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Whorwell P, Lange R, Scarpignato C. Review article: do stimulant laxatives damage the gut? A critical analysis of current knowledge. Therap Adv Gastroenterol 2024; 17:17562848241249664. [PMID: 38887508 PMCID: PMC11181897 DOI: 10.1177/17562848241249664] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/08/2024] [Indexed: 06/20/2024] Open
Abstract
Stimulant laxatives are well established as first- or second-line treatments for constipation and although they have a reliable therapeutic effect, alleged safety concerns still exist, particularly with long-term use. The potential harmful effects on the gastrointestinal system (including carcinogenicity) of the long-term use of diphenylmethane [bisacodyl, sodium picosulfate (SPS)] and senna stimulant laxatives were assessed in a comprehensive review of the publications identified in literature searches performed in PubMed and Embase up to and including June 2023. We identified and reviewed 43 publications of interest. While stimulant laxatives at supratherapeutic doses have been shown to cause structural alterations to surface absorptive cells in animals and humans, these effects are reversible and not considered clinically relevant. No formal long-term studies have demonstrated morphological changes in enteric neural elements or intestinal smooth muscle with bisacodyl or SPS in humans. Furthermore, there is no convincing evidence that stimulant laxatives are associated with the development of colon cancer, and in fact, chronic constipation itself has been reported to potentially increase the risk of colon cancer, therefore, the use of stimulant laxatives might reduce this risk. Many studies suggesting a possible harmful effect from laxatives were limited by their failure to consider confounding factors such as concomitant neurological disease, metabolic disorders, and age. These findings highlight the lack of evidence for the harmful effects of laxatives on the colon, and thus, the benefits of treatment with stimulant laxatives, even in the long-term, should be reconsidered for the management of patients with constipation.
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Affiliation(s)
- Peter Whorwell
- Neurogastroenterology Unit, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | | | - Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta
- Faculty of Medicine, Chinese University of Hong Kong, Sha Tin, Hong Kong
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Lacy BE, Delfini R, Fladung B, Lange R. Prevalence and patterns of laxative use in subjects with self-reported constipation: results from a multinational digestive health survey. Therap Adv Gastroenterol 2024; 17:17562848241232605. [PMID: 38445248 PMCID: PMC10913501 DOI: 10.1177/17562848241232605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/17/2024] [Indexed: 03/07/2024] Open
Abstract
Background Constipation is characterized by symptoms of straining, hard stool, difficult evacuation, and infrequent bowel movements. Online surveys provide valuable information about patients' perspectives, symptoms, management, treatment satisfaction, and risk factors. Methods This survey explored subject experiences involving 20 gastrointestinal (GI) conditions. In total, 20,099 respondents in seven countries with varied cultural and socioeconomic backgrounds participated. Post hoc analysis of 'self-reported constipation' and related symptoms experienced within the past 6 months and the last episode of constipation provided data on prevalence, demographics, frequency and duration of episodes and related symptoms, impact on quality of life (QoL), management with or without laxatives, and resulting treatment satisfaction. Results In total, 10,425 subjects reported constipation within 6 months and 2637 at the last episode. Prevalence was highest in females and younger adults. Most subjects reported various coexisting GI symptoms. Almost 80% of 6865 episodes reported by 5337 subjects occurred every 2-3 months to every 2-3 weeks. A higher frequency of constipation correlated with a greater impact on QoL. On a 10-point scale, the mean impact was 6.4. More than 90% of respondents had episodes ranging from 1 day to 1 week. More than 90% took action; 16% used laxatives, of whom 80.3% were satisfied. Conclusion Constipation, a highly prevalent disorder, spans cultures and socioeconomic classes. Its chronic recurrence has a significant impact on QoL, resulting in symptom self-management in >90% of subjects. Significantly higher satisfaction rates in subjects treated with than without laxatives reflect subjects' reports that self-reported constipation can be treated effectively with laxatives.
