REPORT
“The last thing that we want to do in the palliative care setting is to reduce the analgesic effects of our opioids, because our primary goal is to reduce pain in these patients,” said Dr. Pergolizzi.
Epidemiology and Consequences of OIC OIC is an anticipated side effect of opioid therapy. Its overall relevance to the clinical community continues to increase, mainly because of the rising therapeutic use of opioids.17 For example, OIC rates in patients receiving cancer treatment and opioids can range from 69% to 90%,18,19 and studies of patients with advanced cancer who are receiving hospice care report rates as high as 87%.20 Additionally, among individuals with advanced illnesses other than cancer who are receiving opioid therapy, the prevalence of opioid-induced GI AEs approaches 90%.21 “In the palliative care patient with advanced disease, we are more aggressive in the use of opioids to reduce pain with the goal of comfort,” said Dr. Pergolizzi. “Although we try to balance the role of analgesic-related side effects, oftentimes, relief of pain is more important for these patients. As such, we typically use higher dose of opioids, which results in more adverse effects.” Risk factors for OIC include advanced age, opioid type/ strength, and advanced illness (eg, cancer, AIDS, or cardiovascular disease).18,20,21 Furthermore, the risk for OIC increases with relative immobility, dehydration, and altered nutritional intake, all of which are common in patients with advanced illnesses, particularly in the palliative care setting.21 Although patients may slowly acquire a tolerance to opioid-related side effects such as nausea or sedation, OIC may continue unabated throughout treatment.21 Dr. Pergolizzi said that there are several notable consequences of OIC. “First, OIC can result in other GI symptoms, including nausea and vomiting and a decreased ability to take in oral medications and nutrients. Second, if patients have no remedy to relieve the symptoms and complications of OIC as an outpatient, they really have no other option than to come to the emergency department to be evaluated. In some cases, the symptomatology and consequences of OIC are sufficiently severe to warrant hospitalization for more aggressive
interventions,” he said. “When you consider the patient with advanced illness, especially those in the palliative care setting, they would really rather not be hospitalized provided they have some option to adequately relieve OIC at home.” The consequences of OIC are diverse and significant. Clinical manifestations include abdominal pain, distension, and nausea and vomiting.9 When left untreated, OIC may lead to inadequate absorption of oral medications, fecal impaction, hemorrhoids, bowel obstruction, and intestinal perforation.9 “There is a vicious circle that exists between opioid use for the relief of pain and the subsequent pain and discomfort that can result from the development of secondary constipation,” said Dr. Pergolizzi. “Specifically, patients are given opioids to relieve the primary pain related to their advanced illness but end up developing OIC, which can, itself, be a painful condition. [When laxative agents provide insufficient relief,] patients are then faced with the choice of either refraining from further opioid therapy to relieve OIC, in which case the pain from their primary condition is not adequately treated, or taking larger doses of opioids and potentially worsening the pain associated with OIC.”
Treatment of OIC in Advanced Illness Physiologic constipation is typically managed through a combination of behavioral strategies and the use of agents designed to increase stool bulk, improve intestinal motility, and/ or aid the passage of stools through softening agents.9 Supportive strategies include increased hydration and improved patient mobilization—which can be difficult for patients with advanced illness—along with addressing the etiologic triggers of constipation.9 Laxatives are the first-line therapeutic option for OIC, and the various classes of laxative agents used to relieve physiologic mechanisms of constipation are summarized in Table 1.22,23 However, data from clinical trials suggest that conventional laxatives (eg, over-the-counter laxatives, polyethylene glycol, lactulose, magnesium citrate) may not offer adequate symptom relief for some patients.15,21 As reviewed in the section on the pathophysiology of different types of constipation, OIC in advanced illness is unique from other forms of constipation. “When we look at laxatives
Important Safety Information (continued) and promptly notify their physician if they develop severe, persistent, and/or worsening abdominal symptoms. Use of RELISTOR has not been studied in patients with peritoneal catheters. Use of RELISTOR beyond four months has not been studied. Safety and efficacy of RELISTOR have not been established in pediatric patients.
The most common adverse reactions reported with RELISTOR compared with placebo in clinical trials were abdominal pain (28.5%), flatulence (13.3%), nausea (11.5%), dizziness (7.3%), diarrhea (5.5%), and hyperhidrosis (6.7%). Please see Important Safety Information throughout and brief summary of Prescribing Information on page 12.
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