Constipation—modern laxative therapy

It is estimated that one third of the population in Western industrial countries suffers from constipation at least from time to time. Constipation may have somatopathic or functional causes. Furthermore, a great number of substances are known to cause medication-induced constipation, i.e. opioid-induced constipation is caused by linkage of the opioid to opioid receptors in the bowel and the central nerve system. Whenever possible, causal therapy should be undertaken. Patients in palliative care mostly suffer from chronic functional constipation. The treatment consists of basic measures and the application of laxatives. According to their mode of action, they are divided into bulk-forming laxatives, osmotic laxatives, stimulant laxatives, lubricating agents and others. Bulk-forming laxatives are not recommended for use in palliative care patients, for such patients are normally not able to take in the required amount of fluids. Osmotic laxatives are divided into (magnesium) salts, saccharine, alcohols and macrogols. Lactulose is the most popular saccharine laxative. Because of its side effects (flatulence, bloating and abdominal cramping), lactulose is not a laxative of our choice; instead, we prefer to give macrogol. Orally administered, macrogol is not metabolised and pH value and bowel flora remain unchanged. Macrogol hydrates hardened stools, increases stool volume, decreases the duration of colon passage and dilates the bowel wall that then triggers the defecation reflex. Even when given for some time, the effectiveness of macrogol will not decrease. Because of its high effectiveness and commonly good tolerance, macrogol has become the laxative of first choice in palliative care patients with all kinds of chronic constipation, if these patients are able to take in the necessary amount of fluids. From the general medical point of view, lubricating agents have become obsolete. In palliative care patients, however, they are still important laxatives for prophylactic treatment or therapy of constipation. Due to clinical experience, in palliative care a laxative ladder has proven successful.Presented as an invited lecture at the 15th International Symposium Supportive Care in Cancer, Berlin, Germany, June 18–21, 2003.     

Methylnaltrexon

Chronic pain patients using opioids frequently suffer from constipation which compromises well-being. Such an opioid-induced gastro-intestinal complication can occur regularly in patients in palliative care as well as in analgesic sedated intensive care patients or during prolonged perioperative pain therapy. Discomfort and distress in the affected patients can be so severely pronounced that they would rather suffer from the pain than from the side effect of constipation. Conventional therapy can be insufficient in providing satisfactory relief of constipation, mostly because this opioid-induced bowel hypomotility can be laxative-resistant. Moreover, constipation does not decrease during the course of therapy as do other side effects. It is well known that opioid-induced constipation is mediated via activation of µ-opioid receptors in the gastrointestinal tract. Selective peripheral µ-receptor antagonists (such as methylnaltrexone, Relistor®) can effectively treat opioid-induced constipation. An interference with central analgesia does not occur as the molecules cannot pass the blood-brain barrier due to their charged states. A reduction of opioid therapy or the development of withdrawal symptoms can be avoided. Studies have shown that methylnaltrexone is not only safe and efficient for chronically constipated palliative care patients but offers promising therapeutic options for further patient collectives.     

Analgesia Issues in Palliative Care

Some recent literature relevant to analgesia in palliative care is reviewed. Reports on clinical use of bisphosphonates for bone pain in cancer, controlled release opioids, selection of laxatives for opioid-induced constipation and the calcium channel blocker nifedipine as an analgesic are described.     

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.     

Analgesia issues in palliative care: bone pain, controlled release opioids, managing opioid-induced constipation and nifedipine as an analgesic

Some recent literature relevant to analgesia in palliative care is reviewed. Reports on clinical use of bisphosphonates for bone pain in cancer, controlled release opioids, selection of laxatives for opioid-induced constipation and the calcium channel blocker nifedipine as an analgesic are described.     

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.     

Pharmaceutical interventions facilitate premedication and prevent opioid-induced constipation and emesis in cancer patients

Background  

Opioid analgesics possess a number of side effects, among which constipation and nausea/vomiting occur most frequently. Although pretreatment with laxatives and antiemetics for the prophylaxis of opioid-induced constipation and nausea/vomiting, respectively, is recommended, such side effects are still a matter of concern in clinical setting.     

