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Squeo F, Celiberto F, Ierardi E, Russo F, Riezzo G, D’Attoma B, Leo AD, Losurdo G. Opioid-induced Constipation: Old and New Concepts in Diagnosis and Treatment. J Neurogastroenterol Motil 2024; 30:131-142. [PMID: 38576366 PMCID: PMC10999847 DOI: 10.5056/jnm23144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 04/06/2024] Open
Abstract
Daily use of opioid analgesics has significantly increased in recent years due to an increasing prevalence of conditions associated with chronic pain. Opioid-induced constipation (OIC) is one of the most common, under-recognized, and under-treated side effects of opioid analgesics. OIC significantly reduces the quality of life by causing psychological distress, lowering work productivity, and increasing access to healthcare facilities. The economic and social burden of OIC led to the development of precise strategies for daily clinical practice. Key aspects are the prevention of constipation through adequate water intake and fiber support, avoidance of sedentariness, and early recognition and treatment of cofactors that could worsen constipation. Recommended first-line therapy includes osmotic (preferably polyethylene glycol) and stimulant laxatives. Peripherally acting μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, or naldemedine, should be used in patients that have not responded to the first-line treatments. The bowel functional index is the main tool for assessing the severity of OIC and for monitoring the response. The paper discusses the recent literature on the pathophysiology, clinical evaluation, and management of OIC and provides a pragmatic approach for its assessment and treatment.
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Affiliation(s)
- Francesco Squeo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesca Celiberto
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
- PhD Course in Organs and Tissues Transplantation and Cellular Therapies, Department of Precision Medicine Jonic Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Russo
- Functional Gastrointestinal Disorders Research Group, National Institute of Gastroenterology IRCCS “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Giuseppe Riezzo
- Functional Gastrointestinal Disorders Research Group, National Institute of Gastroenterology IRCCS “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Benedetta D’Attoma
- Functional Gastrointestinal Disorders Research Group, National Institute of Gastroenterology IRCCS “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
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Jesuyajolu DA, Abubakar AK, Kowe T, Ogunlade S, Abioye AI, Tangeman J, Latuga N, Omotayo MO. The Management of Opioid-Induced Constipation in Cancer and Advanced Illness: A Meta-Analysis. J Pain Symptom Manage 2024; 67:e285-e297. [PMID: 38092261 DOI: 10.1016/j.jpainsymman.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024]
Abstract
CONTEXT Constipation is a common problem among patients with cancer. By some accounts, about 60% of cancer patients experience constipation. There is limited empirical evidence of the clinical effectiveness of pharmacologic agents in opioid-induced constipation in advanced diseases. OBJECTIVES We sought to quantitatively summarize the therapeutic effectiveness of the pharmacologic means of managing opioid-induced constipation. METHODS Randomized control trials (RCTs) identified from medical literature databases that reported quantitative measures of the effect of pharmacotherapeutic agents to treat opioid induced constipation in patients with cancers and other advanced illnesses were included in this study. A conventional random effects meta-analysis was conducted including >3 trials with the same exposure and outcome assessed, and a network-meta-analysis was conducted for all placebo-controlled trials. RESULTS Eighteen studies that examined the effect of various pharmacotherapeutic agents were included. The medications were Methylnatrexone (N = 5), Naldemedine (N = 5), other conventional agents (N = 4) and herbal medicines (N = 4). In conventional meta-analysis, methylnaltrexone increased the proportion achieving rescue-free laxation by 2.68 fold (95% CI: 1.34, 5.37; P = 0.0054) within 4 hours of the administration compared to placebo. In network meta-analysis, the pooled RR of the pharmacotherapeutic agents on rescue-free bowel movements as 2.26 (95% CI: 1.52, 3.36) for methylnaltrexone, 1.58 (95% CI: 0.94, 2.66) for naldemedine, and 0.74 (95% CI: 0.45, 1.23) for polyethylene glycol, compared to placebo. CONCLUSION Methylnatrexone and Naldemedine have currently shown promise in randomized trials concerning opioid-induced constipation in cancer and advanced illness. It is imperative that future research ascertain not just the relative therapeutic efficacy but also the cost-benefit analyses of these newer regimens with more commonly used and accessible laxatives.
