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Akhgarandouz S, Moshiri M, Etemad L, Dadpour B, Khadem-Rezaiyan M, Vahdati-Mashhadian N. Effect of oral naloxone on opioid-induced constipation in methadone maintenance treatment patients, a double-blind, placebo-control, clinical trial. Ir J Med Sci 2024; 193:1807-1815. [PMID: 38502432 DOI: 10.1007/s11845-024-03652-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Opioid-induced constipation (OIC) is the most prevalent side effect of methadone maintenance therapy (MMT). Naloxone could reduce the OIC. METHOD Fifty-six MMT cases (< 75 mg/day methadone, > 3 months) were entered randomly into four groups of a trial. They received placebo or naloxone tablets (0.5, 2, or 4 mg/day) once a day for 2 weeks. They continued their conventional laxative. Their constipation and opiate withdrawal (OWS) were evaluated by the Bristol Stool Form Scale (stool consistency and frequency), Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire, Constipation Scoring System (CSS), and the Subjective Opiate Withdrawal Scale (SOWS) before starting treatment and at the end of the first and second weeks. RESULTS The dose of 4 mg/day naloxone was excluded from the study due to severe OWS. The precipitants of groups had similar ages, methadone dose and duration, laxative use, and constipation scores at the start of the trial. However, 2 mg of naloxone could change the stool consistency (PV = 0.0052) and frequency (P = 0.0133), 0.5 mg/day dose only improved the stool consistency (P = 0.0016). The patients' CSS and PAC-SYM scores were reduced by naloxone after the 1st week of treatment. However, there was no significant difference in the mean score of SOWS at different assessment times and groups. Also, 3 and 4 cases of 0.5 and 2 mg/day groups, respectively, withdrew from the study due to OWS. CONCLUSION Oral naloxone at doses of 0.5 and 2 mg/day was significantly more effective than placebo on OIC in MMT. However, the dose of 4 mg induced intolerable OWS.
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Affiliation(s)
| | - Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Etemad
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Dadpour
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Majid Khadem-Rezaiyan
- Community medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasser Vahdati-Mashhadian
- Department of Pharmacodynamics and Toxicology, Mashhad University of Medical Sciences, Mashhad, Iran.
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Abdel Shaheed C, Hayes C, Maher CG, Ballantyne JC, Underwood M, McLachlan AJ, Martin JH, Narayan SW, Sidhom MA. Opioid analgesics for nociceptive cancer pain: A comprehensive review. CA Cancer J Clin 2024; 74:286-313. [PMID: 38108561 DOI: 10.3322/caac.21823] [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: 07/23/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 12/19/2023] Open
Abstract
Pain is one of the most burdensome symptoms in people with cancer, and opioid analgesics are considered the mainstay of cancer pain management. For this review, the authors evaluated the efficacy and toxicities of opioid analgesics compared with placebo, other opioids, nonopioid analgesics, and nonpharmacologic treatments for background cancer pain (continuous and relatively constant pain present at rest), and breakthrough cancer pain (transient exacerbation of pain despite stable and adequately controlled background pain). They found a paucity of placebo-controlled trials for background cancer pain, although tapentadol or codeine may be more efficacious than placebo (moderate-certainty to low-certainty evidence). Nonsteroidal anti-inflammatory drugs including aspirin, piroxicam, diclofenac, ketorolac, and the antidepressant medicine imipramine, may be at least as efficacious as opioids for moderate-to-severe background cancer pain. For breakthrough cancer pain, oral transmucosal, buccal, sublingual, or intranasal fentanyl preparations were identified as more efficacious than placebo but were more commonly associated with toxicities, including constipation and nausea. Despite being recommended worldwide for the treatment of cancer pain, morphine was generally not superior to other opioids, nor did it have a more favorable toxicity profile. The interpretation of study results, however, was complicated by the heterogeneity in the study populations evaluated. Given the limited quality and quantity of research, there is a need to reappraise the clinical utility of opioids in people with cancer pain, particularly those who are not at the end of life, and to further explore the effects of opioids on immune system function and quality of life in these individuals.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher Hayes
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher G Maher
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Jane C Ballantyne
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer H Martin
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sujita W Narayan
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark A Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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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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4
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Kistemaker KRJ, Sijani F, Brinkman DJ, de Graeff A, Burchell GL, Steegers MAH, van Zuylen L. Pharmacological prevention and treatment of opioid-induced constipation in cancer patients: A systematic review and meta-analysis. Cancer Treat Rev 2024; 125:102704. [PMID: 38452708 DOI: 10.1016/j.ctrv.2024.102704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Cancer-related pain often requires opioid treatment with opioid-induced constipation (OIC) as its most frequent gastrointestinal side-effect. Both for prevention and treatment of OIC osmotic (e.g. polyethylene glycol) and stimulant (e.g. bisacodyl) laxatives are widely used. Newer drugs such as the peripherally acting µ-opioid receptor antagonists (PAMORAs) and naloxone in a fixed combination with oxycodone have become available for the management of OIC. This systematic review and meta-analysis aims to give an overview of the scientific evidence on pharmacological strategies for the prevention and treatment of OIC in cancer patients. METHODS A systematic search in PubMed, Embase, Web of Science and the Cochrane Library was completed from inception up to 22 October 2022. Randomized and non-randomized studies were systematically selected. Bowel function and adverse drug events were assessed. RESULTS Twenty trials (prevention: five RCTs and three cohort studies; treatment: ten RCTs and two comparative cohort studies) were included in the review. Regarding the prevention of OIC, three RCTs compared laxatives with other laxatives, finding no clear differences in effectivity of the laxatives used. One cohort study showed a significant benefit of magnesium oxide compared with no laxative. One RCT found a significant benefit for the PAMORA naldemedine compared with magnesium oxide. Preventive use of oxycodone/naloxone did not show a significant difference in two out of three other studies compared to oxycodone or fentanyl. A meta-analysis was not possible. Regarding the treatment of OIC, two RCTs compared laxatives, of which one RCT found that polyethylene glycol was significantly more effective than sennosides. Seven studies compared an opioid antagonist (naloxone, methylnaltrexone or naldemedine) with placebo and three studies compared different dosages of opioid antagonists. These studies with opioid antagonists were used for the meta-analysis. Oxycodone/naloxone showed a significant improvement in Bowel Function Index compared to oxycodone with laxatives (MD -13.68; 95 % CI -18.38 to -8.98; I2 = 58 %). Adverse drug event rates were similar amongst both groups, except for nausea in favour of oxycodone/naloxone (RR 0.51; 95 % CI 0.31-0.83; I2 = 0 %). Naldemedine (NAL) and methylnaltrexone (MNTX) demonstrated significantly higher response rates compared to placebo (NAL: RR 2.07, 95 % CI 1.64-2.61, I2 = 0 %; MNTX: RR 3.83, 95 % CI 2.81-5.22, I2 = 0 %). With regard to adverse events, abdominal pain was more present in treatment with methylnaltrexone and diarrhea was significantly more present in treatment with naldemedine. Different dosages of methylnaltrexone were not significantly different with regard to both efficacy and adverse drug event rates. CONCLUSIONS Magnesium oxide and naldemedine are most likely effective for prevention of OIC in cancer patients. Naloxone in a fixed combination with oxycodone, naldemedine and methylnaltrexone effectively treat OIC in cancer patients with acceptable adverse events. However, their effect has not been compared to standard (osmotic and stimulant) laxatives. More studies comparing standard laxatives with each other and with opioid antagonists are necessary before recommendations for clinical practice can be made.
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Affiliation(s)
- K R J Kistemaker
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands.
| | - F Sijani
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - D J Brinkman
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC location Vrije Universiteit Amsterdam, Internal Medicine, Section Pharmacotherapy, De Boelelaan 1117, Amsterdam, the Netherlands
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, de Bilt, the Netherlands
| | - G L Burchell
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M A H Steegers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
| | - L van Zuylen
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
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5
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Wong AK, Vogrin S, Le B, Klepstad P, Rubio JP, Somogyi AA, Philip J. Background and Breakthrough Opioid Choice May Determine Different Pain Outcomes. J Pain Symptom Manage 2024; 67:e259-e261. [PMID: 38101491 DOI: 10.1016/j.jpainsymman.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 11/26/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Aaron K Wong
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia.
| | - Sara Vogrin
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia
| | - Brian Le
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia
| | - Pal Klepstad
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia
| | - Justin P Rubio
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia
| | - Andrew A Somogyi
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia
| | - Jennifer Philip
- Peter MacCallum Cancer Centre (A.K.W., B.L., J.P.), Melbourne, Victoria, Australia; The Royal Melbourne Hospital (A.K.W., B.L., J.P.), Parkville, Victoria, Australia; Department of Medicine (A.K.W., B.L., J.P.), University of Melbourne Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia; Department of Medicine (S.V.), St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia; Department Intensive Care Medicine (P.K.), St. Olavs University Hospital, Trondheim, Norway; Florey Institute of Neuroscience & Mental Health (J.P.R.), Victoria, Australia; Clinical and Experimental Pharmacology (A.A.S.), Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; St Vincent's Hospital, Palliative Care Service (J.P.), Victoria Parade, Fitzroy, Victoria, Australia
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Kistemaker KRJ, de Graeff A, Crul M, de Klerk G, van de Ven PM, van der Meulen MP, van Zuylen L, Steegers MAH. Magnesium hydroxide versus macrogol/electrolytes in the prevention of opioid-induced constipation in incurable cancer patients: study protocol for an open-label, randomized controlled trial (the OMAMA study). BMC Palliat Care 2023; 22:22. [PMID: 36915062 PMCID: PMC10012532 DOI: 10.1186/s12904-023-01143-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a common symptom in cancer patients treated with opioids with a prevalence of up to 59%. International guidelines recommend standard laxatives such as macrogol/electrolytes and magnesium hydroxide to prevent OIC, although evidence from randomized controlled trials is largely lacking. The aim of our study is to compare magnesium hydroxide with macrogol /electrolytes in the prevention of OIC in patients with incurable cancer and to compare side-effects, tolerability and cost-effectiveness. METHODS Our study is an open-label, randomized, multicenter study to examine if magnesium hydroxide is non-inferior to macrogol/electrolytes in the prevention of OIC. In total, 330 patients with incurable cancer, starting with opioids for pain management, will be randomized to treatment with either macrogol/electrolytes or magnesium hydroxide. The primary outcome measure is the proportion of patients with a score of < 30 on the Bowel Function Index (BFI), measured on day 14. The Rome IV criteria for constipation, side effects of and satisfaction with laxatives, pain scores, quality of life (using the EQ-5D-5L), daily use of laxatives and escape medication, and cost-effectiveness will also be assessed. DISCUSSION In this study we aim to examine if magnesium hydroxide is non-inferior to macrogol/electrolytes in the prevention of OIC. The outcome of our study will contribute to prevention of OIC and scientific evidence of guidelines on (opioid-induced) constipation. TRIAL REGISTRATION This trial is registered at clinicaltrials.gov: NCT05216328 and in the Dutch trial register: NTR80508. EudraCT number 2022-000408-36.
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Affiliation(s)
- K R J Kistemaker
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands. .,Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands. .,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, De Bilt, The Netherlands
| | - M Crul
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Clinical Pharmacology and Pharmacy, De Boelelaan 1117, Amsterdam, The Netherlands
| | - G de Klerk
- Spaarne Gasthuis Location Hoofddorp, Medical Oncology, Spaarnepoort 1, Hoofddorp, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M P van der Meulen
- Department of Epidemiology and Health Economics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L van Zuylen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - M A H Steegers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
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7
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Go SI, Kim JH, Kang JH. Treatment of Opioid Withdrawal Syndrome Triggered by Oxycodone/Naloxone with Dexmedetomidine. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2023; 26:18-21. [PMID: 37753319 PMCID: PMC10519718 DOI: 10.14475/jhpc.2023.26.1.18] [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: 01/01/2023] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 09/28/2023]
Abstract
The combination of oxycodone and naloxone is useful for cancer pain management. Naloxone, as a pure opioid antagonist, cannot be used simultaneously with opioids. However, owing to its low bioavailability, it can be used in an oral composite formulation. We present the case of a 55-year-old man with gastric cancer who experienced severe opioid withdrawal syndrome (OWS) triggered by oxycodone/naloxone that was successfully managed with dexmedetomidine. He had been in a stable condition on intravenous morphine to alleviate cancer pain. Intravenous morphine was switched to oral oxycodone/naloxone for discharge from the hospital. The patient suddenly developed restlessness, heartburn, and violent behavior 30 minutes after taking oxycodone/naloxone. We attempted sedation with midazolam and propofol, but paradoxical agitation and desaturation occurred. Next, we tried dexmedetomidine and the patient showed a decreased heart rate and reduced agitation. The patient was eventually stabilized by increasing the dose of dexmedetomidine. This report informs clinicians of the possibility of OWS when switching from opioids to oxycodone/naloxone, which can be overcome with the appropriate use of sedatives and dexmedetomidine depending on the patient's condition.
