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Iyer V, Saberi SA, Pacheco R, Sizemore EF, Stockman S, Kulkarni A, Cantwell L, Thakur GA, Hohmann AG. Negative allosteric modulation of CB 1 cannabinoid receptor signaling suppresses opioid-mediated tolerance and withdrawal without blocking opioid antinociception. Neuropharmacology 2024; 257:110052. [PMID: 38936657 PMCID: PMC11261750 DOI: 10.1016/j.neuropharm.2024.110052] [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: 01/07/2024] [Revised: 06/02/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
The direct blockade of CB1 cannabinoid receptors produces therapeutic effects as well as adverse side-effects that limit their clinical potential. CB1 negative allosteric modulators (NAMs) represent an indirect approach to decrease the affinity and/or efficacy of orthosteric cannabinoid ligands or endocannabinoids at CB1. We recently reported that GAT358, a CB1-NAM, blocked opioid-induced mesocorticolimbic dopamine release and reward via a CB1-allosteric mechanism of action. Whether a CB1-NAM dampens opioid-mediated therapeutic effects such as analgesia or alters other unwanted opioid side-effects remain unknown. Here, we characterized the effects of GAT358 on nociceptive behaviors in the presence and absence of morphine in male rats. We examined the impact of GAT358 on formalin-evoked pain behavior and Fos protein expression, a marker of neuronal activation, in the lumbar spinal cord. We also assessed the impact of GAT358 on morphine-induced slowing of colonic transit, tolerance, and withdrawal behaviors in male mice. GAT358 attenuated morphine antinociceptive tolerance without blocking acute antinociception and reduced morphine-induced slowing of colonic motility without impacting fecal boli production. GAT358 also produced antinociception in the presence and absence of morphine in the formalin model of inflammatory nociception and reduced the number of formalin-evoked Fos protein-like immunoreactive cells in the lumbar spinal cord. Finally, GAT358 mitigated the somatic signs of naloxone-precipitated, but not spontaneous, opioid withdrawal following chronic morphine dosing. Our results support the therapeutic potential of CB1-NAMs as novel drug candidates aimed at preserving opioid-mediated analgesia while preventing their unwanted side-effects. Our studies also uncover previously unrecognized antinociceptive properties associated with an arrestin-biased CB1-NAM.
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Affiliation(s)
- Vishakh Iyer
- Program in Neuroscience, Indiana University, Bloomington, IN, USA; Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Shahin A Saberi
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Romario Pacheco
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Emily Fender Sizemore
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Sarah Stockman
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Abhijit Kulkarni
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Lucas Cantwell
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Ganesh A Thakur
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Andrea G Hohmann
- Program in Neuroscience, Indiana University, Bloomington, IN, USA; Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA; Gill Center for Biomolecular Science, Indiana University, Bloomington, IN, USA.
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Miura R, Utano T, Miura Y, Chiba K, Hasegawa A, Takafuji Y, Takahashi H, Tanzawa A, Iwahashi K, Yamatani A, Yotani N. Efficacy and Safety of Naldemedine for Opioid-Induced Constipation in Children. J Palliat Med 2024. [PMID: 39122251 DOI: 10.1089/jpm.2024.0018] [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: 08/12/2024] Open
Abstract
Background: Naldemedine, a peripherally acting opioid μ receptor antagonist, is effective for prevention of opioid-induced constipation (OIC); however, evidence on its use in children is limited. Objective: To evaluate the efficacy and safety of naldemedine in pediatric patients with OIC. Design, Setting/Subjects: Retrospective analysis of 32 pediatric patients with OIC treated with naldemedine in a single institution in Japan from June 2017 to March 2021. Measurements: Efficacy was evaluated in 13 evaluable patients with bowel movement (BM) response, defined as those with at least three BMs in the first 7 days after naldemedine initiation and an increase of at least one BM from baseline. Safety was evaluated by examining adverse events (AEs) based on the Common Terminology Criteria for AEs (v5.0). Results: BM response was recorded in 11 of the 13 patients (85%), and the number BMs per day significantly increased from 0.43 before naldemedine to 1.00 after naldemedine (p = 0.025). The most common AE was diarrhea, observed in 16 of the 32 patients (50%), and all instances were grade 1 or 2. In three of the 16 patients, naldemedine was discontinued owing to worsening diarrhea. Conclusions: In pediatric patients, naldemedine resulted in a high rate of BM response and increased the BM frequency, indicating its efficacy. In some patients, grade 2 diarrhea required naldemedine discontinuation, suggesting that it should be used with caution in pediatric patients. Further studies are warranted to determine the optimal naldemedine dose in pediatric patients.
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Affiliation(s)
- Rina Miura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoyuki Utano
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Yoriko Miura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Kyoko Chiba
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Ayaka Hasegawa
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Yukiko Takafuji
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Hayato Takahashi
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Ayano Tanzawa
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Kana Iwahashi
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Akimasa Yamatani
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuyuki Yotani
- Division of Palliative Medicine, National Center of Child Health and Development, Tokyo, Japan
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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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Lacy BE, Cangemi DJ. Opioids and the Gastrointestinal Tract: The Role of Peripherally Active µ-Opioid Receptor Antagonists in Modulating Intestinal Permeability. Am J Gastroenterol 2024:00000434-990000000-01186. [PMID: 38870087 DOI: 10.14309/ajg.0000000000002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 06/10/2024] [Indexed: 06/15/2024]
Abstract
Opioid receptors are found throughout the gastrointestinal tract, including the large intestine. Many patients treated with opioids experience opioid-induced constipation (OIC). Laxatives are not effective in most patients, and in those who do initially respond, the efficacy of laxatives generally diminishes over time. In addition, OIC does not spontaneously resolve for most patients. However, complications of opioids extend far beyond simply slowing gastrointestinal transit. Opioid use can affect intestinal permeability through a variety of mechanisms. Toll-like receptors are a crucial component of innate immunity and are tightly regulated within the gut epithelium. Pathologic µ-opioid receptor (MOR) and toll-like receptor signaling, resulting from chronic opioid exposure, disrupts intestinal permeability leading to potentially harmful bacterial translocation, elevated levels of bacterial toxins, immune activation, and increased cytokine production. Peripherally active MOR antagonists, including methylnaltrexone, are effective at treating OIC. Benefits extend beyond simply blocking the MOR; these agents also act to ameliorate opioid-induced disrupted intestinal permeability. In this review, we briefly describe the physiology of the gastrointestinal epithelial border and discuss the impact of opioids on gastrointestinal function. Finally, we consider the use of peripherally active MOR antagonists to treat disrupted intestinal permeability resulting from opioid use and discuss the potential for improved morbidity and mortality in patients treated with methylnaltrexone for opioid-induced bowel disorders.
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O'Donnell MT, Haviland SM. Functional Constipation and Obstructed Defecation. Surg Clin North Am 2024; 104:565-578. [PMID: 38677821 DOI: 10.1016/j.suc.2023.11.007] [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: 04/29/2024]
Abstract
Constipation encompasses symptoms of decreased colonic motility or difficulty with the defecation process. As a broad definition, this can be inclusive of functional constipation (FC) or colonic inertia, obstructed defecation (OD), and irritable bowel syndrome-constipation type (IBS-CS). After excluding IBS-C, FC and OD diagnosis and management require a multidisciplinary approach often involving nutritionists, pelvic floor therapists, urogynecologists, and colon and rectal surgeons. Differentiating the presence or absence of each can direct therapy and prognosticate chances for improvement in this often complex combination of disorders.
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Affiliation(s)
- Mary T O'Donnell
- Department of General Surgery Walter Reed National Military Medical Center, Colon and Rectal Surgery Division, 8901 Rockville Pike, Bethesda, MD 20889, USA.
| | - Sarah M Haviland
- Department of General Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
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Imai H, Fujita Y, Hiruta E, Masuno T, Yamazaki S, Tanaka H, Kamiya T, Sandoh M, Takei S, Arai K, Nishiba H, Mogi J, Koizuka S, Saito T, Obayashi K, Kaira K, Minato K. Efficacy and safety of naldemedine for opioid-induced constipation in older patients with cancer: a retrospective study. Eur J Gastroenterol Hepatol 2024; 36:571-577. [PMID: 38477855 DOI: 10.1097/meg.0000000000002746] [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: 03/14/2024]
Abstract
BACKGROUND Opioids are pain relievers that are often associated with opioid-induced constipation (OIC) that worsens with age. We performed a multicenter, retrospective analysis on the efficacy and safety of naldemedine, an opioid receptor antagonist, in treating OIC in patients with cancer (age >75 years). METHODS The electronic medical records of cancer patients who received naldemedine at 10 Japanese institutions between 7 June 2017 and August 31, 2019, were retrieved. Patients aged ≥75 years who were treated with naldemedine for the first time and hospitalized for at least 7 days before and after initiating naldemedine therapy were included in this analysis. RESULTS Sixty patients were observed for at least 7 days before and after starting naldemedine. The response rate was 68.3%, and the frequency of bowel movements increased significantly after naldemedine administration in the overall population ( P < 0.0001) and among those who defecated <3 times/week before naldemedine administration ( P < 0.0001). Diarrhea was the most frequent adverse event in all grades, observed in 45% of patients, of which 92.6% were Grade 1 or 2. Grade 4 or higher adverse events, including death, were not observed. CONCLUSION Naldemedine exhibits significant efficacy and safety in OIC treatment in older patients with cancer.