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Affiliation(s)
| | - Aminu Kende Abubakar
- Kebbi Medical Centre (A.K.A.), Kebbi State Ministry of Health, Birnin-Kebbi, Nigeria
| | - Temitope Kowe
- StatsClinic Inc. (T.K., A.I.A.), Barrington, Rhode Island
| | - Samuel Ogunlade
- Faculty of Clinical Sciences (S.O.), Olabisi Onabanjo University, Sagamu, Ogun State, Nigeria
| | - Ajibola Ibraheem Abioye
- StatsClinic Inc. (T.K., A.I.A.), Barrington, Rhode Island; Avicenna Research and Insights Center (A.I.A.), Bariga, Lagos, Nigeria
| | - John Tangeman
- Center for Palliative Health (J.T., N.L., M.O.O.), Buffalo, New York
| | - Natalie Latuga
- Center for Palliative Health (J.T., N.L., M.O.O.), Buffalo, New York
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Cook ME, Knoph CS, Fjelsted CA, Frøkjær JB, Bilgrau AE, Novovic S, Jørgensen MT, Mortensen MB, Nielsen LBJ, Hadi A, Berner-Hansen M, Rutkowski W, Vujasinovic M, Löhr M, Drewes AM, Olesen SS. Effects of a peripherally acting µ-opioid receptor antagonist for the prevention of recurrent acute pancreatitis: study protocol for an investigator-initiated, randomized, placebo-controlled, double-blind clinical trial (PAMORA-RAP trial). Trials 2023; 24:301. [PMID: 37127657 PMCID: PMC10150502 DOI: 10.1186/s13063-023-07287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/31/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Acute and chronic pancreatitis constitute a continuum of inflammatory disease of the pancreas with an increasing incidence in most high-income countries. A subset of patients with a history of pancreatitis suffer from recurrence of acute pancreatitis attacks, which accelerate disease progression towards end-stage chronic pancreatitis with loss of exocrine and endocrine function. There is currently no available prophylactic treatment for recurrent acute pancreatitis apart from removing risk factors, which is not always possible. Pain is the primary symptom of acute pancreatitis, which induces the endogenous release of opioids. This may further be potentiated by opioid administration for pain management. Increased exposure to opioids leads to potentially harmful effects on the gastrointestinal tract, including, e.g. increased sphincter tones and decreased fluid secretion, which may impair pancreatic ductal clearance and elevate the risk for new pancreatitis attacks and accelerate disease progression. Peripherally acting µ-opioid receptor antagonists (PAMORAs) have been developed to counteract the adverse effects of opioids on the gastrointestinal tract. We hypothesize that the PAMORA naldemedine will reduce the risk of new pancreatitis attacks in patients with recurrent acute pancreatitis and hence decelerate disease progression. METHODS The study is a double-blind, randomized controlled trial with allocation of patients to either 0.2 mg naldemedine daily or matching placebo for 12 months. A total of 120 outpatients will be enrolled from five specialist centres in Denmark and Sweden. The main inclusion criteria is a history of recurrent acute pancreatitis (minimum of two confirmed pancreatitis attacks). The primary endpoint is time to acute pancreatitis recurrence after randomization. Secondary outcomes include changes in quality of life, gastrointestinal symptom scores, new-onset diabetes, exocrine pancreatic insufficiency, disease severity, health care utilization, adherence to treatment, and frequency of adverse events. Exploratory outcomes are included for mechanistic linkage and include the progression of chronic pancreatitis-related findings on magnetic resonance imaging (MRI) and changes in circulating blood markers of inflammation and fibrosis. DISCUSSION This study investigates if naldemedine can change the natural course of pancreatitis in patients with recurrent acute pancreatitis and improve patient outcomes. TRIAL REGISTRATION EudraCT no. 2021-000069-34. CLINICALTRIALS gov NCT04966559. Registered on July 8, 2021.
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Affiliation(s)
- Mathias E Cook
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases and Mech-Sense, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Cecilie S Knoph
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases and Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Camilla A Fjelsted
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases and Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens B Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anders E Bilgrau
- Department of Mathematical Sciences, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Maiken Thyregod Jørgensen
- Department of Surgery, Odense Pancreas Centre (OPAC), HPB Section, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- Department of Surgery, Odense Pancreas Centre (OPAC), HPB Section, Odense University Hospital, Odense, Denmark
| | - Liv B J Nielsen
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Amer Hadi
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mark Berner-Hansen
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Wiktor Rutkowski
- Department for Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department for Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Matthias Löhr
- Department for Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases and Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren S Olesen
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases and Mech-Sense, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Ishida M, Uchida N, Yabuno A, Hasegawa K, Mizunuma N, Takahashi T, Onishi H. Opioid withdrawal syndrome developing after long-term administration of naldemedine. Palliat Support Care 2022; 20:897-899. [PMID: 35543119 DOI: 10.1017/s147895152200044x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE One of the side effects of opioid administration is opioid-induced constipation (OIC). To address this side effect, the oral peripheral μ opioid receptor antagonist naldemedine was developed. As this drug does not cross the blood-brain barrier, it is thought that it does not lead to opioid withdrawal syndrome (OWS) with central nervous system symptoms. METHODS Here, we report a cancer patient who presented with symptoms centered round anxiety and irritation 4 months after administration of naldemedine for OIC and who was diagnosed with OWS after close investigation. RESULTS The patient was a 65-year-old female who had surgery for stage IB endometrial cancer 4 years previously, but experienced recurrence involving the pelvis 2 years later. Medical narcotics were used to control pain, but naldemedine was started to control subsequent constipation. When naldemedine-related OWS was suspected and the administration of naldemedine discontinued, the above symptoms disappeared within two days, and no recurrence was observed thereafter. SIGNIFICANCE OF THE RESULTS For patients receiving naldemedine, it is necessary to consider the possibility of OWS regardless of the period of administration in order to maintain patient quality of life.