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Affiliation(s)
- Se-Il Go
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Jung Hoon Kim
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
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8
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Wong AK, Grobler A, Le B. ENhANCE trial protocol: A multi-centre, randomised, phase IV trial comparing the efficacy of oxycodone/naloxone prolonged release (OXN PR) versus oxycodone prolonged release (Oxy PR) tablets in patients with advanced cancer. Contemp Clin Trials Commun 2022; 30:101036. [PMID: 36407843 PMCID: PMC9672918 DOI: 10.1016/j.conctc.2022.101036] [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: 03/21/2022] [Revised: 09/01/2022] [Accepted: 11/07/2022] [Indexed: 11/14/2022] Open
Abstract
Background Oxycodone is a frequently used opioid in cancer. Opioid-induced constipation (OIC) is common. Oxycodone/Naloxone Prolonged Release (OXN PR) contains naloxone, which mitigates OIC. Trials have either focused on non-cancer pain, or conducted before significant experience of using OXN PR. This trial aims to: demonstrate (1) analgesic equivalence between OXN PR and Oxycodone Prolonged Release (Oxy PR), and (2) superiority of constipation outcomes in OXN PR compared to Oxy PR in cancer pain. Unlike other trials, it will only include patients with at least moderate pain scores (≥4/10), allow usual laxatives, and exclude potential liver dysfunction. Methods This is a multi-centre, open-label, randomised, phase IV study of OXN PR vs Oxy PR in patients with cancer-related pain. The primary outcome is pain difference on Brief Pain Inventory-Short Form (BPI-SF) at 5 weeks. Secondary outcomes are comparison of other pain outcomes (BPI-SF) and neuropathic pain measures (Leeds Assessment of Neuropathic Symptoms & Signs (S-LANNS)), constipation (Bowel Function Index (BFI)), quality of life (EORTC-QLQ-C30), rescue analgesia use, total opioid dose, and total laxative dose over 5 weeks. Conclusion The comparison of analgesic efficacy between both arms, and superiority of constipation in the OXN PR arm will add new knowledge on the comparisons of both agents, and oxycodone independently. This trial will extend knowledge of the effectiveness, safety, and adverse effect profiles of both drugs in terms of pain, constipation, quality of life outcomes for patients with cancer pain, and provide clinicians with high quality data to guide decision making. Trial registration Name of the registry: ANZCTR Trial registration number ACTRN12619001282178 Date of registration 17/09/2019 URL of trial registry record https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377673&isReview=true Protocol version 2.1_28 August 2020 Opioid-induced constipation is the commonest side effect in cancer pain management. Oxycodone/naloxone prolonged release aims to reduce opioid-induced constipation. Trials have little focus on cancer pain, concurrent liver impairment, and laxatives. This trial evaluates these key problems practically to guide decision making.
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Andresen V, Becker G, Frieling T, Goebel-Stengel M, Gundling F, Herold A, Karaus M, Keller J, Kim M, Klose P, Krammer H, Kreis ME, Kuhlbusch-Zicklam R, Langhorst J, Layer P, Lenzen-Großimlinghaus R, Madisch A, Mönnikes H, Müller-Lissner S, Rubin D, Schemann M, Schwille-Kiuntke J, Stengel A, Storr M, van der Voort I, Voderholzer W, Wedel T, Wirz S, Witzigmann H, Pehl C. Aktualisierte S2k-Leitlinie chronische Obstipation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie & Motilität (DGNM) – April 2022 – AWMF-Registriernummer: 021–019. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1528-1572. [PMID: 36223785 DOI: 10.1055/a-1880-1928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- V Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - G Becker
- Klinik für Palliativmedizin, Freiburg, Deutschland
| | - T Frieling
- Medizinische Klinik II, Helios-Klinikum Krefeld, Krefeld, Deutschland
| | | | - F Gundling
- Medizinische Klinik II (Gastroenterologie, Gastroenterologische Onkologie, Hepatologie, Diabetologie, Stoffwechsel, Infektiologie), Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Herold
- Sozialstiftung Bamberg, End- und Dickdarm-Zentrum Mannheim, Mannheim, Deutschland
| | - M Karaus
- Abt. Innere Medizin, Evang. Krankenhaus Göttingen-Weende, Göttingen, Deutschland
| | - J Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - M Kim
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie (Chirurgische Klinik I) des Universitätsklinikums, Zentrum Operative Medizin (ZOM), Würzburg, Deutschland
| | - P Klose
- Universität Duisburg-Essen, Medizinische Fakultät, Essen, Deutschland
| | - H Krammer
- Sozialstiftung Bamberg, End- und Dickdarm-Zentrum Mannheim, Mannheim, Deutschland
| | - M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | | - J Langhorst
- Knappschafts-Krankenhaus, Essen, Deutschland
| | - P Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | | | - A Madisch
- Klinik für Gastroenterologie, interventionelle Endoskopie und Diabetologie, Klinikum Siloah-Oststadt-Heidehaus, Hannover, Deutschland
| | - H Mönnikes
- Klinik für Innere Medizin, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | | | - D Rubin
- Klinik für Innere Medizin Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Mitte, Berlin, Deutschland.,Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, Vivantes Klinikum Spandau, Spandau, Deutschland
| | - M Schemann
- Lehrstuhl für Humanbiologie, TU München, Freising, Deutschland
| | - J Schwille-Kiuntke
- Innere Medizin VI Psychosomat. Medizin u. Psychotherapie, Universitätsklinikum Tübingen, Tübingen, Deutschland.,Institut für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - A Stengel
- Medizinische Klinik mit Schwerpunkt Psychosomatik, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - M Storr
- Zentrum für Endoskopie, Starnberg, Deutschland
| | - I van der Voort
- Klinik für Innere Medizin Gastroenterologie und Diabetologie, Jüdisches Krankenhaus Berlin, Berlin, Deutschland
| | | | - T Wedel
- Anatomisches Institut, Universität Kiel, Kiel, Deutschland
| | - S Wirz
- Cura Krankenhaus Bad Honnef, Bad Honnef, Deutschland
| | - H Witzigmann
- Klinik für Allgemein- und Viszeralchirurgie, Krankenhaus Dresden-Friedrichstadt, Dresden, Deutschland
| | - C Pehl
- Medizinische Klinik, Krankenhaus Vilsbiburg, Vilsbiburg, Deutschland
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Candy B, Jones L, Vickerstaff V, Larkin PJ, Stone P. Mu-opioid antagonists for opioid-induced bowel dysfunction in people with cancer and people receiving palliative care. Cochrane Database Syst Rev 2022; 9:CD006332. [PMID: 36106667 PMCID: PMC9476137 DOI: 10.1002/14651858.cd006332.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Opioid-induced bowel dysfunction (OIBD) is characterised by constipation, incomplete evacuation, bloating, and gastric reflux. It is one of the major adverse events (AEs) of treatment for pain in cancer and palliative care, resulting in increased morbidity and reduced quality of life. This review is a partial update of a 2008 review, and critiques as previous update (2018) trials only for people with cancer and people receiving palliative care. OBJECTIVES To assess for OIBD in people with cancer and people receiving palliative care the effectiveness and safety of mu-opioid antagonists (MOAs) versus different doses of MOAs, alternative pharmacological/non-pharmacological interventions, placebo, or no treatment. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science (December 2021), clinical trial registries and regulatory websites. We sought contact with MOA manufacturers for further data. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the effectiveness and safety of MOAs for OIBD in people with cancer and people at a palliative stage irrespective of the type of terminal disease. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias and extracted data. The appropriateness of combining data from the trials depended upon sufficient homogeneity across trials. Our primary outcomes were laxation response, effect on analgesia, and AEs. We assessed the certainty of evidence using GRADE and created summary of findings tables. MAIN RESULTS We included 10 studies (two new trials) randomising in-total 1343 adults with cancer irrespective of stage, or at palliative care stage of any disease. The MOAs were oral naldemedine and naloxone (alone or in combination with oxycodone), and subcutaneous methylnaltrexone. The trials compared MOAs with placebo, MOAs at different doses, or in combination with other drugs. Two trials of naldemedine and three of naloxone with oxycodone were in people with cancer irrespective of disease stage. The trial on naloxone alone was in people with advanced cancer. Four trials on methylnaltrexone were in palliative care where most participants had advanced cancer. All trials were vulnerable to biases; most commonly, blinding of the outcome assessor was not reported. Oral naldemedine versus placebo Risk (i.e. chance) of spontaneous laxations in the medium term (over two weeks) for naldemedine was over threefold greater risk ratio (RR) 2.00, 95% confidence interval (CI) 1.59 to 2.52, 2 trials, 418 participants, I² = 0%. Number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 3 to 4; moderate-certainty evidence). Earlier risk of spontaneous laxations and patient assessment of bowel change was not reported. Very low-certainty evidence showed naldemedine had little to no effect on opioid withdrawal symptoms. There was little to no difference in the risk of serious (non-fatal) AEs (RR 3.34, 95% CI 0.85 to 13.15: low-certainty evidence). Over double the risk of AEs (non-serious) reported with naldemedine (moderate-certainty evidence). Low-dose oral naldemedine versus higher dose Risk of spontaneous laxations was lower for the lower dose (medium term, 0.1 mg versus 0.4 mg: RR 0.69, 95% CI 0.53 to 0.89, 1 trial, 111 participants (low-certainty evidence)). Earlier risk of spontaneous laxations and patient assessment of bowel change not reported. Low-certainty evidence showed little to no difference on opioid withdrawal symptoms (0.1 mg versus 0.4 mg mean difference (MD) -0.30, 95% CI -0.85 to 0.25), and occurrences of serious AEs (0.1 mg versus 0.4 mg RR 0.25, 95% CI 0.03 to 2.17). Low-certainty evidence showed little to no difference on non-serious AEs. Oral naloxone versus placebo Risk of spontaneous laxations and AEs not reported. Little to no difference in pain intensity (very low-certainty evidence). Full data not given. The trial reported that no serious AEs occurred. Oral naloxone + oxycodone versus oxycodone Risk of spontaneous laxations within 24 hours and in the medium term not reported. Low-certainty evidence showed naloxone with oxycodone reduced the risk of opioid withdrawal symptoms. There was little to no difference in the risk of serious (non-fatal) AEs (RR 0.68, 95% CI 0.44 to 1.06), 3 trials, 362 participants, I² = 55%: very low-certainty evidence). There was little to no difference in risk of AEs (low-certainty evidence). Subcutaneous methylnaltrexone versus placebo Risk of spontaneous laxations within 24 hours with methylnaltrexone was fourfold greater than placebo (RR 2.97, 95% CI 2.13 to 4.13. 2 trials, 287 participants, I² = 31%. NNTB 3, 95% CI 2 to 3; low-certainty evidence). Risk of spontaneous laxations in the medium term was over tenfold greater with methylnaltrexone (RR 8.15, 95% CI 4.76 to 13.95, 2 trials, 305 participants, I² = 47%. NNTB 2, 95% CI 2 to 2; moderate-certainty evidence). Low-certainty evidence showed methylnaltrexone reduced the risk of opioid withdrawal symptoms, and did not increase risk of a serious AE (RR 0.59, 95% CI 0.38 to 0.93. I² = 0%; 2 trials, 364 participants). The risk of AEs was higher for methylnaltrexone (low-certainty evidence). Lower-dose subcutaneous methylnaltrexone versus higher dose There was little to no difference in risk of spontaneous laxations in the medium-term (1 mg versus 5 mg or greater: RR 2.91, 95% CI 0.82 to 10.39; 1 trial, 26 participants very low-certainty evidence), or in patient assessment of improvement in bowel status (RR 0.98, 95% CI 0.71 to 1.35, 1 trial, 102 participants; low-certainty evidence). Medium-term assessment of spontaneous laxations and serious AEs not reported. There was little to no difference in symptoms of opioid withdrawal (MD -0.25, 95% CI -0.84 to 0.34, 1 trial, 102 participants) or occurrence of AEs (low-certainty evidence). AUTHORS' CONCLUSIONS This update's findings for naldemedine and naloxone with oxycodone have been strengthened with two new trials, but conclusions have not changed. Moderate-certainty evidence for oral naldemedine on risk of spontaneous laxations and non-serious AEs suggests in people with cancer that naldemedine may improve bowel function over two weeks and increase the risk of AEs. There was low-certainty evidence on serious AEs. Moderate-certainty evidence for methylnaltrexone on spontaneous laxations over two weeks suggests subcutaneous methylnaltrexone may improve bowel function in people receiving palliative care, but certainty of evidence for AEs was low. More trials are needed, more evaluation of AEs, outcomes patients rate as important, and in children.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Philip J Larkin
- UCD School of Nursing, Midwifery and Health Systems and Our Lady's Hospice and Care Services, UCD College of Health Sciences, Dublin, Ireland
