Frequency Of Spontaneous Movements Research Articles

Efficacy of naldemedine for the treatment of opioid-induced constipation: A meta-analysis.

Opioid induced constipation (OIC) is the most common side effect of opioid therapy. It can lead to a decreased quality of life. Naldemedine is a peripherally acting μ-opioid receptor antagonist that has been recently studied in randomized controlled trials (RCTs) for the management of OIC. The aim of this study is to perform a meta-analysis of existing clinical trials to estimate the efficacy and safety of naldemedine in opioid-induced constipation. A systematic search of PubMed, CINAHL, Scopus, Cochrane database of systematic reviews, and ClinicalTrials.gov registry was performed in March 2018. Two independent reviewers systematically identified prospective RCTs published in the English language that compared the effect of oral naldemedine versus placebo in adults with OIC. Meta-analysis was performed using a random effects model to assess the primary outcome: spontaneous bowel movement (SBM) responder rates. Assessed secondary outcomes were: a change in SBM frequency per week from baseline during the treatment period, change from baseline in the frequency of complete SBM and incidence of treatment-emergent adverse events. Review Manager 5.3 software program was utilized for statistical analysis. Six RCTs met the inclusion criteria. A total of 2,762 patients were included in the meta-analysis. The proportion of SBM responders was significantly higher in the naldemedine group compared to the placebo group (56.4%, vs. 34.7%, p<0.00001). There was no statistically significant difference in treatment-emergent adverse events between naldemedine group and placebo group (mean odds ratio=1.18, p = 0.25, 95% CI: 0.89-1.55). Change in SBM frequency was higher in the naldemedine group versus placebo group (p<0.00001), as well as the change in complete SBM frequency. Naldemedine 0.2 mg daily significantly improved symptoms in patients with opioid-induced constipation and was generally well tolerated. These results support the use of naldemedine for the treatment of opioid-induced constipation.

Efficacy and safety of a crystalline lactulose preparation (SK-1202) in Japanese patients with chronic constipation: a randomized, double-blind, placebo-controlled, dose-finding study

BackgroundClinical evidence of lactulose for chronic constipation in Japan was lacking. We performed a randomized, double-blind, placebo-controlled, dose-finding study in Japanese patients with chronic constipation to estimate the optimal clinical dose of lactulose.MethodsOverall, 250 patients were randomized to receive SK-1202 (13, 26, or 39 g/day, as crystalline lactulose dosage) or placebo twice daily (morning and evening) orally for 2 weeks. The primary endpoint was the change from baseline frequency of spontaneous bowel movements (SBMs) at Week 1. The secondary endpoints included the change from baseline of SBMs at Week 2, percentage of patients experiencing SBM within 24 and/or 48 h of the initial dose, stool consistency, and constipation severity, and adverse events were also evaluated.ResultsThe 26 and 39 g/day of SK-1202 induced significantly and dose-dependently more increase in SBM at Week 1 than placebo (p = 0.003, p < 0.001). These groups also showed significant improvements in the secondary endpoints. There were no significant differences in the incidence of adverse drug reactions (ADRs) between the placebo and SK-1202 groups. Gastrointestinal disorder was the most common ADR, and diarrhea developed in 6 patients (9.7%) treated with 39 g/day; however, the symptoms were mild in severity and resolved after follow-up, dose reduction, or dose suspension. SK-1202 was generally well tolerated up to 39 g/day.ConclusionOur results suggest that SK-1202 is useful in Japanese patients with chronic constipation, and optimal dose of SK-1202 is 26 g/day.

Pharmacological characteristics and clinical study results of ileal bile acid transporter inhibitor elobixibat (GOOFICE® tablet 5 mg)

Elobixibat is a novel small-molecule that acts as an inhibitor of the ileal bile acid transporter (IBAT), and used for chronic constipation in Japan. Elobixibat selectively inhibited IBAT in vitro, and dose-dependently inhibited the absorption of bile acids in vivo. Also, elobixibat dose-dependently increased wet fecal weight in a rat loperamide-induced constipation model. The drug-drug interaction study suggested that elobixibat may have a clinically slight inhibitory effect on P-glycoprotein. In a phase II study with chronic constipation, the recommended dosage for oral administration of elobixibat once daily was estimated to be 10 mg. In a phase 3 study with chronic constipation, the superiority of the elobixibat 10 mg group to the placebo group was demonstrated in the change from baseline (ie, the last week of the 2-week run-in period) in the frequency of spontaneous bowel movements per week during the first week of treatment set as the primary endpoint. In a long-term study in which elobixibat was administered to patients with chronic constipation for 52 weeks, the ameliorating effects of elobixibat on constipation were observed from the first week of treatment and maintained well until week 52. In addition, the safety/tolerability of elobixibat administered once daily for 52 weeks was considered to be acceptable. Therefore, elobixibat has a mechanism of action that differs from any of the existing therapeutic agents for constipation and is expected to become one of the new treatment options for chronic constipation.

