Alvimopan for the Management of Postoperative Ileus

Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway

BACKGROUND

Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery.

METHODS

We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4 days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50-75%), positive evidence (75-95%), strong evidence (95-99%), and very strong evidence (> 99%).

RESULTS

There were 323 patients analyzed (mean age 63.5 years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48 h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3 ml/kg/h for laparoscopic and 5 ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI.

CONCLUSIONS

The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.

Increased incidence of prolonged ileus after colectomy for inflammatory bowel diseases under ERAS protocol: a cohort analysis

BACKGROUND

Postoperative ileus is a common problem after colorectal surgery. The aim of the study was to investigate the incidence and risk factors for prolonged postoperative ileus (POI) after colectomy for inflammatory bowel diseases (IBDs).

METHODS

Consecutive patients who underwent colorectal resection for IBD versus colorectal cancer (CRC) patients under enhanced recovery after surgery protocol were retrospectively analyzed. Primary assessment end point is the incidence of prolonged POI (>4 days); secondary end points were GI-2 recovery (time to first toleration of solid food and first bowel movement), nasogastric tube reinsertion, and postoperative length of stay. Risk factors for prolonged POI in IBD patients were assessed by multiple logistic regression analysis with P score matching.

RESULTS

The incidence of prolonged POI was higher in IBD versus CRC group (28.8% versus 14.8%, P < 0.001). Patients with IBD had a longer time to GI-2 recovery (4.8 ± 2.1 versus 3.7 ± 1.4 d, P < 0.001), postoperative length of stay (10.7 ± 6.2 versus 7.9 ± 5.3 d, P < 0.001), higher incidence of nasogastric tube reinsertion (9.8% versus 4.0%, P = 0.02). After propensity-score matching analysis, the differences were still significant. Preoperative steroid use >20 mg/d (odds ratio, [OR] = 2.19, P = 0.048), hypoalbuminemia (<35 g/L; OR 2.72, P = 0.03), systemic inflammatory response syndrome status (OR 4.91, P = 0.03), and postoperative intraabdominal sepsis (OR 9.31, P = 0.001) were independent risk factors for prolonged POI in IBD patients.

CONCLUSIONS

In the setting of enhanced recovery after surgery, colectomy for IBD is associated with delayed gastrointestinal function recovery and higher incidence of prolonged POI compared to CRC patients. Normalizing preoperative albumin level, weaning off steroids, reducing preoperative systemic inflammatory response syndrome, and early management of postoperative intraabdominal sepsis may reduce POI in IBD population.

Alvimopan combined with enhanced recovery strategy for managing postoperative ileus after open abdominal surgery: a systematic review and meta-analysis

BACKGROUND

To assess the efficacy and safety of alvimopan in conjunction with enhanced recovery strategy, compared with this strategy alone, in management of postoperative ileus in patients undergoing open abdominal surgery.

METHODS

Electronic databases were comprehensively searched for relevant randomized controlled trials. We were interested in doses of 6 and 12 mg. The efficacy end points included the time to recovery of full gastrointestinal (GI) function (a composite end point measured by the time to first toleration of solid food [SF] and the time to first passage of stool, GI-2), the recovery of upper (SF) or the lower (the time to first bowel movement, BM) GI function, and the length of hospital stay (the time to discharge order written). Safety end points included GI-related, non-GI-related, and serious adverse events. These parameters were all analyzed by RevMan 5.3 software.

RESULTS

Nine randomized controlled trials involving 4075 patients were enrolled in this study. The pooled results showed that alvimopan significantly decreased the time to GI-2 recovery (6 mg, hazard ratio [HR] = 1.45, P < 0.00001; 12 mg, HR = 1.59, P < 0.00001), BM (6 mg, HR = 1.54, P < 0.00001; 12 mg, HR = 1.74, P = 0.0002), and the time to discharge order written (6 mg, HR = 1.37, P < 0.00001; 12 mg, HR = 1.34, P < 0.00001) compared with the placebo group. However, SF was significantly reduced in 6 mg group (HR = 1.23, P = 0.008) rather than 12 mg group (HR = 1.14, 95% confidence interval 1.00, 1.30, P = 0.04). The incidence of some GI-related and serious adverse events were significantly lower in the alvimopan group than the placebo group, and the dose of 12 mg was superior to 6 mg in this regard.

