Constipation In Palliative Care Research Articles

Transcutaneous Electrical Nerve Stimulation (TENS) for Opioid-Induced Constipation in Palliative Care: A Systematic Review and Network Meta-Analysis.

Opioid-induced constipation (OIC) has become increasingly prevalent with the rise of prescription opioid use, particularly in patients with advanced illnesses. Existing literature suggests that transcutaneous electrical nerve stimulation (TENS) could be applied to treat cancer pain and reduce OIC incidence. However, there need to be more systematic review studies on the effectiveness of TENS in treating OIC. In order to fill the gap of TENS in treating OIC in current knowledge, we have conducted a systematic review and network meta-analysis. The comprehensive computer retrieval PubMed, Embase, Cochrane, China National Knowledge Infrastructure (CNKI), Chinese Biomedical (CBM), and Wanfang Database were used to collect literature for relevant studies of TENS treatment of OIC, in accordance with the standard of literature filtering, data extraction, and quality evaluation. The data were meta-analysed using ReviewManager 5.3 software recommended by Cochrane. A total of 180 pieces of literature were yielded through original search. Based on the inclusion and exclusion criteria, a total of 9 articles were included in this study. Our analysis of seven studies has revealed that TENS (28.18%) significantly reduces the incidence rate of OIC compared to control (52.45%) (I 2 = 57%, P=0.03; OR = 0.66 (95% CI, 0.53 to 0.82), Z = 3.70, P < 0.01). The results of two studies indicated that TENS significantly improved the quality of life compared to the control group (i.e., treatment-as-usual only) (I 2 = 80%, P=0.03; OR = -1.91; 95% CI, -2.54 to -1.29, Z = 6.00, P < 0.01). The administration of TENS therapy holds the potential to mitigate the occurrence of OIC and augment the quality of life for individuals suffering from cancer. Particularly, TENS therapy proves to be appropriate for propagation within community and domestic environments. Nevertheless, advanced clinical randomized controlled trials of superior quality are necessary to authenticate the comprehensive clinical efficiency and safety of this therapy. Further investigation is indispensable to comprehend its mechanism in greater detail and establish the optimum therapeutic strategy.

Opioid-induced constipation in palliative care: state of the art

OBJECTIVE: The study’s purpose has been to address the state of the art in investigations such as clinical trials, systematic reviews with meta-analysis and case studies, which report how to minimize opioid-induced constipation in patients undergoing palliative care. METHODS: This is an exploratory study through an integrative review of four databases addressing published articles from 2013 to 2017. RESULTS: A total of 117 publications were presented, which 17 presented the inclusion criteria. The studies describe the prevalence of constipation rates induced by the use of opioids. CONCLUSION: Although these drugs alleviate pain, the adverse reactions may generate discomfort and loss of the patient’s life quality. There are limited data on the treatment of constipation. It was observed that few authors mentioned diet as a helper on this situation, emphasizing the use of medications. Further studies should be encouraged aiming to find the balance between analgesia and reduction of adverse effects.

Itopride increases the effectiveness of the management of opioid-induced constipation in palliative care patients: an observational non-interventional study

IntroductionIt is strongly recommended that laxatives be routinely prescribed for the prevention of opioid-induced constipation (OIC). The evidence supporting the effectiveness of prokinetics for this indication is sparse. This study aims to verify if itopride, added to preventive OIC therapy, increases the effectiveness of the prevention of opioid-induced constipation in adult palliative care patients.Material and methodsIn a questionnaire-based observational study, all patients received regular laxatives plus one of the following: oxycodone/naloxone (OXN); itopride (ITP); or oxycodone/naloxone + itopride (OXN + ITP). The primary measure was the decrease in the necessity of laxative use in a 0–4 scale assessed after 7 days of treatment.ResultsNinety-two patients met the inclusion criteria in the four groups: OXN (n = 12), ITP (11), OXN + ITP (9), and the control group (laxatives only if needed) (60). The necessity of laxatives decreased in groups where itopride was used, with a statistically significant difference versus control, oxycodone/naloxone (p = 0.009), or in combination. The OXN did not decrease laxative use (p = 0.22).ConclusionsAll interventions appeared similarly effective in the prevention of OIC. However, adding itopride, but not oxycodone/naloxone, resulted in a decrease in the necessity of laxative use in OIC patients, and it seems to be valuable in this often refractory condition. Randomised, controlled trials would be valuable to obtain good quality evidence without systematic bias.

