% and 80.0% to 88.0% in the total population, respectively. CONCLUSIONS Naldemedine was well tolerated and effective in patients with opioid-induced constipation and cancer pain regardless of the subgroups investigated.
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Affiliation(s)
- Noriyuki Naya
- Medical Affairs Department, Shionogi & Co. Ltd., Osaka, JPN
| | - Hiroaki Oka
- Pharmacovigilance Department, Shionogi & Co. Ltd., Osaka, JPN
| | - Sayo Hashimoto
- Pharmacovigilance Department, Shionogi & Co. Ltd., Osaka, JPN
| | | | - Yoshiyuki Kizawa
- Department of Palliative and Supportive Care, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
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Chey WD, Brenner DM, Cash BD, Hale M, Adler J, Jamindar MS, Rockett CB, Almenoff JS, Bortey E, Gudin J. Efficacy and Safety of Naloxegol in Patients with Chronic Non-Cancer Pain Who Experience Opioid-Induced Constipation: A Pooled Analysis of Two Global, Randomized Controlled Studies. J Pain Res 2023; 16:2943-2953. [PMID: 37664485 PMCID: PMC10473436 DOI: 10.2147/jpr.s417045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/18/2023] [Indexed: 09/05/2023] Open
Abstract
Objective This study evaluates the onset, magnitude, and consistency of improvement of opioid-induced constipation (OIC) symptoms with naloxegol treatment. Methods This was a pooled analysis of two Phase 3, double-blind, randomized, placebo-controlled studies (KODIAC-04/05, NCT01309841/NCT01323790) in patients with chronic non-cancer pain and OIC treated with naloxegol 25mg or 12.5mg daily. This analysis assessed improvements in response rates, frequency of spontaneous bowel movement (SBM) and complete SBMs (CSBM), OIC constipation symptoms (straining, stool consistency), time to first post-dose SBM and CSBM, and onset of adverse events over the 12-week period. Subjects The population of 1337 subjects had a mean age of 52 years and mean duration of opioid use of 3.6 years at baseline. Mean SBM frequency was 1.4/week. Results Naloxegol 25mg and 12.5mg demonstrated significantly higher response rates vs placebo (PBO) [41.9% (P < 0.001), 37.8% (P = 0.008), 29.4% respectively]. Rapid (within 1 week) and sustained (over 12 weeks) symptom improvement was significantly greater for naloxegol vs PBO (P < 0.05). Both doses showed statistically significant and clinically meaningful improvements in straining, stool consistency, number of SBMs and CSBMs/wk. Significantly shorter times to first post-dose SBM and CSBM were observed with naloxegol vs PBO (SBM HR: 25mg = 1.90, 12.5mg= 1.60; CSBM HR: 25mg = 1.42, 12.5mg = 1.36; P < 0.001 for each regimen). Adverse events occurred more frequently in the naloxegol 25mg group and were most frequently reported during the first week. Conclusion In patients with chronic non-cancer pain, naloxegol 25mg and 12.5mg demonstrated significantly higher response rates and rapid and sustained improvements in OIC symptoms compared with PBO.
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Affiliation(s)
- William D Chey
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Darren M Brenner
- Departments of Medicine and Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brooks D Cash
- Division of Gastroenterology, Hepatology, and Nutrition at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Jeremy Adler
- Pacific Pain Medicine Consultants, Encinitas, CA, USA
| | | | | | | | - Enoch Bortey
- Pharmaceutical Development Strategies, L.L.C, Chapel Hill, NC, USA
| | - Jeffrey Gudin
- Department of Anesthesiology and Pain Management, University of Miami, Miami, FL, USA
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Okdahl T, Emmanuel A, Morlion B, Farmer A, Varrassi G, Drewes AM. Recommendations for the management of opioid-induced constipation - how to improve usability in clinical practice. Expert Rev Gastroenterol Hepatol 2023; 17:975-983. [PMID: 37822210 DOI: 10.1080/17474124.2023.2267441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Opioid-induced constipation remains undertreated despite effective and safe treatment options exists. Previous guidelines have only been partially effective in improving management, possibly due to their complexity, and studies suggest that a simple setup of concise and behaviorally-orientated steps improves usability. AREAS COVERED This article introduces the concept of opioid-induced constipation and provides an overview of existing guidelines in this field. We also propose simplified recommendations for managing opioid-induced constipation, derived from a synthesis of current guidelines and the principles of optimal guideline design theory. EXPERT OPINION Despite standard treatment with laxatives and fluid intake in patients with opioid-induced constipation, escalation of treatment is often needed where μ-opioid receptor antagonists or newer medications such as lubiprostone, linaclotide, or prucalopride are used. Previous guidelines have not been used sufficiently and thus management of the condition is often insufficient. We therefore propose simplified recommendations to management, which we believe can come into broader use. It was validated in primary care for credibility, clarity, relevance, usability, and overall benefit. We believe that this initiative can lead to better management of the substantial proportion of patients suffering from side effects of opioids.
