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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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Garutti M, Noto C, Pastò B, Cucciniello L, Alajmo M, Casirati A, Pedrazzoli P, Caccialanza R, Puglisi F. Nutritional Management of Oncological Symptoms: A Comprehensive Review. Nutrients 2023; 15:5068. [PMID: 38140327 PMCID: PMC10745914 DOI: 10.3390/nu15245068] [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: 11/01/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.
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Affiliation(s)
- Mattia Garutti
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
| | - Claudia Noto
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Brenno Pastò
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Linda Cucciniello
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | | | - Amanda Casirati
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Paolo Pedrazzoli
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
| | - Fabio Puglisi
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
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Essmat N, Karádi DÁ, Zádor F, Király K, Fürst S, Al-Khrasani M. Insights into the Current and Possible Future Use of Opioid Antagonists in Relation to Opioid-Induced Constipation and Dysbiosis. Molecules 2023; 28:7766. [PMID: 38067494 PMCID: PMC10708112 DOI: 10.3390/molecules28237766] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Opioid receptor agonists, particularly those that activate µ-opioid receptors (MORs), are essential analgesic agents for acute or chronic mild to severe pain treatment. However, their use has raised concerns including, among others, intestinal dysbiosis. In addition, growing data on constipation-evoked intestinal dysbiosis have been reported. Opioid-induced constipation (OIC) creates an obstacle to continuing treatment with opioid analgesics. When non-opioid therapies fail to overcome the OIC, opioid antagonists with peripheral, fast first-pass metabolism, and gastrointestinal localized effects remain the drug of choice for OIC, which are discussed here. At first glance, their use seems to only be restricted to constipation, however, recent data on OIC-related dysbiosis and its contribution to the appearance of several opioid side effects has garnered a great of attention from researchers. Peripheral MORs have also been considered as a future target for opioid analgesics with limited central side effects. The properties of MOR antagonists counteracting OIC, and with limited influence on central and possibly peripheral MOR-mediated antinociception, will be highlighted. A new concept is also proposed for developing gut-selective MOR antagonists to treat or restore OIC while keeping peripheral antinociception unaffected. The impact of opioid antagonists on OIC in relation to changes in the gut microbiome is included.
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Affiliation(s)
- Nariman Essmat
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Egypt
| | - Dávid Árpád Karádi
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Ferenc Zádor
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Kornél Király
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Susanna Fürst
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Mahmoud Al-Khrasani
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
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Porzio G, Capela A, Giusti R, Lo Bianco F, Moro M, Ravoni G, Zułtak-Baczkowska K. Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature. Drugs Context 2023; 12:dic-2022-11-7. [PMID: 37077766 PMCID: PMC10108666 DOI: 10.7573/dic.2022-11-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/10/2023] [Indexed: 04/21/2023] Open
Abstract
Underlying cancer pain has heterogenous aetiologies and mechanisms. It requires detailed and comprehensive pain assessment, combined with personalized treatment. A multidisciplinary team is essential to providing the best management of cancer pain at every disease stage, improving the quality of life and outcomes in patients with cancer. This narrative literature review emphasizes the value of providing all patients with multidisciplinary pain management in their preferred care setting. Real-life experiences are also reported to witness the efforts of physicians to properly manage cancer pain. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
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Affiliation(s)
| | - Andreia Capela
- Centro Hospitalar Vila Nova de Gaia, Espinho; Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Arcozelo – Vila Nova de Gaia, Portugal
| | - Raffaele Giusti
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Francesca Lo Bianco
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Mirella Moro
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Giulio Ravoni
- Tuscany Tumor Association, Home Care Service, Florence, Italy
| | - Katarzyna Zułtak-Baczkowska
- Zakład Zdrowia Publicznego, Wydział Nauk o Zdrowiu, Pomorski Uniwersytet Medyczny w Szczecinie, Stettin, Poland
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Li X, Yu H, Guo W, Cheng M, Song Q, Ding L. Development and validation of a highly sensitive and selective LC-MS/MS method for the determination of 15-hydroxylubiprostone in human plasma: Application to a pharmacokinetic study in healthy Chinese volunteers. Xenobiotica 2022; 52:567-574. [PMID: 36129160 DOI: 10.1080/00498254.2022.2123751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Lubiprostone, a derivative of prostaglandin E1, is the first chemical-type constipation treatment approved by FDA. Lubiprostone has low systemic exposure after oral administration. Therefore, it is recommended that 15-hydroxylubiprostone, which is a dominant active metabolite of lubiprostone, be used as the pharmacokinetic evaluation indicator. Due to the microdosage of the lubiprostone capsules, it is difficult to develop a highly sensitive bioanalytical method for 15-hydroxylubiprostone.In this study, a highly sensitive and selective liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) method has been established and fully validated for the quantification of 15-hydroxylubiprostone in human plasma, and the validated bioanalytical method has been applied to a pharmacokinetic study of lubiprostone capsules successfully.The pharmacokinetics of 15-hydroxylubiprostone were observed after fed administration in healthy Chinese volunteers. The Cmax and AUC0-t were 75.8 ± 57.6 pg/mL and 222 ± 68.0 pg·h/mL for 15-hydroxylubiprostone.This study investigated the pharmacokinetic properties of 15-hydroxylubiprostone under fed conditions in healthy Chinese volunteers and would provide clinical guidance for the application and further development of lubiprostone capsules.