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Affiliation(s)
- Mayumi Ishida
- Departments of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Nozomu Uchida
- Department of General Medicine, Ogano Town Central Hospital, Hidaka, Saitama, Japan
| | - Akira Yabuno
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kosei Hasegawa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Naoki Mizunuma
- Departments of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
- Tokyo Kagurazaka Law Firm, Tokyo, Japan
| | - Takao Takahashi
- Departments of Supportive Medicine, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hideki Onishi
- Departments of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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Tack J, Camilleri M, Hale M, Morlion B, Nalamachu S, Webster L, Wild J. Establishing Minimal Clinically Important Differences in Quality of Life Measures in Opioid-Induced Constipation. Clin Gastroenterol Hepatol 2022; 20:855-863. [PMID: 33965574 DOI: 10.1016/j.cgh.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Opioids have a role in chronic pain management. However, opioid-induced constipation may cause patients to skip or reduce opioid doses, leading to inadequate pain relief and negatively impacting quality of life. We sought to establish a minimal clinically important difference to understand whether changes in quality of life scores are of value to patients. METHODS Integrated data from the double-blind, controlled, phase 3 COMPOSE-1 and COMPOSE-2 trials of naldemedine in chronic noncancer pain and opioid-induced constipation were used to determine minimal clinically important differences using Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. Patients completed the questionnaires (5-point Likert scale; predose, Weeks 2, 4, and 12), kept a daily log of Bowel Movement and Constipation Assessment, and rated satisfaction at end of study. Minimal clinically important differences were computed using an anchor-based method with 6 anchors: 5 from the Bowel Movement and Constipation Assessment and 1 from patient satisfaction. Threshold values for each anchor were set to define responders versus nonresponders based on score definitions. Clinically meaningful cutoff values for changes in PAC-SYM and PAC-QOL scores were determined using receiver operating characteristic curves. RESULTS Data from 1095 patients (549, naldemedine; 546, placebo) were analyzed. The area under the curve for the receiver operating characteristic curves (ranges, 0.719 to 0.798 for PAC-SYM and 0.734 to 0.833 for PAC-QOL) indicated that both instruments can discriminate responders and nonresponders for each anchor. PAC-SYM cutoff values ranged from -1.04 to -0.83; PAC-QOL cutoff values ranged from -0.93 to -0.82. CONCLUSIONS Based on data derived from the anchor method, reductions in PAC-SYM and PAC-QOL scores of >1.0 in patients with chronic noncancer pain and opioid-induced constipation are clinically meaningful. CLINICALTRIALS gov Registration: NCT01965158; NCT01993940.
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Affiliation(s)
- Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium.
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Martin Hale
- Gold Coast Research, LLC, Plantation, Florida
| | - Bart Morlion
- Leuven Center for Algology and Pain Management, University Hospital Leuven, University of Leuven, Leuven, Belgium
| | | | | | - James Wild
- Upstate Clinical Research Associates, Williamsville, New York
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Kanbayashi Y, Ishizuka Y, Shimizu M, Sawa S, Yabe K, Uchida M. Risk factors for opioid-induced constipation in cancer patients: a single-institution, retrospective analysis. Support Care Cancer 2022; 30:5831-5836. [PMID: 35355120 DOI: 10.1007/s00520-022-07002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To identify risk factors for opioid-induced constipation (OIC). METHODS This study retrospectively analyzed 175 advanced cancer patients who were receiving pain treatment with opioids and were newly prescribed laxatives for OIC at Seirei Hamamatsu General Hospital between November 2016 and June 2021. For the regression analysis of factors associated with OIC, variables were extracted manually from clinical records. The effect of newly prescribed laxatives for OIC was evaluated as "effective" in cases where the number of spontaneous bowel movements increased at least once in the first 3 days. The OIC was defined based on Rome IV diagnostic criteria. Multivariate logistic regression analysis was performed to identify risk factors for OIC. Optimal cutoff thresholds were determined using receiver operating characteristic analysis. Values of P < 0.05 (two-tailed) were considered significant. RESULTS Significant factors identified included body mass index (BMI) (odds ratio [OR] = 0.141, 95% confidence interval [CI] = 0.027-0.733; P = 0.020), chemotherapy with taxane within 1 month of evaluation of laxative effect (OR = 0.255, 95% CI = 0.068-0.958; P = 0.043), use of naldemedine (OR = 2.791, 95% CI = 1.220-6.385; P = 0.015), and addition or switching due to insufficient prior laxatives (OR = 0.339, 95% CI = 0.143-0.800; P = 0.014). CONCLUSION High BMI, chemotherapy including a taxane within 1 month of evaluation of laxative effect, no use of naldemedine, and addition or switching due to insufficient prior laxatives were identified as risk factors for OIC in advanced cancer patients with cancer pain.
