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Liu X, Yu N, Lu H, Zhang P, Liu C, Liu Y. Effect of opioids on constipation in critically ill patients: A meta-analysis. Aust Crit Care 2024; 37:338-345. [PMID: 37586897 DOI: 10.1016/j.aucc.2023.06.006] [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: 04/17/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES This meta-analysis evaluated the effect of opioids on constipation in ICU patients. REVIEW METHOD USED Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang DATA databases. REVIEW METHODS Random or fixed-effects meta-analyses were used. Subgroup analysis was performed according to the definition of constipation (three vs. six days), opioids (fentanyl vs. morphine), study design (prospective vs. retrospective), adjustment of confounders (No vs. Yes), and patient's age (adults vs. children). We used sensitivity analysis to test the robustness of results with significant statistical heterogeneity. RESULTS Seven studies (2264 patients) were included. Opioid use in ICU patients was associated with an increased risk of constipation (relative risk [RR]=1.14; 95% confidence interval [CI]=1.05 to 1.24; I2=49.8%). Subgroup analysis further showed that adjustment form, category of opioid, study design, and patient's age significantly influenced the relationship between opioid use and the risk of constipation. Sensitivity analysis confirmed the robustness of pooled results. CONCLUSION Opioids significantly increase the risk of constipation in critically ill patients, especially children. It is worth noting that the adjustment of the constipation definition used for ICU significantly influenced the relationship between opioid use and the risk of constipation. Therefore, It is necessary to clearly define ICU constipation and conduct time-based layered treatment. Additional prospective studies are needed to investigate the consistent definition of ICU constipation.
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Affiliation(s)
- Xuefang Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ning Yu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huaihai Lu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pei Zhang
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chao Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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Abstract
Opioid-related constipation encompasses constipation directly caused by opioid use (opioid-induced constipation [OIC]) as well as pre-existing constipation worsened by opioid use (opioid-exacerbated constipation [OEC]). Over-the-counter laxatives should be used as first-line agents for both OIC and OEC, given their efficacy, low cost, and high safety profiles. Symptoms of OIC and responses to therapy can be assessed with the Bowel Function Index. Individuals with OIC refractory to laxatives may be responsive to peripherally acting μ-opioid receptor antagonists. Although data supporting the superiority of one prescription agent over another is lacking, all have proven effective for the treatment of OIC.
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Coluzzi F, Alvaro D, Caraceni AT, Gianni W, Marinangeli F, Massazza G, Pinto C, Varrassi G, Lugoboni F. Common Clinical Practice for Opioid-Induced Constipation: A Physician Survey. J Pain Res 2021; 14:2255-2264. [PMID: 34335054 PMCID: PMC8318709 DOI: 10.2147/jpr.s318564] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/02/2021] [Indexed: 12/20/2022] Open
Abstract
Background Opioid-induced constipation (OIC) remains an important clinical obstacle despite the availability of several guidelines and pharmacological options for its management. Here, we surveyed common practices and perceptions about OIC among physicians who prescribe opioids in Italy. Methods The online survey included 26 questions about OIC. Responses were analyzed descriptively and aggregated by physician specialty. Results A total of 501 physicians completed the survey. Most respondents (67%) did not feel adequately educated about OIC despite general consensus regarding interest in the topic. Overall, 62–75% of physicians regularly evaluated intestinal function or OIC symptoms in patients receiving opioid therapy. The most common method for assessment was patient diary; few physicians used a validated instrument such as the Rome IV criteria. Psychiatrists and addiction specialists showed the lowest interest and poorest practices. Most respondents (78%) preferred macrogol prophylaxis followed by macrogol plus another laxative for first-line treatment of OIC symptoms. Peripheral-acting mu opioid receptor antagonists (PAMORAs) were not widely used among physicians; 61% had never prescribed a PAMORA for OIC. Conclusion Our findings reveal important differences in clinical practice for OIC across physician specialties. Additional formative efforts are necessary to improve awareness about best practices in OIC.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, LT, Italy.,Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant'Andrea University Hospital, Rome, RM, Italy