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Affiliation(s)
- Xianjing Li
- Key Laboratory of Drug Quality Control and Pharmacovigilance, Ministry of Education, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China.,Department of pharmaceutical Analysis, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Haitao Yu
- Nanjing Chia Tai Tianqing Pharmaceutical Co., Ltd, Nanjing 210038, China
| | - Wenjing Guo
- Key Laboratory of Drug Quality Control and Pharmacovigilance, Ministry of Education, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China.,Department of pharmaceutical Analysis, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Minlu Cheng
- Nanjing Clinical Tech. Laboratories Inc., 18 Zhilan Road, Jiangning District, Nanjing 211100, China
| | - Qinxin Song
- Key Laboratory of Drug Quality Control and Pharmacovigilance, Ministry of Education, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China.,Department of pharmaceutical Analysis, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Li Ding
- Key Laboratory of Drug Quality Control and Pharmacovigilance, Ministry of Education, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China.,Department of pharmaceutical Analysis, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China.,Nanjing Clinical Tech. Laboratories Inc., 18 Zhilan Road, Jiangning District, Nanjing 211100, China
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Kern KU, Vogelmann T, Tölle TR. [Tapentadol versus classical WHO-III opioids for chronic back pain. Health services research study based on representative data from health insurance funds]. MMW Fortschr Med 2022; 164:19-27. [PMID: 35449488 DOI: 10.1007/s15006-022-0876-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND/OBJECTIVE In clinical trials, tapentadol prolonged release (PR) showed a more favourable gastrointestinal tolerability profile compared to other strong opioids in the treatment of pain. The present analysis compared tapentadol PR and classical WHO-III PR opioids in routine clinical practice. METHOD Retrospective cohort study (matched pair approach) using anonymised health insurance data of patients with chronic low back pain who were prescribed strong opioids following pretreatment with WHO-I/II analgesics. Data were analysed from the date of first prescription in 2015 over a maximum period of two years. The primary analysis parameter was the prescription of laxatives. RESULTS Data of 227 patients per cohort could be included in the analysis. Significantly fewer tapentadol PR than WHO-III PR patients were prescribed laxatives (20.3% vs. 37%; p < 0.0001). In addition, laxative dosages were significantly lower in the tapentadol PR cohort (26.4 vs. 82.5 defined daily doses; p < 0.0001). A significant difference in laxative prescription was also observed under long-term treatment (tapentadol PR patients 27.7% vs. WHO-III PR patients 50%; p = 0.0029). CONCLUSION Routine clinical practice indirectly confirmed the more favourable gastrointestinal tolerability of tapentadol PR in the treatment of chronic pain which had previously been demonstrated in clinical trials and non-interventional studies.
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Affiliation(s)
- Kai-Uwe Kern
- Schmerzpraxis Wiesbaden, Institut für Schmerzmedizin, Sonnenberger Str. 68, 65193, Wiesbaden, Germany.
| | | | - Thomas R Tölle
- Neurologische Klinik u. Poliklinik, Klinikum rechts d. Isar d. TU München, München, Germany
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Abstract
Opioid-related constipation encompasses constipation directly caused by opioid use (opioid-induced constipation [OIC]) as well as pre-existing constipation worsened by opioid use (opioid-exacerbated constipation [OEC]). Over-the-counter laxatives should be used as first-line agents for both OIC and OEC, given their efficacy, low cost, and high safety profiles. Symptoms of OIC and responses to therapy can be assessed with the Bowel Function Index. Individuals with OIC refractory to laxatives may be responsive to peripherally acting μ-opioid receptor antagonists. Although data supporting the superiority of one prescription agent over another is lacking, all have proven effective for the treatment of OIC.