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Affiliation(s)
- Tina Okdahl
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Anton Emmanuel
- GI Physiology Unit, University College London, London, UK
| | - Bart Morlion
- Department of Cardiovascular Sciences, Section Anesthesiology and Algology, University of Leuven, Leuven, Belgium
| | - Adam Farmer
- Department of Gastroenterology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | | | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
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30
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Rizwan MZ, Garcia R, Mara K, Nei S. Evaluating the Safety and Efficacy of Naloxegol in Critically Ill Opioid-Induced Constipation Patients. Cureus 2023; 15:e41422. [PMID: 37546147 PMCID: PMC10403335 DOI: 10.7759/cureus.41422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background Opioid-induced constipation (OIC) has become more common in the intensive care unit (ICU) due to increased opioid utilization. Traditional laxatives often prove ineffective against OIC, leading to the increased utilization of naloxegol. However, further research is needed to confirm naloxegol's effectiveness and safety in critical care. This study aimed to explore the safety and efficacy of this intervention in critically ill OIC patients. Methods A single-center retrospective study was conducted on 353 patients who received one or more doses of naloxegol from January 1, 2019, to June 30, 2020, for OIC at a tertiary care center. The primary endpoint of this study was to evaluate serious adverse events such as reduced analgesic effect, gastrointestinal perforation, seizure, acute myocardial infarction (AMI), or ventricular arrhythmias using Naranjo Scale in critically ill patients. The secondary goal was to assess the efficacy of naloxegol, measured by the time of the first bowel movement. Results The average duration of naloxegol use was three days, with the first bowel movement occurring at an average of 11.3 hours. Furthermore, 59.8% of individuals had their first bowel movement within 20 hours of receiving naloxegol. There was a low level of causality between naloxegol use and adverse events such as gastrointestinal perforation, seizures, AMI, cardiovascular mortality, stroke, and ventricular arrhythmia. Additionally, reduction in analgesia showed no strong relationship with naloxegol use indicated by the Naranjo Scale assessment. Conclusion Naloxegol showed promising safety and efficacy profiles in treating OIC amongst critically ill patients, though our findings require further validation through prospective studies. This research paves the way for further investigation into naloxegol's role in OIC management, emphasizing the necessity of personalized treatment strategies in critical care settings.
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Affiliation(s)
| | | | - Kristin Mara
- Department of Biostatistics, Mayo Clinic, Rochester, USA
| | - Scott Nei
- Department of Pharmacy, Mayo Clinic, Rochester, USA
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31
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Mozaffari S, Mousavi T, Nikfar S, Abdollahi M. Common gastrointestinal drug-drug interactions in geriatrics and the importance of careful planning. Expert Opin Drug Metab Toxicol 2023; 19:807-828. [PMID: 37862038 DOI: 10.1080/17425255.2023.2273384] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/17/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Polypharmacy, which uses multiple medications to treat chronic illnesses, is common among elderly patients. However, it can lead to drug interactions, especially with gastrointestinal (GI) medicines that are extensively used. These drug interactions can have severe consequences and pose a significant challenge to healthcare providers. Therefore, it is crucial to identify the underlying mechanisms of these interactions and develop strategies to minimize medication errors. AREAS COVERED We analyzed databases on GI illnesses common in older adults, including GERD, peptic ulcer disease, IBS, IBD, constipation, and diarrhea. Our research identified noteworthy drug interactions and utilized major electronic databases such as USFDA, PubMed, Scopus, and Google Scholar until 15 May 202315 May 2023, along with a review of reference lists. EXPERT OPINION Aging can affect how the body processes drugs, leading to an increased risk of drug interactions. Therefore, healthcare professionals must carefully evaluate a patient's medical history and health condition to design personalized treatment plans.
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Affiliation(s)
- Shilan Mozaffari
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, and Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Taraneh Mousavi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, and Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Personalized Medicine Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, and Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
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Higashibata T, Kessoku T, Morioka Y, Koretaka Y, Mishima H, Shibahara H, Masuda Y, Ichikawa Y, Nakajima A, Hisanaga T. A Nationwide Hospital Claims Database Analysis of Real-World Patterns of Laxative Use for Opioid-Induced Constipation in Japanese Patients with Cancer. Pain Ther 2023:10.1007/s40122-023-00520-2. [PMID: 37195398 DOI: 10.1007/s40122-023-00520-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Opioid-induced constipation (OIC) is one of the most common side effects in patients with cancer treated with opioid analgesics. The actual use of laxatives for OIC in Japan remains unelucidated. This study aimed to investigate the real-world patterns of laxative use for patients with cancer who newly initiated opioid analgesic therapy. METHODS We used a Japanese nationwide hospital claims database (January 2018-December 2019). Patients with cancer newly receiving opioid analgesic therapy were included and classified on the basis of opioid classes (weak or strong) and route of administration (oral or transdermal) at initiation. The patients were divided into two groups on the basis of whether they received early medication (starting laxatives within 3 days after initiating opioid analgesic therapy), and patterns of laxative use were analyzed. RESULTS There were 26,939 eligible patients, with 50.7% of them initiated with strong opioids. The proportion of patients who received early medication was 25.0% for weak opioids and 57.3% for strong opioids. Osmotic laxatives were most frequently used as first-line therapy in the early medication group (oral weak opioids: 12.3%, oral strong opioids: 29.4%, transdermal strong opioids: 12.8%). Stimulant laxatives were frequently used as first-line therapy, to the same extent or more than osmotic laxatives in the non-early medication group (oral weak opioids: 13.7%, oral strong opioids: 7.7%, transdermal strong opioids: 15.1%). Peripherally acting μ-opioid receptor antagonists were the second most frequently used in the early medication group for those on oral strong opioids (9.4%). CONCLUSION This study demonstrated for the first time that the patterns of laxative use for OIC in Japanese patients with cancer were different, depending on the opioid types at initiation and the timing of laxative medication.