CONCLUSIONS

Alvimopan can accelerate recovery of GI function (especially for the lower GI tract), shorten the length of hospital stay, and reduce postoperative ileus-related morbidity without compromising opioid analgesia in an enhanced recovery setting.

Si-jun-zi decoction treatment promotes the restoration of intestinal function after obstruction by regulating intestinal homeostasis

Intestinal obstruction is a common disease requiring abdominal surgery with significant morbidity and mortality. Currently, an effective medical treatment for obstruction, other than surgical resection or decompression, does not exist. Si-Jun-Zi Decoction is a famous Chinese medicine used to replenish qi and invigorate the functions of the spleen. Modern pharmacological studies show that this prescription can improve gastrointestinal function and strengthen immune function. In this study, we investigated the effects of a famous Chinese herbal formula, Si-Jun-Zi Decoction, on the restoration of intestinal function after the relief of obstruction in a rabbit model. We found that Si-Jun-Zi Decoction could reduce intestinal mucosal injury while promoting the recovery of the small intestine. Further, Si-Jun-Zi Decoction could regulate the intestinal immune system. Our results suggest that Si-Jun-Zi Decoction promotes the restoration of intestinal function after obstruction by regulating intestinal homeostasis. Our observations indicate that Si-Jun-Zi Decoction is potentially a therapeutic drug for intestinal obstruction.

Recent advances in the pharmaceutical management of pain

Pain is an unpleasant sensory and emotional experience for patients. Management of pain is the most frequent issue encountered by clinicians and treatment is usually with pharmacological therapy. This review discusses recent pharmaceutical advances in pain management with respect to new modes of analgesic delivery, as well as new analgesic agents and adjuvants that are currently being investigated for their analgesic properties. New modes of administration include transdermal delivery in the form of skin patches, transmucosal delivery, inhalational administration, various patient-controlled devices and extended-release analgesic formulations. Up-to-date research is presented on classical analgesics, such as opioids, anti-inflammatory agents, including cyclo-oxygenase-2 inhibitors and paracetamol (acetaminophen), local anesthetics and ketamine. In addition, newer agents such as antidepressants and antiepileptic drugs as well as medicinal cannabinoids are discussed. As our understanding of the multiple pain pathways involved in the pathogenesis of pain expands, further compounds with analgesic properties will be developed.

Postoperative ileus: strategies for reduction

Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI's significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention.

Resolution of opioid-induced postoperative ileus in a newborn infant after methylnaltrexone

Transient impairment of bowel function is a frequent and distressing problem in neonates on opioid-induced analgesia. Methylnaltrexone, a peripheral-acting μ-opioid receptor antagonist, has been studied in adults for the treatment of opioid-induced constipation in advanced illness and has been suggested as a promising therapeutic concept for reducing postoperative ileus. Here, we report on a newborn infant on fentanyl analgesia after major abdominal surgery with aggravated ileus. After 8 days of quiescent bowel, the patient's intestinal dysmotility resolved within 15 minutes after intravenous administration of methylnaltrexone (0.15 mg/kg body weight). Methylnatrexone was repeated daily until cessation of fentanyl administration. There were no signs of pain or opioid withdrawal.

An Evaluation of Alvimopan Use as Part of Perioperative Management of Patients Undergoing Laparoscopic Small and Large Bowel Resections

Objective

Delayed gastrointestinal (GI) recovery (postoperative ileus) is a risk for patients undergoing bowel resection (BR) and presents clinical challenges including prolonged hospital length of stay (LOS) and increased postoperative morbidity. Alvimopan, an oral, peripherally acting mu-opioid receptor antagonist, is the first therapy approved to accelerate GI recovery after BR. Published data have described alvimopan use in open BR. In contrast, this study focused on laparoscopic BR.