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Gifford CS, McGahan BG, Miracle SD, Minnema AJ, Murphy CV, Vazquez DE, Weaver TE, Farhadi HF. Perioperative subcutaneous methylnaltrexone does not enhance gastrointestinal recovery after posterior short-segment spinal arthrodesis surgery: a randomized controlled trial. Spine J 2022; 22:444-453. [PMID: 34419626 DOI: 10.1016/j.spinee.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/16/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative ileus is a major barrier to gastrointestinal recovery following surgery. Opioid analgesics likely play an important causative role, particularly in spinal or orthopedic surgeries not involving bowel manipulation. Methylnaltrexone, a peripherally-acting µ-opioid receptor antagonist, is a potential prophylactic treatment. PURPOSE To assess the influence of perioperative subcutaneous methylnaltrexone administration on gastrointestinal recovery following short-segment lumbar arthrodesis surgeries. DESIGN This is a randomized, double-blind, controlled trial. PATIENT SAMPLE Eligible patients undergoing posterior short-segment lumbar arthrodesis surgeries at a single institution between February 2019 and April 2021 were enrolled in this study. OUTCOME MEASURES The primary outcome measure was time-to-first bowel movement. Secondary outcome measures included time-to-discharge/discharge eligibility. Exploratory outcome measures included daily postoperative opioid consumption and pain scores. METHODS In this study, eligible patients were enrolled to receive either methylnaltrexone or placebo perioperatively. Time-to-bowel movement, time-to-discharge/discharge eligibility, intra and postoperative analgesic administration, and pain scores were recorded and compared. RESULTS Eighty two patients in total were enrolled; 41 to the methylnaltrexone and 41 to the placebo group. Both groups were similar in their baseline characteristics. There was no difference in median (range) time-to-bowel movement between the 2 groups [61.8 hours (35.7-93.6) versus 50.7 hours (17.8-110.8), p = .391]. There was also no difference in time-to-discharge/discharge eligibility [105.0 hours (81.0 - 201.3) versus 90.7 (77.5 - 184.5), p=.784]. Finally, there were no differences in either postoperative opioid consumption or numeric rating scores for back, leg, or abdominal pain on postoperative days 0 to 4 (p>.05). CONCLUSIONS Methylnaltrexone did not accelerate gastrointestinal recovery and did not affect opioid consumption or pain scores following short-segment spinal surgery as compared to placebo. Additional studies will be needed to identify effective opioid receptor antagonist dosing regimens for patients undergoing either short- or long-segment spinal arthrodesis procedures.
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Affiliation(s)
- Connor S Gifford
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210
| | - Benjamin G McGahan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210
| | - Shelby D Miracle
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210
| | - Amy J Minnema
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210
| | - Daniel E Vazquez
- Department of General Surgery, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, Ohio, USA, 44307
| | - Tristan E Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210
| | - H Francis Farhadi
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210.
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Post-marketing surveillance of the safety and effectiveness of naldemedine in the management of opioid-induced constipation in patients with cancer pain in Japan. Support Care Cancer 2022; 30:3943-3954. [PMID: 35044484 PMCID: PMC8942924 DOI: 10.1007/s00520-022-06807-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/31/2021] [Indexed: 01/09/2023]
Abstract
Purpose This prospective post-marketing surveillance (PMS) was designed to collect data on the safety and effectiveness of naldemedine in routine clinical practice in patients with opioid-induced constipation (OIC) and cancer pain in Japan and explore the characteristics of patients prone to diarrhea. Methods The enrolled patients received naldemedine (0.2 mg, once a day) orally for up to 12 weeks. In the safety analysis, adverse drug reactions (ADRs), including diarrhea as a special interest, were assessed. Effectiveness was evaluated, especially regarding the frequency and condition of bowel movement. Results In the safety analysis set (n = 1177), 145 ADRs occurred in 133 (11.30%) patients, and diarrhea was the most frequent event (n = 107, 9.09%). Most cases of diarrhea were non-serious (98.1%). Most ADRs were non-serious (93.8%), and they resolved within 2 weeks (75.9%). No patient characteristics influenced the risk of diarrhea development or aggravation. Both the frequency (75.0% and 83.2%) and condition of bowel movement (80.0% and 88.0%) were improved at 2 and 12 weeks, respectively in the effectiveness analysis set (n = 953). Frequency and condition of bowel movement were also improved in patients excluded (e.g., Eastern Cooperative Oncology Group performance status was ≥ 3) or with very small numbers (e.g., received weak opioid) in the clinical trials. Conclusions This PMS indicates that naldemedine is well tolerated and effective in patients of various backgrounds in routine clinical practice who have OIC and cancer pain. Trial registration UMIN000042851. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-06807-y.
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Impact and Consequences of Opioid-Induced Constipation: A Survey of Patients. Pain Ther 2021; 10:1139-1153. [PMID: 34081260 PMCID: PMC8586064 DOI: 10.1007/s40122-021-00271-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Opioids are a valuable tool to help achieve control of pain. However, opioid-induced constipation (OIC) is an important limitation of treatment with this class of drugs. METHODS To better understand the impact of OIC on patient-reported outcomes, we carried out a survey involving patients being treated with opioids. Both ad hoc questions and the PROMIS and PAC-SYM and PAC-QOL scores were used. RESULTS Of the 597 participants, 150 (25%) had cancer-related pain, and 447 (75%) had non-cancer pain; 66% experienced OIC. PROMIS pain interference questions indicated that pain is more likely to interfere with a patient's life when they have OIC. PAC-QOL and PAC-SYM revealed that 58% of patients with non-cancer pain and OIC reported at least one "severe" or "very severe" constipation symptom, compared to 83% with cancer-related pain. Younger age and less time on opioids were associated with greater impact of OIC on quality of life. Only 41% of patients were satisfied with how their constipation was managed. Over 50% of those with non-cancer pain said that they modified their opioid regimen due to constipation, vs. 6% of those with cancer pain. Constipation had been discussed with the healthcare provider (HCP) in 48% of non-cancer patients and in 73% of cancer patients. In those with chronic pain and OIC, 24% expressed varying degrees of dissatisfaction with the healthcare system, vs. 37% in those with cancer pain and OIC. CONCLUSION Our results provide additional evidence that management of OIC is inadequate in many cases. Moreover, they indicate that there is a definite need for better education about OIC among HCPs.