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Affiliation(s)
- Hisao Imai
- Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Hidaka, Saitama
- Division of Respiratory Medicine, Gunma Prefectural Cancer Center
| | | | - Eriko Hiruta
- Division of Pharmacy, Gunma Prefectural Cancer Center, Ota
| | | | | | - Hajime Tanaka
- Division of Pharmacy, Haramachi Red Cross Hospital, Agatsuma-gun
| | - Teruhiko Kamiya
- Department of Pharmacy, Tatebayashi Kosei General Hospital, Tatebayashi
| | | | | | - Kazuya Arai
- Division of Pharmacy, Gunma Saiseikai Maebashi Hospital, Maebashi
| | - Hiromi Nishiba
- Division of Pharmacy, Japan Community Health Care Organization (JCHO) Gunma Chuo Hospital, Maebashi
- Graduate School of Pharmaceutical Sciences, Takasaki University of Health and Welfare
| | - Junnosuke Mogi
- Division of Pharmacy, Hidaka Hospital. 886 Nakao, Takasaki
| | - Shiro Koizuka
- Division of Palliative Care, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Taeko Saito
- Division of Pharmacy, Gunma Prefectural Cancer Center, Ota
| | - Kyoko Obayashi
- Graduate School of Pharmaceutical Sciences, Takasaki University of Health and Welfare
| | - Kyoichi Kaira
- Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Hidaka, Saitama
| | - Koichi Minato
- Division of Respiratory Medicine, Gunma Prefectural Cancer Center
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Formenti P, Umbrello M, Pignataro M, Sabbatini G, Dottorini L, Gotti M, Brenna G, Menozzi A, Terranova G, Galimberti A, Pezzi A. Managing Severe Cancer Pain with Oxycodone/Naloxone Treatment: A Literature Review Update. J Pers Med 2024; 14:483. [PMID: 38793067 PMCID: PMC11122522 DOI: 10.3390/jpm14050483] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Severe cancer pain substantially affects patients' quality of life, increasing the burden of the disease and reducing the disability-adjusted life years. Although opioid analgesics are effective, they may induce opioid-induced bowel dysfunction (OIBD). Oxycodone/naloxone combination therapy has emerged as a promising approach to mitigate opioid-induced constipation (OIC) while providing effective pain relief. This review provides an updated analysis of the literature of the last decade regarding the use of oxycodone/naloxone in the management of severe cancer pain. Through a comprehensive search of databases, studies focusing on the efficacy, safety, and patient experience of oxycodone/naloxone's prolonged release in severe cancer pain management were identified. Furthermore, the literature discusses the mechanism of action of naloxone in mitigating OIC without compromising opioid analgesia. Overall, the evidence suggests that oxycodone/naloxone combination therapy offers a valuable option for effectively managing severe cancer pain while minimizing opioid-induced constipation, thereby improving patients' quality of life. However, further research is needed to optimize dosing regimens, evaluate long-term safety, and assess patient outcomes in diverse cancer populations.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Michele Umbrello
- Department of Intensive Care, New Hospital of Legnano (Ospedale Nuovo di Legnano), 20025 Legnano, Italy
| | | | - Giovanni Sabbatini
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | | | - Miriam Gotti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Giovanni Brenna
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Alessandro Menozzi
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy
| | - Gaetano Terranova
- Anaesthesia and Intensive Care Department, Asst Gaetano Pini, 20100 Milano, Italy
| | - Andrea Galimberti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Angelo Pezzi
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
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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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Odgaard L, Rasmussen AA, Feo R, Kristensen PK. Characteristics of constipation screening and assessment tools: a scoping review protocol. BMJ Open 2024; 14:e076978. [PMID: 38521529 PMCID: PMC10961535 DOI: 10.1136/bmjopen-2023-076978] [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: 06/22/2023] [Accepted: 03/15/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Constipation is a common and significant burden on individuals and healthcare systems. Accurate assessment of constipation severity and symptom improvement are vital aspects of caring for patients with constipation. Therefore, nurses and allied healthcare professionals should possess knowledge regarding the characteristics of constipation assessment tools (ie, aim, scope, definition of constipation, content, structure, mode, administration time and context of use). However, existing reviews summarising characteristics of tools have been restricted to chronic constipation and self-reported measures. Furthermore, they have not included literature published after 2011. This scoping review aims to identify and comprehensibly map the characteristics of available tools for screening and assessment of constipation in order to manage the nursing care need related to constipation within any healthcare or research context and any patient group. METHODS AND ANALYSIS This review will include primary research articles, methodological papers and clinical guidelines using tools for constipation screening and assessment, pertinent to nursing care management. It is not limited to a specific population or healthcare setting. Databases to be searched include PubMed, Embase, CINAHL, ProQuest, ClinicalKey and Google Scholar. To identify grey literature, national health services in selected countries will be searched. Papers written in English, Nordic language or German will be included. The reviewers will independently review the retrieved citations against the inclusion criteria, and data from included papers will be extracted using a data extraction form developed for this review. The scoping review will be conducted following the Joanna Briggs Institute Guidelines. The results will be presented in a table accompanied by a narrative summary. ETHICS AND DISSEMINATION Ethical approval is not required, as no individual patient data are included. Findings will be shared and discussed with relevant stakeholders and disseminated through peer-reviewed publications and conference presentations. The protocol is registered on Open Science Framework (registration number: osf.io/h2vzd).
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Affiliation(s)
- Lene Odgaard
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Hammel, Denmark
| | - Anne A Rasmussen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecca Feo
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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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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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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12
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Goudsward HJ, Ruiz-Velasco V, Stella SL, Willing LB, Holmes GM. Coexpressed δ-, μ-, and κ-Opioid Receptors Modulate Voltage-Gated Ca 2+ Channels in Gastric-Projecting Vagal Afferent Neurons. Mol Pharmacol 2024; 105:250-259. [PMID: 38182431 PMCID: PMC10877734 DOI: 10.1124/molpharm.123.000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/12/2023] [Accepted: 12/19/2023] [Indexed: 01/07/2024] Open
Abstract
Opioid analgesics are frequently associated with gastrointestinal side effects, including constipation, nausea, dysphagia, and reduced gastric motility. Though it has been shown that stimulation of opioid receptors expressed in enteric motor neurons contributes to opioid-induced constipation, it remains unclear whether activation of opioid receptors in gastric-projecting nodose ganglia neurons contributes to the reduction in gastric motility and emptying associated with opioid use. In the present study, whole-cell patch-clamp recordings were performed to determine the mechanism underlying opioid receptor-mediated modulation of Ca2+ currents in acutely isolated gastric vagal afferent neurons. Our results demonstrate that CaV2.2 channels provide the majority (71% ± 16%) of Ca2+ currents in gastric vagal afferent neurons. Furthermore, we found that application of oxycodone, U-50488, or deltorphin II on gastric nodose ganglia neurons inhibited Ca2+ currents through a voltage-dependent mechanism by coupling to the Gα i/o family of heterotrimeric G-proteins. Because previous studies have demonstrated that the nodose ganglia expresses low levels of δ-opioid receptors, we also determined the deltorphin II concentration-response relationship and assessed deltorphin-mediated Ca2+ current inhibition following exposure to the δ-opioid receptor antagonist ICI 174,864 (0.3 µM). The peak mean Ca2+ current inhibition following deltorphin II application was 47% ± 24% (EC50 = 302.6 nM), and exposure to ICI 174,864 blocked deltorphin II-mediated Ca2+ current inhibition (4% ± 4% versus 37% ± 20%). Together, our results suggest that analgesics targeting any opioid receptor subtype can modulate gastric vagal circuits. SIGNIFICANCE STATEMENT: This study demonstrated that in gastric nodose ganglia neurons, agonists targeting all three classical opioid receptor subtypes (μ, δ, and κ) inhibit voltage-gated Ca2+ channels in a voltage-dependent mechanism by coupling to Gαi/o. These findings suggest that analgesics targeting any opioid receptor subtype would modulate gastric vagal circuits responsible for regulating gastric reflexes.
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Affiliation(s)
- Hannah J Goudsward
- Departments of Neural and Behavioral Sciences (H.J.G., S.L.S., L.B.W., G.M.H.) and Anesthesiology and Perioperative Medicine (V.R.-V.), Penn State University College of Medicine, Hershey, Pennsylvania
| | - Victor Ruiz-Velasco
- Departments of Neural and Behavioral Sciences (H.J.G., S.L.S., L.B.W., G.M.H.) and Anesthesiology and Perioperative Medicine (V.R.-V.), Penn State University College of Medicine, Hershey, Pennsylvania
| | - Salvatore L Stella
- Departments of Neural and Behavioral Sciences (H.J.G., S.L.S., L.B.W., G.M.H.) and Anesthesiology and Perioperative Medicine (V.R.-V.), Penn State University College of Medicine, Hershey, Pennsylvania
| | - Lisa B Willing
- Departments of Neural and Behavioral Sciences (H.J.G., S.L.S., L.B.W., G.M.H.) and Anesthesiology and Perioperative Medicine (V.R.-V.), Penn State University College of Medicine, Hershey, Pennsylvania
| | - Gregory M Holmes
- Departments of Neural and Behavioral Sciences (H.J.G., S.L.S., L.B.W., G.M.H.) and Anesthesiology and Perioperative Medicine (V.R.-V.), Penn State University College of Medicine, Hershey, Pennsylvania
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13
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Iyer V, Saberi SA, Pacheco R, Sizemore EF, Stockman S, Kulkarni A, Cantwell L, Thakur GA, Hohmann AG. Negative allosteric modulation of cannabinoid CB 1 receptor signaling suppresses opioid-mediated tolerance and withdrawal without blocking opioid antinociception. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.06.574477. [PMID: 38260598 PMCID: PMC10802405 DOI: 10.1101/2024.01.06.574477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The direct blockade of CB 1 cannabinoid receptors produces therapeutic effects as well as adverse side-effects that limit their clinical potential. CB 1 negative allosteric modulators (NAMs) represent an indirect approach to decrease the affinity and/or efficacy of orthosteric cannabinoid ligands or endocannabinoids at CB 1 . We recently reported that GAT358, a CB 1 -NAM, blocked opioid-induced mesocorticolimbic dopamine release and reward via a CB 1 -allosteric mechanism of action. Whether a CB 1 -NAM dampens opioid-mediated therapeutic effects such as analgesia or alters other unwanted side-effects of opioids remain unknown. Here, we characterized the effects of GAT358 on nociceptive behaviors in the presence and absence of morphine. We examined the impact of GAT358 on formalin-evoked pain behavior and Fos protein expression, a marker of neuronal activation, in the lumbar dorsal horn. We also assessed the impact of GAT358 on morphine-induced slowing of colonic transit, tolerance, and withdrawal behaviors. GAT358 attenuated morphine antinociceptive tolerance without blocking acute antinociception. GAT358 also reduced morphine-induced slowing of colonic motility without impacting fecal boli production. GAT358 produced antinociception in the presence and absence of morphine in the formalin model of inflammatory nociception and reduced the number of formalin-evoked Fos protein-like immunoreactive cells in the lumbar spinal dorsal horn. Finally, GAT358 mitigated the somatic signs of naloxone-precipitated, but not spontaneous, opioid withdrawal following chronic morphine dosing in mice. Our results support the therapeutic potential of CB 1 -NAMs as novel drug candidates aimed at preserving opioid-mediated analgesia while preventing their unwanted side-effects. Our studies also uncover previously unrecognized antinociceptive properties associated with an arrestin-biased CB 1 -NAMs. Highlights CB 1 negative allosteric modulator (NAM) GAT358 attenuated morphine tolerance GAT358 reduced morphine-induced slowing of colonic motility but not fecal productionGAT358 was antinociceptive for formalin pain alone and when combined with morphineGAT358 reduced formalin-evoked Fos protein expression in the lumbar spinal cordGAT358 mitigated naloxone precipitated withdrawal after chronic morphine dosing.