Methods

Historic data were retrospectively collected and alvimopan data were prospectively collected from 1 surgeon at our facility. Adults undergoing laparoscopic partial small or large BR with primary anastamosis scheduled to receive intravenous, opioid-based, patient-controlled analgesia were eligible. Pregnancy, opioid analgesic on the home medication reconciliation form, complete bowel obstruction, colostomy or ileostomy creation, and unplanned surgery were exclusion criteria. All patients were uniformly managed with a standardized accelerated postoperative care pathway to facilitate GI recovery. LOS, time to first bowel movement (BM), 30-day readmission rate, and the cost were evaluated. Data were analyzed using Pearson chi-square and independent samples t tests.

Results

Thirty-nine alvimopan and 56 historic cohort patients were included. Time to first BM was reduced by 1.2 days and LOS was reduced by 1.1 days (both P < .001) in the alvimopan cohort compared with control. Overall variable cost data were reduced by $1,368 in the alvimopan cohort. Readmission rates were low and comparable.

Conclusions

Laparoscopic surgery can decrease LOS compared with open BR; however, alvimopan use at our facility reduced LOS and time to BM while remaining cost-effective in this patient population.

Anesthetic Routines: The Anesthesiologist's Role in GI Recovery and Postoperative Ileus

All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system.

Nutritional strategies in severe acute pancreatitis: a systematic review of the evidence

Nutrition in severe acute pancreatitis is a critical aspect in the management of this condition. This review aims to systematically review the evidence available to inform the use of nutritional support in severe acute pancreatitis. High quality (level 1) evidence supports naso-jejunal enteral nutrition (NJ-EN) over parenteral nutrition (PN) reducing infectious morbidity and showing a trend towards reduced organ failure although there is no detectable difference in mortality. Trial data may underestimate benefit as patients are often recruited with predicted rather than proven severe disease. NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often impractical and naso-gastric (NG) feeding seems to be equivalent in terms of safety and outcomes whilst being more practical (level 2 evidence). Regarding feed supplementation, probiotic feed supplementation is not beneficial (level 1 evidence) the and may cause harm with excess mortality (level 2 evidence). No evidence exists to confirm benefit of the addition of prokinetics in severe acute pancreatitis (SAP) although their use is proven in other critically ill patients. Level 2 evidence does not currently support the use of combination immuno-nutrition though further work on individual agents may provide differing results. Level 2 evidence does not support intravenous supplementation of anti-oxidants and has demonstrated that these too may cause harm.

Postoperative ileus: it costs more than you expect

BACKGROUND

The clinical impact of postoperative ileus (POI) after colectomy is difficult to quantify financially because of administrative coding limitations. Accurate data are important to allow pharmaco-economic analysis of methods aimed at reducing POI. The aim of this study was to assess the financial impact of POI for the 30-day episode of care for colectomy.

STUDY DESIGN

We reviewed all colectomy patients at our institution from July 2007 to June 2008. Primary POI was defined as more than three episodes of emesis with return to NPO diet status and/or reinsertion of nasogastric tube; secondary POI was associated with intraabdominal complications. Readmission for gastrointestinal failure was defined as delayed POI (no radiologic or surgical identification of small bowel obstruction). All other complications requiring readmission were grouped together for analysis. Data reviewed included primary admission and readmission costs, reason for readmission, intervention, index and total length of stay, narcotic use, time to ambulation, and time to enteral feeds.

RESULTS

One hundred eighty-six colectomies were eligible for analysis, with 45 cases (38 primary and 7 secondary) of POI during the index admission. The total cost was significantly higher for patients with POI ($16,612 versus $8,316; p < 0.05). However, readmission costs were not statistically different for delayed POI and other complications ($3,546 versus $6,705).