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Affiliation(s)
- Takahiro Higashibata
- Department of Palliative and Supportive Care, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takaomi Kessoku
- Department of Palliative Medicine, International University of Health and Welfare Narita Hospital, Narita, Japan
- Department of Gastroenterology, International University of Health and Welfare Narita Hospital, Narita, Japan
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | | | | | | | | | | | - Yasushi Ichikawa
- Department of Oncology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
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Chaurawal N, Kataria M, Kumar MV, Mishra NP, Goni VG, Raza K. Emerging Advances in Nanocarriers Approaches in the Effective Therapy of Pain Related Disorders: Recent Evidence and Futuristic Needs. AAPS PharmSciTech 2023; 24:111. [PMID: 37118029 DOI: 10.1208/s12249-023-02567-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023] Open
Abstract
Pain disorders are the primary cause of disability nowadays. These disorders, such as rheumatoid arthritis (RA) and osteoarthritis (OA), cause loss of function, joint pain and inflammation and deteriorate the quality of life. The treatment of these inflammatory diseases includes anti-inflammatory drugs administered via intra-articular, topical or oral routes, physical rehabilitation or surgery. Owing to the various side effects these drugs could offer, the novel approaches and nanomaterials have shown potential to manage inflammatory diseases, prolonged half-life of anti-inflammatory drugs, reduced systemic toxicity, provide specific targeting, and refined their bioavailability. This review discusses in brief about the pain pathophysiology and its types. The review summarizes the conventional therapies used to treat pain disorders and the need for novel strategies to overcome the adverse effects of conventional therapies. The review describes the recent advancements in nanotherapeutics for inflammatory diseases using several lipids, polymers and other materials and their excellent efficiency in improving the treatment over conventional therapies. The results of the nanotherapeutic studies inferred that the necessity to use nanocarriers is due to their controlled release, targeting drug delivery to inflamed tissues, low toxicity and biocompatibility. Therefore, it is possible to assert that nanotechnology will emerge as a great tool for advancing the treatment of pain disorders in the near future.
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Affiliation(s)
- Nishtha Chaurawal
- Department of Pharmacy, School of Chemical Sciences and Pharmacy, Central University of Rajasthan, Bandarsindri, Ajmer, Rajasthan, 305817, India
| | - Mohak Kataria
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Muniramiah Vinod Kumar
- Professor of Orthopaedics, East Point College of Medical Sciences and Research Centre, Bangaluru, Karnataka, 560049, India
| | - Narayan Prasad Mishra
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Vijay G Goni
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Kaisar Raza
- Department of Pharmacy, School of Chemical Sciences and Pharmacy, Central University of Rajasthan, Bandarsindri, Ajmer, Rajasthan, 305817, India.
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Graven-Nielsen CS, Knoph CS, Okdahl T, Høyer KL, Krogh K, Hellström PM, Drewes AM. Opioids in the Treatment of Chronic Idiopathic Diarrhea in Humans—A Systematic Review and Treatment Guideline. J Clin Med 2023; 12:jcm12072488. [PMID: 37048572 PMCID: PMC10094889 DOI: 10.3390/jcm12072488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
In patients with chronic idiopathic diarrhea resistant to standard treatment, opioids are often used as rescue therapy. This systematic review investigated opioid effects on gut function in chronic diarrhea. PubMed and Embase were searched regarding effects of opioid agonists on the gastrointestinal tract in humans with chronic or experimentally induced diarrhea. A total of 1472 relevant articles were identified and, after thorough evaluation, 11 clinical trials were included. Generally, studies reported a reduction in stool frequency and an increase in transit time during treatment with the opioid receptor agonists loperamide, asimadoline, casokefamide, and codeine compared with placebo. Loperamide and diphenoxylate significantly improved stool consistency compared with placebo, whereas asimadoline showed no such effects. Compared with placebo, loperamide treatment caused less abdominal pain and urgency. Asimadoline showed no significant subjective improvements, but fedotozine was superior to placebo in reducing abdominal pain and bloating in selected patients. Only two relevant studies were published within the last 20 years, and standardized endpoint measures are lacking. Most trials included few participants, and further evidence is needed from larger, prospective studies. Likewise, consensus is needed to standardize endpoints for stool frequency, transit time, and consistency to conduct future meta-analyses on opioids in management of chronic idiopathic diarrhea.
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35
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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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Tian SX, Xu T, Shi RY, Cai YQ, Wu MH, Zhen SJ, Wang W, Zhou Y, Du JY, Fang JF, Shao XM, Liu BY, Jiang YL, He XF, Fang JQ, Liang Y. Analgesic effect of electroacupuncture on bone cancer pain in rat model: the role of peripheral P2X3 receptor. Purinergic Signal 2023; 19:13-27. [PMID: 35478452 PMCID: PMC9984641 DOI: 10.1007/s11302-022-09861-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/28/2022] [Indexed: 11/25/2022] Open
Abstract
Upregulation of P2X3 receptor (P2X3R) has been strongly implicated in nociceptive signaling including bone cancer pain (BCP). The present study, using rat bone cancer model, aimed to explore the role of P2X3R in regulating rat pain behavior under the intervention of electroacupuncture (EA). The BCP model was successfully established by injection with MRMT-1 breast cancer cell into the medullary cavity of left tibia for 3 × 104 cells/3 μL PBS in rats as revealed by obvious bone destruction, decreased paw withdrawal thresholds (PWTs), and reduced paw withdrawal latencies (PWLs). Western blot analyses showed that P2X3R expression was significantly upregulated in ipsilateral lumbar 4-6 (L4-6) dorsal root ganglia (DRG), but the difference not seen in spinal cord dorsal horn (SCDH). With the in-depth study of P2X3R activation, we observed that intrathecal injection of P2X3R agonist α,β-meATP aggravated MRMT-1 induced BCP, while injection of P2X3R inhibitor A-317491 alleviated pain. Subsequently, we demonstrated that BCP induced mechanical allodynia and thermal hyperalgesia were attenuated after EA treatment. Under EA treatment, total P2X3R protein expression in ipsilateral DRGs was decreased, and it is worth mentioning that decreased expression of P2X3R membrane protein, which indicated that both the expression and membrane trafficking of P2X3R were inhibited by EA. The immunofluorescence assay showed that EA stimulation exerted functions by reducing the expression of P2X3R-positive cells in ipsilateral DRGs of BCP rats. Ca2+ imaging analysis revealed that the EA stimulation decreased the percentage of α,β-meATP responsive neurons in DRGs and inhibited calcium influx. Notably, the inhibitory effect of EA on mechanical allodynia and nociceptive flinches was abolished by intrathecal injection of α,β-meATP. These findings demonstrated EA stimulation ameliorated mechanical allodynia and thermal hyperalgesia in rat model of MRMT-1-induced BCP. EA exerts analgesic effect on BCP by reducing the overexpression and functional activity of P2X3R in ipsilateral DRGs of BCP rats. Our work first demonstrates the critical and overall role of P2X3R in EA's analgesia against peripheral sensitization of MRMT-1-induced BCP and further supports EA as a potential therapeutic option for cancer pain in clinic.