Pharmacological and clinical profile of linaclotide (Linzess®), a novel therapeutic agent for irritable bowel syndrome with constipation and chronic constipation

Linaclotide (Linzess® tablets 0.25 mg) is a guanylate cyclase-C (GC-C) agonist with high selectivity and binding affinity to GC-C. In Japan, linaclotide was approved for 〝irritable bowel syndrome with constipation (IBS-C)〟 in December 2016 and 〝chronic constipation (CC) (excluding constipation due to organic disease)〟 in August 2018. Non-clinical studies demonstrated that linaclotide binding to GC-C increases intracellular cyclic guanosine monophosphate (cGMP), resulting in increased fluid secretion and gastrointestinal transit. In rats with colonic hyperalgesia, but not in normal rats, linaclotide suppressed the visceral nociceptive response, mediated by increased submucosal cGMP. In clinical studies in Japan, improvements were observed in the responder rates for global assessment of IBS symptom relief, complete spontaneous bowel movements in patients with IBS-C, and the frequency of spontaneous bowel movement in patients with CC, which were maintained during long-term treatment. Additionally, abdominal bloating, which has been associated with lower quality of life (QOL) and lower satisfaction with other approved therapies, and IBS QOL were improved throughout treatment with linaclotide. Diarrhea, a consequence of linaclotide's mechanism of action, was observed during the clinical studies, but was generally controllable by decreasing the linaclotide dose. No drug resistance was observed during the clinical studies, unlike some other approved agents. These results of non-clinical and clinical studies demonstrate that linaclotide can improve constipation, various abdominal symptoms, and QOL with a favorable safety profile in patients with IBS-C and CC.

Corrigendum to "A Randomized Controlled Trial of Chinese Patent Medicine Xiao'er Biantong Granules in the Treatment of Functional Constipation in Children".

[This corrects the article DOI: 10.1155/2018/4941505.].

Top New Drug Approvals of 2018

Top New Drug Approvals of 2018

Effect of single and multiple doses of elobixibat, an ileal bile acid transporter inhibitor, on chronic constipation: A randomized controlled trial.

AimsElobixibat is a minimally absorbed ileal bile acid transporter inhibitor. This study aimed to investigate the safety, tolerability, efficacy, pharmacokinetics and pharmacodynamics of elobixibat in Japanese patients with chronic constipation.MethodsThis study consisted of single‐dose and multiple‐dose tests with a dose‐escalating design. Sixty patients including females and males were randomized into five dose levels of elobixibat (2.5, 5, 10, 15 or 20 mg, n = 10 per level) and corresponding placebo (n = 2 per group). A crossover design was used to examine food effect in single‐dose test. Patients received test tablets once daily for 14 days in multiple‐dose test. We assessed pharmacokinetic‐dose proportionality, levels of serum high‐ and low‐density lipoprotein cholesterol and plasma 7α‐hydroxy‐4‐cholesten‐3‐one (C4), food effect and sex‐specific effect. Adverse events and bowel functions such as bowel movements, stool consistency and straining were also evaluated.ResultsFood consumption reduced systemic exposure by around 80% [e.g. least squares mean (ratio of breakfast/no breakfast) maximum plasma concentration: 0.2085 (90% confidence interval, 0.1371–0.3172) at 15 mg] while increased plasma C4 level (P < 0.001). In the multiple‐dose test, elobixibat reduced low‐density lipoprotein cholesterol and increased C4 whilst unaltering high‐density lipoprotein cholesterol level. The increased spontaneous bowel movement frequency was correlated with higher dosage and higher C4 level (R2 = 0.5929 at Week 2). Adverse events were mainly gastrointestinal symptoms, most of which were mild.ConclusionsElobixibat should be taken before breakfast. Once‐daily administration of elobixibat was found to be safe and tolerated up to 20 mg in female and male patients with chronic constipation.