CONCLUSIONS

POI occurred in 24% (84% primary) of colectomy patients and disproportionately affected cost at the index admission. Interestingly, delayed POI was similar in cost to readmission for other serious adverse surgical complications.

Recent Advances in Pharmacotherapy

Many unique and clinically important medications were approved by the Food and Drug Administration from December 2007 through May 2008 for various conditions encountered in an internal medicine setting. These new treatments dramatically vary in their targeted body system and include agents for the cardiovascular system (nebivolol), central nervous system (desvenlafaxine), gastrointestinal tract (certolizumab, methylnaltrexone, and alvimopan), immunological function (etravirine), and metabolic function (sapropterin). This article discusses medications by their respective body system. Each review is comprised of an overview of the Food and Drug Administration–approved indication and the drug’s role in treatment of that disease state. Current dosing guidance, clinical efficacy and clinically relevant adverse drug reactions, drug interactions, contraindications, and precautions are also presented. This review is designed to focus on the new molecular entities and biological approvals clinicians may potentially encounter in an internal medicine practice.

Peripherally acting mu-opioid receptor antagonists and postoperative ileus: mechanisms of action and clinical applicability

Postoperative ileus (POI), a transient cessation of coordinated bowel function after surgery, is an important health care problem. The etiology of POI is multifactorial and related to both the surgical and anesthetic pathways chosen. Opioids used to manage surgical pain can exacerbate POI, delaying gastrointestinal (GI) recovery. Peripherally acting mu-opioid receptor (PAM-OR) antagonists are designed to mitigate the deleterious effects of opioids on GI motility. This new class is investigational for POI management with the goal of accelerating the recovery of upper and lower GI tract function after bowel resection. In this review, we summarize the mechanisms by which POI occurs and the role of opioids and opioid receptors in the enteric nervous system, discuss the mechanism of action of PAM-OR antagonists, and review clinical pharmacology and Phase II/III POI trial results of methylnaltrexone and alvimopan. Finally, the role of anesthesiologists in managing POI in the context of a multimodal approach is discussed.

Safety and efficacy update: Alvimopan in postoperative ileus

Postoperative ileus (POI) in patients undergoing abdominal surgery is associated with significant morbidity. In 2008, alvimopan (Entereg®) was approved by the Food and Drug Administration (FDA), and is the only available POI therapy in the United States for patients undergoing bowel resection. Data from preclinical studies demonstrate that alvimopan and its primary metabolite, ADL 08-0011, behave as potent μ. opioid receptor antagonists. In animals, alvimopan and ADL 08-0011 attenuate opioid agonist-induced reductions in gastrointestinal (GI) transit. Higher doses of alvimopan are required to inhibit opioid-induced analgesia as a result of its inability to penetrate the central nervous system (CNS). ADL 08-0011 is also peripherally selective, although to a lesser degree than alvimopan. In multiple species, including humans, alvimopan has low oral bioavailability, while ADL 08-0011, following its generation by human gut microflora, is more readily absorbed and achieves higher exposures. Three Phase 2 and five Phase 3 clinical trials have been conducted to investigate the efficacy and tolerability of alvimopan in patients undergoing bowel resection. An additional Phase 3 study was conducted in hysterectomy patients. In the majority of the studies, statistically significant, and clinically meaningful, acceleration of GI recovery has been demonstrated. Consistent with animal data, alvimopan has no effect on opioid agonist-induced analgesia in healthy human subjects and POI patients. Clinical experience to date in POI patients indicates that alvimopan is well tolerated when used according to its approved dosing regimen (12 mg b.i.d. for up to 7 days). In this article, the preclinical and clinical properties of alvimopan are reviewed.

Clinical trial: alvimopan for the management of post-operative ileus after abdominal surgery: results of an international randomized, double-blind, multicentre, placebo-controlled clinical study

BACKGROUND

Post-operative ileus (POI) affects most patients undergoing abdominal surgery.