Opioid antagonists: a review of their role in palliative care,focusing on use in opioid-related constipation

Opioid antagonists have well-established indications in the reversal of life-threatening opioid toxicity, but also hold considerable promise for other applications in palliative care practice, particularly management of opioid-related constipation. We briefly review current understanding of opioid receptors, focusing on their complex role in gastrointestinal physiology. We summarize the pharmacology, conventional indications, and clinical usage of three major groups of opioid antagonists, including a promising new peripherally acting agent, methylnaltrexone, which is not commercially available. We suggest an approach to administering opioid antagonists for reduction of life-threatening opioid toxicity in patients with pain. The literature on opioid-induced constipation and its treatment with opioid-antagonists is reviewed in detail. Finally, other potential uses of opioid antagonists in palliative care are described, especially strategies for reducing such opioid side effects as nausea and pruritus and for improving analgesia or reducing tolerance by concomitantly administrating both an opioid agonist and low dosages of an antagonist.     

Constipation in Palliative Care: What Do We Use as Definitions and Outcome Measures?

ContextAdvances in the management of constipation in palliative care remain hindered by the lack of agreed-upon diagnostic criteria.ObjectivesThe objective of this work was to emphasize this issue by systematically examining the eligibility and primary outcome measures in studies of constipation in the hospice and palliative care population.MethodsA palliative care-specific electronic literature search was undertaken using the validated domain filter “palliative care” and topic filter “constipation” in CareSearch (www.caresearch.com.au), which interrogates PubMed in real time (1965–2011). Studies were included if they were primary reports of the treatment of constipation in a palliative care setting. Articles could be prospective or retrospective; randomized controlled trials, cohort studies, or case series.ResultsTwenty articles on the palliative care population were included in which there were six different definitions of constipation. Only 12 of 20 articles used their cited definitions of constipation as the studies' primary outcome measures and four of four blinded, randomized, controlled trials. Articles that used the time between bowel actions or the use of laxatives as the definition of constipation were most likely to report outcomes based on these criteria.ConclusionConstipation is a significant problem in palliative care; however, not having an agreed-upon definition limits research initiatives and the ability to apply these results clinically to people with constipation. Four domains are suggested as pivotal to the diagnosis: any life-long history of constipation (using the Rome Criteria), evaluation of physical changes that may cause or worsen constipation, the subjective sensation (such as feelings of incomplete defecation or bloating or fullness), and objective changes (such as frequency or consistency of stools).     

Opioid antagonists in the treatment of opioid-induced constipation and pruritus

OBJECTIVE: To describe the role of opioid antagonists in the treatment of opioid-induced constipation and pruritus. DATA SOURCES: A MEDLINE search was performed (1966-February 2000) for narcotics and opioid antagonists. Results were limited to English-language and clinical trials. Background information was obtained from pharmacology and pharmacotherapy references and review articles. Hand searching of selected bibliographies yielded several references. STUDY SELECTION AND DATA EXTRACTION: Studies were reviewed that examined the use of naloxone, naltrexone, and methylnaltrexone for opioid-related constipation and pruritus. Selected citations included various clinical trials and case series. DATA SYNTHESIS: Opioid agents are used for cancer and nonmalignant pain. Peripheral opioid receptor stimulation due to endogenous (i.e., endorphins) or exogenous (i.e., morphine) stimulants may result in negative adverse effects, including constipation and pruritus. Adjuvant agents, such as laxatives and antihistamines, are often used to treat these adverse effects, but are themselves associated with adverse effects and are sometimes ineffective. Opioid antagonists have demonstrated reversal of peripheral opioid receptor stimulation. Clinical trials show adequate maintenance of pain control, as well as decreases in opioid-induced constipation and pruritus. CONCLUSIONS: Opioid antagonists offer a therapeutic alternative to conventional adjuvant agents, with the risk of loss of analgesia at higher doses. Methylnaltrexone offers the advantage of peripheral action only, therefore not reversing analgesia. Results are promising; however, larger clinical trials are necessary before opioid antagonists become the standard of care for opioid-induced constipation and pruritus.     

Chronic Constipation

Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit. Defecatory disorders are often responsive to biofeedback therapies, whereas slow-transit constipation may require surgical intervention in selected patients. Both efficacy and cost should guide the choice of treatment for functional constipation and opiate-induced constipation. Currently, no studies have compared inexpensive laxatives with newer drugs that work by other mechanisms.     