Randomized phase III and extension studies: efficacy and impacts on quality of life of naldemedine in subjects with opioid-induced constipation and cancer

BackgroundThe efficacy and safety of naldemedine (a peripherally acting µ-opioid receptor antagonist) for opioid-induced constipation (OIC) in subjects with cancer was demonstrated in the primary report of a phase III, double-blind study (COMPOSE-4) and its open-label extension (COMPOSE-5). The primary end point, the proportion of spontaneous bowel movement (SBM) responders, was met. Here, we report results from secondary end points, including quality of life (QOL) assessments from these studies. Patients and methodsIn COMPOSE-4, eligible adults with OIC and cancer were randomly assigned 1:1 to receive once-daily oral naldemedine 0.2 mg (n = 97) or placebo (n = 96) for 2 weeks, and those who continued on to COMPOSE-5 received naldemedine for 12 weeks (n = 131). Secondary assessments in COMPOSE-4 included the proportion of complete SBM (CSBM) responders, SBM or CSBM responders by week, and subjects with ≥1 SBM or CSBM within 24 h postinitial dose. Changes from baseline in the frequency of SBMs or CSBMs per week were assessed at weeks 1 and 2. Time to the first SBM or CSBM postinitial dose was also evaluated. In both studies, QOL impact was evaluated by Patient Assessment of Constipation-Symptoms (PAC-SYM) and PAC-QOL questionnaires. ResultsNaldemedine improved bowel function for all secondary efficacy assessments versus placebo (all P ≤ 0.0002). The timely onset of naldemedine activity versus placebo was evidenced by median time to the first SBM (4.7 h versus 26.6 h) and CSBM (24.0 h versus 218.5 h) postinitial dose (all P < 0.0001). In COMPOSE-4, significant differences between groups were observed with the PAC-SYM stool domain (P = 0.045) and PAC-QOL dissatisfaction domain (P = 0.015). In COMPOSE-5, significant improvements from baseline were observed for overall and individual domain scores of PAC-SYM and PAC-QOL. ConclusionsNaldemedine provided effective and timely symptomatic relief from OIC and improved the QOL of subjects with OIC and cancer. Trial registration IDwww.ClinicalTrials.jp: JAPIC-CTI-132340 (COMPOSE-4) and JAPIC-CTI-132342 (COMPOSE-5).

Safety and efficacy of elobixibat for chronic constipation: results from a randomised, double-blind, placebo-controlled, phase 3 trial and an open-label, single-arm, phase 3 trial

A subset of patients with constipation has reduced colonic bile acid concentrations, which are associated with slow colonic transit. In a previous study, elobixibat, a locally acting ileal bile acid transporter inhibitor, accelerated colonic transit in Japanese patients with functional constipation. In this study, we aimed to determine the efficacy of elobixibat for short-term treatment of chronic constipation, and safety, patient satisfaction, and quality of life with long-term treatment. We did two phase 3 studies of patients aged 20-80 years in Japan with at least 6 months of chronic constipation, who satisfied Rome III criteria for functional constipation, including fewer than three spontaneous bowel movements per week. The first trial, including patients enrolled at 16 clinics, was a 2-week, randomised, double-blind, placebo-controlled study in which (after a 2-week run-in period) patients were randomly assigned (1:1) to either elobixibat 10 mg/day for 2 weeks or placebo. Randomisation was done with permuted block method (block size six) without stratification. Masking to treatment allocation was achieved with identical appearances of elobixibat and placebo, which were supplied in sealed, opaque containers. Group assignment was concealed from patients, investigators, and analysts. The second trial, including patients enrolled at 34 clinics or hospitals, was an open-label, 1-year study in which all patients received elobixibat; participants could titrate the dose to 5 mg/day or 15 mg/day, or maintain the 10 mg/day dose. In both studies, participants took the study drug as an oral tablet once per day before breakfast. The primary outcome of the 2-week randomised trial was the change from baseline (ie, last week of the 2-week run-in) in the frequency of spontaneous bowel movements during week 1 of treatment. The primary outcome of the 52-week open-label trial was safety (type, severity, and incidence of adverse drug reactions) at all times from treatment initiation. All efficacy analyses were based on the modified intention-to-treat (ITT) population without imputation for any missing data. Safety analyses included all patients who received at least one dose of study drug. These trials are registered with the Japan Pharmaceutical Information Center (numbers JapicCTI-153061 and JapicCTI-153062) and have been completed. Between Nov 4, 2015, and June 11, 2016, we assigned 133 patients to treatment in the 2-week randomised trial: 70 to elobixibat (69 included in the modified ITT and safety populations) and 63 to placebo. The frequency of spontaneous bowel movements per week during week 1 of treatment was greater with elobixibat (least-squares mean 6·4, 95% CI 5·3-7·6) than with placebo (1·7, 1·2-2·2), p<0·0001). Between Oct 31, 2015, and March 15, 2017, we allocated 341 patients to 52 weeks of elobixibat (340 included in the modified ITT and safety populations). 163 (48%) patients in the 52-week trial had an adverse drug reaction, the most common of which were mild gastrointestinal disorders (in 135 [40%] patients). Inguinal hernia was reported in one patient with elobixibat in the 52-week study as a moderate adverse drug reaction. The most common adverse drug reactions in both trials were mild abdominal pain (13 [19%] patients with elobixibat and one [2%] with placebo in the 2-week randomised trial, and 82 [24%] patients in the 52-week trial) and diarrhoea (nine [13%] patients with elobixibat and none with placebo in the 2-week randomised trial and 50 [15%] in the 52-week trial). Elobixibat resolved constipation in the short-term, and was well tolerated with both short-term and long-term treatment. The evidence supports the use of this novel approach to increase intracolonic concentrations of endogenous bile acid for the treatment of chronic constipation. EA Pharma and Mochida Pharmaceutical.