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Affiliation(s)
- Brian E. Lacy
- Division of Gastroenterology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Bernward Fladung
- Freelance Medical Advisor, Linnich, Germany
- Régis Delfini is currently affiliated to Boehringer Ingelheim, Ingelheim, Germany
| | - Robert Lange
- Industriepark Hoechst, Building K 607, 65929 Frankfurt am Main, Germany
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Song HJ, Kim JE, Jin YJ, Roh YJ, Seol A, Kim TR, Park KH, Park ES, An BS, Yang SY, Seo S, Jo SM, Jung YS, Hwang DY. Complement C3-Deficiency-Induced Constipation in FVB/N-C3 em1Hlee/Korl Knockout Mice Was Significantly Relieved by Uridine and Liriope platyphylla L. Extracts. Int J Mol Sci 2023; 24:15757. [PMID: 37958740 PMCID: PMC10649790 DOI: 10.3390/ijms242115757] [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: 08/21/2023] [Revised: 10/22/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Complement component 3 (C3) deficiency has recently been known as a cause of constipation, without studies on the therapeutic efficacy. To evaluate the therapeutic agents against C3-deficiency-induced constipation, improvements in the constipation-related parameters and the associated molecular mechanisms were examined in FVB/N-C3em1Hlee/Korl knockout (C3 KO) mice treated with uridine (Urd) and the aqueous extract of Liriope platyphylla L. (AEtLP) with laxative activity. The stool parameters and gastrointestinal (GI) transit were increased in Urd- and AEtLP-treated C3 KO mice compared with the vehicle (Veh)-treated C3 KO mice. Urd and AEtLP treatment improved the histological structure, junctional complexes of the intestinal epithelial barrier (IEB), mucin secretion ability, and water retention capacity. Also, an improvement in the composition of neuronal cells, the regulation of excitatory function mediated via the 5-hydroxytryptamine (5-HT) receptors and muscarinic acetylcholine receptors (mAChRs), and the regulation of the inhibitory function mediated via the neuronal nitric oxide synthase (nNOS) and inducible NOS (iNOS) were detected in the enteric nervous system (ENS) of Urd- and AEtLP-treated C3 KO mice. Therefore, the results of the present study suggest that C3-deficiency-induced constipation can improve with treatment with Urd and AEtLP via the regulation of the mucin secretion ability, water retention capacity, and ENS function.
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Affiliation(s)
- Hee-Jin Song
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Ji-Eun Kim
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - You-Jeong Jin
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Yu-Jeong Roh
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Ayun Seol
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Tae-Ryeol Kim
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Ki-Ho Park
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Eun-Seo Park
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Beum-Soo An
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Seung-Yun Yang
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Sungbaek Seo
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Seong-Min Jo
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
| | - Young-Suk Jung
- College of Pharmacy, Pusan National University, Busan 46241, Republic of Korea;
| | - Dae-Youn Hwang
- Department of Biomaterials Science (BK21 FOUR Program)/Life and Industry Convergence Research Institute/Laboratory Animals Resources Center, College of Natural Resources and Life Science, Pusan National University, Miryang 50463, Republic of Korea; (H.-J.S.); (J.-E.K.); (Y.-J.J.); (Y.-J.R.); (A.S.); (T.-R.K.); (K.-H.P.); (E.-S.P.); (B.-S.A.); (S.-Y.Y.); (S.S.); (S.-M.J.)