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Affiliation(s)
- Yuko Kanbayashi
- Department of Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, 4-20-1 Nasahara, Takatsuki, Osaka, 569-1094, Japan.
| | - Yuichi Ishizuka
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Mayumi Shimizu
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Shohei Sawa
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Katsushige Yabe
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Mayako Uchida
- Department of Education and Research Center for Pharmacy Practice, Doshisha Women's College of Liberal Arts, Kyotanabe, Japan
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Takata K, Nakazawa M, Honda K, Hashimoto S. Post-marketing surveillance of the safety and effectiveness of naldemedine in the management of opioid-induced constipation in patients with cancer pain in Japan. Support Care Cancer 2022. [PMID: 35044484 DOI: 10.1007/s00520-022-06807-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/31/2021] [Indexed: 01/09/2023]
Abstract
Purpose This prospective post-marketing surveillance (PMS) was designed to collect data on the safety and effectiveness of naldemedine in routine clinical practice in patients with opioid-induced constipation (OIC) and cancer pain in Japan and explore the characteristics of patients prone to diarrhea. Methods The enrolled patients received naldemedine (0.2 mg, once a day) orally for up to 12 weeks. In the safety analysis, adverse drug reactions (ADRs), including diarrhea as a special interest, were assessed. Effectiveness was evaluated, especially regarding the frequency and condition of bowel movement. Results In the safety analysis set (n = 1177), 145 ADRs occurred in 133 (11.30%) patients, and diarrhea was the most frequent event (n = 107, 9.09%). Most cases of diarrhea were non-serious (98.1%). Most ADRs were non-serious (93.8%), and they resolved within 2 weeks (75.9%). No patient characteristics influenced the risk of diarrhea development or aggravation. Both the frequency (75.0% and 83.2%) and condition of bowel movement (80.0% and 88.0%) were improved at 2 and 12 weeks, respectively in the effectiveness analysis set (n = 953). Frequency and condition of bowel movement were also improved in patients excluded (e.g., Eastern Cooperative Oncology Group performance status was ≥ 3) or with very small numbers (e.g., received weak opioid) in the clinical trials. Conclusions This PMS indicates that naldemedine is well tolerated and effective in patients of various backgrounds in routine clinical practice who have OIC and cancer pain. Trial registration UMIN000042851. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-06807-y.
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Ishida M, Hiraoka M, Yaguchi A, Sugano K, Adachi N, Itoga T, Ishiguro T, Onishi H. Naldemedine-induced opioid withdrawal syndrome with severe psychiatric symptoms in an advanced cervical cancer patient without brain metastasis. Palliat Support Care 2021;:1-3. [PMID: 34955117 DOI: 10.1017/S1478951521001917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Naldemedine, an oral peripheral μ-opioid receptor antagonist, was developed for the treatment of constipation, a side effect of opioid use. Naldemedine is not generally recognized as causing opioid withdrawal in which associated symptoms affecting the central nervous system. METHOD From the series of cancer patients undergoing symptom management, we report a case treated with naldemedine for constipation in relation to the use of opioids for cancer pain and who displayed severe psychological symptoms associated with withdrawal immediately after the use of naldemedine. RESULTS The patient was a 36-year-old woman diagnosed with cervical cancer Stage IIB, PS3. When the patient, who was using oxycodone hydrochloride hydrate (80 mg/day) for ileal pain, was started on naldemedine for constipation, she complained of sweating after just 5 min and hallucinations after 1 h. The patient also displayed physical/behavioral abnormalities such as diarrhea and hyperactivity, and psychological abnormalities such as aggression toward staff.Despite the psychiatric symptoms worsening over time, there were no abnormalities in terms of blood biochemical data, and no brain metastasis was observed on MRI. Based on the Clinical Opiate Withdrawal Scale, these symptoms were judged to indicate opioid withdrawal. Naldemedine was discontinued due to naldemedine-related opioid withdrawal syndrome and, thereafter, the psychiatric symptoms diminished, with no recurrence of similar symptoms observed to date. SIGNIFICANCE OF RESULTS If mental and behavioral abnormalities occur in patients receiving naldemedine, it is necessary to consider the possibility of opioid withdrawal syndrome as a differential diagnosis.