Preventive effects of transcutaneous electrical acustimulation on ischemic stroke-induced constipation mediated via the autonomic pathway.

The aim of this study was to explore the preventive effect and possible mechanisms of transcutaneous electrical acustimulation (TEA) on stroke-induced constipation. A total of 86 ischemic stroke patients were randomly allocated to 2-wk TEA or sham-TEA group. Bowel dairy and Bristol Stool Form Scale were recorded daily. Constipation and dyspeptic symptom assessment was performed at the end of the 14-day treatment. Electrocardiogram was recorded for the assessment of autonomic function. The correlation between autonomic function at admission and stroke severity was assessed. The univariate and multivariate regression analyses were performed to investigate the risk factors for stroke-induced constipation. The cumulative incidence of stroke-induced constipation was 68.2% at the acute stage. Sympathetic nerve activity at admission was positively correlated with stroke severity ( R = 0.47, P < 0.001). Sympathetic nerve activity and stroke severity were independent risk factors for stroke-induced constipation. TEA decreased cumulative incidence of stroke-induced constipation (42.9 vs. 68.2%, P = 0.029). TEA significantly increased frequency of bowel movements (4.5 vs. 5.5, P = 0.001) and spontaneous bowel movements (3.0 vs. 4.5, P = 0.003) per week. TEA decreased straining defecations (0.2 vs. 0, P < 0.001) and laxative use (1 vs. 0, P < 0.001). TEA improved stool consistency and patients' quality of life ( P < 0.05, resp.). TEA increased vagal activity ( P < 0.001 vs. baseline) and decreased sympathetic activity ( P < 0.001 vs. baseline). Ischemic stroke patients are predisposed to autonomic function imbalance. TEA was effective in the prevention of stroke-induced constipation, and the effect was possibly mediated via the autonomic function. NEW & NOTEWORTHY This study illustrated that the brain-gut dysfunction, primarily autonomic function imbalance, was correlated with the stroke-induced constipation. This was the first study to report that transcutaneous electrical acustimulation had a preventive effect on stroke-induced constipation, suggesting a potential novel therapy for bowel problem management. The effect was possibly mediated via the autonomic function.

A Randomized Controlled Trial of Chinese Patent Medicine Xiao'er Biantong Granules in the Treatment of Functional Constipation in Children.