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Diverting Loop Ileostomy in the Management of Medically Refractory Constipation Cases Not Falling Into Classical Categories. Dis Colon Rectum 2022; 65:909-916. [PMID: 34907987 DOI: 10.1097/dcr.0000000000002373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The approach to constipation refractory to medical management does not necessarily follow classical teaching and is challenging. Although the role of surgery is unclear, diverting loop ileostomy may be offered to gauge symptom response followed by colectomy for appropriate patients. OBJECTIVE Our goal was to examine outcomes in patients with constipation not falling into classical subtypes who underwent diverting loop ileostomy creation as the initial surgical intervention. Our secondary aim was to offer patients colectomy and anastomosis and examine their outcome if they improved after ileostomy. DESIGN The study design was a retrospective review. SETTINGS This study was conducted in the pelvic floor center of our colorectal surgery department from January 2006 to December 2018. PATIENTS Patients with medically refractory constipation referred for surgical consideration and not falling into classical constipation categories (slow transit, normal transit, or pelvic floor dysfunction) underwent evaluation with transit marker study, cinedefecography, and anal physiology and were offered ileostomy as initial surgical management. MAIN OUTCOME MEASURES The primary measures were symptom improvement and self-reported quality of life improvement with increased patient satisfaction. RESULTS Eighty-seven patients underwent diverting loop ileostomy as initial surgical therapy. Group 1 had 54 (62%) patients who self-reported symptom improvement, discontinued anticonstipation medication, and had ileostomy output >200 mL/day. Of these 54 patients, 25 had colectomy with anastomosis, 16 (64%) of whom had symptom improvement, stayed off bowel medication, and had >1 bowel movement daily. Group 2 had 33 patients who did not meet the above criteria after initial ileostomy. Nine patients in group 2 elected colectomy with anastomosis after intensive counseling; 6 (66%) reported the same positive results above. LIMITATIONS The study limitations included: 1) no objective outcome measures of patient's perceived symptom improvement and satisfaction and 2) retrospective review. CONCLUSION Initial creation of diverting loop ileostomy may be offered to a subset of refractory constipation patients not falling into classical categories after thorough workup. Patients who self-report symptom improvement, have ileostomy output >200 mL/day, and do not require bowel medication may have acceptable results with subsequent colectomy and ileorectal anastomosis. See Video Abstract at http://links.lww.com/DCR/B854. ILEOSTOMA EN ASA DERIVATIVA EN CASOS DE ESTREIMIENTO REFRACTARIOS AL TRATAMIENTO MDICO, QUE NO PERTENECEN A LAS CATEGORAS CLSICAS ANTECEDENTES:El enfoque del estreñimiento refractario al tratamiento médico, que no siempre se presenta como las formas descritas clasicamente, es un desafío. Si bien el papel de la cirugía no está claro, se puede ofrecer una ileostomía en asa para medir la respuesta de los síntomas, seguida de colectomía en pacientes seleccionados.OBJETIVO:Evaluar los resultados de pacientes con estreñimiento, que no pertenecen a las formas clásicas de presentación, que se les realizó una ileostomía en asa de derivación, como intervención quirúrgica inicial. El objetivo secundario fue ofrecer a los pacientes una colectomía con anastomosis primaria y evaluar si mejoraban sus resultados después de la ileostomía.DISEÑO:El diseño del estudio fue una revisión retrospectiva.MARCO:Este estudio se realizó en el centro del piso pélvico de nuestro departamento de cirugía colorrectal, e incluyo los pacientes atendidos entre enero de 2006 y diciembre de 2018.PACIENTES:Se incluyeron los pacientes con estreñimiento refractario al tratamiento médico, derivados para evaluación quirúrgica, que no presentaban las formas clásicas de presentación (tránsito lento, tránsito normal, disfunción del suelo pélvico). Estos se sometieron a evaluación con estudio de tránsito colónico, cinedefecografía y fisiología anal, y se les ofreció una ileostomía en asa como tratamiento quirúrgico inicial.PRINCIPALES MEDIDAS DE RESULTADO:Las primeras medidas fueron la mejora de los síntomas y la calidad de vida informado por el paciente.RESULTADOS:Ochenta y siete pacientes fueron sometidos a ileostomía en asa como tratamiento quirúrgico inicial. El grupo 1 tenía 54 (62%) pacientes que informaron mejoría de los síntomas, interrumpieron la medicación proquinética y tuvieron un débito por la ileostomía >200 cc/día. De estos 54 pacientes, 25 se sometieron a colectomía más anastomosis primaria y 16 (64%) tuvieron una mejoría de los síntomas, dejaron de tomar medicamentos proquinéticos y tuvieron más de una evacuación al día. El grupo 2 tenía 33 pacientes que no cumplían con los criterios de mejoría de los síntomas después de la ileostomía inicial. Nueve pacientes del grupo 2 eligieron colectomía con anastomosis después de un asesoramiento intensivo, 6 (66%) informaron resultados positivos de mejoría de los síntomas.LIMITACIONES:Las limitaciones del estudio incluyeron 1) ninguna medida de resultado objetiva de la mejora y satisfacción de los síntomas percibidos por el paciente 2) revisión retrospectiva.CONCLUSIÓNES:La creación inicial de una ileostomía en asa de derivación se puede ofrecer a un subgrupo de pacientes con estreñimiento refractario que no entran en las categorías clásicas después de un estudio exhaustivo. La mejoría de los síntomas, informado por los pacientes, producción de ileostomía >200 cc/día y que no requieren medicación proquinética, pueden tener resultados aceptables con colectomía y anastomosis ileorrectal. Consulte Video Resumen en http://links.lww.com/DCR/Bxxx. (Traducción-Dr. Rodrigo Azolas).