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Schmidt-Hansen M, Bennett MI, Arnold S, Bromham N, Hilgart JS, Page AJ, Chi Y. Oxycodone for cancer-related pain. Cochrane Database Syst Rev 2022; 6:CD003870. [PMID: 35679121 PMCID: PMC9180760 DOI: 10.1002/14651858.cd003870.pub7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many people with cancer experience moderate to severe pain that requires treatment with strong opioids, such as oxycodone and morphine. Strong opioids are, however, not effective for pain in all people, neither are they well tolerated by all people. The aim of this review was to assess whether oxycodone is associated with better pain relief and tolerability than other analgesic options for adults with cancer pain. This is an updated Cochrane review previously published in 2017. OBJECTIVES To assess the effectiveness and tolerability of oxycodone by any route of administration for pain in adults with cancer. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and MEDLINE In-Process (Ovid), Embase (Ovid), Science Citation Index, Conference Proceedings Citation Index - Science (ISI Web of Science), BIOSIS (ISI), and PsycINFO (Ovid) to November 2021. We also searched four trial registries, checked the bibliographic references of relevant studies, and contacted the authors of the included studies. We applied no language, date, or publication status restrictions. SELECTION CRITERIA We included randomised controlled trials (parallel-group or cross-over) comparing oxycodone (any formulation or route of administration) with placebo or an active drug (including oxycodone) for cancer background pain in adults by examining pain intensity/relief, adverse events, quality of life, and participant preference. DATA COLLECTION AND ANALYSIS Two review authors independently sifted the search, extracted data and assessed the included studies using standard Cochrane methodology. We meta-analysed pain intensity data using the generic inverse variance method, and pain relief and adverse events using the Mantel-Haenszel method, or summarised these data narratively along with the quality of life and participant preference data. We assessed the overall certainty of the evidence using GRADE. MAIN RESULTS For this update, we identified 19 new studies (1836 participants) for inclusion. In total, we included 42 studies which enrolled/randomised 4485 participants, with 3945 of these analysed for efficacy and 4176 for safety. The studies examined a number of different drug comparisons. Controlled-release (CR; typically taken every 12 hours) oxycodone versus immediate-release (IR; taken every 4-6 hours) oxycodone Pooled analysis of three of the four studies comparing CR oxycodone to IR oxycodone suggest that there is little to no difference between CR and IR oxycodone in pain intensity (standardised mean difference (SMD) 0.12, 95% confidence interval (CI) -0.1 to 0.34; n = 319; very low-certainty evidence). The evidence is very uncertain about the effect on adverse events, including constipation (RR 0.71, 95% CI 0.45 to 1.13), drowsiness/somnolence (RR 1.03, 95% CI 0.69 to 1.54), nausea (RR 0.85, 95% CI 0.56 to 1.28), and vomiting (RR 0.66, 95% CI 0.38 to 1.15) (very low-certainty evidence). There were no data available for quality of life or participant preference, however, three studies suggested that treatment acceptability may be similar between groups (low-certainty evidence). CR oxycodone versus CR morphine The majority of the 24 studies comparing CR oxycodone to CR morphine reported either pain intensity (continuous variable), pain relief (dichotomous variable), or both. Pooled analysis indicated that pain intensity may be lower (better) after treatment with CR morphine than CR oxycodone (SMD 0.14, 95% CI 0.01 to 0.27; n = 882 in 7 studies; low-certainty evidence). This SMD is equivalent to a difference of 0.27 points on the Brief Pain Inventory scale (0-10 numerical rating scale), which is not clinically significant. Pooled analyses also suggested that there may be little to no difference in the proportion of participants achieving complete or significant pain relief (RR 1.02, 95% CI 0.95 to 1.10; n = 1249 in 13 studies; low-certainty evidence). The RR for constipation (RR 0.75, 95% CI 0.66 to 0.86) may be lower after treatment with CR oxycodone than after CR morphine. Pooled analyses showed that, for most of the adverse events, the CIs were wide, including no effect as well as potential benefit and harm: drowsiness/somnolence (RR 0.88, 95% CI 0.74 to 1.05), nausea (RR 0.93, 95% CI 0.77 to 1.12), and vomiting (RR 0.81, 95% CI 0.63 to 1.04) (low or very low-certainty evidence). No data were available for quality of life. The evidence is very uncertain about the treatment effects on treatment acceptability and participant preference. Other comparisons The remaining studies either compared oxycodone in various formulations or compared oxycodone to different alternative opioids. None found any clear superiority or inferiority of oxycodone for cancer pain, neither as an analgesic agent nor in terms of adverse event rates and treatment acceptability. The certainty of this evidence base was limited by the high or unclear risk of bias of the studies and by imprecision due to low or very low event rates or participant numbers for many outcomes. AUTHORS' CONCLUSIONS The conclusions have not changed since the previous version of this review (in 2017). We found low-certainty evidence that there may be little to no difference in pain intensity, pain relief and adverse events between oxycodone and other strong opioids including morphine, commonly considered the gold standard strong opioid. Although we identified a benefit for pain relief in favour of CR morphine over CR oxycodone, this was not clinically significant and did not persist following sensitivity analysis and so we do not consider this important. However, we found that constipation and hallucinations occurred less often with CR oxycodone than with CR morphine; but the certainty of this evidence was either very low or the finding did not persist following sensitivity analysis, so these findings should be treated with utmost caution. Our conclusions are consistent with other reviews and suggest that, while the reliability of the evidence base is low, given the absence of important differences within this analysis, it seems unlikely that larger head-to-head studies of oxycodone versus morphine are justified, although well-designed trials comparing oxycodone to other strong analgesics may well be useful. For clinical purposes, oxycodone or morphine can be used as first-line oral opioids for relief of cancer pain in adults.
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Affiliation(s)
- Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Nathan Bromham
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jennifer S Hilgart
- Scientific Resource Center, VA Portland Research Foundation, Portland, Oregon, USA
| | - Andrew J Page
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Yuan Chi
- Yealth Network, Beijing Yealth Technology Co., Ltd, Beijing, China
- Cochrane Campbell Global Ageing Partnership, UK
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Chen HY, Wang ZN, Zhang WY, Zhu T. Advances in the clinical application of oxycodone in the perioperative period. World J Clin Cases 2022; 10:5156-5164. [PMID: 35812649 PMCID: PMC9210879 DOI: 10.12998/wjcc.v10.i16.5156] [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: 12/22/2021] [Revised: 01/29/2022] [Accepted: 04/03/2022] [Indexed: 02/06/2023] Open
Abstract
To review the research progress of pure opioid receptor agonist oxycodone. The research progress of oxycodone in terms of pharmacokinetics, pharmacodynamics, adverse reactions, clinical application, combined medication and new progress in clinical application was summarized by referring to the literature. Oxycodone is a semi-synthetic thebaine derivative of opioid alkaloids, and is a pure opioid μ and κ receptor agonist. The main action sites are the central nervous system and visceral smooth muscle. Due to its advantages of low adverse reactions, good analgesic effects, and a wide range of safe doses, the drug has been widely used in the control of acute and chronic postoperative pain, as well as malignant and non-malignant pain. Since the end of the 20th century, researchers have begun to formulate antipyretic analgesics, opioid receptor agonists, opioid receptor antagonists, dopamine receptor antagonists and other drugs with oxycodone in different proportions to enhance the analgesic effect. At the same time, it can reduce the dosage of oxycodone and reduce its adverse reactions, so as to achieve the purpose of limiting opioid abuse. With the continuous research on the efficacy and safety of oxycodone in the perioperative period at home and abroad, oxycodone has become the only dual-opioid potent analgesic that can be used in clinical work.
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Affiliation(s)
- Hong-Yang Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Ning Wang
- Department of Anesthesiology, West China School of Clinical Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei-Yi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Forget P, Vermeersch M. To what extent are we confident that tapentadol induces less constipation and other side effects than the other opioids in chronic pain patients? a confidence evaluation in network meta-analysis. Br J Pain 2021; 15:380-387. [PMID: 34840785 DOI: 10.1177/2049463720945289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background A confidence evaluation helps to make informed decisions about the results of meta-analyses. The goal of this work is to perform a confidence evaluation of results of a network meta-analysis (NMA) on the digestive side effects of tapentadol in patients with chronic pain. Methods An updated search in PubMed/Medline and Web of Science search until March 2020 was done to perform pairwise meta-analyses with NMA using random-effect models and confidence in network meta-analysis (CiNeMA) for the confidence analysis. Results Twenty-five studies were included in the final analyses. Pairwise and indirect comparisons showed a reduced risk of constipation with tapentadol compared to oxycodone. The confidence evaluation did not raise any concerns in terms of confidence for the oxycodone versus tapentadol comparisons. The oxycodone-naloxone versus tapentadol comparisons showed some concerns, particularly in terms of imprecision and incoherence. Regarding the overall risk of any side effects, the confidence evaluation showed a major concern regarding imprecision, but not for the comparison between tapentadol and oxycodone. However, this comparison showed a major heterogeneity. Discussion and conclusions A confidence evaluation in meta-analysis on the effect of tapentadol compared to other opioids in chronic pain showed possible imprecision, heterogeneity and/or incoherence. However, with a high level of confidence, tapentadol was associated with a lower incidence of constipation than oxycodone. Confidence analyses can help to get more information from meta-analyses.
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Affiliation(s)
- Patrice Forget
- Institute of Applied Health Sciences, Epidemiology group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, department of Anaesthesia, NHS Grampian, Aberdeen, UK
| | - Mathieu Vermeersch
- Anesthesiology and Perioperative Medicine, Acute and Chronic Pain Therapy, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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De Giorgio R, Zucco FM, Chiarioni G, Mercadante S, Corazziari ES, Caraceni A, Odetti P, Giusti R, Marinangeli F, Pinto C. Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel. Adv Ther 2021; 38:3589-3621. [PMID: 34086265 PMCID: PMC8279968 DOI: 10.1007/s12325-021-01766-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/28/2021] [Indexed: 12/14/2022]
Abstract
The prescribing and use of opioid analgesics is increasing in Italy owing to a profusion in the number and types of opioid analgesic products available, and the increasing prevalence of conditions associated with severe pain, the latter being related to population aging. Herein we provide the expert opinion of an Italian multidisciplinary panel on the management of opioid-induced constipation (OIC) and bowel dysfunction. OIC and opioid-induced bowel dysfunction are well-recognised unwanted effects of treatment with opioid analgesics that can profoundly affect quality of life. OIC can be due to additional factors such as reduced mobility, a low-fibre diet, comorbidities, and concomitant medications. Fixed-dose combinations of opioids with mu (μ) opioid receptor antagonists, such as oxycodone/naloxone, have become available, but have limited utility in clinical practice because the individual components cannot be independently titrated, creating a risk of breakthrough pain as the dose is increased. A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control. Recommended first-line pharmacological treatment of OIC is with an osmotic laxative (preferably polyethylene glycol [macrogol]), or a stimulant laxative such as an anthraquinone. A second laxative with a complementary mechanism of action should be added in the event of an inadequate response. Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as methylnaltrexone, naloxegol or naldemedine, should be considered in patients with OIC that has not responded to combination laxative treatment. Prokinetics or intestinal secretagogues, such as lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in Italy, and should therefore be restricted to settings such as specialist centres and clinical trials.
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Le BH, Aggarwal G, Douglas C, Green M, Nicoll A, Ahmedzai S. Oxycodone/naloxone prolonged-release tablets in patients with moderate-to-severe, chronic cancer pain: Challenges in the context of hepatic impairment. Asia Pac J Clin Oncol 2021; 18:13-18. [PMID: 33660420 DOI: 10.1111/ajco.13561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/29/2020] [Indexed: 01/13/2023]
Abstract
Opioids such as oxycodone are recommended in the management of moderate-to-severe, chronic cancer pain. All opioids can potentially cause constipation, which may be a significant barrier to their use. Multiple randomised clinical trials have shown that the use of naloxone as a peripherally acting mu-opioid receptor antagonist, in combination with oxycodone can prevent or reduce opioid-induced constipation while having equivalent analgesic efficacy to oxycodone alone. However, clinical experience has shown that unexpected events may occur in some patients when unrecognized liver impairment is present. We describe the underlying biological reasons and propose simple, but effective steps to avoid this unusual but potentially serious occurrence. In healthy individuals, naloxone undergoes extensive hepatic first pass metabolism resulting in low systemic bioavailability. However, in patients with hepatic impairment, porto-systemic shunting can increase systemic bioavailability of naloxone, potentially compromising the analgesic efficacy of oral naloxone-oxycodone combinations. This reduced first pass effect can occur in a range of settings that may not always be apparent to the treating clinician, including silent cirrhosis, non-cirrhotic portal hypertension and disruption of liver internal vasculature by metastases. Hepatic function test results correlate poorly with presence and extent of liver disease, and are not indicative of porto-systemic shunting. Presence of hepatic impairment should thus be considered when medication-related outcomes with oxycodone-naloxone combination are not as expected, even if liver function test results are normal.