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Gifford CS, McGahan BG, Miracle SD, Minnema AJ, Murphy CV, Vazquez DE, Weaver TE, Farhadi HF. Design and feasibility of a double-blind, randomized trial of peri-operative methylnaltrexone for postoperative ileus prevention after adult spinal arthrodesis. Contemp Clin Trials 2021; 112:106623. [PMID: 34798295 DOI: 10.1016/j.cct.2021.106623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/30/2021] [Accepted: 11/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Postoperative ileus (POI) is a common complication with no proven prophylactic measures in place. While perioperative opioid use has been implicated in POI development, current treatments fail to target this disease mechanism. Methylnaltrexone (MNTX) has been used to prevent the effects of opioids on the bowel and could reduce the incidence of POI when administered preoperatively. METHODS In this phase IIb randomized controlled trial, we assessed the effect of perioperative MNTX on time-to-first-bowel movement following spinal arthrodesis surgeries. RESULTS 82 patients were randomly selected in a 1:1 ratio to be included in either the treatment or placebo groups. Comparison of relevant factors of included patients to patients who refused to participate (n = 21) and to a prior retrospective series (n = 241) revealed no differences in age, male sex, liver disease, and number of surgical levels. Overall treatment fidelity (98% adherence) and retention (100% at one-month follow-up) were high. The predicted POI incidence (9.3-11.1%) was also equivalent to a prior retrospective series. However, the overall observed POI incidence (3.7%) was lower than expected, which could reflect a superimposed 'trial effect' related to standardized care in a research setting. CONCLUSIONS Since exposure to significant opioid doses represents a barrier to enhanced recovery after surgery, the results of this innovative trial may provide further guidance for the peri-operative use of opioid-receptor blockers. Here, we show that MNTX can be effectively administered in the peri-operative period with appropriate follow-up achieved in a representative population of patients undergoing spinal surgery. TRIAL REGISTRATION NUMBERS Clinicaltrials.gov - NCT03852524 and Institutional Review Board - 2018H0260.
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Affiliation(s)
- Connor S Gifford
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Benjamin G McGahan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Shelby D Miracle
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Amy J Minnema
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Daniel E Vazquez
- Department of General Surgery, Cleveland Clinic Akron General, Akron, OH, United States of America
| | - Tristan E Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - H Francis Farhadi
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America.
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Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ. Subcutaneous Methylnaltrexone for Treatment of Opioid-Induced Constipation in Cancer versus Noncancer Patients: An Analysis of Efficacy and Safety Variables from Two Studies. J Pain Res 2021; 14:2687-2697. [PMID: 34512008 PMCID: PMC8420564 DOI: 10.2147/jpr.s312731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Methylnaltrexone inhibits opioid-induced constipation (OIC) by binding to peripheral µ-opioid receptors without impacting central opioid receptor mediated analgesia. This analysis compared methylnaltrexone efficacy and safety among advanced illness patients with and without active cancer and OIC. Patients and Methods This post hoc analysis included two multicenter, randomized, double-blind, placebo-controlled studies in adults with advanced illness and OIC who received subcutaneous methylnaltrexone. Efficacy endpoints included the proportion of patients achieving rescue-free laxation (RFL), time to RFL, weekly laxations within 24 hours after dosing, rescue laxative use, and pain scores. Adverse events were monitored for safety. Results After pooling, 178 patients received methylnaltrexone (n = 116 with cancer) and 185 received placebo (n = 114 with cancer). Median baseline daily opioid morphine equivalents (mg/d) were higher in cancer (methylnaltrexone: 180; placebo: 188) versus noncancer patients (methylnaltrexone: 120; placebo: 80). The proportions of patients achieving RFL within 4 hours after ≥2 of the first 4 doses were significantly greater with methylnaltrexone (cancer: 56.9%; noncancer: 58.1%) versus placebo (cancer: 5.3%; noncancer: 11.3%; P < 0.0001). The median time to laxation within 24 hours after the first methylnaltrexone dose was significantly shorter in cancer and noncancer patients versus placebo (cancer: 0.96 vs 22.53 hours, P < 0.0001; noncancer: 1.25 vs >24 hours, P = 0.0002). The mean number of weekly laxations within 24 hours after dosing by week 2 was significantly higher in methylnaltrexone- vs placebo-treated cancer and noncancer patients (cancer: 7.9 vs 4.9, P < 0.0001; noncancer: 8.4 vs 5.0, P < 0.0001). Methylnaltrexone reduced rescue laxative use without impacting pain scores. Consistent with previous data, methylnaltrexone was well tolerated in cancer and noncancer patients, and the AE profile did not suggest symptoms of opioid withdrawal. Conclusion Methylnaltrexone reduced RFL time in advanced-illness patients with and without active cancer, while maintaining pain control with opioid treatment despite higher baseline opioid use among cancer patients.