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Liu SH, Zhang YH, Niu HT, Tian DX, Qin F, Jiao W. Vaginal enterocele after cystectomy: A case report. World J Clin Cases 2022; 10:2045-2052. [PMID: 35317139 PMCID: PMC8891769 DOI: 10.12998/wjcc.v10.i6.2045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/09/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND After undergoing radical cystectomy combined with hysterectomy, female patients may suffer from pelvic organ prolapse due to the destruction of pelvic structures, which mainly manifests as the prolapse of tissues of the vulva to varying degrees and can be accompanied by symptoms, such as bleeding and inflammation. Once this complication is present, surgical intervention is needed to resolve it. Therefore, preventing and managing this complication is especially important.
CASE SUMMARY The postoperative occurrence of acute enterocele is rare, and a case of acute small bowel vaginosis 2 mo after radical cystectomy with hysterectomy is reported. When the patient was admitted, physical examination revealed that the small bowel was displaced approximately 20 cm because of vaginocele. A team of gynecological, general surgery, and urological surgeons was employed to return the small bowel and repair the lacerated vaginal wall during the emergency operation. Eventually, the patient recovered, and no recurrence was seen in the half year of follow-up.
CONCLUSION We review the surgical approach for such patients, analyze high-risk factors for the disease and suggest corresponding preventive measures.
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Affiliation(s)
- Shuai-Hong Liu
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
- Department of Clinical Medicine, Qingdao University, Qingdao 266000, Shandong Province, China
| | - Yu-Hao Zhang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
- Department of Clinical Medicine, Qingdao University, Qingdao 266000, Shandong Province, China
| | - Hai-Tao Niu
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Dong-Xu Tian
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
- Department of Clinical Medicine, Qingdao University, Qingdao 266000, Shandong Province, China
| | - Fei Qin
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
- Department of Clinical Medicine, Qingdao University, Qingdao 266000, Shandong Province, China
| | - Wei Jiao
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
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Safety and Efficacy of Intermittent Colonic Exoperistalsis Device to Treat Chronic Constipation: A Prospective Multicentric Clinical Trial. Clin Transl Gastroenterol 2021; 11:e00267. [PMID: 33512794 PMCID: PMC7671882 DOI: 10.14309/ctg.0000000000000267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic constipation is associated with various comorbidities and reduced quality of life. Current solutions, either pharmacological or invasive, show limited efficacy. Manual colon-specific massage is a well-established intervention to treat chronic constipation, but it should be applied daily. MOWOOT automatically provides intermittent colonic exo-peristalsis (ICE) treatment like that in manual massage.