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Nishiyama S, Uchino S, Sasabuchi Y, Masuyama T, Lefor AK, Sanui M. Naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation: A retrospective, single-center cohort study. PLoS One 2024; 19:e0295952. [PMID: 38170714 PMCID: PMC10763934 DOI: 10.1371/journal.pone.0295952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION There are few reports describing the association of naldemedine with defecation in critically ill patients with opioid-induced constipation. The purpose of this study was to determine whether naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation. METHODS In this retrospective cohort study, patients admitted to the Intensive Care Unit (ICU) without defecation for 48 hours while receiving opioids were eligible for enrollment. The primary endpoint was the time of the first defecation within 96 hours after inclusion. Secondary endpoints included presence of diarrhea, duration of mechanical ventilation, ICU length of stay, ICU mortality, and in-hospital mortality. The Cox proportional hazard regression analysis with time-dependent covariates was used to evaluate the association naldemedine with earlier defecation. RESULTS A total of 875 patients were enrolled and were divided into 63 patients treated with naldemedine and 812 patients not treated. Defecation was observed in 58.7% of the naldemedine group and 48.8% of the no-naldemedine group during the study (p = 0.150). The naldemedine group had statistically significantly prolonged duration of mechanical ventilation (8.7 days vs 5.5 days, p < 0.001) and ICU length of stay (11.8 days vs 9.2 days, p = 0.001) compared to the no-naldemedine group. However, the administration of naldemedine was significantly associated with earlier defecation [hazard ratio:2.53; 95% confidence interval: 1.71-3.75, p < 0.001]. CONCLUSION The present study shows that naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation.
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Affiliation(s)
- Seiya Nishiyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tomoyuki Masuyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
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15
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Duffy EP, Bachtell RK, Ehringer MA. Opioid trail: Tracking contributions to opioid use disorder from host genetics to the gut microbiome. Neurosci Biobehav Rev 2024; 156:105487. [PMID: 38040073 PMCID: PMC10836641 DOI: 10.1016/j.neubiorev.2023.105487] [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: 08/29/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023]
Abstract
Opioid use disorder (OUD) is a worldwide public health crisis with few effective treatment options. Traditional genetics and neuroscience approaches have provided knowledge about biological mechanisms that contribute to OUD-related phenotypes, but the complexity and magnitude of effects in the brain and body remain poorly understood. The gut-brain axis has emerged as a promising target for future therapeutics for several psychiatric conditions, so characterizing the relationship between host genetics and the gut microbiome in the context of OUD will be essential for development of novel treatments. In this review, we describe evidence that interactions between host genetics, the gut microbiome, and immune signaling likely play a key role in mediating opioid-related phenotypes. Studies in humans and model organisms consistently demonstrated that genetic background is a major determinant of gut microbiome composition. Furthermore, the gut microbiome is susceptible to environmental influences such as opioid exposure. Additional work focused on gene by microbiome interactions will be necessary to gain improved understanding of their effects on OUD-related behaviors.
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Affiliation(s)
- Eamonn P Duffy
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA; Institute for Behavioral Genetics, University of Colorado Boulder, Boulder, CO, USA.
| | - Ryan K Bachtell
- Institute for Behavioral Genetics, University of Colorado Boulder, Boulder, CO, USA; Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Marissa A Ehringer
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA; Institute for Behavioral Genetics, University of Colorado Boulder, Boulder, CO, USA
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16
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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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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: 3] [Impact Index Per Article: 3.0] [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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Berlund P, Reddington C, Cheng C, Healey M. Constipation After Elective Laparoscopy for Benign Gynecological Indications-A Prospective Observational Study. J Minim Invasive Gynecol 2023; 30:827-832. [PMID: 37321297 DOI: 10.1016/j.jmig.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023]
Abstract
STUDY OBJECTIVE Discover the rate of post-operative constipation in participants undergoing elective laparoscopy for benign gynecological indications DESIGN: Prospective observational study SETTING: Single site, tertiary level gynecology unit with a focus on pelvic pain and endometriosis. PATIENTS Recruited participants were patients of the institution over the age of 18 who had planned to undergo an elective laparoscopy for benign gynecological indications prior to enrolment in the study. Participants were excluded if they were not English speaking, had a chronic bowel condition (with the exception of irritable bowel syndrome), were planned to have bowel surgery, hysterectomy, or converted to laparotomy. INTERVENTION In this prospective study, participants completed 3 consecutive surveys. One prior to surgery, one a week post-surgery, and a third 3 months post-surgery. The surveys collected data regarding the participant's bowel habits, pain relief used, laxatives used, and the distress or bother caused by their bowels. MEASUREMENT AND MAIN RESULTS Constipation was defined by a modified ROME IV criteria. Opiate use and laxative use were defined by patient-reported tablet counts. The level of distress was measured as a continuously variable scale from 0 to 100. Variables adjusted for included subject's demographics, pre-operative constipation, indication for surgery, duration of surgery, estimated blood loss, opiate use (preoperative, peri-operative, and post-operative), laxative use, and length of stay. A total of 153 participants were recruited, of which 103 completed both the pre-operative and post-operative survey. Post-operative constipation was present in 70% of participants. The mean length of time to first bowel motion was 3 days, with 32% of participants having their first bowel motion after the third post-operative day. The level of bother caused by their bowel habit was higher in the constipation group compared to those without constipation. Post-operatively opiates were used in 84.9% of participants, and laxatives were used in 47.1%. Visits to the general practitioner for constipation occurred in 5.8% of participants. CONCLUSION Post-operative constipation is common and bothersome in participants who undergo elective laparoscopy for benign gynecological indications. Analysis of individual variables failed to identify any factors that influenced the rate of constipation.
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Affiliation(s)
- Paul Berlund
- From the Gynecology 2 Unit (Drs. Berlund, Reddington, Cheng, and Healey), The Royal Womens Hospital, Parkville, Australia.
| | - Charlotte Reddington
- From the Gynecology 2 Unit (Drs. Berlund, Reddington, Cheng, and Healey), The Royal Womens Hospital, Parkville, Australia; Department Obstetrics & Gynecology (Drs. Reddington, Cheng, and Healey), University of Melbourne, Parkville, Australia
| | - Claudia Cheng
- From the Gynecology 2 Unit (Drs. Berlund, Reddington, Cheng, and Healey), The Royal Womens Hospital, Parkville, Australia; Department Obstetrics & Gynecology (Drs. Reddington, Cheng, and Healey), University of Melbourne, Parkville, Australia
| | - Martin Healey
- From the Gynecology 2 Unit (Drs. Berlund, Reddington, Cheng, and Healey), The Royal Womens Hospital, Parkville, Australia; Department Obstetrics & Gynecology (Drs. Reddington, Cheng, and Healey), University of Melbourne, Parkville, Australia
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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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Gharibo C, Drewes AM, Breve F, Rekatsina M, Narvaez Tamayo MA, Varrassi G, Paladini A. Iatrogenic Side Effects of Pain Therapies. Cureus 2023; 15:e44583. [PMID: 37790027 PMCID: PMC10545448 DOI: 10.7759/cureus.44583] [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: 08/19/2023] [Accepted: 09/02/2023] [Indexed: 10/05/2023] Open
Abstract
Pain regimens, particularly for chronic cancer and noncancer pain, must balance the important analgesic benefits against potential risks. Many effective and frequently used pain control regimens are associated with iatrogenic adverse events. Interventional procedures can be associated with nerve injuries, vascular injuries, trauma to the spinal cord, and epidural abscesses. Although rare, these adverse events are potentially catastrophic. Pharmacologic remedies for pain must also consider potential side effects that can occur even at therapeutic doses of over-the-counter remedies such as paracetamol (acetaminophen) or nonsteroidal anti-inflammatory drugs. Opioids are effective pain relievers but are associated with many side effects, some of which can be treatment limiting. A prevalent and distressing side effect of opioid therapy is constipation. Opioid-induced constipation is caused by binding to opioid receptors in the gastrointestinal system, making conventional laxatives ineffective. Peripherally acting mu-opioid receptor antagonists are a new drug class that offers the benefits of preserving opioid analgesia without side effects in the gastrointestinal system. An important safety concern, particularly among geriatric patients is the increasingly prevalent condition of polypharmacy. Many senior patients take five or more medications, including some that may be contraindicated in geriatric patients, duplicative of other drugs, have potential pharmacokinetic drug-drug interactions, or may not be the optimal choice for the patient's age and condition. Careful assessment of medications in the elderly, including possibly deprescribing with tapering of certain drugs, may be warranted but should be done systematically and under clinical supervision.
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Affiliation(s)
| | - Asbjørn M Drewes
- Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, DNK
| | - Frank Breve
- Pharmacy, Temple University, Philadelphia, USA
| | | | | | | | - Antonella Paladini
- Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
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21
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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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22
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Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ. Methylnaltrexone Treatment for Opioid-Induced Constipation in Patients with and without Cancer: Effect of Initial Dose. J Pain Res 2023; 16:2595-2607. [PMID: 37533563 PMCID: PMC10391063 DOI: 10.2147/jpr.s405825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/09/2023] [Indexed: 08/04/2023] Open
Abstract
Purpose Opioid-induced constipation (OIC) is a common side effect of opioid therapy. Methylnaltrexone (MNTX) is a selective, peripherally acting μ-opioid receptor antagonist, with demonstrated efficacy in treating OIC. We pooled results from MNTX clinical trials to compare responses to an initial dose in patients with chronic cancer and noncancer pain. Patients and Methods This post hoc analysis used pooled data from 3 randomized, placebo-controlled studies of MNTX in patients with advanced illness with OIC. Assessments included the proportions of patients achieving rescue-free laxation (RFL) within 4 and 24 hours of the first study drug dose, time to RFL, current and worst pain intensity, and adverse events, stratified by the presence/absence of cancer. Results A total of 355 patients with cancer (MNTX n = 198, placebo n = 157) and 163 without active cancer (MNTX n = 83; placebo n = 80) were included. More patients treated with MNTX compared with those who received placebo achieved an RFL within 4 (cancer: MNTX, 61.1% vs placebo,15.3%, p<0.0001; noncancer: MNTX, 62.2% vs placebo, 17.5%, p<0.0001) and 24 hours (cancer: MNTX, 71.2% vs placebo, 41.4%, p<0.0001; noncancer: MNTX, 74.4% vs placebo, 37.5%, p<0.0001) of the initial dose. Cumulative RFL response rates within 4 hours of the first, second, or third dose of study drug were also higher in MNTX-treated patients. The estimated time to RFL was shorter among those who received MNTX and similar in cancer and noncancer patients. Mean pain scores declined similarly in all groups. The most common adverse events in both cancer and noncancer patients were abdominal pain, flatulence, and nausea. Conclusion After the first dose, MNTX rapidly induced a laxation response in the majority of both cancer and noncancer patients with advanced illness. Opioid-induced analgesia was not compromised, and adverse events were primarily gastrointestinal in nature. Methylnaltrexone is a well-tolerated and effective treatment for OIC in both cancer and noncancer patients.