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Affiliation(s)
| | - Michelle Rhiner
- Loma Linda University Health, Department of Family Medicine, Loma Linda, CA, USA
| | - Neal E Slatkin
- University of California Riverside, School of Medicine, Riverside, CA, USA.,Salix Pharmaceuticals, Medical Affairs, Bridgewater, NJ, USA
| | - Nancy Stambler
- Progenics Pharmaceuticals, Inc., a subsidiary of Lantheus Holdings Inc., Clinical Research, New York, NY, USA
| | - Robert J Israel
- Bausch Health US, LLC, Clinical and Medical Affairs, Bridgewater, NJ, USA
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13
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Pergolizzi JV, Magnusson P, LeQuang JA, Breve F, Taylor R, Wollmuth C, Varrassi G. Can NSAIDs and Acetaminophen Effectively Replace Opioid Treatment Options for Acute Pain? Expert Opin Pharmacother 2021; 22:1119-1126. [PMID: 33689517 DOI: 10.1080/14656566.2021.1901885] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Opioid analgesia for acute painful conditions has come under increasing scrutiny with the public health crisis of opioid overdose, leading clinicians to seek nonopioid alternatives, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (paracetamol). AREAS COVERED This perspective evaluates recent clinical trials of nonopioids, opioids, and combination therapy for use in acute pain. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide adequate analgesia, although these agents are not without risks. Combination therapy using a small amount of opioid together with a nonopioid pain reliever has been shown effective and reduces opioid consumption. EXPERT OPINION The short-term use of opioids under close clinical supervision, such as in-hospital use of opioid analgesics for postoperative pain, may be appropriate, but even here, combination therapy or nonopioid therapy may be preferred. The use of opioids even for acute pain of short duration has been questioned. The ideal analgesic has yet to be developed, but effective pain control pharmacological regimens for acute pain are available.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.,Cardiology Research Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Frank Breve
- Department of Pharmacy, Temple University, Philadelphia, Pennsylvania, USA
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14
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Sharma A, Rao SSC, Kearns K, Orleck KD, Waldman SA. Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders. Aliment Pharmacol Ther 2021; 53:1250-1267. [PMID: 33909919 PMCID: PMC8252518 DOI: 10.1111/apt.16369] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/24/2020] [Accepted: 03/31/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders. AIM To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic-based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation. METHODS Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices. RESULTS Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects. CONCLUSIONS Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence-based treatments by a gastroenterology provider.
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Affiliation(s)
- Amol Sharma
- Division of Gastroenterology/HepatologyMedical College of GeorgiaAugusta UniversityAugustaGAUSA
| | - Satish S. C. Rao
- Division of Gastroenterology/HepatologyMedical College of GeorgiaAugusta UniversityAugustaGAUSA
| | | | | | - Scott A. Waldman
- Department of Pharmacology and Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPAUSA
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15
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Diagnosing Constipation Spectrum Disorders in a Primary Care Setting. J Clin Med 2021; 10:jcm10051092. [PMID: 33807888 PMCID: PMC7961346 DOI: 10.3390/jcm10051092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Understanding pathophysiological causes of constipation is worthwhile in directing therapy and improving symptoms. This review aims to identify and fill gaps in the understanding of the pathophysiology of constipation, understand its prevalence, review diagnostic tools available to primary care physicians (PCPs), and highlight patients’ expectations for the management of this common spectrum of disorders. Literature searches conducted via PubMed included terms related to constipation, diagnosis, and patient perceptions. Case studies were developed to highlight the differences between patients who may be appropriately managed in the primary care setting and those requiring specialty consultation. Myriad pathophysiological factors may contribute to constipation, including stool consistency, altered intestinal motility, gut microbiome, anorectal abnormalities, as well as behavioral and psychological factors. Common diagnoses of “primary constipation” include slow-transit constipation, defecation disorders, irritable bowel syndrome with constipation, and chronic idiopathic constipation. A detailed medical history should be conducted to exclude alarm features and PCPs should be familiar with pathophysiological factors that cause constipation, available diagnostic tools, alarm signs, and the various classification criteria for constipation subtypes in order to diagnose and treat patients accordingly. PCPs should understand when a referral to a gastroenterologist, anorectal specialist, pelvic floor physical therapist, and/or mental health specialist is appropriate.