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Milosavljevic T, Popovic DD, Mijac DD, Milovanovic T, Krstic S, Krstic MN. Chronic Constipation: Gastroenterohepatologist's Approach. Dig Dis 2021; 40:175-180. [PMID: 33946065 DOI: 10.1159/000516976] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Constipation is a common problem in gastroenterological practice. The prevalence of constipation is about 16%. Constipation can be primary or secondary. SUMMARY The diagnostic and therapeutic approach to patients with constipation begins with a detailed history and physical examination. In selected cases, the use of additional diagnostic procedures is very important. This includes the use of laboratory, endoscopic, and radiological examinations, as well as advanced physiological testing (anorectal manometry, balloon expulsion test, colonic transit studies, and defecography). Constipation therapy can be both nonoperative and operative. Nonoperative therapy includes the application of a lifestyle measures, pharmacotherapy and biofeedback therapy. Key Messages: Two key things when taking a medical history and physical examination are to rule out the existence of alarm symptoms/signs and to rule out secondary constipation (primarily drug-induced). Therapy begins with lifestyle modification, and in case of failure, bulk or osmotic laxatives are used. In case of failure, the use of lubiprostone is indicated, as well as linaclotide. Surgical treatment of constipation is reserved for cases of refractory constipation, with delayed intestinal transit.
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Affiliation(s)
| | - Dusan D Popovic
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Danilo Mijac
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tamara Milovanovic
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Krstic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Emergency Centre, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Miodrag N Krstic
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
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Pelechas E, Voulgari PV, Drosos AA. Recent advances in the opioid mu receptor based pharmacotherapy for rheumatoid arthritis. Expert Opin Pharmacother 2020; 21:2153-2160. [PMID: 33135514 DOI: 10.1080/14656566.2020.1796969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Opioids are used for severe forms of acute and cancer pain. Over the last years, their potential use in patients with noncancer pain such as those with rheumatoid arthritis (RA) has been postulated. A recent population-based comparative study showed that chronic opioid use was 12% vs. 4% among RA and non-RA patients, respectively. Another study showed an increase from 7.4% to 16.9% (2002 to 2015). In general, there has been an increasing tendency to use opioids in recent years. AREAS COVERED The authors have performed an extensive literature search using PubMed for articles including noncancer pain and the use of the mu opioid receptor (MOR) agonists in patients with RA. EXPERT OPINION Data is not sufficient to support opioid use for the treatment of chronic pain in patients with RA. Data is scarce and inconclusive. Rheumatologists should think and ponder the question: Why is this patient in pain? Differential diagnosis should include a disease flare, degenerative changes of the musculoskeletal system, and fibromyalgia. And while there are new strategies for opioid administration currently being researched, unfortunately, they are far from being applied to human subjects in the everyday clinical setting, and are still being evaluated at an experimental level. CNS: Central nervous system; DORs: delta opioid receptor agonists; GI: Gastrointestinal; GPCRs: G protein-coupled receptors; IL: Interleukin; JAK: Janus kinase; KORs: kappa opioid receptor agonists; MCPs: Metacarpophalangeal joints; MORs: Mu opioid receptor agonists; MTPs: Metatarsophalangeal joints; NSAIDs: Non-steroidal anti-inflammatory drugsOA: Osteoarthritis; ORs: Opioid receptors; PD: Pharmacodynamic; PIPs: Proximal interphalangeal joints; PK: Pharmacokinetic; PNS: Peripheral nervous system; RA: Rheumatoid arthritis; RGS: Regulator of G protein signaling; SSRIs: Selective serotonin reuptake inhibitors; TNF: Tumor necrosis factor.