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Affiliation(s)
| | - Michelle Rhiner
- Department of Family Medicine, Loma Linda University Health, 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, North Billerica, MA, USA
| | - Robert J Israel
- Bausch Health US, LLC, Clinical and Medical Affairs, Bridgewater, NJ, USA
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23
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Kong D, Sun JX, Yang JQ, Li YS, Bi K, Zhang ZY, Wang KH, Luo HY, Zhu M, Xu Y. Ketogenic diet: a potential adjunctive treatment for substance use disorders. Front Nutr 2023; 10:1191903. [PMID: 37575322 PMCID: PMC10414993 DOI: 10.3389/fnut.2023.1191903] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Substance use disorders (SUD) can lead to serious health problems, and there is a great interest in developing new treatment methods to alleviate the impact of substance abuse. In recent years, the ketogenic diet (KD) has shown therapeutic benefits as a dietary therapy in a variety of neurological disorders. Recent studies suggest that KD can compensate for the glucose metabolism disorders caused by alcohol use disorder by increasing ketone metabolism, thereby reducing withdrawal symptoms and indicating the therapeutic potential of KD in SUD. Additionally, SUD often accompanies increased sugar intake, involving neural circuits and altered neuroplasticity similar to substance addiction, which may induce cross-sensitization and increased use of other abused substances. Reducing carbohydrate intake through KD may have a positive effect on this. Finally, SUD is often associated with mitochondrial damage, oxidative stress, inflammation, glia dysfunction, and gut microbial disorders, while KD may potentially reverse these abnormalities and serve a therapeutic role. Although there is much indirect evidence that KD has a positive effect on SUD, the small number of relevant studies and the fact that KD leads to side effects such as metabolic abnormalities, increased risk of malnutrition and gastrointestinal symptoms have led to the limitation of KD in the treatment of SUD. Here, we described the organismal disorders caused by SUD and the possible positive effects of KD, aiming to provide potential therapeutic directions for SUD.
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Affiliation(s)
- Deshenyue Kong
- General Hospital of Eastern Theater Command, Nanjing, China
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jia-xue Sun
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ji-qun Yang
- Third People’s Hospital of Kunming City/Drug Rehabilitation Hospital of Kunming City, Kunming, China
| | - Yuan-sen Li
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ke Bi
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zun-yue Zhang
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
| | - Kun-hua Wang
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
| | - Hua-you Luo
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mei Zhu
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yu Xu
- General Hospital of Eastern Theater Command, Nanjing, China
- Yunnan Technological Innovation Centre of Drug Addiction Medicine, Yunnan University, Kunming, China
- First Affiliated Hospital of Kunming Medical University, Kunming, China
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24
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Zhang Q, Yuan Y, Zhang M, Qiao B, Cui Y, Wang Y, Feng L. Efficacy and safety of acupuncture-point stimulation combined with opioids for the treatment of moderate to severe cancer pain: a network meta-analysis of randomized controlled trials. Front Oncol 2023; 13:1166580. [PMID: 37333815 PMCID: PMC10272816 DOI: 10.3389/fonc.2023.1166580] [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] [Received: 02/20/2023] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
Background Pain is one of the most common and troublesome symptoms of cancer. Although potential positive effects of acupuncture-point stimulation (APS) on cancer pain have been observed, knowledge regarding the selection of the optimal APS remains unclear because of a lack of evidence from head-to-head randomized controlled trials (RCTs). Objective This study aimed to carry out a network meta-analysis to compare the efficacy and safety of different APS combined with opioids in treating moderate to severe cancer pain and rank these methods for practical consideration. Methods A comprehensive search of eight electronic databases was conducted to obtain RCTs involving different APS combined with opioids for moderate to severe cancer pain. Data were screened and extracted independently using predesigned forms. The quality of RCTs was appraised with the Cochrane Collaboration risk-of-bias tool. The primary outcome was the total pain relief rate. Secondary outcomes were the total incidence of adverse reactions, the incidence of nausea and vomiting, and the incidence of constipation. We applied a frequentist, fixed-effect network meta-analysis model to pool effect sizes across trials using rate ratios (RR) with their 95% confidence intervals (CI). Network meta-analysis was performed using Stata/SE 16.0. Results We included 48 RCTs, which consisted of 4,026 patients, and investigated nine interventions. A network meta-analysis showed that a combination of APS and opioids was superior in relieving moderate to severe cancer pain and reducing the incidence of adverse reactions such as nausea, vomiting, and constipation compared to opioids alone. The ranking of total pain relief rates was as follows: fire needle (surface under the cumulative ranking curve (SUCRA) = 91.1%), body acupuncture (SUCRA = 85.0%), point embedding (SUCRA = 67.7%), auricular acupuncture (SUCRA = 53.8%), moxibustion (SUCRA = 41.9%), transcutaneous electrical acupoint stimulation (TEAS) (SUCRA = 39.0%), electroacupuncture (SUCRA = 37.4%), and wrist-ankle acupuncture (SUCRA = 34.1%). The ranking of total incidence of adverse reactions was as follows: auricular acupuncture (SUCRA = 23.3%), electroacupuncture (SUCRA = 25.1%), fire needle (SUCRA = 27.2%), point embedding (SUCRA = 42.6%), moxibustion (SUCRA = 48.2%), body acupuncture (SUCRA = 49.8%), wrist-ankle acupuncture (SUCRA = 57.8%), TEAS (SUCRA = 76.3%), and opioids alone (SUCRA = 99.7%). Conclusions APS seemed to be effective in relieving cancer pain and reducing opioid-related adverse reactions. Fire needle combined with opioids may be a promising intervention to reduce moderate to severe cancer pain as well as reduce opioid-related adverse reactions. However, the evidence was not conclusive. More high-quality trials investigating the stability of evidence levels of different interventions on cancer pain must be conducted. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier CRD42022362054.
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Affiliation(s)
- Qinglin Zhang
- Department of Oncology, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuntong Yuan
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Meiling Zhang
- Department of Oncology, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Baohua Qiao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yiyuan Cui
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Feng
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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25
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Fujita Y, Imai H, Hiruta E, Masuno T, Yamazaki S, Tanaka H, Kamiya T, Sandoh M, Takei S, Arai K, Nishiba H, Mogi J, Koizuka S, Saito T, Obayashi K, Kaira K, Minato K. Efficacy and Safety of Naldemedine Administration for Opioid-Induced Constipation in Cancer Patients with Poor Performance Status. J Palliat Med 2023; 26:548-553. [PMID: 36971576 DOI: 10.1089/jpm.2022.0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: Constipation is a concern among patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 3 and 4. Objectives: To assess naldemedine's efficacy and safety in cancer patients on opioids with poor PS. Design: Multicenter, retrospective study. Setting/Subjects: Japanese cancer patients with ECOG performance status 3 or 4 who received naldemedine. Measurements: Frequency of defecations before/after naldemedine use. Responders were patients whose defecation frequency increased to ≥3 times/week, from baseline ≥1 defecations/week over seven days after naldemedine administration. Results: Seventy-one patients were analyzed; 66.1% were responders (95% confidence interval: 54.5%-76.1%). Defecation frequency increased significantly after naldemedine in the overall population (6 vs. 2, p < 0.0001) and among those who defecated <3 times/week before naldemedine (4.5 vs. 1, p < 0.0001). Diarrhea (38.0%) of all grades was the most common adverse event; 23 (85.2%) events were classified as Grade 1 or 2. Conclusion: Naldemedine is effective and safe among cancer patients with poor PS.
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Affiliation(s)
- Yukiyoshi Fujita
- Divisions of Pharmacy, Gunma Prefectural Cancer Center, Ota, Japan
| | - Hisao Imai
- Respiratory Medicine, Gunma Prefectural Cancer Center, Ota, Japan
- Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Eriko Hiruta
- Divisions of Pharmacy, Gunma Prefectural Cancer Center, Ota, Japan
| | - Takashi Masuno
- Division of Pharmacy, Fujioka General Hospital, Fujioka, Japan
| | - Shigeki Yamazaki
- Division of Pharmacy, Kiryu Kosei General Hospital, Kiryu, Japan
| | - Hajime Tanaka
- Division of Pharmacy, Haramachi Red Cross Hospital, Agatsuma-gun, Japan
| | - Teruhiko Kamiya
- Department of Pharmacy, Tatebayashi Kosei General Hospital, Tatebayashi, Japan
| | | | - Satoshi Takei
- Division of Pharmacy, Tone Central Hospital, Numata, Japan
| | - Kazuya Arai
- Division of Pharmacy, Gunma Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Hiromi Nishiba
- Division of Pharmacy, Japan Community Health Care Organization (JCHO) Gunma Chuo Hospital, Maebashi, Japan
- Laboratory of Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Japan
| | | | - Shiro Koizuka
- Palliative Care, Gunma Prefectural Cancer Center, Ota, Japan
| | - Taeko Saito
- Divisions of Pharmacy, Gunma Prefectural Cancer Center, Ota, Japan
| | - Kyoko Obayashi
- Laboratory of Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Japan
| | - Kyoichi Kaira
- Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Koichi Minato
- Respiratory Medicine, Gunma Prefectural Cancer Center, Ota, Japan
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An H, Liu YC. Gastroparesis after video-assisted thoracic surgery: A case report. World J Clin Cases 2023; 11:1862-1868. [PMID: 36969994 PMCID: PMC10037284 DOI: 10.12998/wjcc.v11.i8.1862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/19/2023] [Accepted: 02/21/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Video-assisted thoracic surgery (VATS) lobectomy is a common treatment for patients with early-stage lung cancer. Some patients can experience slight gastrointestinal discomfort after lobectomy for a moment. Gastroparesis is a gastrointestinal disorder that can be severe; it is associated with an increased risk of aspiration pneumonia and impaired postoperative recovery. Here, we report a rare case of gastroparesis after VATS lobectomy.