Objective To confirm the effect and safety of Xiao'er Biantong (XEBT) granules for treating chronic constipation in children. Methods This randomized, double-blind, multicenter study enrolled 480 children with age of 1–14 years who had FC. All of them were randomly assigned to receive either XEBT granules or its placebo in the ratio of 3 : 1. The primary efficacy outcome was the frequency of spontaneous bowel movements (SBM) for 14 days, and secondary outcomes were effectual time, score of main symptoms, effect of constipation, disappearance rate of accompanying symptoms, and recurrence rate. We also observed the adverse event (AE) and adverse drug reaction (ADR) to evaluate safety. Results The sociodemographic characteristics and efficiency data were comparable in the two groups at baseline. The mean values of SBM for 14 days were 8.89 and 5.63 in the XEBT group and the placebo group, respectively, and there were 86.87% and 30.91% subjects in two groups up to SBM ≥ 3/week, respectively. There were significant differences between the two groups. The effects in the XEBT group on median effectual time of defecation, main symptom score, disappearance rate of symptoms, and the differences were significant. The conclusions based on full analysis set (FAS) and per protocol set (PPS) were consistent. Nine AEs were reported, of which 7 were in the XEBT group (2.02%) while 2 were in the placebo group (1.77%). There were no significant differences in the occurrence rate of AE and ADR between the two groups. Conclusions Xiao'er Biantong granules have superior efficacy compared to the placebo for the treatment of functional constipation in children and are well tolerated.

Home-Based Transcutaneous Neuromodulation Improved Constipation via Modulating Gastrointestinal Hormones and Bile Acids.

This study aims to investigate the role of transcutaneous neuromodulation (TN) on the regulation of gastrointestinal hormones and bile acids in patients with functional constipation (FC). Twenty FC patients were treated with TN for four weeks. The effects of TN on symptoms were evaluated by questionnaires. Plasma levels of serotonin (5-HT), motilin, somatostatin, and vasoactive intestinal peptide (VIP) were measured by ELISA and 12 individual bile acids assayed by liquid chromatography tandem mass spectrometry. Results were as follows. (1) TN treatment increased the frequency of spontaneous bowel movement, improved the Bristol Stool Score, and reduced Patient Assessment of Constipation Symptom score and Patient Assessment of Constipation Quality of Life score. (2) FC patients showed decreased plasma levels of 5-HT, motilin, and VIP and an increased plasma level of somatostatin (P < 0.05). Four-week TN treatment increased plasma levels of 5-HT and motilin and decreased the plasma level of somatostatin in the FC patients (P < 0.05). (3) Taurocholic deoxycholate, taurocholic acid, and taurocholic lithocholic acid were increased in the FC patients (P < 0.005) but reduced by TN treatment (P < 0.05). This study has suggested that the therapy may improve the symptoms of FC by alleviating the disorders of gastrointestinal hormones and bile acids.

Response mechanisms to joint exposure of triclosan and its chlorinated derivatives on zebrafish (Danio rerio) behavior

Triclosan (TCS), 2,4,6-trichlorophenol (2,4,6-TCP) and 2,4-dichlorophenol (2,4-DCP) frequently co-exist in real-world aquatic environments; the latter two contaminants contributing to TCS photolytic products or chlorinated derivatives. There is a paucity of information regarding their joint toxicity to aquatic organisms leading us to study their effects on the swimming behavior of zebrafish (Danio rerio). Herein, we reported that 0.28 mg/L TDT exposure (mixtures of TCS, 2,4,6-TCP and 2,4-DCP) enhanced 24-hpf embryonic spontaneous movement frequency, 96-hpf larval activity; however, the 0.56 and 1.12 mg/L TDT treatments decreased all of these behavioral endpoints. All adult behavioral tests demonstrated that chronic TDT exposure (0.14 mg/L) led to hyperactivity and restlessness in adult zebrafish. A 0.14 mg/L TD DATE /@ "M/d/yyyy" 11/21/2017T treatment led to anxiety-like behavior in a bottom dwelling test and excessive panic and low hedging capacity in a conditioned place preference test. Social interaction test demonstrated that zebrafish preferred quiet and isolated space in response to TDT stress. Zebrafish memory was significantly decreased in a T-maze experiment. Whole mount in situ hybridization of pax2a and bcl2l11 genes revealed that their differential expression in the brain and skeleton were related to the corresponding phenotypic behavioral abnormality. A series of biomarker and estrogen receptor assays demonstrated that TDT acute exposure caused abnormal energy metabolism and neurological diseases. AO staining revealed that TDT exposure produced vascular ablation in the head, as well as the occurrence of massive apoptosis in the brain. TEM observation showed pyknosis of nucleus following TDT exposure. These results allow assessment of mechanisms for zebrafish abnormal behavior in response to TDT exposure, and are useful for early intervention and gene therapy of contaminant-induced diseases.