Rola obwodowo działających antagonistów opioidowych mu (PAMORA) w leczeniu zaparcia w opiece paliatywnej

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Dzierżanowski T. The role of peripherally acting mu-opioid receptor antagonists (PAMORA) in the treatment of constipation in palliative care. Medycyna Paliatywna/Palliative Medicine. 2019;11(2):51-57. doi:10.5114/pm.2019.86528. APA Dzierżanowski, T. (2019). The role of peripherally acting mu-opioid receptor antagonists (PAMORA) in the treatment of constipation in palliative care. Medycyna Paliatywna/Palliative Medicine, 11(2), 51-57. https://doi.org/10.5114/pm.2019.86528 Chicago Dzierżanowski, Tomasz. 2019. "The role of peripherally acting mu-opioid receptor antagonists (PAMORA) in the treatment of constipation in palliative care". Medycyna Paliatywna/Palliative Medicine 11 (2): 51-57. doi:10.5114/pm.2019.86528. Harvard Dzierżanowski, T. (2019). The role of peripherally acting mu-opioid receptor antagonists (PAMORA) in the treatment of constipation in palliative care. Medycyna Paliatywna/Palliative Medicine, 11(2), pp.51-57. https://doi.org/10.5114/pm.2019.86528 MLA Dzierżanowski, Tomasz. "The role of peripherally acting mu-opioid receptor antagonists (PAMORA) in the treatment of constipation in palliative care." Medycyna Paliatywna/Palliative Medicine, vol. 11, no. 2, 2019, pp. 51-57. doi:10.5114/pm.2019.86528. Vancouver Dzierżanowski T. The role of peripherally acting mu-opioid receptor antagonists (PAMORA) in the treatment of constipation in palliative care. Medycyna Paliatywna/Palliative Medicine. 2019;11(2):51-57. doi:10.5114/pm.2019.86528.

Opioid-Induced Constipation in Palliative Care. How to Prevent? How to Treat?

Opioid-Induced Constipation in Palliative Care. How to Prevent? How to Treat?

Constipation in specialized palliative care: factors related to constipation when applying different definitions.

For patients in palliative care, constipation is primarily a result of opioid treatment. Impacts from other factors related to constipation in palliative care are rarely studied. The aim was to identify factors related to constipation in patients in palliative care, and then to compare these factors between patients with different types of constipation and patients without constipation. Cross-sectional data on constipation was collected with a 26-item questionnaire from 485 patients in 38 specialist palliative care units in Sweden. Three different constipation groups were used; MC ONLY, PC ONLY, and MC & PC. Logistic regression analyses were used to calculate odds ratios. Patients with <3 defecations/week, MC ONLY, (n = 36) had higher odds of being hospitalized, bed-restricted, in need of personal assistance for toilet visits, and of having a poor fluid intake. Patients with the perception of being constipated, PC ONLY, (n = 93) had higher odds of having poor appetite, hemorrhoids, hard stool, more opioid treatment, less laxative treatment and of being more dissatisfied with constipation information. Patients with both <3 defecations/week and a perception of being constipated, MC & PC, (n = 78) had higher odds of having cancer- disease. There were several significant factors related to constipation with higher odds than opioid- treatment, for patients in palliative care, such as; hard stool, cancer diagnosis, dissatisfaction with information, low fluid intake, hemorrhoids, bed restriction, hospitalization, and need of personal assistance for toilet visits.

Behavioral risk factors of constipation in palliative care patients.

BackgroundConstipation is frequently encountered in palliative care patients and remains a significant therapeutic problem. The etiology of constipation is multifactorial. Nutritional and behavioral factors are considered common causes of constipation; however, their impact has not yet been assessed precisely.ObjectiveThe aim of this study was to assess the correlation between the frequency of bowel movements (FoBM) and risk factors of constipation in palliative care patients.Design and subjectsA cohort retrospective study was performed in three palliative care centers, including outpatient, home, and inpatient care cancer patients using questionnaires on bowel dysfunction symptoms, behavioral risk factors, and opioid use. The inclusion criterion was adult patients examined on the day of admission. The exclusion criterion was Karnofsky performance status score ≤20.MeasurementsSpearman’s rank correlation coefficient was used to measure the statistical dependence between two variables and frequency analysis was performed using the chi-squared test and Fisher’s exact test.ResultsTwo hundred thirty-seven valid questionnaires were collected. We found the correlation between FoBM and insufficient food and fluid intake (p < 0.0001), as well as for inadequate conditions of privacy (p = 0.0008), dependency on a caregiver (p = 0.0059), and the patient’s overall performance status (p = 0.013). We did not manage to prove bed rest as the independent risk factor of constipation.ConclusionsThe main risk factors of constipation in palliative care patients appeared to be insufficient fluid and food intake, inadequate conditions of privacy, dependency on a caregiver, as well as poor general performance status.