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Gastroenterology Division, Sapienza University of Rome, Rome, RM, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy, and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, MI, Italy
| | - Walter Gianni
- Department of Internal Medicine and Geriatric Medicine, University Hospital Policlinico Umberto I, Rome, RM, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Pain Medicine, and Palliative care, University of L'Aquila, L'Aquila, AQ, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin and "Città della Salute e della Scienza" University Hospital, Torino, TO, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Clinical Cancer Center, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, RE, Italy
| | | | - Fabio Lugoboni
- Department of Medicine, Addiction Unit, University Hospital of Verona, Verona, VR, Italy
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Alvaro D, Caraceni AT, Coluzzi F, Gianni W, Lugoboni F, Marinangeli F, Massazza G, Pinto C, Varrassi G. What to Do and What Not to Do in the Management of Opioid-Induced Constipation: A Choosing Wisely Report. Pain Ther 2020; 9:657-667. [PMID: 32940898 PMCID: PMC7648765 DOI: 10.1007/s40122-020-00195-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Despite the essential utility of opioids for the clinical management of pain, opioid-induced constipation (OIC) remains an important obstacle in clinical practice. In patients, OIC hinders treatment compliance and has negative effects on quality of life. From a clinician perspective, the diagnosis and management of OIC are hampered by the absence of a clear, universal diagnostic definition across disciplines and a lack of standardization in OIC treatment and assessment. Methods A multidisciplinary panel of physician experts who treat OIC was assembled to identify a list of ten corrective actions—five “things to do” and five “things not to do”—for the diagnosis and management of OIC, utilizing the Choosing Wisely methodology. Results The final list of corrective actions to improve the diagnosis and clinical management of OIC emphasized a need for: (i) better physician and patient education regarding OIC; (ii) systematic use of diagnostically validated approaches to OIC diagnosis and assessment (i.e., Rome IV criteria and Bristol Stool Scale, respectively) across various medical contexts; and (iii) awareness about appropriate, evidence-based treatments for OIC including available peripheral mu-opioid receptor antagonists (PAMORAs). Conclusions Physicians who prescribe long-term opioids should be forthcoming with patients about the possibility of OIC and be adequately versed in the most recent guideline recommendations for its management.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Gastroenterology Division, Sapienza University of Rome, Rome, RM, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy, and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, MI, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, LT, Italy.
- Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant'Andrea University Hospital, Rome, RM, Italy.
| | - Walter Gianni
- Department of Internal Medicine and Geriatry, University Hospital Policlinico Umberto I, Rome, RM, Italy
| | - Fabio Lugoboni
- Department of Medicine, Addiction Unit, University Hospital of Verona, Verona, VR, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Pain Medicine, and Palliative care, University of L'Aquila, L'Aquila, AQ, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin and "Città della Salute e della Scienza" University Hospital, Turin, TO, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Clinical Cancer Center, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, RE, Italy
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Mesía R, Virizuela Echaburu JA, Gómez J, Sauri T, Serrano G, Pujol E. Opioid-Induced Constipation in Oncological Patients: New Strategies of Management. Curr Treat Options Oncol 2019; 20:91. [PMID: 31853656 PMCID: PMC6920224 DOI: 10.1007/s11864-019-0686-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Cancer-associated pain has traditionally been treated with opioid analgesics, often in escalating doses. Opioid-induced constipation (OIC) is a common problem associated with chronic use of opioid analgesics. Typical treatment strategies to alleviate constipation are based on dietary changes, exercise, and laxatives. However, laxatives have a nonspecific action and do not target underlying mechanisms of OIC. This article will review prevalent, clinical presentation and recommendations for the treatment of OIC. An independent literature search was carried out by the authors. We reviewed the literature for randomized controlled trials that studied the efficacy of laxatives, naloxone, and naloxegol in treating OIC. Newer strategies addressing the causal pathophysiology of OIC are needed for a more effective assessment and management of OIC. Finally, traditional recommended therapies are appraised and compared with the latest pharmacological developments. Future research should address whether naloxegol is more efficacious by its comparison directly with first-line treatments, including laxatives.