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Affiliation(s)
- Brian H Le
- The Royal Melbourne Hospital, Parkville Integrated Palliative Care Service, Victoria, Australia.,Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Ghauri Aggarwal
- Concord Hospital, Concord Centre for Palliative Care, New South Wales, Australia
| | - Carol Douglas
- Royal Brisbane and Women's Hospital Health Service, Palliative Care, Queensland, Australia
| | - Michael Green
- Department of Medicine, The University of Melbourne, Victoria, Australia.,Sunshine Hospital, Medical Oncology, Victoria, Australia.,Peter MacCallum Cancer Centre, Medical Oncology, Melbourne, Victoria, Australia
| | - Amanda Nicoll
- Box Hill Hospital, Gastroenterology, Victoria, Australia
| | - Sam Ahmedzai
- The University of Sheffield, Oncology, Western Bank, Sheffield, UK
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Viscusi ER, Viscusi AR. Blood-brain barrier: mechanisms governing permeability and interaction with peripherally acting μ-opioid receptor antagonists. Reg Anesth Pain Med 2020; 45:688-695. [PMID: 32723840 PMCID: PMC7476292 DOI: 10.1136/rapm-2020-101403] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022]
Abstract
The blood-brain barrier (BBB) describes the unique properties of endothelial cells (ECs) that line the central nervous system (CNS) microvasculature. The BBB supports CNS homeostasis via EC-associated transport of ions, nutrients, proteins and waste products between the brain and blood. These transport mechanisms also serve as physiological barriers to pathogens, toxins and xenobiotics to prevent them from contacting neural tissue. The mechanisms that govern BBB permeability pose a challenge to drug design for CNS disorders, including pain, but can be exploited to limit the effects of a drug to the periphery, as in the design of the peripherally acting μ-opioid receptor antagonists (PAMORAs) used to treat opioid-induced constipation. Here, we describe BBB physiology, drug properties that affect BBB penetrance and how data from randomized clinical trials of PAMORAs improve our understanding of BBB permeability.
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Affiliation(s)
- Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andrew R Viscusi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Lombardi N, Crescioli G, Maggini V, Ippoliti I, Menniti-Ippolito F, Gallo E, Brilli V, Lanzi C, Mannaioni G, Firenzuoli F, Vannacci A. Acute liver injury following turmeric use in Tuscany: An analysis of the Italian Phytovigilance database and systematic review of case reports. Br J Clin Pharmacol 2020; 87:741-753. [PMID: 32656820 DOI: 10.1111/bcp.14460] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Several cases of acute non-infectious cholestatic hepatitis recently appeared in Italy following consumption of Curcuma longa-containing dietary supplements. The aim of this research was to describe the Tuscan (Italy) cases of acute hepatitis and to compare them with similar cases of hepatotoxicity published in the literature by performing a systematic review. METHODS Records of Tuscan cases of acute hepatitis were obtained from the Italian Phytovigilance system. Each spontaneous report was analysed in order to collect all relevant clinical information of patients and information concerning the Curcuma longa-containing dietary supplement. Moreover, both the RUCAM and WHO-UMC systems were used to evaluate the causal relationship between the use of dietary supplement and acute hepatitis. A systematic literature review was performed in MEDLINE and Embase and all case-reports and case-series published in English were included. RESULTS Seven cases of acute hepatitis occurring in Tuscany up to September 2019 are described. In all cases, hepatotoxicity was associated with Curcuma longa formulations with high bioavailability and high dosage of curcumin/curcuminoids. The causal relationship was also supported by the positive dechallenge observed in most cases. In the 23 cases identified through the systematic review, the majority of patients were concomitantly exposed to at least one other medication and 16 of them experienced a positive dechallenge. CONCLUSIONS Within the frame of poorly controlled and regulated products, such as dietary supplements, the evaluation of Italian cases of Curcuma longa-induced acute hepatitis and the systematic review of literature confirmed the association between Curcuma longa and liver injury.
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Affiliation(s)
- Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Valentina Maggini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,CERFIT, Research and Innovation Center in Phytotherapy and Integrated Medicine, Referring Center for Phytotherapy, Tuscany Region, Careggi University Hospital, Florence, Italy
| | - Ilaria Ippoliti
- National Centre for Drug Research and Evaluation, National Institute of Health, Rome, Italy
| | | | - Eugenia Gallo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,CERFIT, Research and Innovation Center in Phytotherapy and Integrated Medicine, Referring Center for Phytotherapy, Tuscany Region, Careggi University Hospital, Florence, Italy
| | - Valentina Brilli
- Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Cecilia Lanzi
- Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Guido Mannaioni
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy.,Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Fabio Firenzuoli
- CERFIT, Research and Innovation Center in Phytotherapy and Integrated Medicine, Referring Center for Phytotherapy, Tuscany Region, Careggi University Hospital, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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18
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Vijayvargiya P, Camilleri M, Vijayvargiya P, Erwin P, Murad MH. Systematic review with meta-analysis: efficacy and safety of treatments for opioid-induced constipation. Aliment Pharmacol Ther 2020; 52:37-53. [PMID: 32462777 DOI: 10.1111/apt.15791] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/09/2019] [Accepted: 04/23/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND When opioid-induced constipation is treated with centrally acting opioid antagonists, there may be opioid withdrawal or aggravation of pain due to inhibition of μ-opioid analgesia. This led to the development of peripherally acting μ-opioid receptor antagonists (PAMORAs). AIM To evaluate the efficacy of available PAMORAs and other approved or experimental treatments for relieving constipation in patients with opioid-induced constipation, based on a systematic review and meta-analysis of published studies. METHODS A search of MEDLINE, EMBASE and EBM Reviews Cochrane Central Register of Controlled Trials was completed in July 2019 for randomised trials compared to placebo. FDA approved doses or highest studied dose was evaluated. Efficacy was based on diverse endpoints, including continuous variables (the bowel function index, number of spontaneous bowel movements and stool consistency based on Bristol Stool Form Scale), or responder analysis (combination of >3 spontaneous bowel movements or complete spontaneous bowel movements plus 1 spontaneous bowel movement or complete spontaneous bowel movements, respectively, over baseline [so-called FDA endpoints]). Adverse effects evaluated included central opioid withdrawal, serious adverse events, abdominal pain and diarrhoea. RESULTS We included 35 trials at low risk of bias enrolling 13 566 patients. All PAMORAs demonstrated efficacy on diverse patient response endpoints. There was greater efficacy with approved doses of the PAMORAs (methylnaltrexone, naloxegol and naldemidine), with lower efficacy or lower efficacy and greater adverse effects with combination oxycodone with naloxone, lubiprostone and linaclotide. CONCLUSIONS Therapeutic response in opioid-induced constipation is best achieved with the PAMORAs, methylnaltrexone, naloxegol and naldemidine, which are associated with low risk of serious adverse events.
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Affiliation(s)
- Priya Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | | | - Patricia Erwin
- Division of Library Services, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence Based Practice Center, Mayo Clinic, Rochester, MN, USA
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Iorno V, Landi L, Porro GA, Egan CG, Calderini E. Long-term effect of oxycodone/naloxone on the management of postoperative pain after hysterectomy: a randomized prospective study. Minerva Anestesiol 2020; 86:488-497. [DOI: 10.23736/s0375-9393.20.13745-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Leng X, Zhang F, Yao S, Weng X, Lu K, Chen G, Huang M, Huang Y, Zeng X, Hopp M, Lu G. Prolonged-Release (PR) Oxycodone/Naloxone Improves Bowel Function Compared with Oxycodone PR and Provides Effective Analgesia in Chinese Patients with Non-malignant Pain: A Randomized, Double-Blind Trial. Adv Ther 2020; 37:1188-1202. [PMID: 32020565 PMCID: PMC7089730 DOI: 10.1007/s12325-020-01244-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Indexed: 12/17/2022]
Abstract
Introduction Prolonged-release oxycodone/naloxone (OXN PR), combining an opioid analgesic with selective blockade of enteric µ-opioid receptors, provided effective analgesia and improved bowel function in patients with moderate-to-severe pain and opioid-induced constipation in clinical trials predominantly conducted in Western countries. This double-blind randomized controlled trial investigated OXN PR (N = 116) versus prolonged-release oxycodone (OXY PR, N = 115) for 8 weeks at doses up to 50 mg/day in patients with moderate-to-severe, chronic, non-malignant musculoskeletal pain and opioid-induced constipation recruited in China. Methods A total of 234 patients at least 18 years of age with non-malignant musculoskeletal pain for more than 4 weeks that was moderate-to-severe in intensity and required round-the-clock opioid therapy were randomized (1:1) to OXN PR or OXY PR. The primary endpoint was bowel function using the Bowel Function Index (BFI). Secondary endpoints included safety, Brief Pain Inventory-Short Form (BPI-SF), use of analgesic and laxative rescue medication, and health-related quality of life (EQ-5D). Results While BFI scores were comparable at baseline, at week 8 improvements were greater with OXN PR vs OXY PR (least squares mean [LSM] difference (95% CI) − 9.1 (− 14.0, − 4.2); P < 0.001. From weeks 2 to 8, mean BFI scores were in the range of normal bowel function (≤ 28.8) with OXN PR but were in the range of constipation (> 28.8) at all timepoints with OXY PR. Analgesia with OXN PR was similar and non-inferior to OXY PR on the basis of modified BPI-SF average 24-h pain scores at week 8: LSM difference (95% CI) − 0.3 (− 0.5, − 0.1); P < 0.001. The most frequent treatment-related AEs were nausea (OXN PR 5% vs OXY PR 6%) and dizziness (4% vs 4%). Conclusion OXN PR provided clinically meaningful improvements in bowel function and effective analgesia in Chinese patients with moderate-to-severe musculoskeletal pain and pre-existing opioid-induced constipation. Trial Registration ClinicalTrials.gov, identifier NCT01918098. Electronic supplementary material The online version of this article (10.1007/s12325-020-01244-x) contains supplementary material, which is available to authorized users.
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Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials. BMC Palliat Care 2020; 19:6. [PMID: 31918702 PMCID: PMC6953282 DOI: 10.1186/s12904-019-0506-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials. METHODS A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data. RESULTS One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations. CONCLUSION Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.
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22
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Swarm RA, Paice JA, Anghelescu DL, Are M, Bruce JY, Buga S, Chwistek M, Cleeland C, Craig D, Gafford E, Greenlee H, Hansen E, Kamal AH, Kamdar MM, LeGrand S, Mackey S, McDowell MR, Moryl N, Nabell LM, Nesbit S, O'Connor N, Rabow MW, Rickerson E, Shatsky R, Sindt J, Urba SG, Youngwerth JM, Hammond LJ, Gurski LA. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:977-1007. [PMID: 31390582 DOI: 10.6004/jnccn.2019.0038] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.
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Affiliation(s)
- Robert A Swarm
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Judith A Paice
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Doralina L Anghelescu
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | | | - Ellin Gafford
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Heather Greenlee
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Susan LeGrand
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Nina O'Connor
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | - Jill Sindt
- Huntsman Cancer Institute at the University of Utah
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Thapa N, Kappus M, Hurt R, Diamond S. Implications of the Opioid Epidemic for the Clinical Gastroenterology Practice. Curr Gastroenterol Rep 2019; 21:44. [PMID: 31346779 DOI: 10.1007/s11894-019-0712-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW The opioid epidemic in the USA has led to a rise in opioid-related gastrointestinal (GI) side effects that are often difficult to diagnose and treat. The aim of this report is to discuss opioid pathophysiology, opioid-related GI side effects, clinical presentation, and diagnostic criteria and to review the current pharmacotherapy available. RECENT FINDINGS Opioid-related GI disorders are increasingly recognized and include, but are not limited to, opioid-induced esophageal dysfunction (OIED), gastroparesis, opioid-induced constipation (OIC), narcotic bowel syndrome (NBS), acute post-operative ileus, and anal sphincter dysfunction. Treatment of these conditions is challenging. OIC has the most available pharmacotherapy for treatment, including classical laxatives, peripherally acting μ-receptor antagonists (PAMORAs), novel therapies (lubiprostone, prucalopride- 5-HT agonist), and preventative therapies (PR oxycodone/naloxone). The gastrointestinal effects of opioid therapy are variable and often debilitating. While medical management for some opioid-related GI side effects exists, limiting or completely avoiding opioid use for chronic non-cancer pain will mitigate these effects most effectively.
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Affiliation(s)
- Namisha Thapa
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Matthew Kappus
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ryan Hurt
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Diamond
- Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L-461, Portland, OR, 97239, USA.
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Patel J, Lucas CJ, Margalit M, Martin JH. Laxative Use in Inpatients on Oxycodone/Naloxone Prolonged Release and Oxycodone Prolonged Release for Cancer and Non-cancer Pain. J Pain Palliat Care Pharmacother 2019; 32:116-123. [DOI: 10.1080/15360288.2018.1545725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Leppert W, Zajaczkowska R, Wordliczek J. The role of oxycodone/naloxone in the management of patients with pain and opioid-induced constipation. Expert Opin Pharmacother 2019; 20:511-522. [PMID: 30625013 DOI: 10.1080/14656566.2018.1561863] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Common opioid adverse effects (AE) of the gastrointestinal tract include opioid-induced constipation (OIC) and opioid-induced bowel dysfunction (OIBD) with traditional laxatives being of limited efficacy, having AEs and not addressing the pathophysiology of OIC or OIBD. Targeted treatment comprises of PAMORA (peripherally acting mu-opioid receptor antagonists) and a combination of an opioid receptor agonist with its antagonist, namely prolonged-release oxycodone with prolonged-release naloxone (OXN) tablets at a fixed ratio of 2:1. Oxycodone provides analgesia, whereas naloxone prevents binding or displaces it from opioid receptors located in the gut wall. Areas covered: The authors review the role of OXN in the management of patients with pain and OIC. A literature search was performed using the search terms 'oxycodone/naloxone' and 'opioid-induced constipation' using the PubMed database up to October 2018. Expert opinion: OXN delivers analgesia comparable (or superior versus placebo and in observational studies) to oxycodone alone and other opioids with a limited or decreased disturbing effect on bowel function. OXN in daily doses of up to 160 mg/80 mg provides effective analgesia with little negative impact on bowel function. OXN may be successfully used in patients with chronic pain, to prevent or treat symptoms of OIC and OIBD.