Opioid Antagonists

Opioid Antagonists

Pharmacological treatment of constipation in palliative care

The prevalence of constipation in palliative care patients varies. There is uncertainty about the choice from varying recommendations for pharmacological management of constipation and a varying clinical practice in palliative care settings. The purpose of the review was to evaluate the current recommendations of therapy guidelines and to determine the effectiveness and safety of laxative administration for the management of constipation in palliative care patients. Despite the clinical importance, there are limited data on the efficacy and safety of laxatives in palliative care patients. The social acceptability varies from country to country, but overall, oral laxatives should, where possible, be used in preference. Systemic opioid antagonists, such as naloxone and methylnaltrexone have been studied in few clinical trials. There is a paucity of well designed, prospective, randomized controlled trials with large enough numbers of patients suffering from constipation and treated with pharmacological methods. There are limited data available on the conventional pharmacological treatment of constipation in palliative care patients due to insufficient randomized controlled trials. However, subcutaneously administered methylnaltrexone was found to be effective in aiding of laxation and well tolerated with limited or transient side effects in palliative care patients.

Constipation in palliative care: treatment options and considerations for individual patient management

Constipation is an all too common symptom in palliative care patients and may be associated with a range of severe issues and experiences. Its effects on patients contribute to both physical and psychological scarring during a very distressing stage of life not only for the patient but also for their caregivers. It is during this time that, too often, the complexity of managing the condition moves the locus of control away from the patient toward the health professionals. This article considers a number of different treatment options and facets of individual management that may enable patients to move the locus of control back to a position of joint management by patients, caregivers, and health professionals.

Methylnaltrexone for the treatment of opioid-induced constipation

Opioids are the drugs of choice for treating moderate-to-severe pain, especially for patients in the end stage of cancer or other advanced illnesses, and also in critical care or for the treatment of chronic pain. Side effects such as nausea, pruritus, dizziness and constipation have to be controlled in order to use these drugs to their full potential. Opioid-induced bowel syndrome and constipation caused by activation of μ-receptors in the gut can have such distressing effects that some patients prefer to forego adequate pain control. Methylnaltrexone is a μ-opioid receptor antagonist that, unlike naltrexone or naloxone, does not pass the blood–brain barrier, and therefore does not impair the centrally mediated analgesic effect of opioids. It is licensed for the treatment of opioid-induced constipation in palliative care in more than 50 countries. This article presents practically relevant pharmacological data, basic research results and evidence from clinical research about methylnaltrexone, and outlines potential future therapeutic options for this promising drug.

Assessing constipation in palliative care within a gastroenterology framework

Background: Constipation is common and distressing in palliative care. Despite this, approaches to assessment and subsequent treatment are most remarkable for the numbers who fail adequate palliation. Aim: The primary aim of this paper is to summarise the current approaches to assessing constipation in palliative care, contrasting these approaches with those recommended by gastroenterologists in the assessment of resistant constipation in non-palliative care. The secondary aim is to suggest ways that the approaches used by gastroenterologist could be modified to be tolerable to palliative care. Design: A non-systematic review of the literature was undertaken. Data sources: The electronic databases (MEDLINE, CINHAL) were searched for English language articles that explored assessment of constipation in palliative care and evidence-based gastroenterology guidelines that summarised assessment and management of constipation. Results: Currently, the assessment of constipation in palliative care is predominantly based on people’s reports, physical examination and if further imaging is deemed necessary, a plain abdominal radiograph. However, data in non-palliative care patients refutes the usefulness of self-reported symptoms to localise whether problems are due to colon dysfunction or structures of defaecation. Plain radiographs are most useful to exclude a bowel obstruction only. In cases of resistant constipation, gastroenterology guidelines recommend an assessment approach that includes measuring colon transit time and an assessment of the structures that facilitate defaecation. Conclusions: Current approaches to assessing constipation in palliative care are very different to those recommended by gastroenterology guidelines. However, modified approaches may be tolerable to palliative care patients and offer the chance of developing targeted palliation.