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Affiliation(s)
- Shu-Xin Tian
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Ting Xu
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Ren-Yi Shi
- Department of Acupuncture and Moxibustion, Sanya Traditional Chinese Medicine Hospital, Sanya, 572000, China
| | - Yang-Qian Cai
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Ming-Hui Wu
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Si-Jia Zhen
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Wen Wang
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - You Zhou
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Jun-Ying Du
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Jun-Fan Fang
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Xiao-Mei Shao
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Bo-Yi Liu
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Yong-Liang Jiang
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Xiao-Fen He
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China
| | - Jian-Qiao Fang
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China.,Department of Acupuncture and Moxibustion, The Third Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, 310005, China
| | - Yi Liang
- Department of Neurobiology and Acupuncture Research, The Third School of Clinical Medicine, Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou, 310053, Zhejiang Province, China. .,Department of Acupuncture and Moxibustion, The Third Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, 310005, China.
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Okdahl T, Mark EB, Nedergaard RB, Knoph CS, Cook ME, Krogh K, Drewes AM. Effects of opium tincture on the enteric and central nervous systems: A randomized controlled trial. Basic Clin Pharmacol Toxicol 2023; 132:434-448. [PMID: 36851814 DOI: 10.1111/bcpt.13850] [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: 01/23/2023] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/01/2023]
Abstract
Opioids change gut motility, and opium tincture has been used for treatment of chronic diarrhoea for centuries. However, the effects have never been documented in controlled trials. We aimed to investigate the effects of opium tincture on gastrointestinal transit and motility, frequency of bowel movements, stool consistency, gastrointestinal symptoms and sedation. Twenty healthy subjects were included in this randomized controlled trial. Opium tincture or placebo was each applied for 9 days. Gastrointestinal transit and motility were investigated with the 3D-transit system. Bowel movements and gastrointestinal symptoms were recorded daily. General cognition, reaction time, memory and electroencephalography were used to assess effects on the central nervous system. Opium tincture doubled colonic transit (49 vs. 23 h, p < 0.001), decreased antegrade colonic movements (p < 0.05), reduced daily bowel movements (0.7 vs. 1.2, p < 0.001) and increased stool consistency (Type 3 vs. Type 4, p < 0.001). No changes in general cognition, reaction time or memory were observed, and minor changes of power observed by electroencephalography did not indicate sedation. This study is the first to show that opium tincture has anti-propulsive properties in the healthy gut, while no sedative effects were seen. This indicates that opium tincture is a relevant and safe treatment option in chronic diarrhoea.
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Affiliation(s)
- Tina Okdahl
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Cecilie Siggaard Knoph
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Mathias Ellgaard Cook
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - 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.,Clinical Institute, Aalborg University, Aalborg, Denmark
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Mousavi T, Nikfar S, Abdollahi M. An update on the use of pharmacotherapy for opioid-induced bowel dysfunction. Expert Opin Pharmacother 2023; 24:359-375. [PMID: 36548911 DOI: 10.1080/14656566.2022.2161883] [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: 12/24/2022]
Abstract
INTRODUCTION With the growing rate of aging and the incidence of chronic diseases, there has been an upsurge in opioid prescription and abuse worldwide. This has been associated with increased reports of opioid-related adverse events, particularly opioid-induced bowel dysfunction (OIBD), calling for a rational clinical management strategy. AREAS COVERED Through searching PubMed, Scopus, Cochrane Library, and Web of Science, English literature was gathered as of 1 January 2017. Furthermore, the USFDA, EMA, TGA, Clinicaltrials.Gov, WHO-ICTRP databases, and the latest guidelines were reviewed to extract ongoing clinical studies and provide an evidence-based expert opinion with detailed information on efficacy, safety, approval status, and pharmacokinetics of the currently used medications. EXPERT OPINION Despite the significant burden of OIBD, the clinical development of agents lags behind disease progress. Although in most places, management of opioid-induced constipation (OIC) is initiated by lifestyle modifications followed by laxatives, opioid antagonists, and secretagogue agents, there are still major conflicts among global guidelines. The fundamental reason is the lack of head-to-head clinical trials providing inter- and intragroup comparisons between PAMORAs, laxatives, and secretagogue agents. These investigations must be accompanied by further valid biopharmaceutical and economic evaluations, paving the way for rational clinical judgment in each context.