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16
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Okamoto A, Ikemura K, Mizutani E, Iwamoto T, Okuda M. Opioid therapy duration before naldemedine treatment is a significant independent risk of diarrhea: a retrospective cohort study. J Pharm Health Care Sci 2021; 7:3. [PMID: 33517900 PMCID: PMC7849155 DOI: 10.1186/s40780-020-00187-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/21/2020] [Indexed: 01/05/2023] Open
Abstract
Background The most common adverse event (AE) associated with opioid analgesics is opioid-induced constipation (OIC). Naldemedine (NAL) is widely used for the treatment of OIC. However, diarrhea has been reported as the most common treatment-emergent AE of NAL, and little is known about the risk factors associated with the development of diarrhea during NAL administration. This study examined the risk factors for NAL-induced diarrhea via a retrospective chart review of hospitalized patients. Methods The data of 101 hospitalized adult patients who received NAL for the first time for the treatment of OIC at Mie University Hospital between June 2017 and December 2018 were extracted from electronic medical records. According to the inclusion and exclusion criteria, 70 of the 101 patients were enrolled in this study. Diarrhea was defined as “diarrhea” on the medical record within 2 weeks of NAL administration. Univariate and multivariate analyses were performed to identify risk factors for the development of diarrhea in patients receiving NAL. Results Twenty-two of the 70 patients enrolled (31%) developed diarrhea within 2 weeks of NAL administration. The median duration (range) of NAL treatment before diarrhea onset was 3 (1–12) days. Patients with diarrhea had a significantly longer duration of opioid therapy before NAL administration than patients without diarrhea (P=0.002). Multivariate logistic regression analysis indicated that the independent risk factors for the development of NAL-induced diarrhea were NAL administration after more than 17 days of opioid therapy (odds ratio [OR]=7.539; P=0.016) and pancreatic cancer (OR=6.217; P=0.025). In fact, the incidence of diarrhea in patients who were administered NAL within a day of opioid therapy was significantly lower than that in patients who were administered NAL after more than 17 days of opioid therapy (13% vs. 54%, P=0.030). Conclusions These results suggested that a prolonged duration of opioid therapy prior to NAL initiation is associated with increased incidence of diarrhea. Supplementary Information The online version contains supplementary material available at 10.1186/s40780-020-00187-3.
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Affiliation(s)
- Akiharu Okamoto
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.,Department of Clinical Pharmaceutics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kenji Ikemura
- Department of Pharmacy, Osaka University Hospital, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Eri Mizutani
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan. .,Department of Clinical Pharmaceutics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Masahiro Okuda
- Department of Pharmacy, Osaka University Hospital, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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17
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Alvaro D, Caraceni AT, Coluzzi F, Gianni W, Lugoboni F, Marinangeli F, Massazza G, Pinto C, Varrassi G. What to Do and What Not to Do in the Management of Opioid-Induced Constipation: A Choosing Wisely Report. Pain Ther 2020; 9:657-667. [PMID: 32940898 PMCID: PMC7648765 DOI: 10.1007/s40122-020-00195-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Despite the essential utility of opioids for the clinical management of pain, opioid-induced constipation (OIC) remains an important obstacle in clinical practice. In patients, OIC hinders treatment compliance and has negative effects on quality of life. From a clinician perspective, the diagnosis and management of OIC are hampered by the absence of a clear, universal diagnostic definition across disciplines and a lack of standardization in OIC treatment and assessment. Methods A multidisciplinary panel of physician experts who treat OIC was assembled to identify a list of ten corrective actions—five “things to do” and five “things not to do”—for the diagnosis and management of OIC, utilizing the Choosing Wisely methodology. Results The final list of corrective actions to improve the diagnosis and clinical management of OIC emphasized a need for: (i) better physician and patient education regarding OIC; (ii) systematic use of diagnostically validated approaches to OIC diagnosis and assessment (i.e., Rome IV criteria and Bristol Stool Scale, respectively) across various medical contexts; and (iii) awareness about appropriate, evidence-based treatments for OIC including available peripheral mu-opioid receptor antagonists (PAMORAs). Conclusions Physicians who prescribe long-term opioids should be forthcoming with patients about the possibility of OIC and be adequately versed in the most recent guideline recommendations for its management.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Gastroenterology Division, Sapienza University of Rome, Rome, RM, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy, and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, MI, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, LT, Italy.
- Anesthesiology, Intensive Care, and Pain Medicine Unit, 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, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, RE, Italy
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18
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Viscusi ER, Viscusi AR. Blood-brain barrier: mechanisms governing permeability and interaction with peripherally acting μ-opioid receptor antagonists. Reg Anesth Pain Med 2020; 45:688-695. [PMID: 32723840 PMCID: PMC7476292 DOI: 10.1136/rapm-2020-101403] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022]
Abstract
The blood-brain barrier (BBB) describes the unique properties of endothelial cells (ECs) that line the central nervous system (CNS) microvasculature. The BBB supports CNS homeostasis via EC-associated transport of ions, nutrients, proteins and waste products between the brain and blood. These transport mechanisms also serve as physiological barriers to pathogens, toxins and xenobiotics to prevent them from contacting neural tissue. The mechanisms that govern BBB permeability pose a challenge to drug design for CNS disorders, including pain, but can be exploited to limit the effects of a drug to the periphery, as in the design of the peripherally acting μ-opioid receptor antagonists (PAMORAs) used to treat opioid-induced constipation. Here, we describe BBB physiology, drug properties that affect BBB penetrance and how data from randomized clinical trials of PAMORAs improve our understanding of BBB permeability.
