Alvimopan for postoperative ileus: Only one piece of the puzzle

Abstract

Alvimopan is a promising agent to speed the recovery of bowel function in patients undergoing open abdominal surgery with bowel resection who receive systemic opioids for analgesia, and it is currently the only drug therapy for the treatment of postoperative ileus that is approved for marketing in the United States. In this issue of AJHP, Bream-Rouwenhorst and Cantrell1 review the pharmacology of and clinical data for alvimopan in the treatment of postoperative ileus. See also page 1267. Clinical trials have left several unanswered questions about alvimopan’s exact place in therapy. In addition to primary outcomes, Phase III trials of alvimopan in patients who underwent bowel resection demonstrated several encouraging results, including a lower frequency of nausea and vomiting, lower rates of nasogastric tube insertion after surgery, a lower frequency of prolonged hospital stay or readmission (within 7–10 days of discharge), and a shorter time until a discharge order is written.2,–6 Although the time to a discharge order was used in the Phase III trials, the actual length of stay (LOS) was reported in the most recently published study, by Ludwig et al.6 The mean LOS in the alvimopan 12-mg group was 1 day shorter than that in the placebo group (5.2 days versus 6.2 days, p < 0.001). The investigators also reported that most patients were discharged within four hours of the discharge order being written. Reducing the adverse effects related to postoperative ileus and hastening the return of bowel function are important. However, it seems that widespread use of alvimopan would be justified only if reductions in LOS (≥1 day) and readmission rates could be realized.