AIM

To evaluate the effect of alvimopan, a peripherally acting mu-opioid receptor antagonist, on POI by negating the impact of opioids on gastrointestinal (GI) motility without affecting analgesia in patients outside North America.

METHODS

Adult subjects undergoing open abdominal surgery (n = 911) randomly received oral alvimopan 6 or 12 mg, or placebo, 2 h before, and twice daily following surgery. Opioids were administered as intravenous patient-controlled analgesia (PCA) or bolus injection. Time to recovery of GI function was assessed principally using composite endpoints in subjects undergoing bowel resection (n = 738).

RESULTS

A nonsignificant reduction in mean time to tolerate solid food and either first flatus or bowel movement (primary endpoint) was observed for both alvimopan 6 and 12 mg; 8.5 h (95% CI: 0.9, 16.0) and 4.8 h (95% CI: -3.2, 12.8), respectively. However, an exploratory post hoc analysis showed that alvimopan was more effective in the PCA (n = 317) group than in the non-PCA (n = 318) group. Alvimopan was well tolerated and did not reverse analgesia.

CONCLUSION

Although the significant clinical effect of alvimopan on reducing POI observed in previous trials was not reproduced, this trial suggests potential benefit in bowel resection patients who received PCA.

Adynamic ileus and acute colonic pseudo-obstruction

Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.

Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use

BACKGROUND

Postoperative ileus is a transient cessation of bowel motility that occurs after bowel resection (BR). Alvimopan, a peripherally acting mu-opioid receptor antagonist accelerated gastrointestinal (GI) recovery in 5 randomized, double-blind, phase III postoperative ileus trials.

METHODS

Individual covariates (age, gender, race) were assessed separately using Cox proportional hazards models that included the main effects of treatment and covariate factor. Time-to-GI recovery (GI-3 [first toleration of solid food and first bowel movement or flatus]; GI-2 [first toleration of solid food and first bowel movement]) for patients who underwent open laparotomy for BR in the absence of epidural anesthesia and received alvimopan (12 mg) or placebo was analyzed within subgroups (age, gender, race, concomitant medication use) using Cox proportional hazards models to generate hazard ratios (HRs). P values were calculated with the Wald chi2 test.

RESULTS

Elderly (>or=65 years), male, and nonwhite patients achieved GI-3 recovery later than younger (<65 years), female, and white patients (HR > 1 and P < .05 for all). Overall, alvimopan (12 mg) accelerated GI-3 recovery by 12 hours and GI-2 recovery by 17 hours compared with placebo. Within subgroups, regardless of covariate effect, patients who received alvimopan (12 mg) achieved GI-2 and GI-3 recovery sooner than patients who received placebo (HR > 1 and P < .05 for all).

CONCLUSIONS

These post hoc analyses support that alvimopan (12 mg) accelerates GI recovery across various patient populations.

Postoperative Ileus-Related Morbidity Profile in Patients Treated with Alvimopan after Bowel Resection

BACKGROUND

Postoperative ileus (POI), an interruption of coordinated bowel motility after operation, is exacerbated by opioids used to manage pain. Alvimopan, a peripherally acting mu-opioid receptor antagonist, accelerated gastrointestinal (GI) recovery after bowel resection in randomized, double-blind, placebo-controlled, multicenter phase III POI trials. The effect of alvimopan on POI-related morbidity for patients who underwent bowel resection was evaluated in a post-hoc analysis.

STUDY DESIGN

Incidence of POI-related postoperative morbidity (postoperative nasogastric tube insertion or POI-related prolonged hospital stay or readmission) was analyzed in four North American trials for placebo or alvimopan 12 mg administered 30 minutes or more preoperatively and twice daily postoperatively until hospital discharge (7 or fewer postoperative days). GI-related adverse events and opioid consumption were summarized for each treatment. Estimations of odds ratios of alvimopan to placebo and number needed to treat (NNT) to prevent one patient from experiencing an event of POI-related morbidity were derived from the analysis.