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Affiliation(s)
- Wojciech Leppert
- a Laboratory of Quality of Life Research, Chair and Department of Palliative Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Renata Zajaczkowska
- b Department of Interdisciplinary Intensive Care , Jagiellonian University Medical College , Krakow , Poland.,c Department of Anesthesiology and Intensive Therapy , University Hospital , Krakow , Poland
| | - Jerzy Wordliczek
- b Department of Interdisciplinary Intensive Care , Jagiellonian University Medical College , Krakow , Poland.,c Department of Anesthesiology and Intensive Therapy , University Hospital , Krakow , Poland
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Nusrat S, Syed T, Saleem R, Clifton S, Bielefeldt K. Pharmacological Treatment of Opioid-Induced Constipation Is Effective but Choice of Endpoints Affects the Therapeutic Gain. Dig Dis Sci 2019; 64:39-49. [PMID: 30284134 DOI: 10.1007/s10620-018-5308-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 09/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Widespread opioid use has led to increase in opioid-related adverse effects like constipation. We examined the impact of study endpoints on reported treatment benefits. METHODS Using MEDLINE, EMBASE, and ClinicalTrials.gov, we searched for randomized control trials targeting chronic opioid-induced constipation (OIC) and subjected them to meta-analysis. Data are given with 95% confidence intervals. RESULTS Thirty trials met our inclusion criteria. Combining all dichotomous definitions of responders, active drugs were consistently more effective than placebo, with an odds ratio (OR): 2.30 [2.01-2.63; 15 studies], independent of the underlying drug mechanism. The choice of endpoints significantly affected the therapeutic gain. When time from drug administration to defecation was used, the OR decreased from 4.74 [2.71-4.74] at 6 h or less to 2.46 [1.80-3.30] at 24 h (P < 0.05). Using other response definitions, the relative benefit over placebo was 2.10 [1.77-2.50; 12 studies] for weekly bowel frequency, 2.03 [1.39-2.95; 9 studies] for symptom scores, 2.21 [1.25-3.90; 4 studies] for global assessment scales, and 1.27 [0.79-2.03; 7 studies] for rescue laxative use. CONCLUSION While treatment of OIC with active drugs is more effective than placebo, the relative gain depends on the choice of endpoints. The commonly used time-dependent response definition is associated with the highest response rate but is of questionable relevance in a chronic disorder. The limited data do not clearly demonstrate a unique advantage of the peripherally restricted opioid antagonists, suggesting that treatment with often cheaper agents should be optimized before shifting to these novel expensive agents.
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Affiliation(s)
- Salman Nusrat
- Neurogastroenterology and Motility Program, Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Andrews Academic Tower, Suite 7400, 800 Stanton L. Young Blvd, Oklahoma City, OK, 73104, USA.
| | - Taseen Syed
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, 1200 Children's Ave, Oklahoma City, OK, 73104, USA
| | - Rabia Saleem
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, 1200 Children's Ave, Oklahoma City, OK, 73104, USA
| | - Shari Clifton
- Health Sciences Library and Information Management, Graduate College, University of Oklahoma Health Sciences Center, 1105 N. Stonewall Ave, Oklahoma City, OK, 73117, USA.,Reference and Instructional Services, Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, 1105 N. Stonewall Ave, Oklahoma City, OK, 73117, USA
| | - Klaus Bielefeldt
- Section of Gastroenterology, George E. Wahlen VAMC, 500 Foothill Dr, Salt Lake City, UT, 84103, USA
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Guo KK, Deng CQ, Lu GJ, Zhao GL. Comparison of analgesic effect of oxycodone and morphine on patients with moderate and advanced cancer pain: a meta-analysis. BMC Anesthesiol 2018; 18:132. [PMID: 30249205 PMCID: PMC6154420 DOI: 10.1186/s12871-018-0583-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 08/21/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Morphine and oxycodone are considered as wide-spreadly used opioids for moderate/severe cancer pain. However, debate exists about the evidence regarding their relative tolerability and underlying results. METHODS A systematic search of online electronic databases, including PubMed, Embase, Cochrane library updated on October 2017 were conducted. The meta-analysis was performed including the studies that were designed as randomized controlled trials. RESULTS In total, seven randomized clinical trials met our inclusion criteria. No statistical differences in analgesic effect between oxycodone and morphine were observed. Both the pooled analysis of API (MD =0.01, 95% CI -0.22 - 0.23; p = 0.96) and WPI (MD = - 0.05, 95% CI -0.21 - 0.30; p = 0.72) demonstrated clinical non-inferiority of the efficacy of morphine compared with oxycodone, respectively. Additionally, no significant difference in PRR response was observed in either oxycodone or morphine that were used in patients (MD =0.99, 95% CI -0.88 - 1.11; p = 0.87). With the pooled result of AEs indicating the comparable safety profiles between the 2 treatment groups, the meta-analysis on the nausea (OR = 1.20, 95% CI 0.90-1.59; p = 0.22), vomiting (OR = 1.33, 95% CI 0.75-2.38; p = 0.33), somnolence (OR = 1.35, 95% CI 0.95-1.93; p = 0.10), diarrhea (OR = 1.01, 95% CI 0.60-1,67; p = 0.98), and constipation (OR = 1.04, 95% CI 0.77-1.41; p = 0.79) was conducted, respectively. CONCLUSIONS In the current study, no remarkable difference was identified either in analgesic efficacy or in tolerability of oxycodone and morphine as the first-line therapy for patients with moderate to severe cancer pain. Thus, no sufficient clinical evidence on the superior effects of oxycodone to morphine was provided in this experimental hypothesis.
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Affiliation(s)
- Kai-Kai Guo
- Department of Pain Management, The Center of Anaesthetized Operation, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Cheng-Qi Deng
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing, 100048, China
| | - Gui-Jun Lu
- Department of Pain Management, The Center of Anaesthetized Operation, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
| | - Guo-Li Zhao
- Department of Pain Management, The Center of Anaesthetized Operation, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
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Incidence and Health Related Quality of Life of Opioid-Induced Constipation in Chronic Noncancer Pain Patients: A Prospective Multicentre Cohort Study. PAIN RESEARCH AND TREATMENT 2018; 2018:5704627. [PMID: 30112202 PMCID: PMC6077510 DOI: 10.1155/2018/5704627] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/10/2018] [Indexed: 12/13/2022]
Abstract
Background High rates of opioid use for chronic noncancer pain (CNCP) have been reported worldwide, despite its association with adverse events, inappropriate use, and limited analgesic effect. Opioid-induced constipation (OIC) is the most prevalent and disabling adverse effect associated with opioid therapy. Our aim was to assess the incidence, health related quality of life (HRQOL), and disability in OIC patients. Methods A prospective cohort study was performed, with 6 months of follow-up, of adult CNCP patients consecutively admitted in 4 multidisciplinary pain clinics (MPC). Demographic and clinical data have been collected. Brief Pain Inventory (BPI) and Short version of Treatment Outcomes in Pain Survey (S-TOPS) were used to measure functional outcomes and HRQOL. OIC was assessed using Bowel Function Index (BFI). Results 694 patients were recruited. OIC prevalence at baseline was 25.8%. At 6 months, OIC incidence was 24.8%. Female gender (OR = 1.65, p = 0.039), opioid therapy (OR 1.65, p = 0.026), and interference pain score on BPI (OR 1.10, p = 0.009) were identified as OIC independent predictors. OIC patients presented higher disability and pain interference and severity scores. OIC patients reported less satisfaction with outcome (p = 0.038). Discussion Constipation is a common adverse event among opioid users with major functional and quality of life impairment. These findings emphasise the need of OIC adequate assessment and management.
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Candy B, Jones L, Vickerstaff V, Larkin PJ, Stone P. Mu-opioid antagonists for opioid-induced bowel dysfunction in people with cancer and people receiving palliative care. Cochrane Database Syst Rev 2018; 6:CD006332. [PMID: 29869799 PMCID: PMC6513061 DOI: 10.1002/14651858.cd006332.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid-induced bowel dysfunction (OIBD) is characterised by constipation, incomplete evacuation, bloating, and gastric reflux. It is one of the major adverse events of treatment for pain in cancer and in palliative care, resulting in increased morbidity and reduced quality of life.This is an update of two Cochrane reviews. One was published in 2011, Issue 1 on laxatives and methylnaltrexone for the management of constipation in people receiving palliative care; this was updated in 2015 and excluded methylnaltrexone. The other was published in 2008, Issue 4 on mu-opioid antagonists (MOA) for OIBD. In this updated review, we only included trials on MOA (including methylnaltrexone) for OIBD in people with cancer and people receiving palliative care. OBJECTIVES To assess the effectiveness and safety of MOA for OIBD in people with cancer and people receiving palliative care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, and Web of Science to August 2017. We also searched clinical trial registries and regulatory websites. We contacted manufacturers of MOA to identify further data. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed the effectiveness and safety of MOA for OIBD in people with cancer and people at a palliative stage irrespective of the type of terminal disease they experienced. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias and extracted data. The appropriateness of combining data from the trials depended upon sufficient homogeneity across the trials. Our primary outcomes were laxation, impact on pain relief, and adverse events. Impact on pain relief was a primary outcome because a possible adverse effect of MOAs is a reduction in pain relief from opioids. We assessed the evidence on these outcomes using GRADE. MAIN RESULTS We identified four new trials for this update, bringing the total number included in this review to eight. In total, 1022 men and women with cancer irrespective of stage or at a palliative care stage of any disease were randomised across the trials. The MOAs evaluated were oral naldemedine and naloxone (alone or in combination with oxycodone), and subcutaneous methylnaltrexone. The trials compared with MOA with a placebo or with the active intervention administered at different doses or in combination with other drugs. The trial of naldemedine and the two of naloxone in combination with oxycodone were in people with cancer irrespective of disease stage. The trial on naloxone alone was in people with advanced cancer. The four trials on methylnaltrexone were undertaken in palliative care where most participants had cancer. All trials were vulnerable to biases; four were at a high risk as they involved a sample of fewer than 50 participants per arm.In the trial of naldemedine compared to placebo in 225 participants, there were more spontaneous laxations over the two-week treatment for the intervention group (risk ratio (RR) 1.93, 95% confidence intervals (CI) 1.36 to 2.74; moderate-quality evidence). In comparison with higher doses, lower doses resulted in fewer spontaneous laxations (0.1 mg versus 0.2 mg: RR 0.73, 95% CI 0.55 to 0.95; 0.1 mg versus 0.4 mg: RR 0.69, 95% CI 0.53 to 0.89; moderate-quality evidence). There was moderate-quality evidence that naldemedine had no effect on opiate withdrawal. There were five serious adverse events. All were in people taking naldemedine (low-quality evidence). There was an increase in the occurrence of other (non-serious) adverse events in the naldemedine groups (RR 1.36, 95% CI 1.04 to 1.79, moderate-quality evidence). The most common adverse event was diarrhoea.The trials on naloxone taken either on its own, or in combination with oxycodone (an opioid) compared to oxycodone only did not evaluate laxation response over the first two weeks of administration. There was very low-quality evidence that naloxone alone, and moderate-quality evidence that oxycodone/naloxone, had no effect on analgesia. There was low-quality evidence that oxycodone/naloxone did not increase the risk of serious adverse events and moderate-quality evidence that it did not increase risk of adverse events.In combined analysis of two trials of 287 participants, we found methylnaltrexone compared to placebo induced more laxations within 24 hours (RR 2.77, 95% CI 1.91 to 4.04. I² = 0%; moderate-quality evidence). In combined analysis, we found methylnaltrexone induced more laxation responses over two weeks (RR 9.98, 95% CI 4.96 to 20.09. I² = 0%; moderate-quality evidence). The proportion of participants who had a rescue-free laxation response within 24 hours of the first dose was 59.1% in the methylnaltrexone arms and 19.1% in the placebo arm. There was moderate-quality evidence that the rate of opioid withdrawal was not affected. Methylnaltrexone did not increase the likelihood of a serious adverse event; there were fewer in the intervention arm (RR 0.59, 95% CI 0.38 to 0.93; I² = 0%; moderate-quality evidence). There was no difference in the proportion of participants experiencing an adverse event (RR 1.17, 95% CI 0.94 to 1.45; I² = 74%; low-quality evidence). Methylnaltrexone increased the likelihood of abdominal pain and flatulence.Two trials compared differing methylnaltrexone schedules of higher doses with lower doses. For early laxation, there was low-quality evidence of no clear difference between doses on analgesia and adverse events. Both trials measured laxation response within 24 hours of first dose (trial one: RR 0.82, 95% CI 0.41 to 1.66; trial two: RR 1.07, 95% CI 0.81 to 1.42). AUTHORS' CONCLUSIONS In this update, the conclusions for naldemedine are new. There is moderate-quality evidence to suggest that, taken orally, naldemedine improves bowel function over two weeks in people with cancer and OIBD but increases the risk of adverse events. The conclusions on naloxone and methylnaltrexone have not changed. The trials on naloxone did not assess laxation at 24 hours or over two weeks. There is moderate-quality evidence that methylnaltrexone improves bowel function in people receiving palliative care in the short term and over two weeks, and low-quality evidence that it does not increase adverse events. There is a need for more trials including more evaluation of adverse events. None of the current trials evaluated effects in children.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry6th Floor, Maple House149 Tottenham Court RoadLondonUKW1T 7NF
| | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry6th Floor, Maple House149 Tottenham Court RoadLondonUKW1T 7NF
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry6th Floor, Maple House149 Tottenham Court RoadLondonUKW1T 7NF
| | - Philip J Larkin
- UCD College of Health SciencesUCD School of Nursing, Midwifery and Health Systems and Our Lady's Hospice and Care ServicesDublinIreland
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, UCL Division of PsychiatryDivision of PsychiatryRoom 119, First Floor, Charles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
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Kim ES. Oxycodone/Naloxone Prolonged Release: A Review in Severe Chronic Pain. Clin Drug Investig 2018; 37:1191-1201. [PMID: 29098567 DOI: 10.1007/s40261-017-0593-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Oral oxycodone/naloxone prolonged release (PR) [Targin®, Targinact®, Targiniq®] is a 12-hourly opioid receptor agonist and opioid receptor antagonist fixed-dose combination product that is approved in countries in the EU for the management of severe pain (adequately manageable only with opioid analgesics) in adults. Oral naloxone prevents oxycodone from binding to μ-receptors in the gastrointestinal (GI) tract, thereby counteracting opioid-induced constipation (OIC). In short-term (5- to 12-week) clinical trials of adults with moderate to severe, chronic pain and OIC (OXN3001, OXN3006, OXN3506), oxycodone/naloxone PR significantly improved OIC while providing noninferior analgesia relative to oxycodone PR; results were consistent between cancer and non-cancer patients in OXN3506. Analgesia and improvements in bowel function were sustained with an additional 24-52 weeks of oxycodone/naloxone PR treatment in long-term extension studies. Results in real-world studies were consistent with those in clinical trials. Oxycodone/naloxone PR was generally well tolerated, with nausea, hyperhidrosis, and diarrhoea (generally transient) reported as the most commonly occurring adverse events. Thus, oxycodone/naloxone PR is a useful treatment option to consider in adults with severe chronic pain that can be adequately managed only with opioid analgesics, particularly in those with OIC.