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Iwaki M, Kessoku T, Kanamori T, Abe K, Takeno N, Kawahara R, Fujimoto T, Igarashi T, Kumakura Y, Suzuki N, Kamiya K, Suzuki N, Tagami K, Saeki T, Mawatari H, Sakurai H, Higashibata T, Hirohashi T, Nakajima A, Ichikawa Y, Ishiki H. Tapentadol Safety and Patient Characteristics Associated with Treatment Discontinuation in Cancer Therapy: A Retrospective Multicentre Study in Japan. Pain Ther 2021; 10:1635-1648. [PMID: 34581982 PMCID: PMC8586125 DOI: 10.1007/s40122-021-00327-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Tapentadol has analgesic effects comparable to those of conventional opioids and is associated with fewer side effects, including gastrointestinal symptoms, drowsiness, and dizziness, than other opioids. However, the safety of tapentadol in the Japanese population remains unclear; the present multicentre study aimed to examine the safety of tapentadol and the characteristics of patients likely to discontinue this treatment owing to adverse events. METHODS The safety of tapentadol was assessed retrospectively in patients with any type of cancer treated between August 18, 2014 and October 31, 2019 across nine institutions in Japan. Patients were examined at baseline and at the time of opioid discontinuation. Multivariate analysis was performed to identify factors associated with tapentadol discontinuation owing to adverse events. RESULTS A total of 906 patients were included in this study, and 685 (75.6%) cases were followed up until tapentadol cessation for any reason. Among patients who discontinued treatment, 119 (17.4%) did so because of adverse events. Among adverse events associated with difficulty in taking medication, nausea was the most common cause of treatment discontinuation (4.7%), followed by drowsiness (1.8%). Multivariate analysis showed that those who were prescribed tapentadol by a palliative care physician (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.36-4.99, p = 0.004), patients switching to tapentadol due to side effects from previous opioids (OR 2.19, 95% CI 1.05-4.56, p = 0.037), and patients who did not use naldemedine (OR 5.06, 95% CI 2.47-10.37, p < 0.0001) had an increased risk of treatment discontinuation owing to adverse events. CONCLUSIONS This study presents the safety profile of tapentadol and the characteristics of patients likely to discontinue this treatment owing to adverse events in the Japanese population. Prospective controlled trials are required to evaluate the safety of tapentadol and validate the present findings. TRIAL REGISTRATION NUMBER UMIN 000044282 (University Hospital Medical Information Network).
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Affiliation(s)
- Michihiro Iwaki
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takaomi Kessoku
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Taro Kanamori
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Kentaro Abe
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Nobuhiro Takeno
- Department of Pharmacy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryoko Kawahara
- Department of Palliative Care, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Taisuke Fujimoto
- Department of Hospital Pharmacy, National Cancer Centre Hospital East, Chiba, Japan
| | - Takashi Igarashi
- Department of Hospital Pharmacy, National Cancer Centre Hospital East, Chiba, Japan
| | - Yasutomo Kumakura
- Department of Anaesthesiology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Naoki Suzuki
- Department of Palliative Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kouhei Kamiya
- Department of Palliative Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Naoto Suzuki
- Laboratory of Oncology, Pharmacy Practice and Sciences, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Tomoya Saeki
- Department of Hospital Pharmacy, Yokohama Minami Kyousai Hospital, Yokohama, Kanagawa, Japan
| | - Hironori Mawatari
- Department of Palliative and Supportive Care, Yokohama Minami Kyousai Hospital, Yokohama, Kanagawa, Japan
| | - Hiroki Sakurai
- Department of Palliative Medicine, Toranomon Hospital, Tokyo, Japan
| | - Takahiro Higashibata
- Palliative Care Team, Department of General Medicine and Primary Care, University of Tsukuba Hospital, Tsukuba, Japan
| | | | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yasushi Ichikawa
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
- Department of Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan.
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10
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Okamoto A, Ikemura K, Mizutani E, Iwamoto T, Okuda M. Opioid therapy duration before naldemedine treatment is a significant independent risk of diarrhea: a retrospective cohort study. J Pharm Health Care Sci 2021; 7:3. [PMID: 33517900 PMCID: PMC7849155 DOI: 10.1186/s40780-020-00187-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/21/2020] [Indexed: 01/05/2023] Open
Abstract
Background The most common adverse event (AE) associated with opioid analgesics is opioid-induced constipation (OIC). Naldemedine (NAL) is widely used for the treatment of OIC. However, diarrhea has been reported as the most common treatment-emergent AE of NAL, and little is known about the risk factors associated with the development of diarrhea during NAL administration. This study examined the risk factors for NAL-induced diarrhea via a retrospective chart review of hospitalized patients. Methods The data of 101 hospitalized adult patients who received NAL for the first time for the treatment of OIC at Mie University Hospital between June 2017 and December 2018 were extracted from electronic medical records. According to the inclusion and exclusion criteria, 70 of the 101 patients were enrolled in this study. Diarrhea was defined as “diarrhea” on the medical record within 2 weeks of NAL administration. Univariate and multivariate analyses were performed to identify risk factors for the development of diarrhea in patients receiving NAL. Results Twenty-two of the 70 patients enrolled (31%) developed diarrhea within 2 weeks of NAL administration. The median duration (range) of NAL treatment before diarrhea onset was 3 (1–12) days. Patients with diarrhea had a significantly longer duration of opioid therapy before NAL administration than patients without diarrhea (P=0.002). Multivariate logistic regression analysis indicated that the independent risk factors for the development of NAL-induced diarrhea were NAL administration after more than 17 days of opioid therapy (odds ratio [OR]=7.539; P=0.016) and pancreatic cancer (OR=6.217; P=0.025). In fact, the incidence of diarrhea in patients who were administered NAL within a day of opioid therapy was significantly lower than that in patients who were administered NAL after more than 17 days of opioid therapy (13% vs. 54%, P=0.030). Conclusions These results suggested that a prolonged duration of opioid therapy prior to NAL initiation is associated with increased incidence of diarrhea. Supplementary Information The online version contains supplementary material available at 10.1186/s40780-020-00187-3.