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Affiliation(s)
- Eleftherios Pelechas
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina , Ioannina, Greece
| | - Paraskevi V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina , Ioannina, Greece
| | - Alexandros A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina , Ioannina, Greece
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Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative use in patients with advanced chronic kidney disease transitioning to dialysis. Nephrol Dial Transplant 2020; 36:2018-2026. [PMID: 33035325 DOI: 10.1093/ndt/gfaa205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Constipation is highly prevalent in patients with chronic kidney disease (CKD), particularly among those with end-stage renal disease (ESRD), partly due to their dietary restrictions, comorbidities and medications. Laxatives are typically used for constipation management; however, little is known about laxative use and its associated factors in patients with advanced CKD transitioning to ESRD. METHODS In a retrospective cohort of 102 477 US veterans transitioning to dialysis between October 2007 and March 2015, we examined the proportion of patients who filled a prescription for any type of laxative within each 6-month period over 36 months pre- and post-transition to ESRD. Factors associated with laxative use during the last 1-year pre-ESRD period were identified by multivariable logistic regression. RESULTS The proportion of patients prescribed laxatives increased as patients progressed to ESRD, peaking at 37.1% in the 6 months immediately following ESRD transition, then remaining fairly stable throughout the post-ESRD transition period. Among laxative users, stool softeners were the most commonly prescribed (∼30%), followed by hyperosmotics (∼20%), stimulants (∼10%), bulk formers (∼3%), chloride channel activator (<1%) and several combinations of these. The use of anticoagulants, oral iron supplements, non-opioid analgesics, antihistamines and opioid analgesics were among the factors independently associated with pre-ESRD laxative use. CONCLUSION The use of laxatives increased considerably as patients neared transition to ESRD, likely mirroring the increasing burden of drug-induced constipation during the ESRD transition period. Findings may provide novel insight into better management strategies to alleviate constipation symptoms and reduce medication requirements in patients with advanced CKD.
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Affiliation(s)
- Keiichi Sumida
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ankur A Dashputre
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,College of Graduate Health Sciences, Institute for Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Praveen K Potukuchi
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,College of Graduate Health Sciences, Institute for Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, Division of Biostatistics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, Division of Transplant, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Justin D Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, TN, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative Use and Change in Estimated Glomerular Filtration Rate in Patients With Advanced Chronic Kidney Disease. J Ren Nutr 2020; 31:361-369. [PMID: 32952006 DOI: 10.1053/j.jrn.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/30/2020] [Accepted: 08/09/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Constipation is highly prevalent in advanced chronic kidney disease (CKD), due in part to dietary (e.g., fiber) restrictions, and is often managed by laxatives; however, the effect of laxative use on kidney function in advanced CKD remains unclear. We aimed to examine the association of laxative use with longitudinal change in estimated glomerular filtration rate (eGFR) in patients with advanced CKD. DESIGN AND METHODS In a retrospective cohort of 43,622 US veterans transitioning to end-stage renal disease (ESRD) from 2007 to 2015, we estimated changes in eGFR (slope) by linear mixed-effects models using ≥2 available outpatient eGFR measurements during the 2-year period before transition to ESRD. The association of laxative use with change in eGFR was examined by testing the interaction of time-varying laxative use with time for eGFR slope in the mixed-effects models with adjustment for fixed and time-varying confounders. RESULTS Laxatives were prescribed in 49.8% of patients during the last 2-year pre-ESRD period. In the crude model, time-varying laxative use was modestly associated with more progressive eGFR decline compared with non-use of laxatives (median [interquartile interval] -7.1 [-11.9, -4.3] vs. -6.8 [-11.6, -4.0] mL/min/1.73 m2/year, P < .001). After multivariable adjustment, a faster eGFR decline associated with laxative use (vs. non-use of laxatives) remained statistically significant, although the between-group difference in eGFR slope was minimal (median [interquartile interval] -8.8 [-12.9, -5.9] vs. -8.6 [-12.6, -5.6] mL/min/1.73 m2/year, P < .001). The significant association was no longer evident across different types of laxatives (i.e., stool softeners, stimulants, or hyperosmotics). CONCLUSIONS There was a clinically negligible association of laxative use with change in eGFR during the last 2-year pre-ESRD period, suggesting the renal safety profile of laxatives in advanced CKD patients.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankur A Dashputre
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee; Division of Transplant, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Justin D Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee.