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Affiliation(s)
- Taraneh Mousavi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran, Iran.,Personalized Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
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Wang W, Liu Y, Yang X, Sun J, Yue Z, Lu D, Zhou K, Sun Y, Hou A, Zang Z, Jin X, Liu C, Wang Y, Yu J, Zhu L, Liu Z. Effects of Electroacupuncture for Opioid-Induced Constipation in Patients With Cancer in China: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e230310. [PMID: 36811861 PMCID: PMC9947731 DOI: 10.1001/jamanetworkopen.2023.0310] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Opioid-induced constipation (OIC) is prevalent among patients treated with opioids for cancer pain. Safe and effective therapies for OIC in patients with cancer remain an unmet need. OBJECTIVE To determine the efficacy of electroacupuncture (EA) for OIC in patients with cancer. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted at 6 tertiary hospitals in China among 100 adult patients with cancer who were screened for OIC and enrolled between May 1, 2019, and December 11, 2021. INTERVENTIONS Patients were randomized to receive 24 sessions of EA or sham electroacupuncture (SA) over 8 weeks and then were followed up for 8 weeks after treatment. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of overall responders, defined as patients who had at least 3 spontaneous bowel movements (SBMs) per week and an increase of at least 1 SBM from baseline in the same week for at least 6 of the 8 weeks of the treatment period. All statistical analyses were based on the intention-to-treat principle. RESULTS A total of 100 patients (mean [SD] age, 64.4 [10.5] years; 56 men [56.0%]) underwent randomization; 50 were randomly assigned to each group. Among them, 44 of 50 patients (88.0%) in the EA group and 42 of 50 patients (84.0%) in the SA group received at least 20 (≥83.3%) sessions of treatment. The proportion of overall responders at week 8 was 40.1% (95% CI, 26.1%-54.1%) in the EA group and 9.0% (95% CI, 0.5%-17.4%) in the SA group (difference between groups, 31.1 percentage points [95% CI, 14.8-47.6 percentage points]; P < .001). Compared with SA, EA provided greater relief for most OIC symptoms and improved quality of life among patients with OIC. Electroacupuncture had no effects on cancer pain and its opioid treatment dosage. Electroacupuncture-related adverse events were rare, and, if any, all were mild and transient. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that 8-week EA treatment could increase weekly SBMs with a good safety profile and improve quality of life for the treatment of OIC. Electroacupuncture thus provided an alternative option for OIC in adult patients with cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03797586.
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Affiliation(s)
- Weiming Wang
- Department of Acupuncture and Moxibustion, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Liu
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaofang Yang
- College of Acumox and Tuina, Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Jianhua Sun
- Department of Acupuncture Rehabilitation, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zenghui Yue
- College of Acupuncture and Tuina, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Dianrong Lu
- Department of Oncology, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kehua Zhou
- Department of Hospital Medicine, ThedaCare Regional Medical Center–Appleton, Appleton, Wisconsin
| | - Yuanjie Sun
- Department of Acupuncture and Moxibustion, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Aihua Hou
- Department of Oncology, Yantai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Zhiwei Zang
- Department of Acupuncture, Yantai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Xiaoqing Jin
- Department of Acupuncture, Zhejiang Hospital, Hangzhou, China
| | - Chao Liu
- College of Acumox and Tuina, Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Yuhang Wang
- Department of Acupuncture Rehabilitation, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jinna Yu
- Department of Acupuncture and Moxibustion, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lili Zhu
- Department of Acupuncture and Moxibustion, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhishun Liu
- Department of Acupuncture and Moxibustion, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Paice JA, Bohlke K, Barton D, Craig DS, El-Jawahri A, Hershman DL, Kong LR, Kurita GP, LeBlanc TW, Mercadante S, Novick KLM, Sedhom R, Seigel C, Stimmel J, Bruera E. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol 2023; 41:914-930. [PMID: 36469839 DOI: 10.1200/jco.22.02198] [Citation(s) in RCA: 59] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults. METHODS A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time. RECOMMENDATIONS Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Judith A Paice
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Debra Barton
- University of Michigan School of Nursing, Ann Arbor, MI
| | - David S Craig
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | - Dawn L Hershman
- Mailman School of Public Health and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Lynn R Kong
- Ventura County Hematology Oncology Specialists, Oxnard, CA
| | - Geana P Kurita
- Rigshospitalet Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Kristina L M Novick
- Penn Radiation Oncology Chester County, Chester County Hospital, West Chester, PA
| | - Ramy Sedhom
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | | | | | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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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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Kanbayashi Y, Shimizu M, Ishizuka Y, Sawa S, Yabe K, Uchida M. Factors associated with non-response to naldemedine for opioid-induced constipation in cancer patients: A subgroup analysis. PLoS One 2022; 17:e0278823. [PMID: 36490241 PMCID: PMC9733844 DOI: 10.1371/journal.pone.0278823] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Opioid-induced constipation (OIC) is one of the most common adverse events of opioid therapy and can severely reduce quality of life (QOL). Naldemedine is the orally available peripheral-acting μ-opioid receptor antagonist approved for OIC treatment. However in daily clinical practice, some cancer patients show insufficient control of OIC even while receiving naldemedine. OBJECTIVE To identify factors associated with non-response to naldemedine in cancer patients. METHODS This study retrospectively analyzed 127 cancer patients prescribed naldemedine at Seirei Hamamatsu General Hospital in Japan between November 2016 and June 2021. For the regression analysis of factors associated with OIC, variables were extracted manually from electronic medical records. Naldemedine had been prescribed by the attending physician after the presence of OIC had been defined with reference to Rome IV diagnostic criteria. Naldemedine was evaluated as "effective" in cases where the number of defecations increased at least once in the first 3 days after starting naldemedine. Multivariate logistic regression analysis was performed to identify factors associated with non-response to naldemedine. The data used were from the group of patients who received naldemedine in our previous study. RESULTS Factors significantly associated with non-response to naldemedine included chemotherapy with taxanes within 1 month of evaluation of naldemedine effect (odds ratio [OR] = 0.063; 95% confidence interval [CI] = 0.007-0.568), and addition of or switching to naldemedine due to insufficient efficacy of prior laxatives (OR = 0.352, 95% CI = 0.129-0.966). CONCLUSION The identification of factors associated with non-response to naldemedine prescribed for OIC may help improve QOL among cancer patients.