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Affiliation(s)
- Akiharu Okamoto
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.,Department of Clinical Pharmaceutics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kenji Ikemura
- Department of Pharmacy, Osaka University Hospital, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Eri Mizutani
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan. .,Department of Clinical Pharmaceutics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Masahiro Okuda
- Department of Pharmacy, Osaka University Hospital, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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11
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Inagaki M, Kanemasa T, Yokota T. Naldemedine: Peripherally Acting Opioid Receptor Antagonist for Treating Opioid-induced Adverse Effects. Curr Top Med Chem 2020; 20:2830-2842. [PMID: 32648846 DOI: 10.2174/1568026620666200710105953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/31/2020] [Accepted: 06/19/2020] [Indexed: 11/22/2022]
Abstract
Opioids are widely used for pain management in moderate-to-severe pain. However, opioids are associated with adverse events, such as constipation and emesis/vomiting. To reduce these undesired effects, a structure-activity relationship study of morphinan derivatives was conducted, and a promising lead compound with inhibitory effects on opioid receptors was obtained. Further improvement in the potency and pharmacokinetic profiles of the lead compound led to the discovery of naldemedine, which showed anti-constipation and anti-emetic effects against these adverse events that were induced by morphine without influencing morphine's analgesic effect. Naldemedine was launched in Japan and the USA in 2017 and in the EU in 2019, for treating opioid-induced constipation.
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Affiliation(s)
- Masanao Inagaki
- Medicinal Chemistry Research Laboratory, Shionogi Co., Ltd. Osaka, Japan
| | - Toshiyuki Kanemasa
- Corporate Strategy Division, Corporate Planning Department, Shionogi Co., Ltd. Osaka, Japan
| | - Takaaki Yokota
- Project Management Department, Shionogi Co., Ltd. Global Development Division, Osaka, Japan
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12
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Kanemasa T, Matsuzaki T, Koike K, Hasegawa M, Suzuki T. Preventive effects of naldemedine, peripherally acting μ-opioid receptor antagonist, on morphine-induced nausea and vomiting in ferrets. Life Sci 2020; 257:118048. [PMID: 32622946 DOI: 10.1016/j.lfs.2020.118048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
AIMS Naldemedine is a peripherally acting μ-opioid receptor antagonists (PAMORAs) indicated for the treatment of opioid-induced constipation (OIC). We investigated the preventive effect of naldemedine on morphine-induced nausea and vomiting in ferrets and conducted a pharmacokinetic/pharmacodynamic (PK/PD) analysis. MAIN METHODS The antiemetic effect of naldemedine was evaluated as the frequency and time of retching (rhythmic abdominal contractile motion) and vomiting (throwing up vomit or similar reactions) caused by morphine in ferrets. After a single oral administration of naldemedine to ferrets, the plasma concentrations of naldemedine and morphine were measured by liquid chromatography-tandem mass spectrometry. KEY FINDINGS Naldemedine showed a potent and dose-dependent anti-emetic effects against morphine-induced emetic responses, for up to 6 h. The dose of naldemedine that produced half the maximal effect (ED50) value for anti-emetic effect of naldemedine in the morphine-treated ferrets was 0.033 mg/kg. The PK/PD analysis revealed that the antiemetic effect was related to the plasma naldemedine concentration, with a half maximal effective concentration that produces half the maximal effect (EC50) of 3.51 ng/mL. The plasma concentration producing an antiemetic effect was almost 200-fold lower than that inducing an anti-analgesic effect in rats. SIGNIFICANCE Naldemedine showed potent inhibition of morphine-induced vomiting for up to 6 h after dosing. These data suggest that naldemedine possesses antiemetic properties and could be effective against opioid-induced nausea and vomiting (OINV).