RESULTS

Patients receiving alvimopan 12 mg were less likely to experience POI-related morbidity than patients receiving placebo (odds ratio = 0.44, p < 0.001). Fewer patients receiving alvimopan (alvimopan, 7.6%; placebo, 15.8%; NNT = 12) experienced POI-related morbidity. There was a lower incidence of postoperative nasogastric tube insertion, and other GI-related adverse events on postoperative days 3 to 6 in the alvimopan group than the placebo group. Opioid consumption was comparable between groups.

CONCLUSIONS

Alvimopan 12 mg was associated with reduced POI-related morbidity compared with placebo, without compromising opioid-based analgesia in patients undergoing bowel resection. Relatively low NNTs are clinically meaningful and reinforce the potential benefits of alvimopan for the patient and health care system.

Treatment of opioid-induced gut dysfunction

Opioid analgesics are the mainstay in the treatment of moderate-to-severe pain, yet their use is frequently associated with adverse effects, the most common and debilitating being constipation. Opioid-induced motor stasis results from blockade of gastrointestinal peristalsis and fluid secretion, and reflects the action of the endogenous opioid system in the gut. Methylnaltrexone and alvimopan are new investigational drugs that selectively target peripheral mu-opioid receptors because they are poorly absorbed in the intestine and do not enter the brain. Clinical studies have proved the concept that these drugs prevent opioid-induced bowel dysfunction without interfering with analgesia. As reviewed in this article, opioid receptor antagonists with a peripherally restricted site of action also hold therapeutic promise in postoperative ileus and chronic constipation due to the fact that they have been found to stimulate intestinal transit.

Projecting future drug expenditures—2007

PURPOSE

Drug expenditure trends in 2005 and 2006, projected drug expenditures for 2007, and factors likely to influence drug costs are discussed.

SUMMARY

Various factors are likely to affect drug costs, including drug prices, drugs in development, and generic drugs. In 2005, there was a continued moderation of the increase in drug expenditures. Total prescription drug expenditures increased by 5.5% from 2004 to 2005, with total spending rising from $239 billion to $252 billion. Through the first nine months of 2006, hospital drug expenditures increased by only 3% compared with 2005. This moderation of the growth of prescription drug expenditures can be attributed to three major factors: availability of major prescription drugs in generic form, continued increase in cost sharing for employees in employer-sponsored health plans, and decreased use due to safety concerns. It is expected that expenditures in 2007 will be influenced by similar factors, with few costly new products reaching the market, increased concern over product safety reducing the use of older agents and slowing the diffusion of newer agents that do reach the market, and several important patent expirations, leading to slower growth in expenditures.

CONCLUSION

In 2007, we project a 5-7% increase in drug expenditures in outpatient settings, a 14-16% increase in clinics, and a 4-6% increase in hospitals.

Use of novel prokinetic agents to facilitate return of gastrointestinal motility in adult critically ill patients

PURPOSE OF REVIEW

Intolerance of enteral feeding due to impaired gastrointestinal motility is common in critically ill patients. Strategies to prevent or treat gastrointestinal hypomotility include the use of prokinetic agents. Many currently employed prokinetic agents are associated with serious adverse drug reactions. The novel prokinetic agents - alvimopan, tegaserod, and dexloxiglumide - are reviewed.

RECENT FINDINGS

Alvimopan exerts mixed, but generally favorable, effects on restoration of gastrointestinal motility in patients with postoperative ileus. The observation of increased opioid requirements (without increased pain scores) and associated clinical ramifications requires further study. Tegaserod stimulates the peristaltic reflex and improves motility in multiple sites along the gastrointestinal tract. Its efficacy in improving gastrointestinal hypomotility in the critically ill population has not yet been determined. Furthermore, its use has been associated with the development of ischemic colitis and increased requirement for abdominal/pelvic surgery. Dexloxiglumide may be beneficial for improving gastric emptying in critically ill patients, especially those receiving lipid-enriched enteral feeds.