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Affiliation(s)
- Yuko Kanbayashi
- Faculty of Pharmacy, Department of Education and Research Center for Clinical Pharmacy, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
- * E-mail:
| | - Mayumi Shimizu
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yuichi Ishizuka
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Shohei Sawa
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Katsushige Yabe
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Mayako Uchida
- Department of Education and Research Center for Pharmacy Practice, Doshisha Women’s College of Liberal Arts, Kyotanabe, Japan
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Nehra AK, Sheedy SP, Johnson CD, Flicek KT, Venkatesh SK, Heiken JP, Wells ML, Ehman EC, Barlow JM, Fletcher JG, Olson MC, Bharucha AE, Katzka DA, Fidler JL. Imaging Review of Gastrointestinal Motility Disorders. Radiographics 2022; 42:2014-2036. [PMID: 36206184 DOI: 10.1148/rg.220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The motor function of the gastrointestinal tract relies on the enteric nervous system, which includes neurons spanning from the esophagus to the internal anal sphincter. Disorders of gastrointestinal motility arise as a result of disease within the affected portion of the enteric nervous system and may be caused by a wide array of underlying diseases. The etiology of motility disorders may be primary or due to secondary causes related to infection or inflammation, congenital abnormalities, metabolic disturbances, systemic illness, or medication-related side effects. The symptoms of gastrointestinal dysmotility tend to be nonspecific and may cause diagnostic difficulty. Therefore, evaluation of motility disorders requires a combination of clinical, radiologic, and endoscopic or manometric testing. Radiologic studies including fluoroscopy, CT, MRI, and nuclear scintigraphy allow exclusion of alternative pathologic conditions and serve as adjuncts to endoscopy and manometry to determine the appropriate diagnosis. Additionally, radiologist understanding of clinical evaluation of motility disorders is necessary for guiding referring clinicians and appropriately imaging patients. New developments and advances in imaging techniques have allowed improved assessment and diagnosis of motility disorders, which will continue to improve patient treatment options. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Avinash K Nehra
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Shannon P Sheedy
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - C Daniel Johnson
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Kristina T Flicek
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Sudhakar K Venkatesh
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Jay P Heiken
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Michael L Wells
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Eric C Ehman
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - John M Barlow
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Joel G Fletcher
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Michael C Olson
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Adil E Bharucha
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - David A Katzka
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Jeff L Fidler
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
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Rationale and design of a multicenter, double-blinded, randomized, placebo-controlled trial to investigate the effects of naldemedine on opioid-induced constipation for patients with cancer pain: A study protocol. Contemp Clin Trials Commun 2022; 29:100967. [PMID: 35967517 PMCID: PMC9372594 DOI: 10.1016/j.conctc.2022.100967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background It is unclear which laxatives are appropriate to prevent opioid-induced constipation (OIC). This study will evaluate whether prophylactic use of naldemedine prevents OIC in patients with cancer who start opioid administration. Methods This study is a multicenter, double-blinded, randomized, placebo-controlled trial. Patients who meet the eligibility criteria and give consent will be randomly assigned to the naldemedine or placebo group. Both groups will take each drug once a day after breakfast for 14 days. Results The primary endpoint is the proportion of patients with a Bowel Function Index of less than 28.8 on Day 14. The secondary endpoints include assessment scales of the impact of constipation on comprehensive quality of life. Conclusions This is the first study proposed to assess the superiority of naldemedine over placebo in the prevention of OIC. If naldemedine is found to be effective in reducing OIC compared with the placebo, it will be regarded as a new standard for OIC prophylaxis at opioid initiation. Trial registration jRCT identifier: jRCTs031200397. Registered March 5, 2021, https://rctportal.niph.go.jp/en/detail?trial_id=jRCTs031200397.
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Sonohata M, Wada S, Koretaka Y, Morioka Y, Mishima H, Mawatari M. A Survey of the Incidence of Constipation in Patients with Chronic Non-cancer Pain Using Opioid Analgesics in Japan. Pain Ther 2022; 11:845-859. [PMID: 35598289 PMCID: PMC9314494 DOI: 10.1007/s40122-022-00392-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/27/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Although opioids have potent analgesic properties, their use is associated with side effects, including opioid-induced constipation (OIC). This study investigated the incidence of OIC based on the Rome IV diagnostic criteria in patients using opioid analgesics for chronic non-cancer pain and to explore and compare the risk factors for the development of OIC in opioid analgesic users. METHODS We surveyed patients aged 20 years or more living in Japan via the internet; who had been using opioid or non-opioid analgesics (N = 500 each) for at least 3 months for relief from chronic non-cancer musculoskeletal pain (low back pain or osteoarthritis); and who provided electronic consent to participate in and complete the survey. The groups were matched for age and sex. RESULTS Of the patients using opioid analgesics, 89% were taking weak opioids. The proportion of patients perceiving constipation was comparable between the opioid and non-opioid analgesic groups (34% vs 29%, respectively); however, a significantly higher proportion of patients in the opioid group, compared to the non-opioid group, reported self-assessed constipation (40% vs 18%, respectively) after using an analgesic and fulfilled two or more symptoms of the Rome IV diagnostic criteria for constipation (28% vs 19%, respectively). A higher proportion of patients were taking prescribed medicine for constipation in the opioid group compared with the non-opioid group (33% vs 18%, respectively). Low back pain, but not opioid strength and scheduled dosing, was identified as a risk factor for OIC among various covariates assessed in the logistic regression analysis in 81 patients with OIC and Rome IV diagnosis vs 419 patients without OIC in the opioid group. CONCLUSION Use of opioid analgesics, including weak opioids, for treating chronic non-cancer musculoskeletal pain is associated with OIC. This finding highlights the need for appropriate treatment of constipation in patients with chronic non-cancer pain in Japan. TRIAL REGISTRATION UMIN000043985.