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13
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Ozaki A, Kessoku T, Iwaki M, Kobayashi T, Yoshihara T, Kato T, Honda Y, Ogawa Y, Imajo K, Higurashi T, Yoneda M, Taguri M, Yamanaka T, Ishiki H, Kobayashi N, Saito S, Ichikawa Y, Nakajima A. Comparing the effectiveness of magnesium oxide and naldemedine in preventing opioid-induced constipation: a proof of concept, single institutional, two arm, open-label, phase II, randomized controlled trial: the MAGNET study. Trials 2020; 21:453. [PMID: 32487150 PMCID: PMC7268242 DOI: 10.1186/s13063-020-04385-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 05/06/2020] [Indexed: 12/18/2022] Open
Abstract
Background Patients taking opioids are known to develop opioid-induced constipation (OIC), which reduces their quality of life. The aim of this study is to compare magnesium oxide with naldemedine and determine which is more effective in preventing OIC. Methods This proof-of-concept, prospective, randomized controlled trial commenced in Japan in March 2018. Initially, a questionnaire-based survey will be conducted targeting adult patients with cancer who concomitantly commenced opioid treatment and OIC prevention treatment. Patients will then be randomly allocated to a magnesium oxide group (500 mg thrice daily) or a naldemedine group (0.2 mg once daily). Each drug will be orally administered for 12 weeks. The primary endpoint is defined as any improvement in scores on the Japanese version of Patient Assessment of Constipation Quality of Life questionnaire (JPAC-QOL) from baseline to 2 weeks of treatment. Discussion The primary endpoint is change in JPAC-QOL score from baseline to 2 weeks of intervention. The key secondary endpoint will be change in spontaneous bowel movements at 2 and 12 weeks of intervention. This study will determine whether magnesium oxide or naldemedine is more effective for the prevention of OIC. Trial registration University Hospital Medical Information Network (UMIN) Clinical Trials Registry, UMIN000031891. Registered March 25, 2018.
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Affiliation(s)
- Anna Ozaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takaomi Kessoku
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Palliative Care Center, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Michihiro Iwaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Tsutomu Yoshihara
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Palliative Care Center, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takayuki Kato
- Department of Gastroenterology, International University of Health and Welfare Atami Hospital, 13-1 Higashikaigan-cho, Atami, 413-0012, Japan
| | - Yasushi Honda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Palliative Care Center, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yuji Ogawa
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Kento Imajo
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Masataka Taguri
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takeharu Yamanaka
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Noritoshi Kobayashi
- Department of Oncology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Satoru Saito
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yasushi Ichikawa
- Department of Palliative Care Center, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Oncology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
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14
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Takagi Y, Osawa G, Kato Y, Ikezawa E, Kobayashi C, Aruga E. Prevention and management of diarrhea associated with naldemedine among patients receiving opioids: a retrospective cohort study. BMC Gastroenterol 2020; 20:25. [PMID: 32005157 PMCID: PMC6995158 DOI: 10.1186/s12876-020-1173-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 01/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Naldemedine, a novel peripherally-acting mu-opioid receptor antagonist, has improved opioid-induced constipation in randomized controlled trials. The most frequent adverse event of naldemedine is diarrhea, which can cause abdominal pain and often leads to treatment discontinuation. We aimed to identify risk factors and appropriate management strategies for key adverse events including diarrhea associated with naldemedine, since those have not been extensively studied. METHODS We conducted a multi-center retrospective cohort study. Eligible patients had cancer, had undergone palliative care at participating centers, had been prescribed regular opioids, and had taken at least one dose of naldemedine between June 2017 and March 2018. The primary endpoint was the incidence of diarrhea according to baseline characteristics. Secondary endpoints included the duration of naldemedine administration, daily defecation counts before and after starting naldemedine, duration and severity of diarrhea as an adverse event of naldemedine, other adverse events, and the incidence of constipation within 7 days after recovery from diarrhea. We defined patients who started naldemedine within three days of starting a regularly prescribed opioid as the early group, and the remainder as the late group. RESULTS Among 103 patients who received naldemedine, 98 fulfilled the eligibility criteria. The median age was 68 years and 48% of the patients were female. Median performance status was 3, and the median oral intake was 50%. The median duration of naldemedine administration and overall survival were 25 and 64 days, respectively. The incidence of diarrhea in the early group (n = 26) was significantly lower than in the late group (n = 72) (3.9% vs. 22.2%, p = 0.02). Daily defecation counts increased after late (median 0.43 to 0.88, p < 0.001), but remained stable after early naldemedine administration (median 1.00 to 1.00, p = 0.34). Constipation after the diarrhea was resolved was common (53%), especially among patients who stopped naldemedine (78%). The diarrhea was improved within three days in 92% of patients who stopped other laxatives. CONCLUSIONS The early administration of naldemedine is beneficial because it reduces adverse events including diarrhea. Diarrhea caused by naldemedine can be effectively managed by stopping other laxatives while continuing naldemedine.