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Affiliation(s)
- Ricard Mesía
- Servicio de Oncología Médica, Instituto Catalán de Oncología, Badalona, Spain
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Lang-Illievich K, Bornemann-Cimenti H. Opioid-induced constipation: a narrative review of therapeutic options in clinical management. Korean J Pain 2019; 32:69-78. [PMID: 31091505 PMCID: PMC6549585 DOI: 10.3344/kjp.2019.32.2.69] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/02/2019] [Accepted: 01/14/2019] [Indexed: 12/12/2022] Open
Abstract
Pain therapy often entails gastrointestinal adverse events. While opioids are effective drugs for pain relief, the incidence of opioid-induced constipation (OIC) varies greatly from 15% to as high as 81%. This can lead to a significant impairment in quality of life, often resulting in discontinuation of opioid therapy. In this regard, a good doctor-patient relationship is especially pivotal when initiating opioid therapy. In addition to a detailed history of bowel habits, patient education regarding the possible gastrointestinal side effects of the drugs is crucial. In addition, the bowel function must be regularly evaluated for the entire duration of treatment with opioids. Furthermore, if the patient has preexisting constipation that is well under control, continuation of that treatment is important. In the absence of such history, general recommendations should include sufficient fluid intake, physical activity, and regular intake of dietary fiber. In patients of OIC with ongoing opioid therapy, the necessity of opioid use should be critically reevaluated in terms of an with acceptable quality of life, particularly in cases of non-cancer pain. If opioids must be continued, lowering the dose may help, as well as changing the type of opioid. If these measures do not suffice, the next step for persistent OIC is the administration of laxatives. If these are ineffective as well, treatment with peripherally active μ-opioid receptor antagonists should be considered. Enemas and irrigation are emergency measures, often used as a last resort.
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Affiliation(s)
- Kordula Lang-Illievich
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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Song X, Wang D, Qu X, Dong N, Teng S. A meta-analysis of naldemedine for the treatment of opioid-induced constipation. Expert Rev Clin Pharmacol 2019; 12:121-128. [PMID: 30652502 DOI: 10.1080/17512433.2019.1570845] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Opioid-induced constipation (OIC) is a common adverse effect in patients under long-term opioid therapy. Naldemedine is a novel peripherally acting μ-opioid receptor antagonists being developed for the treatment of OIC without affecting central analgesia. This meta-analysis is to assess the current evidence for efficacy and safety of naldemedine for the treatment of OIC. Areas covered: We searched through MEDLINE, EMBASE, Web of Science and Cochrane Library, 'ISRCTN Register' and'ClinicalTrials.gov' (up to Aug 2018). Our final review included five randomized clinical trials (1751 participants in total), three trials observed naldemedine for the treatment of OIC in non-cancer patients and two trials in cancer patients. A Random Effects model was used for all comparisons. Subgroup analyses for the following subgroups were carried out: naldemedine 0.1 mg; 0.2 mg; 0.4 mg; cancer patients; non-cancer patients. Expert opinion: Naldemedine improved the proportion of responders and spontaneous bowel movements frequency. The incidence of serious adverse effects (AEs) in naldemedine group was higher than placebo, especially in cancer patient subgroup. The AEs occurred in participants with naldemedine were mild to moderate and well tolerated during treatment. The results of this network meta-analysis will guide the future researchers in evaluating naldemedine for the treatment of OIC.
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Affiliation(s)
- Xuesong Song
- a Department of Anesthesiology , the First Hospital of Jilin University , Changchun , China
| | - Dunwei Wang
- a Department of Anesthesiology , the First Hospital of Jilin University , Changchun , China
| | - Xiaoyu Qu
- b Department of Pharmacy , the First Hospital of Jilin University , Changchun , China
| | - Naifu Dong
- a Department of Anesthesiology , the First Hospital of Jilin University , Changchun , China
| | - Shiyong Teng
- a Department of Anesthesiology , the First Hospital of Jilin University , Changchun , China
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Mozaffari S, Nikfar S, Abdollahi M. Methylnaltrexone bromide for the treatment of opioid-induced constipation. Expert Opin Pharmacother 2018; 19:1127-1135. [DOI: 10.1080/14656566.2018.1491549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Shilan Mozaffari
- Division of Pharmaceutical and Narcotic Affaire, Vice Chancellor for Food and Drug, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy and Pharmaceutical Policy Research Center, Tehran University of Medical Sciences, Tehran, Iran
- The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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