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Affiliation(s)
- Motoki Sonohata
- grid.412339.e0000 0001 1172 4459Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501 Japan
| | - Shihomi Wada
- grid.419164.f0000 0001 0665 2737Medical Affairs Department, Shionogi & Co., Ltd., 1-8, Doshomachi 3-Chome, Chuo-ku, Osaka, 541-0045 Japan
| | - Yuichi Koretaka
- grid.419164.f0000 0001 0665 2737Data Science Department, Shionogi & Co., Ltd., 1-8, Doshomachi 3-Chome, Chuo-ku, Osaka, 541-0045 Japan
| | - Yasuhide Morioka
- grid.419164.f0000 0001 0665 2737Medical Affairs Department, Shionogi & Co., Ltd., 1-8, Doshomachi 3-Chome, Chuo-ku, Osaka, 541-0045 Japan
| | - Hirokazu Mishima
- grid.419164.f0000 0001 0665 2737Medical Affairs Department, Shionogi & Co., Ltd., 1-8, Doshomachi 3-Chome, Chuo-ku, Osaka, 541-0045 Japan
| | - Masaaki Mawatari
- grid.412339.e0000 0001 1172 4459Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501 Japan
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Opioid-Associated Anorectal Dysfunction in Chronic Constipation. Dig Dis Sci 2022; 67:3904-3910. [PMID: 34699000 DOI: 10.1007/s10620-021-07288-5] [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: 07/17/2021] [Accepted: 10/11/2021] [Indexed: 12/09/2022]
Abstract
INTRODUCTION The role of anorectal and defecatory dysfunction in opioid-related constipation is unclear. We aimed to evaluate the relationship between opioid use and rectal sensation, defecatory function, and balloon expulsion on anorectal physiology testing. METHODS This was a retrospective cohort study of consecutive adults undergoing high-resolution anorectal manometry (HRAM) at a tertiary center for constipation. Clinical characteristics, medication use, and HRAM findings were obtained. Statistical analyses were performed using Fisher-exact/student t-test for univariate analyses and logistic/general linear regression for multivariable analyses to compare patients with no opioid use, recent (< 3 months) use, and distant (> 3 months) use. RESULTS 424 patients (49.8 ± 17.2 years; 85.6% female) were included. Compared to those without opioid history, patients with recent use had increased volumes for first rectal sensation (70.4 mL vs 59.4, p = 0.043), urge (120.5 mL vs 101.5, p = 0.017), and maximal tolerance (170.2 mL vs 147.2, p = 0.0018), but not patients with distant use. Recent opioid use was associated with increased risk of dyssynergic defecation (DD) (61.8% vs 46.4%, p = 0.035), but not failed balloon expulsion. On multivariable models controlling for potential confounders, recent opioid use, but not distant use, remained independently correlated with increased volumes for first rectal sensation (β-coefficient 9.78, p = 0.019), urge (β-coefficient 16.7, p = 0.0060), and maximal tolerance (β-coefficient 22.9, p = 0.0032), and higher risk for DD (aOR = 2.18, p = 0.026). CONCLUSION Recent opioid use was an independent risk factor for rectal hyposensitivity and DD on HRAM in patients with constipation, but that effect may decrease with discontinuation of use. Anorectal physiology testing should be considered in patients with opioid-associated constipation.
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Alvaro D, Coluzzi F, Gianni W, Lugoboni F, Marinangeli F, Massazza G, Pinto C, Varrassi G. Opioid-Induced Constipation in Real-World Practice: A Physician Survey, 1 Year Later. Pain Ther 2022; 11:477-491. [PMID: 35122615 PMCID: PMC9098716 DOI: 10.1007/s40122-022-00354-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/14/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Opioid-induced constipation (OIC) is the most common adverse effect of opioid therapy, but it is underdiagnosed and undertreated. Last year, a survey among Italian healthcare providers revealed important differences in the clinical management of OIC across physician specialties, the need of standardization of diagnosis and treatment, and the urgency of further education. Herein, we submitted an updated version of the survey to the same cohort of experts to evaluate potential progress. METHODS The online survey included 15 questions about OIC. Responses were analyzed descriptively and aggregated by physician specialty. RESULTS A total of 190 physicians completed the survey. Most respondents (65%) did not feel adequately educated about OIC despite general consensus regarding interest in the topic and acknowledgement of OIC impact on patients' QoL and adherence to opioid therapy. Overall, 55-77% of physicians regularly evaluated intestinal function or OIC symptoms in patients receiving opioid therapy, with one-third of respondents implementing it in the past year. Even though the most common method for assessment was still patient diary, the use of specific scales underwent a small but significant increase compared to the previous year, with major implementation in the use of Rome IV criteria. As regards first-line treatment, most respondents (49%) preferred macrogol prophylaxis followed by macrogol plus another laxative. For second-line treatment, we revealed a growth in the prescription of peripherally acting mu-opioid receptor antagonists (PAMORAs), with 46% of all the respondents having increased their use during the past year. CONCLUSIONS Despite some limitations, our study demonstrated a slow but important step closer to standardization of diagnosis and treatment of OIC. Further educational and training efforts should be put in place to favor best evidence-based clinical practice.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Gastroenterology Division, Sapienza University of Rome, Rome, RM, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, SAPIENZA University of Rome, Polo Pontino, Latina, Corso della Repubblica 79, 04100, Latina, LT, Italy.