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11
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Sumida K, Yamagata K, Kovesdy CP. Constipation in CKD. Kidney Int Rep 2020; 5:121-134. [PMID: 32043026 PMCID: PMC7000799 DOI: 10.1016/j.ekir.2019.11.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/15/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022] Open
Abstract
Constipation is one of the most common gastrointestinal disorders among patients with chronic kidney disease (CKD) partly because of their sedentary lifestyle, low fiber and fluid intake, concomitant medications (e.g., phosphate binders), and multiple comorbidities (e.g., diabetes). Although constipation is usually perceived as a benign, often self-limited condition, recent evidence has challenged this most common perception of constipation. The chronic symptoms of constipation negatively affect patients' quality of life and impose a considerable social and economic burden. Furthermore, recent epidemiological studies have revealed that constipation is independently associated with adverse clinical outcomes, such as end-stage renal disease (ESRD), cardiovascular (CV) disease, and mortality, potentially mediated by the alteration of gut microbiota and the increased production of fecal metabolites. Given the importance of the gut in the disposal of uremic toxins and in acid-base and mineral homeostasis with declining kidney function, the presence of constipation in CKD may limit or even preclude these ancillary gastrointestinal roles, potentially contributing to excess morbidity and mortality. With the advent of new drug classes for constipation, some of which showing unique renoprotective properties, the adequate management of constipation in CKD may provide additional therapeutic benefits beyond its conventional defecation control. Nevertheless, the problem of constipation in CKD has long been underrecognized and its management strategies have scarcely been documented. This review outlines the current understanding of the diagnosis, prevalence, etiology, outcome, and treatment of constipation in CKD, and aims to discuss its novel clinical and therapeutic implications.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
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Mesía R, Virizuela Echaburu JA, Gómez J, Sauri T, Serrano G, Pujol E. Opioid-Induced Constipation in Oncological Patients: New Strategies of Management. Curr Treat Options Oncol 2019; 20:91. [PMID: 31853656 PMCID: PMC6920224 DOI: 10.1007/s11864-019-0686-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Cancer-associated pain has traditionally been treated with opioid analgesics, often in escalating doses. Opioid-induced constipation (OIC) is a common problem associated with chronic use of opioid analgesics. Typical treatment strategies to alleviate constipation are based on dietary changes, exercise, and laxatives. However, laxatives have a nonspecific action and do not target underlying mechanisms of OIC. This article will review prevalent, clinical presentation and recommendations for the treatment of OIC. An independent literature search was carried out by the authors. We reviewed the literature for randomized controlled trials that studied the efficacy of laxatives, naloxone, and naloxegol in treating OIC. Newer strategies addressing the causal pathophysiology of OIC are needed for a more effective assessment and management of OIC. Finally, traditional recommended therapies are appraised and compared with the latest pharmacological developments. Future research should address whether naloxegol is more efficacious by its comparison directly with first-line treatments, including laxatives.
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Affiliation(s)
- Ricard Mesía
- Servicio de Oncología Médica, Instituto Catalán de Oncología, Badalona, Spain
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Abstract
Naldemedine [Symproic® (Japan; USA); Rizmoic® (EU)], an orally available peripherally acting μ-opioid receptor antagonist (PAMORA), is approved in several countries for the treatment of opioid-induced constipation. In phase III trials, naldemedine was more effective than placebo at increasing the frequency of bowel movements in patients with constipation induced by opioid treatment for cancer pain or chronic non-cancer pain. Naldemedine was also associated with improvements in patient-rated constipation-related symptoms and quality of life. Naldemedine was generally well tolerated, including over the longer term. Because naldemedine specifically targets opioid receptors in the gastrointestinal (GI) tract and does not cross the blood-brain barrier, it does not cause opioid withdrawal symptoms or interfere with centrally mediated opioid analgesia. Consistent with its mechanism of action, the most commonly reported adverse events were GI in nature. In conclusion, current data indicate that naldemedine is an effective and generally well-tolerated treatment option for opioid-induced constipation in patients with cancer pain or chronic non-cancer pain, with the convenience of once-daily oral dosing.
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Affiliation(s)
- Hannah A Blair
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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Müller-Schilling M, Gockel I. Functional Diagnosis in Upper and Lower Gastrointestinal Diseases: Relevance for Conservative, Interdisciplinary and Surgical Therapies. Visc Med 2018; 34:90-91. [PMID: 29888235 PMCID: PMC5981664 DOI: 10.1159/000489028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
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