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Affiliation(s)
- Esther S Kim
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand.
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O'Brien T, Christrup LL, Drewes AM, Fallon MT, Kress HG, McQuay HJ, Mikus G, Morlion BJ, Perez-Cajaraville J, Pogatzki-Zahn E, Varrassi G, Wells JCD. European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain 2018; 21:3-19. [PMID: 27991730 PMCID: PMC6680203 DOI: 10.1002/ejp.970] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 02/06/2023]
Abstract
Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non‐specialist opioid prescribers. There is much confusing and conflicting information available to non‐specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi‐faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non‐specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. Significance This position paper provides expert recommendations for primary care physicians and other non‐ specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi‐faceted approach to pain management, in properly selected and supervised patients.
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Affiliation(s)
- T O'Brien
- Marymount University Hospital & Hospice, Curraheen, Cork, Ireland.,Cork University Hospital, Wilton, Cork and College of Medicine and Health, University College, Cork, Ireland
| | - L L Christrup
- Department of Drug Design and Pharmacology, University of Copenhagen, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark
| | - M T Fallon
- Edinburgh Cancer Research Centre, University of Edinburgh, UK
| | - H G Kress
- Department of Special Anaesthesia and Pain Therapy, Medical University of Vienna/AKH, Austria
| | | | - G Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital, Heidelberg, Germany
| | - B J Morlion
- Leuven Centre for Algology & Pain Management, University Hospital Leuven, Belgium
| | | | - E Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Müenster, Germany
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Kim BS, Jin JY, Kwon JH, Woo IS, Ko YH, Park SY, Park HJ, Kang JH. Efficacy and safety of oxycodone/naloxone as add-on therapy to gabapentin or pregabalin for the management of chemotherapy-induced peripheral neuropathy in Korea. Asia Pac J Clin Oncol 2017; 14:e448-e454. [PMID: 29280313 DOI: 10.1111/ajco.12822] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/28/2017] [Indexed: 12/12/2022]
Abstract
AIMS To investigate the efficacy and safety of oxycodone/naloxone in patients with chemotherapy-induced peripheral neuropathy (CIPN) inadequately controlled with pregabalin or gabapentin. METHODS This 4-week, multicenter, interventional, single-arm phase IV study included 72 Korean patients with CIPN inadequately controlled with pregabalin or gabapentin (Numeric Rating Scale 0-10; NRS ≥4 at baseline). In addition to pregabalin or gabapentin at existing doses, patients received 20/10 mg/day oxycodone/naloxone (up-titrated to 80/40 mg/day as needed). The primary endpoint was change in NRS score after 4 weeks. Secondary endpoints included Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-NTX) scores and safety assessments. RESULTS The mean ± standard deviation (SD) dose of oxycodone/naloxone was 23.3 ± 7.5 mg/day. At week 4, NRS score reduction was 1.29 ± 1.84 points (21.4% reduction; P < 0.0001). Patients on taxane-based chemotherapy experienced a significantly smaller mean change in NRS score at week 4 compared to patients on other chemotherapy (-0.63 ± 1.54 [n = 30] vs. -1.83 ± 1.00 [n = 36]; P = 0.0072). Although there were no significant changes in FACT/GOG-NTX total scores, improvements were observed in the neurotoxicity subscale measuring numbness/tingling of hands (mean ± SD change: -0.27 ± 1.04; P = 0.0427) and feet (-0.60 ± 1.09; P < 0.0001). Forty-two (58.3%) patients reported adverse events. There were no clinically significant changes in laboratory tests or vital signs. CONCLUSION Oxycodone/naloxone added to pregabalin or gabapentin provided additional pain relief and symptom control in Korean patients with CIPN, without clinically significant safety concerns.
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Affiliation(s)
- Bong-Seog Kim
- Division of Hemato-Oncology, VHS Medical Center, Seoul, South Korea
| | - Jong-Youl Jin
- Division of Hemato-Oncology, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, South Korea
| | - Jung Hye Kwon
- Division of Hemato-Oncology, Kangdong Sacred Heart Hospital, Hallym University, Seoul, South Korea
| | - In Sook Woo
- Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoon Ho Ko
- Division of Oncology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, South Korea
| | - Suk-Young Park
- Division of Oncology, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, South Korea
| | - Hye-Jeong Park
- Medical Affairs, Mundipharma Korea Ltd., Seoul, South Korea
| | - Jin Hyung Kang
- Division of Medical Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Koopmans-Klein G, Van Op den Bosch J, van Megen Y, Prenen H, Huygen F, Mancini I. Prolonged release oxycodone and naloxone treatment counteracts opioid-induced constipation in patients with severe pain compared to previous analgesic treatment. Curr Med Res Opin 2017; 33:2217-2227. [PMID: 28805471 DOI: 10.1080/03007995.2017.1367276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Treatment with prolonged-release oxycodone/naloxone (PR OXN) has been shown to improve opioid induced constipation (OIC) in constipated patients. This publication reports on a real-life observational study investigating the efficacy of PR OXN with regard to bowel function in patients switching to PR OXN from WHO step 1, step 2 and step 3 opioids. METHODS Patients with chronic pain experiencing insufficient pain relief and/or unacceptable side effects were switched to PR OXN and monitored in this observational study with respect to efficacy regarding bowel function and efficacy regarding pain relief in comparison with previous analgesic therapy. A patient was considered a responder with respect to efficacy if this assessment was "slightly better", "better" or "much better" compared with previous therapy. Bowel function index, pain intensity, quality of life, laxative medication use, and safety analgesic were also evaluated. RESULTS A total of 1338 patients (mean [SD] age 64.3 [14.9], 63% female) were observed for 43 [3-166] days (median [range]) during treatment with PR OXN. Overall response rate regarding bowel function efficacy was 82.5%. Patients with symptoms of constipation at study entry obtained a clinically relevant improvement of the bowel function index (BFI) within the first 2 weeks of PR OXN treatment. Non-constipated patients at study entry maintained normal bowel function despite switching to treatment with the opioid PR OXN. CONCLUSION In conclusion, treatment with PR OXN results in a significant and clinically relevant improvement of bowel function. During the observation of the treatment with PR OXN patients reported an improvement of quality of life (QoL). More interestingly, non-constipated patients maintained a normal bowel function, showing prevention of constipation despite the use of an opioid.
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Affiliation(s)
- Gineke Koopmans-Klein
- a Mundipharma Pharmaceuticals BV , Medical Department , Leusden , The Netherlands
- b Center for Pain Medicine, Erasmus MC , Rotterdam , The Netherlands
| | | | - Yvonne van Megen
- a Mundipharma Pharmaceuticals BV , Medical Department , Leusden , The Netherlands
| | - Hans Prenen
- d Digestive Oncology Unit , University Hospital Leuven , Leuven , Belgium
| | - Frank Huygen
- b Center for Pain Medicine, Erasmus MC , Rotterdam , The Netherlands
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Morlion BJ, Mueller-Lissner SA, Vellucci R, Leppert W, Coffin BC, Dickerson SL, O'Brien T. Oral Prolonged-Release Oxycodone/Naloxone for Managing Pain and Opioid-Induced Constipation: A Review of the Evidence. Pain Pract 2017; 18:647-665. [DOI: 10.1111/papr.12646] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Bart J. Morlion
- Leuven Centre for Algology and Pain Management; Anaesthesiology and Algology; Department of Cardiovascular Sciences; University Hospitals Leuven; University of Leuven; Leuven Belgium
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit; University Hospital; Careggi Florence Italy
| | - Wojciech Leppert
- Department of Palliative Medicine; Poznan University of Medical Sciences; Poznan Poland
- Department of Quality of Life Research; Medical University of Gdansk; Gdansk Poland
| | - Benoît C. Coffin
- Department of Gastroenterology; Louis Mourier Hospital; Assistance Publique - Hôpitaux de Paris; Colombes France
- University Denis Diderot-Paris VII; Paris France
| | - Sara L. Dickerson
- Mundipharma International Ltd; Cambridge Science Park; Cambridge U.K
| | - Tony O'Brien
- Marymount University Hospital and Hospice; Cork Ireland
- Cork University Hospital and College of Medicine and Health; University College Cork; Cork Ireland
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Can early oral prolonged-release oxycodone with or without naloxone reduce the duration of epidural analgesia after cystectomy? A 3-arm, randomized, double-blind, placebo-controlled trial. Pain 2017; 159:560-567. [DOI: 10.1097/j.pain.0000000000001112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
There is a paucity of data on whether interventions in individual palliative care units are evidence-based. Thirteen years ago an initial study evaluated the evidence base of interventions in palliative care. Using similar methodology in the present study, we evaluated the evidence for interventions performed in an inpatient palliative care setting, looking at level of evidence as well as quality and outcome of evidence. More than half of all the interventions (47 interventions, 59 percent) we looked at in a Brisbane, Australia, inpatient palliative care setting were based on a high level of evidence in the form of systematic reviews of randomized controlled trials (level I or level II). There were only a few interventions (10 percent) for which no evidence could be retrieved. Our results show that the evidence base for interventions in palliative care continues to evolve, but that there are still areas for which further high-quality studies are needed.
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Affiliation(s)
- Korana Kindl
- Department of Palliative Care, St. Vincent's Private Hospital, Brisbane, Queensland, Australia
| | - Phillip Good
- Mater Research Institute-University of Queensland; Department of Palliative and Supportive Care, Mater Health Services; and Department of Palliative Care, St. Vincent's Private Hospital, 411 Main Street, Kangaroo Point, Brisbane, Queensland, Australia 4169
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Müller-Lissner S, Bassotti G, Coffin B, Drewes AM, Breivik H, Eisenberg E, Emmanuel A, Laroche F, Meissner W, Morlion B. Opioid-Induced Constipation and Bowel Dysfunction: A Clinical Guideline. PAIN MEDICINE (MALDEN, MASS.) 2017; 18:1837-1863. [PMID: 28034973 PMCID: PMC5914368 DOI: 10.1093/pm/pnw255] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction. SETTING Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction." METHODS A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system. RESULTS From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction. CONCLUSIONS In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.