DA-9701 improves colonic transit time and symptoms in patients with functional constipation: A prospective study.

DA-9701, a newly developed prokinetic agent formulated with Pharbitis Semen and Corydalis Tuber, has been shown to effectively treat functional dyspepsia. Recently, it has also been suspected to improve gastrointestinal motor function. The aims of this study were to assess the effect of DA-9701 on colonic transit time (CTT) and symptoms of functional constipation. Thirty-three patients with functional constipation based on the Rome III criteria were prospectively enrolled. The patients received 30-mg DA-9701 three times a day for 24days. CTT was estimated initially and at the end of treatment. Symptoms such as spontaneous bowel movements, straining, stool form, feeling of incomplete emptying and anorectal blockage, abdominal discomfort and pain, overall defecation satisfaction, and incidence of adverse events were also analyzed. Twenty-seven patients completed the study. DA-9701 was associated with a significantly reduced CTT from 34.9±17.6 to 23.7±19.1h (P=0.001). Segmental CTT also significantly decreased after treatment (right CTT: from 16.8 [0.0-28.8] to 6.0 [0.0-25.2] hours, P<0.001; rectosigmoid transit time: from 13.2 [0.0-38.4] to 6.0 [0.0-33.6] hours, P=0.021). In addition, all constipation-related subjective symptoms, including spontaneous bowel movement frequency, significantly improved compared with those before treatment. Serious adverse events did not occur. DA-9701 accelerates colonic transit and safely improves symptoms in patients with functional constipation. Therefore, we suggest that this novel agent could help to treat patients with this condition.

Efficacy of Lubiprostone for the Treatment of Opioid-Induced Constipation, Analyzed by Opioid Class

To examine the efficacy and safety of lubiprostone for the treatment of opioid-induced constipation (OIC) in patients by opioid class received. Data were pooled from three phase III, randomized, double-blind, placebo-controlled studies. Adults with chronic noncancer pain receiving opioid therapy for 30 or more days and diagnosed with OIC. Overall mean change from baseline in spontaneous bowel movement (SBM) frequency, overall treatment response (≥1 SBM/week improvement over baseline SBM frequency in all treatment weeks with available data and ≥3 SBMs/week for ≥9 of the 12 weeks of treatment), and OIC-related symptoms were examined in patients taking opioids. Data were pooled and analyzed by opioid group. In patients receiving phenanthrene opioids (e.g., oxycodone; N = 1,159), lubiprostone significantly increased overall mean changes in SBM frequency from baseline (P = 0.0001), increased overall response rate (P = 0.0024), and improved OIC symptoms (P ≤ 0.0229) vs placebo. Patients receiving phenylpiperidine opioids (e.g., fentanyl; N = 137) had significant improvement in SBM frequency (P = 0.0129) and favorable trends in response rates (21.4% vs 9.8%; P = 0.0723) and OIC symptoms vs placebo. Efficacy was not observed in overall analyses of patients receiving diphenylheptane opioids (e.g., methadone), although an increase in SBM frequency was observed in patients who received a morphine-equivalent daily dose of 200 or fewer mg, suggesting a dose-dependent negative interference of this opioid class on lubiprostone effects. For all groups, the lubiprostone adverse event profile was similar; the most common treatment-emergent adverse events were nausea and diarrhea. In patients using commonly prescribed opioids, lubiprostone is effective and generally well tolerated for the treatment of OIC.

Effect of Naldemedine on Frequency of Spontaneous Bowel Movements and Associated Symptoms