SUMMARY

Novel prokinetic agents show promise for management of gastrointestinal hypomotility in the critically ill population. However, further study is required before these agents can be recommended for use.

Peripherally Acting Mu-Opioid-Receptor Antagonists and the Connection Between Postoperative Ileus and Pain Management: The Anesthesiologist’s View and Beyond

The adverse effects of opioids are well documented. Because opioid receptors have a wide-ranging anatomic distribution, the effects subsequent to opioid binding, both good and bad, occur centrally and in the periphery. Postoperative strategies to reduce opioid burden, therefore, are in the patient's best interest. Multimodal analgesia is the key towards balancing the need for opioids while simultaneously reducing their burden. Alternative anesthesia and analgesia options such as regional anesthesia, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 enzyme inhibitors should be considered part of multimodal protocols. Familiarity of where these drugs are active in the body and how they can be employed is imperative for all surgical team members. Optimal implementation of multimodal approaches can reduce hospital stay and improve clinical outcomes, including patient satisfaction. Finally, strategies that may help reduce rates of hospital readmission also contribute to overall improved outcome. New peripherally acting mu-opioid-receptor antagonists represent significant progress in the ability of perianesthesia nurses to play an even greater role in achieving these goals. In contrast to older opioid-receptor antagonists, these agents specifically target an important aspect of the multifactorial etiology of postoperative ileus (POI), mu-opioid-receptor-mediated activity in the GI tract. In addition, they do not pass the blood-brain barrier or diminish opioid-mediated analgesia. Advanced clinical trials have already demonstrated the ability of one of these agents, alvimopan, to reduce POI and improve other postoperative outcomes while maintaining adequate analgesia. Combined with other options aimed at reducing opioid burden, alvimopan and similar drugs in development hold promise as part of multimodal protocols to optimize pain management while minimizing postoperative morbidities.

Nurses Are Everywhere: A Practical Perspective on the Surgical Team in Managing Postoperative Ileus

Because the availability of new, peripherally acting mu-opioid-receptor antagonists is expected soon, it is important for all members of the surgical team to familiarize themselves with new approaches and also re-evaluate older approaches to help improve patient outcomes. "Preop nurses" have numerous responsibilities, among which are mitigating some of the adverse outcomes of surgery such as postoperative ileus (POI), making these nursing personnel indispensable to the proper implementation of multimodal management protocols for POI. Establishing basic preoperative procedures is an important primary consideration. Preoperative evaluation of general health, medical history (including surgical history), and an assessment of gastrointestinal (GI) function and habits should all be part of careful up-front assessment for each patient, especially because POI and other GI adverse effects are so often encountered in the PACU. Hand-in-hand with how we as nurses interact with our surgical colleagues is patient education regarding hospitalization and postrecovery expectations. PACU nurses will be key players in maintaining proper implementation of multimodal regimens, essentially doing this in two "phases": Phase I interventions comprise the ongoing assessment and monitoring of patients, administering medications, and evaluating patient satisfaction and overall status; Phase II considerations encompass a further set of practice guidelines that center on optimizing discharge status, including pain management and education as well as other discharge needs. Where new agents may fit into multimodal regimens that optimally incorporate preoperative and postanesthesia protocols remains to be determined. What is clear is that as nurses and the entire surgical team strive to enhance patient satisfaction, nursing personnel must assume leadership roles in how new multimodal strategies are implemented and executed. Advanced clinical data for the new peripherally acting mu-opioid-receptor antagonist alvimopan, and for the drug class as a whole, have contributed to a greater impetus on reassessing perioperative protocols and policy, helping to broach innovative clinical frontiers of how we treat pain and POI, and thus improve patient outcomes.