Treating Constipation in Palliative Care

Opioids are major contributing factors to the problem of constipation in palliative care. Whilst this is without doubt, it remains unclear how much other factors also contribute to the problem. The aim of this audit is to review what other contributing factors are present when methylnaltrexone, the peripheral opioid antagonist is prescribed for constipation. The medical records of people prescribed methylnaltrexone over a four-month period were reviewed to examine certain characteristics of people including the whether the reason for constipation was charted, whether other factors that could contribute to constipation were considered and the effectiveness of methylnaltrexone. Over the study period, 10 people received methylnaltrexone, only 4 of whom had a bowel action less than 24 hours after administration with 3 not having any bowel actions reported 6 days after administration. Whilst all were receiving opioids, the opioids doses were in the moderate range (61-200 mg morphine equivalent). However, all had other factors that could contribute to constipation including impaired functional status and medications with anti-cholinergic effects (mean anti-cholinergic load 4.5). In conclusion, methylnaltrexone is targeted treatment for the management of opioid-induced constipation. However, there is a percentage of people who fail to respond. The impact of other factors on the problem of constipation requires greater clarification.

Laxatives or methylnaltrexone for the management of constipation in palliative care patients

Background: Constipation is common in palliative care; it can generate considerable suffering due to the unpleasant physical symptoms. In the first Cochrane Review on effectiveness of laxatives for the management of constipation in palliative care patients, published in 2006, no conclusions could be drawn because of the limited number of evaluations. This article describes the first update of this review. / Objectives: To determine the effectiveness of laxatives or methylnaltrexone for the management of constipation in palliative care patients. / Search methods: We searched databases including MEDLINE and CENTRAL (The Cochrane Library) in 2005 and in the update to August 2010. / Selection criteria: Randomised controlled trials (RCTs) evaluating laxatives for constipation in palliative care patients. In the update we also included RCTs on subcutaneous methylnaltrexone; an opioid-receptor antagonist that is now licensed for the treatment of opioid-induced constipation in palliative care when response to usual laxative therapy is insufficient. / Data collection and analysis: Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. / Main results: We included seven studies involving 616 participants; all under-reported methodological features. In four studies the laxatives lactulose, senna, co-danthramer, misrakasneham, and magnesium hydroxide with liquid paraffin were evaluated. In three methylnaltrexone. In studies comparing the different laxatives evidence was inconclusive. Evidence on subcutaneous methylnaltrexone was clearer; in combined analysis (287 participants) methylnaltrexone, in comparison with a placebo, significantly induced laxation at 4 hours (odds ratio 6.95; 95% confidence interval 3.83 to 12.61). In combined analyses there was no difference in the proportion experiencing side effects, although participants on methylnaltrexone suffered more flatulence and dizziness. No evidence of opioid withdrawal was found. In one study severe adverse events, commonly abdominal pain, were reported that were possibly related to methylnaltrexone. A serious adverse event considered to be related to the methylnaltrexone also occurred; this involved a participant having severe diarrhoea, subsequent dehydration and cardiovascular collapse. / Authors' conclusions: The 2010 update found evidence on laxatives for management of constipation remains limited due to insufficient RCTs. However, the conclusions of this update have changed since the original review publication in that it now includes evidence on methylnaltrexone. Here it found that subcutaneous methylnaltrexone is effective in inducing laxation in palliative care patients with opioid-induced constipation and where conventional laxatives have failed. However, the safety of this product is not fully evaluated. Large, rigorous, independent trials are needed.

Exploring the Relationship Between the Frequency of Documented Bowel Movements and Prescribed Laxatives in Hospitalized Palliative Care Patients

Retrospective analysis of 211 admissions to a palliative care unit was undertaken to explore the relationship between prescribed laxatives and the frequency of documentation of bowel movements. Bivariate analysis flailed to identify relationships between laxatives and the frequency of bowel movements. Relationships were identified between less frequent bowel movements and type and duration of illness phase. Regression analysis identified 2 variables strongly predictive of the frequency with which bowel movements were documented. People in longer illness phases were more likely to have regular bowel movements (Z = 3.02, P = .003). The second significant result was that, even accounting for the short duration of the terminal phase, people who were dying were 13 times less likely to have any bowel movements documented than those in the stable phase (OR = 13.2, 95%CI = 2.0-89.2). The lack of relationship between laxatives and documentation of bowel movements suggests alternative approaches to understanding and managing the symptom of constipation in palliative care are necessary.