Introduction: Opioid-induced constipation (OIC) is a well-known side effect of opioid therapy. Naldemedine (NAL) is a peripherally-acting μ-opioid receptor antagonist approved for the treatment of OIC in patients with chronic non-cancer pain. Methods: Two randomized, double-blind placebo (PBO) controlled 12-week studies (NCT01965158 and NCT01993940), assessed the effect over time of NAL 0.2 mg once daily vs PBO in the frequency of spontaneous bowel movements (SBMs), complete SBMs (CSBMs, defined as SBMs with a perception of complete evacuation), SBMs without straining, and SBMs with a Bristol Stool Scale (BSS) Score of 3 or 4 in adult (age 18-80 years) subjects with chronic non-cancer pain and OIC. Subjects were required to not be on laxatives at screening or to agree to discontinue laxatives upon signing informed consent. The mean changes in the frequency per week from baseline to each week was compared between NAL and PBO, with a mixed-effects model repeated measures which opioid dose strata and study as a covariate and treatment group, time, time-by-treatment group interaction as fixed effects. Safety was assessed based on the incidence of adverse events (AEs). Results: In the two studies pooled, 1095 subjects were randomized 1:1 to NAL (N=549) or PBO (N=546) for 12 weeks. In all four endpoints, NAL was associated with a significantly (P≤0.0001) greater improvement from baseline at each week relative to PBO, starting at Week 1 and up to Week 12 (Figure). The overall incidence of AEs was generally similar between groups. Treatment with NAL was associated with a greater incidence of gastrointestinal AEs (abdominal pain, diarrhea, nausea) compared with PBO (Table).Figure: Change from Baseline* to Each Week (LS Mean ± SE) in Assessed Endpoints.Table: Table. Overall Summary of Treatment Emergent Adverse Events (Safety Population)Conclusion: Treatment with NAL over 12 weeks compared with placebo improved the frequency of bowel movements as well as the signs and symptoms of OIC frequently reported with bowel movements including perception of incomplete evacuation, need for straining, and hard stools,. NAL was generally well tolerated.

Effect of Linaclotide DR1, a Delayed-Release Formulation of Linaclotide, in IBS-C Patients: Analysis of Symptom Improvement Using Responder Radar Plots

Introduction: Linaclotide (LIN) is a guanylate cyclase-C agonist approved as an immediate-release (IR) formulation for irritable bowel syndrome with constipation (IBS-C). A LIN delayed-release (DR) formulation, DR1, was developed with the hypothesis that targeting the ileal region would increase abdominal pain relief and cause less fluid secretion. A Phase 2b dose-ranging study in IBS-C patients showed that a 300μg dose of LIN DR1 improved abdominal and bowel symptoms with an acceptable safety profile. This analysis aims to further examine symptom improvement in that study using responder radar plots, with a focus on LIN DR1 300μg (planned Phase 3 dose), LIN IR, and placebo (PBO). Methods: IBS-C patients meeting Rome III IBS criteria and baseline symptom requirements were randomized to 1 of 8 groups; this analysis includes the 199 patients in the PBO, LIN IR 290μg, and LIN DR1 300μg groups. Patients reported abdominal/bowel symptoms daily and adequate relief (yes/no) weekly during 2-week baseline (BL) and 12-week treatment periods. Change-from-BL and responder endpoints (abdominal pain [≥30% decrease from BL], CSBM+1 [increase of ≥1 complete spontaneous bowel movement from BL], APC+1 [both abdominal pain and CSBM+1 in the same week], and adequate relief, each for ≥6/12 weeks and ≥9/12 weeks) were analyzed. Results: Improvements from BL in abdominal pain, abdominal discomfort, spontaneous bowel movement (SBM) frequency, straining, and stool consistency were seen for DR1 vs PBO (nominal P<0.05); numerical improvements vs PBO were seen for other symptoms (Table). Changes from BL were generally similar in the DR1 and IR groups. 6/12 week responder rates were higher in DR1 vs PBO patients (nominal P<0.05) for APC+1, CSBM+1, and adequate relief; and numerically higher for abdominal pain (P=0.053; Figure). DR1 responder rates were numerically higher vs IR for APC+1, abdominal pain, and adequate relief, and similar for CSBM+1 (Figure). More stringent 9/12 week responder endpoints showed abdominal pain and adequate relief improvement for DR1 vs PBO (nominal P<0.05) and numerical improvement in abdominal pain vs IR (Figure). Diarrhea, the most common AE, led to discontinuation in 3%, 6%, and 0% of DR1, IR, and PBO patients, respectively.FigureTable: Table. Change from Baseline in Abdominal and Bowel SymptomsConclusion: Targeted LIN delivery with DR1 300μg appears to maintain constipation relief and may enhance benefit for abdominal pain and abdominal discomfort in IBS-C patients. Further study is warranted to confirm these results.