The developing role of children's nurses in community palliative care

This article addresses some of the contemporary issues in relation to providing palliative care for children in Ireland, particularly focusing on the creation of the specialist palliative care nursing outreach posts. The recent publication of an Irish national policy on palliative care for children with life-limiting illness is welcome news for paediatric nurses in Ireland. Children are valued members of society and have a right to receive quality health care and support appropriate to meet both children and the families' precise needs. However, community services for children with life-limiting illnesses remain inadequate, with many parents and families struggling to provide palliative care for children in the home. Currently, community nurses, who are not always registered children's nurses, are providing palliative care for children at the end of life. These nurses may not fully understand the specific needs of critically or chronically ill children and their families. In addition, there are no specific palliative care educational programmes in Ireland with regard to end-of-life care for children. The challenges of providing palliative care to children and their families in relation to symptom control, controversial ethical and legal issues, and emotional and practical support, mean that advanced knowledge is required in order to progress the agenda and thus provide excellence in children's palliative care in Ireland. It is important that the agenda is moved forward so that children and their families requiring palliative care and nursing support do not suffer from a lack of professional provision for their needs.     

Supportive and palliative care needs of families of children who die from cancer: an Australian study

OBJECTIVE: To obtain feedback from parents of children who died from cancer about their understanding of palliative care, their experiences of palliative and supportive care received during their child's illness, and their palliative and supportive care needs. DESIGN: A qualitative study with semi-structured interviews. PARTICIPANTS: 24 parents from Perth (n = 10), Melbourne (n = 5), Brisbane (n = 5) and Sydney (n = 4). Setting: Five Australian tertiary paediatric oncology centres. Results Parents whose children died from cancer live within a context of chronic uncertainty and apprehension. Parents construed palliative care negatively as an independent process at the end of their children's lives rather than as a component of a wider and continuous process where children and their families are offered both curative and palliative care throughout the cancer trajectory. The concept of palliative care was perceived to be misunderstood by key health professionals involved in the care of the child and family. The importance and therapeutic value of authentic and honest relationships between health professionals and parents, and between health professionals and children were highlighted as a critical aspect of care. Also highlighted was the need to include children and adolescents in decision making, and for the delivery of compassionate end-of-life care that is sensitive to the developmental needs of the children, their parents and siblings. CONCLUSIONS: There is a need for health professionals to better understand the concept of palliative care, and factors that contribute to honest, open, authentic and therapeutic relationships of those concerned in the care of the dying child. This will facilitate a better understanding by both parents and their children with cancer, and acceptance of the integration of palliative and supportive care in routine cancer care.     

Managing constipation: a focus on care and treatment in the palliative setting

Constipation can cause unnecessary discomfort and suffering for patients, and there appears to be a lack of awareness among nurses and doctors about its cause, impact and management. A large proportion of the evidence for the assessment and management of constipation in the context of palliative care is derived from the perspective of advanced cancer and from guidelines developed at a European level. Although constipation remains a problem for palliative care patients, early intervention combined with continuous and impeccable assessment can assist in its management and improve patient comfort at the end of life.     

Ist die pharmakologische Therapie der Obstipation in der Palliativmedizin evidenzbasiert?

Materials and methods

To evaluate the evidence for clinically established pharmacological therapies for constipation in palliative care, a systematic literature review was performed in different databases (Cochrane Library, Embase, PubMed, Ovid MEDLINE, CINAHL), textbooks, and publications.

Results

Whereas 130 randomized controlled trials were found with patients outside of palliative care settings, only 10?controlled studies with patients in end-of-life situations were identified: three RCTs with methylnaltrexone and one with the combination of oxycodone and naloxone showed the effect and safety of opiate antagonists for patients who are not at risk of gastrointestinal perforation. There have been no studies which test methylnaltrexone against the optimization of therapy with conventional laxatives. Six other controlled studies of limited quality in design and execution and with only few participants tested naloxone, senna, lactulose, Co-danthramer, an Ayurvedic preparation (Misrakasneham), magnesium hydroxide, fluid paraffin, sodium picosulfate and docusate without finding statistically significant differences in efficacy or side effects. Most patients in these studies had cancer. Only case studies with few patients in palliative care were found for meglumine, neostigmine, and other substances mentioned above.

Conclusion

Evidence on medical treatment of constipation in palliative care is sparse and guidelines have to refer to evidence from outside the palliative care setting and to expert opinions. Results from studies with other patient groups can only be transferred with limitations to very ill patients at the end of life who might have a higher risk for potential side effects such as gastrointestinal perforation in case of abdominal tumor manifestation. Therefore further studies are required to evaluate the medical treatment of multiple reasons for constipation in these patients. These studies should focus on feasibility, clinical relevance and quality of life. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).     