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Affiliation(s)
- Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andrew R Viscusi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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19
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Abstract
Opioid-induced bowel dysfunction (OIBD) is a common complication in long-term opioid users and abusers. It is a burdensome condition, which significantly limits quality of life and is associated with increasing health costs. OIBD affects up to 60% of patients with chronic non-cancer pain and over 80% of patients suffering from cancer pain and is one of the conditions of the most common symptoms associated with opioid maintenance. Given the continued use of opioids for chronic pain management in appropriate patients, OIBD is likely to persist in clinical practice in the coming years. We will herein review its underlying pathophysiological mechanisms and the available treatments. In the last years, pharmaceutical research has focused on the opportunity of targeting peripheral mu-opioid receptors without affecting their analgesic activity in the central nervous system, and several peripherally acting mu-opioid receptors antagonists (PAMORAs) drugs have been approved. We will mainly focus on naldemedine, discussing its pharmacological properties, its clinical efficacy and side effects. Head-to-head comparisons between naldemedine and the other PAMORAs are not available yet, but some considerations will be discussed based on the pharmacological and clinical data. As a whole, the available data suggest that naldemedine is a valid treatment option for OIBD, as it is a well-tolerated drug that alleviates constipation without affecting analgesia or causing symptoms of opioid withdrawal.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Latina, Italy
| | - Maria Sole Scerpa
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Latina, Italy
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20
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Brenner DM, Argoff CE, Fox SM, Bochenek W, D'Astoli P, Blakesley RE, Reasner DS, O'Dea CR, Cash BD. Efficacy and safety of linaclotide for opioid-induced constipation in patients with chronic noncancer pain syndromes from a phase 2 randomized study. Pain 2020; 161:1027-1036. [PMID: 32310620 PMCID: PMC7170446 DOI: 10.1097/j.pain.0000000000001754] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/31/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
Abstract
Constipation is the most common adverse event (AE) of opioid therapy. This multicenter, phase 2 study evaluated the efficacy and safety of linaclotide in treating opioid-induced constipation (OIC) in patients with chronic noncancer pain syndromes (NCT02270983). Adults with OIC (<3 spontaneous bowel movements [SBMs]/week) related to chronic noncancer pain were randomized 1:1:1 to receive linaclotide 145 µg, linaclotide 290 µg, or placebo once daily for 8 weeks. The primary endpoint was change from baseline in 8-week SBM frequency rate (SBMs/week). Secondary efficacy endpoints included 6/8-week SBM 3 + 1 responders, time to first SBM, and changes from baseline in 8-week stool consistency, abdominal bloating, and straining. Additional endpoints included treatment satisfaction and adequate relief responders. In total, 254 patients were randomized: 87, 88, and 79 received linaclotide 145 µg, linaclotide 290 µg, and placebo, respectively. The mean changes from baseline in SBMs/week during the treatment period were 2.9 and 3.5 in the linaclotide 145 and 290 µg groups (P < 0.01 for both doses), respectively, vs 1.6 in the placebo group. Diarrhea, the most common AE, was generally mild, resulting in 1.1%, 5.7%, and 1.3% of patients discontinuing in the linaclotide 145 μg, linaclotide 290 μg, and placebo groups, respectively. No serious AEs related to diarrhea were reported in any treatment group. Compared with placebo, linaclotide-treated patients had significant improvements in stool consistency, straining, abdominal bloating, and treatment satisfaction scores (P < 0.05). Linaclotide significantly improved OIC symptoms and was well tolerated in patients with chronic noncancer pain.