Determining an optimal clinical dose of elobixibat, a novel inhibitor of the ileal bile acid transporter, in Japanese patients with chronic constipation: a phase II, multicenter, double-blind, placebo-controlled randomized clinical trial

BackgroundElobixibat is an oral treatment candidate for chronic constipation with a novel mechanism of action via inhibition of the ileal bile acid transporter. We performed this randomized, double-blind, placebo-controlled, dose-finding phase IIb study in Japanese patients with chronic constipation to determine the optimal clinical dose of elobixibat.MethodsJapanese patients with chronic constipation were randomized to receive elobixibat (5, 10, or 15 mg) or placebo once daily for 2 weeks. The primary efficacy endpoint was the change from baseline in frequency of spontaneous bowel movements at Week 1 of treatment. Secondary endpoints and adverse events were also examined.ResultsAmong 226 patients who provided informed consent, 163 patients were randomized and included in the full analysis set. In the 10- and 15-mg groups, frequency of spontaneous bowel movements (±standard deviation) were significantly higher than baseline (5.7 ± 4.2 and 5.6 ± 3.5 times per week, respectively, compared with 2.6 ± 2.9 times per week in the placebo group [P = 0.0005, P = 0.0001, respectively]). Subgroup analysis indicated that elobixibat was equally effective in patients with or without constipation-predominant irritable bowel syndrome. Common adverse events included mild abdominal pain and diarrhea in the elobixibat groups; no serious or severe adverse events occurred. Elobixibat was well tolerated at once-daily oral doses up to 15 mg for 2 weeks.ConclusionsOur study results suggest that 10 mg of elobixibat is a clinically optimal dose for Japanese patients with chronic constipation.Clinical trial registration numberJapicCTI-142608.

I7. The Effect of Naloxegol on Stool Consistency in Patients with Noncancer Pain and Opioid-Induced Constipation

Patients with opioid-induced constipation (OIC) frequently relate their constipation burden to uncomfortable passing of hard, dry stools. Although naloxegol (Movantik™) increases spontaneous bowel movement frequency, its effects on normalizing stool consistency have not been fully described. This post-hoc analysis of the KODIAC clinical trials describes naloxegol effects on stool consistency.

Translating Clinical Findings into the Patient’s Perspective: Post-hoc Pooled Analysis of Bowel Movement Changes as a Predictor of Improvement in Patients’ Opioid-induced Constipation Symptoms and Outcomes

PurposeOpioid-induced constipation (OIC) is a bothersome side effect of opioid use for the management of noncancer pain, affecting patients’ health-related quality of life and chronic-pain management. The objective of this study was to examine the relationship between changes in the frequency of spontaneous bowel movements (SBMs) and changes in patient-reported outcomes (PROs) among patients with OIC treated with naloxegol. MethodsPost hoc analyses were conducted using pooled data from two Phase III 12-week, placebo-controlled trials of naloxegol for the treatment of OIC (NCT01309841 and NCT01323790). Patients completed the Patient Assessment of Constipation–Quality of Life (PAC-QOL) and PAC–Symptoms (PAC-SYM) at each study visit, and the Straining Scale and Bristol Stool Scale (BSS) with each bowel movement for the study duration. Four subgroups were created based on improvements from baseline in mean frequency of SBMs per week: 0 or worse (no change), +1 SBM, +2 SBMs, and +≥3 SBMs. Spearman correlations assessed the association between mean SBM changes from baseline and mean changes from baseline in PROs; analysis of covariance was used to compare changes from baseline. FindingsA total of 1337 patients with mean (SD) age of 52.2 (11.0) years were included in this analysis. The patient population was predominantly white (79.0%) and female (62.4%). At baseline, mean SBM frequency was 1.4 (1.0) per week. At study end, all 4 SBM-change subgroups experienced improvements in PAC-QOL, PAC-SYM, Straining Scale, and BSS scores, and these changes were significantly correlated with mean changes from baseline in SBMs per week. The subgroup of patients with an increase in SBMs of ≥3 per week experienced the greatest improvements in PROs. ImplicationsIn these patients with OIC, an improvement in the frequency of SBMs by ≥3 per week was associated with consistent improvements in PROs, providing support for the use of improvements in SBMs as a clinical outcome surrogate for managing patients with OIC. Further research is needed to determine a threshold for change in SBMs that is clinically meaningful in both research and clinical settings. A key limitation was the post hoc nature of the study, which was not powered prospectively to examine these relationships.