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Affiliation(s)
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia School of Medicine, Piazza Università, 1, Perugia, Italy
| | - Benoit Coffin
- AP-HP Hôpital Louis Mourier, University Denis Diderot-Paris 7, INSERM U987, Paris, France
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Harald Breivik
- Department of Pain Management and Research, University of Oslo, Rikshospitalet, Oslo, Norway
| | - Elon Eisenberg
- Institute of Pain Medicine, Rambam Health Care Campus, The Technion, Israel Institute of Technology, Haifa, Israel
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, Queen Square, London, UK
| | | | | | - Bart Morlion
- The Leuven Center for Algology and Pain Management, University of Leuven, KU Leuven, Leuven, Belgium
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Lee KH, Kim TW, Kang JH, Kim JS, Ahn JS, Kim SY, Yun HJ, Eum YJ, Koh SA, Kim MK, Hong YS, Kim JE, Lee GW. Efficacy and safety of controlled-release oxycodone/naloxone versus controlled-release oxycodone in Korean patients with cancer-related pain: a randomized controlled trial. CHINESE JOURNAL OF CANCER 2017; 36:74. [PMID: 28893309 PMCID: PMC5594448 DOI: 10.1186/s40880-017-0241-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 09/01/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Controlled-release oxycodone/naloxone (OXN-CR) maintains the effect of opioid-induced analgesia through oxycodone while reducing the occurrence rate of opioid-induced constipation through naloxone. The present study was designed to assess the non-inferiority of OXN-CR to controlled-release oxycodone (OX-CR) for the control of cancer-related pain in Korean patients. METHODS In this randomized, open-labeled, parallel-group, phase IV study, we enrolled patients aged 20 years or older with moderate to severe cancer-related pain [numeric rating scale (NRS) pain score ≥4] from seven Korean oncology/hematology centers. Patients in the intention-to-treat (ITT) population were randomized (1:1) to OXN-CR or OX-CR groups. OXN-CR was administered starting at 20 mg/10 mg per day and up-titrated to a maximum of 80 mg/40 mg per day for 4 weeks, and OX-CR was administered starting at 20 mg/day and up-titrated to a maximum of 80 mg/day for 4 weeks. The primary efficacy endpoint was the change in NRS pain score from baseline to week 4, with non-inferiority margin of -1.5. Secondary endpoints included analgesic rescue medication intake, patient-reported change in bowel habits, laxative intake, quality of life (QoL), and safety assessments. RESULTS Of the ITT population comprising 128 patients, 7 with missing primary efficacy data and 4 who violated the eligibility criteria were excluded from the efficacy analysis. At week 4, the mean change in NRS pain scores was not significantly different between the OXN-CR group (n = 58) and the OX-CR group (n = 59) (-1.586 vs. -1.559, P = 0.948). The lower limit of the one-sided 95% confidence interval (-0.776 to 0.830) for the difference exceeded the non-inferiority margin (P < 0.001). The OXN-CR and OX-CR groups did not differ significantly in terms of analgesic rescue medication intake, change in bowel habits, laxative intake, QoL, and safety assessments. CONCLUSIONS OXN-CR was non-inferior to OX-CR in terms of pain reduction after 4 weeks of treatment and had a similar safety profile. Studies in larger populations of Korean patients with cancer-related pain are needed to further investigate the effectiveness of OXN-CR for long-term pain control and constipation alleviation. Trial registration ClinicalTrials.gov NCT01313780, registered March 8, 2011.
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Affiliation(s)
- Kyung-Hee Lee
- Department of Hematology-Oncology, Yeungnam University Medical Center, Daegu, 42415 South Korea
| | - Tae Won Kim
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, 05505 South Korea
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736 South Korea
| | - Jung-Hun Kang
- Department of Hematology-Oncology, Gyeongsang National University Hospital, Jinju, 52727 South Korea
| | - Jin-Soo Kim
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, 07061 South Korea
| | - Jin-Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Seoul, 06351 South Korea
| | - Sun-Young Kim
- Department of Hematology-Oncology, National Cancer Center, Ilsan, 10408 South Korea
| | - Hwan-Jung Yun
- Department of Hematology-Oncology, Chungnam National University Hospital, Daejeon, 35015 South Korea
| | - Young-Jun Eum
- Medical Affairs, Mundipharma Korea Ltd, Seoul, 04637 South Korea
| | - Sung Ae Koh
- Department of Hematology-Oncology, Yeungnam University Medical Center, Daegu, 42415 South Korea
| | - Min Kyoung Kim
- Department of Hematology-Oncology, Yeungnam University Medical Center, Daegu, 42415 South Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, 05505 South Korea
| | - Jeong Eun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, 05505 South Korea
| | - Gyeong-Won Lee
- Department of Hematology-Oncology, Gyeongsang National University Hospital, Jinju, 52727 South Korea
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Roberto A, Greco MT, Legramandi L, Galli F, Galli M, Corli O. A comparison between the administration of oral prolonged-release oxycodone-naloxone and transdermal fentanyl in patients with moderate-to-severe cancer pain: a propensity score analysis. J Pain Res 2017; 10:2123-2133. [PMID: 28919810 PMCID: PMC5590764 DOI: 10.2147/jpr.s141928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Opioids are the most important pharmacological treatment for moderate-to-severe cancer pain, but side effects limit their use. Transdermal fentanyl (TDF) and oral prolonged-release oxycodone-naloxone (OXN-PR) are effective in controlling chronic pain, with less constipation compared to other opioids. However, TDF and OXN-PR have never been directly compared. PATIENTS AND METHODS Cancer patients with moderate-to-severe chronic pain were consecutively enrolled in two prospective 28-day trials, received either TDF or OXN-PR, and were assessed at baseline and after 7, 14, 21, and 28 days. The primary endpoint was 28-day analgesic response rate (average pain intensity decrease ≥30% from baseline). Other outcome measures included opioid daily dose changes over time; need for adjuvant analgesics; number of switches; premature discontinuation; presence and severity of constipation; and other adverse drug reactions. To compare the efficacy and the safety of TDF and OXN-PR, we used the propensity score analysis to adjust for heterogeneity between the two patient groups. RESULTS Three hundred ten out of 336 patients originally treated (119 TDF and 191 OXN-PR) were included in the comparative analysis. The amount of responders was comparable after TDF (75.3%) and OXN-PR administration (82.9%, not significant [NS]). The final opioid daily dose expressed as morphine equivalent was 113.6 mg for TDF and 44.5 mg for OXN-PR (p<0.0001). A daily opioid dose escalation >5% was less common after OXN-PR (19.3%) than after TDS administration (37.9%, p<0.0001). Opioid switches and discontinuation were similar in both groups. Severe constipation in the two groups was comparable (32.6% after TDF vs 24.7% after OXN-PR, NS). Nausea, vomiting, and dry mouth were significantly less frequent in the OXN-PR group than in the TDF group. CONCLUSION Despite a similar analgesic activity in moderate-to-severe cancer pain, OXN-PR is characterized by lower daily dosages, less need for drug escalation, and fewer side effects compared to TDF.
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Affiliation(s)
- A Roberto
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - M T Greco
- Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | - L Legramandi
- Methodology for Clinical Research Laboratory, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - F Galli
- Methodology for Clinical Research Laboratory, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - M Galli
- Scientific Medical Communication srl, Novara, Italy
| | - O Corli
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Abstract
BACKGROUND Many people with cancer experience moderate to severe pain that requires treatment with strong opioids, such as oxycodone and morphine. Strong opioids are, however, not effective for pain in all people, neither are they well-tolerated by all people. The aim of this review was to assess whether oxycodone is associated with better pain relief and tolerability than other analgesic options for adults with cancer pain. This is an updated version of the original Cochrane review published in 2015, Issue 2 on oxycodone for cancer-related pain. OBJECTIVES To assess the effectiveness and tolerability of oxycodone by any route of administration for pain in adults with cancer. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and MEDLINE In-Process (Ovid), Embase (Ovid), Science Citation Index, Conference Proceedings Citation Index - Science (ISI Web of Science), BIOSIS (ISI), and PsycINFO (Ovid) to November 2016. We also searched four trial registries, checked the bibliographic references of relevant studies, and contacted the authors of the included studies. We applied no language, date, or publication status restrictions. SELECTION CRITERIA We included randomised controlled trials (parallel group or cross-over) comparing oxycodone (any formulation or route of administration) with placebo or an active drug (including oxycodone) for cancer background pain in adults by examining pain intensity/relief, adverse events, quality of life, and participant preference. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the included studies using standard Cochrane methodology. We meta-analysed pain intensity data using the generic inverse variance method, and adverse events using the Mantel-Haenszel method, or summarised these data narratively along with the quality of life and participant preference data. We assessed the overall quality of the evidence using GRADE. MAIN RESULTS For this update, we identified six new studies (1258 participants) for inclusion. In total, we included 23 studies which enrolled/randomised 2648 participants, with 2144 of these analysed for efficacy and 2363 for safety. The studies examined a number of different drug comparisons.Pooled analysis of three of the four studies comparing controlled-release (CR) oxycodone to immediate-release (IR) oxycodone showed that the ability of CR and IR oxycodone to provide pain relief were similar (standardised mean difference (SMD) 0.1, 95% confidence interval (CI) -0.06 to 0.26; low quality evidence). Pooled analyses of adverse events showed no significant differences between CR and IR oxycodone for asthenia (risk ratio (RR) 0.58, 95% CI 0.2 to 1.68), confusion (RR 0.78, 95% CI 0.2 to 3.02), constipation (RR 0.71, 95% CI 0.45 to 1.13), dizziness/lightheadedness (RR 0.74, 95% CI 0.4 to 1.37), drowsiness/somnolence (RR 1.03, 95% CI 0.69 to 1.54), dry mouth (RR 1.14, 95% CI 0.48 to 2.75), insomnia (RR 1.04, 95% CI 0.31 to 3.53), nausea (RR 0.85, 95% CI 0.56 to 1.28), nervousness (RR 0.57, 95% CI 0.2 to 1.64), pruritus (RR 1.46, 95% CI 0.65 to 3.25), vomiting (RR 0.66, 95% CI 0.38 to 1.15), and discontinuation due to adverse events (RR 0.6, 95% CI 0.29 to 1.22). The quality of the evidence was very low for all these adverse events. Three of the four studies found similar results for treatment acceptability.Pooled analysis of seven of the nine studies comparing CR oxycodone to CR morphine indicated that pain relief was significantly better after treatment with CR morphine than CR oxycodone (SMD 0.14, 95% CI 0.01 to 0.27; low quality evidence). However, sensitivity analysis did not corroborate this result (SMD 0.12, 95% CI -0.02 to 0.26).Pooled analyses of adverse events showed no significant differences between CR oxycodone and CR morphine for confusion (RR 1.01 95% CI 0.78 to 1.31), constipation (RR 0.98, 95% CI 0.82 to 1.16), dizziness/lightheadedness (RR 0.76, 95% CI 0.33 to 1.76), drowsiness/somnolence (RR 0.9, 95% CI 0.75 to 1.08), dry mouth (RR 1.01, 95% CI 0.8 to 1.26), dysuria (RR 0.71, 95% CI 0.4 to 1.26), nausea (RR 1.02, 95% CI 0.82 to 1.26), pruritus (RR 0.81, 95% CI 0.51 to 1.29), vomiting (RR 0.94, 95% CI 0.68 to 1.29), and discontinuation due to adverse events (RR 1.06, 95% CI 0.43 to 2.6). However, the RR for hallucinations was significantly lower after treatment with CR oxycodone compared to CR morphine (RR 0.52, 95% CI 0.28 to 0.97). The quality of the evidence was very low for all these adverse events. There were no marked differences in treatment acceptability or quality of life ratings.The remaining studies either compared oxycodone in various formulations or compared oxycodone to different alternative opioids. None found any clear superiority or inferiority of oxycodone for cancer pain, neither as an analgesic agent nor in terms of adverse event rates and treatment acceptability.The quality of this evidence base was limited by the high or unclear risk of bias of the studies and by imprecision due to low or very low event rates or participant numbers for many outcomes. AUTHORS' CONCLUSIONS The conclusions have not changed since the previous version of this review. The data suggest that oxycodone offers similar levels of pain relief and overall adverse events to other strong opioids including morphine. Although we identified a clinically insignificant benefit on pain relief in favour of CR morphine over CR oxycodone, this did not persist following sensitivity analysis and so we do not consider this important. However, in this updated analysis, we found that hallucinations occurred less often with CR oxycodone than with CR morphine, but the quality of this evidence was very low so this finding should be treated with utmost caution. Our conclusions are consistent with other reviews and suggest that while the reliability of the evidence base is low, given the absence of important differences within this analysis it seems unlikely that larger head to head studies of oxycodone versus morphine are justified, although well-designed trials comparing oxycodone to other strong analgesics may well be useful. For clinical purposes, oxycodone or morphine can be used as first-line oral opioids for relief of cancer pain in adults.
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Affiliation(s)
- Mia Schmidt‐Hansen
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlRegent's ParkLondonUKNW1 4RG
| | - Michael I Bennett
- University of LeedsLeeds Institute of Health SciencesCharles Thackrah Building101 Clarendon RoadLeedsUKLS2 9LJ
| | - Stephanie Arnold
- Royal College of Obstetricians and Gynaecologists27 Sussex PlaceRegent's parkLondonUKNW1 4RG
| | - Nathan Bromham
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlRegent's ParkLondonUKNW1 4RG
| | - Jennifer S Hilgart
- National Collaborating Centre for Cancer2nd Floor, Park House, Greyfriars RoadCardiffWalesUKCF10 3AF
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Odonkor CA, Kim G, Erdek M. Global cancer pain management: a systematic review comparing trials in Africa, Europe and North America. Pain Manag 2017; 7:299-310. [PMID: 28699421 DOI: 10.2217/pmt-2016-0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIM Despite the rise in cancer survivorship, few reviews have examined the quality of studies of cancer pain management and practices around the globe. With a void in trials spanning multiple geographical settings, this review evaluates the quality of cancer trials across three continents. MATERIALS & METHODS A literature review and search of established databases was conducted to identify eligible studies. The Cochrane method, the Jadad Score and a cancer pain-specific ad hoc tool were used to evaluate quality of studies. RESULTS Eighteen studies representing a total of 4693 individuals were included in the review. Study quality correlated positively with study sample size and palliative care index. Trials in all three continents were prone to use opioids for pain management, whereas trials in Europe and North America utilized other adjuvant therapies such as antidepressants and steroids. CONCLUSION This review underscores the need for better multidimensional quality assessment tools for cancer pain trials.