CASE SUMMARY A 61-year-old man underwent VATS right lower lobectomy uneventfully but had an obstruction of the upper digestive tract 2 d after surgery. Acute gastroparesis was diagnosed after emergency computed tomography and oral iohexol X-ray imaging. After gastrointestinal decompression and administration of prokinetic drugs, the patient’s gastrointestinal symptoms improved. Since perioperative medication was applied according to the recommended dose and there was no evidence of electrolyte imbalance, intraoperative periesophageal vagal nerve injury was the most likely underlying cause of gastroparesis.
CONCLUSION Although gastroparesis is a rare perioperative complication following VATS, clinicians should be on the alert when patients complain about gastrointestinal discomfort. When surgeons resect paraesophageal lymph nodes with electrocautery, excessive ambient heat and compression of paraesophageal hematoma might induce vagal nerve dysfunction.
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Affiliation(s)
- Hang An
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Yu-Cun Liu
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
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A Retrospective Study of the Efficacy and Safety of Naldemedine for Treatment of Opioid-Induced Constipation in Patients with Hepatobiliary Pancreatic Cancer. Medicina (B Aires) 2023; 59:medicina59030492. [PMID: 36984494 PMCID: PMC10051263 DOI: 10.3390/medicina59030492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/03/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Background and Objectives: Opioid analgesics, which are used for cancer-related pain management, cause opioid-induced constipation (OIC). Naldemedine, a peripheral opioid receptor antagonist, is an OIC-modifying agent, but no focused efficacy and safety analysis has been conducted for its use in hepatobiliary pancreatic cancers. We performed a multi-institutional study on the efficacy and safety of naldemedine in patients with hepatobiliary pancreatic cancer using opioids in clinical practice. Materials and Methods: We retrospectively evaluated patients with hepatobiliary pancreatic cancer (including liver, biliary tract, and pancreatic cancers) treated with opioids and naldemedine during hospitalization at ten institutions in Japan from June 2017 to August 2019. We assessed the frequency of bowel movements before and after the initiation of naldemedine therapy. Responders were defined as patients who defecated ≥3 times/week, with an increase from a baseline of ≥1 defecations/week over seven days after the initiation of naldemedine administration. Results: Thirty-four patients were observed for one week before and one week after starting naldemedine. The frequency of bowel movements increased by one over the baseline frequency or to at least thrice per week in 21 patients. The response rate was 61.7% (95% confidence interval: 45.4–78.0%). The median number of weekly bowel movements before and after naldemedine treatment was 2 (range: 0–9) and 6 (range: 1–17), respectively, in the overall population (n = 34); the increase in the number of bowel movements following naldemedine administration was statistically significant (Wilcoxon signed-rank test, p < 0.0001). Diarrhea was the predominant gastrointestinal symptom, and 10 (29.4%) patients experienced grade 1, grade 2, or grade 3 adverse events. The only other adverse event included fatigue in one patient; grade 2–4 adverse events were absent. Conclusions: Naldemedine is effective, and its use may be safe in clinical practice for patients with hepatobiliary pancreatic cancer receiving opioid analgesics.
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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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Farchadi D, Slatkin NE, Stambler N, Israel RJ, Matus M. Cumulative Laxation Response with Methylnaltrexone: Implications for Hospitalized Patients with Advanced Illness and Opioid-Induced Constipation. CURRENT THERAPEUTIC RESEARCH 2023; 98:100694. [PMID: 36875317 PMCID: PMC9981808 DOI: 10.1016/j.curtheres.2023.100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
Background Opioid-induced constipation (OIC) may increase the risk of fecal impaction and mortality in patients with advanced illness. Methylnaltrexone (MNTX) is efficacious for OIC. Objective The purpose of this analysis was to evaluate cumulative rescue-free laxation response with repeat MNTX dosing in patients with advanced illness who were refractory to current laxative regimens and to assess the influence, if any, of poor functional status on response to MNTX treatment. Methods This analysis included pooled data from patients with advanced illness and established OIC who were on a stable opioid regimen in a pivotal, randomized, placebo (PBO)-controlled clinical trial (study 302 [NCT00402038]) or a randomized, PBO-controlled Food and Drug Administration-required postmarketing study (study 4000 [NCT00672477]). Patients in study 302 received subcutaneous MNTX 0.15 mg/kg or PBO every other day, whereas those in study 4000 received MNTX 8 mg (body weight ≥38 to <62 kg), MNTX 12 mg (body weight ≥62 kg), or PBO every other day. Outcomes included cumulative rescue-free laxation rates at 4- and 24-hours postdose for the first 3 doses of study drug and time to rescue-free laxation. To assess if functional status influenced treatment outcomes, we performed a secondary analysis on the outcomes stratified by baseline World Health Organization/Eastern Cooperative Oncology Group performance status, pain scores, and safety. Results One hundred eighty-five patients received PBO and 179 patients received MNTX. The median age was 66.0 years, 51.5% were women, 56.5% had a baseline World Health Organization/Eastern Cooperative Oncology Group performance status score >2, and 63.4% had a primary diagnosis of cancer. Cumulative rescue-free laxation rates were significantly higher with MNTX than PBO 4- and 24-hours after doses 1, 2, and 3 (P < 0.0001), and between-treatment comparisons remained significant (P < 0.0001) regardless of performance status. The estimated time to first rescue-free laxation was shorter for patients receiving MNTX versus PBO. No new safety signals were identified. Conclusions Repeated use of MNTX represents a safe and effective treatment for OIC in patients with advanced illness regardless of baseline performance status. ClinicalTrials.gov identifier: NCT00672477. (Curr Ther Res Clin Exp. 2023; 84:XXX-XXX)© 2023 Elsevier HS Journals, Inc.
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Affiliation(s)
- David Farchadi
- Loma Linda University Medical Center, Loma Linda, California
| | - Neal E Slatkin
- School of Medicine, University of California Riverside, Riverside, California.,Salix Pharmaceuticals, Bridgewater, New Jersey
| | - Nancy Stambler
- Progenics Pharmaceuticals, Inc, a subsidiary of Lantheus Holdings, Inc, Clinical Research, New York, New York
| | | | - Michael Matus
- Loma Linda University Medical Center, Loma Linda, California
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Hek K, Lghoul-Oulad Saïd F, Korevaar JC, Flinterman LE, van Dijk L, van den Bemt PMLA. Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands. BMC PRIMARY CARE 2022; 23:312. [PMID: 36464672 PMCID: PMC9721085 DOI: 10.1186/s12875-022-01911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Guidelines recommend to prescribe a laxative with an opioid to prevent constipation. We aimed to determine the adherence by general practitioners (GPs) to this recommendation and to explore which GP- and patient related factors were associated with it from the perspective of the GP. METHODS: We conducted an observational study using GPs' prescription data from the Nivel Primary Care Database combined with a questionnaire asking for reasons of non-adherence. The proportion of first opioid prescriptions prescribed together with a laxative was determined as primary outcome. Possible explanatory factors such as the quality of registration, the level of collaboration with the pharmacy, familiarity with the recommendation and use of a clinical decision support system were explored, as were the self-reported reasons for non-adherence (classified as either GP-related or patient-related). We assessed the association of factors with the primary outcome using univariable multilevel logistic regression analysis. RESULTS The recommendation was measured in 195 general practices. The median proportion of first opioid prescriptions prescribed together with a laxative in these practices was 54% (practice range 18-88%). None of the determinants was consistently associated with the primary outcome. GPs from 211 practices filled out the questionnaire and the most frequently mentioned reason not to prescribe a laxative was that the patient has laxatives in stock, followed by that the patient doesn't want a laxative; both were patient-related factors. CONCLUSION There was room for improvement in following the guideline on laxative prescribing in opioid use. A main reason seemed to be that the patient refuses a laxative. Improvement measures should therefore focus on communication between GPs and patients on the relevance of co-using a laxative with opioids. Future studies need to establish the effect of such improvement measures, and determine whether reasons for non-adherence to the guideline changed over time.
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Affiliation(s)
- Karin Hek
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands
| | - Fouzia Lghoul-Oulad Saïd
- grid.5132.50000 0001 2312 1970Division of BioTherapeutics, Leiden Academic Centre for Drug Research (LACDR), Gorlaeus Laboratories, Leiden University, Leiden, The Netherlands ,grid.4494.d0000 0000 9558 4598Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joke C. Korevaar
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands
| | - Linda E. Flinterman
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands
| | - Liset van Dijk
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands ,grid.4830.f0000 0004 0407 1981Department of PharmacoTherapy, -Epidemiology and -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | - Patricia M. L. A. van den Bemt
- grid.4494.d0000 0000 9558 4598Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Wang L, Huang L, Li S, Yang J, Tian W, Ji F, Wu K, Zheng M. Electroacupuncture Before Gastrectomy Accelerates Recovery from Gastrointestinal Dysfunction: A Feasibility Study. Med Acupunct 2022; 34:371-379. [PMID: 36644423 PMCID: PMC9805842 DOI: 10.1089/acu.2021.0085] [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] Open
Abstract
Objective This study investigated the feasibility and effectiveness of preoperative electroacupuncture (EA), given within 30 minutes before surgery, on postoperative gastrointestinal dysfunction (PGD) in patients undergoing open gastrectomy. Materials and Methods Patients (N = 60) undergoing open gastrectomy were allocated randomly to a usual care (UC) group (n = 30) or an EA group (n = 30). Patients in the EA group were given bilateral EA on ST-36 (Zusanli), ST-37 (Shangjuxv), and ST-39 (Xiajuxv) within 30 minutes before the surgery. The UC group had no acupuncture treatment. Primary outcomes were feasibility of recruitment, retention, acceptability, and patients' global satisfaction. Secondary outcomes included time to first flatus, defecation, liquid diet, incidence and severity of abdominal distension (AD), and incidence of postoperative nausea (PON) and postoperative vomiting (POV). EA-related adverse events were recorded. Results Of the 61 recruited patients, 1 declined to participate and 60 were randomized into the 2 study groups. All participants completed the interventions. On the acceptability questionnaire, participants' acceptance of EA was statistically improved after the treatment (P < 0.001). Global satisfaction was higher in the EA group (P < 0.001) at 8 (range: 7-8) versus the UC group at 6 (range: 5-7), and the proportion of patients with at least good satisfaction (numerical scale of more than 7 of 10) reached 80% in the EA group. Compared to the UC group, the EA group had a shorter time to first flatus (EA: 57.67 ± 23.09 hours versus 71.27 ± 17.78 hours; P = 0.013). There were no significant differences in time to first defecation (P = 0.081) and liquid diet (P = 0.068), AD (P = 0.436), PON (P = 0.667), or POV (P = 1.000). EA-related adverse events were similar in the 2 groups (P = 1.000). Conclusions EA is feasible, acceptable to patients, and associated with higher postoperative satisfaction in patients undergoing open gastrectomy. A large multicentered trial is needed to test the effectiveness of EA on PGD.