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Affiliation(s)
- Darren M. Brenner
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Charles E. Argoff
- Comprehensive Pain Center, Albany Medical College, Albany, NY, United States
| | - Susan M. Fox
- Clinical Development Department, Allergan plc, Madison, NJ, United States
| | - Wieslaw Bochenek
- Clinical Development Department, Allergan plc, Madison, NJ, United States
| | - Patricia D'Astoli
- Clinical Development Department, Allergan plc, Madison, NJ, United States
| | - Rick E. Blakesley
- Biostatistics Department, Allergan plc, Madison, NJ, United States. Dr. Blakesley is now with Biostatistics, Alnylam Pharmaceuticals, Cambridge, MA, United States
| | - David S. Reasner
- Data Science Department, Ironwood Pharmaceuticals, Inc, Cambridge, MA, United States. Dr. Reasner is now with Data Science and Analytics, Imbria Pharmaceuticals, Boston, MA, United States
| | - Christopher R. O'Dea
- Clinical Development Department, Ironwood Pharmaceuticals, Inc, Cambridge, MA, United States
| | - Brooks D. Cash
- Ertan Digestive Disease Center, University of Texas Health Science Center, Houston, TX, United States
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21
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Pergolizzi JV, Christo PJ, LeQuang JA, Magnusson P. The Use of Peripheral μ-Opioid Receptor Antagonists (PAMORA) in the Management of Opioid-Induced Constipation: An Update on Their Efficacy and Safety. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:1009-1025. [PMID: 32210534 PMCID: PMC7075239 DOI: 10.2147/dddt.s221278] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/21/2020] [Indexed: 12/12/2022]
Abstract
Peripherally acting μ-opioid receptor antagonists (PAMORAs) constitute a class of drugs which reverse opioid-induced constipation (OIC) with similar opioid analgesic effects. OIC differs from other forms of constipation in that it is an iatrogenic condition that occurs when an opioid acts on the dense network of μ-opioid receptors in the enteric system, which affect a variety of functions including gastrointestinal motility, secretion, and other factors that can cause bowel dysfunction. Unfortunately, laxative products, bowel regimens, dietary changes, and lifestyle modifications have limited effectiveness in preventing OIC, Opioid-associated adverse effect which occurs in 40% to 80% of opioid patients and may led to cessation of the treatment. PAMORAs are μ-receptor opioid antagonists specifically developed so that they have very limited ability to cross the blood-brain barrier and thus they are able to antagonize peripheral but not central μ-opioid receptors. PAMORAs are designed to have no effect on the analgesic benefits of opioid pain relievers but to relieve but antagonizing the effects of the opioid in the gastrointestinal system. The three main PAMORAS are methyltrexone (oral or parenteral), naldemedine (oral only), and naloxegol (oral only). Clinical studies demonstrate the safety and efficacy of these agents for alleviating constipation without diminishing the analgesic effect of opioid therapy. The aim of this narrative review to update the current status of PAMORAs for treating OIC in terms of safety and efficacy.
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Affiliation(s)
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, ML, USA
| | | | - Peter Magnusson
- Cardiology Research Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Centre for Research and Development, Uppsala University/Region, Gävleborg, Sweden
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22
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Daniali M, Nikfar S, Abdollahi M. Evaluating naloxegol for the treatment of opioid-induced constipation. Expert Opin Pharmacother 2020; 21:883-891. [DOI: 10.1080/14656566.2020.1735354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Marzieh Daniali
- Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Toxicology and Pharmacology, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Evidence-Based Evaluation of Cost-Effectiveness and Clinical Outcomes Group, Pharmaceutical Sciences Research Center (PSRC), and the Pharmaceutical Management and Economics Research Center (PMERC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Toxicology and Pharmacology, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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23
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Mesía R, Virizuela Echaburu JA, Gómez J, Sauri T, Serrano G, Pujol E. Opioid-Induced Constipation in Oncological Patients: New Strategies of Management. Curr Treat Options Oncol 2019; 20:91. [PMID: 31853656 PMCID: PMC6920224 DOI: 10.1007/s11864-019-0686-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Cancer-associated pain has traditionally been treated with opioid analgesics, often in escalating doses. Opioid-induced constipation (OIC) is a common problem associated with chronic use of opioid analgesics. Typical treatment strategies to alleviate constipation are based on dietary changes, exercise, and laxatives. However, laxatives have a nonspecific action and do not target underlying mechanisms of OIC. This article will review prevalent, clinical presentation and recommendations for the treatment of OIC. An independent literature search was carried out by the authors. We reviewed the literature for randomized controlled trials that studied the efficacy of laxatives, naloxone, and naloxegol in treating OIC. Newer strategies addressing the causal pathophysiology of OIC are needed for a more effective assessment and management of OIC. Finally, traditional recommended therapies are appraised and compared with the latest pharmacological developments. Future research should address whether naloxegol is more efficacious by its comparison directly with first-line treatments, including laxatives.
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Affiliation(s)
- Ricard Mesía
- Servicio de Oncología Médica, Instituto Catalán de Oncología, Badalona, Spain
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24
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Abstract
Naldemedine [Symproic® (Japan; USA); Rizmoic® (EU)], an orally available peripherally acting μ-opioid receptor antagonist (PAMORA), is approved in several countries for the treatment of opioid-induced constipation. In phase III trials, naldemedine was more effective than placebo at increasing the frequency of bowel movements in patients with constipation induced by opioid treatment for cancer pain or chronic non-cancer pain. Naldemedine was also associated with improvements in patient-rated constipation-related symptoms and quality of life. Naldemedine was generally well tolerated, including over the longer term. Because naldemedine specifically targets opioid receptors in the gastrointestinal (GI) tract and does not cross the blood-brain barrier, it does not cause opioid withdrawal symptoms or interfere with centrally mediated opioid analgesia. Consistent with its mechanism of action, the most commonly reported adverse events were GI in nature. In conclusion, current data indicate that naldemedine is an effective and generally well-tolerated treatment option for opioid-induced constipation in patients with cancer pain or chronic non-cancer pain, with the convenience of once-daily oral dosing.
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Affiliation(s)
- Hannah A Blair
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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