Constipation management in palliative care: treatments and the potential of independent nurse prescribing

Constipation is a common symptom in palliative care patients that can generate considerable suffering owing to both the inherent physical discomfort and the attendant psychological issues such as embarrassment. This article considers the management of constipation for palliative care patients, including the importance of the patient's own definition of their problem, the need for thorough and frequent assessment, established treatment options, and the challenges that nurses may face. It provides a simple algorithm to assist in the management process, and also looks at the current strength of the evidence base for two more recent therapies. Finally, it examines the potential of the independent nurse prescriber (INP) for constipation management in the UK, using a brief case study to illustrate a commonly experienced constipation management scenario for the INP in the community setting.     

Palliative care and pain: new strategies for managing opioid bowel dysfunction

Opioid analgesics are a cornerstone of pain therapy in the hospice and palliative care population. However, opioid-induced bowel dysfunction (OBD) is a commonly associated condition that frequently compromises the usefulness of these agents. Although its most common and debilitating symptom is constipation, the impact of OBD extends beyond constipation to encompass a myriad of gastrointestinal (GI) signs and symptoms, ranging from decreased gastric emptying and reflux to abdominal pain, cramping, bloating, nausea, and vomiting. Even after aggressive therapies to improve bowel function have been implemented, many patients continue to experience symptoms of OBD. To avoid these unwanted effects, some even choose to decrease or discontinue therapy with opioid analgesics, and experience inadequate pain control. The net result of OBD is a seriously negative impact on quality of life (QOL). For these reasons, it is important that palliative care practitioners have an adequate understanding of normal GI function and the underlying mechanisms responsible for OBD, the burden of OBD in the context of appropriate and effective pain management, and the benefits provided by effective pharmacotherapy. Several real-world cases are discussed to illustrate the application of optimal symptom management and the use of strategies that minimize the effects of OBD and improve patient QOL.     

Assessment and management of constipation in older people

Older people, particularly those with underlying health problems, commonly experience constipation, which is a distressing symptom that can adversely affect quality of life. Assessment of constipation is vital to exclude treatable and underlying conditions and a step-wise approach should be taken to managing chronic constipation in older people. Lifestyle modification and laxatives remain the mainstay of constipation management, but newer interventions are being developed and applied to the care of older people. Nurses are often pivotal to the identification and successful management of constipation. They should ensure that their knowledge and skills are maintained to enable them to implement care that is effective and evidence based.     

Parent involvement in children''s pain care: views of parents and nurses

AIM OF THE STUDY: This study investigated the views of parents and nurses about the involvement of parents in the management of their child's pain during the first 48 hours after surgery. BACKGROUND: Children's pain management has been found to be problematic and in need of improvement. Nurses are the key health care professionals with responsibility for managing children's pain. Parents can make important contributions to assessment and management of their child's pain. METHODS: Using a phenomenological approach, nurses and parents were interviewed about their perceptions of parent involvement in pain management. FINDINGS: The findings indicated that parental involvement in their child's pain management is superficial and limited in nature. Parents described a passive role in relation to their child's pain care and conveyed feelings of frustration. Only a minority of parents expressed satisfaction with their child's pain care. Nurses perceived that there was adequate involvement of parents and adequate pain management for children. CONCLUSIONS: These findings may be somewhat explained by differing views and a lack of effective communication between parents and nurses. There is a clear need for nurses to discuss parent involvement with parents and negotiate roles in relation to pain management.     

The clinical effectiveness of Movicol in children with severe constipation: an outcome audit

This audit reviewed the clinical effectiveness of polyethylene glycol 3350 plus electrolytes (PEG+E, Movicol) in the management of severe paediatric constipation. A seven-day disimpaction regimen was initiated followed by a maintenance dose as appropriate. An information and support service was provided by the community children's nursing team (CCNT) at Darent Valley Hospital. Twenty-three parents completed questionnaires on their children's experiences with previous and current laxative treatments, bowel movement status, in-patient admissions or home visits required and the perceived value of the back up service. The mean age of children studied was 6.7 years. Prior to PEG+E treatment, 57 per cent of children were admitted to hospital and 26 per cent required home visits for constipation treatment. After treatment, no child needed either intervention. Thirty-nine percent of parents used the support service, of which 96 per cent rated the information it provided as adequate. When asked about their satisfaction with the control of their children's constipation, 96 per cent of parents were 'more than happy' after treatment with PEG+E. The treatment of severe paediatric constipation with PEG+E in conjunction with a support and advice service was both clinically and economically effective.