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Affiliation(s)
- Charles A Odonkor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Gabriel Kim
- Department of Internal Medicine, Howard University College of Medicine, Washington, DC 20059, USA
| | - Michael Erdek
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Turner JR. Commissioner Gottlieb and the Crusade Against Opioid Abuse: Baptism by Fire. Ther Innov Regul Sci 2017; 51:400-403. [DOI: 10.1177/2168479017716636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Brant J, Keller L, McLeod K, Hsing Yeh C, Eaton L. Chronic and Refractory Pain: A Systematic Review of Pharmacologic Management in Oncology. Clin J Oncol Nurs 2017; 21:31-53. [DOI: 10.1188/17.cjon.s3.31-53] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Meng Z, Yu J, Acuff M, Luo C, Wang S, Yu L, Huang R. Tolerability of Opioid Analgesia for Chronic Pain: A Network Meta-Analysis. Sci Rep 2017; 7:1995. [PMID: 28515426 PMCID: PMC5435686 DOI: 10.1038/s41598-017-02209-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/07/2017] [Indexed: 12/17/2022] Open
Abstract
Aim of this study was to study the tolerability of opioid analgesia by performing a network meta-analysis (NMA) of randomized-controlled trials (RCTs) which investigated effectiveness of opioids for the management of chronic pain. Research articles reporting outcomes of RCT/s comparing 2 or more opioid analgesics for the management of chronic pain were obtained by database search. Bayesian NMAs were performed to combine direct comparisons between treatments with that of indirect simulated evidence. Study endpoints were: incidence of adverse events, incidence of constipation, trial withdrawal rate, and patient satisfaction with treatment. Outcomes were also compared with conventional meta-analyses. Thirty-two studies investigating 10 opioid drugs fulfilled the eligibility criteria. Tapentadol treatment was top-ranking owing to lower incidence of overall adverse events, constipation, and least trial withdrawal rate. Tapentadol was followed by oxycodone-naloxone combination in providing better tolerability and less trial withdrawal rate. Patient satisfaction was found to be higher with oxycodone-naloxone followed by fentanyl and tapentadol. These results were in agreement with those achieved with conventional meta-analyses. Tapentadol and oxycodone-naloxone are found to exhibit better tolerability characteristics in comparison with other opioid drugs for the management of chronic pain and are associated with low trial withdrawal rate and better patient satisfaction.
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Affiliation(s)
- Zengdong Meng
- Department of Orthopaedics, First People's Hospital of YunNan Province, YunNan, P.R. China
| | - Jing Yu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Acuff
- Rusk Rehabilitation Center, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Chong Luo
- Department of Orthopaedics, First People's Hospital of YunNan Province, YunNan, P.R. China
| | - Sanrong Wang
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.,Department of Pain Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Lehua Yu
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.,Department of Pain Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Rongzhong Huang
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China. .,Department of Pain Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.
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Dupoiron D, Stachowiak A, Loewenstein O, Ellery A, Kremers W, Bosse B, Hopp M. Long-term efficacy and safety of oxycodone-naloxone prolonged-release formulation (up to 180/90 mg daily) - results of the open-label extension phase of a phase III multicenter, multiple-dose, randomized, controlled study. Eur J Pain 2017; 21:1485-1494. [PMID: 28474460 PMCID: PMC5655918 DOI: 10.1002/ejp.1050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 12/12/2022]
Abstract
Background The inclusion of naloxone with oxycodone in a fixed combination prolonged‐release formulation (OXN PR) improves bowel function compared with oxycodone (Oxy) alone without compromising analgesic efficacy. In a recent 5‐week, randomized, double‐blind comparative trial of OXN PR and OxyPR, it could be shown that the beneficial properties of OXN PR extend to doses up to 160/80 mg. Methods Bowel function, pain, quality of life (QoL) and safety of OXN PR up to 180/90 mg daily were evaluated in a 24‐week open‐label extension phase of the 5‐week randomized comparative study in patients with non‐malignant or malignant pain requiring opioids and suffering from opioid‐induced constipation. Results During treatment with a mean (SD) daily dose OXN PR of 130.7 (26.56) mg (median, maximum: 120 and 180 mg), the Bowel Function Index (BFI) decreased from 45.3 (26.37) to 26.7 (21.37) with the largest decrease seen in the first week. The average pain over the last 24 h remained stable (median Pain Intensity Scale score 4.0) and QoL was maintained throughout the study. Adverse events were consistent with the known effects of OXN PR and no new safety concerns emerged. Equivalent efficacy and safety benefits were observed in cancer patients. Conclusions The OXN PR in doses up to 180/90 mg provides effective analgesia with maintenance of bowel function during long‐term treatment. The beneficial effects of such dose levels of OXN PR contribute to stable patient‐reported QoL and health status despite serious underlying pain conditions, such as cancer. Significance In patients with pain requiring continuous opioid therapy at doses above 80 mg of oxycodone, stable and effective long‐term analgesia can be achieved using OXN PR up to 180/90 mg daily without compromising bowel function and may be preferential to supplemental oxycodone.
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Affiliation(s)
- D Dupoiron
- Département d'Anesthésie - Douleur, Institut de Cancérologie de l'Ouest - Paul Papin, Angers, France
| | - A Stachowiak
- Pallmed sp. z o.o., NZOZ Dom Sue Ryder, Bydgoszcz, Poland
| | - O Loewenstein
- Gemeinschaftspraxis Löwenstein - Dr. Hesselbarth, Schmerz- und Palliativzentrum DGS Mainz, Mainz, Germany
| | - A Ellery
- NHS Kernow Clinical Commissioning Group, Saint Austell, UK
| | - W Kremers
- Mundipharma Research GmbH & Co. KG, Limburg, Germany
| | - B Bosse
- Mundipharma Research GmbH & Co. KG, Limburg, Germany
| | - M Hopp
- Mundipharma Research GmbH & Co. KG, Limburg, Germany
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High dosage of a fixed combination oxycodone/naloxone prolonged release: efficacy and tolerability in patients with chronic cancer pain. Support Care Cancer 2017; 25:3051-3058. [DOI: 10.1007/s00520-017-3709-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/10/2017] [Indexed: 11/25/2022]
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Mercadante S. New drugs for pain management in advanced cancer patients. Expert Opin Pharmacother 2017; 18:497-502. [DOI: 10.1080/14656566.2017.1299711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Koopmans-Klein G, Wagemans MFM, Wartenberg HCH, Van Megen YJB, Huygen FJPM. The efficacy of standard laxative use for the prevention and treatment of opioid induced constipation during oxycodone use: a small Dutch observational pilot study. Expert Rev Gastroenterol Hepatol 2016; 10:547-53. [PMID: 26641540 DOI: 10.1586/17474124.2016.1129275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Dutch clinical guidelines recommend that a standard laxative treatment (SLT) should be prescribed concomitantly when starting opioid treatment to prevent opioid-induced constipation (OIC). METHODS Clinical evidence for SLT in the treatment of OIC is lacking, therefore an observational pilot study was performed to explore the efficacy and tolerability of SLT on OIC in patients treated with the opioid oxycodone. RESULTS Twenty-four patients (58% female, median (range) age 65 (39-92)) were included in this pilot study. The analysis showed that 9 out of 21 patients (43%) were non-responders to SLT. When also taking into consideration patients tending to develop diarrhea 75% of patients are non-responsive to SLT. CONCLUSION This pilot study indicates that optimal laxative therapy (SLT) might not be effective and feasible for the prevention and treatment of OIC.
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Affiliation(s)
- Gineke Koopmans-Klein
- a Medical Department , Mundipharma Pharmaceuticals BV , Hoevelaken , The Netherlands.,b Center for Pain Medicine , Erasmus MC , Rotterdam , The Netherlands
| | - Michel F M Wagemans
- c Department of Anesthesiology and Pain Medicine , Reinier de Graaf , Delft , The Netherlands
| | - Hans C H Wartenberg
- d Department of Anesthesiology, Academisch Medisch Centrum , University of Amsterdam , Amsterdam , the Netherlands
| | - Yvonne J B Van Megen
- a Medical Department , Mundipharma Pharmaceuticals BV , Hoevelaken , The Netherlands
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Hjalte F, Ragnarson Tennvall G, Welin KO, Westerling D. Treatment of Severe Pain and Opioid-induced Constipation: An Observational Study of Quality of Life, Resource Use, and Costs in Sweden. Pain Ther 2016; 5:227-236. [PMID: 27830531 PMCID: PMC5130909 DOI: 10.1007/s40122-016-0059-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Opioid-induced constipation (OIC) is a common and costly side effect of opioid treatment affecting patients' quality of life (QoL). The combination oxycodone/naloxone reduces OIC while providing effective analgesia in patients with moderate to severe pain. The objective of this observational study was to compare health-related quality of life (HRQoL), healthcare resource use, and costs in patients with severe pain who were initially treated with oxycodone and laxatives and then subsequently switched to treatment with oxycodone/naloxone. METHODS Data were collected by means of questionnaires completed by patients with OIC before and after the initiation of oxycodone/naloxone treatment at different clinical centers in Sweden. The questionnaires included questions on healthcare resource use and absence from work and also consisted of the Patient Assessment of Constipation-QoL (PAC-QoL) instrument, the EuroQol five dimensions questionnaire (EQ-5D), the Patient Assessment of Constipation Symptoms (PAC-SYM) instrument, and the Bowel Function Index (BFI). RESULTS The analysis included 37 patients. Resource utilization was lower after treatment with oxycodone/naloxone, in terms of both the number of healthcare contacts and the purchases of medicine for the treatment of constipation. According to the BFI score, patients had fewer problems with OIC after the initiation of oxycodone/naloxone. The PAC-QoL score showed a positive change for patients in both the 96-point dissatisfaction index and the 16-point satisfaction index. PAC-SYM scores was lower after the initiation of oxycodone/naloxone treatment, indicating fewer constipation-related problems. CONCLUSION Treatment with oxycodone/naloxone had an overall positive effect on patients, consisting mainly of decreasing the severity of the constipation problems, increasing HRQoL, and decreasing the use of healthcare resources. FUNDING Mundipharma AB, Gothenburg, Sweden.
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Affiliation(s)
- Frida Hjalte
- IHE, The Swedish Institute for Health Economics, Lund, Sweden.
| | | | - Karl-Olof Welin
- IHE, The Swedish Institute for Health Economics, Lund, Sweden
| | - Dagmar Westerling
- Pain Unit, Department of Anesthesiology, Central Hospital of Kristianstad, Kristianstad, Sweden.,Section of Anaesthesiology and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
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He F, Jiang Y, Li L. The effect of naloxone treatment on opioid-induced side effects: A meta-analysis of randomized and controlled trails. Medicine (Baltimore) 2016; 95:e4729. [PMID: 27631221 PMCID: PMC5402564 DOI: 10.1097/md.0000000000004729] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To evaluate the effects of naloxone on opioid-induced side effects, the present meta-analysis was constructed. METHODS Electronic databases including PubMed, EMBASE, and CNKI (China National Knowledge Internet) were used for literature search. Studies on comparison of opioid-side effects between naloxone-treated group and placebo or normal saline-related group were included in the meta-analysis. Heterogeneity analysis was performed with Chi-square and I test. Pooled analysis was based on fixed-effects model, if heterogeneity between the eligible studies was negligible (I < 50%, P > 0.05), otherwise, random-effects model was used. Sensitivity analysis was applied to assess the robustness of the results and publication bias was evaluated by Begg and Egger test. RESULTS Thirteen studies including 1138 patients were included in the meta-analysis. Pooled analysis indicated that naloxone could significantly reduce the occurrence of pruritus (RR [risk ratio] = 0.252, 95% CI [confidence interval] = 0.137-0.464), nausea (RR = 0.323, 95% CI = 0.245-0.428), and vomiting (RR = 0.338, 95% CI = 0.192-0.593) which were induced by opioids. However, naloxone did not relieve pain (standardized mean difference [SMD] = -0.052, 95% CI = -0.453 to 0.348) and somnolence (RR = 0.561, 95% CI = 0.287 to 1.097) in patients received opioid treatment. Additionally, there were no significant publication bias between the included studies (Begg test, P = 0.602; Egger test, P = 0.388). CONCLUSION Addition of naloxone might act as an effective treatment for prophylaxis of opioid-induced pruritus, nausea, and vomiting in clinical practice.
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Affiliation(s)
- Feifang He
- Department of Anesthesiology & Pain Management, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yilei Jiang
- Department of Anesthesiology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Li Li
- Department of General Practice, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Correspondence: Li Li, Department of General Practice, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3, East Qingchun Road, Hangzhou 310016, Zhejiang, China (e-mail: )
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