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Affiliation(s)
- Liping Wang
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Libing Huang
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Sha Li
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Jie Yang
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Weiqian Tian
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Fangbing Ji
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Kangli Wu
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
| | - Man Zheng
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China
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Zhang M, Xu B, Li N, Zhang R, Zhang Q, Chen D, Rizvi SFA, Xu K, Shi Y, Yu B, Fang Q. OFP011 Cyclic Peptide as a Multifunctional Agonist for Opioid/Neuropeptide FF Receptors with Improved Blood-Brain Barrier Penetration. ACS Chem Neurosci 2022; 13:3078-3092. [PMID: 36262082 DOI: 10.1021/acschemneuro.2c00442] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Mounting evidence indicates that the neuropeptide FF (NPFF) system is involved in the side effects of opioid usage, including antinociceptive tolerance, hyperalgesia, abuse, constipation, and respiratory depression. Our group recently discovered that the multitarget opioid/NPFF receptor agonist DN-9 exhibits peripheral antinociceptive activity. To improve its metabolic stability, antinociceptive potency, and duration, in this study, we designed and synthesized a novel cyclic disulfide analogue of DN-9, OFP011, and examined its bioactivity through in vitro cyclic adenosine monophosphate (cAMP) functional assays and in vivo behavioral experiments. OFP011 exhibited multifunctional agonistic effects at the μ-opioid and the NPFF1 and NPFF2 receptors and partial agonistic effects at the δ- and κ-opioid in vitro, as determined via the cAMP functional assays. Pharmacokinetic and pharmacological experiments revealed improvement in its blood-brain barrier permeability after systemic administration. In addition, subcutaneous OFP011 exhibited potent and long-lasting antinociceptive activity via the central μ- and κ-opioid receptors, as observed in different physiological and pathological pain models. At the highest antinociceptive doses, subcutaneous OFP011 exhibited limited tolerance, gastrointestinal transit, motor coordination, addiction, reward, and respiration depression. Notably, OFP011 exhibited potent oral antinociceptive activities in mouse models of acute, inflammatory, and neuropathic pain. These results suggest that the multifunctional opioid/NPFF receptor agonists with improved blood-brain barrier penetration are a promising strategy for long-term treatment of moderate to severe nociceptive and pathological pain with fewer side effects.
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Affiliation(s)
- Mengna Zhang
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Biao Xu
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Ning Li
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Run Zhang
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Qinqin Zhang
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Dan Chen
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Syed Faheem Askari Rizvi
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Kangtai Xu
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Yonghang Shi
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Bowen Yu
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
| | - Quan Fang
- Key Laboratory of Preclinical Study for New Drugs of Gansu Province, and Institute of Physiology, School of Basic Medical Sciences, and State Key Laboratory of Veterinary Etiological Biology, College of Veterinary Medicine, Lanzhou University, 199 Donggang West Road, Lanzhou 730000, P. R. China
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El Iskandarani S, Deng G. Acupuncture in hematologic malignancies and hematopoietic cell transplantation. Blood Rev 2022; 56:100985. [PMID: 35725779 PMCID: PMC10359773 DOI: 10.1016/j.blre.2022.100985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/02/2022]
Abstract
Acupuncture is an integrative medicine modality that has been used historically and studied recently for managing various symptoms and diseases. Patients with hematological malignancies often experience a high symptom burden including pain, fatigue, nausea, vomiting, and insomnia. Pharmacological interventions are the mainstay of managing these symptoms, although they may not provide adequate control or are not well tolerated due to side effects. There have been many randomized controlled trials of acupuncture on reduction of these symptoms. In this review, we will summarize the current evidence on the effect of acupuncture on the management of common symptoms experienced by patients with hematological malignancies and the current understanding of acupuncture's mechanism of action. The evidence is the strongest for reducing pain and nausea vomiting, less strong for symptoms such as peripheral neuropathy, fatigue, constipation, insomnia, night sweat, and pruritus.
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Affiliation(s)
- Sarah El Iskandarani
- Memorial Sloan Kettering Cancer Center, Integrative Medicine Service, New York, NY, USA
| | - Gary Deng
- Memorial Sloan Kettering Cancer Center, Integrative Medicine Service, New York, NY, USA.
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34
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Heitmann PT, Keightley L, Wiklendt L, Wattchow DA, Brookes SSJ, Spencer NJ, Costa M, Dinning PG. The effects of loperamide on excitatory and inhibitory neuromuscular function in the human colon. Neurogastroenterol Motil 2022; 34:e14442. [PMID: 36054796 DOI: 10.1111/nmo.14442] [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: 07/25/2021] [Revised: 06/15/2022] [Accepted: 07/21/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND In most animal species, opioids alter colonic motility via the inhibition of excitatory enteric motor neurons. The mechanisms by which opioids alter human colonic motility are unclear. The aim of this study was to describe the effects of loperamide on neuromuscular function in the human colon. METHODS Tissue specimens of human colon from 10 patients undergoing an anterior resection were divided into three inter-taenial circular muscle strips. Separate organ baths were used to assess: (1) excitatory transmission (selective blockade of inhibitory transmission: L-NOARG/MRS2179); (2) inhibitory transmission (selective blockade of excitatory transmission: hyoscine hydrobromide); and (3) a control bath (no drug additions). Neuromuscular function was assessed using force transducer recordings and electrical field stimulation (EFS; 20 V, 10 Hz, 0.5 ms, 10 s) prior to and following loperamide and naloxone. KEY RESULTS In human preparations with L-NOARG/MRS2179, loperamide had no significant effects on isometric contractions. In preparations with hyoscine hydrobromide, loperamide reduced isometric relaxation during EFS (median difference + 0.60 g post-loperamide, Z = -2.35, p = 0.019). CONCLUSIONS AND INFERENCES Loperamide had no effect on excitatory neuromuscular function in human colonic circular muscle. These findings suggest that loperamide alters colonic function by acting primarily on inhibitory motor neurons, premotor enteric neurons, or via alternative non-opioid receptor pathways.
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Affiliation(s)
- Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Lauren Keightley
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Lukasz Wiklendt
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Simon S J Brookes
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Nicholas J Spencer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Marcello Costa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
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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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Hayes CJ, Koonce RM, Gressler LE, Hu B, Williams JS, Martin BC. Association between opioid therapy trajectories and potential opioid-related adverse health events. Pharmacoepidemiol Drug Saf 2022; 31:1075-1090. [PMID: 35695189 PMCID: PMC10052807 DOI: 10.1002/pds.5495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/10/2022] [Accepted: 05/18/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE We identified associations between membership in seven group-based trajectories based on supply of filled opioid prescriptions and potential opioid-related adverse health events over a 720-day window. METHODS We identified two veteran cohorts with chronic non-cancer pain who initiated treatment with long-term opioid therapy between 2008 and 2015, excluding those with prior substance use disorder (n = 373 941) or non-SUD, opioid-related adverse outcome (n = 405 631) diagnoses. Outcomes of interest included opioid use disorder, non-opioid drug use disorder, and alcohol use disorder for the first cohort; or accidents resulting in wounds or injuries, self-inflicted injuries, opioid-related accidents and overdoses, alcohol and non-opioid drug-related accidents and overdoses, and violence-related injuries for the second cohort. Using a cross-sectional design, Veterans were followed until the specific outcome of interest was diagnosed, they died, the study ended, or they were lost to follow up. Accelerated failure time models were estimated for each outcome. RESULTS Membership in persistent moderate days covered and persistent modest days covered trajectories was associated with decreased risk of opioid use disorder (Moderate: θ = 0.59, 95%CI:0.54, 0.64; Modest: θ = 0.54, 95%CI:0.50, 0.59) and opioid overdose (Moderate: θ = 0.67,95%CI: 0.57, 0.79; Modest: θ = 0.72, 95%CI:0.61, 0.85) versus higher-utilizing persistent users. Rapid discontinuation was associated with decreased risk of opioid use disorder (θ = 0.86, 95% CI:0.77, 0.95) and opioid overdose (θ = 0.54, 95%CI:0.41, 0.71), but increased risk of alcohol use disorder (θ = 1.07, 95%CI:1.00, 1.15) and other substance use disorders. Delayed discontinuation or delayed reduction was associated with increased risk for most opioid related adverse health events. CONCLUSION Persistent use trajectories with low levels of opioid utilization were associated with lower risks of potential opioid-related adverse health events.
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Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Ruston M Koonce
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Laura Elisabeth Gressler
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bo Hu
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - James Silas Williams
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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37
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Webster LR, Brenner D, Israel RJ, Stambler N, Slatkin NE. Reductions in All-Cause Mortality Associated with the Use of Methylnaltrexone for Opioid-Induced Bowel Disorders: A Pooled Analysis. PAIN MEDICINE 2022; 24:341-350. [PMID: 36102822 PMCID: PMC9977130 DOI: 10.1093/pm/pnac136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Preclinical and clinical studies suggest that activation of the µ-opioid receptor may reduce overall survival and increase the risk for all-cause mortality in patients with cancer and noncancer pain. Methylnaltrexone, a selective, peripherally acting µ-opioid receptor antagonist, has demonstrated efficacy for the treatment of opioid-induced constipation. This retrospective analysis of 12 randomized, double-blind, placebo-controlled studies of methylnaltrexone evaluated the treatment of opioid-induced bowel disorders in patients with advanced illness or noncancer pain. METHODS The risk of all-cause mortality within 30 days after the last dose of study medication during the double-blind phase was compared between methylnaltrexone and placebo groups. The data were further stratified by cancer vs noncancer, age, gender, and acute vs chronic diagnoses. RESULTS Pooled data included 2,526 methylnaltrexone-treated patients of which 33 died, and 1,192 placebo-treated patients of which 35 died. The mortality rate was 17.8 deaths/100 person-years of exposure in the methylnaltrexone group and 49.5 deaths/100 person-years of exposure for the placebo group. The all-cause mortality risk was significantly lower among patients receiving methylnaltrexone compared with placebo (hazard ratio: 0.399, 95% confidence interval: 0.25, 0.64; P = .0002), corresponding to a 60% risk reduction. Significant risk reductions were observed for those receiving methylnaltrexone who had cancer or chronic diagnoses. Methylnaltrexone-treated patients had a significantly reduced mortality risk compared with placebo regardless of age or gender. CONCLUSIONS Methylnaltrexone reduced all-cause mortality vs placebo treatment across multiple trials, suggesting methylnaltrexone may confer survival benefits in patients with opioid-induced bowel disorders taking opioids for cancer-related or chronic noncancer pain.