- Unit of Anesthesia, Intensive Care and Pain Medicine, Sant'Andrea University Hospital, Rome, RM, Italy.
| | - Walter Gianni
- Department of Internal Medicine and Geriatry, University Hospital Policlinico Umberto I, Rome, RM, Italy
| | - Fabio Lugoboni
- Department of Medicine, Addiction Unit, University Hospital of Verona, Verona, VR, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Pain Medicine, and Palliative Care, University of L'Aquila, L'Aquila, AQ, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin and "Città della Salute e della Scienza" University Hospital, Turin, TO, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Clinical Cancer Center, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, RE, Italy
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Gudin J, Vu L, Ceschim MR, Gude L, Peskin E, Alvarez A, Horn DB. Peripherally acting mu-opioid receptor antagonists for the treatment of opioid-induced constipation. Aliment Pharmacol Ther 2022; 55 Suppl 2:S8-S15. [PMID: 35544279 DOI: 10.1111/apt.16864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Jeffrey Gudin
- Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ly Vu
- Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mariana Rubini Ceschim
- Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Luis Gude
- Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan Peskin
- Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Armando Alvarez
- Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Danielle Bodzin Horn
- Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
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Tryson AR, Hennessey EK, Crannage AJ. Evaluation of a Pharmacist-Driven Protocol for the Treatment of Opioid-Induced Constipation. J Pharm Pract 2022; 35:218-222. [PMID: 35484871 DOI: 10.1177/0897190020966203] [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: 11/17/2022]
Abstract
BACKGROUND Opioid-induced constipation (OIC) treatment guidelines recommend over-the-counter laxatives as first-line therapy, followed by treatment with a peripherally-acting mu-opioid receptor antagonist (PAMORA) in refractory patients. OBJECTIVE To evaluate the ability of a pharmacist-driven OIC protocol to promote increased scheduled laxative use prior to escalation to PAMORA therapy. METHODS This retrospective, single-center cohort study evaluated patients 2 years pre- and post-protocol implementation. The primary outcome was the difference in the percentage of patients receiving 2 scheduled laxatives for ≥ 2 days prior to PAMORA therapy pre- and post-protocol. Secondary outcomes included difference in time to first bowel movement after PAMORA initiation, difference in total number of laxative/PAMORA doses administered, and difference in overall estimated total cost. Data was analyzed using chi-squared tests and Student's t tests. RESULTS Three-hundred patients were included (150 patients in the pre and post-protocol groups). In the pre-protocol group, 53 patients (35%) received 2 scheduled laxatives for 2 days prior to naloxegol/methylnaltrexone compared to 96 patients (64%) in the postprotocol group (p < 0.0001). One-thousand twenty-one scheduled laxative doses were given pre-protocol versus 1625 doses post-protocol. Average time to first bowel movement was similar between groups (17.7 hours vs 16.0 hours p = 0.441). Estimated total cost of OIC reversal therapy decreased from $20,896.95 to $13,405.47. CONCLUSION A pharmacist-driven OIC protocol is associated with an increase in the use of scheduled laxatives prior to PAMORA administration and decreased overall estimated total cost. A larger, prospective study is necessary to assess if this promotes more efficacious OIC.
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Affiliation(s)
| | - Erin K Hennessey
- St. Louis College of Pharmacy/Mercy Hospital St. Louis, Saint Louis, MO, USA
| | - Andrew J Crannage
- St. Louis College of Pharmacy/Mercy Hospital St. Louis, Saint Louis, MO, USA
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Effectiveness of Naldemedine Compared with Magnesium Oxide in Preventing Opioid-Induced Constipation: A Randomized Controlled Trial. Cancers (Basel) 2022; 14:cancers14092112. [PMID: 35565243 PMCID: PMC9102438 DOI: 10.3390/cancers14092112] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Opioids are used in cancer pain management, however, their continuous use may not be tolerable owing to adverse effects such as constipation, sleepiness, nausea, and respiratory depression. Opioid-induced constipation reduces the quality of life of patients, and osmotic laxatives are conventionally recommended for preventing opioid-induced constipation. Recently, naldemedine, a peripherally acting μ-opioid receptor antagonist, can be used to safely and effectively treat opioid-induced constipation based on its etiological mechanism, without affecting central analgesia. In this study, we compared the effectiveness of magnesium oxide with that of naldemedine in preventing opioid-induced constipation. Naldemedine significantly prevented deterioration in the quality of defecation (the Japanese Patient Assessment of Constipation Quality of Life and complete spontaneous bowel movement) and reduced gastrointestinal adverse effects, mainly nausea, compared with magnesium oxide during 12-week administration. Abstract Opioid-induced constipation (OIC) may occur in patients receiving opioid treatment, decreasing their quality of life (QOL). We compared the effectiveness of magnesium oxide (MgO) with that of naldemedine (NAL) in preventing OIC. This proof-of-concept, randomized controlled trial (registration number UMIN000031891) involved 120 patients with cancer scheduled to receive opioid therapy. The patients were randomly assigned and stratified by age and sex to receive MgO (500 mg, thrice daily) or NAL (0.2 mg, once daily) for 12 weeks. The change in the average Japanese version of Patient Assessment of Constipation QOL (JPAC-QOL) from baseline to 2 weeks was assessed as the primary endpoint. The other endpoints were spontaneous bowel movements (SBMs) and complete SBMs (CSBMs). Deterioration in the mean JPAC-QOL was significantly lower in the NAL group than in the MgO group after 2 weeks. There were fewer adverse events in the NAL group than in the MgO group. Neither significant differences in the change in SBMs between the groups nor serious adverse events/deaths were observed. The CSBM rate was higher in the NAL group than in the MgO group at 2 and 12 weeks. In conclusion, NAL significantly prevented deterioration in constipation-specific QOL and CSBM rate compared with MgO.
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