Screening for Constipation in Palliative Care Patients

The objective of this study was to establish screening criteria for constipation in palliative care and, subsequently, to determine data for diagnostic suspicion of constipation in a palliative care population. Also we investigate the incidence of fecal impaction in the same sample of palliative care patients. A descriptive, multicenter cross-sectional study was done. All patients in active care by a group of hospital and home palliative care teams were studied. A questionnaire on signs (frequency and consistency of stools) and symptoms (pain, discomfort, or a sensation of incomplete evacuation when having a bowel movement) of constipation in last weeks, and a verbal numerical scale (VNS) (0-10) on discomfort or difficulty with constipation was completed by the patients. The patients were asked about impaction in the last 3 months. One hundred twenty patients from 21 palliative care teams were included; the majority of patients received opiates (66%) and also laxatives (60%). Bowel movement rate less than three stools per week was found in 13% of patients, stools harder than normal were experienced in 24% patients, and 33% exhibited pain, discomfort, or sensation of incomplete evacuation. Of the patients studied 13% had some signs of habitual constipation but they did not complain of symptoms, others (17%) had some discomfort in spite of not having signs of constipation. As screening criteria for constipation in palliative care we elected to include indistinct presence of constipation symptoms or constipation signs in recent weeks. A diagnosis of suspicion of constipation was established in almost 1 of 2 patients (48%) of our palliative care population. VNS with cutoff point of 3 or more of 10, showed a sensitivity of 0.70 and a specificity of 0.74 and positive predictive value (PPV) of 73% positive and negative predictive value (NPV) of 70%. In addition to these findings a considerable number of our palliative care patients (20%) reported episodes of fecal impaction in the last 3 months. The screening for constipation in palliative care should be performed exploring subjective symptoms and other objective signs. A diagnosis of suspected constipation was found in almost half of the palliative care patients studied. A VNS of constipation did not produce good predictive values for the detection of constipation in our sample.

Exploring the causes, assessment and management of constipation in palliative care

Constipation is one of the most common problems in patients receiving palliative care, often having a profound effect on their quality of life. Its management has a significant impact on healthcare provision in terms of cost and nursing time. Nurses are well placed to assess and manage constipation and this article seeks to aid in the decision-making process. The causes, assessment and management of constipation, from prophylaxis to new pharmacological developments, will be explored in a pragmatic approach.

The management of constipation in palliative care: clinical practice recommendations

Constipation is one of the most common problems in patients receiving palliative care and can cause extreme suffering and discomfort. The aims of this study are to raise awareness of constipation in palliative care, provide clear, practical guidance on management and encourage further research in the area. A pan-European working group of physicians and nurses with significant experience in the management of constipation in palliative care met to evaluate the published evidence and produce these clinical practice recommendations. Four potentially relevant publications were identified, highlighting a lack of clear, practical guidance on the assessment, diagnosis and management of constipation in palliative care patients. Given the limited data available, our recommendations are based on expert clinical opinion, relevant research findings from other settings and best practice from the countries represented. Palliative care patients are at a high risk of constipation, and while general principles of prevention should be followed, pharmacological treatment is often necessary. The combination of a softener and stimulant laxative is generally recommended, and the choice of laxatives should be made on an individual basis. The current evidence base is poor and further research is required on many aspects of the assessment, diagnosis and management of constipation in palliative care.

Management of constipation in palliative care patients

Constipation is a common symptom in palliative care patients that can generate considerable suffering due to both unpleasant physical symptoms and psychological preoccupations that may arise. There is uncertainty about the choice from varying recommendations for management of constipation and a varying clinical practice in palliative care settings. The purpose of the review is to evaluate the current recommendations of therapy guidelines and to determine the effectiveness of laxative administration for the management of constipation in palliative care patients. Recent findings in the literature include an updated version of the Rome criteria and related information on the functional gastrointestinal disorders, as well as information on opioid antagonists. Knowledge of the role of definitions, causes of constipation and the pathophysiology of opioid-induced constipation must be given a high priority in the treatment of patients receiving opioids. Diagnosis and therapy of constipation, therefore, should relate to findings in clinical investigation. The treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient randomized controlled trial data. Recommendations for laxative use can be related to efficacy. Particularly in patients with advanced-stage tumor disease this must be undertaken with careful consideration of their physical activity and dietary needs.

Constipation and palliative care – where are we now?

Constipation is an unpleasant and distressing symptom that many palliative care patients may experience, often having a profound effect on their quality of life. The many management options available reflect the multifactorial nature of constipation. The article explores the complexity of constipation in palliative care and highlights the challenge of managing opioid-induced constipation. Advances in the pharmacological and non-pharmacological management of constipation are reviewed and discussed in the light of relevant research. Further discussion includes definitions, incidence and causes of constipation in palliative care.