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Affiliation(s)
- Lynn R Webster
- Correspondence to: Lynn R. Webster, MD, PRA Health Sciences, 1255 East 3900 South, Salt Lake City, UT 84124, USA. Tel: 801-892-5140; E-mail:
| | - Darren Brenner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Nancy Stambler
- Progenics Pharmaceuticals, Inc., a subsidiary of Lantheus Holdings Inc., North Billerica, Massachusetts, USA
| | - Neal E Slatkin
- University of California Riverside, School of Medicine, Riverside, California, USA,Salix Pharmaceuticals, a Division of Bausch Health US, LLC, Bridgewater, New Jersey, USA
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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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Schultz MJ, Licciardone JC. The effect of long-term opioid use on back-specific disability and health-related quality of life in patients with chronic low back pain. J Osteopath Med 2022; 122:469-479. [PMID: 35950241 DOI: 10.1515/jom-2021-0172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 04/18/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Opioids are commonly utilized for the treatment of chronic pain. However, research regarding the long-term (≥12 months) outcomes of opioid therapy remains sparse. OBJECTIVES This study aims to evaluate the effects of long-term opioid therapy on measures of back-specific disability and health-related quality of life in patients with chronic low back pain. METHODS In this retrospective cohort study, patients with chronic low back pain who reported consistent opioid use or abstinence for at least 12 months while enrolled in the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation Pain Research Registry were classified as long-term opioid users or nonusers, respectively. For comparison, intermediate-term and short-term opioid users and nonusers were also identified. Multiple linear regression analysis was performed to compare back-specific disability (Roland-Morris Disability Questionnaire [RMDQ]) and health-related quality of life (29-item Patient-Reported Outcomes Measurement Information System [PROMIS]) between opioid users and nonusers while controlling for pain intensity, depression, age, body mass index (BMI), and eight common comorbid conditions (herniated disc, sciatica, osteoporosis, osteoarthritis, heart disease, hypertension, diabetes, and asthma). Statistically significant findings were assessed for clinical relevance. RESULTS There were 96 long-term opioid users and 204 long-term opioid nonusers. After controlling for potential confounders, long-term opioid use was a predictor of worse back-specific disability (adjusted mean difference=2.85, p<0.001), physical function (adjusted mean difference=-2.90, p=0.001), fatigue (adjusted mean difference=4.32, p=0.001), participation in social roles (adjusted mean difference=-4.10, p<0.001), and pain interference (adjusted mean difference=3.88, p<0.001) outcomes. Intermediate-term opioid use was a predictor of worse back-specific disability (adjusted mean difference=2.41, p<0.001), physical function (adjusted mean difference=-2.26, p=0.003), fatigue (adjusted mean difference=3.70, p=0.002), and sleep disturbance outcomes (adjusted mean difference=3.03, p=0.004), whereas short-term opioid use was a predictor of worse back-specific disability (adjusted mean difference=2.42, p<0.001) and physical function outcomes (adjusted mean difference=-1.90, p<0.001). CONCLUSIONS The findings of this study are largely consistent with existing literature regarding the outcomes of long-term opioid therapy. Taken in conjunction with the well-established risks of opioid medications, these findings draw into question the utility of long-term opioid therapy for chronic low back pain.
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Affiliation(s)
- Matthew J Schultz
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - John C Licciardone
- Department of Family Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA
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Swiggett SJ, Ciminero ML, Weisberg MD, Vakharia RM, Sadeghpour R, Choueka J. Implant-related complications in patients with opioid use disorder undergoing primary shoulder arthroplasties: a matched-controlled analysis. Shoulder Elbow 2022; 14:395-401. [PMID: 35846397 PMCID: PMC9284306 DOI: 10.1177/1758573221994790] [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: 10/20/2020] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether patients undergoing primary shoulder arthroplasty with opioid use disorder have higher rates of (1) implant-related complications; (2) in-hospital lengths of stay; (3) readmission rates; and (4) costs of care. METHODS Opioid use disorder patients undergoing primary shoulder arthroplasty were queried and matched in a 1:5 ratio to controls by age, sex, and medical comorbidities within the Medicare database. The query yielded 25,489 patients with (n = 4253) and without (n = 21,236) opioid use disorder. Primary outcomes analyzed included: 2-year implant related complications, in-hospital lengths of stay, 90-day readmission rates, and 90-day costs of care. A p value less than 0.01 was considered statistically significant. RESULTS Opioid use disorder patients had significantly longer in-hospital lengths of stay (3 days vs. 2 days; p < 0.0001) compared to matched controls. Opioid use disorder patients were also found to have higher incidence and odds (OR) of readmission rates (12.84 vs. 7.45%; OR: 1.16, p < 0.0001) and implant-related complications (20.03 vs. 7.95%; OR: 1.82, p < 0.0001). Study group patients also incurred significantly higher 90-day costs of care ($16,918.85 vs. $15,195.37, p < 0.0001). DISCUSSION This study can be used to help further augment efforts to reduce opioid prescriptions from healthcare providers in shoulder arthroplasty settings.
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Affiliation(s)
| | | | | | - Rushabh M Vakharia
- Rushabh M Vakharia, Maimonides Medical Center, 4802
10th Avenue, Brooklyn, NY 11219, USA.
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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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Imai H, Fujita Y, Hiruta E, Masuno T, Yamazaki S, Tanaka H, Kamiya T, Sandoh M, Takei S, Arai K, Nishiba H, Mogi J, Kaira K, Minato K. A retrospective study of the efficacy and safety of naldemedine for opioid-induced constipation in thoracic cancer patients. Thorac Cancer 2022; 13:2301-2308. [PMID: 35790500 PMCID: PMC9376157 DOI: 10.1111/1759-7714.14557] [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: 04/25/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 12/01/2022] Open
Abstract
Background We conducted a multicenter, retrospective study on the efficacy and safety of naldemedine in thoracic cancer patients using opioids in clinical practice. Methods We retrospectively evaluated thoracic cancer patients treated with naldemedine at 10 institutions in Japan. Clinical data of patients administered naldemedine between June 2017 and August 2019 were extracted from electronic medical records. Inclusion criteria were as follows: (i) patients hospitalized for at least seven days before and after naldemedine administration, and (ii) those whose frequency of defecation was entered in the medical records. Results Forty patients were analyzed, and defecation frequency was observed for at least seven days before and after naldemedine administration. The response rate was 65.0% (95% CI: 50.2%–79.7%). The number of defecations increased significantly after naldemedine administration in the overall population, as well as among only those who defecated <3 times/week before naldemedine administration, and those that were administered ≥30 mg/day of morphine equivalent. Diarrhea was the most common adverse event in all grades, occurring in 11 patients (27.5%), of which 9 (81.8%) were grade 1 or 2. None of the patients experienced grade 4 or higher adverse events. Conclusion The efficacy and safety of naldemedine for thoracic cancer patients in clinical practice were comparable with those of prospective studies, which suggest that naldemedine may be effective and feasible for most thoracic cancer patients.
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Affiliation(s)
- Hisao Imai
- Division of Respiratory Medicine, Gunma Prefectural Cancer Center, Ota, Japan.,Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Yukiyoshi Fujita
- Division of Pharmacy, Gunma Prefectural Cancer Center, Ota, Japan
| | - Eriko Hiruta
- Division of Pharmacy, Gunma Prefectural Cancer Center, Ota, Japan
| | - Takashi Masuno
- Division of Pharmacy, Fujioka General Hospital, Fujioka, Japan
| | - Shigeki Yamazaki
- Division of Pharmacy, Kiryu Kosei General Hospital, Kiryu, Japan
| | - Hajime Tanaka
- Division of Pharmacy, Haramachi Red Cross Hospital, Higashiagatsuma-machi, Agatsuma-gun, Japan
| | - Teruhiko Kamiya
- Department of Pharmacy, Tatebayashi Kosei General Hospital, Tatebayashi, Japan
| | | | - Satoshi Takei
- Division of Pharmacy, Tone Central Hospital, Numata, Japan
| | - Kazuya Arai
- Division of Pharmacy, Gunma Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Hiromi Nishiba
- Division of Pharmacy, Japan Community Health Care Organization (JCHO) Gunma Chuo Hospital, Maebashi, Japan.,Graduate School of Pharmaceutical Sciences, Takasaki University of Health and Welfare, Takasaki, Japan
| | | | - Kyoichi Kaira
- Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Koichi Minato
- Division of Respiratory Medicine, Gunma Prefectural Cancer Center, Ota, Japan
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Simpson S, Mclellan R, Wellmeyer E, Matalon F, George O. Drugs and Bugs: The Gut-Brain Axis and Substance Use Disorders. J Neuroimmune Pharmacol 2022; 17:33-61. [PMID: 34694571 PMCID: PMC9074906 DOI: 10.1007/s11481-021-10022-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/06/2021] [Indexed: 02/07/2023]
Abstract
Substance use disorders (SUDs) represent a significant public health crisis. Worldwide, 5.4% of the global disease burden is attributed to SUDs and alcohol use, and many more use psychoactive substances recreationally. Often associated with comorbidities, SUDs result in changes to both brain function and physiological responses. Mounting evidence calls for a precision approach for the treatment and diagnosis of SUDs, and the gut microbiome is emerging as a contributor to such disorders. Over the last few centuries, modern lifestyles, diets, and medical care have altered the health of the microbes that live in and on our bodies; as we develop, our diets and lifestyle dictate which microbes flourish and which microbes vanish. An increase in antibiotic treatments, with many antibiotic interventions occurring early in life during the microbiome's normal development, transforms developing microbial communities. Links have been made between the microbiome and SUDs, and the microbiome and conditions that are often comorbid with SUDs such as anxiety, depression, pain, and stress. A better understanding of the mechanisms influencing behavioral changes and drug use is critical in developing novel treatments for SUDSs. Targeting the microbiome as a therapeutic and diagnostic tool is a promising avenue of exploration. This review will provide an overview of the role of the gut-brain axis in a wide range of SUDs, discuss host and microbe pathways that mediate changes in the brain's response to drugs, and the microbes and related metabolites that impact behavior and health within the gut-brain axis.