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Affiliation(s)
- Yusuke Takagi
- Department of Palliative Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
- Toda-chuo General Hospital, 1-19-3 Honcho, Toda City, Saitama, 335-0023, Japan.
| | - Gakuji Osawa
- Department of Palliative Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Yoriko Kato
- Toda-chuo General Hospital, 1-19-3 Honcho, Toda City, Saitama, 335-0023, Japan
- Saiseikai Kawaguchi General Hospital, 5-11-5 Nishi-kawaguchi, Kawaguchi City, Saitama, 332-8558, Japan
| | - Eri Ikezawa
- Toda-chuo General Hospital, 1-19-3 Honcho, Toda City, Saitama, 335-0023, Japan
| | - Chika Kobayashi
- Toda-chuo General Hospital, 1-19-3 Honcho, Toda City, Saitama, 335-0023, Japan
| | - Etsuko Aruga
- Department of Palliative Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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15
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Abstract
1. Naldemedine is a peripherally acting μ-opioid receptor antagonist for the treatment of opioid-induced constipation. 2. This phase 1 study investigated the absorption, distribution, metabolism and excretion of naldemedine, following a single oral 2-mg dose of [oxadiazole-14C]-naldemedine or [carbonyl-14C]-naldemedine to 12 healthy adult male subjects. Pharmacokinetic assessments were performed on blood, urine and fecal samples collected at defined intervals. 3. Naldemedine was the major circulating component in plasma with a median Tmax of approximately 0.8-0.9 h and a geometric mean t1/2,z of approximately 11 h. Total systemic exposures, AUC, of metabolites nor-naldemedine were less abundant than those of naldemedine (9% or 13% of AUC of naldemedine) and 16.2% or 18.1% of naldemedine was excreted as unchanged in urine after administration of [oxadiazole-14C]-naldemedine or [carbonyl-14C]-naldemedine, respectively, and benzamidine was the major radioactive component after administration of [oxadiazole-14C]-naldemedine (32.5% of administered dose). Overall, the recovery of total radioactivity was 92% (57.3% in urine; 34.8% in feces) after administration of [oxadiazole-14C]-naldemedine and 85% (20.4% in urine; 64.3% in feces) after administration of [carbonyl-14C]-naldemedine. 4. Our findings suggest that naldemedine is mainly metabolized to nor-naldemedine. Naldemedine was rapidly absorbed and well tolerated, with no major safety signals observed.
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Affiliation(s)
- Shuichi Ohnishi
- a Drug Metabolism & Pharmacokinetics , Shionogi & Co., Ltd. Osaka , Japan
| | - Kazuya Fukumura
- b Clinical Pharmacology & Pharmacokinetics , Shionogi & Co., Ltd. , Osaka , Japan
| | - Ryuji Kubota
- b Clinical Pharmacology & Pharmacokinetics , Shionogi & Co., Ltd. , Osaka , Japan
| | - Toshihiro Wajima
- b Clinical Pharmacology & Pharmacokinetics , Shionogi & Co., Ltd. , Osaka , Japan
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16
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Webster LR, Yamada T, Arjona Ferreira JC. A Phase 2b, Randomized, Double-Blind Placebo-Controlled Study to Evaluate the Efficacy and Safety of Naldemedine for the Treatment of Opioid-Induced Constipation in Patients with Chronic Noncancer Pain. Pain Med 2018; 18:2350-2360. [PMID: 28371937 PMCID: PMC5914456 DOI: 10.1093/pm/pnw325] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective This study evaluated the efficacy and safety of oral naldemedine 0.1 mg, 0.2 mg, or 0.4 mg once daily in patients who had opioid-induced constipation (OIC) and maintained a stable laxative regimen. Methods This four-week, phase 2b, randomized, double-blind placebo-controlled trial (clinicaltrials.gov identifier NCT01443403) enrolled patients on long-term opioid therapy for chronic noncancer pain with OIC. The primary efficacy end point was change in weekly spontaneous bowel movement (SBM) frequency from baseline to the last two weeks of treatment. Secondary end points included the proportion of SBM responders (patients with ≥3 SBMs/week and an increase of ≥1 SBM/week from baseline over the last 2 weeks of treatment). Safety parameters assessed included adverse events, effects on analgesia, and opioid withdrawal symptoms. Results Overall, 244 patients were randomized 1:1:1:1 to naldemedine 0.1 mg, 0.2 mg, 0.4 mg, or placebo. Baseline patient characteristics were comparable. Weekly SBM frequency was significantly higher with naldemedine 0.2 mg (3.37, P = 0.0014) and 0.4 mg (3.64, P = 0.0003), but not with 0.1 mg (1.98, P = 0.3504), vs placebo (1.42). The proportion of SBM responders was significantly higher with naldemedine 0.2 mg (71.2%, P = 0.0005) and 0.4 mg (66.7%, P = 0.003), but not with 0.1 mg (52.5%, P = 0.1461), vs placebo (39.3%). Treatment-emergent adverse events were generally mild to moderate in severity; incidences increased with naldemedine dose. No clinically meaningful changes in other safety parameters were observed. Conclusion Naldemedine 0.2 mg once daily is the optimal dose for future confirmatory trials in OIC.
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Affiliation(s)
- Lynn R Webster
- PRA Health Sciences, Early Development Services, Salt Lake City, Utah
| | - Tadaaki Yamada
- Shionogi, Inc., Clinical Development, Florham Park, New Jersey, USA
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