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Affiliation(s)
- Sierra Simpson
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US.
| | - Rio Mclellan
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
| | - Emma Wellmeyer
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
| | - Frederic Matalon
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
| | - Olivier George
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
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Wang W, Wang X, Liu Y, Sun Y, Liu X, Yan Y, Liu Z. Effects of Electroacupuncture on Opioid-Induced Constipation in Patients With Cancer: Study Protocol for a Multicenter Randomized Controlled Trial. Front Med (Lausanne) 2022; 9:818258. [PMID: 35492306 PMCID: PMC9043766 DOI: 10.3389/fmed.2022.818258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/10/2022] [Indexed: 01/30/2023] Open
Abstract
Background Opioid-induced constipation (OIC) is one of the most prevalent adverse events associated with cancer patients who receive opioid analgesics for moderate to severe pain. Acupuncture may be an effective treatment for OIC. We designed this trial to assess the efficacy and safety of electroacupuncture for OIC in cancer patients. Methods This is a multicenter, sham-controlled, parallel-group, subject- and assessor-blinded randomized trial. A total of 100 cancer patients with OIC will be randomly assigned to either the electroacupuncture group or the sham electroacupuncture group at a ratio of 1:1. Patients in each group will receive a total of 24-session treatment over 8 weeks, three sessions a week and 30 min each session. Thereafter, patients will be followed up for another 8 weeks. The primary outcome will be the proportion of responders, defined as a patient who has ≥3 spontaneous bowel movements (SBMs)/wk and ≥ increase of 1 SBM from baseline simultaneously for at least 6 out of 8 weeks of the treatment period. The secondary outcomes will include the mean weekly SBMs and complete spontaneous bowel movements, the mean Bristol Stool Form Scale score for stool consistency, the mean score for straining of SBM, the total and subscale scores of Patient Assessment of Constipation-Symptom questionnaires, and the total and subscale scores of Patient Assessment of Constipation-Quality of Life questionnaire. Patients' global assessment of treatment effectiveness, patients' expectation toward the effectiveness of acupuncture and safety of acupuncture will also be assessed. All efficacy analyses will be performed in the intention-to-treat population. Discussion To improve the adherence to intervention protocols, the majority of the participants will be recruited from an inpatient setting. The results will help to determine the clinical effects and safety of electroacupuncture for the treatment of OIC among patients with cancer. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT03797586, registered on 4 January 2019, https://clinicaltrials.gov/ct2/show/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
| | - Xinlu 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 Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuanjie Sun
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaoxu Liu
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Yan
- 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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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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Peacock WF, Slatkin N, Gagnon-Sanschagrin P, Maitland J, Guérin A, Joseph G. Opioid-Induced Constipation: Cost Impact of Approved Medications in the Emergency Department. Adv Ther 2022; 39:2178-2191. [PMID: 35298784 PMCID: PMC9056463 DOI: 10.1007/s12325-022-02090-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/14/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Opioid-induced constipation (OIC) prescription medications (OIC-Rx) like methylnaltrexone subcutaneous (SC) have shown efficacy in treating OIC in the emergency department (ED). This study aimed to describe and compare healthcare resource utilization (HRU) and healthcare costs in ED patients with OIC receiving OIC-Rx versus those not receiving OIC-Rx. METHODS Adult patients with OIC during an ED encounter were identified from a hospital-based ED encounters database (2016-2019) and classified on the basis of receipt of OIC-Rx (OIC-Rx versus No OIC-Rx cohorts). Entropy balancing was used to reweight characteristics of the two cohorts. HRU and healthcare costs were measured and compared during the ED encounter and 30-day post-discharge period. RESULTS Among 11,135 patients in the OIC-Rx cohort (21,474 in the No OIC-Rx cohort), 93% received methylnaltrexone SC. Patients in the OIC-Rx cohort had 0.7 fewer inpatient days per OIC ED encounter and 64% decreased odds of being hospitalized versus the No OIC-Rx cohort (both p < 0.001). During the post-discharge period, the OIC-Rx cohort had 35% decreased odds of any re-encounter (p < 0.001). The OIC-Rx cohort had a $732 reduction in costs per OIC ED encounter versus the No OIC-Rx cohort (p < 0.001), driven by larger hospitals and patients with Medicare or Commercial insurance. During the post-discharge period, the OIC-Rx cohort had a $421 reduction in costs associated with any re-encounter versus the No OIC-Rx cohort (p = 0.004). CONCLUSION Patients receiving OIC-Rx in the ED had decreased odds of being hospitalized and fewer re-encounters in the 30-day post-discharge period versus patients who did not receive OIC-Rx, resulting in cost savings for insurance agencies and healthcare providers.
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Affiliation(s)
- W. Frank Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030 USA
| | - Neal Slatkin
- Bausch Health US, LLC, 400 Somerset Corporate Blvd., Bridgewater, NJ 08807 USA
| | - Patrick Gagnon-Sanschagrin
- Analysis Group, Inc, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montréal, QC H3B 0G7 Canada
| | - Jessica Maitland
- Analysis Group, Inc, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montréal, QC H3B 0G7 Canada
| | - Annie Guérin
- Analysis Group, Inc, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montréal, QC H3B 0G7 Canada
| | - George Joseph
- Bausch Health US, LLC, 400 Somerset Corporate Blvd., Bridgewater, NJ 08807 USA
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Cash BD. Incidence, pathophysiology, and implications of opioid-induced constipation and suggestions for patient-provider interactions. Aliment Pharmacol Ther 2022; 55 Suppl 2:S1-S7. [PMID: 35544278 DOI: 10.1111/apt.16702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/04/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Brooks D Cash
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas, Health Science Center at Houston, Houston, TX, USA
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BouSaba J, Sannaa W, Camilleri M. Update on the role of naldemedine in opioid-induced constipation in patients with chronic noncancer pain. Therap Adv Gastroenterol 2022; 15:17562848221078638. [PMID: 35509419 PMCID: PMC9058332 DOI: 10.1177/17562848221078638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Chronic noncancer pain (CNCP) affects up to 20% of adults and can interfere with activities of daily living. Up to 4% of adults in the United States receive chronic opioid therapy and up to 57% of patients on long-term opioids for CNCP report opioid-induced constipation (OIC). OIC is essentially constipation occurring after starting opioid treatment. While laxatives are traditionally the first-line therapy for OIC, 81% of patients taking daily laxatives and opioids still reported OIC and considered that it negatively affected their quality of life. Naldemedine is a peripherally acting µ-opioid receptor antagonists (PAMORA) approved for the treatment of OIC in patients with CNCP. This article reviews the mechanism of action, efficacy, and safety of naldemedine in CNCP patients. Naldemedine improves OIC in patients with CNCP by acting as an opioid receptor antagonist in the gastrointestinal tract. It does not interfere with the analgesic properties of opioids or cause withdrawal symptoms since these effects are centrally mediated, and naldemedine does not cross the blood brain barrier. Naldemedine showed significant and sustained improvement in frequency of bowel movements, quality of life, and constipation-related symptoms. It is generally well tolerated with a higher incidence of gastrointestinal adverse events of mild or moderate severity such as diarrhea, abdominal pain, or vomiting compared to placebo. While there are no randomized, controlled trials that compare head-to-head pharmacological therapies used for treatment of OIC, network meta-analysis shows that naldemedine has an overall good benefit-risk profile compared to the other approved medications.
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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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Tack J, Camilleri M, Hale M, Morlion B, Nalamachu S, Webster L, Wild J. Establishing Minimal Clinically Important Differences in Quality of Life Measures in Opioid-Induced Constipation. Clin Gastroenterol Hepatol 2022; 20:855-863. [PMID: 33965574 DOI: 10.1016/j.cgh.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Opioids have a role in chronic pain management. However, opioid-induced constipation may cause patients to skip or reduce opioid doses, leading to inadequate pain relief and negatively impacting quality of life. We sought to establish a minimal clinically important difference to understand whether changes in quality of life scores are of value to patients. METHODS Integrated data from the double-blind, controlled, phase 3 COMPOSE-1 and COMPOSE-2 trials of naldemedine in chronic noncancer pain and opioid-induced constipation were used to determine minimal clinically important differences using Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. Patients completed the questionnaires (5-point Likert scale; predose, Weeks 2, 4, and 12), kept a daily log of Bowel Movement and Constipation Assessment, and rated satisfaction at end of study. Minimal clinically important differences were computed using an anchor-based method with 6 anchors: 5 from the Bowel Movement and Constipation Assessment and 1 from patient satisfaction. Threshold values for each anchor were set to define responders versus nonresponders based on score definitions. Clinically meaningful cutoff values for changes in PAC-SYM and PAC-QOL scores were determined using receiver operating characteristic curves. RESULTS Data from 1095 patients (549, naldemedine; 546, placebo) were analyzed. The area under the curve for the receiver operating characteristic curves (ranges, 0.719 to 0.798 for PAC-SYM and 0.734 to 0.833 for PAC-QOL) indicated that both instruments can discriminate responders and nonresponders for each anchor. PAC-SYM cutoff values ranged from -1.04 to -0.83; PAC-QOL cutoff values ranged from -0.93 to -0.82. CONCLUSIONS Based on data derived from the anchor method, reductions in PAC-SYM and PAC-QOL scores of >1.0 in patients with chronic noncancer pain and opioid-induced constipation are clinically meaningful. CLINICALTRIALS gov Registration: NCT01965158; NCT01993940.
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Affiliation(s)
- Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium.
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Martin Hale
- Gold Coast Research, LLC, Plantation, Florida
| | - Bart Morlion
- Leuven Center for Algology and Pain Management, University Hospital Leuven, University of Leuven, Leuven, Belgium
| | | | | | - James Wild
- Upstate Clinical Research Associates, Williamsville, New York
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